·The for
Supplementa 141 o Ace Luisingce may be obcaed from
ACTA LADIALOG, Sonile. 2 Suder

·MOV THE LOENTGEN DEPARTNENT (DIRECTOI MONESSOR F KAUTISOV)
VERSITY HOSPITAL UITSALA SIEDEN AND MON THE HISTOLOGICAL DEPARTMENT
(DIRECTOL MOFESSOR N VITE) UNIVERSITY OF UPPSALA, STEDEN
THE VASCULAR ANATOMY OF
LONG BONES
A RADIOLOGICAL AND HISTOLOGICAL STUDY
BY
GUNNAR TILLING
STOCHOUC 1938

·Translated from tbe Swedish
by
Marcus Shoch
P Sunire
AMTEULOS BOKTYAXU AJ
UITSALA M

·Contents 5 INTRODUCTION 6 CULAFTER 1 EARLJER RESEARCH MATERIAL 16 CHAPTER IL CHAPTER III TECINIQUE 1 Injection into 742 nutricia 2. Injection into arteria and vena femoralis 3 Intra-otscous injection 17 17 18 19 CHATTEI IV 20 20 21 21 ROENTGEN INVESTIGATIONS IN CALE 1 The venous system of the tibial diaphysu 2. The venous system of the tibial epiphyses 3 The venous system of the lower femoral epiphysis 4 Simultancow filling of the epiphyscal and diaphyseal vers after injection into vena fenoralis 5 The venous system of the humerus 6 The arterial system of the abial diaphysis 7 The arterial system of the ublal epiphyses 8 The arterial syntem of the femoral diaphysis 9 Simultaneous filling of arteries of the tibial epiphyses and diaphysis after injection into antena femoralis 10 Simultancous filling of arteries of the lower femoral epiphysis and upper tibial cpipby os after injection into antena poplites 36 36 36 49 50 50 51 CHATTE ROENTGEN INITSTIGADO' IN Cor I The venous system of the tibial diaphysis 2. The renous system of the upper obial epiphysis 3 The arterial system of the abial diaphysis 4 Simultaneous filling of the arteries within the tibia after injection into anteria femoralus 59 59 59 66 ·4 CHAPTER VI ROENTGEN INVESTIGATIONS IN HUMAN MATERIAL 72 1 The venous system of the obial diaphysis of the full term fetus 72 2 Intra-osseous and intracartilaguous injections into the upper tibial epiphysis in the child 72 3 The arterial system of the lower femoral diaphysis of the fetus 76 4 The arterial system of the abial diaphytus of the chuld 76 5 Arteries of the lower femoral metaphysis of the child 81 6 Simultaneous filling of arterios in the lower femur and the abu after injection into arteria femoralis 81 CHAPTER VI HISTOLOGICAL INVESTIGATIONS 1 Canalis nutricus of the abial diaphysis of calf 2. The upper obial epiphyseal plare in calf 3 The upper tibial and lower femoral epiphytes in the human fetus 86 86 86 89 CHAPTER VIII CONCLUSIONS 1 Roentgen investigations in calf 2. Roentgen investigations in cow 3 Roentgen investigations in human material 4 Histological investigations 96 96 97 97 98 SUMMARY 99 REFERENCES 107 ·Introduction In order to understand many of the problems of the normal and morbid anatomy of the skeleton a knowledge of its blood supply is essential. Angiography of the living subject bu increased our knowledge of the normal and pathological vascular anatomy of the soft parts, but the usual procedure givo no information on the vessels of the bones. These are too fine to be visualized by standard contrast radiography Injection into the spongiosa results in filling of vessels within only a limited region up to the nearest veios leaving the bone. In children, injection into the marrow cavity has resulted in filling of the larger venous trunks throughout the diaphysis Most roentgen studies on the vascular asatomy of bones bave been performed on post mortem matenal however It is the anatomy of the vessels of long bonds during the growing period that has been the main object of my studies, since opinions vary greatly aspecially with regard to the blood supply of the epiphytti. In particular I have examined by means of angiography the tibia of calf and cow and have also performed similar covestigations on some human material. The histological investigations are intended to confirm the roentgen findings aspecally with regard to the vascular canals of the cpiphyses in calvo and human fetuses ·CHAPTER I Earlier Research LANGER S great work Uber das Gefässystem der Robtenknochen was pub- Iished in 1876 He examined the human ubia and femur by injecting dye into the vessels, and then making casts of the vascular systera. Both macroscopic and microscopic ravesagations were performed. He studied in detail the vascalar octwork of the periosteum and demonstrated the entry of the vessels into it at the attachments of the muscles, aponcuroses, and fasciae. In the femur these vessels enter the periosteum along linea aspera, and in the abia along f2012 cruris and membrana interossea. The perroneal vessels form nag en circling the boncs, and they often consist of an artery accompanied by two veios. There are also longitudinal vessels connecting the periosteal rings, and producing a periosteal vascular network which, in both bones, has anastomouc connexions with the capsular vessels. The periosteal arteria also anastomose with the large arteriae Dutriciae before these enter the nutrient canals. The vessels supplying the epiphyseal perchondrum anse from the capsular vessels, and are particularly obvious on the femoral condyles, where they are radially armaged on the outer surfaces. While the epiphyseal plate perasts, the perichondnal vessels of the epiphyses have no connaion with the periosteal vessels. The periosteal vessels give off branches that penetrate into the bone and these branches are largest in the metaphyseal regions. In the epiphyses the vessels from the perichondnum enter chiefly on the lateral and medial sides, and, in the case of the lower femoral epiphysis, in urea intercondylaris. By squeezing the diaphysis with a powerful forceps, Langex demonstrated the paths by which the blood leaves the bone, vrz, veri nutrica and the veins draining the metaphyses. Another of his cuperiments was to inject 2 resinous substance into the bone, thereby obtaining a cost of the veins draining it. In the lower femoral epiphyas the largest yans lave the bone posteriorly area intercondylaris, and in the upper tibial cpiphysis the largest veins are found in area intercondylaris antenor The natra-osseous rens are very thuwalled Outade the bone valves are present. The ruscular canals usually contain an artery and one vein, but after leaving the bone the veio commonly branches into two vossels ·7 LANGER demonstrated communications between the vessels of the marrow arity and those of the periosteum pia vascular canals in the corta viz, the Haversian canals. These canals are largest in the metaphyseal regions LANGER also demonstrated that vena nutriga of the diapbysis divides into kteral branches as it approaches the metaphysis, there to anastomose with CITTA-Osseous vessels entering via the cortical canals LANGER also described vascular canals in the epiphyscal cartilage. He examined the distal femoral epiphysis of a 5'/r-months fetus, and pointed out that the arrangement of these canals corresponds with that of the vascular canals of the adult bone. In the canals he described an artery and one or two vans. He maintained that the arteries within the canals are end arteries. He also showed that some of the canals penetrate to the diaphysis. The carliest stage at which Langer demonstrated vascular canals in the carolage was in a 3 months fetus. Langer demonstrated vascular channels penetraong the cpiphyseal plata, and was of the opinion that these are cpiphyseal vessels. In a new bom infant he found 15-20 such vascular canals in the lower femoral epiphyseal plate. These canals contain the same vessels as the caralage canals in general LANGER also pointed out that vessels perforating the epiphyseal plates are found in horses and cattle. From LANGER S impressive work it is difficult to obtain a clear picture of the large intramedullary vessels, howerer Not until roentgen methods were introduced did this become possible. The first to carry out extensive investigations on the anatomy of the vessels of the bones by contrast radiography was LEXEx at the beginning of the twen uieth century With a number of collaborators he injected into the osseous arteries contrast medium consisting of mercury and terpentine. His expenments were came out on human material and the injections were as a rule made into one anteria carous, the contralateral vena jugulans baving been opened The procedure was sometimes complemented by injection directly into the great arteries of the catremides. On completion of the injection stereoscopic radio grams of the skeleton were taken first with the periosteum in situ and then after removing it. In children 3 vascular regions were easily dosanguished, the cpiphrral the metaphyseal and the diaphrseal According to LEXER the branches of arteria nuincia of the diaphysis only excepnonally penetrate as far is the epiphyseal places here arteries from the metaphyseal region are responsible for the blood supply He maintained that a few of the metaphyseal arteries branch towards the epiphyseal plates, and penetrate them The arteries enter the epiphyses at the attachments of the joint capsule and ligaments, and the cpiphracal vessels conrerge from all sides upon the ossificauon centre. This is also the case in the apophyses. Some of the epiphyseal vessels give off ·8 branches to the point caralage before entering the ossificabon cthoe. Some of the vessels turn towards the cpiphyseal plates and penetrate them The three groups of vessels anastomose more and more with increasing age. The region supplied by arteria outriga diminishes us growth proceeds, and instead the metaphyseal arteries increase in number Numerous anastomoses develop between the three groups of vessels towards the end of growth. LEXER main tained that in the adult arteria nutricia of the diaphysis is considerably less significant than the arteries of the epiphyseal and metaphyseal regions. In 1906 Bidder described vascular canals of epiphyseal carulage in growing children. As a rule he found an artery and two vans in the canals, and con sidered the arteries to be end arteria. He also demonstrated vascular canals piercing longitudinally the opiphyseal plates, and providing conneoons with diaphyseal vessels. He maintained that these canals played a significant part in the nutrition of the cartilage and in the osuficauon of the epiphyses. BIDDEX assumed that there were also vessels perforating the apophyseal plates, but never succeeded in demonstrating them. These three researchers were thus of the opinion that even during the growing period there are anastomoses between the vessels of the epiphyses and meta plyses, via vascular canals perforating the epiphyseal plates. Most later workers however deny the existence of such vascular connexion In 1921 Gutgoire and CARRIÈRE carried out an investigation on infants aged 0_2 years. They injected annabar or red lead and terpentine into the aorta, and reported that the branches of uteria nutricia of the diaphysis did not reach the epiphyseal plates, and that the metaphyses were supplied by metaphyseal arteries. They were unable to state whether anastomosis took place between these two groups of vessels, but they denied the existence of anastomoses between periosteal and medallary vessels. They considered the cpipbyses to be devoid of vessels, since they assumed they were made up of non vascular hyaline cartilage. In 1924 NUSSBAUM sptroduced dye and contrast nedion into the arteries of the skeleton, by injection into the norts, and then treated the specimens by Spalteholz s technique. (Io this, the bones are rendered transparent, and the blood vessels are seen filled with dye.) NUSSBAUM claimed that during the growing penod there are no connexions between epiphysis and diaphysis. He regarded the vascular system of the epiphysis to be completely independent. The vosels in the carulage caou's be regarded to be end arterio unul the appearance of the ossification centres, when he clumed that anastomoses de veloped H A HARRIS (1930) Lojected armene gelatine into the great irtenes in children and young animals, and then examined the long bones. He demoostrated ·9 arteries in the epiphyses, even dunng the cartilaginous stage, but never found any in the epiphyseal places which he regarded as a barrier In 1932 RUBASCHETA and Prices published an account of a roentgen 10 vestigation on the vessels of long bona of adult dogs and puppies They used white lead or red lead in liquid paraffin and terpxnane. In the case of the anterior antremities injection was made into arteria allans, and with the posterior autremities into the aorta immediately above the bifurcation The bones were aamined after removal of the soft parts, in the mame manner as Lazer employed. They concluded that the branches of artena nutricia reach as far as the epiphyseal plates, and there anastomose with metaphyscal vessels. In the epiphyses they demonstrated several vessels passing from the perchon down in towards the centre. In the distal femoral epiphysis they found that the largest retsels enter postenorly in area intercondylans, and branch in stellate fashion In the upper abial epiphysis the largest vessels enter in area intercondylans anterior and posterior These researchers are of the opinion that in the young animal the epiphyseal plate constitutos a total barner isolating the epiphysis from the diaphysis. Anastomoses develop they maintain with increasing age, as the cpiphyseal cartilage disappears. In 1951 DE MARNEFFE published a work with the atle Recherches sur la cuscularisation osseuse based on extensive morphological and esperimental in vestigations on rats, guinea pigs, rabbits, and dogs. He employed several techniques, 1 Injection of India ink (25 per cent suspension 10 physiological saline) into the aorta of living animals. The bones were examined post mortem both macro- and microscopically after considerable preparation. 2 Injection of banum sulphate in gelatine solution, by the same method as 1 The isolated skeletal parts were radiographed before and after decalcı fication 3 Casts of the vessels were prepared after injection of plastic substances such as Neoprene-Later DE MARNEFTE reports that the branches of the diaphyseal arteriae nutriciae of the femur and abia cxtend as far as the epiphyseal places, where they branch to form a nch subchondnal network. These longitudinal branches be regards as end artenes. In addition the main trunk and major branches of arteria nutncia gve off transverse branches that anastomose with cach other Dr MARNET describes a large venous trunk in the diaphysis, into which vens from the capillary network drain. This trunk is connected with vena nutncia. In addiuon, there are large venous trunks posterior to tuberosuus nbise that drain into large metaphyscal rans. These latter vessels he interprets as a special diaphyseal venous system ·10 According to De MARNEIFL, the cpiphyses are supplied by one or more arteries and their accompanying veins. The capillary system of the epiphyses is built up in the same manner as that of the diaphyses He maintains that the vascular canals of the cartilage conecy vaisels bound for the ossification centre and not concerned with the nutrition of the cartilage. He denies the pracnce of vessels in the epiphyseal plates. He thus claims that during the growing period the vascular systems of the epiphysis and diaphysus are separate. The compact bone is supplied by the medullary and periosteal networks, and DE MARNCFFE us of the opinion that these are quite distinct. He has also noted that the compact bone of the upper diaphysu (ubia and femur) is largely supplied by medullary vessels, whereas the compact bone of the lower diaphysis receives its blood supply mostly from the periosteal network. Fig 1 is a diagram of the tibial vessels of a rabbit taken from DE MARNEFTE book. HULTH (1956) carried out investigations on the arteries and veins of caput femoris from human adults. The arteries he filled with contrast medium by 10 yection of cinnabar into arteria circumflora farmoni medialu.. The veins were filled with India ink by intra-osscous injection into the femoral head. He found that arteries are always accompanied by veins. In patients with medial fractures of the femoral neck he made intra-osscous injections of contrast medium into the head fragment. In cases in which he obtained no filling of the extra Osseous veins he concluded that both arteries and veins to the head were torn And in these cases necrosis of the head took place. Comprehensive research has been carried out in recent yeart by TRUITA and collaborators. The main object of their attention bas been the upper part of the femur They used Micropaque, injecting it into major arterial trunks Both standard and micro-roentgen methods were employed, together with histological investigation TRUETA also used the transparency technique of Spalteholz after injection of 2 per cent Prusuan blue. He had access to much post mortem material consisting of children of all ages, and classifies these as follows, 1 Birth-4 months, 2. 4 months 4 years (infant) 3 4-10 years (intermediate) 4 10 years onwards (pre-adolescent) 5 Adolescent. At binh, the osaficnuon of the femur has reached the region of the future neck and trochanter major In newly born infants vessels from the metaphysis penetrate in their medial part those artilage cells that later are to form the cpiphyseal plate. This is a large group of vowels, which run vertically In addition the head receives vessels that ron horizontally from the lateral nde

