FOREARM

The forearm is the part of the upper limb that extends between the elbow and wrist joints.
Proximally, most structures pass between the arm and forearm through, or in relation to, the
cubital fossa, except for the ulnar nerve, which passes posterior to the medial epicondyle of the
humerus. Distally, structures pass between the forearm and the hand through, or anterior to, the
carpal tunnel, except for the radial artery, which passes dorsally around the wrist (Fig.1A).

❖ Skin of the Forearm

The sensory nerve supply to the skin of the forearm (Fig. 2) is from:
o The anterior and posterior branches of the lateral cutaneous nerve of the forearm (a
continuation of the musculocutaneous nerve)
o The anterior and posterior branches of the medial cutaneous nerve of the forearm.
o A narrow strip of skin down the middle of the posterior surface of the forearm is supplied by
the posterior cutaneous nerve of the forearm (a branch from the radial nerve).
The superficial veins of the forearm (Fig. 3) lie in the superficial fascia.
o The cephalic vein arises from the lateral side of the dorsal venous arch on the back of the
hand and winds around the lateral border of the forearm; it then ascends into the cubital fossa
and up the front of the arm on the lateral side of the biceps. It terminates in the axillary vein
in the deltopectoral triangle. As it passes up the upper limb, it receives a variable number of
tributaries from the lateral and posterior surfaces of the limb.
The median cubital vein, a branch of the cephalic vein in the cubital fossa, runs upward and
medially and joins the basilic vein. In the cubital fossa, it crosses in front of the brachial
artery and the median nerve, but it is separated from them by bicipital aponeurosis.
o The basilic vein arises from the medial side of the dorsal venous arch on the back of the
hand and winds around the medial border of the forearm; it then ascends into the cubital
fossa and up the front of the arm on the medial side of the biceps. It terminates by joining the
venae comitantes of brachial artery to form the axillary vein. It receives the median cubital
vein and a number of tributaries from the medial and posterior surfaces of the upper limb.
The superficial lymph vessels from the thumb and lateral fingers and the lateral areas of the
hand and forearm follow the cephalic vein to the infraclavicular group of nodes.
Those from the medial fingers and the medial areas of the hand and the forearm follow the
basilic vein to the cubital fossa. Here, some of the vessels drain into the supratrochlear
(epitrochlear) lymph node, whereas others bypass the node and accompany the basilic vein to
the axilla, where they drain into the lateral group of axillary nodes. The efferent vessels from
the supratrochlear node also drain into the lateral axillary nodes.

Dr. Mohammed Hussein Assi

MBChB-MSc-PhD-MRCPCH-DCH (UK)
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❖ Bones of the Forearm
The Radius
The radius is the lateral bone of the forearm (Fig. 4A).
Its proximal end articulates with the humerus at the elbow joint and with the ulna at the proximal
radioulnar joint. Its distal end articulates with the scaphoid and lunate bones of the hand at the
wrist joint and with the ulna at the distal radioulnar joint.
At the proximal end of the radius is the small circular head. The upper surface of the head is
concave and articulates with the convex capitulum of the humerus. The circumference of the
head articulates with the radial notch of the ulna.
Below the head, the bone is constricted to form the neck. Below the neck is the bicipital
tuberosity for the insertion of the biceps muscle.
The shaft of the radius is wider below than above. It has a sharp interosseous border medially for
the attachment of the interosseous membrane that binds the radius and ulna together.
The pronator tubercle, for insertion of the pronator teres, lies halfway down on its lateral side.
At the distal end is the styloid process, which projects distally from its lateral margin. On the
medial surface is the ulnar notch, which articulates with the round head of the ulna.
On the posterior aspect of the distal end is a small tubercle, the dorsal tubercle, which is grooved
on its medial side by the tendon of the extensor pollicis longus.
The inferior articular surface articulates with the scaphoid and lunate bones.
The Ulna
The ulna is the medial bone of the forearm (Fig. 4B).
Its proximal end articulates with the humerus at the elbow joint and with the head of the radius at
the proximal radioulnar joint. Its distal end articulates with the radius at the distal radioulnar
joint, but it is excluded from the wrist joint by an articular disc.
The proximal end of the ulna is large and is known as the olecranon process; this forms the
prominence of the elbow. It has a notch on its anterior surface, the trochlear notch, which
articulates with the trochlea of the humerus. Below the trochlear notch is the coronoid process,
which has on its lateral surface the radial notch for articulation with the head of the radius.
The shaft of the ulna tapers from above down. It has a sharp interosseous border laterally for the
attachment of the interosseous membrane. The posterior border is rounded and subcutaneous and
can be easily palpated throughout its length. Below the radial notch is the supinator crest that
gives origin to the supinator muscle. At the distal end of the ulna is the small, rounded head,
which projected from its medial aspect the styloid process.
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❖ Fascial Compartments of the Forearm
As in the arm, the forearm is divided into anterior and posterior compartments (Fig.1B).
In the forearm, these compartments are separated by:
1. a lateral intermuscular septum, which passes from the anterior border of the radius to deep
fascia surrounding the limb;
2. an interosseous membrane, which links adjacent borders of the radius and ulna along most of
their length; and
3. the attachment of deep fascia along the posterior border of the ulna.
Muscles in the anterior compartment (also named flexor or flexor-pronator compartment) flex
the wrist and digits and pronate the hand.
Muscles in the posterior compartment (also named extensor or extensor-supinator compartment)
extend the wrist and digits and supinate the hand.

