Study of Neurovascular Foramina of the Human Clavicle and Their Clinical Significance.
Sreepreeti Champatyray1,SarthakRanjan Nayak2,Tapaswini Mishra3, SaurjyaRanjan Das4
1Department of Oral Pathology2Department of Biochemistry, 3Department of
Physiology,1Department of Anatomy, IMS and SUM Hospital, Siksha 'O' Anusandhan (Deemed to be University), Bhubaneswar- 751003 (Odisha) India
1.ASSISTANT [email protected] 2.PROFESSOR [email protected]
3.ASSOCIATE [email protected] 4.ASSOCIATE PROFESSOR- [email protected]
*Corresponding author Dr. SaurjyaRanjan Das
Associate ProfessorDepartment of AnatomyIMS and SUM HospitalBhubaneswar Email: [email protected]
Cell; 09439921177 Abstract
Background
The clavicle transfers the body weight from upper limb to the axial skeleton. Commonly one nutrient foramen is found on shaft of the clavicle away from the growing end and allows the passage of main nutrient artery. Vascularized clavicle helps principally in joint allograft and bone grafting. The objective of our study was to determine the number, position, direction, of nutrient foramen and the foraminal index.
Material & methods:
This present study was performed on 62 clavicles obtained from the Department of Anatomy and Forensic Medicine, IMS and SUM Hospital, Bhubaneswar. Among them 34 and 28 belongs to the right and left side respectively. The number, location and direction of nutrient foramina was documented and compared with the investigations done by the preceding authors. Mean foramen index was calculated by applying Hughes formula.
Result:
Total 92 nutrient foramina were observed in 62 bones. Out of them single foramina was detected in 42 (67.74%) and double foramina in 12 (19.35%). More than 2 nutrient foramina were found in 8 (12.89%) clavicles. Location of the foramina was more common on posterior surface (76%) than on the inferior surface (24%). 65.21% of the foramina were present in middle 1/3rd of the clavicle. All are directed away from the growing end of the bones. Our study shows the average distance of the foramen from the sternal end was 67.9mm and the mean foramen index was 53.80.
Conclusion:
Recognition of nutrient foramina is critical for vascularized bone graft, positioning of internal fixation, and in microsurgical vascularized bone transplantation. It also sustains arterial supply during the radiation therapy.
Keywords: Clavicle, Nutrient foramen, Foramen index, Sternal end, Bone grafting
INTRODUCTION
The clavicle is a modified long bone of pectoral girdle placed horizontally and is subcutaneous throughout its length. Clavicle transmits the weight of the body from the upper limb to the axial skeleton. It develops from the membrane and devoid of medullary cavity. It bears the glenohumeral joint so that the arm can swing easily away from the trunk.
Usually clavicle contains one nutrient foramen for the entry of main nutrient artery present in the shaft. [1] The nutrient foramen develops naturally during the growth of the fetus. The nutrient foramen is present in the inferior surface of shaft, lateral to subclavian groove of clavicle. [2]
The direction of nutrient foramen is directed away from the growing end as a rule. e.i towards the acromial end of the clavicle. The nutrient artery is the key source of the blood supply to a long bone, which enters the bone shaft along with the nerves through the nutrient foramen during its growth period.The nutrient artery is originated from the clavicular branch of suprascapular artery or acromiothroasic artery. [3,4] In one study it was published that the clavicle is supplied by the periosteal arteries and is devoid of nutrient artery. [5]
The study of nutrient foramina is clinically important as it is involved in the repair of clavicular fracture which produces brachial plexus injury and supraclavicular nerve entrapment syndrome.
[6] There is maximum chance of non union of clavicle in fracture of clavicle, so microsurgical procedures are done by orthopedician surgeons for proper union of clavicular fracture. [7]
Identification of nutrient foramina is crucial for various surgical procedures such as vascularized bone grafting, positioning of internal fixation, and microsurgical vascularized bone transplantation where there is preservation of the circulation of the affected bone is maintained for quick healing of the graft in the recipient as well as osteoclast and osteoblast cell. [8,9]
Material and methods
The current study was conducted on 62 clavicles of unidentified age and sex, out of them, 34 belong to right and 28 belong to left side. The bones were collected from the museum of Department of Anatomy and Forensic Medicine, IMS and SUM HOSPITAL, Bhubaneswar.
