ARTERIAL

SUPPLY

AT

THE

CLINICAL
F. R.
Research

Avascular

the

femur

but

A ssistant

in

necrosis

of

it may

also

the

TUCKER,

LIVERPOOL,

Department

due

head

to

hip joint,
basis
of

is most

slipping

ITS

Surgery,

often

of the

University

seen

upper

after

of Liverpool

fracture

femoral

of

to the head
and this

years.

subject.
precarious
state
of the circulation
Astley
Cooper
(1822)
knew
of the

of the
study

the

epiphysis,

neck

of

reduction

of

of the femoral
these
problems,

femur
is essential.
The relative
is presented
in an attempt
to

the
The

in the femoral
head
has been
blood
supply
from vessels
which

neck,
and from small
subsidiary
vessels
fractures
invariably
failed to unite
unless

in the ligamentum
they were impacted.

reason
for this failure
was
separated
from
its cervix,

of ossific action
being
supported

the
its

absence
life then

Non-union
was the dominant
was important
only
in so
distinguish
between
femoral

problem
and inadequacy
far as it affected
union
heads
which
had some

were

necrotic.

such

AND

and pyogenic
or tuberculous
infections
Perthes
disease.
In understanding

knowledge
of the arterial
supply
is voluminous
but contradictory,

clarify

HEAD

ENGLAND

of Orthopaedic

femoral

be

congenital
dislocation
of the
neck : it is the pathological
accurate
literature

the

FEMORAL
IMPORTANCE

entirely

avascular

and

With
improved
methods
fractures.
Eyre-Brook

fractures

; and

Boyd

forty-one
fractures.
is well established,

and

and

of immobilisation,
Pridie
(1941)

George

The important
however,
that

(1947)

(1941),

(1936),

and

Seddon

noted

the

high

intracapsular
the principal

of the thigh
bone when
the ligamentum
teres.

is now achieved
union in 587 per

in the majority
cent. of seventy-five

in 865

of one

union

circumstances
weight-bearing
at the junction
of dead
and
Carrell
and Carrell
(1941),

day,
that

for many
along
the

of blood
supply
to the femoral
head
of a fracture.
Astley
Cooper
did not
residual
blood
supply
and those
which

per

cause
of non-union
take place even when

avascular.
In these
pathological
fracture
frequent
complication.

In his
claimed

in the head
solely
by

union
reported

reported

remaining
union
may

teres.
He

known
passed

cent.

is avascular
the head

hundred

of
and

necrosis.
of the femur

It
is

causes
fragmentation
of the dead bone,
or
living
bone.
Secondary
arthritis
is then a
Brailsford
(1943),
Eyre-Brook
and Pridie

incidence

of

avascular

changes

after

fracture

of

the femoral
neck
in children.
Brailsford
reported
fifteen
such
fractures,
more
than
half
of which
showed
avascular
changes.
Eyre-Brook
and Pridie
(1941) described
the
fractureshaft
angle
and were impressed
by the relationship
between
this
angle
and
the incidence
of avascular
necrosis.
Such
necrosis
developed
in 147 per cent.
of their
patients,
and in every
case the fracture-shaft

angle
was less than
37 degrees.
Linton
(1944)
studied
365 intracapsular
fractures
and
presented
statistical
evidence
that fixation
with a Smith-Petersen
nail increased
the incidence
of necrosis.
This method
is widely
practised
and it is important
to determine
whether
or not
insertion
of such a nail has harmful
effects
and, if so, whether
they can be avoided.
HISTORICAL

REVIEW

The history
of investigations
into the
arterial
supply
reviewed
fully by Chandler
and Kreuscher
(1932), Nordenson
this paper
reference
will be made
only to some of the more
stated
that
the vessels
of the ligamentum
teres
head,
but that
they spread
out upon
the surface
foveolar
veins.
Langer
(1876) showed
by injection
82

of the
femoral
head
has been
(1938), and Wolcott
(1943) ; and in
important
studies.
Hyrtl
(1846)

were not of nutritional

value
of the fovea
and immediately
that vessels
did in fact enter
THE

JOURNAL

OF

BONE

AND

to the femoral
entered
the
the developing
JOINT

SURGERY

ARTERIAL

femoral
to the

head
ossific

secondary

SUPPLY

through
centre.

