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Recent advances in the

biomechanics of the
forearm

Christian Dumontier, MD, PhD (Guadeloupe)
Marc Soubeyrand, MD, PhD (Paris)

The forearm is by sure very
useful ! you need one
“Hey! I’m trying to
pass the potatoes!
….Remember, my
forearms are just as
useless as yours!”

And it can be so useful
that it can compensate
for severe loss of
function of the hand

Amaranth S et al. Krukenberg operation: The "lobster claw" for traumatic amputation of the left
hand. 2014

This is because the forearm is
a joint (an association of joints)
That allows two different
bones (radius and ulna)
to move one aroud the
other

The forearm biomechanics
is about pronosupination
A joint: The association of three
joints
A mouvement: rotation of the
forearm
An axis: starting at the radial head
and ending at the ulnar head
Motors: muscles for pronation
and supination

PRUJ and DRUJ are wellknow synovial joints
For teaching purposes,
CG. HAGERT used to
removed the middle
forearm to explain
forearm rotation

Proximal
ulna

Distal radius

Proximal
radius

Distal ulna

The axis of rotation
Each joint has its own
axis of rotation
Which is identical for the
three joints

Both PRUJ and DRUJ
are pivot joint (trochoid)

The forearm should be regarded as the
third joint: The middle radioulnar joint

Forearm rotation is not possible is
the third joint is not functional +++
LaStayo PC, Lee MJ (2006) The forearm complex: anatomy, biomechanics and clinical
considerations. J Hand Ther 19:137–144

As any joint, it has bony structures
Whose shape and alignment
are important for motion
Ulnar shaft, almost linear
Radial shaft has two
curvatures (supinator
proximal, pronator distal)
Failure to restore the normal
radial bow to within 4% to 5%
of the contralateral forearm has
been associated with greater
than 20% loss of forearm
rotation.
Schemitsch EH, Richards RR. The effect of malunion on functional outcome after plate fixation of fractures
of both bones of the forearm in adults. J Bone Joint Surg 1992;74A:1068–1078.


and « ligaments »

The Interosseous membrane : thickness
2,18 mm

Assemblage
nucleus

Two type of fibers according to their
direction forming a criss-cross system
Most of them originates from the
«assemblage nucleus» ≈ 8 cm from
elbow joint
Poitevin LA (2001) Anatomy and biomechanics of the interosseous membrane: its importance in the
longitudinal stability of the forearm. Hand Clin 17:97–110

Like most joints it has fibers that we do not
understand their role at the moment
Oblique cord
(Weitbrecht’s ligament),
thick structure (≈ 1-3 mm)
Proximal band (inconstant
- 2,87 +/- 0,71 mm
thickness)

Posterior view

1,1 to 2,6 cm
2,7-3,5 cm

57%

7,7 cm

25°
13,2 cm

32%
Anterior view

Distinct patterns
Central band: 1,3 mm thick /
1 cm large
Accessory bands on either
sides: 1 mm thick

K. Noda et al. JHS 2009; 34A: 415-422

Distal membranous portion
Presence of a distal oblique bundle in 12/30
specimens
Distal fibers blend with the DRUJ (even TFCC)

K. Noda et al. JHS 2009; 34A: 415-422

Rigidity:

13,1 +/- 3,0 N/mm

Elastic modulus: 608,1 +/- 160,2 mPa
Elasticity:

9,0 +/- 2,0 %

Composition
Prolongation of the
periosteum of ulna and
radius
Collagen (60-90%) and
elastin

Proximal and distal part

Central band (ligament)
Intermediate structure between a
fascia and a ligament
Microvascularization which
diminish with time

Central band

« Indirect » physiological role
Insertions for some
muscles of the forearm
(FPL, FDP, APL, EIP,
EPL)
Limits one of the
boarder of the
compartment

Direct physiological role
Only known for the
central band
Transmission of axial
and transversal loads

Its role in transverse stability

Convergent transverse
forces are controlled by
bony architecture
Radioulnar abutment can
be seen after radial head or
ulnar head resection

Its role in transverse stability
Loads tend to put the two bones apart
The IOM has a transverse vector that
participates to control the divergence
However it is much less important that
the PRUJ and DRUJ who are the main
stabilizers

Its role in transverse
stability
However in severe Monteggia’s
or Galeazzi’s fracture, the IOM is
involved and contribute to the
instability of such fractures
DRUJ dislocation cannot occur
without IOM disruption

In full-pronation, once the radial
head is removed, you cannot
laterally translate the radial head
if the IOM is intact
Validated if > 5,5 mm in
supination (Kochei, JHS 2015s)

and a pneumatic device to !grip" the metacarpals (Fig.
nd
device
to k-wire
!grip" the
metacarpals
(Fig.ulna,
1).a Apneumatic
transverse
2 mm
passed
across the
.perpendicular
A transverse to
2 mm
k-wire passed
the ulna,
the olecranon
bolt,across
and rested
on two
erpendicular to the olecranon bolt, and rested on two
further 5mm bolts attached to the frame to prevent rotaurther 5mm bolts attached to the frame to prevent rotation of the ulna.
on of the ulna.

displacement shown as a displacement versus time g
displacement
shown
a displacement
versus by
time
graph
on the PC.
The as
DVRT
was calibrated
the
manu
on the
PC.and
Thethe
DVRT
was calibrated
by the manufacturer
readings
were in millimetres.
The s
turer and the readings were in millimetres. The strain
was calculated as the change in length over the ori
was calculated as the change in length over the original
length of the DVRT at the start of a set of reading
length of the DVRT at the start of a set of readings.

Longitudinal stability

g.Fig.
1. Specimen
mounted
on frame.
Hand
passed
through
slot on
2. DVRT
sutured
to thetocentral
band of
the ofinterosseous
1. Specimen
mounted
on frame.
Hand
passed
through
slot on Fig. Fig.
2. DVRT
sutured
the central
band
the interos
tating
device
andand
gripped
around
metacarpals.
membrane.
rotating
device
gripped
around
metacarpals.
membrane.

Longitudinal stability
At the wrist, about 80% of axial
loads go through the radius
At the elbow, ulna carries about
60% of axial loads
Transfer of loads is made possible
by the orientation of the fibers of the
interosseous membrane

Load transfer varies according to:
Frontal inclination of the wrist,
Wrist positioning in flexion or
extension,
Forearm rotation
Elbow inclination in the frontal
plane

Radial head resection
Allows proximal
migration of 7 mm,
even if soft-tissues are
intact
IOM is responsible for
71% of the stiffness and
carries 90% of axial
loads

TFCC or IOM section

Combined section + radial
head resection

Major displacement

Elbow:

Forearm :

Wrist :

Radius > annular ligament
Interosseous membrane
TFCC

Elements of longitudinal stability

Anatomical factors responsible
for proximal radius migration
Biceps
Humero-carpal muscles (FCR, FCU,
FDP, FCS, ECRL, ECRB, EDC)
Deep posterior muscles

Take home message
The forearm should be considered as a functional unit
made of three consecutive joints which function is to
allow forearm rotation
The IOM is part of the middle radio-ulnar joint
Although incompletely understood, its major role is to
provide longitudinal stability

Gracias por su atención