·11
valstcou tpiphysotros
pre arttro spraw
vaisseaux métaphysala
reto tubéroultors
mteme median ct atome
axtate groue veines
mediane retro-tuberosit.
valsseaux nourridos
diaphysetres poster
grosse veine
diaphysalre intér
volaseaux épiphrysales
rétro-maléolaires
(interne a orterne)
LEGENDE
vaisseaux artériels
valgecur reinax
Fr 1 Blood reuela of obe tibia of rabbrt (After de Mandfe.)

·12 into the epiphysis. There are also irregular vessels enterog from ligamentum tcra. At 4 months at about the time the ossificadon centre anses, TRUETA states that the vessels from ligamentum teres disappear At 8 months the ascending metaphyseal arteries have diminished in number and the remaining ones enter the epiphysis after having perforated the periphery of the epiphyseal plate. The lateral vessels are small large. In the third age group the metaphyseal vessels have disappeared, and the epiphyseal plate has become a total barrier The epiphyns is supplied only by the lateral group of vessels In the fourth group vessels have again appeared in ligamentum teresIn the adult the barrier formed by the epiphyscal plate is broken, and anastomoses develop with the vessels in the metaphyseal region. TRUITA IS of the opinion that the epiphyseal plate u quaire devoid of vessels. Nutrition of the caralage us derived from the vessels supplying the omnficabon centre, and from below from the richly vascular metaphyns. TRUITA und HARRISON (1953) invesugated the upper femur of human adoles of 20–100 years of ags, and were apable to demonstrate regression of the skeletal vasels with advancing age. LETIS (1956) carned out experiments on young rabbits and rabbit embryos. He injected dye paste into major artens, and then examined hustologically the long bones. He reports that roiually the metaphysus is ruppled solely by arteria nutricia of the diaphysis, but the metaphyseal artena take over this fiction As the bone grow. He was unable to demonstrate any vessels perforaung the cpiphyseal plates. DALE and W R. HARRIS (1958) investigated monkeys. They introduced a conoula into the left ventricle of living animals. First they injected vasodilatory kod anticoagulant drugs, and then a muture of India wok in 5 per cent gelatina. The animals were then killed, and the epiphyses dissected out, fired in formalın and created by Spaltcholz s technique. Dale and Hurns distinguuh two types of cpiphysis, (1) thoxe curely surrounded by joint cartilage, and (2) those only pasually enclosed by joune carplage. In (1) vessels catering the epiphysis must penetrate the perichondrium surrounding the epiphyseal plate. In (2) the blood vessels enter the epiphysu directly without coming into contact with the perichondnum of the plate. These researchers, too believe the epiphyreal plate to form 1 barrier since they have never found any vessels passing through it. Rocus and GLADSTONE (1950) ined the distal part of the human femur at different ages. They paid particular aumtion to the vascular foremios which they classify into rupracondylar condylar and intercondylar The inter condylar group 4 especully largs, and they term it area cribross vasorum intercondyloideae femoris. They demonstrated that both arteries and vans pass ·13 through all these foramina. They examined the arteries after injecting a mixture of mercury and terpentine into arteria femoralis. In children they found that the arteries of the epiphysis converged on the Ossificanon centre. They mention nothing of vessels perforating the epiphyseal plate. The considerable blood supply of the distal portion of the femur they consider to prevent necrosis in fractures in this region Most inveagations on the vascular anatomy of long bones are concerned chiefly with the artene HASHIMOTO (1935 1936) has also carried out con siderable research on the velos. He used adult rabbits, vital staining the vessels and subsequently treaung the preparations by the transparency technique. He performed both macro- and microscopical craminations. He describes a large vein running from metaphysis to metaphysis, about which the artenes wind. The vein has anastomotic connexions with the extra-osseous venous network, via the main vena nutnoa of the diaphysis, and the large veins draining the metaphyscal regions Concerning the finer intramedullary branches, he describes penipheral veous sinuses into which the arterial capillana open The peripheral s10 uses flow into a larger sinus that opens into the large van above-mentioned. Haenatopoiesus takes place outside the peripheral minuses, and the blood corpuscles burnt through the single-layered sinus wall and enter the lumen. In the yellow marrow the peripheral sinusa are atrophic. DOAN (1922) demonstrated a shunt between the arterial capillana and the larger sous, which enables the blood to pass from the artenes to the reins without entering the peripheral sinuses EcoIFFIL PROT GRIFFIŁ, and CATACH (1956) investigated the veins of long bones of adult and growing rabbits. They injected Micropaque into the bones, and thus filled the intra-osseous veins. The preparations were tramined radiologically (including micro-roentgen invesagation) and histologically They too demonstrated a central venous trunk anastomosing with the extra-osseous veins in the metaphyses and v1a vena nutricia of the diaphysi. Secondary branches, whuch have anastomouc connexions with the primary venous channels, drain into the main trunk They point out that the capiaty of the veins us much greater than that or the artenes, and that the veios fulfil a double function draining the tissue in the ordinary way and also serving to collect the products of the bone marrow In growing anumals the primary channels are more numerous than in the adulu. The epiphyseal vascular system they consider to be isolated from that of the diaphvris the cpiphrseil plate constituting a barrier SHESS (1950) injected contrast medium (Perabrodu) into the bone marrow of living puppies and adult dog. He studied the drainage channels, which he found to be greatest in the metaphyseal regions. He was unable to distinguish ant rossels penetrating the epiphyseal plates hich he regards as a barna ·14 RATTI AGUZZI and MARLEY (1956) carried out extensive research on the venous endo-osseous circulation in living subjects (osteom edullography) They injected contrast mediumo (Joduron Urograf and Pielonl) into the bone marrow of the metaphyses of children and adulo, by means of a sternal puncture needle. They often obtained filling of the lange venous trunk of the diaphyis and 1tr exit paths via the main vena nutngia and the metaphyseal vans. Among children they obtained opacity of the ossification centre which they attribute to retrograde filling from the capsular network of vens. The epiphyseal plates they regard as a barrier through which contrast medium cannot pass Occa sonally they obtained filling of another type of vessel, which they term the reticulo-vascular type -finc vessels within the endosteum. In there are the F! ? Blood vessels of a long bone daring growth, uod in adulthood (from Tabook of Histolov umow uod Blowen.)

