The Intraosseous Blood Supply of the Fifth Metatarsal: Implications for Proximal Fracture Healing

Foot & Ankle ◽  
1992 ◽  
Vol 13 (3) ◽  
pp. 143-152 ◽  
Author(s):  
Judith W. Smith ◽  
Steven P. Arnoczky ◽  
Alexander Hersh
Keyword(s):  
Fracture Healing ◽  
Blood Supply ◽  
Vascular Anatomy ◽  
Delayed Union ◽  
Nonoperative Treatment ◽  
Anatomical Location ◽  
Nutrient Artery ◽  
India Ink ◽  
Increased Risk ◽  
Fresh Frozen

Fractures of the proximal fifth metatarsal can be divided into two distinct groups based on anatomical location and clinical course. Fractures of the tuberosity often heal well with nonoperative treatment, whereas fractures occurring in the proximal diaphysis (up to 1.5 cm distal to the tuberosity) have significantly increased risk for delayed union or nonunion. It is the purpose of this paper to describe the intraosseous vascular anatomy of the fifth metatarsal, and the clinical implications for basilar fracture healing. Ten fresh-frozen amputation or cadaver specimens were studied following arterial injection with India ink or barium sulfate suspension. The intraosseous blood supply to the fifth metatarsal tuberosity arose from numerous metaphyseal vessels penetrating the nonarticular surfaces of the tuberosity in a random, radiate pattern. The blood supply to the proximal diaphysis was derived primarily from the nutrient artery, which gave rise to longitudinal intramedullary branches. The arterial supply to the tuberosity joined the supply of the proximal diaphysis in the area just distal to the tuberosity, corresponding to the region of poor prognosis for fracture healing. This suggests that a relative lack of blood supply following a proximal diaphyseal fracture may contribute to delayed union and nonunion.

scholarly journals Variations in Blood Supply from Proximal to Distal in the Ulnar Collateral Ligament of the Elbow: A Qualitative Descriptive Cadaveric Study

2019 ◽  
Vol 7 (7_suppl5) ◽  
pp. 2325967119S0036
Author(s):  
Patrick S. Buckley ◽  
Elizabeth R. Morris ◽  
Colin Robbins ◽  
Bryson Kemler ◽  
Salvatore Joseph Frangiamore ◽  
...  
Keyword(s):  
Blood Supply ◽  
Average Length ◽  
Vascular Anatomy ◽  
Ulnar Collateral Ligament ◽  
Vascular Supply ◽  
Medial Epicondyle ◽  
Qualitative Description ◽  
Return To Play ◽  
Collateral Ligament ◽  
India Ink

Objectives: The vascular supply of the ulnar collateral ligament (UCL) is unknown. Previous studies have reported varying success in return to play rates after non-operative management of partial UCL tears and suggest a varying healing capacity as possibly related to UCL injury location. The purpose of this study was to analyze the macroscopic vascular anatomy of the ulnar collateral ligament of the elbow. Methods: Eighteen, fresh-frozen, male cadaveric elbows from nine donors were sharply dissected 15 cm proximal to the medial epicondyle. Sixty mL of India Ink was injected through the brachial artery of each elbow. Arms were then frozen at -10°C, radial side down in 15-20° of elbow flexion. A bandsaw was used to section the frozen elbows into 5 mm coronal or sagittal sections. Sections were cleared for visualization using the modified Spalteholz technique. Images of specimens were taken and the qualitative description of the UCL vascularity was undertaken. Results: We consistently found a dense blood supply to the proximal UCL, while the distal UCL was hypovascular. We observed a possible osseous contribution to the proximal UCL from the medial epicondyle in addition to an artery from the flexor/pronator musculature that consistently appeared to provide vascularity to the proximal UCL. The degree of vascular penetration moving from proximal to distal in the UCL ranged from 39-68% of the overall UCL length, with a 49% average length of vascular penetration of the UCL. Conclusion: Our study found a difference in the vascular supply of the ulnar collateral ligament. The proximal UCL was well vascularized, while the distal UCL was hypovascular. This difference in vascular supply may be a factor in the differential healing capacities of the UCL based on the location of injury. An improved understanding of the macroscopic vascular supply of the UCL may aid in the clinical management of partial UCL tears and suggest an indication for treatments with respect to location of UCL injuries.

