JBJS | The Extraosseous and Intraosseous Arterial Anatomy of the Adult Elbow*†

The Journal of Bone & Joint Surgery, Volume 79, Issue 11

Articles | November 01, 1997

The Extraosseous and Intraosseous Arterial Anatomy of the Adult Elbow*†

KEN YAMAGUCHI, M.D.‡; FRED A. SWEET, M.D.‡; RANDIP BINDRA, M.D.‡; BERNARD F. MORREY, M.D.§; RICHARD H. GELBERMAN, M.D.‡, ST. LOUIS, MISSOURI

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Investigation performed at Washington University, St. Louis

The Journal of Bone & Joint Surgery. 1997; 79:1653-62

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Abstract

We investigated the extraosseous and intraosseous arterial anatomy of the human adult elbow. Twenty-two fresh adult cadaveric upper extremities were studied with a technique of combined India-ink and latex injection followed by chemical débridement. The intraosseous vascularity of twelve extremities was then evaluated with a rapid Spalteholz clearing technique. Our findings demonstrated consistent patterns of extraosseous and intraosseous vascular anatomy, which were organized into three vascular arcades: medial, lateral, and posterior. The medial arcade was formed by the superior and inferior ulnar collateral arteries and the posterior ulnar recurrent artery. The lateral arcade was formed by the radial and middle collateral, radial recurrent, and interosseous recurrent arteries. The posterior arcade was formed by the medial and lateral arcades and the middle collateral artery. The intraosseous circulation of the elbow, which was segmental in organization, appeared to be dependent on the local blood supply. The capitellum and the lateral aspect of the trochlea were supplied by posterior perforating vessels arising from the radial recurrent, radial collateral, and interosseous recurrent arteries. The medial aspect of the trochlea was supplied by a circumferential vascular ring originating from the inferior ulnar collateral artery. Watershed areas were apparent between the blood supplies to the medial and lateral aspects of the distal end of the humerus. The olecranon was richly supplied by vessels coursing along its medial aspect from the posterior ulnar recurrent artery and along its lateral aspect from the interosseous recurrent artery. The radial head had a dual extraosseous blood supply from a single branch of the radial recurrent artery, which supplied the head directly, and from additional vessels from both the radial and the interosseous recurrent artery, which penetrated the capsular insertion at the neck of the radius.CLINICAL RELEVANCE: Our findings demonstrate that arterial contributions to the intraosseous circulation of the elbow are more specific than previously appreciated. The intraosseous circulation of the elbow is derived mainly from perforating vessels that arise from neighboring extraosseous arteries. These perforating arteries may be damaged by trauma or by extensile dissection during reconstruction of the elbow. An understanding of the extraosseous and intraosseous circulation of the elbow may help to avoid iatrogenic injury to the intraosseous circulation.

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Introduction

Introduction | Materials and Methods | Results | Discussion | References

Little detailed information is available on the arterial circulation of the adult elbow. Previous studies of elbows, which were primarily concerned with capitellar osteochondrosis, have focused on the vascular supply to the lateral aspect of skeletally immature specimens^7,8,12. Other than the descriptions in standard anatomy textbooks, there is limited information on the extraosseous blood supply to the adult elbow¹³.

Modern techniques employing latex injection coupled with chemical débridement have provided detailed characterization of the vascular anatomy of the carpus and talus^5,6. In addition, Spalteholz clearing of tissues injected with India ink has yielded fine detail and characterization of the intraosseous microvasculature^5,6. The purpose of the present study was to enhance our understanding of the vascular anatomy of the elbow with use of a modification of these methods.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†Winner of the American Orthopaedic Association-Zimmer Annual Travel Award for Orthopaedic Residents, 1997 (F.A.S.).

‡Department of Orthopaedic Surgery, Washington University School of Medicine, One Barnes Hospital Plaza, Suite 11300, St. Louis, Missouri 63110. The e-mail address for Dr. Yamaguchi is yamaguchi@wudosz.wustl.edu.

§Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, Minnesota 55905.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†Winner of the American Orthopaedic Association-Zimmer Annual Travel Award for Orthopaedic Residents, 1997 (F.A.S.).

§Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, Minnesota 55905.

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Fig. 1-A Schematic (Fig. 1-A) and photograph (Fig. 1-B) of the anterior extraosseous vascular anatomy, demonstrating the medial arcade and the relationship of the radial recurrent artery (RR) to the proximal aspect of the radius. The inferior ulnar collateral artery (IUC) provides perforators to the supracondylar region, medial aspect of the trochlea, and medial epicondyle before it courses posteriorly to anastomose with the superior ulnar collateral (SUC) and posterior ulnar recurrent (PUR) arteries. The radial recurrent artery provides an osseous perforator to the radius as it travels proximally and posteriorly. B = brachial artery and R = radial artery.

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Fig. 1-B Schematic (Fig. 1-A) and photograph (Fig. 1-B) of the anterior extraosseous vascular anatomy, demonstrating the medial arcade and the relationship of the radial recurrent artery (RR) to the proximal aspect of the radius. The inferior ulnar collateral artery (IUC) provides perforators to the supracondylar region, medial aspect of the trochlea, and medial epicondyle before it courses posteriorly to anastomose with the superior ulnar collateral (SUC) and posterior ulnar recurrent (PUR) arteries. The radial recurrent artery provides an osseous perforator to the radius as it travels proximally and posteriorly. B = brachial artery and R = radial artery.

