THE FOREARM
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OBJECTIVES
At the end of this lecture students should be
able to:
Describe the muscles, vessels and nerves in
the anterior and posterior compartment of
the forearm
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INTRODUCTION
The forearm extends from elbow to wrist.
It posses two bones radius laterally and ulna
medially.
The two bones are connected together by
interosseous membrane.
This membrane allows movement of pronation
and supination while the two bones are
connected together.
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Also it gives origin for the deep muscles.
FASCIAL COMPARTMENTS OF THE FOREARM
The forearm is enclosed in sheath of deep fascia
of the forearm (antebrachial fascia).
This deep fascia, together with interosseous
membrane and fibrous intermuscular septa
divide the forearm into several compartments,
each having its own muscles, nerves, and blood
supply.
Classically, the forearm is divided into the two
compartments:
(a) anterior compartment and
(b) posterior compartment . 4
FASCIAL COMPARTMENT OF THE
FOREARM
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FLEXOR RETINACULUM
The flexor retinaculum is a strong fibrous band formed by
the thickening of deep fascia in front of the carpus
(anatomical wrist).
It is rectangular in shape and it presents two surfaces and
four borders.
Medially it is attached to the pisiform and the hook of the
hamate.
Laterally it is attached to the tubercle of scaphoid and
crest of the trapezium.
With the carpus, it forms an osseofibrous tunnel called
carpal tunnel for the passage of flexor tendons of the 6
digits.
FLEXOR RETINACULUM
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ANTERIOR COMPARTMENT OF THE
FOREARM
Muscles: Eight muscles, arranged in two
groups.
Arteries: Two arteries, radial and ulnar.
Nerves: Three nerves, median, ulnar, and
radial.
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MUSCLES OF THE ANTERIOR
COMPARTMENT OF FOREARM
Superficial Layer (4)
i. Pronator Teres
ii. Flexor Carpi Radialis
iii. Flexor Carpi Ulnaris
iv. Palmaris Longus
Intermediate Layer (1)
i. Flexor digitorum Superficialis
Deep Layer (3)
i. Flexor Digitorum profundus
ii. Flexor Pollicis Longus 9
iii. Pronator Quadratus
PRONATOR TERES
Origin: Medial distal humerus (condyle)
& medial aspect of coronoid process
of ulna
Insertion: Lateral aspect of radius;
middle
1/3
Action: Elbow pronation & flexion
Innervation: Median Nerve
Note:
a) It is the most superficial of the
muscles arising from the medial
side of the humerus
b) It forms the medial border of the 10
cubital fossa
FLEXOR CARPI RADIALIS
Origin: Medial epicondyle
(Common flexor origin)
Insertion: Palmar aspect of base
of second metacarpal
Actions:
Flexion of the wrist: in
conjunction with the Flexor
Carpi Ulnaris.
Abduction of the Wrist: in
conjunction with Extensor Carpi
Radialis.
Simultaneously flexes and
abducts the wrist when acting
alone. 11
Innervation: Median Nerve
FLEXOR CARPI ULNARIS
Origin: Humeral head: Medial epicondyle
(Common flexor origin) Ulna head: Olecranium
Insertion: Pisiform, hook of hamate and base of
5th metacarpal
Actions:
Flexion of the wrist in conjunction with the
Flexor Carpi Radialis
Adduction of the Wrist in conjunction with
Extensor Carpi Ulnaris
Simultaneously flexes and adducts the wrist
when acting alone
Innervation: Ulna nerve
Note:
The most medial of the superficial flexor
muscles.
The ulnar nerve enters the forearm by passing
between the humeral and the ulnar heads of its
proximal attachment.
