0198-0211/91/1106-0350$03.00/0 FOOT8 ANKLE Copyright 0 1991 by the American Orthopaedic Foot and Ankle Society, Inc
Vascular Anatomy of the Fifth Metatarsal Michael J. Shereff, M.D.,' Quing Ming Yang, M.D.,t Frederick J. Kummer, Ph.D.,S Carol C. Frey, M.D.,$ and N. Greenidgen Milwaukee, Wisconsin, Shanghai, China, New York, New York, and Los Angeles, California
peroneal arteries with normal saline, Mercox acrylic resin was injected. Soft tissue was digested by chemical means6 and photographs were taken at various intervals. Twenty specimens were processed using a modified Spalteholz technique for invesigation of the intraosseous vascular a n a f ~ m yThese .~ were injected with a
ABSTRACT The extraosseous and intraosseous vascular anatomy to the fifth metatarsal as visualized in a group of below-theknee amputation specimens has been described. The extrinsic circulation to the area is provided by the dorsal metatarsal artery, the plantar metatarsal arteries, and the fibular plantar marginal artery. These three source arteries supply branches to the metatarsal and adjacent joints. The intraosseous vascularity consists of a periosteal plexus, a nutrient artery, and a system of metaphyseal and capital vessels. INTRODUCTION
Delayed union and nonunion of the fifth metatarsal after osteotomy or fracture are well described complications of surgery or injury in this region. It is believed that interruption of the circulation to the bone may be responsible for these problems. The purpose of this study was to identify the extraosseous and intraosseous vascular anatomy of the fifth metatarsal. It is hoped that this information will provide further insight into the clinical management of disorders of the fifth ray. MATERIAL AND METHODS
The extraosseous vascular anatomy was studied in 15 fresh frozen below-the-knee amputation specimens. After irrigation of the anterior tibial, posterior tibial, and ~~~
Director, Divisionof Foot and Ankle Surgery, Milwaukee Regional Medical Center, Associate Professor, Department of Orthopaedic Surgery, Medical College of Wisconsin. t Orthopaedic Research Fellow, Hospital for Joint Diseases Orthopaedic Institute, New York, New York, and Attending Orthopaedic Surgeon, Rui Jin Hospital, Shanghai, China. $ Associate Director, Division of Bioengineering,Hospital for Joint Diseases Orthopaedic Institute, New York, New York. §Director Foot and Ankle Service and Assistant Professor of Orthopedic Surgery, University of Southern California, Los Angeles, California. ll Research Associate, Division of Bioengineering, Hospital for Joint Diseases Orthopaedic Institute, New York, New York. Address correspondence and reprint requests to Michael Shereff, M.D., Medical College of Wisconsin, 8700 W. Wisconsin Ave., Milwaukee, WI 53226.
Fig. 1. The dorsal metatarsal artery to the fourth interspace (arrow) originates from the proximal perforating artery in approximately 50% of specimens. Less often this artery was seen to emanate from the arcuate artery or the lateral tarsal artery. Note the course of this vessel in the fourth interspace dorsal to the dorsal interosseous muscle.
350
Downloaded from fai.sagepub.com at University of Sussex Library on May 14, 2016
VASCULAR ANATOMY OF THE FIFTH METATARSAL
Foot & Ankle/Vol. 1 1, No. 6/June 199 1
mixed solution of India ink, gelatin, and sodium nitrate. The bones were then removed and cleared. RESULTS Extraosseous Vascular Anatomy
The extraosseous circulation of the fifth metatarsal is provided by the dorsal metatarsal artery, the plantar metatarsal arteries, and an inconsistent branch of the lateral plantar artery known as the fibular plantar marginal artery.
MARGINAL
SUPERFICIAL METATARSALARTERY DEEP INTER-/ METATARSAL ARTERY
I
1
''
LATERAL PLANTAR ARTERY
DEEP PLANTAR BRANCH OF THE DORSALIS PEOIS ARTERY PROXIMAL PERFORATING ARTERY \ '\ DEEP PLANTAR ARCH
Fig. 2. The plantar circulation to this area is provided by the deep plantar arch formed by the union of the lateral plantar artery with a deep plantar branch of the dorsalis pedis artery.
