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AJR 2000; 174:151-159
© American Roentgen Ray Society


Pictorial Essay

The Forearm

Anatomy of Muscle Compartments and Nerves

Carol A. Boles1, Srilatha Kannam2 and Anne B. Cardwell2

1 Department of Radiology, Wake Forest University School of Medicine, Medical Center Blvd., Winston-Salem, NC 27157-1088.
2 Rush-Presbyterian—St. Luke's Medical Center, Department of Radiology and Nuclear Medicine, 1653 W. Congress Pkwy., Chicago, IL 60612.

Received January 28, 1999; accepted after revision June 11, 1999.

 
Address correspondence to C. A. Boles.


Introduction
Top
Introduction
Compartments of the Forearm
Courses of the Nerves
Conclusion
References
 
Knowledge of the compartmental anatomy of the forearm can aid the radiologist both in providing useful information to the surgeon and in clarifying ambiguous clinical findings. The anatomy of the forearm is depicted in several excellent atlases; however, its compartmental anatomy has not been widely reviewed in the radiology literature. Division of the forearm into the mobile wad, volar, and dorsal compartments provides a convenient and practical way to review its important muscles, nerves, and vessels.

The radial, median, and ulnar nerves and their branches traverse the forearm compartments. Compression or entrapment of these nerves may be caused by adjacent masses but may also occur at specific transition zones along the nerve path. We review the compartmental anatomy of the forearm and describe the courses of the radial, median, and ulnar nerves as they traverse the compartments.


Compartments of the Forearm
Top
Introduction
Compartments of the Forearm
Courses of the Nerves
Conclusion
References
 
The antebrachial fascia is a continuation of the brachial fascia. The antebrachial fascia surrounds the musculature of the forearm and divides it into mobile wad, volar, and dorsal compartments. Fascia surrounds the individual muscles and provides strong septal attachments to the radius, ulna, and interosseous membrane. If the fascia is incomplete, some communication between compartments may be permitted [1].

Mobile Wad Compartment (Radial Group Forearm Muscles)
Muscles.—The mobile wad compartment is composed of two wrist extensors and a forearm flexor. The extensor carpi radialis brevis and extensor carpi radialis longus extend and abduct the hand, and the brachioradialis flexes the forearm (Fig. 1A, Fig. 1B, Fig. 1C, Fig. 1D, Fig. 1E, Fig. 1F).




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Fig. 1. —Forearm compartments. ECRB = extensor carpi radialis brevis, ECRL = extensor carpi radialis longus, BR = brachioradialis, FCU = flexor carpi ulnaris, PL = palmaris longus, FCR = flexor carpi radialis, FDS = flexor digitorum superficialis, ED = extensor digitorum, EDM = extensor digiti minimi, ECU = extensor carpi ulnaris, FDP = flexor digitorum profundus, FPL = flexor pollicis longus, PT = pronator teres, S = supinator, APL = abductor pollicis longus, EPB = extensor pollicis brevis, EPL = extensor pollicis longus, EI = extensor indices, R = radius, U = ulna.

A, Drawing of proximal forearm. (See key.)

 


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Fig. 1. —Forearm compartments. ECRB = extensor carpi radialis brevis, ECRL = extensor carpi radialis longus, BR = brachioradialis, FCU = flexor carpi ulnaris, PL = palmaris longus, FCR = flexor carpi radialis, FDS = flexor digitorum superficialis, ED = extensor digitorum, EDM = extensor digiti minimi, ECU = extensor carpi ulnaris, FDP = flexor digitorum profundus, FPL = flexor pollicis longus, PT = pronator teres, S = supinator, APL = abductor pollicis longus, EPB = extensor pollicis brevis, EPL = extensor pollicis longus, EI = extensor indices, R = radius, U = ulna.

B, Corresponding MR image of healthy 32-year-old woman shows proximal forearm distal to radial tuberosity. Anterior interosseous nerve has already branched from median nerve. Radial nerve has divided. Deep radial nerve is within supinator muscle and not visible. Anconeus muscle is proximal to this level.