The bones were cleaned, dried and numbered. The deformed bones were discarded. A magnifying glass was utilized to detect the foramina. The nutrient foramina were recognized by the existence of a well defined groove which has slightly elevated edge at the opening of the canal. The total length of the clavicle & the distance of foramina from the sternal end were
hypodermic needle) was considered. Hughes formula was used to calculate the Mean foramen index.
Foramen Index (FI) = (DNF/TL) x 100
The FI can be obtained by dividing the distance of the foramen from the sternal end (DNF) by the total length of the bone (TL), and multiplied by 100.
The position of the foramen with regard to the surface of the clavicle was observed and analyzed.
The lengths of the clavicles were estimated and each was equally divided into three parts and the position of the foramen was noted. The foramen index was calculated for all the clavicles and the foramina were topographically classified into 1/3 regions (medial 1/3, middle 1/3 and lateral 1/3). The Range, Mean and Standard Deviation of Foramina Indices (FI) were determined. The number, location and the direction of nutrient foramina were registered and compared with the investigations done by the earlier authors. All the findings were tabulated and analyzed statistically by using Microsoft excel software.
Results
Nutrient foramina were observed in 62 (100%) clavicles as below Number of Nutrient Foramen –
The foramen was found single in 42 (67.74%) clavicles, double in 12 clavicles (19.35%) and more than 2 foramina in 8 clavicles (12.90%). Most of the right clavicles carry single foramina (62.74%) and double foramina (23.52%) whereas left clavicles carry single foramina (71.42%) and double foramina (14.28%) more than two foramina (14.28%). Three foramina and four foramina were found only in two clavicles (7.14%) and that was in the left sided clavicle (Table 1).
Table1. Numbers of nutrient foramina in clavicles Number(s) of
nutrient foramina Clavicles
Right (34) Left (28) Total
1 22 (64.70%) 20 (71.42%) 42 (62.74%)
2 8 (23.52%) 4 (14.28%) 12 (19.35%)
3 4 (11.76%) 2 (7.14%) 6 (9.67%)
4 0 2 (7.14%) 2 (3.27%)
Location of Nutrient Foramen- Total 92 number of nutrient foramen was found. We observed 22 (24%) foramen were located on the inferior surface and 70 (76%) foramen were located on the posterior surface of the clavicles. Total number of clavicles mentioned was 68 as few of them carried nutrient foramen on both posterior and inferior surfaces (Table 2).
Table 2-Location of foramen
SURFACE Number of Nutrient
Foramina
Number of Clavicles
Inferior 22 (24%) 18 (26.5%)
Posterior 70 (76%) 50(73.5%)
Total 92 68
Position of Nutrient Foramen -
The foramina were located at the middle 1/3 region in 56 (51.52%) clavicles, at the medial 1/3 region in 22 (23.91%) clavicles and at the lateral 1/3 region in 14 (15.21%) clavicles.
Percentage-wise calculation of clavicles accommodating these foramens at various regions was also done. Total numbers of clavicles were mentioned 76 as some of them contained more than one foramina at particular regions (medial, middle or lateral) as shown in table 3
Table 3-Location of Nutrient Foramen Region of Clavicle Number of Nutrient
Foramina
Number of Clavicles
Medial 1/3 rd 22 (23.91%) 14 (18.42%)
Middle 1/3 rd 56 (51.52%) 48 (63.15%)
Lateral 1/3 rd 14 (15.21%) 14 (18.42%)
Total 92 76
Foramen Index;
The average distance of the foramina from the sternal end was found to be 67.9 mm (6.79 cm) and the average total length of clavicles was 126.2 mm resulting in the mean foraminal index of 53.80 (Table 4).
Table 4: Foramen Index
DNF in mm TL in mm FI
67.9 mm 126.2 53.80
The location of the nutrient foramen was determined by the foramen index which was 53.80.
Most of the foramen was found in the posterior surface in the middle 1/3rd of the clavicles.
