668

THE VASCULAR PATTERN OF THEANTERIOR MUSCLES OF THE FOREARM INADULTS IN RELATION TO VOLKMANN'S

ISCHAEMIC CONTRACTUREV. BONI,* M.D.(Bologna)

From the Nuffield Orthopaedic Centre, Oxford

There exists already a copious literature on theblood supply of various organs and tissues, yetonly a few papers are dedicated to the descriptionof vascular patterns in human skeletal muscles.

Wollenberg'2 and Campbell and Pennefather5drew attention to the lack of anastomoses betweenadjacent muscle groups in the lower limbs, andthey stressed the fact that certain muscles werepenetrated by a number of vessels, whereas othersreceived their supply from a single artery.

Blomfield' recognized five main types of vesseldistribution in muscles of the lower extremities ofman. He related the vulnerability or otherwise ofsome muscles to ischaemia to several vascularfactors, among them the number of nutrientarteries derived from independent sources andthe particular intramuscular arrangement, thelongitudinal disposition being more susceptibleto injury than the pattern of anastomotic loops.

Edwards7 classified the muscles of the lowerlimbs of man into: (a) Those receiving vesselsfrom several sources; (b) those possessing a seriesof arteries arising from a long segment of onemajor trunk; (c) those supplied by one or by onlya few branches, taking origin from a localizedsegment of one arterial trunk. In explaining theliah ity of particular muscles to ischaemia, heins ed that the circulation in a muscle is anisolated unit, the arteries having no substantialconnections with the vessels of the neighbouringstructures. An intramuscular network of anasto-moses between branches of the arteries does exist,but as Le £Gros Clark and Blomfield8 have shown,it is often of a pattern which does not preventischaemia after occlusion.

Brash3 claimed that in most of the musclesthere are subsidiary arteries, usually placed at

* Dr. Vittorio Boni, Instituto Ortopedico Toscano.'P. Palagi,' Viale Michelangelo 41-47, Florence, Italy.

their periphery, close to bony attachments ortendinous endings; much variation in this auxiliaryblood supply is, however, present.

Salmon10 contrasted the arrangements of ar-terial blood supply of the flexor muscles of theforearm with those of the extensor group. Henoted a more abundant supply of vessels in theflexor groups and he emphasized their greaterliability to vascular injury.

It would appear from a review of the literaturethat more attention should be focussed on theintramuscular vascular patterns of those muscleswhich, like some in the forearm, are prone to beaffected by Volkmann's paralysis.The purpose of the present paper is to describe

the vascular anatomy of each of the muscles of theanterior compartment of the forearm, and todiscuss the possible implication of these ana-tomical findings in explaining the pathogenesis ofthe ischaemic contracture known as Volkmann'sparalysis.

Materials and MethodsFourteen forearms of adult cadavers have been

studied after intra-arterial injection. The investi-gation was confined to the muscles of the anterioraspect of the forearm.

Micropaque, a io% barium sulphate suspensionalone or mixed with carmine red (2% or 4%) wasinjected under a constant pressure of I40 mm. Hgthrough a fine polythene cannula (3 mm. diameter)into the distal end of the brachial artery.The muscles were dissected out individually

after fixation of the whole forearm in neutralformalin. Each muscle was carefully dissectedunder water, so that the perimysium could becompletely removed. The specimens were thenX-rayed, using fine-grain films. The generalpattern of vessel distribution was further studiedin specimens cleared by the Spalteholz technique.

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November I960 BONI: The Vascular Pattern in Relation to Volknann's Contracture 669

Some of the specimens of whole muscles werecut transversely into three or four segments andthese also were radiographed. In this way moredetailed pictures of the intramuscular anastomoseswere obtained.The arterial patterns are described below. A

few minor variations were noted in some speci-mens and these will be mentioned.