·15 large venous trunks of the marrow were not filled, the contrast mcdium leaving the bone via fine cortical paths They conclude that this picture is seen when the point of the needle is lying in the region of the endosteum Modern research thus denies the presence of anastomoses between epiphysis and diaphysis during the growing years with the exception of that of Trueta, in the case of the upper epiphyseal plates of the femur of children aged less than 4 years) and this is the predominating teaching in all textbooks of ana tomy and histology In most textbooks, the cartilage within the epiphyses is described as avuscular The vessels are claimed to penetrate into the epiphyses only when the osnfica tion centres ari. Manno and Bloom write, in their Textbook of Histology (1957) that the cartilage is an avascular assue and if vessels arc present they are only passing through the arulage to some other tissue. Only in the penchondnum are there any vessels that are concerned with the nutrition of the arulage. Thus, during the cartilaginous stage, the central parts of an epi phyos are poorly supplied with blood, and are the parts which are first become calafied. Not usul omficadon has commenced do vessels start to enter the Osafication centre BUCHER is of the same opinion in hu Histologie und Mikroskopische Anatomie (1956) as is also BARGMANN in his Histologie und Mikroskopische Anatomie des Menscben (1956) Fig. 2 is taken from MarTvOr and Bloom s textbook and shows the plan of the vascular system dunog growth and adulthood.

·CHAPTER II Material Investigations have been carried out on calves and cows, and on a small human series. The calves were aged 1 day-2 months. In the calf the preparation citended from above the knee yomt to below the ankle joint, all soft parts escept the skin being present. The vascular system of the abia was the mun object of study but the distal femoral epiphysis was also crimined in these preparations. A few investigations were also carried out on the calf humerus and femur after removal of the muscles. In the cow the cibla only was investigated. The buran material was very limited. I have carmined immature and fullterm fetuses, and cases aged 2 months, 6 months, 10 months, 7 years, and 11 years.

·CHAPTER 111 Technique Selective angiography by injection into artery or ven in caoalis nutricius and angiography via anteria or vena femoralis were carned out. A few in vestigations were performed by intra-osscous injection, 1 Injection into rea nutricum Selective investigation of these vessels has previously been made in order to obtain casts of the intra-osseous vessels, or to fill them with dye but as far as I know the procedure has never been employed with contrast media for the purposes of serial roentgenography I have repeatedly succeeded in filling vena nutricia in the tibial diaphysis of the calf by cannulation of canalis nutricius. The vein occupies almost the entre lomen of the canal which is clearly visible on screening I introduced the cannula during screening after puncture of the soft parts. Arterie natricia of the tibial diaphysis of the calf were filled with contrast medium after dissection. As a rule I dissected out arteria ubialis anterior opened it up and introduced the catheter or cannula through the ongin of artctl nutricia. The following method was also employed. The catheter was passed down the unopened arteria tibialis via arteria poplitea as far as arteria nutricia of the tibial diaphyns When the ap of the catheter reached the origin of thus branch I ligated arteria ubialis above and below the ap of the catheter (N B In the calf artena nutricia commonly gives off one or tno mall branches to the soft parts before it enters the foramen and these must be died off ) In the ubud epiphysis I dissected down to the largest foramma nutricia, and introduced a cannula into the rain or inery The up of the cannula must be passed beyond the valves that are always present just outside foramina nutnaa Selective angiography of the tibial epipbyses is very difficult because the Fessels are extremely narrow and because there is no great artery or on hich may KTTC 15 starung point In invesugating thc upper abial epiphysis, arteria genu medialıs, bich purses obliquely downwards and forn ards from the medial side of the joint capsule GYUMI ·18 may be traced a branch of thus artery passes through the infrapatellar pad of fat and continues to the largest nutrient foramen, which Les medially in area intercondylari antenor The artery is accompanied by two yaos. It is necessary to dissect to this foramen, and try to enter the fine vessels I confirmed that the canaula or catheter was lying properly in the lumen of vessel by injecting physiological salinc. When the instrument had been cor rectly introduced, I often fixed it by dropping melted paraffin war about the site of 1ojection The contrast medium used for selecuve angiography was 70 per cent Urokon (Pharmaaa) Thu consists of the sodium salt of 3 acetylamino-2 4 6 tn jodobenzoic acid. The contrast medium must be water soluble. Suspensions of the diononl and banum-sulphate type are too thick dioposil passes through the capillanos only with the greatest difficulty and the barium suspension does not pass them at all The exposures were made on roll film uang Gidlunds angle plane changer With this apparatus it is possible to make several exposures per second during the injection The first czposure was made at the commencement of the injec tion which was performed by hand with a record syriage. Occasionally during the course of the experiment I made a brief pause in the injection to rotate the preparation in order to obtain both frontal and lateral projections 2 Injections into arteria and vena femoralis This procedure was followed in a few anses, and barium-sulphate suspension (equal quznuties of Micropaque and physiological saline) was employed. The thigh was divided, and the skin left in place. The pirucles in a barium suspen sion arc smaller than red blood cells, but this contrast medium does not pass through the capillanas, probably owing to agglunnaton of the particla. Injection into the femoral ven under high pressure causes overfilling with valvular insufficiency as result. Contrast medium can then enter the mtra OSCOUS veins The advantage of selective angiography is that it enables the examiner to trace the path of the contrast medium through the intra-osseous vessels The water-soluble contrast medium passes the capillaries without difficulty The disadvantage is that the highly concentrated iodine salts that are used diffuse out of the vessels after only a short time, so that the outlines become blurred and the solution may even crystallize in the vessels of a long pause is made during the injection An advantage of the Micropaque method is that the barium suspension is inert, and remains unaltered in the vessels. Another advantage is that different vascular regions are filled simultaneously in the same preparation A dis ·19 advantage u that it is difficult to examine the skeletal vasels in detail owing to filling of vessels in the overlying soft parts. The films are read more easily when the soft parts have first been removed. Further small vessels may fail to fill owing to the nature of the contrast medrud 3 Intra-ossCons onjection lotra-osseous injection was performed in a few of the human preparations in which selective angiography had been unsuccessful. A cannula was introduced into the spongiosa, and Urokon injected after withdrawal of the stuette. It has been found that blood vessels filled by intra-osseous injection are always veids the lunina of the skeletal veins are so much greater than those of the arteries that the contrast mediurn flows into the veins. In all investigations involving intravascular injection if must be borne in mind that the injected fluid takes the path of least resistance Conclusions may therefore be drawn from posiave roentgen findings, but negative findings should be assessed with caution.

·CHAPTER IV Roentgen Investigations in Calf 1 The venous system of the tibid dupbysis The van which is singls, fills out almost the entre lumen of canalis nutriaus. Externally the forumen opens posteriorly on the lateral ade of the tibial dia physis, about 3 cm below the cpiphyseal bae. It is fairly canly accessble, since, in the calf the fibula is absent or rudimentary In the new-bom animal the canal is about 5 cm in length. The internal opening lies at the junction of the upper and middle thirds of the diaphysis. Vena nutricia to the diaphyas arise fror vena tibralus anterior After vena nutrica has passed the internal opening of the canal it give off threc large ascending branches. The main vein then proceeds downwards, becoming rapidly narrower until at about the middle of the diaphysu, it divides into 2 or 3 descending branches. All these ascending and descending branches and the main vein itself give off many small branches that in turn divide repeatedly On injection into vena nutricia of the diaphysis the contrust medium traversos a betwork of small van in the upper and lower physes, finally to enter longitudinal veins that perforate the cpıpbyseal plate at its centre. The venous systems of the epiphyses are filled in this manner (Fig 3) I have seen up to three large perforaang veins in the upper epiphyseal plate, and one large vein in the lower plate. The contrast medium enters one of the major ascending branches of vena nutricia passing behind crusta tibiae, traversos & network of veurels, and then enters another fairly large van. This versel perforates the apophyseal plate between tuberositas abize and the metaphysis, on the lateral side of the tuberosity Within the carulage this van contoues as two parallel metaphyseal veins that traverse the cartilage and pass to the periosteum of the metaphysis, where they are easily seen (Fig 4) Between these veins lies an artery In addition to the metaphyseal vans of tuberositas ubiae the network of veins in the osuficauon centre of tuberositas abue is also filled and when the contrast medium has penetrated this network, a van perforating the apophyseal ·21 plate between tuberositas tibiae and the epiphysis becomes filled. This latter ven has connexions with the epiphyseal rans. Tuberositas tībuc is therefore a meetng place of epiphyseal metaphyseal and diaphyseal veins (Fig 4) 2. The cenons system of the tibial epapbyses Upper epiphysis The largest foramen nomcium is situated in area intercondylans antenor slightly medial to the mid linc. This contains 2 vans and one artery branches of the capsular vessels. The larrer vein givos off first a large branch which passes through the apophyseal plate on its way to tuberositas tibiac (Fig. 5) It then continues towards the centre of the epiphysis, where it branches in all directions. It communicates with other veins passing through smaller foramina at eminentia intercondylaris and area intercondylaris posterior From the main cpiphyseal vena nutriga anse longitudinal perforating veins which penetrate the epiphyseal plate, and pass to the metaphyseal venous net work Thus on injection of contrast medium into vens of the upper ublal cpiphysis, reins perforating the epiphyseal and apophyseal plates are also filled (Fig 5) These are the perforanng veins described on page 20 They are primary branches of the central veins of the cpiphysis. I have observed that on injecting into vena nutricia of the diaphysis the veins perforating the cpiphyscal plate are not filled until after the contrast medium has passed through a network of small veins in the metaphysis. The perforating vens then continue direct to the great central vans of the epiphy ns Morphologically the parforating veins would seem to belong to the epiphyscal group Louer epiphysis Here the largest foramen nutriciom is on the anterior surface slightly medial to the mid line Injection of contrax medium into the rein lying in this foramen reveals a system similar to that in the upper epiphysis, with a large vein passing to the centre and there branching in all directions. From thus vein runs a longirudmal rein that perforates the lon et epiphyseal place at about its centre (F166) I have muceeded in filling the greater mtra-osseous venous chaonels of the entire tibia by injecting contrast mediuta into the vein of the loxet cpiphras (Fig. 6) 1 The tenons system of ibe lover femoral epiphysis There is a large foramen nutricium posteriorls bets een the condylos of the lonst femoral epiphuu. Through this piss large rains that drain into vena ·22 Fy Calf ped 2 weekl Canopla (no in cialis ourdo of the tbul daphyus. Urokon A, and D, lateral kn, Biod C, frontal . 1 Vena trich ind excoding and descendios branches 2. Vao perform the lower epiphyal platt Boon entonog thu moel the contrast brosum parsa through a rikular at work in the metaphys Note The pocorre Doritos are relection from the Kral as posure mode danog ach apermeat They are consequently anged m chronologal order od the course of the cootrag medium can therefore be tnad Lateral and frooul w placed together are taken at the sagt ·23 7- D 4 А 410 ken ka ng the lower Puphysa by a franca Atrium s ghily medial to the mxd Inne Interiorly (at ) To perforating the upper emphyseal plate Via the con contrat medin partes 10 Tour in the emphyar. 5 cm parung behund tu tibuse and perforati be ipopbyxeal plate betura taberosus tubur ud the metaphys It contiam to the otficon catre of rubrrottas tur After pass throu to a cnoo Beti ork m the idetosus comprar pedicom moren Taru slorating the pophyseal plate bet to the tuberouty sad the epiphyus (at 6) und thu pasi ato C1m 10 the rephyan. The coupbyraal mot doan ito a real lanak by a foruma Onyom (at 7) in area mtet ondylars anterior NR Ito a umall Braphy kalan at s rukdo contrart medium