Fig. 3. A superficial metatarsal artery (white arrow) is commonly present running plantar to the interossei along the fifth metatarsal shaft. A deep plantar intermetatarsal artery is often seen running between the plantar and dorsal interossei.The fibular plantar marginal artery was visualized in 20% of specimens (black arrow).
351
The dorsal metatarsal artery of the fourth interspace emanates from the arcuate artery, the lateral tarsal artery, or the proximal perforating artery of the fourth interspace (Fig. 1). It then courses in the fourth interspace dorsal to the dorsal interosseous muscle. The plantar circulation to this area is provided by the deep plantar arch, which is formed by the union of the lateral plantar artery with the deep plantar branch of the dorsalis pedis artery (Fig. 2). The deep plantar arch is the source of several potential arteries at the plantar aspect of the fifth metatarsal. A superficial metatarsal artery is commonly present running plantar to the interossei along the midline of the fifth metatarsal shaft (Fig. 3). Less often a deep plantar metatarsal artery courses between the plantar and dorsal interossei. In the fourth web space a deep plantar intermetatarsal artery was identified in a small percentage of specimens. Our specimens revealed a superficial metatarsal artery and a deep intermetatarsal artery in most cases. In about one-fifth of our specimens the fibular plantar marginal artery (Fig. 3) was seen to arise from the lateral plantar artery and course distally between the flexor digiti minimi brevis and the abductor minimi muscles. These source arteries course distally along the fifth metatarsal and give off variable numbers of branches to the base shaft and head of the bone (Fig. 4). These discrete branches then proceed to take part in the intraosseous circulation. Branches to the base and
Fig. 4. The source arteries ( A ) course distally along the fifth metatarsal and give off variable number of branches to the base, shaft and head of the bone (13).
Downloaded from fai.sagepub.com at University of Sussex Library on May 14, 2016
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SHEREFF ET AL.
Fig. 6. Photograph of specimen indicating the intraosseous circulation to the fifth metatarsal. Note the abundant periosteal plexus enveloping the fifth metatarsal. The single nutrient artery ( A ) penetrating the fifth metatarsal at the junction of the proximal and middle thirds. This vessel enters the medullary canal where it divides into a shorter proximal branch (€3) which supplies the metatarsal base and a longer distal branch (C) which courses toward the metatarsal head.
Fig. 5. The greatest confluence of extraosseous vessels occurs at the medial side of the fifth metatarsal just proximal to the site of articulation between the fourth and fifth metatarsals.
head supply the tarsometatarsal and metatarsophalangeal joints. It was our impression that the greatest confluence of extraosseous vessels occurred at the medial side of the fifth metatarsal. Of particular interest was the confluence of arteries just proximal to the site of articulation between the fourth and fifth metatarsal (Figs. 1, 2, and 5). In this region is the point of origin of the deep intermetatarsal artery, the superficial metatarsal artery, the dorsal metatarsal artery and the proximal perforating artery. lntraosseous Vascular Anatomy
The intraosseous circulation to the fifth metatarsal consists of three systems of vessels including a periosteal plexus, a nutrient artery, and metaphyseal and epiphyseal vessels. Periosteal Plexus: Branches of the dorsal and plantar source arteries provide a myriad of smaller arteries which envelop the fifth metatarsal and penetrate the
