Intraosseous Blood Supply to the Distal Humerus

Abstract

We read with interest the recent article titled “Intraosseous Blood Supply to the Distal Humerus” by Kimball et al (J Hand Surg 2007;32A:642–646). We first of all make a point of congratulating the authors for this remarkable anatomic study. Photographs of the anatomic specimens prepared according to the modified Spalteholz technique are particularly conclusive especially when one knows the difficulty to carry out a diaphanization.1Wavreille G. Cassio J.B. Chantelot C. Mares O. Guinand R. Fontaine C. Anatomical bases of the second toe composite dorsal flap for simultaneous skin defect coverage and tendinous reconstruction of the dorsal aspect of the fingers.J Plast Reconstr Aesthet Surg. 2007; 60: 710-719Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar We however regret that our work2Wavreille G. Dos Remedios C. Chantelot C. Limousin M. Fontaine C. Anatomic bases of vascularized elbow joint harvesting to achieve vascularized allograft.Surg Radiol Anat. 2006; 28: 498-510Crossref PubMed Scopus (16) Google Scholar published very recently in Surgical and Radiologic Anatomy was not quoted. This study, carried out on 102 dry bones and 18 elbows, described periarticular vascularization of the elbow. Location of the diaphyseal nutrient foramen of humerus was located precisely: in the anterior medial diaphysis aspect in 96% near the medial border but in 4% in its posterior aspect near the lateral aspect. It is interesting to note that Kimball et al described constant anterior vessels in the anterior aspect of the lateral column that have not previously been described. In our anatomic study, however, we found in all specimens an artery, quite absent from the classic textbooks, which we called the “musculoperiosteal radial artery” because of its characteristics. It arose usually from the posterior aspect of the brachial artery at the same level as the inferior ulnar collateral artery. Its origin was measured 63 mm on average above the brachial artery bifurcation. This artery formed a periosteal network on the anterolateral aspect of the humeral condyle after having perforated the brachialis muscle and provided it 2–4 collateral branches by following a curve with inferolateral concavity. It usually anastomosed with the recurrent radial artery, the radial collateral artery, and sometimes with the inferior ulnar collateral artery. The article of Kimball et al precisely describes intraosseous vascularization without noting the origin of the vessels, the modified Spalteholz technique not allowing it. On the other hand, our study attempted to describe precisely the origin, the course, and the gauge of all small arteries of the elbow joint until their osseous penetration. We could define arterial periosteal territories, which seem more relevant to us than the quantification of the metaphyseal foramens to preserve osseous vascularization. In the anterior or posterior aspect, the epiphyseal humeral blood supply was by the anterior ulnar recurrent artery medially and by the radial recurrent artery laterally. The humeral metaphyseal blood supply was in the anterior aspect by the inferior ulnar collateral artery medially and by the musculoperiosteal radial artery laterally; in the posterior aspect by the inferior ulnar collateral artery distally and by the superior ulnar collateral artery humeral proximally; on the lateral aspect by the posterior branch of the profunda brachii artery. The gauges of the recurrent arteries were notable; that of the posterior branch of the profunda brachii artery the smallest. The vascularization of the lateral portion of the distal extremity of the humerus thus appears more precarious. In ReplyJournal of Hand SurgeryVol. 32Issue 8PreviewWe thank Drs. Wavreille, Chantelot, and Fontaine for their excellent comment concerning our article “Intraosseous Blood Supply to the Distal Humerus.” We were unaware of their report (Wavreille G, Dos Remedios C, Chantelot C, Limousin M, Fontaine C. Anatomic bases of vascularized elbow joint harvesting to achieve vascularized allograft. Surg Radiol Anat 2006;28:498–510) when we first submitted our report for publication. Our manuscript had to be revised several times, and unfortunately during that lengthy process we did not update our references. Full-Text PDF