 



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Fig. 1. —Forearm compartments. ECRB = extensor carpi radialis brevis, ECRL = extensor carpi radialis longus, BR = brachioradialis, FCU = flexor carpi ulnaris, PL = palmaris longus, FCR = flexor carpi radialis, FDS = flexor digitorum superficialis, ED = extensor digitorum, EDM = extensor digiti minimi, ECU = extensor carpi ulnaris, FDP = flexor digitorum profundus, FPL = flexor pollicis longus, PT = pronator teres, S = supinator, APL = abductor pollicis longus, EPB = extensor pollicis brevis, EPL = extensor pollicis longus, EI = extensor indices, R = radius, U = ulna.

C, Drawing of mid forearm compartments. (See key.)

 


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Fig. 1. —Forearm compartments. ECRB = extensor carpi radialis brevis, ECRL = extensor carpi radialis longus, BR = brachioradialis, FCU = flexor carpi ulnaris, PL = palmaris longus, FCR = flexor carpi radialis, FDS = flexor digitorum superficialis, ED = extensor digitorum, EDM = extensor digiti minimi, ECU = extensor carpi ulnaris, FDP = flexor digitorum profundus, FPL = flexor pollicis longus, PT = pronator teres, S = supinator, APL = abductor pollicis longus, EPB = extensor pollicis brevis, EPL = extensor pollicis longus, EI = extensor indices, R = radius, U = ulna.

D, Corresponding MR image of healthy 32-year old woman.

 



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Fig. 1. (continued)—Forearm compartments. FCR = flexor carpi radialis, PL = palmaris longus, FDS = flexor digitorum superficialis, FCU = flexor carpi ulnaris, FPL = flexor pollicis longus, FDP = flexor digitorum profundus, PQ = pronator quadratus, R = radius, U = ulna, BR = brachioradialis, APL = abductor pollicis longus, ECRL = extensor carpi radialis longus, ECRB = extensor carpi radialis brevis, EPB = extensor pollicis brevis, EPL = extensor pollicis longus, EI = extensor indices, ED = extensor digitorum, ECU = extensor carpi ulnaris, EDM = extensor digiti minimi.

E, Drawing of distal forearm at junction of radial diaphysis and metaphysis.

 


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Fig. 1. (continued)—Forearm compartments. FCR = flexor carpi radialis, PL = palmaris longus, FDS = flexor digitorum superficialis, FCU = flexor carpi ulnaris, FPL = flexor pollicis longus, FDP = flexor digitorum profundus, PQ = pronator quadratus, R = radius, U = ulna, BR = brachioradialis, APL = abductor pollicis longus, ECRL = extensor carpi radialis longus, ECRB = extensor carpi radialis brevis, EPB = extensor pollicis brevis, EPL = extensor pollicis longus, EI = extensor indices, ED = extensor digitorum, ECU = extensor carpi ulnaris, EDM = extensor digiti minimi.

F, Corresponding MR image of healthy 32-year-old woman.

 

Neurovascular structures.—No major neurovascular structures are located within this compartment. Proximally, the radial nerve, its two main branches, and the radial artery lie between this compartment and the volar compartment.

Volar Compartment
Muscles.—The volar compartment contains the flexor and pronator muscles. A transverse septum divides the muscles into deep and superficial groups [2]. The deep group consists of the flexor digitorum profundus and the flexor pollicis longus, which flex the phalanges, and the pronator quadratus, which pronates the forearm. An accessory slip of the flexor pollicis longus, Gantzer's muscle, may be present as a large discrete muscle in 45% of individuals [3]. All muscles of the deep compartment originate on the radius or ulna. The superficial group contains the flexor carpi ulnaris, palmaris longus, flexor carpi radialis, and flexor digitorum superficialis, which flex the hand and wrist, and the pronator teres, which pronates the forearm and aids in elbow flexion (Fig. 1A, Fig. 1B, Fig. 1C, Fig. 1D, Fig. 1E, Fig. 1F).

Neurovascular structures.—Several nerves are located within or traverse the volar compartment: the median nerve and its branch, the anterior interosseous nerve, the ulnar nerve, and the deep branch of the radial nerve. The major vessels of the forearm are also within this compartment.