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Fig. 2 Schematic of the posterior collateral circulation of the elbow. There are perforating vessels on the posterior aspect of the lateral epicondyle, in the olecranon fossa, and on the medial aspect of the trochlea. The tip of the olecranon is supplied by perforators from the posterior arcade in the olecranon fossa. The superior ulnar collateral artery (SUC) is seen terminating in the posterior arcade. IUC = inferior ulnar collateral artery, PUR = posterior ulnar recurrent artery, IR = interosseous recurrent artery, RR = radial recurrent artery, RC = radial collateral artery, and MC = middle collateral artery.

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Fig. 3-A Figs. 3-A, 3-B, and 3-C: The medial arcade. Fig. 3-A: Schematic showing the inferior ulnar collateral artery (IUC) anastomosing with the superior ulnar collateral artery (SUC) at the level of the medial epicondyle and with the posterior ulnar recurrent artery (PUR) in the cubital tunnel. Deep to this, on the medial aspect of the trochlea, a ring of perforating vessels is formed by all three of these arteries.

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Fig. 3-B: Photograph of a cadaveric elbow after partial chemical débridement, revealing the arcade on the medial aspect of the trochlea formed by the inferior ulnar collateral (IUC), superior ulnar collateral (SUC), and posterior ulnar recurrent (PUR) arteries.

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Fig. 3-C: Close-up photograph of the medial aspect of the trochlea after complete chemical débridement, revealing the vascular ring.

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Figs. 4-A, 4-B, and 4-C: The lateral arcade. Fig. 4-A: Lateral photograph of a cadaveric elbow, made after latex injection and chemical débridement. The radial head has been dissociated from the proximal aspect of the ulna. The interosseous recurrent artery (IR) supplies the lateral aspect of the olecranon before reaching the posterior aspect of the lateral epicondyle to form the lateral arcade with the radial recurrent (RR), radial collateral (proximal anastomosis with the radial recurrent), and middle collateral (MC) arteries. There are osseous perforators in the posterior aspect of the lateral epicondyle.

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Fig. 4-B Close-up photograph of the proximal aspect of the radius, showing osseous perforators from the radial recurrent artery (RR). The arterial supply comes from a direct branch into the non-articular segment of the circumference of the radial head.

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Fig. 4-C Schematic of the elbow shown in Figs. 4-A and 4-B. IR = interosseous recurrent artery, MC = middle collateral artery, RC = radial collateral artery, and RR = radial recurrent artery.

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Figs. 5-A and 5-B: Photographs of the proximal aspect of the radius after India-ink and latex injection, chemical débridement, and Spalteholz clearing. Fig. 5-A: End-on view of the radial head with the typical coronal vascular pattern provided by a single vessel entering at the bare area (arrow).

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Fig. 5-B Lateral view of the proximal aspect of the radius, showing an extraosseous surface branch of the radial recurrent artery penetrating the radial head in the bare area (arrow). There is relative hypovascularity of the radial head despite dense intramedullary staining distally.

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Figs. 6-A and 6-B: Photographs of the distal aspect of the humerus after India-ink and latex injection, chemical débridement, and Spalteholz clearing. Fig. 6-A: Close-up anterior view of the epicondyles, showing the blood supply entering from the medial aspect of the trochlea and the capitellum with a hypovascular area in the trochlear groove. The lateral aspect of the trochlea is supplied by an intraosseous vessel from the capitellum. The dense vascularity in the supracondylar region reflects contributions from the interosseous nutrient artery and the inferior ulnar collateral artery. The intra-articular distal aspect of the humerus is relatively hypovascular despite dense profusion proximally.

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Fig. 6-B Axial view showing the blood supply to the capitellum and the lateral aspect of the trochlea entering from posterior (white arrow). The medial aspect of the trochlea is supplied by several small perforators from the vascular ring on its non-articular surface both anteriorly and posteriorly (black arrows). Note the watershed area approximated by the trochlear groove.

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TABLE I EXTRAOSSEOUS BLOOD SUPPLY TO THE ELBOW

*Present in nineteen (86 per cent) of the twenty-two specimens.†Present in eleven (50 per cent) of the twenty-two specimens.

Artery	Origin	Distance from Medial Epicondyle (cm)		Common Anastomosis	Supplies
Average	Range
Profunda brachii*	Brachial	21.6	18.2—25.2
Radial collateral	Profundus	19.9	18.0—23.0	Radial recurrent	Lateral aspect of trochlea, capitellum, lateral epicondyle
Middle collateral	Profundus	19.9	18.0—23.0	Interosseous recurrent	Capitellum, medial aspect of olecranon
Superior ulnar collateral	Brachial	17.2	13.5—23.0	Medial arcade, inferior ulnar collateral	Olecranon fossa, medial aspect of trochlea
Inferior ulnar collateral	Brachial	6.7	2.0—11.5	Superior ulnar recurrent, posterior ulnar recurrent	Medial epicondyle, coronoid fossa, medial aspect of trochlea
Radial recurrent	Radial	6.6	5.4—9.0	Radial collateral	Radial head and neck, capitellum
Interosseous recurrent	Posterior interosseous recurrent	8.9	8.0—10.0	Middle collateral	Lateral aspect of olecranon, radial neck, capitellum
Posterior ulnar recurrent	Ulnar	7.3	5.8—9.7	Superior ulnar collateral, inferior ulnar collateral	Medial aspect of olecranon, medial aspect of trochlea
Anterior ulnar recurrent†	Ulnar	6.9	4.0—8.6	Inferior ulnar collateral	Mostly muscular

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TABLE I EXTRAOSSEOUS BLOOD SUPPLY TO THE ELBOW

*Present in nineteen (86 per cent) of the twenty-two specimens.†Present in eleven (50 per cent) of the twenty-two specimens.