·24
A
Fry + Calf aged 2 weeks. Injection lato vena putnicu of the tibul daphy by annuladoo
of aanlis nuncius Urokon
A and D frontal view Band C Lateral Tv
Vena Dutch
2 Vem pasting behind criar oue and filed unb contrast medits that has first puued
through com network
1

·25 D 3 Filing of metaphyseal ens is the lateral part of the apopbywal place between cuberorna, obae and the metaphyss These vaixel pusi to vards the surface of the bone and coninwen the periosteum u to parallel reins (at 4) Tea perforong the apophyseal plate betweea tubcratu tubue and the epiphya. Via ibis cootrart medium enters piphysal you which drain to aptular vau vua tbe large forumas nuncium lyms post medial to the med line a area jote condylans intensor (at 6) be keen at em meua intercondylans (at 7) 5 لاد A 01 butu 2

·26
FS Calf aged 2 week. Canaal Iyot in the root the oppe tibul ppbyun. Uroloo
A, B, ad C, froocal new Dlateral view
1 Cannula lnag lo red to formen parrkaum inim sercondylant anterior
2 Yon perforating the upper spophyseal plate
3 Vea sunt of the diaphys filled with coatres medium thar has fint paced through
Detvork of small rains.

·27
C
D
5
+ Ten perforating the apopbykal place between the epiphy and tuberontas tibue
Ten per rate the apopboueal plate between tuberontas obude and the metaphy ul. Only
Ty little coot as mediam has taken thur path on the acuon.
Tove the calme e branching of piphyseal rant rod anaromony bets een different retos
The
lime the small foram APTIKTUM at comiata intercond, lam (at 6) is filed

·28
Fr. Calf 4fed under 2 DODEL Capoule lying in in to the lover ubual oppbyus Urokon.
A-D Lateral ve E, fronul Y
Cannula In A en m the antero-med) forumo
- Yen perforating the lower cprpbral plate and pumme directly into Act of
thur duphyu.
3 Ascending brand of roa autnat of the dupbye

·29 D + Ian perforad the oppet epiphriesl plate filled with contrast medicon that has firu passed throub a metaphyseal venous det ork Epiphyseal en extending to foram.co nuncium m area intercondylans anterior are filled vu the perforaung rema Injection of contras medium into co to the lower cppbya solo un fillos, va perforator CUAL, of the entire mod intern of the obu.

30No text on this page.

·31 D Fit 7 Calf 2 week. Same preparation u fic 1 A-E, frontal view F Lateral TKW Contrut pedrum has cryaallized in ena nutna of the tibia On coobaoed injection most contrast therefore pane through vena pople Ica. Occasion of vena femorabs forces the contra med om mto tbc vedoos syurm of the lower femoral oppbyas. Large remus eoret Canllyyn larte foramina notras ar intercondyland Senal radiograpby drcloses the ridual iTuncement of the branches hich Puus to all part of the epupbyul

12No text on this page.

·33 2 - E ICT Hi! Call 1 day Joxection of Mixtopaque into rea femoral . Setul dvorrapby A-D AB, and D fronul mos lateral The mbua molated and the peront two remodd. E lateral frontal view The radial mingement of the tatral ant of the lower femoral oppbyis u clearly seen ID AC At 1 auno mieme obe oppbyus from the penchondrium, and 20antomomy with braxtos of the catral velns Other ite lule dakerble oning to be contin odio in le the fuorm of the solated obu are hen apper sprphr al retos perfonatos the apopt xal (2) and epiphixal (3) plats an a of the ubral duphra 3 be to tbe soft part Gint ·34 Fug 9 Calf 2 week.. Canaole lyos m vert nuxe to the bumeral du phyu. Urokon. Moclo removed A laretul m B, frontal view i Vemos perforiting the spophyseal arplare between tuberculom mamou and the metaphyou ·35 Fig 10 Call weeks Upper part of how after inition of Blxropa que into rena and Lane After ECTOD the soft parts, suluding the pernottam, tre rinosed A frontal van B Lateral TiW V nutrka of the diaphrul Imi perforating the apophy kal plate between the diaphy u od tober ulun major Tas paping to caput humeri u the epiphyseal plate ·36 poplitea. These veins pass to the centre of the epiphysis, and branch in all directions (Fig. 7) In addition there are a number of smaller vessels in the perichondrium, 200 these enter the skeleton at vanous points (Fig 8) The largest vessels are those that enter through the large foramen nutriciom however 4 Simultancous filling of obe epiphyseal and dupbyseal veins after mrection into vena femorales A few experiments were made by this method using Micropaque One of these, where the hıod leg of a calf was used, is illostrated in Tig & The central veids, which enter the lower femoral cpiphysis posteriorly in area intercondylans, are clearly seen The radial arrangement of the branches, which pass to all parts of the epiphysis is obvious and the perichondrial vans which anastomose with branches of the central epiphyseal vasels, are also seen The perforating veins from the venous system of the upper abial epiphysis are also clearly demonstrated. 5 Tbe venons system of the homens The upper part of the humerus of the calf was examined to ascertain whether there are any veins perforating other apophyseal or epiphyseal places. Injection into vena nutnca of the humeral diaphysis in 2 preparation freed from muscles revealed several vans perforating the apophyscal plate and con tinuing to tuberculum majus (Fig. 9) Another experiment, in which Micropaque was injected into vena axillans, showed filling of veins perforaang both the epiphyseal plate between caput bumeri and the metaphysis, and the apophyseal plate between tuberculum marus and the metapbysis (Fig 10) 6 Tbe arterial system of the tibial disphysis Arena nutricia of the diaphyss leaves anteria tibialus anterior at an angle of almost 90° (Fig 11) Immediately after entering canalus nutriaus the artery gives off some small branches to soft parts After leaving the anal it gives off 3 large ascending branches (Fig. 12) The artery then continues to about the middle of the diaphysis where it divides into two or three descending branches. Both ascending and descending branches give off brunches that run longitudinally to the cpiphyseal plates. Noteworthy is the contuous course of the large branches in the middle part of the diaphysis. No branches of artena nutncia perforating the epiphyseal plates were filled. On filung of arteria nutricia of the draphysis with contrast medium the vessels of the nchly vascular metaphyseal regions adjacent to the epiphyseal plates and to the apophyseal plate at tuberositas abiae, quickly become filled.