Dorsal Compartment
Muscles.—The dorsal compartment, containing the wrist and finger extensors, is also divided into deep and superficial muscle groups. The deep compartment contains the supinator, which supinates the forearm as it rotates the radius; abductor pollicis longus, which abducts and extends the thumb; and the extensor pollicis brevis, extensor pollicis longus, and extensor indices, which act to extend the phalanges. These three extensors originate from a position distal to the supinator. The superficial compartment contains muscles that extend the digits and hand: the extensor digitorum, extensor digiti minimi, and extensor carpi ulnaris. The anconeus muscle is located in this compartment. Functionally, the anconeus can be considered a part of the long head of the triceps: it supports the elbow during abduction and extension (Fig. 1A, Fig. 1B, Fig. 1C, Fig. 1D, Fig. 1E, Fig. 1F).

Neurovascular structures.—The posterior interosseous nerve, which is a branch of the radial nerve, and the accompanying posterior interosseous artery travel superficially to the extensor pollicis longus until they terminate in the dorsal aspect of the wrist.


Courses of the Nerves
Top
Introduction
Compartments of the Forearm
Courses of the Nerves
Conclusion
References
 
Radial Nerve
The radial nerve descends along the spiral groove of the humerus and into the forearm via the radial tunnel (the space between the brachioradialis and the brachialis). The tunnel is approximately 5 cm long and located 1 cm lateral to the biceps tendon (Figs. 2A and 2B). Deep palpation of the nerve is possible in the tunnel, with resultant discomfort [4]. The radial nerve innervates the anconeus, brachioradialis, and extensor carpi radialis longus forearm muscles. In the radial tunnel, at the level of the radiocapitellar joint, the nerve divides into two branches: the deep (motor) radial nerve and the superficial (sensory) radial nerve. These branches initially lie adjacent to the brachioradialis and extensor carpi radialis longus tendons of the mobile wad compartment (Figs. 2A, 3A, and 3B)



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Fig. 2. —Anatomic drawings of nerve—muscle relationships in forearm from anterior view.

A, Drawing shows course of radial nerve into forearm and division into superficial radial nerve and deep radial nerve (posterior interosseous nerve after passing deep in relation to supinator muscle).

 


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Fig. 2. —Anatomic drawings of nerve—muscle relationships in forearm from anterior view.

B, Drawing shows course of median nerve from arm into forearm and branching off anterior interosseous nerve at level of pronator teres.

 


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Fig. 3. —Serial axial images through forearm in 59-year-old woman with prior tumor resection and radiation therapy. Subsequent muscular atrophy allows excellent visualization of courses of nerves. BR = brachioradialis, B = brachialis, EC = extensor carpi radialis longus, P = pronator teres, h = humeral head of flexor carpi ulnaris, u = ulnar head of flexor carpi ulnaris, S = supinator, FS = flexor digitorum superficialis, FC = flexor carpi ulnaris, F = flexor digitorum profundus.

A, Radial nerve has divided into deep (wavy arrow) and superficial (long thin arrow) branches. Median nerve (white arrow) and brachial artery (short open arrow) are deep in relation to pronator teres. Shaded open arrow is ulnar nerve, and short thin arrow indicates bicipital aponeurosis.

 


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Fig. 3. —Serial axial images through forearm in 59-year-old woman with prior tumor resection and radiation therapy. Subsequent muscular atrophy allows excellent visualization of courses of nerves. BR = brachioradialis, B = brachialis, EC = extensor carpi radialis longus, P = pronator teres, h = humeral head of flexor carpi ulnaris, u = ulnar head of flexor carpi ulnaris, S = supinator, FS = flexor digitorum superficialis, FC = flexor carpi ulnaris, F = flexor digitorum profundus.

B, Deep radial nerve (wavy arrow) courses along extensor carpi radialis as it heads for supinator. Long thin arrow is superficial radial nerve. White arrow is median nerve; shaded open arrow is ulnar nerve.

 

Deep Radial Nerve and Posterior Interosseous Nerve
The deep radial nerve innervates the extensor carpi radialis brevis and the supinator. In approximately 70% of the population, the deep radial nerve then passes into the volar compartment, through the supinator, and into the dorsal compartment (Figs. 3C, 3D, and 4A). In the remaining 30%, the nerve passes via the arcade of Frohse (proximal fibrous border of the supinator) rather than through the belly of the supinator [5] (Fig. 2A). Now known as the posterior interosseous nerve, the deep radial nerve travels with the posterior interosseous artery between the superficial and deep compartments (Figs. 3E and 4B).



