Anatomy of Forearm (2)

8/20/2019 Anatomy of Forearm (2)

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ANTERIOR COMPARTMENT

Superficial Compartment

The superficial muscles in the anterior compartment are the flexor carpi ulnaris, palmaris longus,

flexor carpi radialis and pronator teres. They all originate from a common tendon, which arises

from the medial epicondyle of the humerus.

Flexor Carpi Ulnaris

• Attacments! Originates from the medial epicondyle with the other superficial flexors.

It also has a long origin from the ulna. It passes into the wrist, and attaches to the pisiformcarpal bone.

• Actions! Flexion and adduction at the wrist.

• Inner"ation! Ulnar nerve.

Palmaris #on$us

This muscle is absent in about 1! of the population.

Dissection Tip: Just distal to the wrist, if you reflect back the palmaris longus, you will find themedian nerve immediately underneath it

• Attacments! Originates from the medial epicondyle, attaches to the flexor retinaculum

of the wrist.

• Actions! Flexion at the wrist.

• Inner"ation! "edian nerve.

Flexor Carpi Radialis

• Attacments! Originates from the medial epicondyle, attaches to the base of metacarpals

II and III.

• Actions! Flexion and abduction at the wrist.



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Pronator Teres

The lateral border of the pronator teres forms the medial border of the cubital fossa, ananatomical triangle located over the elbow.

• Attacments! It has two origins, one from the medial epicondyle, and the other from the

coronoid process of the ulna. It attaches laterally to the mid#shaft of the radius.

• Actions! $ronation of the forearm.


% &'1 Teach"e(natomy.co

Fig 1.' ) The superficial muscles of the anterior forearm.

Intermediate Compartment

The flexor di$itorum superficialis is the only muscle of the intermediate compartment. It can

sometimes be classed as a superficial muscle, but in most cadavers it lies between the deep andsuperficial muscle layers.

The muscle is a good anatomical landmar* in the forearm ) the median ner"e andulnar

artery pass between its two heads, and then travel posteriorly.

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• Attacments! It has two heads ) one originates from the medial epicondyle of the

humerus, the other from the radius. The muscle splits into four tendons at the wrist, which

travel through the carpal tunnel, and attaches to the middle phalanges of the four fingers.

• Actions! Flexes the metacarpophalangeal +oints and proximal interphalangeal +oints at the

fingers, and flexes at the wrist.


% &'1 Teach"e(natomy.com

Fig 1.1 ) The intermediate compartment of the anterior forearm. Flexor digitorum superficialishighlighted in blue.

%eep Compartment

There are three muscles in the deep anterior forearm- flexor digitorum profundus, flexor pollicis

longus, and pronator uadratus.

Flexor %i$itorum Profundus

• Attacments! Originates from the ulna and associated interosseous membrane. (t the

wrist, it splits into four tendons, that pass through the carpal tunnel and attach to the distal phalanges of the four fingers.

• Actions! It is the only muscle that can flex the distal interphalangeal +oints of the fingers.

It also flexes at metacarpophalangeal +oints and at the wrist.


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• Inner"ation! The medial half /acts on the little and ring fingers0 is innervated by the

ulnar nerve. The lateral half /acts on the middle and index fingers0 is innervated by the

anterior interosseous branch of the median nerve.

Flexor Pollicis #on$us

This muscle lies laterally to the F$.

• Attacments! Originates from the anterior surface of the radius, and surrounding

interosseous membrane. (ttaches to the base of the distal phalanx of the thumb.

• Actions2 Flexes the interphalangeal +oint and metacarpophalangeal +oint of the thumb.

• Inner"ation2 "edian nerve /anterior interosseous branch0.

Pronator &uadratus

( suare shaped muscle, found deep to the tendons of the F$ and F$3.

• Attacments! Originates from the anterior surface of the ulna, and attaches to the

anterior surface of the radius.

• Actions! $ronates the forearm.

• Inner"ation! "edian nerve /anterior interosseous branch0.

% &'1 Teach"e(natomy.com 455#67#85#8 .'9

Fig 1.& ) eep flexor muscles of the anterior forearm.

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POSTERIOR COMPARTMENT

The muscles in the posterior compartment of the forearm are commonly *nown as the extensor

muscles. The general function of these muscles is to produce extension at the wrist and fingers.

They are all innervated by the radial ner"e.