cortex. This abundant periosteal plexus was visualized in all of our intraosseous specimens (Fig. 6). Nutrient Artery: One single nutrient artery was noted to penetrate the fifth metatarsal at its medial aspect proximally at the junction of the proximal and middle thirds (Fig. 6). Unfortunately, due to the experimental techniques used it was not possible to discern whether this vessel originated from the dorsal or plantar metatarsal arteries. The nutrient vessel entered an oblique foramen oriented from distomedial to proximolateral. The vessel enters the medullary canal where it divides into a shorter proximal branch which supplies the metatarsal base and a longer distal branch which courses toward the metatarsal head. The intramedullary components of the nutrient artery give off numerous smaller branches which proceed radially to the cortex to provide the endosteal circulation to the bone. Metaphyseal and Epiphyseal Vessels: Branches of the source arteries to the base and head of the fifth metatarsal appear to provide intracapsular branches to the tarsometatarsal and metatarsophalangeal joints (Fig. 7). These branches penetrate the capsule and broach the bone in nonarticular areas of the base and the head. The greater confluence of metaphyseal and epiphyseal vessels appear to enter from the dorsal, plantar, and medial aspects of the bone. Of particular note was two arterial branches which penetrate the lateral aspect of the tuberosity in a consistent fashion. DISCUSSION
The use of acrylic casting material was most helpful in identifying extraosseous vessels. lntraosseous vascular anatomy was more clearly identified by means of
Downloaded from fai.sagepub.com at University of Sussex Library on May 14, 2016
Foot & Ankle/Vol. 1 1, No. 6/June 1991
VASCULAR ANATOMY OF THE FIFTH METATARSAL
Fig. 7. Branches of the source arteries to the base and head of the fifth metatarsalprovide intracapsularbranches to the tarsometatarsal and metatarsophalangealjoint. These branches penetratethe capsule and broach the bone in the nonarticular areas of the base and head (arrows).
the India ink gelatin mixture followed by clearing of the bone by a modified Spalteholtz technique. The vascular anatomy revealed by these methods may not be a true representation of the vascularity in vivo. It should also be realized that the blood supply to the forefoot is quite variable. The small sample size may not provide an accurate appraisal of the incidence of the vascular anatomy in the general population. The experimental techniques used required extensive chemical ablation of soft tissue. This procedure may have caused alteration or partial destruction of the small arteries to the bone. Despite these limitations, consistent patterns were noted.
353
Our findings with regard to the anatomy of the extraosseous circulation was in general agreement with those of other It was our impression that the greatest concentration of extraosseous vessels lie at the medial aspect of the fifth metatarsal. The extrinsic vascular supply emanates from several source arteries which have their origin just proximal to the articulation between the bases of the fourth and fifth metatarsals. The nutrient artery penetrates the fifth metatarsal at the medial aspect of the shaft at the junction of the proximal and middle thirds. The intraosseous metaphyseal and epiphyseal arteries originate from the extracapsular branches to the base and the head.
REFERENCES 1. Edwards, E.A.: Anatomy of the small arteries of the foot and toes. Acta Anat., 4:81-96, 1960. 2. Huber, J.F.: The arterial network supplying the dorsum of the foot. Anta. Rec., 80373-391, 1941. 3. Murakami, T.: On the position of the deep plantar arteries, with special reference to the so-called plantar metatarsal arteries. Okajimas folio. Anat. Jpn., 48:295-322, 1971. 4. Panagis, J.S., Gelberman, R.H., Taleisnik, J., and Baumgaertner, M.: The arterial anatomy of the human carpus, part II: The intraosseous vascularity. J. Hand Surg., 8:375-382, 1983. 5. Sarrafian, S.K.: Anatomy of the foot and ankle, Philadelphia, J.B. Lippincott Co., pp. 61-312. 1983. 6. Shereff, M.J., Yang, Q.M., and Kummer, F.J.: Extraosseous and intraosseous arterial supply to the first metatarsal and metatarsophalangeal joint. Foot Ankle, 8:81-93, 1987.
Announcement American Orthopaedic Foot 8, Ankle Society Resident Review Course. This course has been designed to provide an indepth review of pertinent foot and ankle topics for the resident in training, resident preparing for boards, as well as the orthopaedist in practice. A comprehensive syllabus authored entirely by AOFAS members will supplement this course for later board or intraining review. The course will be held in four regional centers in late October and November, 1991: Rochester, Minnesota; New York, New York; San Antonio, Texas; and San Francisco, California.