Artery	Origin	Distance from Medial Epicondyle (cm)		Common Anastomosis	Supplies
Average	Range
Profunda brachii*	Brachial	21.6	18.2—25.2
Radial collateral	Profundus	19.9	18.0—23.0	Radial recurrent	Lateral aspect of trochlea, capitellum, lateral epicondyle
Middle collateral	Profundus	19.9	18.0—23.0	Interosseous recurrent	Capitellum, medial aspect of olecranon
Superior ulnar collateral	Brachial	17.2	13.5—23.0	Medial arcade, inferior ulnar collateral	Olecranon fossa, medial aspect of trochlea
Inferior ulnar collateral	Brachial	6.7	2.0—11.5	Superior ulnar recurrent, posterior ulnar recurrent	Medial epicondyle, coronoid fossa, medial aspect of trochlea
Radial recurrent	Radial	6.6	5.4—9.0	Radial collateral	Radial head and neck, capitellum
Interosseous recurrent	Posterior interosseous recurrent	8.9	8.0—10.0	Middle collateral	Lateral aspect of olecranon, radial neck, capitellum
Posterior ulnar recurrent	Ulnar	7.3	5.8—9.7	Superior ulnar collateral, inferior ulnar collateral	Medial aspect of olecranon, medial aspect of trochlea
Anterior ulnar recurrent†	Ulnar	6.9	4.0—8.6	Inferior ulnar collateral	Mostly muscular

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TABLE II INTRAOSSEOUS BLOOD SUPPLY OF THE ELBOW

Intraosseous Structure	Arterial Supply	Location of Perforator
Distal aspect of humerus
Supracondylar	Inferior ulnar collateral	Anterior
	Intraosseous branch of brachial artery	Medial aspect of midportion of diaphysis
	Posterior arcade	Posterior
Lateral epicondyle	Interosseous recurrent	Posterior
	Middle collateral	Posterior
	Radial collateral	Posterior
	Radial recurrent	Posterior
Lateral aspect of trochlea	Intraosseous from lateral epicondyle
Medial aspect of trochlea	Inferior ulnar collateral	Medial
	Superior ulnar recurrent	Medial
	Posterior ulnar recurrent	Medial
Medial epicondyle	Inferior ulnar collateral	Anterior

Proximal aspect of ulna
Tip of olecranon	Posterior arcade	Anterior to insertion of triceps at tip
Medial aspect of olecranon	Posterior ulnar recurrent	Medial
Lateral aspect of olecranon	Interosseous recurrent	Lateral, proximal to lesser sigmoid notch
Coronoid process	Ulnar	Lateral aspect of coronoid process
Proximal aspect of ulna	lntraosseous branch of ulnar artery	Medial aspect of midportion diaphysis, terminates at coronoid process

Proximal aspect of radius
Radial head	Radial recurrent	Lateral bare area
Radial neck	Radial recurrent	Lateral
	Interosseous recurrent	Posterior
Proximal aspect of radial diaphysis	Intraosseous branch	Mid-portion of diaphysis, terminates at bicipital tuberosity

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TABLE II INTRAOSSEOUS BLOOD SUPPLY OF THE ELBOW

Intraosseous Structure	Arterial Supply	Location of Perforator
Distal aspect of humerus
Supracondylar	Inferior ulnar collateral	Anterior
	Intraosseous branch of brachial artery	Medial aspect of midportion of diaphysis
	Posterior arcade	Posterior
Lateral epicondyle	Interosseous recurrent	Posterior
	Middle collateral	Posterior
	Radial collateral	Posterior
	Radial recurrent	Posterior
Lateral aspect of trochlea	Intraosseous from lateral epicondyle
Medial aspect of trochlea	Inferior ulnar collateral	Medial
	Superior ulnar recurrent	Medial
	Posterior ulnar recurrent	Medial
Medial epicondyle	Inferior ulnar collateral	Anterior

Proximal aspect of ulna
Tip of olecranon	Posterior arcade	Anterior to insertion of triceps at tip
Medial aspect of olecranon	Posterior ulnar recurrent	Medial
Lateral aspect of olecranon	Interosseous recurrent	Lateral, proximal to lesser sigmoid notch
Coronoid process	Ulnar	Lateral aspect of coronoid process
Proximal aspect of ulna	lntraosseous branch of ulnar artery	Medial aspect of midportion diaphysis, terminates at coronoid process

Proximal aspect of radius
Radial head	Radial recurrent	Lateral bare area
Radial neck	Radial recurrent	Lateral
	Interosseous recurrent	Posterior
Proximal aspect of radial diaphysis	Intraosseous branch	Mid-portion of diaphysis, terminates at bicipital tuberosity

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

Twenty-two upper extremities were obtained from fresh human cadavera. There was no known history of previous traumatic injury or congenital abnormalities. The axillary artery was cannulated with a 16-French Foley catheter; the balloon was inflated, and the arterial system was irrigated with normal saline solution until the venous return was clear. India ink (Faber-Castell, Newark, New Jersey) was injected under firm manual pressure until venous return was obtained. Transverse incisions were made over the pulp beds of all distal phalanges. Thirty milliliters of full-strength Ward's Blue Latex (Ward's, Rochester, New York) was then injected under manual pressure. Use of the combined India-ink and latex injection made it possible to demonstrate the extraosseous vessels. Chemical débridement followed by Spalteholz clearing of the same specimens made it possible to demonstrate the intraosseous circulation and the extraosseous vessels from which particular intraosseous vessels were derived. The adequacy of the latex injection was verified by extravasation from the incisions in the fingertips.