TO

the
He

changes

THE

FEMORAL

ligamentum
claimed
that

in which

the

HEAD

teres and
variations

vessels

AND

that
they
existed

of the

round

that
cervical
vessels
took over an almost
exclusive
examined
one hundred
round
ligaments
but never
that arteries
of the ligament
more,
he demonstrated
by
two

children

aged

two

could convey
injection
that

years

foetuses,
infants,
children,
teres played
a certain
role

and

six

CLINICAL

were of fundamental
in the adult
but that

ligament

shrank

a trifling
did not

Kolodny

and concluded
of the femoral

83

IMPORTANCE

amount
supply

(1925)

importance
these
were

to unimportance

supply
of the head.
found
a vessel
of any

no more than
these
vessels
years.

and adults,
in nutrition

ITS

so

Walmsley
(1915)
size ; he concluded
of blood.
the ossific

investigated

Furthercentre
in

a number

of

that
the vessels
of the ligamentum
head
in the new-born
and in children,

but that they were of no importance

in the adult.
Zemansky
and Lippmann
(1929) came to
similar
conclusions.
Chandler
and Kreuscher
(1932)
examined
one hundred
and fourteen
round
ligaments,
and made serial sections
of six femoral
heads,
including
two in which
there
had been fractures
of the femoral
neck.
The subjects
were adults,
averaging
forty-eight
years.
The

ligament

was

absent

in only

one

case

and

all others

contained

vessels.

In four,

were of pre-capillary
size ; but the others
carried
a significant
blood supply.
serial sections
were made
of the femoral
head and the round
ligament,
and
that there was anastomosis
between
the arteries
of the ligament
and those
These
teres

observations
is a vascular

normal

round

are significant
structure.

ligaments.

and they
Nordenson

He

found

that

show that,
even
(1938)
examined
vessels

were

in the
one

present

adult
hip, the
hundred
and

in the

ligament

Wolcott
previously

infants

(1943)
investigated
made
similar

and

children

blood
supply
ligamentum
contribute
the

to the

site

the

from
teres

the arterial
investigations

ossifying

capsular
vessels
nourishment

of implantation

centre

vessels
do not

jn the

at various
ages
His conclusions

developing

head

growing

ligament

femoral

into

the

head,
foveolar

ligamentum
twenty-nine

femur

circumflex
iR

but

Strangely,
vessels
were
were capable
was not more

up to adolescence.
are important
of the

which
arise from the medial
enter
the head
of the femur

of the
of the

pattern
in adults.

vessels

at all ages,

that
with
advancing
age there
was increasing
obliteration
by arteriosclerosis.
however,
he found
that
in medial
fractures
of the femoral
neck
the foveolar
always
large.
He suggested
that these
vessels,
even although
arteriosclerotic,
of hypertrophy,
and that this capacity
might
explain
why necrosis
of the head
common.
had

the

In six specimens,
it was established
within
the head.

He
: 1) In

receives

artery.

children,

nor

except

for very

small

area.

3) Anastomosis

its

2) The
do

they

vessels

at

between

vessels
of the ligameRtum
teres,
capsular
arteries,
and nutrient
arteries
of the shaft,
does
not take place
until
ossification
of the femoral
head is almost
complete,
by which
time the
vessels
of the three
systems
unite
by penetrating
the thinned
area of cartilage
at the fovea.
4) The

such

ligamentum

anastomosis
In

1)

In

teres

describing
of

penetrated
capsule.
ligamentum

the

arrangement

In these

80

advanced
the

2)

per

age,

head

the

of the

opaque

which
the proximal
fragment
teres remaining
intact.
NO.

so far

1, FEBRUARY

as the

and

could

adult,

femoral

head

Wolcott

which

teres

were

carried

anastomosed

20 per cent.
successfully,

at

with

is concerned,

to course

head

was

found

alive

one

vessels

until

only

observations:

main

entering

even

artery
way

of the
of the
head.

the

by

in

which

in which
arteries
to enter
the femoral

through

with

these
successfully,

least

of adult
specimens
the vessels
failed

be seen

made

injected

through
the veins of the ligament.
was the first investigator
to state
contrasts
with other
observations,
(1924),
Hesse
(1925),
and Santos

of the

1949

in the

specimens

ligarnentum

femur,

from whence
it was returned
So far as I know,
Wolcott
increased
in size with age.
This
observed
clinical
facts.
Schmorl

31 B,

of

material

area

VOL.

present

cent.

In approximately
teres
were injected

instances

is closed,

place.

approximately

patients

circulation

takes

arteries

to the

that
the foveolar
but it is compatible
(1930)

presented

vessels

of the

foveolar

vessels
with
cases

ligamentum

in

84

F.

METHODS
This

study

cadavers,
with

and

to
neck.

at

bone,

and

The
to

measure

equivalent

the

fur

IICII1((i

Three

grop

shaft,

ng

VI

\css(i

ligamentum

term

fibres
run

necessarily
artery

retinacular

teres.

