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Copyright 0 1991 by the American Orthopaedic Foot and Ankle Society, Inc
Vascular Anatomy of the Fifth Metatarsal
Michael J. Shereff, M.D.,' Quing Ming Yang, M.D.,t Frederick J. Kummer, Ph.D.,S Carol C. Frey, M.D.,$ and N. Greenidgen
Milwaukee, Wisconsin, Shanghai, China, New York, New York, and Los Angeles, California
peroneal arteries with normal saline, Mercox acrylic
resin was injected. Soft tissue was digested by chemical means6 and photographs were taken at various
intervals.
Twenty specimens were processed using a modified
Spalteholz technique for invesigation of the intraosseous vascular a n a f ~ m yThese
.~
were injected with a
ABSTRACT
The extraosseous and intraosseous vascular anatomy to
the fifth metatarsal as visualized in a group of below-theknee amputation specimens has been described. The
extrinsic circulation to the area is provided by the dorsal
metatarsal artery, the plantar metatarsal arteries, and the
fibular plantar marginal artery. These three source arteries
supply branches to the metatarsal and adjacent joints.
The intraosseous vascularity consists of a periosteal
plexus, a nutrient artery, and a system of metaphyseal
and capital vessels.
INTRODUCTION
Delayed union and nonunion of the fifth metatarsal
after osteotomy or fracture are well described complications of surgery or injury in this region. It is believed
that interruption of the circulation to the bone may be
responsible for these problems. The purpose of this
study was to identify the extraosseous and intraosseous vascular anatomy of the fifth metatarsal. It is
hoped that this information will provide further insight
into the clinical management of disorders of the fifth
ray.
MATERIAL AND METHODS
The extraosseous vascular anatomy was studied in
15 fresh frozen below-the-knee amputation specimens.
After irrigation of the anterior tibial, posterior tibial, and
~~~
Director, Divisionof Foot and Ankle Surgery, Milwaukee Regional
Medical Center, Associate Professor, Department of Orthopaedic
Surgery, Medical College of Wisconsin.
t Orthopaedic Research Fellow, Hospital for Joint Diseases Orthopaedic Institute, New York, New York, and Attending Orthopaedic
Surgeon, Rui Jin Hospital, Shanghai, China.
$ Associate Director, Division of Bioengineering,Hospital for Joint
Diseases Orthopaedic Institute, New York, New York.
§Director Foot and Ankle Service and Assistant Professor of
Orthopedic Surgery, University of Southern California, Los Angeles,
California.
ll Research Associate, Division of Bioengineering, Hospital for
Joint Diseases Orthopaedic Institute, New York, New York.
Address correspondence and reprint requests to Michael Shereff,
M.D., Medical College of Wisconsin, 8700 W. Wisconsin Ave., Milwaukee, WI 53226.
Fig. 1. The dorsal metatarsal artery to the fourth interspace (arrow)
originates from the proximal perforating artery in approximately 50%
of specimens. Less often this artery was seen to emanate from the
arcuate artery or the lateral tarsal artery. Note the course of this
vessel in the fourth interspace dorsal to the dorsal interosseous
muscle.
350
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VASCULAR ANATOMY OF THE FIFTH METATARSAL
Foot & Ankle/Vol. 1 1, No. 6/June 199 1
mixed solution of India ink, gelatin, and sodium nitrate.
The bones were then removed and cleared.
RESULTS
Extraosseous Vascular Anatomy
The extraosseous circulation of the fifth metatarsal
is provided by the dorsal metatarsal artery, the plantar
metatarsal arteries, and an inconsistent branch of the
lateral plantar artery known as the fibular plantar marginal artery.
MARGINAL
SUPERFICIAL
METATARSALARTERY
DEEP INTER-/
METATARSAL
ARTERY
I
1
''
LATERAL
PLANTAR ARTERY
DEEP PLANTAR
BRANCH OF
THE DORSALIS
PEOIS ARTERY
PROXIMAL
PERFORATING
ARTERY
\
'\
DEEP PLANTAR ARCH
Fig. 2. The plantar circulation to this area is provided by the deep
plantar arch formed by the union of the lateral plantar artery with a
deep plantar branch of the dorsalis pedis artery.
