FOREARM CLINICAL NOTE

Dr Sharew Delelegn (OSR)

Adama Hospital Medical college
August 2023
 Introduction ✔️Fascial layers define the boundaries of
these compartments within the forearm.
✔️The forearm is the section of the upper The deep fascia of the forearm encircles
limb from the elbow to the wrist,whose the musculature related to the ulna and
bony structure is formed by the radius radius. Dividing the compartments are
(laterally) and ulna (medially). the intermuscular septum, which
originates from the anterior aspect of the
radius, and is continuous with the deep
fascia of the forearm, and the
interosseous membrane, which forms
between the radius and ulna.

The muscles of the forearm fall into two

categories: intrinsic and extrinsic muscles.
Two muscular compartments -an The intrinsic muscles function to move
anterior (flexor) and posterior (extensor) the forearm by pronating and supinating
compartment - contain together twenty the radius and ulna. The extrinsic muscles
(20) muscles that act on the elbow and flex and extend the digits of the hand. One
wrist joints, as well as carpometacarpal, muscle, the brachioradialis, traverses the
metacarpophalangeal, and elbow joint,running from the arm to the
interphalangeal joints of the hand. Thus, wrist, helping to flex the elbow.
the forearm muscles are essential to the
fine motor actions of the upper limb,
allowing for complex movements of the
arm, wrist, and fingers.

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Embryology where it wraps posteriorly before diving
into the hand.
The skeletal muscles of the limbs are
formed from myoblasts that migrate to Similarly, the ulnar artery gives off two
the developing bones after recurrent branches, the anterior and
epitheliomesenchymal transformation.
posterior, as it passes the elbow. These
During this transformation, the somatic
mesoderm of the ventral somite responds two turn upward and create anastomoses
to molecular signals causing migration to with the inferior and superior collateral
the developing limb bud. Once the cells arteries that branch off the deep brachial
have moved to their final location, the artery. The anterior ulnar recurrent
notochord and neural tube release
artery provides blood to the pronator
peptides that induce further migration
and growth. teres and brachialis, while the posterior

Blood Supply and Lymphatics ulnar recurrent artery provides blood

supply to the proximal portions of the
As the brachial artery runs down flexor muscles, bones, and elbow joint.
the arm and passes through the elbow, it After giving off the recurrent branches,
divides into two terminal branches: the the ulnar artery gives rise to the common
radial artery and the ulnar artery. These interosseous branch, which will continue
two arteries provide the blood supply for to divide into the anterior and posterior
the entire forearm and hand. interosseous arteries. The names of these
The radial artery gives off the recurrent arteries denote which side of the
radial branch just distal to the radial interosseous membrane they run on. The
head and traverses back up to the arm to anterior interosseous branch supplies
form an anastomosis with the radial blood to the muscles of the flexor
collateral of the deep brachial artery. The compartment. As it travels down the
recurrent radial branch provides blood forearm, it will eventually pierce the
to the supinator and the brachioradialis interosseous membrane and anastomose
muscle. The radial artery then continues with the posterior interosseous artery,
down through the forearm to the wrist, which is the blood supply for the
extensor compartment of the forearm.