The

retinacular

and
in

the

the

vessels

of

the

or
term

periphery

impairs
of the

of
the

ligamentum

point

also

made

success

vessels
an

the

round

just

of the

about

ocular

containing

of thirty

periphery

micrometer.

of entry

into

distal

injection,
An

the

of
effort

epiphysis,

or

OF
the

end

neck.

the

external

It

and

is in

common

of

also

the

femur,
the

these

corrects

the

capsule

femoral
simply

namely

foveolar
use

which
fibrous

is adopted

of the

arteries,

relationship

of the

teres,

INVESTIGATION

upper

capsular

the

three

THE

capsular

circulation

tile

groups.

supply

stresses

substance

their

the

vessels

made

were

The
tissue,

Radigrath

sb

5p(I1I0

RESULTS

the

at

of

and

were

head.
fibrous

ears.

retinacular

of

the

means

femoral

fresh
injected

adult.

11G.

(lIe

vessels

marrow

to confirm
of

by

the

were

cartilage,

sections

distribution
assessed

of the

in the

aged

1\itit.

in order

regarding

lumen

position

red
sections

Transverse
head

was

the

the

from

vessels

of

makes

Transverse

obtained

The

decalcification

which
while

opaque.

vessels

femora
years.

after

attachments.

findings

of the

X-ray

transparent,

femoral

forty-four

seventy-seven

method

remain
of the

the
size

of

to
by

marrow
femoral

cartilage

corroborate

made
an

fatty

INVESTIGATION

examination
birth

Spalteholz

sulphate

TUCKER

OF

examined

by

to their

articular

the
was

cleared

close

to the

the
from

and

were
or barium

ligaments,

on

varying

sulphate,

decalcified
cells

based

ages

barium

specimens
red

is

the

R.

and

head.
for
THE

is quite

vessels

have

erroneous
and
The

the

nutrient

artery

view

that

or

accurate,
to

the

that

division

term

artery

artery

of

foveolar,

of
but

the
the

retinacular
these

vessels

the

capsule

in

place

brevity.
JOURNAL

OF

BONE

AND

JOINT

SURGERY

of

ARTERIAL

Nutrient
or

SUPPLY

artery-The

double.

TO

nutrient

The

superior

FEMORAL

THE

artery

branch

HEAD

enters

runs

AND

the

ITS

CLINICAL

mid-shaft

upwards

in

the

of

the

femur

medullary

85

IMPORTANCE

and

cavity

may

and

be

single

anastomoses

with cervical
branches
of the retinacular
arteries.
In no specimen
from a patient
of less than
thirteen
years
of age could
I demonstrate
nutrient
vessels
crossing
the epiphysial
plate
from the metaphysis
to the epiphysis.
However,
such an anastomosis
could be demonstrated
across

this

occurs,

zone

in

because

poor in some
in diameter.
to belong

several

the

adult

presence

It

marrow,

is not

possible

or of a dense

to both

nutrient

and

retinacular

arteries-These
There

trochanteric

is,

fossa

however,

to

which

a
the

arise

brisk

from

the

medial

extracapsular

inferior

gluteal,

and

PII1

profunda

ag((b

sill

GVI

10(0

10(1

arteries
capsule

contribute.
and they

capsule
reflected

near its lateral

extremity
and
cuff of synovial
membrane.

The circumflex
do not run within

retinacular
and
There

and

run

fibres.

As

separate
are

anterior.

they

three

may

main

The

first

the

upper

along

a rule

vessels

groups

two

groups

and

lower

run
It
they

be

medially
is in this
are

NO.

and
1,

seven
FEBRUARY

oclock.
1949

circumflex
region

obturator,

of

and

the

circumflex

2
1d(11(

\(I1..

ug

femoral
the

)II1V

feii

-111

.t(I(

g1I)h
--l1l

1
(ri

to the

distal

of the

arteries

part

of the

fibrous

the

fibrous

pierce

along the neck of the femur,

deep to the
position
that
the vessels
are associated

found

in groups,

of
are

retinacular

although

occasionally

arteries-postero-superior,

branches

borders

of the

of the

medial

neck

of the

Although

31 B,

this
visibility

a few

observed.

between

five

ill

arteries
lie superficial
its substance
; branches

the medial
aspect
eleven
and two

Fl

frequently
made

in

femoris,

e-.t(1(

and neck of the right

femur
from
superior
vessels
are found
between

VOL.

how

lateral

anastomosis

II(..

isolated

say

of capillaries,

arteries.

vessels

I. (balI,

with

to

cloud

specimens.
The anastomosis
occurred
between
vessels
of 01 to O25 millimetres
It may be supplemented
by the inosculation
of fine capillary
tufts,
which
appear

Retinacular
arteries.

specimens.

of red

the

femur.