Interosseous membrane
The interosseous membrane is a thin fibrous sheet that connects the medial and lateral borders of
the radius and ulna, respectively (Fig. 4C). Collagen fibers within the sheet pass predominantly
inferiorly from the radius to the ulna.
The interosseous membrane has a free upper margin, which is situated just inferior to the radial
tuberosity, and a small circular aperture in its distal third. Vessels pass between the anterior and
posterior compartments superior to the upper margin and through the inferior aperture.
The interosseous membrane connects the radius and ulna without restricting pronation and
supination and provides attachment for muscles in the anterior and posterior compartments.
The orientation of fibers in the membrane is also consistent with its role in transferring forces
from the radius to the ulna and, ultimately, from the hand to the humerus.

Flexor and Extensor Retinacula

The flexor and extensor retinacula are strong bands of deep fascia that hold the long flexor and
extensor tendons in position at the wrist.

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 Anterior Compartment of the Forearm
Muscles in the anterior (flexor) compartment of the forearm occur in three layers: superficial,
intermediate, and deep.
All muscles in the anterior compartment of the forearm are innervated by the median nerve,
except for the flexor carpi ulnaris muscle and the medial half of the flexor digitorum profundus
muscle, which are innervated by the ulnar nerve.

➢ The Superficial Layer

The superficial layer contains four muscles, from medial to lateral; these are Flexor carpi
ulnaris, Palmaris longus, Flexor carpi radialis, and Pronator teres (Fig. 5).
All have a common origin from the medial epicondyle of the humerus (the common flexor
origin), and all (except for the pronator teres) extend distally from the forearm into the hand.

o The ulnar nerve enters the anterior compartment of the forearm by passing through the
triangular gap between the humeral and ulnar heads of the flexor carpi ulnaris (Fig. 5B).
o The palmaris longus muscle is absent in about 15% of the population.
o The tendon of the flexor carpi ulnaris forms the medial margin of the distal forearm, while
the tendon of the flexor carpi radialis muscle is positioned just lateral to the midline. In this
position, the tendon can be easily palpated, making it an important landmark for finding the
pulse in the radial artery, which lies immediately lateral to it (Fig. 8).
o The median nerve often exits the cubital fossa by passing between the humeral and ulnar
heads of the pronator teres muscle (Fig. 5A & Fig. 9).

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➢ The Intermediate Layer

The muscle in the intermediate layer of the anterior compartment of the forearm is the Flexor
Digitorum Superficialis muscle (Fig. 6). This large muscle has two heads:
1. the humero-ulnar head, which originates mainly from the medial epicondyle of the
humerus.
2. the radial head, which originates from the anterior oblique line of the radius.
The median nerve and ulnar artery pass deep to the flexor digitorum superficialis between the
two heads.
In the distal forearm, the flexor digitorum superficialis forms four tendons, which pass
through the carpal tunnel of the wrist and into the four fingers. The tendons for the ring and
middle fingers are superficial to the tendons for the index and little fingers.
In the forearm, carpal tunnel, and proximal regions of the four fingers, the tendons of the
flexor digitorum superficialis are anterior to the tendons of the flexor digitorum profundus.
Near the base of the proximal phalanx of each finger, the tendon of the flexor digitorum
superficialis splits into two parts to pass posteriorly around each side of the tendon of the
flexor digitorum profundus and ultimately attach to the margins of the middle phalanx.
The flexor digitorum superficialis flexes the metacarpophalangeal joint and proximal
interphalangeal joint of each finger; it also flexes the wrist joint.