It is the only muscle of the anterior 12
compartment that is FULLY innervated by the
ulna nerve
PALMARIS LONGUS
Origin: Medial epicondyle
(Common flexor origin)
Insertion: Palmar aponeurosis
and part of the flexor
retinaculum
Action: Flexion of the wrist
Innervation: Median nerve
Note:
It is absent in about 14-15%
of the population
At the wrist, it is medial to the 13
Median nerve
FLEXOR DIGITORUM SUPERFICIALIS
Origin: Humero-ulna head: medial
epicondyle and adjacent coronoid process;
Radial head: from oblique line of radius
Insertion: Split to four tendons which are
attached to the base of the 2nd to 5th
middle phalanges
Action: Flexes metacarpophalangeal and
proximal interphalangeal joints
Innervation: Median nerve
Note:
The ulna and the median nerves pass
between the two heads to lie deep to
the muscle
In the palm, the tendons lies in the 14
carpal tunnel
FLEXOR DIGITORUM PROFUNDUS
Origin: Anterior and medial surfaces of
ulna and anterior medial half of
interosseous membrane
Insertion: Base of the 2nd to 5th distal
phalanges
Action: Flexes metacarpophalangeal,
distal and proximal interphalangeal
joints
Innervation: Lateral half by median
nerve (anterior interosseous nerve);
medial half by ulnar nerve
Note:
In the palm, the lumbricals muscles
originate from the sides of the 15
tendons of flexor digitorum profundus.
FLEXOR POLLICIS LONGUS
Origin: Anterior surface of
radius and radial half of inter-
osseous membrane
Insertion: Palmar surface of
base of distal phalanx of
thumb
Action: Flexes
interphalangeal joint of the
thumb; can also flex
metacarpo-phalangeal joint of
the thumb
Innervation: Median nerve 16
(anterior interosseous nerve)
PRONATOR QUADRATUS
Origin: Linear ridge on
distal anterior surface of
ulna
Insertion: Distal anterior
surface of radius
Action: Pronation
Innervation: Median
nerve (anterior
interosseous nerve)
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VESSELS OF THE ANTERIOR
COMPARTMENT OF FOREARM
Ulnar artery
Anterior
interosseous
artery
Radial artery
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ULNA ARTERY
Begins from the brachial artery near the neck of the radius and
passes deep to pronator teres, flexor carpi radialis, palmaris longus
and flexor digitorum superficialis
It runs downwards and reaches the medial side of the forearm
midway between the elbow and wrist.
In the upper one-third of forearm, the course is oblique (i.e.,
downwards and medially) but in lower two-third it is vertical.
The ulnar head of pronator teres separates it from the median
nerve
It enters the palm by passing in front of flexor retinaculum lateral to
the ulnar nerve and the pisiform bone
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Ends in the hand by anastomosis with the superficial palmar branch
of the radial artery, completing the superficial palmar arch.
ULNAR ARTERY
Branches :
Anterior ulnar recurrent artery
Posterior ulnar recurrent artery
Common interosseous artery, which divides
into anterior interosseous artery and
posterior interosseous artery (which gives
rise to the posterior interosseous recurrent
artery) .
Muscular branches
Cutaneous branches along the septum
between flexor carpi ulnaris and flexor 20
digitorum superficialis.
COURSE AND DISTRIBUTION OF ULNAR ARTERY IN THE FOREARM
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ANTERIOR INTEROSSEOUS ARTERY
Begins at the proximal border of the interosseous
membrane.
Descends on the anterior aspect of the interosseous
membrane with the anterior interosseous branch of the
median nerve, between the contiguous sides of flexor
digitorum profundus and flexor pollicis longus.
Pierces the interosseous membrane at the upper border of
pronator quadratus to enter the posterior compartment of
the forearm.
Distally it anastomoses with the posterior interosseous
artery, travels underneath the extensor retinaculum to 22
reach the dorsal aspect of the wrist to join the dorsal
carpal arch.
