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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 10  |  Issue : 1  |  Page : 41-45

A Study on Morphological Features of Nutrient Foramen of the Tibia in Human Population of South Bihar Region


1 Professor, Narayan Medical College, Sasaram, Bihar, India
2 Assistant Professor, Narayan Medical College, Sasaram, Bihar, India
3 Tutor, Department of Anatomy, Narayan Medical College, Sasaram, Bihar, India

Date of Submission12-Sep-2020
Date of Decision19-Nov-2020
Date of Acceptance31-Dec-2020
Date of Web Publication27-Jan-2021

Correspondence Address:
Shambhu Prasad
Department of Anatomy, Narayan Medical College, Jamuhar, Sasaram - 821 305, Bihar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/NJCA.NJCA_36_20

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  Abstract 


Background: Tibia is weight-bearing long bone. Nutrient arteries are the prime source of blood supply for any long bone including tibia. A study of dimensions and location of nutrient foramen and direction of the nutrient artery canal can give an insight into the role that these arteries play in development and sustenance of bone. The objective of the study was to present the morphological features of nutrient foramen of the tibia in South Bihar region. Materials and Methods: Sixty tibias (30 of each side) were used for the study. Morphometric analysis of bones was done to find out number, position, and direction of nutrient foramen. We did a comparative study of our findings with observation of previous workers. Results: All bones had nutrient foramen. Five percent had double while 95% bones had single foramen. Nutrient canal was directed downward in all bones except one. In 84.13% of bones, nutrient foramen was on the posterior surface; foramen was lateral to the soleal line in 81.13% of these bones. 80.95% of the foramens were situated in the superior third of the tibial shaft. Conclusion: Knowledge about possible variations in number, position, and direction of nutrient canal can be of use for preservation of nutrient vessels during surgical procedures as well as in prognostic evaluation of the treatment given.

Keywords: Foramen index, nutrient foramen, tibia


How to cite this article:
Prasad S, Sinha SK, Suman S, B. Hayat SM. A Study on Morphological Features of Nutrient Foramen of the Tibia in Human Population of South Bihar Region. Natl J Clin Anat 2021;10:41-5

How to cite this URL:
Prasad S, Sinha SK, Suman S, B. Hayat SM. A Study on Morphological Features of Nutrient Foramen of the Tibia in Human Population of South Bihar Region. Natl J Clin Anat [serial online] 2021 [cited 2021 Feb 25];10:41-5. Available from: http://www.njca.info/text.asp?2021/10/1/41/308117




  Introduction Top


Arterial supply to long bones comes through several vessels which enter the bone at different levels; they feed sinusoidal networks within the bone. Diaphysial nutrient arteries enter bone shaft obliquely through nutrient foramina. Foramens lead into nutrient canal. Nutrient arteries reach the medullary cavity through these canals where they divide into ascending and descending branches, which run toward epiphyses, dividing repeatedly into smaller helical branches close to the endosteal surface. Operative procedures like intramedullary nailing can damage these endosteal vessels. Near the epiphyses, diaphysial vessels are joined by terminal branches of metaphysial and epiphysial arteries.[1]

Position of nutrient foramen and direction of canal are almost constant and characteristically directed away from the dominant growing epiphysis.[1]

The nutrient foramen in the tibia usually lies near the soleal line and transmits a branch of posterior tibial artery; the nutrient artery may also arise at the level of popliteal artery bifurcation or as a branch from the anterior tibial artery.[1] A large vascular groove is present on bone surface leading toward the nutrient foramen;[1] this can be useful for identification of foramen as well as in knowing the direction of ensuing nutrient canal.

The nutrient artery can be damaged by fractures of the tibia disrupting the nutrient canal, and this can predispose to nonunion of bone fragments.[2]

Knowing about number and position of nutrient foramen and direction of nutrient canal can be of great help in clinical as well as prognostic evaluation of diseases affecting the tibia. It can also be used to formulate orthopedic and microvascular surgical procedures more appropriately.

We could not find any research work regarding these parameters from our region of the country, so this study was designed to provide useful information to clinicians which can be utilized in making more appropriate clinical evaluation, formulating better treatment protocols for the diseases affecting the tibia, and also in making more informed prognostic evaluation, thus helping the society at large.


  Materials and Methods Top


We used 60 bones (30 of each side) available in our institute for teaching MBBS students. We took ethical clearance from the institute for carrying out the study. We do not have record of age and sex of the body donors from whose bodies the bones were obtained. We excluded old bones with indistinct/eroded features from our study. We did morphometric analysis of nutrient foramen with regard to its number and position. We noted surface orientation of the foramen on the tibia in each case, i.e., surface of the tibia on which it was present, relation to its borders, relation to soleal line, location (upper, middle, or lower third of shaft), and distance from the upper end. Measurements were done using digital Vernier caliper.