➢ The Deep Layer

There are three deep muscles in the anterior compartment of the forearm: Flexor Digitorum
Profundus, Flexor Pollicis Longus, and Pronator Quadratus (Fig. 7).

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 o The flexor digitorum profundus originates from the anterior and medial surfaces of the
ulna and from the adjacent interosseous membrane. It gives rise to four tendons, which
pass through the carpal tunnel into the four medial fingers. Throughout their course, the
tendons are deep to those of the flexor digitorum superficialis. Opposite the proximal
phalanx of each finger, each tendon of the flexor digitorum profundus passes through a
split formed in the overlying tendon of the flexor digitorum superficialis and passes
distally to insert into the anterior surface of the base of the distal phalanx. In the palm, the
lumbricals originate from the sides of the tendons of the flexor digitorum profundus.

❖ Arteries of the Anterior Fascial Compartment of the Forearm (Fig. 8)

➢ Ulnar Artery
The ulnar artery is the larger of the two terminal branches of the brachial artery.
It begins in the cubital fossa at the level of the neck of the radius.
It descends through the anterior compartment of the forearm and enters the palm in front of
the flexor retinaculum in company with the ulnar nerve. It ends by forming the superficial
palmar arch, often anastomosing with the superficial palmar branch of the radial artery.
In the upper part of its course, the ulnar artery lies deep to most of the flexor muscles. Below,
it becomes superficial and lies between the tendons of the flexor carpi ulnaris and the tendons
of the flexor digitorum superficialis, here the ulnar artery often remains tucked under the
anterolateral lip of the flexor carpi ulnaris tendon and is therefore not easily palpable.
In front of the flexor retinaculum, the ulnar artery lies just lateral to the pisiform bone and is
covered only by skin and fascia (site for taking ulnar pulse).

Branches of ulnar artery in the forearm

1. Muscular branches to neighboring muscles.
2. Ulnar recurrent artery that takes part in the arterial anastomosis around the elbow joint.
3. Two small carpal arteries (dorsal carpal branch and palmar carpal branch) that take part in
the arterial anastomosis around the wrist joint.
4. The common interosseous artery, which arises from the upper part of the ulnar artery and
after a brief course divide into the anterior and posterior interosseous arteries.
o The posterior interosseous artery passes dorsally over the proximal margin of the
interosseous membrane into the posterior compartment of the forearm.
o The anterior interosseous artery passes distally along the anterior aspect of the
interosseous membrane and supplies muscles of the deep compartment of the forearm and
the radius and ulna. It has numerous branches, which perforate the interosseous
membrane to supply deep muscles of the posterior compartment; it also has a small
branch, which contributes to the vascular network around the carpal bones and joints.
Perforating the interosseous membrane in the distal forearm, the anterior interosseous
artery terminates by joining the posterior interosseous artery.

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➢ Radial Artery
The radial artery is the smaller of the terminal branches of the brachial artery.
It begins in the cubital fossa at the level of the neck of the radius. It passes downward and
laterally, beneath the brachioradialis muscle and resting on the deep muscles of the forearm.
In the middle third of its course, the superficial branch of the radial nerve lies on its lateral
side.
In the distal part of the forearm, the radial artery lies on the anterior surface of the radius and
is covered only by skin and fascia. Here, the artery has the tendon of brachioradialis on its
lateral side and the tendon of flexor carpi radialis on its medial side (site for taking the radial
pulse).
The radial artery leaves the forearm by winding around the lateral aspect of the wrist to reach
the posterior surface of the hand.
Branches of the radial artery in the forearm
1. Muscular branches to neighboring muscles.
2. Radial recurrent artery, which takes part in arterial anastomosis around the elbow joint.
3. a small palmar carpal branch, which contributes to an anastomotic network of vessels that
supply the carpal bones and joints.
4. The superficial palmar branch, which arises just above the wrist, enters the palm and
frequently joins the ulnar artery to form the superficial palmar arch.