The Blood Supply to the Great Toe Sesamoids

Foot & Ankle ◽  
1993 ◽  
Vol 14 (8) ◽  
pp. 435-442 ◽  
Author(s):  
Patricia D. C. Chamberland ◽  
Judith W. Smith ◽  
Lamar L. Fleming
Keyword(s):  
Soft Tissue ◽  
Blood Supply ◽  
Soft Tissues ◽  
Posterior Tibial Artery ◽  
Small Vessels ◽  
Plantar Surface ◽  
India Ink ◽  
Soft Tissue Dissection ◽  
Fresh Frozen ◽  
Medial Plantar Artery

The purpose of this study was to define the intraosseous and extraosseous blood supply of the hallucal sesamoids by studying a total of 10 fresh-frozen, below-knee specimens with no evidence of vascular disease. Most specimens were injected with high grade India ink, cleared using a standard Spalteholz technique, and processed to delineate the extraosseous and intraosseous blood supply to include soft tissue dissection and coronal sectioning. Two additional specimens were injected with blue Mercox acrylic solution to further define the extraosseous vasculature. The major extraosseous blood supply to the sesamoids is via the posterior tibial artery. This vessel then branches into the medial plantar artery which further divides upon entering the medial and lateral sesamoids in their proximal poles. Vessels in the peripheral soft tissues, although abundant, do not seem to penetrate the cortex of the sesamoids. The intraosseous blood supply to the sesamoids seems to be threefold. Mainly, sesamoid arteries enter the lateral and medial sesamoids from the proximal aspect via a single vessel. This proximal vessel proceeds distally with a network of branching. Plantar, nonarticular vessels enter the sesamoids, constituting a second source of vascularity. Finally, small vessels also enter the sesamoids through medial and lateral capsular attachments. Based on this study, a possible explanation for avascular necrosis and nonunion of sesamoids is proposed, and an optimal surgical approach is discussed. A medial operative approach avoiding the proximal pole of the sesamoids will preserve the main arterial source. The plantar surface of the sesamoids should also be avoided. Minimal dissection through the circumferential soft tissue vascular sleeve is recommended.

Variations in Blood Supply From Proximal to Distal in the Ulnar Collateral Ligament of the Elbow: A Qualitative Descriptive Cadaveric Study

2019 ◽  
Vol 47 (5) ◽  
pp. 1117-1123 ◽  
Author(s):  
Patrick S. Buckley ◽  
Elizabeth R. Morris ◽  
Colin M. Robbins ◽  
Bryson R. Kemler ◽  
Salvatore J. Frangiamore ◽  
...  
Keyword(s):  
Blood Supply ◽  
Vascular Anatomy ◽  
Ulnar Collateral Ligament ◽  
Elbow Flexion ◽  
Vascular Supply ◽  
Medial Epicondyle ◽  
Qualitative Description ◽  
Return To Play ◽  
Collateral Ligament ◽  
India Ink