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ANTERIOR INTEROSSEOUS ARTERY
Branches of the anterior interosseous artery
are :
Median artery
Muscular branches for FDP, FPL, pronator
quadratus, and deep extensor muscles
Small cutaneous branches for the lower
lateral border of the forearm
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RADIAL ARTERY
Begins from the brachial artery near the neck of
the radius and passes deep to brachioradialis
At the wrist it passes in the anatomical snuff box
Ends in the hand by anastomosis with the deep
branch of the ulnar artery, completing the deep
palmar arch
Branches :
Radial recurrent artery (anastomoses with the
radial collateral branch of the profunda brachii)
Muscular branches
Cutaneous branches
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RADIAL ARTERY
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APPLIED ANATOMY OF RADIAL
ARTERY
Radial pulse
Volkmann’s ischemic contracture
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MEDIAN NERVE
Enters the forearm between the two heads of Pronator teres
Passes down along posterior surface of flexor digitorum
superficialis (FDS) in between superficial and deep flexors
Descends vertically along midline of forearm 5 cm above flexor
retinaculum
Emerges from medial border of FDS and lies between and deep to
tendon of flexor carpi radialis and palmaris longus
Enters the palm deep to flexor retinaculum
Branches
Muscular branches
Articular branch to the elbow joint
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Anterior Interosseous nerve
Palmar cutaneous branch to skin over lateral part of palm
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APPLIED ANATOMY OF MEDIAN NERVE
Median nerve palsy
Carpal Tunnel syndrome
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BRANCHES OF THE MEDIAN NERVE IN THE FOREARM
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MEDIAN NERVE DISTRIBUTION
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ANTERIOR INTEROSSEOUS NERVE
The anterior interosseous nerve arise from
the median nerve
It passes downward on the anterior surface
of the interosseous membrane, between the
flexor pollicis longus and the flexor digitorum
profundus
Branches
Muscular branches
Articular branches to the wrist and distal
radioulnar joints
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34
ULNA NERVE
Enters the front of the forearm by passing through the gap between
the two heads of flexor carpi ulnaris (cubital tunnel).
It then runs downward on the medial side of the forearm between
the FCU and FDP.
It enters the palm of the hand by passing in front of the flexor
retinaculum lateral to the pisiform bone.
In the distal two-third of the forearm, the ulnar artery is lateral to the
ulnar nerve.
Branches
Muscular branches
Articular branch to the elbow joint.
Palmar cutaneous branch supplies the skin over the hypothenar
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eminence.
Dorsal cutaneous branch
ULNA NERVE DISTRIBUTION
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RADIAL NERVE
It enters the cubital fossa from behind the arm by descending between
the brachioradialis and brachialis muscles.
In front of lateral epicondyle, it divides into two terminal branches; deep
and superficial.
The deep branch of radial nerve winds around the neck of radius
between the two heads of supinator and enters the posterior
compartment of the forearm as posterior interosseous nerve.
The superficial branch of the radial nerve (superficial radial
nerve) is the main continuation of the radial nerve.
It runs downwards under the cover of brachioradialis on the lateral side of
the radial artery.
About 7.5 cm above the wrist, the nerve leaves the artery, passes
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underneath the tendon of brachioradialis to reach the posterior aspect of
the wrist and divides into terminal branches (four or five nerves).
RADIAL NERVE DISTRIBUTION
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POSTERIOR COMPARTMENT OF THE FOREARM
Muscles: twelve muscles, arranged in two
groups.
Arteries: posterior interosseous artery
Nerves: posterior interosseous nerve.
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MUSCLES OF THE POSTERIOR COMPARTMENT OF
FOREARM
Superficial layer Deep layer
Brachioradialis Supinator
Extensor carpi radialis longus Abductor pollicis
longus
Extensor carpi radialis brevis Extensor pollicis
longus
Extensor digitorum Extensor pollicis
brevis
Extensor digiti minimi Extensor indicis
Extensor carpi ulnaris
Anconeus 40
BRACHIORADIALIS
Origin: lateral
supraepicondylar ridge of
humerus
Insertion: Lateral surface of
distal end of radius
Action: Elbow flexion
especially with the arm in
mid- pronation
Innervation: Radial nerve
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EXTENSOR CARPI RADIALIS LONGUS
Origin: lateral supraepicondylar
ridge of humerus
Insertion: Dorsal surface of
base of metacarpal II
Action: Extends and abducts
the wrist
Innervation: Radial nerve
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EXTENSOR CARPI RADIALIS BREVIS