(as in Figs.
oclock,
and

groups

may

postero-inferior,

femoral

circumflex
If one

looks

artery
at

1 and 2 insets)
the
the postero-inferior

extend

on

to

the

front

the

and
head

posterovessels
of the

86

F.

neck, they are usually

the postero-superior
supply

are

to

the

branches

of the

TUCKER

posterior.
These
two groups
are moderately
large
group
being
usually
the larger,
and occasionally

epiphysis.

The

of the

lateral

and

estimations

groups,

R.

anterior

femoral

group

circumflex

of their

sizes,

is the

smallest

artery

(Figs.

are

shown

TABLE
POSTERO-SUPERIOR

Number
.
specimens

Age

of

and

1 and

least

constant

2).

in Tables

The

vessels

frequency

ARTERY

Range
of size
of vessels

iean

24

24

(100

per

ceni.)

0125-1875

Adults

20

20

(100

per

cent.)

0#{149}300-l#{149}550mm.

TABLE

size

0#{149}730mm.

mm.

0839

mm.

Iean

size

II

RETINACULAR

ARTERY

Postero-inferior
vessels
present

of

; its

relative

I to III.

Children

P0STER0-INFERI0R

consistent,
the sole

RETINACULAR

Posterosuperior
vessels
present

and quite
providing

Range
of size
of vessels

Age

Number
specimens

Children

24

23

(95

per

cent.)

0 150-0875

mm.

0#{149}467mm.

Adults

20

16

(80

per

cent.)

0l50-0#{149}625

mm.

0410

TABLE
ANTERIOR

of

Number

Age

III

RETINACULAR

ARTERY

Anterior
vessels
present

specimens

mm.

Range
of size
of vessels

Mean

size

Children

24

16

(65

per

cent.)

0025-0#{149}525

mm.

0184

mm.

Adults

20

(25

per

cent.)

0100-0.300

mm.

0250

mm.

TABLE

IV

FOVEOLAR

Number
.
specimens

Children

24

Adults

20

14

The
like folds
branches
Branches
straight

retinacular

vessels

of

Number
penetrating

Age

lie loosely

of synovial
membrane.
to the femoral
neck

(333
(70

which

with
vessels
per

per

under
In

VESSELS

the mid-cervical
fixation
which

0075-030

cent.)
cent.)

the

synovial

parts
of the
may be noted

mm.

membrane,

their
cervical
course
anastomose
with
the

sometimes

these
nutrient

numerous
femoral
neck.

retinacular
vessels
as they
approach
THE

Mean

mm.

0075-0.625

from
the superior
vessels
are particularly
path
from their
origin
to the base of the

these
branches,
contrast
to the

Range
of size
of vessels

JOURNAL

are quite
the articular
OF

BONE

0183

mm.

0328

mm.

in mesenteric-

vessels
artery

and they
Despite

size

run
the

supply
of the

many
shaft.

a remarkably
attachment

mobile,
in marked
cartilage.
AND

JOINT

SURGERY

of

ARTERIAL

SUPPLY

TO

THE

FEMORAL

HEAD

aged

two

months.

Postero-superior
curved
penetrating

Spalteholz

the

Three

but
do
superficial

not

the

fovea.

reach
the
distribution

ossific
of
photographs

VOL.

31 B,

NO.

1,

FEBRUARY

1949

Foveolar

very

small

centre.
foveolar

the

centre

view
ossific
vessels

vessels

Fig.
5 shows
vessels
can
of

IMPORTANCE

specimens.

not

present.

vessels
are
seen.
A
to the cartilaginous
head.
specimen.

4 shows
posterior
are supplyingthe
region.

CLINICAL

Ossific

postero-inferior
retinacular
foveolar
vessel
is passing
up
The inset
is a photograph
of the

Fig.
vessels

of

preparation.

and

Male,
aged
six
months.
preparation.
Retinacular
beyond
it to the
subarticular
surface

ITS

FIG.

Male,

AND

of
centre
are

pass

the
be

deep

Spalteholz
and passing

spread

out

on

the
surface
oblique
view;
the

seen.

to

Insets

are

87

88

F. R.

The

postero-superior

they

cross

the

The

postero-inferior

substance

the

and

Foveolar

artery-The

arteries,

after

the

femoral

the

foveolar

arteries

off

varied

considerably.

supply

of the

branch

the

either

into

the

epiphysial

centre

corner

of

with

from

the

the

plate.

question

is whether

of the

obturator

pad,

in every

adult

or
in

the

vessel
up

deep

to

In the

vessels

solely

tissue

of

the

to

cartilaginous

with

vessels.

made.