(natomically, the muscles in this compartment can be divided into two

layers- deepand superficial. These two layers are separated by a layer of fascia.

In this article, we shall loo* at the attachments, actions and clinical relevance of the muscles in

the posterior compartment of the forearm.

Superficial Muscles

The superficial layer of the posterior forearm contains seven muscles. Four of these muscles )

extensor carpi radialis brevis, extensor digitorum, extensor carpi ulnaris and extensor digiti

minimi share a common tendinous origin at the lateral epicondyle.

'racioradialis


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The brachioradialis is a paradoxical muscle. Its origin and innervation are characteristic of a

extensor muscle, but it is actually a flexor at the elbow.

The muscle is most visible when the forearm is half pronated, and flexing at the elbow against

resistance.

In the distal forearm, the radial artery and nerve are sandwiched between the brachioradialis and

the deep flexor muscles.

• Attacments2 Originates from the proximal aspect of the lateral supraepicondylar ridge

of humerus, and attaches to the distal end of the radius, +ust before the radial styloid process.

• Actions2 Flexes at the elbow.

• Inner"ation2 :adial nerve.


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• Attacments2 Originates from the lateral epicondyle of the humerus. It attaches, with the

extensor digitorum tendon, into the extensor hood of the little finger.

• Actions2 ;xtends the little finger, and contributes to extension at the wrist.


Extensor Carpi Ulnaris

The extensor carpi ulnaris is located on the medial aspect of the posterior forearm. ue to its

position, it is able to produce adduction as well as extension at the wrist.

• Attacments2 Originates from the lateral epicondyle of the humerus, and attaches to the

base of metacarpal


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Fig 1.1 ) 5ross section of the muscles of the distal forearm. =ome extensor muscles, such as the

aconeus, are not visible as they are situated proximally in the forearm.

Clinical Rele"ance! #ateral Epicondylitis

3ateral epicondylitis /or tennis elbow0 refers to inflammation of theperiosteum of the lateral

epicondyle. The pea* age of onset is '#' years old.

It is caused by repeated use of the superficial extensor muscles, which strains their common

tendinous attachment to the lateral epicondyle.

Deep Muscles

There are five muscles in the deep compartment of the posterior forearm ) the supinator,

abductor pollicis longus, extensor pollicis brevis, extensor pollicis longus and extensor indicis.

>ith the exception of the supinator, these muscles act on the thumb and the index finger.


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• Attacments2 It has two heads of origin. One originates from the lateral epicondyle of

the humerus, the other from the posterior surface of the ulna. They insert together into the

posterior surface of the radius.

• Actions2 =upinates the forearm.


A(ductor Pollicis #on$us

The abductor pollicis longus is situated immediately distal to the supinator muscle. In the hand,

its tendon contributes to the lateral border of the anatomical snuffbox.

• Attacments2 Originates from the interosseous membrane and the ad+acent posterior

surfaces of the radius and ulna. It attaches to the lateral side of the base of metacarpal I.

• Actions2 (bducts the thumb.


Extensor Pollicis 're"is

The extensor pollicis brevis can be found medially and deep to the abductor pollicis longus. In

the hand, its tendon contributes to the lateral border of the anatomical snuffbox.

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• Attacments2 Originates from the posterior surface of the radius and interosseous

membrane. It attaches to the base of the proximal phalanx of the thumb.

• Actions2 ;xtends at the metacarpophalangeal and carpometacarpal +oints of the thumb.


Extensor Pollicis #on$us

The extensor pollicis longus muscle has a large muscle belly than the ;$6. Its tendon travels

medially to the dorsal tubercle at the wrist, using the tubercle as a ?pulley@ to increase the force

exerted.

The tendon of the extensor pollicis longus forms the medial border of theanatomical snuffbox inthe hand.

• Attacments2 Originates from the posterior surface of the ulna and interosseous

membrane. It attaches to the distal phalanx of the thumb.

• Actions2 ;xtends all +oints of the thumb2 carpometacarpal, metacarpophalangeal and

interphalangeal.


Extensor Indicis

This muscle allows the index finger to be independent of the other fingers during extension.

• Attacments2 Originates from the posterior surface of the ulna and interosseous

membrane, distal to the extensor pollicis longus. (ttaches to the extensor hood of the index

finger.

• Actions2 ;xtends the index finger.