The injected specimens were frozen at -20 degrees Celsius for forty-eight hours to allow the latex to consolidate. The skin and subcutaneous tissues were removed, with preservation of the underlying fascia. An external fixator was applied to the proximal aspect of the humerus and the distal aspect of the ulna, with the elbow in 15 degrees of flexion and full supination, in order to facilitate the lifting of specimens without direct handling and to maintain a constant osseous relationship during the later stages of digestion, when many of the ligamentous structures had been dissolved.

Chemical débridement was performed with 5.25 per cent hypochlorite. Photographs and diagrams of the arterial patterns were made during débridement. The locations of major arteries were measured in reference to both the medial epicondyle and the interepicondylar line. At the time of final digestion, bone-perforating vessels were identified to assess the major extraosseous sources of arterial supply to specific osseous regions. The artery that contributed to each of the bone-perforating vessels was identified. The locations of the osseous perforators were also meticulously noted for each specimen, to be verified with subsequent Spalteholz clearing. Predominant arterial patterns were noted, and variations were recorded.

Spalteholz Clearing

After chemical débridement, the intraosseous vascular anatomy of twelve specimens was studied with use of a rapid Spalteholz technique. Each of the twelve specimens was completely digested to bone. Osseous perforators, and the extraosseous arteries from which they were derived (characterized previously during chemical débridement), were carefully noted for each specimen before the Spalteholz clearing. The specimens were cut approximately fifteen centimeters from the joint line and were immersed in 10 per cent formalin solution containing 30 per cent formic acid for three weeks; the solution was changed biweekly. Complete decalcification of the osseous specimens was verified with roentgenography at the end of the three-week period. The specimens were then washed in running water for two hours. Afterward, they were immersed in 30 per cent hydrogen peroxide solution for three days. Ethanol dehydration of these specimens was performed by immersion in 70 per cent ethanol for one day followed by 95 per cent ethanol for one day and then 100 per cent ethanol in a vacuum environment for one week. After dehydration, the specimens were immersed in chloroform for three days. Clearing of the bones was performed with immersion in oil of wintergreen until the bones became transparent. The intraosseous vascularity was recorded graphically and photographed. Intraosseous vascular patterns were compared with the previously recorded data on osseous perforators for each specimen to identify the relevant arterial sources.

Results

Introduction | Materials and Methods | Results | Discussion | References

General Vascular Patterns

The collateral circulation about the elbow was structured in three general arcades: medial, lateral, and posterior. The medial arcade was formed by the superior and inferior ulnar collateral branches from the brachial artery, which anastomosed with the posterior ulnar recurrent branch of the ulnar artery about the medial epicondyle (Figs. 1-A, 1-B, 2, 3-A, 3-B and 3-C). The lateral arcade was formed by the descending radial and middle collateral arteries, which anastomosed with the ascending interosseous and radial recurrent arteries on the posterior aspect of the lateral epicondyle (Figs. 2, 4-A, 4-B, and 4-C). The posterior arcade was formed in the olecranon fossa by contributions from the superior ulnar, radial, and middle collateral arteries proximally and the interosseous recurrent artery distally (Fig. 2).

Arterial Anatomy in the Arm

Two major branches of the brachial artery in the proximal aspect of the arm contributed to the collateral circulation around the elbow. The profunda brachii, present in nineteen (86 per cent) of the twenty-two specimens, arose from the posteromedial aspect of the brachial artery 18.2 to 25.2 centimeters proximal to the medial epicondyle. Coursing posteriorly and laterally with the radial nerve, it entered the posterior compartment and divided into two terminal branches, the radial collateral and middle collateral arteries, 18.0 to 23.0 centimeters proximal to the medial epicondyle. These branches, which were present in all specimens, arose directly from the brachial artery when the profunda brachii was not present. The smaller of the two terminal branches, the middle collateral artery, descended vertically within the medial head of the triceps and terminated at the elbow in an anastomosis with the interosseous recurrent artery. The vessels of the lateral arcade supplied the posterior surface of the lateral epicondyle and the capitellum. The radial collateral artery continued its course along with the radial nerve, terminating in an anastomosis with the radial recurrent artery anterior to the lateral epicondyle. Branches from this anastomosis supplied the lateral epicondyle (Figs. 4-A, 4-B, and 4-C; Table I).

The superior ulnar collateral artery, which was present in all specimens, arose from the brachial artery 13.5 to 23.0 centimeters proximal to the medial epicondyle. It joined the ulnar nerve and accompanied it in its course posterior to the medial intermuscular septum. The medial arcade was formed as the superior ulnar collateral artery joined with the inferior ulnar collateral artery and then with the posterior ulnar recurrent artery in a segmental fashion. Branches arising from the arcade supplied the medial epicondyle, the medial aspect of the trochlea, and the posteromedial aspect of the olecranon (Figs. 1-A, 1-B, 2, 3-A, 3-B and 3-C; Table I).

The inferior ulnar collateral artery, which was present in all specimens, arose from the brachial artery more distally in the arm (2.0 to 11.5 centimeters proximal to the medial epicondyle) and provided osseous perforators to the anterior supracondylar region and the medial aspect of the trochlea in a circumferential fashion. The inferior ulnar collateral artery joined the posterior ulnar recurrent artery superficial to the brachialis muscle and coursed medially to pierce the leading edge of the medial intermuscular septum, entering the cubital tunnel proximal to the medial epicondyle (Figs. 1-A, 1-B, 2, 3-A, 3-B and 3-C; Table I).