Background: The vascular supply of the ulnar collateral ligament (UCL) is unknown. Previous studies reported varying success in return-to-play rates after nonoperative management of partial UCL tears and suggested a varying healing capacity as possibly related to the location of the UCL injury. Purpose: To analyze the macroscopic vascular anatomy of the UCL of the elbow. Study Design: Descriptive laboratory study. Methods: Eighteen fresh-frozen male cadaveric elbows from 9 donors were sharply dissected 15 cm proximal to the medial epicondyle. Sixty milliliters of India ink was injected through the brachial artery of each elbow. Arms were then frozen at −10°C, radial side down, in 15° to 20° of elbow flexion. A band saw was used to section the frozen elbows into 5-mm coronal or sagittal sections. Sections were cleared for visualization with the modified Spalteholz technique. Images of the specimens were taken, and qualitative description of UCL vascularity was undertaken. Results: The authors consistently found a dense blood supply to the proximal UCL, while the distal UCL was hypovascular. They also observed a possible osseous contribution to the proximal UCL from the medial epicondyle in addition to an artery from the flexor/pronator musculature that consistently appeared to provide vascularity to the proximal UCL. The degree of vascular penetration from proximal to distal in the UCL ranged from 39% to 68% of the overall UCL length, with a 49% mean length of vascular penetration of the UCL. Conclusion: This study found a difference in the vascular supply of the UCL. The proximal UCL was well vascularized, while the distal UCL was hypovascular. This difference in vascular supply may be a factor in the differential healing capacities of the UCL based on the location of injury. Clinical Relevance: An improved understanding of the macroscopic vascular supply of the UCL may aid in the clinical management of partial UCL tears and suggests an indication for these treatments with respect to location of UCL injuries.

scholarly journals Timing of Bisphosphonate Initiation After Fracture: What Does the Data Really Say?

2020 ◽  
Vol 11 ◽  
pp. 215145932098036
Author(s):  
David W. Barton ◽  
C. Taylor Smith ◽  
Amit S. Piple ◽  
Sterling A. Moskal ◽  
Jonathan J. Carmouche
Keyword(s):  
Fracture Healing ◽  
Clinical Studies ◽  
Osteoporosis Treatment ◽  
The Body ◽  
Non Union ◽  
Increased Risk ◽  
Level I ◽  
Timing Of Initiation ◽  
The Impact ◽  
Published Research

Introduction: Osteoporosis is often not clinically recognized until after a fracture occurs. Individuals who have 1 fracture are at increased risk of future fractures. Prompt initiation of osteoporosis treatment following fracture is critical to reducing the rate of future fractures. Antiresorptives are the most widely used class of medications for the prevention and treatment of osteoporosis. Many providers are hesitant to initiate antiresorptives in the acute post-fracture period. Concerns include interference with bone remodeling necessary for successful fracture healing, which would cause increased rates of non-union, malunion, and refracture. While such concerns should not extend to anabolic medications, physicians may also hesitate to initiate anabolic osteoporosis therapies due to high cost and/or lack of familiarity. This article aims to briefly review the available data and present a digestible narrative summary to familiarize practicing orthopaedic surgeons with the essential details of the published research on this topic. Results: The results of 20 clinical studies and key pre-clinical studies related to the effect of anti-resorptive medications for osteoporosis on fracture healing are summarized in the body of this narrative review. Discussion & Conclusions: While few level I studies have examined the impact of timing of initiation of osteoporosis medications in the acute post-fracture period, the few that have been published do not support these concerns. Specifically, data from level I clinical trials indicate that initiating bisphosphonates as early as 2 weeks post-fracture does not increase rates of non-union or malunion. By reviewing the available data, we hope to give clinicians the confidence to initiate osteoporosis treatment promptly post-fracture.

scholarly journals Medical Malpractice Trends in Foot and Ankle Surgery

2020 ◽  
Vol 5 (4) ◽  
pp. 2473011420S0004
Author(s):  
Rishin J. Kadakia ◽  
Keith Orland ◽  
Akhil Sharma ◽  
Jie Chen ◽  
Craig C. Akoh ◽  
...  
Keyword(s):  
Medical Malpractice ◽  
Orthopaedic Surgery ◽  
Nonoperative Treatment ◽  
Anatomical Location ◽  
Foot And Ankle ◽  
Common Complication ◽  
Adult Females ◽  
Forefoot Surgery ◽  
Ankle Surgery ◽  
Malpractice Claims