The Arterial Vascularization of the Musclesof the Anterior Compartment of the Forearm

Brachioradialis.-In all the specimens examinedthis muscle had a very distinctive vessel pattern.Where the radial artery was related to its deepsurface in the forearm, a single nutrient arteryentered it. From this long vessel a succession ofbranches arose which entered the muscle proper.Each of these penetrated it as a relatively largetrunk, crossing the muscle belly obliquely, adja-cent nutrient stems running roughly parallel toeach other (Fig. i). These arborized into a massof fine anastomosing channels which were par-ticularly profuse in the.proximal and central seg-ments of the muscle (Fig. 2). There were novessels found entering the muscle from its super-ficial aspect, except in one case, when a few finearteries passed into the anterior surface of thelower third of the muscle. These were derivedfrom arteries coursing in the perineurium -of theradial nerve.

Flexor carpi radialis. - The vascularizationsprang from the radial artery, through a singlevessel shown traversing the length of this muscle.From this, short branches came off at right anglesin every case examined. These branches passedinto the muscle belly and subdivided regularly.Successive divisions, arising from the first genera-tion of branches of the main intramusculararteries, tended to align themselves longitudinallyalong the muscle belly. The anastomosis soformed did not appear as closely woven as itwas in the case of the brachioradialis.

Pronator teres.-The fleshy mass of this musclewas completely filled by a delicate network offine vessels, which arose from an isolated trunkrunning along the lateral length of the muscle.Branches arising from the nutrient artery inregular sequence arborized at once within themuscle mass. In only one case, the pronator tereswas found supplied by three different nutrientvessels, respectively at its upper, middle andlower third, but these arose from a single trunk.

Flexor carpi ulnaris.-This muscle was suppliedby about four or five main vessels entering theradial aspect of the deep surface of the muscle.An irregular pattern of arborization provided afree anastomosis within the muscle. There

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were no connections between these vessels andthose of the structures outside this muscle.

Palmaris longus.-This muscle was suppliedthrough its deep surface by many differentnutrient arteries, every one of which divided

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670 POSTGRADUATE MEDICAL JOURNAL November I960

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into a superior and inferior branch. The intra-muscular pattern resembled that seen in thepronator teres.

Flexor digitorum sublimis.-It possessed twosources of blood supply. One (radial part) gaverise to many branches, arising at regular intervals,which arborized at once within the muscle belly(Fig. 3 (a)). The other source (ulnar part) wasrepresented by a long artery, which supplied theinferior half of the muscle (Fig. 3 (b)). Thisartery coursed between the two flexor muscles,and sent many branches to the flexor digitorumprofundus. The intramuscular pattern showed afree anastomosis between the branches of thesetwo different systems of supply.

Flexor digitorum profundus.-This was suppliedon its anterior surface by several branches arisingfrom a long artery, which ran between this muscleand the flexor digitorum sublimis, to which italso sent some branches (Fig. 4). The anteriorinterosseous artery supplied the deep surface ofthis muscle, running completely along its wholelength between this muscle and the interosseousmembrane. The number of its large arteries ofsupply varied between six and ten. Half of themran into the outer side, half to the inner side.Many other smaller vessels were occasionallyfound crossing the interosseous membrane andpiercing the deep surface of this muscle in itsupper two-thirds. Every vessel ended in thickretiform knots, for the most part within thecentral and medial part of the muscle, anasto-mosing freely with their neighbours. From these

vessels branches also passed into the periosteumof the forearm bones.

Flexor pollicis longus.-This muscle was foundto receive many branches from several sources.The penetrating vessels ended in a delicate net-work within the muscle.

DiscussionTo summarize this study, the anterior muscles

of the forearm in the adult may be grouped intothree main types according to their vascularization:

Type I: Muscles which receive their bloodfrom more than two vascular sources (flexor carpiulnaris, palmaris longus, flexor pollicis longus).

Type 2: Muscles which receive their bloodsupply from only two different arterial sources(flexor digitorum sublimis, flexor digitorum pro-fundus).