Fig. 3. A superficial metatarsal artery (white arrow) is commonly
present running plantar to the interossei along the fifth metatarsal
shaft. A deep plantar intermetatarsal artery is often seen running
between the plantar and dorsal interossei.The fibular plantar marginal
artery was visualized in 20% of specimens (black arrow).
351
The dorsal metatarsal artery of the fourth interspace
emanates from the arcuate artery, the lateral tarsal
artery, or the proximal perforating artery of the fourth
interspace (Fig. 1). It then courses in the fourth interspace dorsal to the dorsal interosseous muscle.
The plantar circulation to this area is provided by the
deep plantar arch, which is formed by the union of the
lateral plantar artery with the deep plantar branch of
the dorsalis pedis artery (Fig. 2). The deep plantar arch
is the source of several potential arteries at the plantar
aspect of the fifth metatarsal. A superficial metatarsal
artery is commonly present running plantar to the interossei along the midline of the fifth metatarsal shaft (Fig.
3). Less often a deep plantar metatarsal artery courses
between the plantar and dorsal interossei. In the fourth
web space a deep plantar intermetatarsal artery was
identified in a small percentage of specimens. Our
specimens revealed a superficial metatarsal artery and
a deep intermetatarsal artery in most cases.
In about one-fifth of our specimens the fibular plantar
marginal artery (Fig. 3) was seen to arise from the
lateral plantar artery and course distally between the
flexor digiti minimi brevis and the abductor minimi muscles.
These source arteries course distally along the fifth
metatarsal and give off variable numbers of branches
to the base shaft and head of the bone (Fig. 4). These
discrete branches then proceed to take part in the
intraosseous circulation. Branches to the base and
Fig. 4. The source arteries ( A ) course distally along the fifth metatarsal and give off variable number of branches to the base, shaft
and head of the bone (13).
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352
Foot 8,Ankle/Vol. 11, No. 6/June 1991
SHEREFF ET AL.
Fig. 6. Photograph of specimen indicating the intraosseous circulation to the fifth metatarsal. Note the abundant periosteal plexus
enveloping the fifth metatarsal. The single nutrient artery ( A ) penetrating the fifth metatarsal at the junction of the proximal and middle
thirds. This vessel enters the medullary canal where it divides into a
shorter proximal branch (€3) which supplies the metatarsal base and
a longer distal branch (C) which courses toward the metatarsal head.
Fig. 5. The greatest confluence of extraosseous vessels occurs at
the medial side of the fifth metatarsal just proximal to the site of
articulation between the fourth and fifth metatarsals.
head supply the tarsometatarsal and metatarsophalangeal joints.
It was our impression that the greatest confluence of
extraosseous vessels occurred at the medial side of
the fifth metatarsal. Of particular interest was the confluence of arteries just proximal to the site of articulation
between the fourth and fifth metatarsal (Figs. 1, 2, and
5). In this region is the point of origin of the deep
intermetatarsal artery, the superficial metatarsal artery,
the dorsal metatarsal artery and the proximal perforating artery.
lntraosseous Vascular Anatomy
The intraosseous circulation to the fifth metatarsal
consists of three systems of vessels including a periosteal plexus, a nutrient artery, and metaphyseal and
epiphyseal vessels.
Periosteal Plexus: Branches of the dorsal and plantar
source arteries provide a myriad of smaller arteries
which envelop the fifth metatarsal and penetrate the
cortex. This abundant periosteal plexus was visualized
in all of our intraosseous specimens (Fig. 6).
Nutrient Artery: One single nutrient artery was noted
to penetrate the fifth metatarsal at its medial aspect
proximally at the junction of the proximal and middle
thirds (Fig. 6). Unfortunately, due to the experimental
techniques used it was not possible to discern whether
this vessel originated from the dorsal or plantar metatarsal arteries. The nutrient vessel entered an oblique
foramen oriented from distomedial to proximolateral.