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Fig 1.A ) >ristdrop of the left forearm, as a result of radial nerve palsy.

Clinical Relevance: Wrist Drop

>rist drop is a sign of radial ner"e in+ury that has occurred proximal to the elbow.

There are two common characteristic sites of damage2

• Axilla ) in+ured via humeral dislocations or fractures of the proximal humerus.

• Radial $roo"e of te umerus ) in+ured via a humeral shaft fracture.

The radial nerve innervates all muscles in the extensor compartment of the forearm. In the event

of a radial nerve lesion, these muscles are paralysed. The muscles that flex the wrist areinnervated by the median ner"e, and thus are unaffected. The tone of the flexor muscles

produces unopposed flexion at the wrist +oint ) wrist drop


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Flexor Tendons of the Digits

The anatomic relationships of the flexor tendons are usually discussed in terms of Bones, shownin the image below. The flexor tendon Bones are modifications of


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Eone I consists of the profundus tendon only and is bounded proximally by the insertion of the

superficialis tendons and distally by the insertion of the flexor digitorum profundus /F$0

tendon into the distal phalanx.

Eone II is often referred to as 6unnellCs no manCs land, indicating the freuent occurrence of

restrictive adhesion bands around lacerations in this area. $roximal to Bone II, the flexor

digitorum superficialis /F=0 tendons lie superficial to the F$ tendons. >ithin Bone II and at

the level of the proximal third of the proximal phalanx, the F= tendons split into & slips,

collectively *nown as 5amper chiasma. These slips then divide around the F$ tendon and

reunite on the dorsal aspect of the F$, inserting into the distal end of the middle phalanx.

Eone III extends from the distal edge of the carpal ligament to the proximal edge of the (1

pulley, which is the entrance of the tendon sheath /see the (1 pulley in the image above0. >ithin

Bone III, the lumbrical muscles originate from the F$ tendons. The distal palmar crease

superficially mar*s the termination of Bone III and the beginning of Bone II.

Eone I< includes the carpal tunnel and its contents /ie, the G digital flexors and the mediannerve0. Eone < extends from the origin of the flexor tendons at their respective muscle bellies to

the proximal edge of the carpal tunnel.

Digital Flexor Sheath

The digital flexor sheath is a closed synovial system consisting of membranous and retinacular portions. The membranous portion is made up of visceral and parietal layers that invest the flexor

digitorum profundus /F$0 and flexor digitorum superficialis /F=0 tendons in the distal aspect

of the hand. The retinacular component consists of tissue condensations arranged in cruciform,

annular, and transverse patterns that overlie the membranous, or synovial, lining.

Ultrastructural analysis by 5ohen and Haplan confirmed that the flexor tendon sheath is a

continuous, uninterrupted membrane.4&A9 The parietal and visceral layers are ualitatively similar,

and synoviocytes are morphologically identical throughout the length of the flexor sheath. /=ee

the image below.0

The digital flexor sheath has been proposed to have a A#fold function, as follows2 /10 it facilitates

smooth gliding of the tendons- /&0 the retinacular component acts as a fulcrum, adding a

mechanical advantage to flexion- /A0 it is a contained system, or bursa, with synovial fluid

bathing the tendons and aiding in their nutrition.


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The membranous portion of the sheath appears macroscopically as a number of cul#de#sacs, or

plicae, that interdigitate between the tendons and the retinacular tissue condensations. The first

cul#de#sac is located approximately 1'#1 mm proximal to the distal metacarpal head and

represents the point of transition between the parietal and visceral layers of synovium. This

outpouching occurs for each separate tendon, in effect forming & separate plicae. /8ote that this

is true only for the middle A rays of the hand. In most instances, the first# and fifth#digit synovial

layers begin much more proximally at the level of the wrist, and are referred to as the radial andulnar bursa, respectively.0

istally, the parietal layer of synovium forms plicae between each of the retinacular elements of

the pulley system. The synovium ends distally, forming a final, single cul#de#sac prior to the

insertion of the F$ tendon on the distal phalanx. (ccording to oyle, in a study of 1 cadaver

fingers, the distal synovial layer did not extend past the distal interphalangeal /I$0 +oint. 4&9

The retinacular portion, or pulley system, of the flexor tendon sheath has been described

extensively. oyle described this pulley system as fibrous tissue bands of various width,

thic*ness, and configuration that overlie the synovial sheath.4&9

The pulley system is thought toconsist of the palmar aponeurosis /$(0 pulley, annular pulleys, and A cruciform pulleys. /=ee

the image below.0 The system supplies mechanical advantage by maintaining the flexor tendons

close to the +ointCs axis of motion. In doing so, the pulleys prevent bowstringing, which ma*es up

interphalangeal and metacarpophalangeal /"5$0 +oint motion.