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Fig. 3. —Serial axial images through forearm in 59-year-old woman with prior tumor resection and radiation therapy. Subsequent muscular atrophy allows excellent visualization of courses of nerves. BR = brachioradialis, B = brachialis, EC = extensor carpi radialis longus, P = pronator teres, h = humeral head of flexor carpi ulnaris, u = ulnar head of flexor carpi ulnaris, S = supinator, FS = flexor digitorum superficialis, FC = flexor carpi ulnaris, F = flexor digitorum profundus.

C, Deep radial nerve (wavy arrow) is within supinator. Superficial radial nerve (long thin arrow) joins radial artery (asterisk). Median nerve (white arrow) is between two heads of pronator teres. Short open arrow is brachial artery.

 


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Fig. 3. —Serial axial images through forearm in 59-year-old woman with prior tumor resection and radiation therapy. Subsequent muscular atrophy allows excellent visualization of courses of nerves. BR = brachioradialis, B = brachialis, EC = extensor carpi radialis longus, P = pronator teres, h = humeral head of flexor carpi ulnaris, u = ulnar head of flexor carpi ulnaris, S = supinator, FS = flexor digitorum superficialis, FC = flexor carpi ulnaris, F = flexor digitorum profundus.

D, Anterior interosseous nerve (arrowhead) dives toward interosseous membrane. Ulnar nerve (shaded open arrow) is located between flexor carpi ulnaris and flexor digitorum profundus. White arrow is median nerve, long thin arrow is superficial radial nerve, and wavy arrow is deep radial nerve.

 


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Fig. 4.—50-year-old healthy woman. Sagittal MR images through elbow, from radius to ulna, show nerves in proximal forearm. S = supinator.

A, Deep radial nerve (wavy arrow) enters supinator.

 


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Fig. 3. (continued)—Serial axial images through forearm in 59-year-old woman with prior tumor resection and radiation therapy. Subsequent muscular atrophy allows excellent visualization of courses of nerves. BR = brachioradialis, FS = flexor digitorum superficialis, FC = flexor carpi ulnaris, P = pronator teres, S = supinator, F = flexor digitorum profundus, EC = extensor carpi radialis longus.

E, Posterior interosseous nerve (straight thick arrow) has exited supinator. Median nerve (white arrow) heads toward flexor digitorum superficialis. As pronator inserts, ulnar artery (plus sign) joins ulnar nerve (shaded open arrow). Long thin arrow is superficial radial nerve; arrowhead is anterior interosseous nerve.

 

Numerous branches supply the remaining muscles of the superficial and deep dorsal compartments. Near the wrist, the posterior interosseous nerve's residual sensory component dives deep in relation to the extensor pollicis longus, to the interosseous membrane, and terminates in the dorsal aspect of the wrist as a small gangliform enlargement (Fig. 3I).



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Fig. 3. (continued)—Serial axial images through forearm in 59-year-old woman with prior tumor resection and radiation therapy. Subsequent muscular atrophy allows excellent visualization of courses of nerves. FS = flexor digitorum superficialis, FC = flexor carpi ulnaris, A = abductor pollicis longus, EC = extensor carpi radialis longus, PQ = pronator quadratus.

I, Anterior interosseous nerve (arrowhead) is deep in relation to pronator quadratus. Sensory remnant of posterior interosseous nerve (straight thick arrow) is now adjacent to interosseous membrane. White arrow is median nerve. Shaded open arrow is ulnar nerve, and long thin arrow is superficial radial nerve.

 

Superficial Radial Nerve
After branching off the radial nerve, the superficial radial nerve approaches the radial artery and travels with the artery as they pass the insertion of the pronator teres (Fig. 3C). In the distal third of the forearm, the nerve separates from the artery and passes through fascia between the tendons of the brachioradialis and extensor carpi radialis, pierces the antebrachial fascia, and becomes subcutaneous dorsally (Figs. 3F, 3G, 3H, 3I. The superficial radial nerve has no motor function and provides sensory function to the dorsum of the hand, the first web space, and the proximal phalanges of the radial three digits.



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Fig. 3. (continued)—Serial axial images through forearm in 59-year-old woman with prior tumor resection and radiation therapy. Subsequent muscular atrophy allows excellent visualization of courses of nerves. BR = brachioradialis, FS = flexor digitorum superficialis, FC = flexor carpi ulnaris, P = pronator teres, S = supinator, F = flexor digitorum profundus, EC = extensor carpi radialis longus.