Arterial Anatomy in the Forearm

The brachial artery divided into the radial and ulnar arteries 1.6 to 6.0 centimeters distal to the interepicondylar line. A high bifurcation of the brachial artery, 4.0 centimeters proximal to the interepicondylar line, was observed in one (5 per cent) of the twenty-two specimens. The radial recurrent artery, which arose from the lateral aspect of the radial artery 1.3 to 6.4 centimeters distal to the interepicondylar line, coursed proximally on the surface of the supinator muscle deep to the brachioradialis muscle to terminate in an anastomosis with the radial collateral artery anterior to the lateral epicondyle (Figs. 1-A, 1-B, 2, 4-A, 4-B, and 4-C). Several short branches of the radial recurrent artery entered the supinator muscle, the most proximal of which pierced the muscle to reach the neck of the radius, forming a delicate subsynovial arterial ring (Figs. 1-A, 1-B, 4-A, 4-B, and 4-C).

The anterior and posterior ulnar recurrent arteries arose from the medial aspect of the ulnar artery 1.9 to 7.0 centimeters and 4.0 to 7.8 centimeters distal to the interepicondylar line, respectively. The anterior ulnar recurrent artery, which was present in eleven (50 per cent) of the twenty-two specimens, traveled proximally to anastomose with the inferior ulnar collateral artery over the brachialis muscle. No direct osseous branches were observed from this consistently diminutive vessel. The larger posterior ulnar recurrent artery passed deep to the common flexor origin, ascending to the cubital tunnel between the two heads of the flexor carpi ulnaris muscle to participate in the medial arcade (Figs. 1-A, 1-B, 2, 3-A, 3-B and 3-C).

The common interosseous artery, a short vessel 0.2 to 1.9 centimeters long, arose from the ulnar artery 5.4 to 8.8 centimeters distal to the interepicondylar line and passed posteriorly to divide into the anterior and posterior interosseous arteries at the proximal edge of the interosseous membrane. These arteries then traversed distally into the antebrachium. The interosseous recurrent artery, which was found in all specimens, arose from the posterior interosseous recurrent artery 5.2 to 9.3 centimeters distal to the interepicondylar line, traveled proximally along the lateral border of the olecranon to provide vessels to its lateral aspect, and terminated in the lateral arcade (Figs. 2, 4-A, 4-B, and 4-C; Table I).

Extraosseous Blood Supply

Distal aspect of the humerus: The extra-articular epicondyles had vascular entry points on all surfaces. The lateral epicondyle received branches anteriorly from the radial collateral artery and posteriorly from vessels arising through the lateral arcade (Figs. 4-A, 4-B, and 4-C). The medial epicondyle was supplied anteriorly by branches from the inferior ulnar collateral artery and posteriorly by branches arising from the medial arcade (Figs. 1-A, 1-B, 3-A, 3-B, and 3-C). The capitellum received its blood supply solely along its posterior aspect from branches arising from the lateral arcade (the radial collateral, radial recurrent, and interosseous recurrent arteries) (Figs. 2, 4-A, 4-B, and 4-C). The trochlea received its arterial supply predominantly from the inferior ulnar collateral artery. A large branch from this artery descended anteriorly to the medial aspect of the trochlea and coursed posteriorly in a circumferential fashion to anastomose either with itself or with the superior ulnar collateral artery. The mid-portion of the circumferential ring often was also supported by vessels arising from the posterior ulnar recurrent artery (Figs. 1-A, 1-B, 2, 3-A, 3-B and 3-C; Table I).

Proximal aspect of the radius and the ulna: Of the multiple vessels arising from the radial recurrent artery that pierced the supinator muscle, one vessel consistently supplied the neck of the radius, forming an extra-articular ring-like structure. Another supplied the radial head (Figs. 4-A, 4-B, 4-C, 5-A and 5-B). Supplied from three sources, the olecranon received several branches from the posterior ulnar recurrent artery posteromedially and several branches from the intraosseous recurrent artery posterolaterally (Figs. 3-A, 3-B, 3-C, 4-A, 4-B and 4-C). The posterior arcade, formed in the olecranon fossa, also provided vessels to the tip of the olecranon (Fig. 2).

Intraosseous Blood Supply

Humerus: A single vessel penetrated the cortex of the mid-portion of the humeral diaphysis and traveled as an intraosseous artery, terminating three to four centimeters proximal to the olecranon fossa. Vessels from the nutrient artery diverged medially and laterally toward the medial and lateral epicondyles and terminated proximal to the perforating vessels that entered the epicondyles directly. Watershed areas were seen between the nutrient artery supply proximally and the distal local circulation (Figs. 6-A and 6-B). Intraosseous vessels appeared to provide segmental vascular patterns without forming important intraosseous collateral anastomoses (Figs. 6-A and 6-B). The vessels of the medial epicondyle did not communicate with the intraosseous vessels of the trochlea. The trochlea was supported by medial and lateral intraosseous vessels with an intercalary watershed area corresponding to the trochlear groove. The medial non-articular surface of the trochlea was penetrated by branches of a semicircular arcade arising primarily from the inferior ulnar collateral artery, as previously described. The capitellum and trochlea lateral to the trochlear groove were supplied by vessels penetrating the posterior portion of the lateral epicondyle and radiating anteriorly and medially (Figs. 6-A and 6-B; Tables I and II).