:etinacular portion of the flexor tendon sheath /pulley system0.

Palmar aponeurosis pulley

The $( pulley consists of transverse fascicular bands arising from the $(.4&9 The bands are

approximately 1 cm in width, and the proximal edge of the pulley is 1#A mm proximal to the

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origin of the membranous tendon sheath. The distal edge lies approximately J#1' mm from the

proximal edge of the first annular pulley. The $( pulley is anchored by vertical septa that attach

to the deep transverse metacarpal ligament beneath the tendons. This pulley is not as closely

applied to the surface of the flexor tendons as the annular and cruciate pulleys. Kowever, during

the act of grasping, increased tension on the palmar fascia by the flexor carpi ulnaris and

palmaris longus muscles moves the pulley closer to the tendon surface.

Annular pulleys

The annular pulleys are as follows2

• (1 pulley # The first annular pulley arises from the palmar plate and proximal portion of

the proximal phalanx, overlies the membranous sheath at the level of the "5$ +oint, and isapproximately J mm in width- this pulley is released during surgical treatment of trigger

finger /stenosing tenosynovitis0

• (& pulley # The second annular pulley consists of obliue fibers that overlie annular

fibers, originates from the proximal and lateral areas of the proximal phalanx, and isapproximately 1L mm in width- this pulley should always be preserved when dealing with

in+uries to the retinacular system

• (A pulley # The third annular pulley is located at the level of the $I$ +oint- it attaches to

the palmar plate and is approximately A mm in width

• ( pulley # 3i*e the (& pulley, the fourth annular pulley, located in the middle phalanx,

also consists of obliue fibers overlying annular fibers and is always preserved during surgery

of the retinacular system- the ( pulley is approximately .L mm in width and has been

shown to be the most important biomechanical pulley for maintaining independentinterphalangeal +oint function

• ( pulley # The fifth annular pulley is located proximal to the I$ +oint, +ust proximal to

the termination of the membranous sheath- the ( pulley is the thinnest of the annular pulleys and has a width of mm

Cruciform pulleys

Te ) cruciform pulleys are as follo*s!

• 51 pulley # The first cruciform pulley lies +ust distal to the (& pulley

• 5& pulley # The second cruciform pulley is located in the space between the (A and (

pulleys

• 5A pulley # The third cruciform pulley is located distal to the ( pulley- a number of

anatomic variations have been described for the retinacular system

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Tum( flexor tendon seat

( separate flexor tendon sheath has been described for the thumb.4&L9 The membranous portion of

the sheath originates proximal to the radial styloid in the wrist and invests the single F$3 tendon.

The retinacular system consists of A separate pulleys overlying the membranous sheath, as

follows2

• (1 pulley # The first annular pulley is located at the level of the "5$ +oint- it is

approximately G mm wide and originates from the volar plate and base of the proximal

phalanx

• Obliue pulley # This pulley overlies the sheath at the midportion of the proximal

phalanx- the fibers of the pulley are angled obliuely in a proximal ulnar)to)distal radialdirection, the pulley is 11 mm wide, and fibers from the adductor pollicis insertion ma*e up

the proximal portion /the obliue pulley is always preserved during surgery of the retinacular

system0

• (& pulley # The second annular pulley is 1' mm in width and attaches to the volar plateof the interphalangeal +oint

Additional details

The function of the flexor tendon sheath becomes apparent with an understanding of its anatomy.

6unnell described the membranous portion of the tendon sheath as an adaptation that allows

tendons to turn corners when he stated, It glides around a curve on a thin film of synovial fluid

between two smooth synovial lined surfaces, +ust as metal surfaces in machinery glide on a thin

film of oil.4&J9

=trauch and de "oura described the membranous synovial lining as a closed mesenteric system

that resembles those of the abdominal and thoracic cavities more than those of a +oint space.4&G9 Furthermore, the cul#de#sacs between the retinacular pulleys allow for contraction and

expansion of the entire system as the digits respectively flex and extend.