Type 3: Muscles which receive vessels from asingle longitudinally placed artery (brachioradialis,flexor carpi radialis, pronator teres).A knowledge of these facts may be of some

importance in interpreting the pathogenesis ofVolkmann's paralysis.

Correlating these findings with a clinical studyon Volkmann's contracture,1l it appears that themuscles which receive their blood supply fromonly one or two arteries are more susceptible tofibrous ischaemic contracture than the others.These arteries may be constricted, either at the

level of their hila, as a result of rising inter-fascicular pressure by oedema confined to themuscle, or throughout their longitudinal course

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November i 960 BONI: The Vascular Pattern in Relation to Volkmann's Contracture 671

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FIG. 3.

as a result of a general increase in transmuralpressure from without. In this aspect it must notbe forgotten that the anterior antebrachial regionis an inextensible anatomical compartment, limitedbehind by the radius and ulna and the tense inter-osseous membrane, and in front by a well-defined

fascial sheath. This large anterior compartmentis divided into many smaller cylindroid sectionsby fascial planes which restrict greatly the area oftissue fluid diffusion.

In each of the muscles we have studied thecapillary vessels form close-mesh plexuses, pre-

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FIG. 4.

dominiantly locatcd in the proximnal and centralsections of the muscles. This particular distri-bution may explain why the pathological changesare confined exclusively to these areas.

SummaryThe arterial supply of the muscles of the

anterior compartment of adult forearms has beenstudied by dissection and microradiography ofinjected specimens obtained at post-mortem.The observation by previous authors that the

arterial supply of each muscle is independentand distinct from that of neighbouring structuresis confirmed.The relationship between the vascular pattern

of muscles and their vulnerability to ischaemia isconsidered.

AcknowledgmentsI wish to thank Professor J. Trueta for his

advice during this work, and also Mr. H. V.Crock for his help in obtaining the specimens.My thanks are also due to Miss M. Litchfield forhelp in preparing the material for examinationand to Mr. Charles for preparing the micro-radiographs.

REFERENCES

T. BLOMFIELD, L. (914-45), Proc. roy. Sor. Med., 33, 617.2. 3OWDEN, R. E. M., and GUTMANN, E. (1949), Y. Bone jt.

SuirA., 3Kb, 356.3. BRASh1, J. C. (I955), 'Neuro-vascular Hila of Limb Muscles.'

Edin'3urgh and London: E. & S. Livingstone Ltd.

.4. BROCKIS, J. G. (I953), . BonejYt Suirg., 35b, I31.5. CAMPBELL, J., and PENNEFATHER, C. M. (I9I9), Lancet,

i, 294.

6. DIBLE, J. I{. (1957), Schweiz. med. Wschr., 87, ii6r.7. EDWARDS, E. A. (1953), Suirg. Gynec. Obstet., 97, 87.8. LE GROS CLARK, W. E., and BLOMFIELD, L. B. (I947),

J. Anat. (Lond.), 79, I5.9. McCORMAK, L. J., CAULDWELL, E. W., and ANSON,

B. J. (I(;53), S'urg. Gynec. Obstet., 96, 43.Io. SALMON, M. (I957), Rev. Chir. Orth., 43, 3.II. SCAGLIETTI, M. (I957), Arch. Pistti Chir. Organi Mov.,

8, 6o.12. WOLLENBERG, G. A. (igo5), Z. orthop. Chir., 14, 3I2.

RUTHIN CASTLE, NORTH WALESA Clinic for the diagnosis and treatment of Internal Diseases (except Mental or Infectious Diseases). The

Clinic is provided with a staff of doctors, nurses, technicians, modern Radiological and Physiotherapydepartments.

The surroundings are beautiful. The climate is mild. There is central heating throughout. The annualrainfall is 30.5 inches, that is less than the average for England.

The Fees are inclusive and vary according to the room occupied.For particulars apply to THE SECRETARY, Ruthin Castle, North Wales.

Telegrams: Castle, Ruthin. Telephone: Ruthin 66

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