It

between

is evident

that

more

retinacular

do not

fovea

possibly

in

foveolar

vessels

diameter

of

the

vessels

illustrated

in

Figs.

7 and

and

there

than

70

in adults

cross

ossific

cent.

seen

is

at

in

by

IV,

that

80

fibrous

attachment

(Figs.

4-6).

the

of twenty
visibility

per

cent.

the

incidence

which

per

of

osseous

head

specimens.
was poor

In
owing
.

and perifoveolar
capillanes,
observations
could
not

70

Table

double

increased

least

the
being

in

As

its

penetrated

to red marrow
and
accurate

is approximately

over
fingers

striking
alteration
of the foveolar

the

centre.

is anastomosis

per

They

sixteen

of the

and
head

in fourteen
out
other
specimens

vessels

other
the

supply

In adults
there
was
in the size and arrangement
6

in number

obviously

ligament

or
very

these
out

like

and

head
were

of

hand,

thirteen

fovea
the

spread

fovea

outstretched

concerned

of

five

IV.

the

age

to

in Table
the

to

vessels

one

size

of twenty-

of

size

of

to

the

out
the

The

the

surface

the

8).

specimens

ligament
but

cartilage
from

femoral

contributes

The

varied

7 and

is shown

zone

the

ligament

the

penetrated

centre.

and

the

along

specimens

artery

ossific

an

the

children
the

(Figs.

cartilaginous

the

with

medial

examined,

eight

the

small

four
years.
Postero-superior
well seen.
Foveolar
vessels

and

transverse

it runs

not
In

supplied

aged
are

head.

Within

or

the

ligament

head.
years,

Male,
vessels

femoral

other,

under

fat

present

four,

FIG.

cartilage;

of the

each

the

acetabulum

Haversian

was

or to that

pierce

the

anastomose

to the

vessel

important

centre,

cut

arises

It passes

foveolar

not

towards

present.

artery

both.

The

ossific

often

are

do

turn

vessels

if these

a pulvinar
The

then

vessels

foveolar

head.

vessels

and

retinacular

or from

giving

of retinacular

periphery
anterior

head,

circumflex
and,

at its
and

of

nutrient

group

plate

TUCKER

of

is found

cent.

adult

cases,

of

penetrating

in children,

Adult

be
and

foveolar

and

the
are

vessels

9.

DISCUSSION

There
head.

is no dispute

Difference

of the

vessels,

have

been

basis

of their

agreed

and
studies,

and

children,

the

unimportant
mentary
heads

adult

been

on

age

as

infrequent.

the

critical

may

head.

Discussion
Foveolar
the

epiphysis
some

have

of the

Observations

groups

of the

on

foveolar

to

is of little

arterial

supply

is centred

upon

of
child

be

increasing

relative

value.
but

Perthes

disease
THE

JOURNAL

diverse

upper

constitute

other
OF

BONE

femoral
of

the

in a minority

they

and

factual

importance
nutrient

from

views

the

It is generally

the

The

of material

femoral

importance

publish

value.
to

of significance

is concerned

Examination
on

the

the

and

Many

failed

papers

to

size

vessels.

have

appear

supplying

relative

chief

are

adults.

arterial

of their
the

vessels

vessels

main

questions

investigators

analysis

represent

in

the

some

vessels

adults

of supply

of three

only

which

arteries.
in

so far
source

has

effect
so that

nutrient

whereas

exists

Unfortunately

retinacular
and

foveolar

the

expressed.

that

epiphysis

as to the existence

of opinion

vessels
a supple-

avascular
necrotic
AND

of
are

femoral
lesions

JOINT

SURGERY

in

ARTERIAL

children

are

SUPPLY

very

conditions.

rare

\Ve

correlate

the

Relative

TO

and

have

I can

no

while

in a few

find

of
and

no

specimens

with

the

the

reference
known

centre

vessels
Most

penetrated
of the

vessels

that
never

are

in

the

bone
VOL.

deep

were
they

vessels

lesions
child

is more

in the
31 B,

adult,
NO.

