Shrrma et al: Nutrient foramina variations Original Article Morphological variations of nutrient foramina in lower limb long bones Sharma M1, Prashar R2, Sharma T3 Wadhwa A4, Kaur J5 ABSTRACT 1Dr Mamta Sharma MS, Associate Professor Background: The major blood supply to long bone is from the nutrient 2 Dr Rajeev Prashar arteries, which enter through nutrient foramina. Nutrient foramen is an MS, PCMS, Dep. of Surgery Civil Hospital Kapurthala, Punjab, opening into the bone shaft which give passage to the blood vessels of India the medullary cavity of a bone The direction of the nutrient foramen of all [email protected] bones is away from growing end and has a particular position for each 3 Dr Tripta Sharma bone. MS, Professor [email protected] Objective: The aim of the present study was to study the topographic 4Dr Ambica Wadhwa anatomy and morphology of the nutrient foramina in human adult lower MS, Professor limb long bones. [email protected] Material and Method: The study was performed on 150 lower limb long 5Dr Jasveen Kaur MS, Assistant Professor bones which included 50 femora, 50 tibiae and 50 fibulae. The bones [email protected] were obtained from department of anatomy, Punjab Institute of Medical 1,3,4,5Department of Anatomy Sciences, Jalandhar. Punjab Institute of Medical Results: The variations were found in number and location of nutrient Sciences Jalandhar, Punjab, India foramen in different lower limb long bones. In femur double and triple foramina were observed. Absence of nutrient foramen was observed in Received: 09-03-2014 femur and fibula. Revised: 04-04-2015 Conclusion: The topographical knowledge of these foramina is useful in Accepted: 20-04-2015 certain operative procedures, in orthopedics as well as in plastic and Correspondence to: reconstructive surgery, to avoid damage to the nutrient vessels. Dr Mamta Sharma Key Words: Nutrient foramen, nutrient artery, femur, tibia, fibula, Linea [email protected] aspera, diaphysis 9463369191 Introduction arteries, and in the case of their absence, The role of nutrient foramina in the the vascularization occur through the nutrition and growth of the bones is evident periosteal vessels. [5] There are considerable from the term ‘Nutrient’ itself. [1] Nutrient intracortical anastomoses between the foramen is an opening into the bone shaft inner medullary and outer periosteal which give passage to the blood vessels of vessels. [6] The vascularization of the long the medullary cavity of a bone. The major bones generally is given by one or two blood supply to long bone is from the diaphyseal nutrient arteries and numerous nutrient arteries, which enter through metaphysiary and epiphysiary arteries. The nutrient foramina especially during the diaphyseal nutrient arteries obliquely active growing period in the embryo and penetrate in the diaphysis of the long foetus, as well as during phases of bones, there entrance point and angulation ossification. [2-4] During childhood, long being relatively constant dividing into bones receive about 80% of the ascending and descending branches. [7] The interosseous blood supply from the nutrient nutrient canal (through which nutrient IJMDS ● www.ijmds.org ● July 2015; 4(2) 802 Shrrma et al: Nutrient foramina variations artery enters the shaft) typically become transmits a branch of the posterior tibial slanted during growth, the direction of slant artery: the nutrient vessel may also arise at from surface to marrow cavity points the popliteal bifurcation or as a branch from towards the end that has grown least the anterior tibial artery. On entering the rapidly. This is due to greater longitudinal bone the nutrient artery divides into growth at the faster growing end. The ascending and descending branches. The direction of the nutrient foramen of all periosteal supply to the shaft arise from the bones is away from growing end. [8] Most of anterior tibial artery and from muscular the nutrient arteries follow the rule, ‘ to the branches. The distal metaphysis is supplied elbow I go, from the knee I flee’ but they by branches from the anastomosis around are variable in position. This is because one the ankle. [12] end of the limb bone grows faster than the In fibula nutrient foramen is present other do. [9] So, the direction of nutrient a little proximal to the midpoint of the canal is important to denote the growing posterior surface and is directed distally. It end of a bone. The nutrient foramen is receive a branch of the fibular artery. An distinguished from any other foramen by appreciation of the detailed anatomy of the the presence of distinct vascular groove fibular artery in relation to the fibula is outside the nutrient foramen. [1, 10] fundamental to the raising of The nutrient foramen has a osteofasciocutaneous free flaps particular position for each bone. [11] In incorporating segments of the bone. Free femur nutrient foramina, directed vascularized diaphysis grafts may also be proximally, appear in the linea aspera taken on a fibular arterial pedicle. The varying in