Direction of Nutrient Foramen–
All foramina are directed away from the growing end of the clavicle towards the acromial end which showed that sternal end of the clavicle is the growing end.
DISCUSSION
The nutrient foramen of each bone leading into the nutrient canal has a definite position. In our study we found at least one nutrient foramen was present in the entire clavicle. [10].The position of the nutrient foramen was located far from the growing end, thus following the concept of growing end theory. The association of the direction of nutrient canal with growth as well as ossification of bone was first described by Bernard.
This present study was compared with the studies done by previous authors as in Table 5-
In this study, we observed that 67.74 % of the clavicle had a single nutrient foramen, 19.35% of clavicles with double foramen and 12.89% of clavicles had more than two nutrient foramina.
This result is very close to the study done by Mulukar et al[11], Rekha et al[12] and Priyanka et al [13] and higher than the study done by Rahul rai et al[14] and less than Suma et al. [15]
In our study, we found the position of nutrient foramina was more on the posterior surface in consistence with the study done by Mulukar et al[11], and Rahul ral et al[14], but in contrast to our study different studies show the nutrient foramen were placed more frequently on the inferior surface [12.13,15]. In depth information about the localization of nutrient foramen is worthwhile to take care of the blood circulation in surgical procedures [10].The recognition of exact location of nutrient foramen is vital for bone grafting [16]. The maximum number of nutrient foramen were located on the middle 1/3 rd of the clavicle (51.52%) which is parallel to the investigations done by different authors, but in contrast to the study done by Rekha et al. [12]
It is of great clinical importance as the clavicle is commonly fractured at the junction of medial 2/3rd and lateral 1/3rd by falling on the out stretched hand. Nutrient artery is commonly originated from the artery which participates in the early invasion of the ossifying cartilage, in such a manner that the nutrient foramen is found at the actual centre of ossification. [11]
Our study established the average distance of the nutrient foramina from the sternal end of clavicle was found to be 67.9 mm (6.79 cm) and the mean foraminal index was calculated as 53.80. The findings of the present study are similar to the investigation done by Rahul Raiet al.
They found the average distance of the nutrient foramen from the sternal end to be 67.6 mm and the mean foraminal index to be 48.01.
Table showing comparison of present study with past studies Number of
foramina
Present study
Mulukar et al. 2011
Rahulral et al. 2014
Suma et al.
2018
Rekha et al .2019
PriyankaSinha et al.
2015
1 67.74 68% 42.5 78 66.6 70
2 19.35 20% 52.5 12 23.8% 20
>2 12.89 11% 5 6 9.4% 10 position
Superior surface
1.4% 4 3.2%
Posterior surface
76 56.3% 64.6 33.8 33.8% 31.82%
Inferior surface
24 41.5% 35.4 62.9 62.9% 68.18
location Medial
third
23.91 8.4 15.4% 6.5% 19 10.4
Middle third
51.52 59.1% 73.8% 85.5% 33 62.5
Lateral third
15.27 32.3% 10.8% 8% 66 27.1
Growing end
Acromial Acromial Acromial Acromial Acromial Acromial
CONCLUSION
Anatomical expertise about the location, position and direction of the nutrient foramina in long bones would be helpful in the preoperative planning of surgeries to be done. It would not only prevent intraoperative injuries but also the post operative complications in orthopedic, as well as in plastic and reconstructive surgery. Study of nutrient foramina is crucial for numerous surgical procedures like vascularized bone grafting, placement of internal fixation, and in microsurgical vascularized bone transplantation where there is preservation of the circulation of the affected bone is maintained for quick healing of the graft in the recipient.
It will also give an idea to the biomedical engineers for designing the clavicle bone model.
Understanding of the nutrient foramina is also requisite to the vascularity during radiation therapy.
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FIGURE 1-CLAVICLE WITH SINGLE NUTRIENT FORAMINA
FIGURE 2- CLAVICLE WITH DOUBLE NUTRIENT FORAMEN
FIGURE 3-CLAVICLE WITH TRIPLE NUTRIENT FORAMEN
FIGURE 4-CLAVICLE WITH QUADRUPLE NUTRIENT FORAMEN