We also noted the direction of nutrient canal in all cases. The direction of canal was established by passing needle (24G) into the foramen. Foramen index (FI) was calculated by Hughes formula:[3] FI = (NFD/TL) × 100, Where NFD is the distance between the nutrient foramen and highest point on the intercondylar eminence; TL is the tibial length as measured between highest point on intercondylar eminence to the tip of medial malleolus of tibia.

Measurements were done using digital Vernier caliper and osteometric board.

We used these data to prepare tables in our study. Software used for statistical analysis was trial version of SPSS software, version 26, IBM Corporation (SPSS Inc., USA).

We compared our findings with observations of earlier worker to find out whether our works findings were in sync with them or was there any difference between our observations and previous work findings and what are possible clinical implications of these findings.


  Results Top


Out of 60 tibias studied, 3 (1 of the right side and 2 of the left side) presented with double foramen and rest of the bones had single foramen [Figure 1],[Figure 2],[Figure 3]. Overall, we got 63 nutrient foramina and canal for observation. Only one canal (in a bone of the left side) was directed upward [Figure 4], and rest of the nutrient artery canals were directed downward.
Figure 1: Nutrient foramen lateral to the soleal line

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Figure 2: Nutrient foramen on the soleal line

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Figure 3: Nutrient foramen on the lateral border

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Figure 4: Nutrient foramina (2) lateral to the soleal line and on the medial border (upward)

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The mean length of bone was 366.7 mm for the right tibia and 371.7 mm for the left tibia while the mean length of all tibias taken together was 369.2 mm [[Figure 5] presents the method used to measure the length of the tibia].
Figure 5: Tibial length measurement

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The mean distance of nutrient foramen from the proximal end was 114.66 mm in the right tibia and 114.72 mm in the left tibia and 114.69 mm overall [[Figure 6] shows the measurement of nutrient foramen distance from the upper end of the bone].
Figure 6: Distance of nutrient foramen from the upper end

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FI was 31.26 for the right tibia, 30.86 for the left tibia, and 31.06 for all bones taken together.

[Table 1],[Table 2],[Table 3] contain data on surface orientation of the nutrient foramen.
Table 1: Position of nutrient foramen in relation to surface and borders

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Table 2: Relation of nutrient foramen to soleal line

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Table 3: Surface positioning of foramen along the length of the shaft

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  Discussion Top


Majority of the workers[4],[5],[6],[7],[8],[9],[10],[11] report single nutrient foramen as the most common finding. Our study also reflects similar opinion with 95% of bones studied having single foramen [Table 4].
Table 4: Comparison of present work findings with previous works observation

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Multiple nutrient foramens[4],[6],[7],[11] and even the absence of foramen[12] have also been reported by many authors. Roul and Goyal[4] found double foramen in 16.20% (very high percentage compared to other workers' findings) of the bones studied, Almansour et al.[11] have reported presence of three nutrient foramens in one of the bones studied by them, while Prashant et al.[12] have reported the absence of nutrient foramen in 1.4% of bones studied by them. We also found double foramen in 5% of bones studied by us though we did not find any bone with three nutrient foramens or the absence of foramen.

The tibial nutrient artery canal was found running craniocaudally in almost all works[5],[6],[7],[9],[10],[11] except for some works[9],[10],[11] reporting upward directed canal in few instances. We also found upward directed canal in only one out of 63 nutrient foramens and canals observed [Table 4].

Most of the observers found nutrient foramen on the posterior surface of the tibia in almost all bones (97.14%–100%),[4],[5],[6],[7],[8],[9],[10],[11],[13] but we found nutrient foramen on the posterior surface in only 84.13% of bones, while in 11.11% of bones, foramen was on the lateral border.

The upper one-third of the shaft of the tibia was the most common location for nutrient foramen as reported by most authors[4],[5],[6],[7],[8],[9],[10],[11] except for Mohan et al.[7] who found more nutrient foramen on the middle third of the shaft. Our finding is in sync with majority of the works (80.95% on the upper third/19.05% on the middle third). We did not find any nutrient foramen in the lower one-third of the shaft of the tibia. Neither did we find any other work mentioning nutrient foramen in the lower one-third of the shaft of the tibia.

Almansour et al.[14] based on a retrospective study of computed tomography features of patients in whom external fixation pins were used for fracture management observed that almost half of the pins applied at the middle third of the tibia injured the tibial nutrient artery, despite adherence to published surgical guidelines for external fixation.

Peng et al.[15] in their observation say that proximal pins of external fixation should be fixed from a lateral rather than an anterior approach as this will protect the tibial nutrient artery and reduce the chances of nonunion or delayed union of fractures.