Downloaded from fai.sagepub.com at University of Sussex Library on May 14, 2016
Vascular Anatomy of the Fifth Metatarsal Michael J. Shereff, M.D.,' Quing Ming Yang, M.D.,t Frederick J. Kummer, Ph.D.,S Carol C. Frey, M.D.,$ and N. Greenidgen Milwaukee, Wisconsin, Shanghai, China, New York, New York, and Los Angeles, California
peroneal arteries with normal saline, Mercox acrylic resin was injected. Soft tissue was digested by chemical means6 and photographs were taken at various intervals. Twenty specimens were processed using a modified Spalteholz technique for invesigation of the intraosseous vascular a n a f ~ m yThese .~ were injected with a
ABSTRACT The extraosseous and intraosseous vascular anatomy to the fifth metatarsal as visualized in a group of below-theknee amputation specimens has been described. The extrinsic circulation to the area is provided by the dorsal metatarsal artery, the plantar metatarsal arteries, and the fibular plantar marginal artery. These three source arteries supply branches to the metatarsal and adjacent joints. The intraosseous vascularity consists of a periosteal plexus, a nutrient artery, and a system of metaphyseal and capital vessels. INTRODUCTION
Delayed union and nonunion of the fifth metatarsal after osteotomy or fracture are well described complications of surgery or injury in this region. It is believed that interruption of the circulation to the bone may be responsible for these problems. The purpose of this study was to identify the extraosseous and intraosseous vascular anatomy of the fifth metatarsal. It is hoped that this information will provide further insight into the clinical management of disorders of the fifth ray. MATERIAL AND METHODS
The extraosseous vascular anatomy was studied in 15 fresh frozen below-the-knee amputation specimens. After irrigation of the anterior tibial, posterior tibial, and ~~~
Director, Divisionof Foot and Ankle Surgery, Milwaukee Regional Medical Center, Associate Professor, Department of Orthopaedic Surgery, Medical College of Wisconsin. t Orthopaedic Research Fellow, Hospital for Joint Diseases Orthopaedic Institute, New York, New York, and Attending Orthopaedic Surgeon, Rui Jin Hospital, Shanghai, China. $ Associate Director, Division of Bioengineering,Hospital for Joint Diseases Orthopaedic Institute, New York, New York. §Director Foot and Ankle Service and Assistant Professor of Orthopedic Surgery, University of Southern California, Los Angeles, California. ll Research Associate, Division of Bioengineering, Hospital for Joint Diseases Orthopaedic Institute, New York, New York. Address correspondence and reprint requests to Michael Shereff, M.D., Medical College of Wisconsin, 8700 W. Wisconsin Ave., Milwaukee, WI 53226.
Fig. 1. The dorsal metatarsal artery to the fourth interspace (arrow) originates from the proximal perforating artery in approximately 50% of specimens. Less often this artery was seen to emanate from the arcuate artery or the lateral tarsal artery. Note the course of this vessel in the fourth interspace dorsal to the dorsal interosseous muscle.
350
Downloaded from fai.sagepub.com at University of Sussex Library on May 14, 2016
VASCULAR ANATOMY OF THE FIFTH METATARSAL
Foot & Ankle/Vol. 1 1, No. 6/June 199 1
mixed solution of India ink, gelatin, and sodium nitrate. The bones were then removed and cleared. RESULTS Extraosseous Vascular Anatomy
The extraosseous circulation of the fifth metatarsal is provided by the dorsal metatarsal artery, the plantar metatarsal arteries, and an inconsistent branch of the lateral plantar artery known as the fibular plantar marginal artery.
MARGINAL
SUPERFICIAL METATARSALARTERY DEEP INTER-/ METATARSAL ARTERY
I
1
''
LATERAL PLANTAR ARTERY
DEEP PLANTAR BRANCH OF THE DORSALIS PEOIS ARTERY PROXIMAL PERFORATING ARTERY \ '\ DEEP PLANTAR ARCH
Fig. 2. The plantar circulation to this area is provided by the deep plantar arch formed by the union of the lateral plantar artery with a deep plantar branch of the dorsalis pedis artery.