1,

Foveolar
passing

but

sustain
the

chief

its

avascular

may

afford

dependent

thus
FEBRUARY

explaining
1949

life.

the

arterial
in

vessels
entirely

In

system

hypothesis

of specimen
the fovea

centre
size

The

evidence

supply

the

in
from

series

to

eight

femoral

children-The
vessels,

reported,

foveolar

be located

protection

retinacular

vessels

greater

frequency

head

the
than

out

of twenty-four.
there
that

in

is accepted
in the

to

cases
therefore

femoral

view

of

preparationL
centre.

epiphysis

indicates
the

to

retinacular

now

(Spalteholz
the ossific

in only
of the

If this

must

into

in these

attempting

circulation.

foveolar
almost

ossific

additional
the

about

of the

of cases.

upon

of the
to

89

IMPORTANCE

half of specimen
(Spalteholz
preparation).
is visible.
A penetrating
foveolar
artery
the postero-superior
retinacular
artery.

vascular
necrosis

CLINICAL

resort

contribute.

area
from

or the
in view

in a minority

causing

supply

seen

cartilage

could

constitute

foveolar

years.
are

small,

of importance

vascular

The

the

vessels

possibility
they

aged
six
Five
vessels

facts

ITS

injection
to

supplied

Male,
aged
sixty-four
years.
Posterior
The
perifoveolar
cloud
of capillaries
moderate
size is passing
toward

Female,

to

and

are

foveolar

AND

but

retinacular

ossific
the

HEAD

therefore,

findings

importance
head

FEMORAL

alternative,

pathological

cartilaginous

THE

the

retinacular

children,
site

centre.

is

corresponding

of avascular

necrosis

every

foveolar
but

that

of obstructive

group

ossific
the

was
the

of vessels.

The

epiphysis
area

in

children.

of

90

F.

Legg-Perlhes
might
of

disease-Although

be

the

cause

undetermined

of
nature

vulnerability

of the

largely

from

supply

provide

the

Jackson

Perthes

postero-superior

concentration

of the

believe

that

the

lip and

its labrum

vascular

the

this

Congenital

dislocation

dislocation

of the

hip

Male,

aged

and

due

specimen.

years.

This

shows

Photograph

and

could
be produced
the substance
of the

it is difficult
capsular
are
hip
left

to believe

vessels

by direct
cartilaginous

that

supplying

hip

the most likely

site of vascular
after
fixation
in full abduction
free.
The degree
of pressure

the

from

after

contrast,
danger.

the

acetabular

hip,

to

Perthes

reduction

of

It

vascular

in

of the

prone

necrosis.

posterior

; the

and

half

arteries

vessels

are

reduction

joint.

of

; and

and

that

disease.
congenital

is unlikely

that

the

decalcificd

and

of

good-sized

the

ossific

centre

from

injury.

Moreover

damage

to extra-

vessel.

trauma
head

manipulative
the

is derived

a potential

most

epiphvsis

disease.

supply
sources

rotation

are

Perthes

blood

epiphvsis

external

nutrient

foveolar

changes
within

of

to pressure

avascular

of

retinacular

obstruction

cause

FIG.

sixty

obstruction

constitutes

who

to

venous
arterial

multiple

of vessels

supply

that
that
the

femoral

of the
be

the

when

is susceptible

abduction

to

is

words,

the

group

of vascular

appears

injury

other

of the hip-Fragmentation
joint

believe

greatest

of

of vessels

of forced

pattern

be
In

to one

group

in positions
with

will

nutrition

supply

postero-supenor

it is individuals

If

vessels.
to

suggested

investigators

cause.

to infarction

a safeguard

(1941)

most

probable

epiphysis

TUCKER

Burrows

disease,

is the

R.

Again,

and

thus

protected

would

cause

I suggest

that

damage.
Fragmentation
and external
rotation,
on the vessels
trapped

extensive
the

lie

deeply

postero-superior

vessels

has

been observed
in the sound
but not when
this joint
has been
between
the femoral
neck
and

acetabular
margin
depends
upon
the degree
of abduction,
the prominence
of the posterior
acetabular
lip, and the tightness
of the adductor
muscles.
After
manipulative
reduction
with gentle
stretching
of the adductor
muscles,
the femur
usually
assumes
a position
of 45
degrees
abduction
; this
may
be accepted
as a position
of safety
so far as the
retinacular
vessels

the

are

concerned

circulation

forcibly,

using

When

in the
the

femoral

postero-superior

the

adductors

head

to
surface

are

very

lengthen
of

tight,

them
the

Epiphyseolysis
capitis
femoris-Avascular
necrosis
type of epiphyseolysis
which
is gradually
progressive.
traumatic
type,
and
in cases
treated
by vigorous
Waldenstr6m
(1934)
suggested
that
these
changes

by

femoral
is

it would
neck

not

seem

tenotomy

as

than

less

JOURNAL

to

stretch

them

a fulcrum.

frequent

complication

It does occur,
however,
manipulative
or operative
were due to surgical
division
THE

dangerous

to

OF

BONE

AND

of

the

in the acute
reduction.
or rupture
JOINT

SURGERY

ARTERIAL

SUPPLY

in the
supply

ligamentum
remaining

of vessels
vascular
vessels
occur

were damaged
more frequently.