>ith respect to the function of the retinacular system, oyle described A *ey anatomic

adaptations that prevent buc*ling of the entire system during flexion2 /10 the broad (& and (

pulleys are located between +oints, whereas the narrow (1 and (A pulleys are positioned over

+oints- /&0 an anatomic accommodation always exists between the (1 and (& pulleys- /A0 the thinand narrow cruciform pulleys are located near +oints where they are able to accommodate flexion

more readily than the larger annular pulleys can.

"ans*e and 3es*er described the functional anatomy of the proximal pulley system in terms of

total range of motion of digital flexion.4A'9 The $(, (1, and (& pulleys of each individual digit in


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1& cadaver hands were cut seuentially. The total loss in range of motion was then calculated for

the various permutations of remaining pulleys.

In terms of functional significance, "ans*e and 3es*er found that the (& pulley was the most

important, followed by the (1 and $( pulleys, respectively. Kowever, loss of flexion with a

missing (1 or (& pulley was proven to be insignificant in the presence of an intact $( pulley.

>ith the absence of an (1 or (& pulley, loss of flexion was significantly greater when combined

with loss of the $( pulley, leading the authors to conclude that the $( pulley should be spared at

all costs when repairing hand in+uries.

6eneath the annular pulleys and on tendon surfaces that are distant from the vincula /from the

French, vincio, meaning to bind- see the image below0 and cul#de#sacs, the synovial layer is

attenuated. In these areas, the synovial cells are sparse and widely spaced, and the supporting

collagen is thin and laminar. Furthermore, capillaries are rarely seen. Kowever, the cul#de#sacs

and areas of vincular origin demonstrate a synovial layer that is several cells thic*, replete with

capillaries and loosely organiBed collagen bundles.4A19

Extensor Tendon Injuries Author: Daniel Hatch

Topic updated on 12/15/14 5:02pm

Introduction

• Injury can be caused by laceration trau!a or overuse

• "pide!iology

http://www.orthobullets.com/user/10415http://www.orthobullets.com/user/10415http://www.orthobullets.com/user/10415


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o !ost co!!only injured digit is the long #nger

o $one %I is the !ost fre&uently injured $one

• 'echanis!

o (one I

forced )exion of extended DI* joint

o (one II

dorsal laceration or crush injury

o (one %

co!!only fro! +#ght bite+

sagittal band rupture ,+)ea )ic-er injury+.

forced extension of )exed digit

!ost co!!on in long #nger

Classifcation

Zones o Extensor Tendon Injuries

(one I / Disruption of ter!inal extensor tendon distal to or at the

DI* joint of the #ngers and I* joint of the thu!b ,"*0.

/ 'allet Finger

(one II / Disruption of tendon over !iddle phalanx or proxi!al

phalanx of thu!b ,"*0.

(one III / Disruption over the *I* joint of digit ,central slip. or 'C*

joint of thu!b ,"*0 and "*1

/ 1outonniere defor!ity


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(one I% / Disruption over the proxi!al phalanx of digit or

!etacarpal of thu!b ,"*0 and "*1.

(one % / Disruption over 'C* joint of digit or C'C joint of thu!b

,"*0 and "*1.

/+Fight bite+ co!!on

/ Sagittal band rupture

(one %I / Disruption over the !etacarpal

/ 2erve and vessel injury li-ely

(one %II / Disruption at the 3rist joint

/ 'ust repair retinaculu! to prevent bo3stringing

/ Tendon repair follo3ed by i!!obili$ation 3ith 3rist in

456 extension and 'C* joint in 756 )exion for 894 3ee-s

(one %III / Disruption at the distal forear!

(one %III / "xtensor !uscle belly

/ sually fro! penetrating trau!a

/ ;ften have associated neurologic injury

/ Tendon repair follo3ed by i!!obili$ation 3ith elbo3 in

)exion and 3rist in extension

Presentation

• (one I

o Inability to extend at the DI* joint

• (one III

o "lson test

)ex the patient


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• (one %

o extensor lag and )exion loss co!!on

o sagittal band rupture

rupture of stronger radial #bers of sagittal band !a

tendon subluxation

#nger held in )exed position at 'C* joint 3ith no a

Imaging

• Radiographs

o >* and lateral of digit to verify no bony avulsion ,boney !a

Treatment

• 2onoperative

o immobilization wit earl! protected motion

indications

lacerations ? @5A of tendon in all $ones if patient ca

resistance

o DIP extension splinting

indications

acute ,?B7 3ee-s. (one B injury ,!allet #nger.