Fig. 3. A superficial metatarsal artery (white arrow) is commonly present running plantar to the interossei along the fifth metatarsal shaft. A deep plantar intermetatarsal artery is often seen running between the plantar and dorsal interossei.The fibular plantar marginal artery was visualized in 20% of specimens (black arrow).
351
The dorsal metatarsal artery of the fourth interspace emanates from the arcuate artery, the lateral tarsal artery, or the proximal perforating artery of the fourth interspace (Fig. 1). It then courses in the fourth interspace dorsal to the dorsal interosseous muscle. The plantar circulation to this area is provided by the deep plantar arch, which is formed by the union of the lateral plantar artery with the deep plantar branch of the dorsalis pedis artery (Fig. 2). The deep plantar arch is the source of several potential arteries at the plantar aspect of the fifth metatarsal. A superficial metatarsal artery is commonly present running plantar to the interossei along the midline of the fifth metatarsal shaft (Fig. 3). Less often a deep plantar metatarsal artery courses between the plantar and dorsal interossei. In the fourth web space a deep plantar intermetatarsal artery was identified in a small percentage of specimens. Our specimens revealed a superficial metatarsal artery and a deep intermetatarsal artery in most cases. In about one-fifth of our specimens the fibular plantar marginal artery (Fig. 3) was seen to arise from the lateral plantar artery and course distally between the flexor digiti minimi brevis and the abductor minimi muscles. These source arteries course distally along the fifth metatarsal and give off variable numbers of branches to the base shaft and head of the bone (Fig. 4). These discrete branches then proceed to take part in the intraosseous circulation. Branches to the base and
Fig. 4. The source arteries ( A ) course distally along the fifth metatarsal and give off variable number of branches to the base, shaft and head of the bone (13).
Downloaded from fai.sagepub.com at University of Sussex Library on May 14, 2016
352
Foot 8,Ankle/Vol. 11, No. 6/June 1991
SHEREFF ET AL.
Fig. 6. Photograph of specimen indicating the intraosseous circulation to the fifth metatarsal. Note the abundant periosteal plexus enveloping the fifth metatarsal. The single nutrient artery ( A ) penetrating the fifth metatarsal at the junction of the proximal and middle thirds. This vessel enters the medullary canal where it divides into a shorter proximal branch (€3) which supplies the metatarsal base and a longer distal branch (C) which courses toward the metatarsal head.
Fig. 5. The greatest confluence of extraosseous vessels occurs at the medial side of the fifth metatarsal just proximal to the site of articulation between the fourth and fifth metatarsals.
head supply the tarsometatarsal and metatarsophalangeal joints. It was our impression that the greatest confluence of extraosseous vessels occurred at the medial side of the fifth metatarsal. Of particular interest was the confluence of arteries just proximal to the site of articulation between the fourth and fifth metatarsal (Figs. 1, 2, and 5). In this region is the point of origin of the deep intermetatarsal artery, the superficial metatarsal artery, the dorsal metatarsal artery and the proximal perforating artery. lntraosseous Vascular Anatomy
The intraosseous circulation to the fifth metatarsal consists of three systems of vessels including a periosteal plexus, a nutrient artery, and metaphyseal and epiphyseal vessels. Periosteal Plexus: Branches of the dorsal and plantar source arteries provide a myriad of smaller arteries which envelop the fifth metatarsal and penetrate the