F, Superficial radial nerve (long thin arrow) exits between brachioradialis and extensor carpi radialis longus tendons. Posterior interosseous nerve is not visible as discrete structure because its numerous branches innervate dorsal muscles (similar in appearance to filum terminale of spinal cord). Arrowhead is anterior interosseous nerve. White arrow is median nerve; shaded open arrow is ulnar nerve.

 


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Fig. 3. (continued)—Serial axial images through forearm in 59-year-old woman with prior tumor resection and radiation therapy. Subsequent muscular atrophy allows excellent visualization of courses of nerves. BR = brachioradialis, FS = flexor digitorum superficialis, FC = flexor carpi ulnaris, P = pronator teres, S = supinator, F = flexor digitorum profundus, EC = extensor carpi radialis longus.

G, Superficial radial nerve (long thin arrow) exits between brachioradialis and extensor carpi radialis longus tendons. Posterior interosseous nerve is not visible as discrete structure because its numerous branches innervate dorsal muscles (similar in appearance to filum terminale of spinal cord). Arrowhead is anterior interosseous nerve. White arrow is median nerve; shaded open arrow is ulnar nerve.

 


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Fig. 3. (continued)—Serial axial images through forearm in 59-year-old woman with prior tumor resection and radiation therapy. Subsequent muscular atrophy allows excellent visualization of courses of nerves. BR = brachioradialis, FS = flexor digitorum superficialis, FC = flexor carpi ulnaris, P = pronator teres, S = supinator, F = flexor digitorum profundus, EC = extensor carpi radialis longus.

H, Superficial radial nerve (long thin arrow) exits between brachioradialis and extensor carpi radialis longus tendons. Posterior interosseous nerve is not visible as discrete structure because its numerous branches innervate dorsal muscles (similar in appearance to filum terminale of spinal cord). Arrowhead is anterior interosseous nerve. White arrow is median nerve; shaded open arrow is ulnar nerve.

 

Median Nerve
The median nerve and the brachial artery enter the volar compartment in the antecubital fossa. The median nerve travels under the bicipital aponeurosis, or lacertus fibrosis, a strong membranous band that reaches inferiorly across the antecubital fossa to join the deep fascia covering the flexor muscles (Figs. 2B and 4D). The nerve passes between the deep and superficial heads of the pronator teres and descends distally (Figs. 2B, 2C, and 3A, 3B, 3C). It passes deep in relation to the fibrous arch formed by the flexor digitorum superficialis and is closely bound to the deep surface of this muscle by its fascial sheath (Figs. 3D, 3E, 3F, 3G, 3H, 3I. The median nerve becomes more superficial and enters the carpal tunnel at the wrist. The median nerve innervates the pronator teres, the flexor carpi radialis, the palmaris longus, and the flexor digitorum superficialis. It supplies branches to proximal portions of the flexor pollicis longus and flexor digitorum profundus. The brachial artery branches to form the radial and ulnar arteries, which travel with the superficial radial nerve and the ulnar nerve, respectively.



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Fig. 4. (continued)—50-year-old healthy woman. Sagittal MR images through elbow, from radius to ulna, show nerves in proximal forearm. F = flexor digitorum profundus, B = brachialis, P = pronator teres, h = humeral head of flexor carpi ulnaris, u = ulnar head of flexor carpi ulnaris, FC = flexor carpi ulnaris.

D, Median nerve (white arrow) and brachial artery (open arrow) in radial tunnel are deep in relation to lacertus fibrosis (bicipital aponeurosis) (short thin arrow).

 


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Fig. 2. —Anatomic drawings of nerve—muscle relationships in forearm from anterior view.

C, Drawing shows that bicipital aponeurosis has been resected. Note superficial head of pronator muscle has been cut and reflected. Also note path of median nerve between two heads of pronator muscle.

 

Anterior Interosseous Nerve
The major branch of the median nerve is the anterior interosseous nerve. At a point 5-8 cm distal to the lateral epicondyle, at the level of the deep head of the pronator teres, the anterior interosseous nerve branches off and travels with the anterior interosseous artery, anterior to the interosseous membrane (Figs. 2C, 3D, 3E, 3F, 3G, 3H, and 4C). It dives deep in relation to the pronator quadratus before terminating at the wrist [3] (Fig. 3I). The anterior interosseous artery is a branch of the common interosseous artery, which is a branch of the ulnar artery. The anterior interosseous nerve innervates the flexor pollicis longus, the lateral portion of the flexor digitorum profundus, and the pronator quadratus.