Although these works have been carried out retrospectively on already treated patients, they outline the need for proper knowledge of nutrient foramen and canal three-dimensional orientation within tibia. In future, Computed Tomography (CT) and 3D reconstruction methods may provide accurate information about the nutrient foramen. Such information prior to the surgery can help in better management of tibial fracture or related diseases.

Fracture of the tibia across the nutrient canal can damage the nutrient artery trunk and compromise blood supply of the bone. This can precipitate malunion/nonunion of the bony fragments after fracture.

Tibias with multiple nutrient foramina receive nutrient arteries through each of the canals. Damage to any one of such canals will not lead to complete loss of blood supply to medullary cavity and deeper cortical bone. Arterial Pedicles enter through these canal and maintain the blood flow, hence bones with multiple foramen may heal faster in case of fracture.

Limitation

The study sample size was small; only 60 bones were taken because of limited availability of bones in the departments. In this study, bone age and sex were unknown, and this study was conducted in a particular region. Large sample size and study done at multiple centers would give more accurate assessment of variations in features of the foramen. Moreover, if we know age and sex of bone, we can find out if there is any change in foramen characteristics in different age group or whether there is any difference in feature of foramen in males and females.


  Conclusion Top


The posterior surface of the upper one-third of the shaft, lateral to the soleal line, is the most common site for nutrient foramen, and the ensuing nutrient canal runs downward in majority of bones. This information may be of use in clinical workup as a fracture of bone or diseases affecting the bone above or below the level of nutrient canal would not damage the main trunk of the nutrient artery passing through the canal.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Standring S. Gray's Anatomy the Anatomical Basis of Clinical Practice. 41st ed. Elsevier Churchill Livingstone. London; 2016. p. 89-90, 1403-5p.  Back to cited text no. 1
    
2.
Moore KL, Dalley AF, Agur AM. Moore Clinically Oriented Anatomy. 7th ed. Philadelphia: Lippincott Williams and Wilkins; 2014. p. 527.  Back to cited text no. 2
    
3.
Hughes H. The factors determining the direction of the canal for the nutrient artery in the long bones of mammals and birds. Acta Anat (Basel) 1952;15:261-80.  Back to cited text no. 3
    
4.
Roul B, Goyal M. A study of nutrient foramen in long bones of inferior extremity in human being. Int J Adv Res 2015;3:945-8.  Back to cited text no. 4
    
5.
Kamath V, Asif M, Bhat S, Avadhani R. Primary nutrient foramina of tibia and fibula and their surgical implications. Indian J Clin Anat Physiol 2016;3:41-4.  Back to cited text no. 5
    
6.
Vinay G, Gowri M. Anatomical study of the nutrient foramen of lower limb long bones in south Indian population. Indian J Clin Anat Physiol 2017;4:222-4.  Back to cited text no. 6
    
7.
Mohan K, Devaraj B, Ramanathan S, Rethinasamy M. Morphometric study of nutrient foramen in the long bones of lower limb. Int J Anat Res 2017;5:3943-8.  Back to cited text no. 7
    
8.
Joshi P, Mathur S. A comprehensive study of nutrient foramina in human lower limb long bones of Indian population in Rajasthan state. Galore Int J Health Sci Res 2018;3:34-42.  Back to cited text no. 8
    
9.
Chavda HS, Jethva NK. Morphometric study of nutrient foramen of adult human tibia bone. IJARS 2019;8:AO05-8.  Back to cited text no. 9
    
10.
Ghosh T, Ray MK. Anthropometric analysis of nutrient foramen of tibia - A study in eastern India. Int J Res Rev 2020;7:100-3.  Back to cited text no. 10
    
11.
Almansour H, Armoutsis E, ReumannMK, Nikolaou K, Springer F. The anatomy of the tibial nutrient artery canal–an investigation of 106 patients using multi-detector computed tomography. J Clin Med 2020;9:1135.  Back to cited text no. 11
    
12.
Prashant KU, Murlimanju BV, Prabhu LV, Kumar CG, Pai MM, Dhananjaya KV. Morphological and topographical anatomy of nutrient foramina in lower limb long bones and its clinical importance. Australas Med J 2011;4: 530-7.  Back to cited text no. 12
    
13.
Parmar A, Maheria P, Shah K. Study of nutrient foramina in human typical long bones of lower limb. Natl J Clin Anat 2019;8(2):77-81  Back to cited text no. 13
    
14.
Almansour H, Jacoby J, Baumgartner H, Reumann MK, Nikolaou K, Springer F. Injury of the tibial nutrient artery canal during external fixation for lower extremity fractures: A computed tomography study. J Clin Med 2020;9:2235.  Back to cited text no. 14
    
15.
Peng Y, Hao M, Chen H, Zhang L, Tang P. Did you notice the tibial nutrient artery when applying external fixation? Int Orthop 2013;37:2089-90.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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