❖ Nerves of the Anterior Fascial Compartment of the Forearm (Fig. 9)

➢ Median Nerve
The median nerve leaves the cubital fossa by passing between the two heads of the pronator
teres. It continues downward behind the flexor digitorum superficialis and rests posteriorly
on the flexor digitorum profundus.
At the wrist, the median nerve emerges from the lateral border of the flexor digitorum
superficialis muscle and lies behind the tendon of the palmaris longus. It enters the palm by
passing behind the flexor retinaculum.
Branches of the median nerve in the forearm
1. Muscular branches in the cubital fossa to the pronator teres, the flexor carpi radialis, the
palmaris longus, and the flexor digitorum superficialis.
2. Articular branches to the elbow joint.
3. Anterior interosseous nerve
4. Palmar cutaneous branch. This arises in the lower part of the forearm and is distributed to
the skin over the lateral part of the palm.

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✓ Anterior Interosseous Nerve
The anterior interosseous nerve arises from the median nerve as it emerges from between the
two heads of the pronator teres. It passes downward on the anterior surface of the
interosseous membrane, between the flexor pollicis longus and the flexor digitorum
profundus. It ends on the anterior surface of the carpus.

Branches
1. Muscular branches to the flexor pollicis longus, the pronator quadratus, and the lateral
half of the flexor digitorum profundus.
2. Articular branches to the wrist and distal radioulnar joints. It also supplies the hand joints.

➢ Ulnar Nerve
The ulnar nerve passes from behind the medial epicondyle of the humerus, crosses the medial
ligament of the elbow joint, and enters the front of the forearm by passing between the two
heads of the flexor carpi ulnaris. It then runs down the forearm between the flexor carpi
ulnaris and the flexor digitorum profundus muscles.
In the distal two thirds of the forearm, the ulnar artery lies on the lateral side of the ulnar
nerve.
At the wrist, the ulnar nerve becomes superficial and lies between the tendons of the flexor
carpi ulnaris and flexor digitorum superficialis muscles.
It enters the palm of the hand by passing in front of the flexor retinaculum and lateral to the
pisiform bone; here, it has the ulnar artery lateral to it.

Branches of ulnar nerve in the forearm

1. Muscular branches to the flexor carpi ulnaris and to the medial half of the flexor
digitorum profundus.
2. Articular branches to the elbow joint.
3. The palmar cutaneous branch is a small branch that arises in the middle of the forearm
and supplies the skin over the hypothenar eminence.
4. The dorsal posterior cutaneous branch is a large branch that arises in the distal third of the
forearm. It passes medially between the tendon of the flexor carpi ulnaris and the ulna
and is distributed on the posterior surface of the hand and fingers.

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 Posterior Compartment of the Forearm

Muscles in the posterior compartment of the forearm occur in two layers (superficial and deep).
All muscles in the posterior compartment of the forearm are innervated by the radial nerve.

➢ The Superficial Layer

The seven muscles in the superficial layer are the Brachioradialis, Extensor Carpi Radialis
Longus, Extensor Carpi Radialis Brevis, Extensor Digitorum, Extensor Digiti Minimi,
Extensor Carpi Ulnaris, and Anconeus (Fig. 10).
All have a common origin from the supraepicondylar ridge and the lateral epicondyle of the
humerus (common extensor origin), and all (except for the brachioradialis and anconeus)
extend as tendons into the hand.

The extensor digitorum muscle is the major extensor of the four fingers (index, middle, ring,
and little fingers). It originates from the lateral epicondyle of the humerus and forms four
tendons, each of which passes into a finger. On the dorsal surface of the hand, adjacent
tendons of the extensor digitorum are interconnected. In the fingers, each tendon inserts, via
a triangular-shaped connective tissue aponeurosis (the extensor hood), into the base of the
dorsal surfaces of the middle and distal phalanges.