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The venous system for the forearm flexor pollicis longus, part of the flexor
comprises superficial and deep veins. digitorum profundus, and gives off
The deep veins compose a plexus that multiple muscular branches that go
run with the arteries described above. directly to the muscles of the flexor
compartment. The ulnar nerve does
The major superficial veins
not have any terminal branches until
include the basilic vein (running on the
it reaches the hand, but it does give off
medial side of the forearm), the cephalic
muscular branches as it goes down the
vein (running on the lateral side of the
forearm that will supply the flexor carpi
forearm), and the median vein (running
ulnaris and the medial side of the flexor
up the forearm to the median antecubital
digitorum profundus. The radial nerve
vein and draining the hand).
gives off the posterior interosseous
Nerves nerve, which supplies all of the muscles
in the posterior compartment except
The three main nerves of the anconeus, brachioradialis, and extensor
forearm are the median, ulnar, and radial carpi radialis longus.
nerves. There are also three nerves that
innervate the skin (medial, lateral, and
posterior cutaneous nerves). All of these Muscles
nerves branch from the brachial plexus in
the axillary region of the arm and There are twenty muscles of the
traverse down the upper extremity to the forearm, divided between the anterior
hand. The median and ulnar nerve (flexor) and posterior (extensor)
provide the innervation for the muscles compartments; each compartment is
of the flexor compartment, while the further divided into superficial and deep
radial nerve provides innervation for the compartments.
extensor compartment. The superficial part of the flexor surface
The median nerve gives off one main of the forearm contains five muscles:
branch known as the anterior ✔️Pronator teres
interosseous nerve. It innervates the ✔️Flexor carpi radialis longus
✔️Palmaris longus
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 ✔️Flexor carpi ulnaris The deep part of the flexor surface of the
✔️Flexor digitorum superficialis
forearm contains three muscles:
All of these muscles originate primarily ✔️Pronator quadratus
from the medial epicondyle of the ✔️Flexor digitorum profundus
humerus, also known as the common ✔️Flexor pollicis longus

flexor origin. The final attachment site Flexor digitorum profundus originates
for the pronator teres is the middle on the proximal three-fourths of the ulna
portion of the radius, forming the medial and from the interosseous membrane. Its
border of the cubital fossa. The flexor tendons pass through the carpal tunnel
carpi radialis and flexor carpi ulnaris to insert into the bases of their respective
insert on the bases of the second, third, distal phalanges, passing between the
and fifth metacarpals, respectively.The divided distal superficial flexor tendons.
flexor carpi ulnaris achieves its distal The flexor pollicis longus originates
insertion at the fifth metacarpal by from the surface of the anterior radius
inserting onto the pisiform bone and the above the origin of the pronator
neighboring pisohamate and quadratus, and its tendon also passes
pisometacarpal ligaments. The flexor through the carpal tunnel to insert into
digitorum superficialis crosses the wrist the base of the distal phalanx of the
through the carpal tunnel and inserts at thumb. The pronator quadratus
the proximal interphalangeal joint at the originates on the distal anteromedial
base of the middle phalanx of digits two ulna and inserts into the distal
through five. The tendon of each digit anterolateral radius. It allows for
splits into two just before insertion into pronation of the forearm.
the anteromedial and anteromedial The superficial part of the extensor
middle phalanx, allowing the tendon of compartment of the forearm contains
flexor digitorum profundus to pass seven muscles:
through and insert further distally.
✔️Brachioradialis
✔️Extensor carpi radialis brevis

✔️Extensor carpi radialis longus

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 ✔️Extensor carpi ulnaris with the extensor digitorum and inserts
✔️Extensor digitorum into the extensor hood of the fifth
metacarpal. Finally, the anconeus is a
✔️Extensor digiti minimi
small muscle arising from the common
✔️Anconeus
extensor origin and inserting onto the
Brachioradialis and extensor carpi lateral olecranon and upper ulna.
radialis longus arises from the lateral
The deep part of the extensor
supracondylar ridge of the humerus. The
compartment of the forearm contains
other muscles of the superficial extensor
five muscles:
compartment arise from the lateral
epicondyle of the humerus, otherwise ✔️Abductor pollicis longus

known as the common extensor origin. ✔️Extensor pollicis longus

Brachioradialis inserts distally to the ✔️Extensor pollicis brevis
flexor side of the wrist at the base of the
✔️Extensor indicis
radial styloid. The extensor carpi radialis
longus, radialis brevis, and ulnaris attach ✔️Supinator