TO

THE

FEMORAL

HEAD

AND

teres.
It is true that
to the slipped
epiphysis.

irreparably
There
are

ITS

CLINICAL

foveolar
vessels
On the other

in every
case of epiphyseolysis,
several
anatomical
facts which

91

IMPORTANCE

may represent
hand,
if the

the main
retinacular

avascular
necrosis
Should
would
explain
escape
from

injury
of the retinacular
vessels
when
slipping
occurs
slowly.
Displacement
occurs
between
the
epiphysial
cartilage
and
the metaphysis
(Waldenstr#{243}m
1930)
at a level
where
the
retinacular
vessels
are still quite mobile,
not yet having
reached
the vicinity
of the epiphysial
plate.
Thus
when
the epiphysial
plate
and epiphysis
slip downwards
and backwards
the
vessels

may

may

escape

elongate

traction

and

injury,

accommodate

particularly

if the

themselves

to the

slipping
new

is gradual

position

or slight

of the

so that

they

But

if the

epiphysis.

slipping
is rapid,
or extensive,
the vessels
are more likely to be damaged.
The postero-inferior
group
of vessels,
which
are even more mobile
than the postero-superior
group,
are more likely
to be injured
by forcible
manipulative
reduction
than by gradual
stretching
due to progressive
displacement
Relative

of the
importance

epiphysis.
of retinacular

and

foveolar

vessels

in adults-In

the

adult,

the

united
epiphysis
receives
nourishment
from additional
sources.
The retinacular
still predominant,
but the nutrient
foveolar
vessels
take over an increasing
share.
of the twenty
specimens
examined,
foveolar
vessels
penetrated
the femoral
head

vessels
are
In fourteen
and supplied

it with

a significant

The

supply

is, however,

amount

of blood,

variable

thus

: sometimes

confirming

there

Wolcotts

is none,

but

in the

observations.
majority

of cases

foveolar

it is present

to avariable
extent.
Fracture
of the neck of the femur-In
fractures
of the neck of the femur,
the fate of the head
depends
upon
the residual
vascularity,
which
is decided
at the moment
of maximal
displacement
of the bone.
It is obvious
that
all intra-osseous
vessels
in the neck are disrupted
and
that

blood

supply

depends

wholly

on the

retinacular

and

foveolar

vessels.

It seems

reasonable

to assume
that
displacement
of the fragments
is greatest
when
the fracture
line is vertical,
and least
when
it is more
horizontal,
especially
when
there
is impaction
of the fragments.
The fracture-shaft
angle
may be accepted
as an index
of the degree
of displacement,
and
probably
therefore
as a guide
to the likelihood
of damage
to the retinacular
arteries.
The
statistics
greater

of
than

Eyre-Brook
40 degrees,

and Pridie
displacement

retinacular
vessels.
It is difficult
to estimate
nourished
fully by the foveolar

(1941)
suggest
of the fragments

that

when
the
is insufficient

fracture-shaft
to cause

angle
disruption

is
of

the

of cases,
in some
near

the
cases

the

expected
One
importance

fovea

vessels
being
capable
(Schmorl
1924, Hesse
in others.

In the

were
was

other

30 per

femoral
supply

the nutrition
of the
1930), and of no more
cent.,

loss

after
fracture
was complete

The medial
revascularised

the adult
foveolar

third

of the
of the
disruption

head
can be
in 70 per cent.

whole
than

retinacular
femoral
of the

femoral
a limited

supply

head
area

would

be

neck
showed
the
retinacular
vessels

of the head was alive ; the

fully
from the living
segment

other
and

twonew

trabeculae.
There
is of course
abundant
evidence
is slow and usually
incomplete,
especially
when the
avascular
fragment
is large
(Phemister
1939)
Only when
there
are large foveolar
vessels
is
vitality
of the head
likely
to be maintained
to a degree
compatible
with a good end-result.
It must not be forgotten,
however,
that proper
reduction
and immobilisation
of the fracture
may also assist
in revascularisation
of the proximal
fragment.
Clearly,
every
effort
should
was

in the

being
laid down
adult,
complete

intact.
already

with
which
is a variable

of maintaining
1925, Santos

to cause avascular
necrosis.
patient
who died
four
months
of the foveolar
vessels.
There

but the foveolar

vessels
thirds,
which
had died,
bone
that,

the frequency
artery.
There

on the dead
regeneration

be made
to avoid
Avascular
necrosis
which
the foveolar
VOL.