·37 IM Day 111 Calf 2 hs Cannula lym; In poplica Un lon Lateral Anetu poplitea Artmu tibul anteur Artctu non of the diaphus 4 Small branches to the soft panth ansla medurel het re the inery emeti the anal 1 ·36 poplitea. These veias pass to the centre of the epiphysis, and branch in all directions (Fig 7) In addition there are a number of maller vessels in the perichondrion and these enter the skeleton at various points (Fig 8) The largest vessels are those that enter through the large foramen nutraum however 4. Semultaneous filling of the epiphyseal and duphyseal veins after injection into vena femoralis A few expenments were made by this method, using Micropaque. One of these, where the hind leg of a calf was used is illustrated in Fig 8 The central veins, which enter the lower femoral cpiphysis posteriorly in arca intercon dylaris, are clearly seen The radial arrangement of the branches, which pass to all parts of the epiphysu is obvious and the perichondrial veins, which anastomose with branches of the central epiphyseal vessels are also seen The perforaang veins from the venous system of the upper tibial epiphysis are also clearly demonstrated. 5 The venous system of the humerus The upper part of the humerus of the calf was examined to ascertain whether there are any veins perforating other apophyseal or epiphyseal plates. Injection into vena nutriaa of the humeral diaphysus in a preparation freed from muscles revealed several velos perforating the apophyseal place and con tinuing to tuberculum majus (Fig. 9) Another experiment, in which Micropaque was injected into vena aullaris, showed filling of veins perforating both the epiphyseal plate between capot humeri and the metaphysu and the apophyseal plate between tuberculum majus and the metaphysis (Fig 10) 6 Tbe sterial system of the cibul duphysss Arteria nutricia of the diaphysis leaves arteria tibialis anterior at an angle of almost 90° (Fig 11) Immediately after entering canalu nutriciw the artery gives off some mall branches to poft parts. After leaving the canal it gives off 3 large ascending branches (Fig 12) The artery then continues to about the middle of the diaphysis, where it divides into two or three descending brancho Both ascending and descending branches give off branches that run loogitudinally to the epiphyseal plates Noteworthy is the tortuous course of the large branches in the middle part of the drapbyus. No branches of artena nutticua perforating the epiphyseal plates were filled On filling of arteria nutnaa of the diaphysis with contrast medium the vessels of the richly vascular metaphyseal regions adjacent to the cpiphyseal plates and to the apophyseal plate at tuberositas ablac, quickly become filled ·37 go Foil Calf 2 week Can ula lyms ar teru poplica Urolon Lateral en 1 Anoru popltca 2 Arton bal loreror Anena atau of the duphies Small brashes to the soft puis, in med tel before the ANTY Con the 3 4 ·36 poplitea. These veins pass to the centre of the epiphysis, and branch in all directions (Fig 7) In addition there are a gumber of smaller vessels in the perichondrium and these enter the skeleton at vanous points (Fig 8) The largest vessels are those that cater through the large foramen nutriciom however 4 Simultaneous filling of the epiphyseal and diaphyseal veins after Inxection into vena femoralus A few aperiments were made by this method using Micropaque. One of these, where the hind leg of a calf was used us illustrated in tig 8 The central veins, which enter the lower femoral epiphysis posteriorly in area intercondylaris, are clearly seen The radial arrangement of the branches, which pass to all parts of the epiphysis, is obvious and the perichondnal veins, which anastomose with branches of the central epiphyseal vessels are also seen The perforating veins from the veous system of the upper tibial epiphysis are also clearly demonstrated 5 The Denous system of the bumerus The upper part of the humerus of the calf was examined to ascertain whether there are any veins perforating other apophyseal or epiphyseal plates Injection into vena outricia of the humeral diaphysis in a preparation freed from musclos revealed several veins perforaong the apophyseal plate and con muing to tuberculum majus (Fig. 9) Another experiment, in which Micropaque was injected into vena allans, showed filling of veins perforaang both the epiphyseal plate between caput humeri and the metaphysis, and the apophyseal plate between tuberculum majus and the metaphysis (Fig 10) 6 Tbe attend system of the tibial dupbysis Arteria putnicia of the diaphysu leaves antena tibialis anterior at an angle of almost 90° (Fig 11) Immediately after entering canalus nutnaus the artery gives off some small branches to soft parts. After leaving the canal it giva off 3 large ascending branches (Fig 12) The artery then continues to about the muddle of the diaphysis, where it divides joto two or three descending branches. Both ascending and descending branches are off branches that run longitudinally to the epiphyseal plates. Noteworthy is the tortuous coure of the large branches in the middle part of the diaphysis. No branches of artena nutraa perforaong the epiphyseal places were filled On filling of anteria nutrica of the diapbysts with contrust medium the vessels of the nchly vascular metaphyseal regions adjacent to the epiphyseal plates and to the apophyseal plate at tuberositas tibiae, quickly become filled.

·37 20 ܙܐܙ 11 ه عمر را بلهnميا 1 Fr 11 Call tena replica Uroloo Lateral Anetu poput 1 Ancrut bul terior 1 Anetu nut wh of the Luaphy Small bra hot The soft pann ansios oradil hare the anet) Catcts the 4 ·38 F12 Calf 2 cher Catheter lyme in uneta bunda of die bul daphyal Dhooosil. A and D Lateral 7 fronul x Catheter 2 Man ne of urtera putrcu ·39 FC t nooth Kendog and duending bristet. 4 lonprudinal hrano reaning tos and the metaphy ki Coat ant med om ullaced in the Beuphical treool ·40 F 1 Cell 2 weeks Cerhet r log in arena WITH of the obvel duaphy A. Urokon AB und E, lateral EYL CDF fronual ver Cathota nanerta otnica, in formen nutrig om 2. Antena utca and asseodmy und derende branches ·41 D 10 3 Metaphyseal + If phykal 0101 5 There Hicht opaty med om f the osafkation centre of ruberostart buze doc to contri ·42 7 Fr 14 Culf 2 vecka Carbeter log in irtona putnicu of the titul du phytu. Urokon A C d F lateral TL B, D ud E. frontal view. 1 Catheter lyg aneis outrcu in cobs Dutro. Aneu aunt, and akooding and dexeodmy bracket ·43 3 ann upper metapbym 4 Epupbykal rons filled from perforating YaaL Coatrin med um in ruberontas tioue cuns art kan ta the apopbıkıl plin. 5 ·44 FIE 15 Calf 2 wee. Garbeter lying in antara tubuls anterio the up kord with the ongla of aneria uincu of the obul duaphyul Luust abo e und belor Urokon AB, C, D T lateral D d Efrontal vens 1 Tp of the catbetar 2. Artemua utriche und bra chee 3 Va pa ung bebud ca obue ·45 D + Tans partnto the apophyseal plain a d mienny tuberositas Transe 5 Yan in forma aunciem. 6. Metaphyxal rein 7 Contrant medium craps from ma unaza foramen noncim of the duphyun. The YOA » domated dorg datectia ·44 Fr 15 Culf 2 week. Cacheter lyg in artetu mbalss unter of the top level wth the ongin of urter utnicu of the soul diaphyu Lature above and bel Urakoo A, B, C, ud i lateral news D und E, fropal mes 1 Tp of the atheter Anerus utna d branches ) va puu , behind an abu 2 ·+5 D 1 F olans penetrating the apophy sal plates and entenng tuberostas nibuse 5 Tour forca nutrctum Metaphy al re 7 Contrakt medium escaping from na autna ia foram.co uram of the dupbyus The TETO 11 damaged during direction ·46 10 G H F: 16 Calf 2 væk Cannula lying n irten OUTIH of the popbyus, un arm stron dylan interior Urokoa A-E, H, I und L Latul FG Jad K, frontal vier Cannoll 2 Anem anca runot boards the crotre of the epiphysi. 3 Retrograde filloos. Tu 201xomoxes of an antha potu In ara mtercoodylent pofterior Coor filing of the upper part of the otfaina centre of toberosios tiba 1 1 ·47 اشم 1 3 THG of the meus phyb. 6 Heuphysal stety 7 lapky al Trial ! Trece of camilaptons versets Ste do G Vas noticia of the diapbyut 10 Anena popl tea. 11 coa poplatek ·48 с 1 Fig 17 Calf 2 booth. Cannab lno in uren out, our intercondylar antenor Urolo. A and C, latenl TTL Bfroata muy Cannula 2 Ancu outnou mang dvards the crotre of the coupbris 3 Brunch of artery perforius the apophysal arplage between the epiphyu and tuberosus bure Illos of tuberonta tiba. 4 ·49 Gradually during the course of injection the entire bone marrow becomes filled with contrast medium and becomes evenly opaque. The capillaries are then filled. The contrast medium penetrates the capillanes and can be traced out into the draining veins (Figt 13 14 and 15) The passage of the contrast medium into the metaphyseal and epiphyseal veins is clearly seen, and also its drainage va vena nutricia of the diaphyns. Thu u best danonstrated when the catheter is not introduced into the actual caoal (Fig 15) In this aperiment the up of the catheter is lying in arteria abialis anterior at the origin of anteria nutraa. The coracal vessels of the tibial diaphysis are too narrow to be visualized by this method. Dunng injec tion blood can be seen escaping at a few places through the conta. After injection into arteria nutrica of the tibial diaphysis, then contrast medium leaves the bone by the following routes, vena nutricia of the diaphysis, 2 the metaphyseal vens, 3 the epiphyseal veins, and 4 the cortical veins of the diaphysik 7 Tbe arterial system of the tibial epiphyses Upper epiphysis The largest artery caters through foramen nutraum in arca intercondylans anterior Together with its corresponding van it passes towards the contre of the epiphysis, and branches in all durections. It anastomoses with arteries that enter by other maller foramina It also has a branch that perforates the carulage between the ubial epiphysis and tuberositas ubiae and there are branches perforating the epiphyseal plate. Fug 16 illustrates an injection by cannulation of arteria nutricia in area in tercondylans anterior The artery passes towards the centre, and is seen to anastomose with another arteria nutnaa entering in area intercondy lans posterior This latter vessel appears to be a small branch of anteria poplitea, which u also filled with opaque substance Contrast medium is seen in tuberositas tibiac and in the upper tibial metaphysis at an early stage during the injection, before the vans are filled this indicates that there are anteries perforaung the apophyseal and epiphyseal plates. A metaphyseal artery is also seen to be filled, lymg between the parallel veids in the periosteum. In tume practically the citire epiphysis becomes filled, and the contrast medium passes into the venous synte, both vans and arterios ulamarely being filled at the same time The contrast medium passes into cpiphyseal metaphyseal, and diaphyseal TOID The ressels of the camlage surrounding the bone appear as a fine millimetrethick fringe best seen on the lateral nbial condyle. The vessels are clearly seen GT ·50 in the actual preparacon, glistening through the camlage. They are particularly obvious after injections when blood is forced out into them Fig 17 illustrates another injection into arteria nutricia of the upper tibial epiphysis of the calf Here an artery is clearly seen perforatog the apophyseal plate between the epiphysis and tuberositas abiae. Fig 18 illustrates injection into an artery supplying the lower trbual epipbyss Here, too is seen a fairly large artery passing to the centre and branching in al directions. The eure epiphysus ultimately becomes filled with contrust medium which also enters the metaphyss via perforaung vessels. It u mposable here to disanguish between perforating arteries and veins. Vena nutraa of the diaphysis are clearly filled, and contrast medium is seen in the two venae tibialos anteriores and in artera tibialus anterior Contrast medium injected into antena nutrkia of the epiphyses leaves the bone by the following routes 1 anastomosing arteries, 2. epiphyseal veins 3 metaphyseal veins and 4 diaphyseal veins. 8 Tbe arterial system of the femoral dupbysus There is only one canalis nutricius in the femoral diaphyns of the calf Externally it opens posteriorly on the lateral side of the diaphyss, at the juoc tion of the muddle and lower thurds. It is directed obliquely upwards, and the canal 13 very short Arteria nutricia continues to the middle of the diaphysis, where it divida into tortuous ascending and descending branches which extend to the epiphyseal plates and to the apophyseal plate at trochanter major The metaphyscal regions adjacent to the epiphyseal and apophyseal carulages are nchly va ular Fig. 19 llustrates an injection into arteria outricia of the femoral diaphysis of the all The muscles have been removed. 9 Simultaneous filling of arienes of ibe tibel epipbyses and dupbysis after injection into arteria femoralis A few experiments were done. The leg wis divided through the thigh and the skin was left intact Fig 20 shows the isolated tibia after the injection. The muscles and perre osteum have been removed. Arteri nutricia of the diaphysis is evidently the largest artery of the obia. The rich vascularity of the metaphyseal regions clearly seen. The epiphyseal arteries are also obviou. In the upper cpiphysis, arterres deriving from the perchondnum are also filled these are most readily seen at the lateral tibial condyle.