The vessel enters the medullary canal where it divides
into a shorter proximal branch which supplies the metatarsal base and a longer distal branch which courses
toward the metatarsal head. The intramedullary components of the nutrient artery give off numerous smaller
branches which proceed radially to the cortex to provide the endosteal circulation to the bone.
Metaphyseal and Epiphyseal Vessels: Branches of
the source arteries to the base and head of the fifth
metatarsal appear to provide intracapsular branches to
the tarsometatarsal and metatarsophalangeal joints
(Fig. 7). These branches penetrate the capsule and
broach the bone in nonarticular areas of the base and
the head. The greater confluence of metaphyseal and
epiphyseal vessels appear to enter from the dorsal,
plantar, and medial aspects of the bone. Of particular
note was two arterial branches which penetrate the
lateral aspect of the tuberosity in a consistent fashion.
DISCUSSION
The use of acrylic casting material was most helpful
in identifying extraosseous vessels. lntraosseous vascular anatomy was more clearly identified by means of
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Foot & Ankle/Vol. 1 1, No. 6/June 1991
VASCULAR ANATOMY OF THE FIFTH METATARSAL
Fig. 7. Branches of the source arteries to the base and head of the
fifth metatarsalprovide intracapsularbranches to the tarsometatarsal
and metatarsophalangealjoint. These branches penetratethe capsule
and broach the bone in the nonarticular areas of the base and head
(arrows).
the India ink gelatin mixture followed by clearing of the
bone by a modified Spalteholtz technique. The vascular
anatomy revealed by these methods may not be a true
representation of the vascularity in vivo. It should also
be realized that the blood supply to the forefoot is quite
variable. The small sample size may not provide an
accurate appraisal of the incidence of the vascular
anatomy in the general population. The experimental
techniques used required extensive chemical ablation
of soft tissue. This procedure may have caused alteration or partial destruction of the small arteries to the
bone. Despite these limitations, consistent patterns
were noted.
353
Our findings with regard to the anatomy of the extraosseous circulation was in general agreement with
those of other
It was our impression that
the greatest concentration of extraosseous vessels lie
at the medial aspect of the fifth metatarsal.
The extrinsic vascular supply emanates from several
source arteries which have their origin just proximal to
the articulation between the bases of the fourth and
fifth metatarsals. The nutrient artery penetrates the fifth
metatarsal at the medial aspect of the shaft at the
junction of the proximal and middle thirds. The intraosseous metaphyseal and epiphyseal arteries originate
from the extracapsular branches to the base and the
head.
REFERENCES
1. Edwards, E.A.: Anatomy of the small arteries of the foot and
toes. Acta Anat., 4:81-96, 1960.
2. Huber, J.F.: The arterial network supplying the dorsum of the
foot. Anta. Rec., 80373-391, 1941.
3. Murakami, T.: On the position of the deep plantar arteries, with
special reference to the so-called plantar metatarsal arteries.
Okajimas folio. Anat. Jpn., 48:295-322, 1971.
4. Panagis, J.S., Gelberman, R.H., Taleisnik, J., and Baumgaertner, M.: The arterial anatomy of the human carpus, part II: The
intraosseous vascularity. J. Hand Surg., 8:375-382, 1983.
5. Sarrafian, S.K.: Anatomy of the foot and ankle, Philadelphia, J.B.
Lippincott Co., pp. 61-312. 1983.
6. Shereff, M.J., Yang, Q.M., and Kummer, F.J.: Extraosseous
and intraosseous arterial supply to the first metatarsal and
metatarsophalangeal joint. Foot Ankle, 8:81-93, 1987.
Announcement
American Orthopaedic Foot 8, Ankle Society Resident Review Course. This course has been designed
to provide an indepth review of pertinent foot and ankle
topics for the resident in training, resident preparing for
boards, as well as the orthopaedist in practice. A comprehensive syllabus authored entirely by AOFAS members will supplement this course for later board or intraining review. The course will be held in four regional
centers in late October and November, 1991: Rochester, Minnesota; New York, New York; San Antonio,
Texas; and San Francisco, California.
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