Origin: Lateral
supraepicondylar ridge of
humerus
Insertion: Dorsal surface of
base of metacarpal II & III
Action: Extends and abducts
the wrist
Innervation: Radial nerve
(Deep branch)
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EXTENSOR DIGITORUM
Origin: Lateral epicondyle
Insertion: Four tendons, which
insert via 'extensor hoods' into
the dorsal aspects of the bases
of the middle and distal
phalanges of the index, middle,
ring, and little fingers
Action: Extends the index,
middle, ring, and little fingers
and the wrist
Innervation: Radial nerve
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(Posterior Interosseus branch)
EXTENSOR DIGITI MINIMI
Origin: Lateral epicondyle of
humerus
Insertion: Dorsal hood of the
little finger
Action: Extends the little finger
Innervation: Posterior
Interosseus nerve
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EXTENSOR CARPI ULNARIS
Origin: lateral epicondyle of
humerus
Insertion: Tubercle on the base
of the medial side of metacarpal
V
Action: Extends and adducts the
wrist
Innervation: Posterior
Interosseus
nerve
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ANCONEUS
Origin: Lateral condyle of
humerus
Insertion: Olecranon process
Action: Elbow extension
Innervation: Radial nerve
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SUPINATOR
Origin: Superficial Head from
Lateral epicondyle of Humerus;
Deep head from supinator crest
of ulna
Insertion: Lateral proximal
radius
Action: Supination
Innervation: Radial nerve
NOTE: The deep branch of radial
nerve enters the posterior
compartment by passing through
the space between the two 48
heads
ABDUCTOR POLLICIS LONGUS
Origin: Posterior surfaces of ulna
and radius distal to the supinator
and Anconeus
Insertion: Lateral side of base of
first metacarpal
Action: Abducts carpometacarpal
joint of thumb; accessory extensor
of the thumb
Innervation: Posterior
interosseous nerve
Note: tendon contributes to the
lateral border of the anatomical 49
snuffbox at the wrist.
EXTENSOR POLLICIS BREVIS
Origin: Posterior surfaces of radius
distal to the Abductor Pollicis
Longus
Insertion: Dorsal surface of base of
proximal phalanx of the thumb
Action: Extends the
metacarpophalangeal joint of the
thumb; can also extend the
carpometacarpal joint of the thumb
Innervation: Posterior interosseous
nerve
Note: tendon contributes to the
lateral border of the anatomical 50
snuffbox at the wrist.
EXTENSOR POLLICIS LONGUS
Origin: Posterior surfaces of ulna
distal to the Abductor Pollicis
Longus
Insertion: Dorsal surface of base
of distal phalanx of the thumb
Action: Extends all joints of the
thumb
Innervation: Posterior
interosseous nerve
Note: tendon forms the medial
border of the anatomical snuffbox
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at the wrist.
EXTENSOR INDICIS
Origin: Posterior surfaces of ulna
distal to the Extensor Pollicis
Longus
Insertion: Extensor hood of
index finger
Action: Extends the index finger
Innervation: Posterior
interosseous nerve
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POSTERIOR INTEROSSEOUS ARTERY
Begins at the proximal border of the interosseous
membrane and passes dorsally between supinator and
abductor pollicis longus
Descends deep in the groove between extensor carpi
ulnaris and extensor digiti minimi
Distally it anastomoses with the terminal part of the
anterior interosseous artery and the dorsal carpal arch.
Branches
Multiple muscular branches
Fascio-cutaneous branches in the intermuscular septum
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POSTERIOR INTEROSSEOUS NERVE
It begins in the cubital fossa as one of the two terminal
branches of radial nerve at the level of lateral
epicondyle of humerus.
It leaves the cubital fossa by winding around the lateral
side of the neck of radius in the substance of supinator.
After emerging from supinator, it runs in the fascial
plane between superficial and deep extensor muscles.
At the lower border of extensor pollicis brevis, it passes
deep to the extensor pollicis longus to lie on the
posterior surface of interosseous nerve, on which it
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runs downwards up to the wrist where it ends into a
pseudoganglion.
POSTERIOR INTEROSSEOUS NERVE
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VEINS OF THE FOREARM
Cephalic vein
Arises from the lateral side of the dorsal venous rete of
hand
Ascends on radial side of the forearm to the elbow and
then in the lateral side of biceps brachii furrow, continues
up the arm in the deltopectoral groove and then to the
infraclavicular fossa, where it pierces clavipectoral fascia
to drain into axillary vein
Basilic vein
Arises from the medial side of the dorsal venous rete of
hand
Ascends on the ulnar side of forearm to the elbow and
then in the medial bicipital brachii furrow to middle of the
arm where it pierces the deep fascia and joins the
brachial vein or axillary vein 57
VEINS OF THE FOREARM
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THANK
YOU
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