31 B,

NO.

damage
to the fovealar
due to the Smith-Petersen
supply
may be affected

1, FEBRUARY

1949

arteries.
nail-There
is no direct
evidence
by a Smith-Petersen
nail.
Linton

as to the

(1944)

way

suggested

in

92

F.

that

there

was

significant

difference

of a Smith-Petersen

means

Avascular

necrosis

in the

nail

occurred

R.

and

TUCKER

incidence

those

in 395

per

of necrosis

immobilised

cent.

as between

by

of fractures

cases

Nystroms

treated

treated

three

by

the

by

small

massive

nails.
nail

and

only in 93 per cent. of fractures

immobilised
by small
nails.
The explanation
seems
to be
obvious.
Any object
driven
into the bone near the fovea
may disrupt
the foveolar
vessels.
Furthermore,
in so far as the anterior
part of the head usually
receives
its blood
supply
from
the posterior
set of retinacular
vessels,
a large centrally
placed
object
may sever intra-osseous
arteries.
The foveolar
vessels
are most prone
to damage
if the nail is near the fovea and with
its tip flush with the articular
surface.
Nystroms
nails, and Austin
Moores
pins, are inserted
more
peripherally
than
the Smith-Petersen
nail and their
bulk is dispersed
; for this reason
they
are likely
to cause
less damage.
The risk of a Smith-Petersen
nail may perhaps
be
reduced
Traumatic
damage
the

by inserting
dislocation
in traumatic

foveolar

vessels

ligamentum
head

it eccentrically
and avoiding
the foveolar
of the hip joint-There
is little
evidence
dislocation
of the hip joint.
Kleinberg
were

teres

from

frequency
between

still

must

foveolar

be ruptured

vessels.

of damage
these
vessels

The

due

after

such

injury,

so that

there

can

incidence

to retinacular
and the nutrient

crossing
the epiphysial
line
there
was such anastomosis.
joint,

patent

to rupture

and

from the metaphysis

Thus,
avascular

of the

retinacular

between
these
vessels
and
in children
than in adults.

the

incidence

reported

in

the

in which

majority

of

supply

to the

depend

first

be no vascular
necrosis

of vascular

a case

must

cases

in cases

artery,

the

femoral
upon

the

then
upon
the incidence
of anastomosis
In children
no nutrient
vessel
was detected

to the epiphysis.
In some adults,
necrosis
after traumatic
dislocation

vessels

nutrient

to the

(1944)

but

of avascular

vessels,
arteries.

area.
as

where

must

there

is no adequate

be expected

to

occur

however,
of the hip
anastomosis

more

frequently

SUMMARY
1.

The

arterial

children
2. The

supply

of

the

upper

and twenty
adults.
arterial
system
was

end

of

demonstrated

the

by

femur

has

injection

been

of

The

retinacular

inferior,

and

at all
5.

vessels

anterior.

consist

These

of

vessels

three

are

the

small

The

material,

with

neck and ligamentum

teres.
of the shaft,
the retinacular
teres.
: postero-superior,

to the

epiphysis

postero-

and

femoral

head

foveolar

artery

constitutes

and

subsidiary

cartilaginous
specimens.

blood

supply

or osseous
The foveolar

to

the

femoral

head in 33 per
vessels
increase

cent.

of

in size

age.

with
6.

for

groups

supply

twenty-four

ages.

epiphysis.
In this series,
it penetrated
the
young
specimens
and 70 per cent.
of adult

The

separate

chief

in

radio-opaque

Spalteholz
method
of clarification,
and histological
section
of the
3. The upper
end of the femur
is supplied
by the nutrient
artery
vessels
of the capsule,
and the foveolar
artery
of the ligamentum
4.

studied

The

site

of the

vascular

like

author
would
their
encouragement

to

pathology

express

and

his

in

various

lesions

to

Professor

T.

thanks

P.

of

the

femoral

McMurray

and

head

is considered.

Professor

H.

L.

Sheehan

assistance.

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BANKS,

S. W.

Journal

of Bone

BOYD,
of

H. B.

Bone

and

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Joint

BRAILSFORD,
BURROWS,

1) : Aseptic
and

29,

Necrosis
Surgery,

GEORGE,

I. L.

Surgery,

29,

J F. (1943)
J. (1941):
.

H.

Joint

(1947)

Femoral

Head

following

Traumatic

Dislocation

of the

Hip.

753.
: Complications

of

Fractures

of the

Neck

of the

Femur.

Journal

13.

: Avascular

Coxa

of the
23,

Plana,

Necrosis

with

of

special

Bone.

reference

Journal

to its

of

Bone

Pathology

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Joint

25,

Surgery,

Kinship.

British

249.
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THE

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SURGERY

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B.,

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S. B.,
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Chirurgie,

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zu

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141.

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