·51 10 Simultaneous filling of arteries of tbe lower femoral epiphysus and upper tibial epiphysis after mjection into antena poplitea In this experiment (fig 21) the leg is divided below canalis nutricus of the femoral diaphysis, Canalis nutriqus of the tibial diaphyas us occluded. Contrast medium cannot therefore enter na the diaphyseal arteries, The arteries entering the lower femoral epiphysis in area intercondylaris posterior and the upper abial epiphysu in area intercondylans anterior are seen well filled These are the largest arteries of these epiphyses. They pass towards the centre, and branch in all directions. In addition the penchondrial arteries are filled. These branch at the per pheries of the cpiphyses, and anastomose with branches from the central arteries of the epiphyses. Filling of the metaphysis also takes place via metaphyseal arteries.

·52 11 с Fix 11 Cell 2 cel Cannola hymg u inetu nohou of the lower bul cpiphytit Urokon. ABD od F frontal ders C und E, lateral views Gunnal. 2. Arteru nutrcu. Verxels perforating the cpiphysal plate.

·53 65 D E Fillot of the metapbrul 5 Veoa autriau of the diepbria. 6. Vou tubuales mateToret. 1 Anetu abulu antenor ·54 3- 35 3- A Fit 13 Calf 2 week. Candula Tylos mineru attcu of the femori duaphyin. Murcia reto ed. Urokoa. A laterul ve frontal cu 1 Cu al 2 Antti nutrcu. 3 Ascending and descending bructies 4 Fillog of the metaphy aductor to the epiphyseal od spophral cartilag ·55 3+ A Fit Call 2 week. The artenal synem of the obra füled by myuion of Micropique isto anteru femorla The soft parts oclodiof the periodeon, are removed A lateral ne B froаral view | Anetu putnica of the deapbru ? Antru ounce of tbe upper Epiphat 3 Artemua netnou of the lovc piparis Aretes foretnog ube upper baal spophy su from the pencboodnom 4 ·56 est A Fu 21 Culf 2 ved The lovet femoral and upper tibu epupbyme after ejection of Micropaque 19 to entenia poplita A, und B, lateral view. C, D und E, frontal Tiar.. lo B und C the mocks od pot apaula are removed I. D mod E the persontra od perichondrum une remored ·57 31 D 1 Cansula Tylos u metu poplina 2 Antense ronde toward the catre of the femoral cpipbym 3 Arone roning towards the centre of tbe ubral cpapbpus. 4 Pencbondrul arterys

·No text on this page.

·CHAPTER Y Roentgen Investigations in Cow 1 The cenous system of the ubral dupbysus Canalus nutncus of the tibial diaphysis of the cow u situated more distally than that of the calf the distance between the external opening and the upper epiphysis being about 1/4 of the length of the diaphysis (in the calf it is about 1/5 of this length) The lumen is Danoner than m the calf The main vena nutricia and its major branches are largely similar to those of the calf Fig 22 illustrates an injection of contrast medium into vena nutnaa of a young cow in wbich the apophyses and cpiphyses have parually united. After leaving the canal the main vein gives off parron ascending branches. Just below the middle of the diaphysis it becomes narrower and gives off fine descending branches. Small branches arise from the main ren and from the accending and descending braoches The contrast medium leaves the bone via cortical veins in both upper and lower metaphyses. In the upper metaphysis the vein can be seen passing behind crista tibiac. As in the calf contrast medium injected into vena nutricia of the diaphysis passes a fine venous network before this vein is filled. At the apophyseal plate the vein enters the parallel veins in the periosteum of the lateral side of the metaphra. Filling of the epiphyscal reins 25 not achieved in this experiment the cortical veins draining the metapbyscal regions are so large that the contrast medium leaves the bonc by them alone. In another expenment (Fig 23) in which contrast medium as injected into vena nutricia of a tibia the muscles of which had been removed the opaque substance is also seen to leave the bone na cortical veins in the metaphyscal regions. Furthermore 2 cortical rein of the middle of the diaphrsis is seen filled at one point, revealing a vein situated in the periosteum 2 The tenious system of the upper tibial epipbrus The foramen nutraum situated in area intercondylans anterior is also very obrious in the con Injection of contrast medium into the vein entering by this foramen reveals its course towards the centre (Fig 24) The vein branches in all directions, and anastomoses with the intra-osscous reas of the metaphysis. The contrast medium leares the bone via epiphyseal and metaphyseal veins, and, because it passes so readily through these channels, filling of roa notncia of the diaphysis o not obtuned ·60 1 F 22. Yomg cor Carbiter ly Tona utra of the tbual duphyto Urokon A Bund D fronul 1. C latenl view Vede ut und sordiog and demand ag branchen 2 ·61 с 2. Vao pamun belupd crosta trbuc, ar ) stodrag the apophytal plate to contine u tro personal rem on the metaphytis Tam of the soft part, flled ru coral path 4 ·62 F U Cor Canouls Imiot a real bune of the mbul dupbyal Nucles remo a Urokoo A, tad lateral new and D, frodal non one with itdrot und descending brunches 2 Vee pusuot be und rura tubes 1 ·63 -5 3 Peronnal vem co the upper brrapbys Cootra medium outade tbe bonc 5 Perokcal rem of the duphy ·3 Tbe mtend system of tbe tibud diapbysis The mun artery and its major branches closely resemble those of the calf but the longitudinal branches running towards the cpiphyseal plates have be come much less pronounced in the cow and do not extend to the epiphyse. In the metaphyseal regions branches of arteria nutrica of the diaphyss anastomose with metaphyseal and epiphyseal arteries. The dense contrast filling of the bone marrow obtained on arteriography in the calf is never seen in the cow This indicates that in the cox the capillary system of the marrow has become greatly reduced. In the muscle-free preparation arteria nutricia 11 seen as a large vessel (Fig. 25) After leaving the canal, the main artery gives off two tortuous, ascending branches, and then itself continues downwards to divids, slightly below the middle of the diaphysis, into three descending branches. In the metaphyses the longitudinal branches divide to form a fine network and the contrast medium leaves the bone via cortical paths in the metaphyseal regions. Fig. 26 illustrates injection of contrast medium via a catheter introduced into antena nutncia of the diaphysis. The muscles are in situ In this experiment the main vena nutnaz of the diaphysis was also filled. In fig 26 A contrast medium - present only in the artery but in the subsequent films the main rein is seen as a farly large vessel accompanying it. Contrast medium must there fore have penetrated the capillary system. This has taken place without be comug obvious on the films which indicates that the capillary system is much umaller than in the calf The fact that arteria nutnga of the lower epiphysis becomes filled is evidence that anastomoses are present between the vanous arterial region. This vessel us a branch of arteri abialu anterior which is entered retrogradely by opaque substance. In addston, contrast medrum leaves the bone via venous channels, both venae tibiales anteriores becoming filled. The corresponding artery is situated between these veins. 4 Smultaneous filling of tbe arteries within the tibu after infection into eteru femoralis The tibia was examined after removal of joint caprule and muscles (Fig. 27) Anteza nutriai of the diaphyss is seen to be the largest vessel supplying the bone. In the periosteum is a network of artgies, but the cortal channels are so fine that contrast medium does not enter them. As in the calf the intery entering the upper tibial cpiphysis via area inter condrlaris ant nor is the largest artery of the epiphysis.

·67 AB -2 C Fit us Con Capgola Ime in arteru Aunu of the obul daphy at Hlaule irmore Urokon A Lateral thew B, fronul na Coblique Tic Antena orxuaith Ikinding uod desetadios branches 2 Cootras mediom ostade the bone, after passage through cortal paths i the meuaphyseal reg001.

·68 с Fr 26 Cor Catheter lyog minetu nunca of the tubul diapbym. Urokoc AC ad E, frontal no.B Dkod I lateral in 1 Cathetet 2 Aneria putrxua and exending and descendmog branches.