nondisplaced bony !allet

chronic !allet #nger ,B7 3ee-s. if joint supple con


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techni&ues

full9ti!e splinting for six 3ee-s

part9ti!e splinting for four to six 3ee-s

avoid hyperextension 3hich !ay cause s-in necr

!aintain *I* !otion

outco!es

nonco!pliance is a co!!on proble!

o PIP extension splinting

indications

closed central slip injury ,$one III.

techni&ues

full9ti!e splinting for six 3ee-s

part9ti!e splinting for four to six 3ee-s

!aintain DI* )exion

o MCP extension splinting

indications

closed $one % sagittal band rupture

techni&ues

full9ti!e splinting for four to six 3ee-s

• ;perative


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o immediate I"D

indications

#ght bite to 'C* joint

techni&ues

close loosely or in delayed fashion

treat 3ith culture9speci#c antibiotics although "i

co!!on !outh organis!

o tendon repair

indications

laceration @5A of tendon 3idth in all $ones

o fxation o bon! a#ulsion

indications

boney !allet #nger 3ith *8 volar subluxation

techni&ues

closed reduction and percutaneous pinning throu

extension bloc- pinning

;RIF if it involves @5A of the articular surface

o tendon reconstruction

indications

chronic tendon injury or 3hen repair not possible

o central slip reconstruction


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techni&ues

tendon graft

extensor turndo3n

lateral band !obili$ation

transverse retinacular liga!ent

FDS slip

o EIP to EP$ tendon transer

indications

chronic "*0 rupture

%urgical Tecni&ues

• Tendon 'epair

o incision techni&ue

utili$e laceration 3hen present and extend incision as neappropriate exposure

longitudinal incision !ay be utili$ed across joints on the d

the pal!ar side

o suture techni&ue

of suture strands that cross the repair site is !ore i!po

grasping loops

in general strength increases 3ith increasing nu!ber of su

repair site thic-ness of the suture and loc-ing of the stitc

49E strands provide ade&uate strength for early active !o


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o circu!ferential epitendinous suture

;ptional for reinforce!ent

o repair failure

tendon repairs are 3ea-est bet3een postoperative day E a

repair usually fails at -nots

• Tendon 'econstruction

o usually done as t3o stage procedure

#rst a silicon tendon i!plant is placed to create a favorabl

3ait 894 !onths and then place biologic tendon graft

only perfor! single stage reconstruction if )exor sheath is

full R;'

o available grafts include

pal!aris longus ,absent in B@A of population.

!ost co!!on

plantaris ,absent in B=A.

indicated if longer graft is needed

long toe extensor

o pulley reconstruction

one pulley should be reconstructed proxi!al and distal to

!ethods include belt loop !ethod and FDS tail !ethod

• Tenol!sis


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o indications

adhesion for!ation 3ith loss of #nger )exion

3ait for soft tissue stabili$ation , 8 !onths. and full pass

o postoperative

o follo3 3ith extensive therapy

Complications

• >dhesion for!ation

o

leads to loss of #nger )exion

o co!!on in $one I% and %II and older patients

o prevented 3ith early protected R;' and dyna!ic splinting

o treat!ent

extensor tenolysis 3ith early !otion indicated after fa

!anage!ent usually 89E !onths

tenolysis contraindicated if done in conjunction 3ith ot

re&uire joint i!!obili$ation

• Tendon rupture

o causes include poor suture !aterial or surgical techni&ue a

and nonco!pliance

o

incidence

@A

!ost fre&uently during #rst to B5 days post9op


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o treat!ent

early recognition !ay allo3 revision repair

tendon reconstruction for late rupture or rupture 3ith e

• S3an nec- defor!ity

o caused by prolonged DI* )exion 3ith dorsal subluxation of

joint hyperextension

o treat!ent

Fo3ler central slip tenoto!y

spiral obli&ue liga!ent reconstruction

• 1outonniere defor!ity ,DI* hyperextension.

o caused by central slip disruption and lateral band volar sub

o treat!ent

dyna!ic splinting or serial casting for !axi!al passive

ter!inal extensor tenoto!y *I* volar plate release

Anatomy of Forearm (2)

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