number and size, one usually proximal and distal ends receive near its proximal end second usually at its metaphyseal vessels from the arterial distal end. The main nutrient artery is anastomosis at the knee and ankles usually derived from 2nd perforating artery. respectively. [12] If two nutrient arteries occur, they may Knowledge about location of these branch from 1st and 3rd perforators. The foramina is useful in certain operative distal metaphysis has many vascular procedures to preserve the circulation. [13-15] foramina. Arterial supply here is from The fibulae are used as vascularized graft genicular anastomosis. The periosteal for conditions such as stabilization of lost vessels arise from the perforators and from mandible, spine and even in tibia. Free the profunda femoris, and run vascularized fibular graft offers a reliable circumferentially rather than longitudinally. method of construction after excision of [12] bone tumour and other bony defects. [16] In tibia, a faint vertical line descends A considerable interest in studying from the centre of the soleal line for a short nutrient foramina resulted not only from distance before becoming indistinct. A large morphological but also from clinical aspects. vascular groove adjoins the end of the line Nutrient foramina reflect to a certain and descends distally into a nutrient degree the bone vascularization. Some foramen. The proximal end of the tibia is pathological bone conditions such as supplied by metaphyseal vessels from the developmental abnormalities,fracture genicular arterial anastomosis. The nutrient healing or acute hematogenic osteomyelitis foramen usually lies near the soleal line and are closely related to the vascular system of IJMDS ● www.ijmds.org ● July 2015; 4(2) 803 Shrrma et al: Nutrient foramina variations bone. [17] Longia GS etal observed that the of the nutrient foramina in long bones is position of nutrient foramina was on the therefore important in orthopedic surgical flexor aspect in their human long bone procedures such as joint replacement specimen. [18] therapy, fracture repair, bone grafts and It is generally agreed that the vessels vascularized bone microsurgery as well as which occupy the nutrient foramen are medicolegal cases. [23] derived from those that took part in the The aim of the present study was to initial invasion of the ossifying cartilage, so study the topographic anatomy and that the nutrient foramen was at the site of morphology of the nutrient foramina in original centre of ossification. [11, 18] human adult lower limb long bones. Humphrey who worked on the direction and obliquity of nutrient canals postulated Material and methods periosteal slipping theory, the canal finally The study included 150 lower limb cadaveric directed away from the growing end. [19] long bones which included 50 femora 25 Harris has stated that the position of right, 25 left), 50 tibiae (25 right, 25 left), 50 nutrient foramina is constant during the fibulae (25 right, 25 left). The bones were growth of long bones. [20] Lutken has stated obtained from osteology section of that position of nutrient foramina is variable department of anatomy, Punjab Institute of and typical position of nutrient foramina Medical Sciences, Jalandhar. All the bones can be determined after a study on human were macroscopically observed for number, bones. [10] location and direction of nutrient foramina. Henderson reported that their A magnifying lens was used to observe the position in mammalian bones are variable foramina. The nutrient foramina were and alter during growth. Though the identified by the presence of a well marked foramina are directed away from the groove leading to them and by a well growing end, their topography might vary at marked, often slightly raised, edge at the the non growing end. So the topographical commencement of the canal. Only anatomy of the nutrient foramina may be diaphyseal nutrient foramina were observed worth. [21] The topographical knowledge of in all the bones. Foramina at the ends of the these foramina is useful in certain bones were ignored. For determining the procedures to preserve the circulation. topographical distribution of nutrient Therefore it is important that the arterial foramen along the length of the bones, supply is preserved in free vascularized each bone was divided into 3 parts (upper, bone grafts so that osteocytes and middle, lower1/3rd) after measuring the osteoblasts survive. [22] length of bone. Each part was noticed for Also the study of relative relationship the presence of nutrient foramen. between the length of bone and distance of nutrient foramen from either end is useful Results in calculating the length of long bone from a In case of femora, 54% (27 out of 50) had given fragment which is important in single nutrient foramen, 42% (21 out of 50) medicolegal and anthropological work. had double foramina , 2% (1 out of 50) had From the length of the long bones height of triple foramina and it was absent in 2% (1 an individual can be reconstructed.