Proximal aspect of the radius: The intraosseous nutrient vessel traveled from the middle of the radius proximally and terminated at the level of the bicipital tuberosity. The neck of the radius received small extraosseous branches that penetrated the bone just distal to the capsular margin. Intraosseous vessels entering the neck traveled proximally to the margins of the radial head. The radial head received a separate source of blood from a single vessel in ten of the twelve specimens, which, after entering the bone, bifurcated into a subarticular plexus oriented in the transverse plane (Figs. 5A and 5-B; Table II). This vessel entered the non-articular portion of the radial head an average of 120 degrees (range, 90 to 180 degrees) posterolateral to the radial tuberosity. In two specimens, the short arteries to the radial neck that were previously described were more prominent and supplied the radial head from the peripheral margins.

Proximal aspect of the ulna and the olecranon: The proximal aspect of the ulna and the olecranon were well vascularized. There were numerous intraosseous anastomoses in this region. Six of the twelve specimens had a vascular plexus at the tip of the olecranon, adjacent to the most proximal point of insertion of the triceps tendon. In all specimens, the olecranon received additional blood supply from both the medial and the lateral aspect corresponding to several osseous perforators from the posterior ulnar recurrent and interosseous recurrent arteries, respectively (Figs. 3-A, 3-B, 3-C, 4-A, 4-B and 4-C). The posterior medial supply appeared to be dominant in all specimens. An intraosseous artery, traveling from the mid-ulnar region proximally, terminated at the level of the coronoid process just distal to the lesser semilunar notch. Minimum arterial contribution was seen from the tip of the coronoid process.

Discussion

Introduction | Materials and Methods | Results | Discussion | References

Despite the fundamental nature of the information, few studies have addressed the vascular anatomy of the elbow¹³. Polonskaja stated that the contribution of the brachial artery to the elbow was so variable that no two upper extremities were similar. Laing, in a study of the intraosseous circulation of the entire humerus, stated that the distal blood supply arose from three primary sources: an intraosseous arterial branch of the major nutrient artery and arterial perforators to the medial and lateral epicondyles^3,11. Although there was intraosseous collateral circulation, watershed areas were commonly observed among the three arteries. Haraldsson showed that the lateral epicondyle and the capitellum in immature bones were supplied mainly by posterior vessels^7,8. To our knowledge, arterial contributions to the medial aspect of the distal end of the humerus, the radial head, or the olecranon have not been described previously.

In contrast to the findings of Polonskaja, but consistent with descriptions in standard anatomy textbooks, we observed a highly consistent extraosseous circulation in the adult elbow. Only four major variations were seen: a high brachial artery bifurcation in one (5 per cent) of the twenty-two extremities, an absent arteria profunda brachii in three extremities (14 per cent), an absent anterior ulnar recurrent artery in eleven extremities (50 per cent), and an interosseous recurrent artery that originated from the common interosseous artery in two extremities (9 per cent).

Our findings with regard to extraosseous vascularity agreed in general with those available in anatomy textbooks. However, with specific reference to the elbow, we found that the collateral circulation could be organized into three arterial arcades (medial, lateral, and posterior), which provided for osseous circulation in a segmental fashion. The lateral arcade was formed by the radial recurrent, interosseous recurrent, and radial collateral arteries, and it supplied the capitellum, lateral epicondyle, and radial head. The medial arcade, formed by the superior ulnar collateral, inferior ulnar collateral, and anterior and posterior ulnar recurrent arteries, supplied the medial epicondyle and the medial aspect of the trochlea. The posterior arcade was formed by contributions from the medial and lateral arcades as well as the medial collateral arteries and it provided blood to the supracondylar part of the humerus through the olecranon fossa.

In agreement with Laing's findings, the intraosseous blood supply to the distal aspect of the humerus appeared to be derived from surrounding vessels. Because the primary intramedullary nutrient artery⁴ stopped short of the joint line for the proximal aspect of the radius, the proximal aspect of the ulna, and the distal aspect of the humerus, the elbow appeared to be relatively dependent on local osseous perforating vessels for a substantial part of its blood supply (Table II). Watershed areas were seen distal to the nutrient artery in the distal aspect of the humerus and proximal to the nutrient artery in the radius and ulna.

As described by Haraldsson^7,8 for the lateral aspect of the distal end of the humerus in immature specimens, local vascular supplies to the lateral epicondyle, capitellum, and lateral aspect of the trochlea came from posterior condylar perforating vessels. The apparent dependence of the lateral structures on the posterior blood supply suggests that, from a vascular perspective, subperiosteal dissection in this location, which is a preferred area for the fixation of fractures^1,9,10,12, should be minimized. After posterior subperiosteal dissection, circulation from the lateral epicondyle would be the only remaining source of lateral osseous blood supply. In contrast, the medial aspect of the distal end of the humerus was supplied by both anterior and posterior vessels. A watershed area corresponding to the trochlear groove was seen between the medial and lateral vascular contributions to the trochlea (Figs. 6-A and 6-B). Damage to either the medial or the lateral blood supply may help to explain the occasional development of avascular necrosis or non-union in this area^9,10,12.

Examination of the circulation of the proximal aspect of the radius showed separate blood supplies to the head and neck. A separate, direct intra-articular supply to the radial head may explain why avascular necrosis is rare after fractures of the radial neck. However, the perforating vessel was seen to enter the non-cartilaginous portion of the radial head, which can be a preferred area for implantation during osteosynthesis^13,15. Soft-tissue dissection in this area for the placement of internal fixation devices may have vascular implications in the presence of a complete fracture of the radial neck.

