The Proof is in the Periosteum: Redefining Metacarpal Perfusion by Micro-Computed Tomography Angiography
Andrew I Abadeer, MD M.Eng.1,2; Cyril S. Gary, MD3; Daina Brooks, MS4; Higgins P. James, MD3; Aviram M Giladi, MD, MS5; Valeriy Shubinets, MD6
1Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC; 2Curtis National Hand Center, Baltimore, DC; 3Curtis National Hand Center, Baltimore, MD; 4Musckuloskeletal Research Center, Baltimore, MD; 5The Curtis National Hand Center, Baltimore, MD; 6Plastic Surgery, Curtis National Hand Center, Baltimore, MD
Introduction: With skeletal healing tightly correlated to blood supply, this study sought to characterize the intraosseous and periosteal arterial perfusion of the metacarpal bone using micro-computed tomography angiography (micro-CTA). An understanding of the arterial perfusion of the metacarpal can inform fracture healing and approaches to osteosynthesis.
Materials & Methods: Six cadaveric upper extremities were injected with a barium sulfate/gelatin suspension. Metacarpals were dissected and imaged at 30 µm per voxel using micro-CTA. Specimens were analyzed with a focus on osseous vascular anatomy and distribution. Endosteal and periosteal blood supply were characterized by length, anatomic course, and caliber. Vascular index was calculated as vessel caliber x length.
Results: Each metacarpal demonstrated a rich periosteal network of vessels. The caliber of periosteal vessels of the metacarpal at the head, shaft and base was 0.35±.07, 0.38±0.02, and 0.32±0.06 mm, while the length of the periosteal vessels was 96.45±49.52, 109.72±47.94, 26.44±9.12 mm respectively. Notably, the vascular index (length x caliber) demonstrated that the head and shaft of the metacarpal were the most well perfused, while the base was the least perfused area (p < 0.05, Figure 1, Figure 2). Periosteal vessels to the metacarpal head traveled within the collateral ligaments and often coursed across the width of the metacarpal. Each metacarpal had a nutrient vessel arising at 42.86±7.06% of the metacarpal height, with an average diameter measuring 0.29±0.025 mm. The nutrient vessel of the metacarpal branched proximally and distally and supplemented the perfusion of the base.
Conclusions: There is an abundance of periosteal perfusion to the shaft and head of the metacarpal, with relatively fewer and smaller periosteal vessels to the base. The abundance of the periosteal perfusion of the metacarpal in relation to its endosteal blood supply lends credence to the use of percutaneous and intramedullary fixation techniques, which preserve the periosteum and do not require soft tissue stripping. Periosteal vessels often coursed within the collateral ligaments, making preservation of the collateral ligament attachments key in the management of metacarpal head fractures, especially in the setting of open fractures and open approaches.
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