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➢ The Deep Layer
The deep layer consists of five muscles: Supinator, Abductor Pollicis Longus, Extensor
Pollicis Brevis, Extensor Pollicis Longus, and Extensor Indicis (Fig.11).
Except for the supinator muscle, all these deep layer muscles originate from the posterior
surfaces of the radius, ulna, and interosseous membrane and pass into the thumb and fingers.
All muscles of the deep layer are innervated by the posterior interosseous nerve, the
continuation of the deep branch of the radial nerve.
o Three of these muscles—the abductor pollicis longus, extensor pollicis brevis, and
extensor pollicis longus — emerge from between the extensor digitorum and the extensor
carpi radialis brevis tendons of the superficial layer and pass into the thumb.
o Two of the three “outcropping” muscles (the abductor pollicis longus and extensor
pollicis brevis) form a distinct muscular bulge in the distal posterolateral surface of the
forearm.

❖ Anatomic Snuffbox
Is a term commonly used to describe a triangular skin depression on the lateral side of the
wrist that is bounded medially by the tendon of the extensor pollicis longus and laterally by
the tendons of the abductor pollicis longus and extensor pollicis brevis. The base of the
triangle is at the wrist and the apex is directed into the thumb (Fig. 12).
The radial artery passes obliquely through the anatomical snuffbox, deep to the extensor
tendons of the thumb and lies adjacent to the scaphoid and trapezium. Terminal parts of the
superficial branch of the radial nerve pass subcutaneously over the snuffbox as does the
origin of the cephalic vein from the dorsal venous arch of the hand.
Its clinical importance lies in the fact that the scaphoid bone is most easily palpated here and
that the pulsations of the radial artery can be felt here.

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❖ Arteries of the Posterior Fascial Compartment of the Forearm (Fig. 13)

✓ The posterior interosseous artery originates in the anterior compartment from the common
interosseous branch of the ulnar artery and passes posteriorly over the proximal margin of the
interosseous membrane and into the posterior compartment of the forearm. It contributes a
branch, the recurrent interosseous artery, to the vascular network around the elbow joint
and then passes between the supinator and abductor pollicis longus muscles to supply the
superficial extensors. After receiving the terminal end of the anterior interosseous artery, the
posterior interosseous artery terminates by joining the dorsal carpal arch of the wrist.
✓ The anterior interosseous artery, a branch of the common interosseous branch of the ulnar
artery, is situated in the anterior compartment of the forearm on the interosseous membrane.
It has numerous perforating branches, which pass directly through the interosseous
membrane to supply deep muscles of the posterior compartment. The terminal end of the
anterior interosseous artery passes posteriorly through an aperture in the interosseous
membrane in distal regions of the forearm to join the posterior interosseous artery.
✓ The radial artery has muscular branches, which contribute to the supply of the extensor
muscles on the radial side of the forearm.

❖ Nerve of the Posterior Fascial Compartment of the Forearm (Fig. 13)

The nerve of the posterior compartment of the forearm is the radial nerve.
Most of the muscles are innervated by the deep branch, which originates from the radial
nerve in the lateral wall of the cubital fossa deep to the brachioradialis muscle and becomes
the posterior interosseous nerve after emerging from between the superficial and deep layers
of the supinator muscle in the posterior compartment of the forearm.
In the lateral wall of the cubital fossa, and before dividing into superficial and deep branches
the radial nerve innervates the brachioradialis and extensor carpi radialis longus muscles.
The deep branch innervates the extensor carpi radialis brevis, then passes between the two
layers of the supinator muscle and follows the plane of separation between the two layers
dorsally and laterally around the proximal shaft of the radius to the posterior aspect of the
forearm. It supplies the supinator muscle and then emerges, as the posterior interosseous
nerve, from the muscle to lie between the superficial and deep layers of muscles.
The posterior interosseous nerve supplies the remaining muscles in the posterior
compartment and terminates as articular branches, which pass deep to the extensor pollicis
longus muscle to reach the wrist.

Clinical applications (read in your textbook / Gray’s Anatomy for Students -4th Edition)
# Fractures of the radius and ulna p.764 # Transection of the radial or ulnar artery p.773
References:
Gray’s Anatomy for Students - 4th Edition
Snell Clinical Anatomy by Regions - 9th Edition
Grant’s Atlas of Anatomy - 14th Edition
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