·69 D Man trook of ma nuncu of the dua pot fuled rah contrast medicon. + Artery to the lorer piphy. 5 Anetua mbulu 101CTIOT 6 Imse oblaki TOTCT ·70 1 + Fit 27 Cow Tibua after la section of Micropaque into artens feruorals A and a lateral van B and D frontal revA, 1 dB, penostrum in situ C and D penonton remo ed ·71 TV 1 Artena putu of the diaphysius 2. Aneta nutnou of the couphysik 3 Perteal anchet ·CHAPTER VI Roentgen Investigations in Human Material The human material avulable was limited. My main object was to demon strate connexions between the ranous vascular regions of the bones in question Selective angiography is very difficult in human bonds the vessels are much smaller than those of the calf 1 Tbe venous system of the tibud diaphysis of the full term fetus In the full term fetus I dissected down to foramen nutricium of the tibial diaphyas, and latroduced a blont cannula into canalis nutncus. The canal is situated posteriorly It opens citernally at the junction between the upper and middle thirds of the diaphysis, and passes medially downwards (Fig. 28) On injection through the cannula fairly large ascending and descending veins become filled as far as the metaphyses, where the contrast medium leaves the bone by cortical vessels passing to the veins of the soft parts. In addition : vein is seen perforating the anterior part of the epiphyseal plate, via which venous channels in the anterior part of the epiphysis become filled. These channels drain into a van laaving the cpiphyrus in area intercondylaris anterior slightly medial to the mid line A small braach from the epiphysal veins passing towards the osufication centre is also filled 2 Intra-osscons and intracartilaginous injections into tbe upper tibial epipbysis in the child Fig 29 illustrates a nearly full term fetus with a wall ossification centre at the upper tibial epiphysis The tip of the cannula is lying in the artilage distal to the centre of Ossification. On injection of contrast medium a vein 11 seen filled passing downwards and laterally to the metaphysis, the antero-lateral part of which becomes filled. The contrast medium leaves the metaphyses chiefly via metaphyseal veins to the veins of the soft parts. Pardal filling of vena nutricia of the diaphysis is also obtained Fig 30 shows a full term fetus with a canula lying in the ossification centre of the upper abial cpiphyns. The centre becomo opaque, and from it are filled several venous channels in the epiphysal cartilage. One of these channels ·73 Fie 21 Tol term fetal Cannula lying on canalis nunom of th mbul duaphytu. Urolon. Dund C, Lateral r1 D frontal TKY 1 Ascending and descending brandbes of rosa 2 vietaphysal 16101 3 To perforaunt the upper couphyseal plate Branch of thu Val dramos tbe ossfanno croire Dunia 4 ·74 Fig 29 Nearly full term ferus Canowa introduced into the artilage of the upper tibul piphyne. Urokon A, B and C frontal view. Dlateral Txw Cannula 2. Vet in the soterior part of the epiphysis, paning to the metaphys 3 Cootras medium m the metaphys. Vent of the soft parts. 5 Vent Dutncu of the duapbysin pantally filled. 4 C C Die 30 full term few. Cannula introduced into the waficnon centre of the upper tibal epipbye Urokop A, and laten TKL Cfrogal vir 1 Os canon cont fuled. 2. Ven 12 the art pe. Conrust Dedium in the latenor part of the metaphy 3 ·75 с For 31 lofat aged 2 months. Candola introduced into the ossification croire of the opper ribual cprphyul Urokon. A, und C, laterul TXWL B and D frontal TKWL 1 Vene in the interior part of the epiphyes. 2 Vam in the upper part of the oppbyn. 3 Voor in the posterior part of the epiphyos. + fillot of res m the interior part of the Detapbyal 5 Vena poplites. 6. Vena saphena ·76 p2using antero-laterally has anastomoses with veios in the metaphyun, which becomes partly filled with contrast medrun. Fig 31 illustrates an intra-osscous injection into the upper tibial cprphysus of a child aged 2 months. The ap of the cannula is lying in the anterior part of the ossification centre. The centre becomes filled with contrast medium, and from it filled veins pass anteriorly superiorly and posteriorly to forumina nutriciac in area intercondylaris anterior emincnaz intercondylans, and area intercondylaris posterior The opaque substance escapes via the capsular vans, and many veins in the soft parts become filled. In this experiment too the anterior part of the metaphysis becomes opaque. Fig 32 shows the cannula introduced into the apper ubial epiphysis of a 7 year-old child, the ap lying in the middle of the Ossification centre. To prevent escape of contrast medium to the capsular veins, the epiphyas and metaphysis are rightly bound with elasac bandages. On injection of contrast medium a longitudinal van perforating the central part of the epiphyscal plate becomes filled. This vain has anastomotic connaion with metaphyseal vans, which dran via cortical channels to veins of the soft parts on the lateral side of the leg 3 The arterial system of tbe lourt femoral diapbysis of the fetus Fig. 33 shows that the oasification centres of the lower femoral epiphyu have not appeared. The fetus is therefore not full term A blunt cannula u introduced into arteria nutnaa of the lower part of the femoral diaphysis. Externally the canal opens posteriorly slightly above the middle of the diaphysis, and passes antenorly downwards. The main artery is rather tortuous. The fine branches are too narrow to be evident on the radiograms. The contrast medium passos quickly to the metaphyns, which becomes opaque. The contrast leaves by cortical vessels wbich pass to veins in the soft parts. 4 Tbe arterial system of the tibial dupbysis of the child Fig 34 shows a catheter lying in arteria outriga of the tibial diaphysis of 10-month-old child. After leaving the canal the main artery gives off . tortuous ascending branch, and slightly below the centre of the duphysis another tortuous, descending branch. The contrast medium diffuses rapidly and in subsequent films it is impossible to distinguish mill anatomial detuls. The contrax medium leaves both metaphyses by metaphyseal venous chaands. Fig 35 illustrates a similar investigation on a child aged 6 months. Even opeaty of the mare diaphysis up to the epiphyseal plates u obtained, as in the alf Here, too, it is impossible to distinguish the finer branches: the technique u too coars for this The contrast medium lera both ends of the bone by metaphyseal veias.

·77 с p Fit J? Cuid, aged 7 years Cannls atrodaced into the onufication centre of the upper tibul piphy. Urokop Aud C. Lateral Kn D frontal TKY 1 Tip of the cannola n the off canon centre 2 lea perforating the epiphyxil plate at #contit 3 letaphral vemos * Toas of soft parts ·78 с un D E FJ Haman ferts Canaula murodoerd into arteria numaa of the lower fmoral diaphy Urokon A, ad E fropul vie B C D und F luteral mo 1 Tp of the annola 2 Mar trunk of the artery Met physeal filling Metaphyical vent popliten + ·79 VI с D E Fre 4 Infass wed 10 months Carbeter lying 18 uera Dutraua of the tibual diaphyun Urokop A, B und L Lateral vw. C ad D frontal vient 1 Carbeter Antena utan Akedding branch + Descending branch Vam druding the metaphyul 5 ·80 A 2 D Fag JJ Infint, aged 6 months Catheter lying in artera nutrau of the ubual dupbyah. Urokon A, B ind E, frontal vw. C, and D Litenl view.. 1 Tip of the atheter Z Arteru putna 3 Metaphyseal yant, In D und E, contrast media is ken to pan night up to the cp phymal platos.

·81 In fig. 36 the catheter is lying in artena nutnaa of the abial diaphysis of a chuld aged 11 years who was tall for his age. The canal is relatively long After leaving the canal the main artery gives off tortuous ascending branches, and then continues downwards, giving off tortuor, descending branches just below the middle of the diaphysis. Before reaching the epiphyseal plates the contrast medium passes via cortical channels in the metaphyset. 5 Arteries of tbe louet femoral metapbysis of the child Fig. 37 show's a catheter lying in a branch of artena poplitea of a 10-monthold child. Large numbers of capsular branches are filled about the upper part of the point capsule. From these branches arise arteries to the metaphyns at the lower end of the femur and opacity of the metaphysis is thus obtained 6 Smultaneous filling of arteries in the lower femur and the ribua after injection mio arteria femoralis Fig 38 illustrates an investigation on a child aged 2 months. All vascular regions are seen to be filled. Dense vascular networks are demonstrated in the peroseum and perichondrium but filling of the cortical ressels of the middle of the diaphyns is not obtained (the contrast medium is unable to penetrate these narrow vessels) The main antenes and major branches in both femur and tibia are well filled but the smaller branches to the metaphyses cannot be distinguished. In the metaphyses, however marked filling is obtained probably both from metaphyseal and diaphyseal arteries. Antries can be seen running to the centre of the epiphyses, and causing filling of the ossification centres and peripheral artenes arising from penetraung branches of penchondrial vessels can be seen. In the distal obial epiphyns several vessels in the cartilage are seen filled. No centre of ossification has yet appeared here ·82 3 C D Fo 16 Child, aged 11 yein Catheter 17 4 surcle of the tibual dia phyu. Urokon. A und Lanctal Tel B and D frooul viet 1 Catheter 2. llain tronk of the artery 3 Tortbous, incendist branch. 4 Tortrots descending branch 5 Vam laring the neupbysu } ·83 C р m a branch of anca popl tea Fir 37 i fant aged 10 mooths Catheter ly Urokon A B, and fronul in Dlateral 1 Tp of the arbetet 2 Capsular inci ) Illan of the lower front metaphy ·84 5- 5: A Fog 4 lafuot, aged 2 DODLE The abu and lower femur after wojection of Micropaque into urteru femorul.. A, and C Lateral viem. B and D frontal KYL A und B penostrum uod per cboodnum in ata C, 100 D perrotten and perscondrom removed ·85 2 -2 4 -2 2 -2 с 1 Arteru putnou of the dapbona 2 lieuphyseal füllung } list of co physoul sa ficaron centret + Arsenes in the epiphykil aandage Perional 1 5 ·CHAPTER VII Histological Investigations Histological investigations were made on preparations from calva, immature human fetuses, and full term fetuses. In the calf I examined canalis nutricius of the tibial diaphyns and the upper tibial cpiphysis. In the human matenal I invesogated the upper tibial epiphysis and the lower femoral epiphyn. The histological investigation us not claimed to be a comprehensive one The object has been to confirm the roentgen findings especially with regard to the blood vessels of the cartulaga 1 Canales nxtricks of tbe mbul dupbysis of call In Fig. 39 it is seen that almost the entre lumen of the canal is occupied by a large, thio walled vena nutricta, the thick walled artery lying to one ade. If a cannula is introduced into the canal the chances of the op entenng the vein Art very great A nerve is also seen in the canal accompanying the vessels into the bonc. Anyone who has performed intra-osscous injections on living subjects will have found that the procedure is aceedingly painful, even when only physiologal saloe is injected. Bone is atremely sensitive to changes in pressure within it. In the preparation the cortical canals (both the larger canals of Volkmann and the maller of Havers) are also clearly visible. Volkmann s penetrate the external and internal bone lamellne, and the Havernan constitute the finer canals of the bone that connect Valkmann i anals with each other 2. The upper uhal epipbyseal plate on call Fug 40 is a longitudinal section of the abia through the upper epiphyseal plate. Two longitudinal vascular canals are clearly seen perforating the arti lage. That to the night is divided along almost its entire length whereas only a part of the other u shown in section. Inregularly arranged, hypertrophic cartilage cells are seen in the cpiphyseal plate, on the side of the ossification centre On the metaphyseal ude the cartilage cells are arranged in columns they increase in size towards the metaphysis ·87 2 2 1 گلا ل Fit ook day Traore Dom through analo atreton of the bal diaphru A, upper part of the anal Borddle part of the canal ( 13 Hammator Loud 1. A the penoncom form part of the cool wall IA B the rul Corbi caurely of bode. Anteny nunca 3 MATT 4 Toliman 1 canal, 5 Harekin aula 6. Done mimos ܢܕܣܩ ܢܗܠܢ ·88 L Fix 40 Calf 2 vecku Longitudinal section of the opper tibus at the level of the epiphysal plate (* 30 HacOI EU n.) 1 Omfication centre of the epiphyuk 2. Metapbyen. 3 Hypertrophx amage cells adjacent to the omifxu tron centre 4 Prohfertig anlegs all with hypertrophic celbs udpecent to the metaphys. 5 Vaxular apals perfondos tbe pophyseal plate 7 ·89 Fig. 41 us a transverse section through the epiphyseal plate at its junction with the metaphysis the preparation therefore shows partly metaphyas and partly epiphyseal cartilage. The cartilage contains many vascular canals transvarsely and oblıquely cut. 3 Tbeopper ubral and lower femoral epiphyses in the haman fetus Fig. 42 shows a longitudinal section throogh the upper tibial epiphysu of a nearly full term human fetus. There is a small centre of ossfication in the epiphysis. Large numbers of vascular canals are seen in the epiphyseal cartı lage and these are certainly of great significance in the nutntion of the carn lage and ossification centre. Fig. 43 illustrates a vascular canal of the carulage in greater magnification An artery and two large veins are seen No capillanes can be dutinguished in the ground substance of the cartilage. Fig 44 1 a longitudinal section through the upper part of the abia At the level of the epiphyscal plate well developed proliferating and hypertrophic cartilage cells are seen. Immediately above the proliferating cartilage there are large vascular canals from which anse branches which pass through the epiphyscal plate to the marrow of the diaphysis. Fig. 45 is a longitudinal section of a similar preparauon and shows the entire course of a perforaung canal down to the martor cavity Fig 46 is a longitudinal section through the knee-point of a 5 month fetus There are many vascular canals in the cartilage of the femoral and tibial epiphyses, and in the patella. One of the canals of the femoral cpiphysis is seen penetraung the bypertrophic carulage cells to reach the marrom cavity of the diaphysis.