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Fig. 4. (continued)—50-year-old healthy woman. Sagittal MR images through elbow, from radius to ulna, show nerves in proximal forearm. F = flexor digitorum profundus, B = brachialis, P = pronator teres, h = humeral head of flexor carpi ulnaris, u = ulnar head of flexor carpi ulnaris, FC = flexor carpi ulnaris.

C, Anterior interosseous nerve and artery (arrowheads) are deep in relation to flexor digitorum profundus.

 

Ulnar Nerve
The ulnar nerve enters the forearm between the medial epicondyle and the ulnar head of the flexor carpi ulnaris and travels between the two heads of the flexor carpi ulnaris in the superficial volar compartment (Figs. 3A and 4E). It then courses between the flexor carpi ulnaris and the flexor digitorum profundus, where it is joined by the ulnar artery (Figs. 3D and 3E). In the distal forearm, the ulnar nerve lies on the volar side of the pronator quadratus (Fig. 3I), becomes superficial and lateral to the flexor carpi ulnaris, and is on the volar side of the flexor retinaculum where it crosses the wrist. The ulnar nerve provides motor function to two muscles in the forearm: the flexor carpi ulnaris and the medial portion of the flexor digitorum profundus.



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Fig. 4. (continued)—50-year-old healthy woman. Sagittal MR images through elbow, from radius to ulna, show nerves in proximal forearm. F = flexor digitorum profundus, B = brachialis, P = pronator teres, h = humeral head of flexor carpi ulnaris, u = ulnar head of flexor carpi ulnaris, FC = flexor carpi ulnaris.

E, Ulnar nerve (shaded open arrow) is seen between two heads of flexor carpi ulnaris.

 



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Fig. 4.—50-year-old healthy woman. Sagittal MR images through elbow, from radius to ulna, show nerves in proximal forearm. S = supinator.

B, After exiting supinator, deep branch of radial nerve is called posterior interosseous nerve (straight thick arrow).

 

Conclusion
Top
Introduction
Compartments of the Forearm
Courses of the Nerves
Conclusion
References
 
The forearm is anatomically divided into three compartments: the mobile wad, the volar, and the dorsal compartments (Tables 1 and 2). Tumor or infection may initially be contained in a single compartment. Imaging of spread beyond a compartment may affect treatment or prognosis. Knowledge of the course of the major neurovascular structures through the compartments may help to establish their involvement or displacement by tumor. As imaging technology improves, a more detailed understanding of the anatomy of the forearm will become increasingly important to the radiologist in the evaluation of tumor resectability and nerve compression syndromes.


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TABLE 1 Anatomic Compartments of the Forearm and Nerve Supply of Each Muscle

 

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TABLE 2 Nerves of the Forearm, Muscles Innervated, and Compartment of Each Muscle

 


Acknowledgments
 
We thank Kristen Wienandt, medical illustrator and designer, Rush-Presbyterian-St. Luke's Medical Center, Chicago, IL, for her original artwork, and Donna S. Garrison, Wake Forest University, Winston-Salem, NC, for assistance in preparation of this manuscript.


References
Top
Introduction
Compartments of the Forearm
Courses of the Nerves
Conclusion
References
 

  1. Gelberman RH, Garfin SR, Hergenroeder PT, Mubarak SJ, Menon J. Compartment syndromes of the forearm: diagnosis and treatment. Clin Orthop 1981;161:252-261
  2. Allen MJ, Steingold F, Kotecha M, Barnes M. The importance of the deep volar compartment in crush injuries of the forearm. Injury 1985;16:273-274[Medline]
  3. Dellon AL, Mackinnon SE. Musculoaponeurotic variations along the course of the median nerve in the proximal forearm. J Hand Surg Br 1987;12B:359-363[Medline]
  4. Lister GD, Belsole RB, Kleinert HE. The radial tunnel syndrome. J Hand Surg Am 1979;4A:52-59[Medline]
  5. Spinner M. The arcade of Frohse and its relationship to posterior interosseous nerve paralysis. J Bone Joint Surg Br 1968;50-B:809-812

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