Compared with the distal aspect of the humerus and the proximal aspect of the radius, the proximal aspect of the ulna appeared to be well vascularized from both posteromedial and posterolateral sources. The major blood supply to the posteromedial aspect of the olecranon coursed along the floor of the cubital tunnel. Posteromedial dissection deep to the cubital tunnel, which is required during extensile triceps-releasing exposures, may damage this arterial supply^2,4,13. However, the lateral blood supply from the interosseous recurrent artery between the radius and ulna is generally maintained; in the absence of fractures, the intraosseous circulation appears to provide substantial blood supply to the proximal aspect of the ulna. This may help to explain the rarity of avascular necrosis of the olecranon after total elbow arthroplasties.

Our findings suggest that there is a highly consistent and extensive collateral circulation about the elbow. These anatomical studies indicate that arterial contributions to osseous structures may be more specific and segmental than previously appreciated. The osseous circulation of the elbow appears to be primarily dependent on locally derived vessels that could be impaired by trauma or by the extensile dissections necessary for reconstructive procedures. It should be possible to avoid iatrogenic injury to the osseous circulation given a detailed understanding of the relevant vascular anatomy.

References

Introduction | Materials and Methods | Results | Discussion | References

Ackerman, G., and Jupiter, J. B.: Non-union of fractures of the distal end of the humerus. J. Bone and Joint Surg.,70-A: 75-83, Jan. 1988.70-A75 1988

Bryan, R. S., and Morrey, B. F.: Extensive posterior exposure of the elbow. A triceps-sparing approach. Clin. Orthop.,166: 188-192, 1982.166188 1982 [PubMed]

Carroll, S. E.: A study of the nutrient foramina of the humeral diaphysis. J. Bone and Joint Surg.,45-B(1): 176-181, 1963.45-B(1)176 1963

Ebraheim, N. A.; Andreshak, T. G.; Yeasting, R. A.; Saunders, R. C.; and Jackson, W. T.: Posterior extensile approach to the elbow joint and distal humerus. Orthop. Rev.,22: 578-582, 1993.22578 1993 [PubMed]

Gelberman, R. H., and Menon, J.: The vascularity of the scaphoid bone. J. Hand Surg,5A: 508-513, 1980.5A508 1980

Gelbermam, R. H., and Mortensen, W. W.: The arterial anatomy of the talus. Foot and Ankle,4: 64-72, 1983.464 1983 [PubMed]

Haraldsson, S.: The intra-osseous vasculature of the distal end of the humerus with special reference to the capitulum. (Preliminary communication.). Acta Orthop. Scandinavica,27: 81-93, 1958.2781 1958

Haraldsson, S.: On osteochondrosis deformans juvenilis capituli humeri including investigation of intra-osseous vasculature in distal humerus. Acta Orthop. Scandinavica, Supplementum 38, 1959.

Helfet, D. L., and Schmeling, G. J.: Bicondylar intraarticular fractures of the distal humerus in adults. Clin. Orthop.,292: 26-36, 1993.29226 1993 [PubMed]

Jupiter, J. B., and Mehne, D. K.: Fractures of the distal humerus. Orthopedics,15: 825-833, 1992.15825 1992 [PubMed]

Laing, P. G.: The arterial supply of the adult humerus. J. Bone and Joint Surg.,38-A: 1105-1116, Oct. 1956.38-A1105 1956

McKee, M.; Jupiter, J.; Toh, C. L.; Wilson, L.; and Colton, C.: Reconstruction after malunion and nonunion of intra-articular fractures of the distal humerus. Methods and results in 13 adults. J. Bone and Joint Surg.,76-B(4): 614-621, 1994.76-B(4)614 1994

Morrey, B. F.: Anatomy of the elbow joint. In The Elbow and Its Disorders, edited by B. F. Morrey. Ed. 2, pp. 16-52. Philadelphia, W. B. Saunders, 1993.

Polonskaja, R.: Zur Frage der Arterienanastomosen im Gebiete der Ellenbagenbeuge des Menschen. Anat. Anzeiger,74: 303-309, 1932.74303 1932

Smith, G. R., and Hotchkiss, R. N.: Radial head and neck fractures: anatomic guidelines for proper placement of internal fixation. J. Shoulder and Elbow Surg.,5: 113-117, 1996.5113 1996

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Fig. 3-C: Close-up photograph of the medial aspect of the trochlea after complete chemical débridement, revealing the vascular ring.

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Fig. 4-C Schematic of the elbow shown in Figs. 4-A and 4-B. IR = interosseous recurrent artery, MC = middle collateral artery, RC = radial collateral artery, and RR = radial recurrent artery.

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TABLE I EXTRAOSSEOUS BLOOD SUPPLY TO THE ELBOW

*Present in nineteen (86 per cent) of the twenty-two specimens.†Present in eleven (50 per cent) of the twenty-two specimens.