to the proximal portion of the second, Three of the muscles originate from the
third, and fifth metacarpals, respectively. ulna: the abductor pollicis longus,
The extensor carpi ulnaris The tendons extensor pollicis longus, and extensor
of the extensor digitorum run under the indicis. These three muscles extend into
extensor retinaculum and divide to the dorsum of the hand and attach to the
attach to the extensor hoods of the digits. The abductor pollicis longus
middle and distal phalanx of each of the connects at the base of the first
digits two through five. It does this by metacarpal and to the trapezium of the
splitting into three slips. The middle slip wrist. The extensor pollicis longus runs
attaches to the base of the middle along the forearm to the wrist, where it
phalanx of each digit, and the collateral makes a sharp turn at Lister’s tubercle
slips converge distally and insert at the and finally attaches to the distal phalanx
base of the distal phalanx of each digit. of the thumb. Extensor indicis runs with
The extensor digiti minimi runs along the extensor digitorum tendon and joins

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the second digit at the extensor hood. connection, which forms in the forearm
Extensor pollicis brevis and the when the median nerve sends a branch to
supinator originate from the radius. join with the ulnar nerve as it passes deep
Extensor pollicis brevis runs with the to the flexor digitorum superficialis.
abductor in the forearm and connects to This occurs in approximately 17% of
the base of the proximal phalanx of the the population and leads to some median
first digit. The supinator is unique nerve innervations in the intrinsic
because it starts on the lateral epicondyle muscles of the hand.
of the humerus along with the radius
before wrapping around the back of the
arm to connect to the radius at the same Surgical Considerations
location at pronator teres. This muscle
Compartment syndrome can be a limb-
allows for the supination of the forearm.
threatening emergency. This syndrome
Physiologic Variants occurs when swelling of the area
compresses the vessels and nerves in the
There are multiple physiological variants
region. The most common cause is
of these muscles. Many of them are a
fractures of the bones of the forearm.
function of where the muscles originate
Signs and symptoms of this condition
or insert. Some variations include the
are pain out of proportion to exam
muscles not being present, which is
findings, pallor, paresthesia’s,
especially true for the palmaris longus,
pulselessness, and paralysis. The
considered a vestigial structure as
examiner should evaluate compartment
approximately 14% of the population
pressures if compartment syndrome is on
has a unilateral or bilateral absence of
the differential. A pressure between 30
this muscle.
to 45 mmHg indicates compartment
As with any nerve, artery, or vein, the syndrome. If the patient has
path it takes and its specific supply is unequivocally positive findings on
based on the growth pattern of the physical exam, surgical management
individual. One of the main variations in before confirmation with compartment
the nerves is the Martin-Gruber pressures may be an option. The
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procedure of choice to relieve it can be challenging to differentiate
compartment syndrome is a fasciotomy, between a strain of the muscles/tendons
a surgical procedure where the skin and and a scaphoid fracture. Even if there is
fascia are cut to open all compartments no evidence of a scaphoid fracture on
of the forearm to release the tension radiographs, these patients should be put
created by the swelling. into a thumb spica splint and followed
up in two weeks for repeat X-rays.
The space of Parona lies between the
long flexor tendons and the deep The proximal-most part of the supinator
pronator quadratus, limited proximally muscle is tendinous in appearance and
by the oblique origin of the former termed the arcade of Frohse. It admits
muscle. This space is continuous with the deep branch of the radial nerve to
the distal synovial sheaths of the flexor pass beneath it on its way to supply
tendons and can therefore become a muscles in the extensor compartment
conduit for extending infection from the further distally. It has been posited that
hand up the forearm. This space can be this is the likely site of nerve
accessed surgically for drainage via radial compression of the deep branch of the
and ulnar incisions. radial nerve, causing a variety of clinical
syndromes.
Clinical Significance
During a neurologic exam, the tendon of
the brachioradialis is used to test C6
deep tendon reflex.

The anatomical snuffbox, which has as

its boundaries the tendons of the
extensor pollicis longus, the extensor
pollicis brevis, and the abductor pollicis,
is also a point of significance. If a patient
falls on their outstretched hand and has
tenderness over the anatomical snuffbox,

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