Category: Other Introduction/Purpose: Medical malpractice lawsuits can place significant economic and psychologic burden on a provider. Orthopaedic surgery is one of the most common subspecialties involved in malpractice claims. There is currently no study examining malpractice lawsuits within foot and ankle surgery. Accordingly, the purpose of this work is to examine trends in malpractice claims in foot and ankle surgery. Methods: The Westlaw legal database was queried for lawsuits pertaining to foot and ankle surgery from 2008 to 2018. Only cases involving medical malpractice were included for analysis. All available details pertaining to the cases were collected. This included plaintiff demographic and geographic data. Details regarding the cases were also collected such as anatomical location, pathology, complications, and case outcomes. Results: Forty nine malpractice lawsuits pertaining to foot and ankle were identified. Most plaintiffs in these cases were adult females, and the majority of cases occurred in the northeast (53.1%). The most common anatomical region involved in claims involved the forefoot (29%). The majority of these claims involved surgery (65%). Infection was the most common complication seen in claims (22%). The jury ruled in favor of the defendant surgeon in most cases (73%). Conclusion: This is the first study to examine trends in medical malpractice within foot and ankle surgery. Infection was the most frequent complication seen in claims and forefoot surgery was the most common anatomic location. A large portion of claims resulted after nonoperative treatment. A better understanding of the trends within malpractice claims is crucial to developing strategies for prevention.

scholarly journals Vascular Supply of the Human Spiral Ganglion: Novel Three-Dimensional Analysis Using Synchrotron Phase-Contrast Imaging and Histology

2020 ◽  
Vol 10 (1) ◽  
Author(s):  
Xueshuang Mei ◽  
Rudolf Glueckert ◽  
Annelies Schrott-Fischer ◽  
Hao Li ◽  
Hanif M. Ladak ◽  
...  
Keyword(s):  
Blood Supply ◽  
Phase Contrast ◽  
Spiral Ganglion ◽  
Three Dimensional ◽  
Vascular Anatomy ◽  
Helical Structure ◽  
Vascular Supply ◽  
Phase Contrast Imaging ◽  
Contrast Imaging ◽  
Temporal Bones

AbstractHuman spiral ganglion (HSG) cell bodies located in the bony cochlea depend on a rich vascular supply to maintain excitability. These neurons are targeted by cochlear implantation (CI) to treat deafness, and their viability is critical to ensure successful clinical outcomes. The blood supply of the HSG is difficult to study due to its helical structure and encasement in hard bone. The objective of this study was to present the first three-dimensional (3D) reconstruction and analysis of the HSG blood supply using synchrotron radiation phase-contrast imaging (SR-PCI) in combination with histological analyses of archival human cochlear sections. Twenty-six human temporal bones underwent SR-PCI. Data were processed using volume-rendering software, and a representative three-dimensional (3D) model was created to allow visualization of the vascular anatomy. Histologic analysis was used to verify the segmentations. Results revealed that the HSG is supplied by radial vascular twigs which are separate from the rest of the inner ear and encased in bone. Unlike with most organs, the arteries and veins in the human cochlea do not follow the same conduits. There is a dual venous outflow and a modiolar arterial supply. This organization may explain why the HSG may endure even in cases of advanced cochlear pathology.

scholarly journals The long and short of it: using the new factor products

Hematology ◽  
2015 ◽  
Vol 2015 (1) ◽  
pp. 26-32 ◽  
Author(s):  
Amy Dunn
Keyword(s):  
Half Life ◽  
Fresh Frozen Plasma ◽  
Recurrent Bleeding ◽  
Prophylactic Therapy ◽  
Improved Outcomes ◽  
Increased Risk ◽  
Plasma Factor ◽  
Fresh Frozen ◽  
Bleeding Episodes ◽  
Viral Attenuation