Artery	Origin	Distance from Medial Epicondyle (cm)		Common Anastomosis	Supplies
Average	Range
Profunda brachii*	Brachial	21.6	18.2—25.2
Radial collateral	Profundus	19.9	18.0—23.0	Radial recurrent	Lateral aspect of trochlea, capitellum, lateral epicondyle
Middle collateral	Profundus	19.9	18.0—23.0	Interosseous recurrent	Capitellum, medial aspect of olecranon
Superior ulnar collateral	Brachial	17.2	13.5—23.0	Medial arcade, inferior ulnar collateral	Olecranon fossa, medial aspect of trochlea
Inferior ulnar collateral	Brachial	6.7	2.0—11.5	Superior ulnar recurrent, posterior ulnar recurrent	Medial epicondyle, coronoid fossa, medial aspect of trochlea
Radial recurrent	Radial	6.6	5.4—9.0	Radial collateral	Radial head and neck, capitellum
Interosseous recurrent	Posterior interosseous recurrent	8.9	8.0—10.0	Middle collateral	Lateral aspect of olecranon, radial neck, capitellum
Posterior ulnar recurrent	Ulnar	7.3	5.8—9.7	Superior ulnar collateral, inferior ulnar collateral	Medial aspect of olecranon, medial aspect of trochlea
Anterior ulnar recurrent†	Ulnar	6.9	4.0—8.6	Inferior ulnar collateral	Mostly muscular

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TABLE I EXTRAOSSEOUS BLOOD SUPPLY TO THE ELBOW

*Present in nineteen (86 per cent) of the twenty-two specimens.†Present in eleven (50 per cent) of the twenty-two specimens.

Artery	Origin	Distance from Medial Epicondyle (cm)		Common Anastomosis	Supplies
Average	Range
Profunda brachii*	Brachial	21.6	18.2—25.2
Radial collateral	Profundus	19.9	18.0—23.0	Radial recurrent	Lateral aspect of trochlea, capitellum, lateral epicondyle
Middle collateral	Profundus	19.9	18.0—23.0	Interosseous recurrent	Capitellum, medial aspect of olecranon
Superior ulnar collateral	Brachial	17.2	13.5—23.0	Medial arcade, inferior ulnar collateral	Olecranon fossa, medial aspect of trochlea
Inferior ulnar collateral	Brachial	6.7	2.0—11.5	Superior ulnar recurrent, posterior ulnar recurrent	Medial epicondyle, coronoid fossa, medial aspect of trochlea
Radial recurrent	Radial	6.6	5.4—9.0	Radial collateral	Radial head and neck, capitellum
Interosseous recurrent	Posterior interosseous recurrent	8.9	8.0—10.0	Middle collateral	Lateral aspect of olecranon, radial neck, capitellum
Posterior ulnar recurrent	Ulnar	7.3	5.8—9.7	Superior ulnar collateral, inferior ulnar collateral	Medial aspect of olecranon, medial aspect of trochlea
Anterior ulnar recurrent†	Ulnar	6.9	4.0—8.6	Inferior ulnar collateral	Mostly muscular

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TABLE II INTRAOSSEOUS BLOOD SUPPLY OF THE ELBOW

Intraosseous Structure	Arterial Supply	Location of Perforator
Distal aspect of humerus
Supracondylar	Inferior ulnar collateral	Anterior
	Intraosseous branch of brachial artery	Medial aspect of midportion of diaphysis
	Posterior arcade	Posterior
Lateral epicondyle	Interosseous recurrent	Posterior
	Middle collateral	Posterior
	Radial collateral	Posterior
	Radial recurrent	Posterior
Lateral aspect of trochlea	Intraosseous from lateral epicondyle
Medial aspect of trochlea	Inferior ulnar collateral	Medial
	Superior ulnar recurrent	Medial
	Posterior ulnar recurrent	Medial
Medial epicondyle	Inferior ulnar collateral	Anterior

Proximal aspect of ulna
Tip of olecranon	Posterior arcade	Anterior to insertion of triceps at tip
Medial aspect of olecranon	Posterior ulnar recurrent	Medial
Lateral aspect of olecranon	Interosseous recurrent	Lateral, proximal to lesser sigmoid notch
Coronoid process	Ulnar	Lateral aspect of coronoid process
Proximal aspect of ulna	lntraosseous branch of ulnar artery	Medial aspect of midportion diaphysis, terminates at coronoid process

Proximal aspect of radius
Radial head	Radial recurrent	Lateral bare area
Radial neck	Radial recurrent	Lateral
	Interosseous recurrent	Posterior
Proximal aspect of radial diaphysis	Intraosseous branch	Mid-portion of diaphysis, terminates at bicipital tuberosity

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TABLE II INTRAOSSEOUS BLOOD SUPPLY OF THE ELBOW

Intraosseous Structure	Arterial Supply	Location of Perforator
Distal aspect of humerus
Supracondylar	Inferior ulnar collateral	Anterior
	Intraosseous branch of brachial artery	Medial aspect of midportion of diaphysis
	Posterior arcade	Posterior
Lateral epicondyle	Interosseous recurrent	Posterior
	Middle collateral	Posterior
	Radial collateral	Posterior
	Radial recurrent	Posterior
Lateral aspect of trochlea	Intraosseous from lateral epicondyle
Medial aspect of trochlea	Inferior ulnar collateral	Medial
	Superior ulnar recurrent	Medial
	Posterior ulnar recurrent	Medial
Medial epicondyle	Inferior ulnar collateral	Anterior

Proximal aspect of ulna
Tip of olecranon	Posterior arcade	Anterior to insertion of triceps at tip
Medial aspect of olecranon	Posterior ulnar recurrent	Medial
Lateral aspect of olecranon	Interosseous recurrent	Lateral, proximal to lesser sigmoid notch
Coronoid process	Ulnar	Lateral aspect of coronoid process
Proximal aspect of ulna	lntraosseous branch of ulnar artery	Medial aspect of midportion diaphysis, terminates at coronoid process

Proximal aspect of radius
Radial head	Radial recurrent	Lateral bare area
Radial neck	Radial recurrent	Lateral
	Interosseous recurrent	Posterior
Proximal aspect of radial diaphysis	Intraosseous branch	Mid-portion of diaphysis, terminates at bicipital tuberosity