cortex. This abundant periosteal plexus was visualized in all of our intraosseous specimens (Fig. 6). Nutrient Artery: One single nutrient artery was noted to penetrate the fifth metatarsal at its medial aspect proximally at the junction of the proximal and middle thirds (Fig. 6). Unfortunately, due to the experimental techniques used it was not possible to discern whether this vessel originated from the dorsal or plantar metatarsal arteries. The nutrient vessel entered an oblique foramen oriented from distomedial to proximolateral. The vessel enters the medullary canal where it divides into a shorter proximal branch which supplies the metatarsal base and a longer distal branch which courses toward the metatarsal head. The intramedullary components of the nutrient artery give off numerous smaller branches which proceed radially to the cortex to provide the endosteal circulation to the bone. Metaphyseal and Epiphyseal Vessels: Branches of the source arteries to the base and head of the fifth metatarsal appear to provide intracapsular branches to the tarsometatarsal and metatarsophalangeal joints (Fig. 7). These branches penetrate the capsule and broach the bone in nonarticular areas of the base and the head. The greater confluence of metaphyseal and epiphyseal vessels appear to enter from the dorsal, plantar, and medial aspects of the bone. Of particular note was two arterial branches which penetrate the lateral aspect of the tuberosity in a consistent fashion. DISCUSSION
The use of acrylic casting material was most helpful in identifying extraosseous vessels. lntraosseous vascular anatomy was more clearly identified by means of
Downloaded from fai.sagepub.com at University of Sussex Library on May 14, 2016
Foot & Ankle/Vol. 1 1, No. 6/June 1991
VASCULAR ANATOMY OF THE FIFTH METATARSAL
Fig. 7. Branches of the source arteries to the base and head of the fifth metatarsalprovide intracapsularbranches to the tarsometatarsal and metatarsophalangealjoint. These branches penetratethe capsule and broach the bone in the nonarticular areas of the base and head (arrows).
the India ink gelatin mixture followed by clearing of the bone by a modified Spalteholtz technique. The vascular anatomy revealed by these methods may not be a true representation of the vascularity in vivo. It should also be realized that the blood supply to the forefoot is quite variable. The small sample size may not provide an accurate appraisal of the incidence of the vascular anatomy in the general population. The experimental techniques used required extensive chemical ablation of soft tissue. This procedure may have caused alteration or partial destruction of the small arteries to the bone. Despite these limitations, consistent patterns were noted.
353
Our findings with regard to the anatomy of the extraosseous circulation was in general agreement with those of other It was our impression that the greatest concentration of extraosseous vessels lie at the medial aspect of the fifth metatarsal. The extrinsic vascular supply emanates from several source arteries which have their origin just proximal to the articulation between the bases of the fourth and fifth metatarsals. The nutrient artery penetrates the fifth metatarsal at the medial aspect of the shaft at the junction of the proximal and middle thirds. The intraosseous metaphyseal and epiphyseal arteries originate from the extracapsular branches to the base and the head.
REFERENCES 1. Edwards, E.A.: Anatomy of the small arteries of the foot and toes. Acta Anat., 4:81-96, 1960. 2. Huber, J.F.: The arterial network supplying the dorsum of the foot. Anta. Rec., 80373-391, 1941. 3. Murakami, T.: On the position of the deep plantar arteries, with special reference to the so-called plantar metatarsal arteries. Okajimas folio. Anat. Jpn., 48:295-322, 1971. 4. Panagis, J.S., Gelberman, R.H., Taleisnik, J., and Baumgaertner, M.: The arterial anatomy of the human carpus, part II: The intraosseous vascularity. J. Hand Surg., 8:375-382, 1983. 5. Sarrafian, S.K.: Anatomy of the foot and ankle, Philadelphia, J.B. Lippincott Co., pp. 61-312. 1983. 6. Shereff, M.J., Yang, Q.M., and Kummer, F.J.: Extraosseous and intraosseous arterial supply to the first metatarsal and metatarsophalangeal joint. Foot Ankle, 8:81-93, 1987.
Announcement American Orthopaedic Foot 8, Ankle Society Resident Review Course. This course has been designed to provide an indepth review of pertinent foot and ankle topics for the resident in training, resident preparing for boards, as well as the orthopaedist in practice. A comprehensive syllabus authored entirely by AOFAS members will supplement this course for later board or intraining review. The course will be held in four regional centers in late October and November, 1991: Rochester, Minnesota; New York, New York; San Antonio, Texas; and San Francisco, California.
Downloaded from fai.sagepub.com at University of Sussex Library on May 14, 2016
