Beruflich Dokumente
Kultur Dokumente
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)
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,
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
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
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(
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.
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
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
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
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
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
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
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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