Abstract Hemophilia A (HA) and B (HB) are classified as mild (>5%-40%) moderate (1%-5%) and severe (<1%) disease based on plasma factor activity. Severity of bleeding is commensurate with baseline factor levels in general; however, heterogeneity of bleeding in patients is well described. Recurrent bleeding with painful and disabling musculoskeletal complications is the largest source of morbidity for persons with hemophilia (PWH) but treatment advances through the years has led to improved outcomes. In the early 20th century, only whole blood and fresh frozen plasma (FFP) was available to treat bleeding episodes. In 1959, cryoprecipitate was discovered and became an option for treatment of HA in 1965. In the 1970s plasma fractionation led to the first standard half-life (SHL) concentrates. These products ushered in the use prophylactic therapy to prevent bleeding episodes. However, viral contamination slowed the use of prophylaxis until the 1980s when viral attenuation steps increased the safety of plasma concentrates. In the 1990s recombinant concentrates were developed and prophylactic therapy is increasing widely yet not yet universally used. However even with frequent SHL concentrate infusions outcomes are not optimal as PWH spend the majority of time with factor levels below the normal range and are at increased risk for bleeding. In 2014, the first extended half-life (EHL) products were approved for use and have begun to change the landscape of hemophilia care. Challenges of EHL implementation include patient selection, product selection, dose and schedule of infusions, monitoring for safety, efficacy and outcomes, and managing economic aspects of care.

ANATOMICAL STUDY OF ARCADE OF STRUTHERS

Hand Surgery ◽  
2010 ◽  
Vol 15 (03) ◽  
pp. 157-159 ◽  
Author(s):  
Piyapong Tiyaworanan ◽  
Surut Jianmongkol ◽  
Tala Thammaroj
Keyword(s):  
Ulnar Nerve ◽  
Anatomical Study ◽  
Medial Epicondyle ◽  
Anatomical Location ◽  
Greater Tuberosity ◽  
Lateral Epicondyle ◽  
Surgical Exploration ◽  
Fresh Frozen ◽  
The Mean ◽  
Proximal Border

The incidence and the anatomical location of the arcade of Struthers as related to the arm length were studied in 62 arms of adult fresh-frozen cadavers. The distance between the greater tuberosity and the lateral epicondyle was designated as the arm length. The arcades of Struthers were identified in 85.4%. The mean arm length was 27.85 ± 1.3 cm. The mean of the distance between proximal border of the arcade of Struthers and the medial humeral epicondyle was 8.24 ± 2.06 cm. The mean ratio between the distance from the proximal border of the arcade to the tip of the medial epicondyle and arm length was 0.29 ± 0.07. We concluded that the anatomical location of the arcade as related to the arm length was 29% proximally, from the tip of the medial epicondyle. This report of the anatomical location of the arcade of Struthers related to the arm length can be useful to identify this structure in the arms which have differences in arm length during the surgical exploration and anterior transposition of the ulnar nerve procedures.

scholarly journals Nonoperative Treatment of Appendicitis during Pregnancy in a Remote Area

2018 ◽  
Vol 08 (01) ◽  
pp. e37-e38 ◽  
Author(s):  
Anne-Kathrine Carstens ◽  
Lise Fensby ◽  
Luit Penninga
Keyword(s):  
Antibiotic Treatment ◽  
Treatment Option ◽  
Fetal Loss ◽  
Surgical Care ◽  
Weather Conditions ◽  
Nonoperative Treatment ◽  
Definitive Treatment ◽  
Bridge To Surgery ◽  
Increased Risk ◽  
Geographical Distances

AbstractAppendicitis is the most common nonobstetric surgical disease during pregnancy. Appendicitis during pregnancy is associated with an increased risk of morbidity and perforation compared with the general population. Furthermore, it may cause preterm birth and fetal loss, and quick surgical intervention is the established treatment option in pregnant women with appendicitis. In Greenland, geographical distances are very large, and weather conditions can be extreme, and surgical care is not always immediately available. Hence, antibiotic treatment is often initiated as a bridge-to-surgery. We report on a pregnant Greenlandic Inuit woman with appendicitis who was treated with intravenous antibiotics. Antibiotic treatment was successful before surgical care became available and the patient was not operated. No complications occurred, and further pregnancy was uneventful. Our case suggests that antibiotic treatment of appendicitis during pregnancy as a bridge-to-surgery may be a sensible treatment option in remote areas, where no surgical care is immediately available. In some cases, antibiotic treatment may turn out to be definitive treatment.

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