·90 AN F: +1 Calf 1 rakl Tronoh kdo throth the upper ubul oppbyxul plate u rujunction with the metaphyse The ration in clado both metaphyer and epiphyxal ampe Alow power ny ( 30). Bpb-power The (100) (Hecosto Eor) Tbert in NDOD, yaxular anals u the am re. There are stand between the bypertropb c artilage cells ) ·91 PE -2 h - Fry 12 Narly fall term homan fetal Longitudinal rection through the upper obral epiphytu (*3 Hacma tor Eow) 1 Oulfiaaton croce of the epiphys (damaged) 2 Vakular anals the artilap ·92 - + DIES 15 L Fix 43 Nearly foll teron human fetus. Upper tibul pephyos, showing canalo the anilase CUT ATOM ( 139, Haemator. Eose) 1 Artery 2. Veint ·93 Fe 44 Nauty full-term human fetes Longitudinal Ketion through the upper ribu, at the level of the epuphorel cartilage (* 40, Hacinato. Eoun.) 1 Proliferating artilage cells 2. Metaphy 3 Large vaxular and in the spiphyral cartilage 4 Vaxulu anals perfonto the proliferating cells ·94 FM 45 Nearly fon-term buman fetes. Longoodbol KcDon throogh the opper tibo at the lord of the sp physt A lov power TXT (20) B high-power vin ( 15). (Haemator. Eogo.) A vascular an clearly ren perforing he proliferatio arbage ) ·95 747 مرات FIE 6 Hean fetus, 3 months. Loopradmal section of the knee point A low power view (43) D, detail of the femur (35) (Haemator Eoun) 1 Draplyus Fooral cpaphras. 3 Tibul cprpbyus 4 Patella. 5. Vakolar canals in the artilage A rikular cinal perforating the cppbykal plate to reach the marrom canity of the femar L 6 ·CHAPTER VIII Conclusions 1 Roentgen investigations in call The arteries are accompanied by the veins. The epiphyses and diaphyses are supplied by both central and peripheral vessel. Vasa nutrica of the diaphysis are the central and also the largest vessels of the obız. The artery leaves arteria abialis anterior at an angle of about 90° The main stem follows a straight course in the long canal. In the marrow the large ascending and descending branches are tortuous. The branches of arteria nutricia continue us far as the epiphyseal and apophyscal plates (the latter at tuberositas tibiae) I have never seen any branch of arteria nutrica perforaang the epiphyseal or apophyseal plates. The growing regions of the metaphysis adjacent to the apophyseal and epiphyseal plates seem to be highly vascular These regions quickly become opaque on injection of contrast medium into the artery Arteria autricia gives off many branches throughout the marrow cavity and the capillary system seems to be atensive. Vena nutricia of the diaphysu us a large vessel that fills out almost the entire lumen of canals outraus. Its ascending and descending branches within the middle part of the diaphysis accompany the branches of the artery The peripheral vessels anise in the periosteum, which is richly vascular The arteries are accompanied by two veins. The vessels running from the penosteal vascular network to the cortex and anastomosing in the cortical vascular canals with branches of via notricia of the diaphysis, are very fine. In the metaphysis these cortical channels, and especially the veins, are larger and can be visualized by injecang contrast medium into veoa outricia of the diaphyss. Injection of Micropaque into arteria fernoralis results in some opacity of the metaphyscal regions, the contrast medium entering via the cortex by arteries from the periostal network. The central vessels, which are the largest supplying the epiphysis, enter by foramioa outrigia, and pass towards the centre branching in all directions. The penpheral vessels are mallet They arise frose perichondral vessels, tad anastomose with the central vessel The epiphyseal vessels also give off numerous branches to the sull unossfied carulage In the calf these can be seen glistening through the joint cartilage.

·97 Vascular canals perforate the epiphyteal plates and run longitudinally to the metaphyses, thus connecting the vascular systems of the cpipbyns and metaphysis. These systems therefore anastomose from the growing period The blood supply of the metaphysos bas therefore three sources, 1 724 nutraa of the diaphysik 2. the emphyseal vessels catering through the epiphyseal plates, and 3 the metaphyseal vessels arising in the periosteum and catering through the corte. The vans of the bones have no valves, and this explains the case with which they can be filled retrogradely As soon as the veins leave the bones, valves are present. It was interesting to examine the vascular system of tuberositas abize, which is an apophysis. The osufication centre has vascular connexions, via the apo physeal plates, with both the epiphysis and the metaphysis. There are arterial connexions with the epiphysis and the metaphysis and the veins anastomose with epiphyseal, metaphyseal and diaphyseal veins Roentgen camination of tuberculum majus has revealed similar vascular connexions through the apophyseal plate, with the upper metaphysis of the homerus. 2 Roentgen investigations in cow The vanous vascular regions have undergone certain changes. An impression is gained of the considerable reduction in the medullary capillary system that has taken place. In the calf marked opaaty of the whole marrow rosults from intra artenal injection of the contrast medium owng to the rich capillary network but in the cow the picture is quite different the contrast medium entering the pains via a apullary system so greatly reduced that dense filling never takes place. Vas nutricia of the diaphyss remain the largest vessels of the long bones, but the arterial branches that in calf supply the growth zones diminish with DeTeasing age and are not found in the adult animal. In the metaphyses there is anastomosis between vessels from the epiphyses, Tetaphyses, and diaphysis. The system in the epiphyses remains the same as in the calf with a central vessel and peripheral vessels The vessels ansing from the periosteum are sull most numerous in the soeta physeal regions. 3 Roentgen intestigations in buman material The human matenal mas, of course very limited but the study has been facilitated by the citenave invesogations on calf and con It is found that the rasular anatomy of human long bonos is closely similar 7 GTI ·98 to that in the calf and cow Thus there are the central rasa nutricia, giving off branches to the epiphysis and diaphysis and the peripheral vessels entering the bone from perchondrium and periosteum. Vescular canals pierce the epi physeal plates to convey vessels from the epiphyses to the metaphyses. Vessels from all three groups, therefors anastomose in the metaphysis during the arliest stages of growth. 4 Hustological investigations My main object has been to demonstrate the vaxular anals of the carlige, and particularly the canals perforating the epiphyseal plates. I have seen per forating canals in human fetuses, both immature and full term It was stnking to see the numerous vascular caoals in the cartilage. No capillaries are seen 1o the ground-substance, the junction between arteries and vens probably taking place in the actual vascular canal Long before the epiphyseal ossifica tion centres appear large numbers of vascular caoals are present in the caralage The canals therefore anise before the formation of the ossification centre. This disproves the view that the ossification centre develops as a result of inadequate blood supply to the middle of the epiphysis. I have seen numerous vagular canals in the distal femoral epiphysis, patella, and upper ubial cpiphysis of a human fetus of only 5 months, and even a vascular canal penetrating to the femoral diaphysi.. PERICHONDATUM EPIPHYSIS EPIPHYSAL PLATE MELAPHYS15 PELOSTEUM DLAPHYSIS CORTEX F 17 Daim to illustrant the Yeels of long bone. A. No oko cente prest the pipha. D. Onufragon centre present C. Adult ·Summary Opinons concerns the risular anatomr of long bones ran greatly Earlier researchers, such as LANGEL, LEXIn, and BIDDEX maintained that the vessels of the cprphras aod diaphrris anastomosed from the first Most later workers boveter are of the opinion that the epiphiseul plate constitutes a barrier which separates the riscular systems of the epiphus and diaphysis. This vier us shared by NUSSBAUM, RUBASCHETA PRISIS M MA* NEFFI, DALE, HARRIS, and others TRUETA too coorders the epiphyseal plate to be a barrier with one caption He has found that the vessels of the upper femoral metaphus penetrate the epiphyseal plate in newly born infants. These vessels, he states disappeared and at + years the epiphyseal plate forms an isolaang barrier which is not then broken unal growth is complete. The vascular supply of the apophyses has received little attention in the past. BIDDER assumed that vessels pierced the apophyscal plates There is a point of great importance concerning the epiply scal resicle demonta the carulaginous stage. Many believe that the vessels on the cpiphone 1.1 develop only when the ossification centres appear LANGIR BIUDEX and other have shows however that vascular canals are present in the cartile long before this My investigations were performed on calves, cows and mone sont de 411 marenal, the tibia being the main object of study is following 1111111011 techniques were employed. 1 Selecuve angrography via a cannula or catheter imenomrel on min of vana nutrcia of the diaphysis or epiphysis, The (chitrant mammu Urokon (Pharmacia) Senal radiography with rapid film Jumes anabole tlou passage of the contrast medium through the vessels to the trucil 2. Injection of Matopaque into anteria or vena Sammatill follower los aimination of the bone before and after removal of their lieben 10 Paten. 3 Intra-osseous and intracarulaginous injectum of Uroko The histologkal investgation was designed to contro ilia pewnopen dinding by demonstrating vascular canals in the episliyera aldea aut man denne The roentgen investigations in calves six weil thu Are HRHET HY want In both epiphyses and diaphyses there are central am ga is loon wla llim ceotral Tessels pass towards the centre of the box on w11411 11 ll In N * ·100 Io the diaphysis the main rasa nutricia are the central passels and in the epiphysos there are large vana nutriga entering via one or more large foramina nutriaa The peripheral vessels of the diaphyses une from the periosteal vascular network and those of the epiphyses arise from the perichondrial network. The central and peripheral vessels anastomose. In the calf arteria putnca of the diaphysis continues up to the epiphyseal plates, but does not seer to penetrate ther. Longitudinal branches of arteria nutricia of the epiphyses on the other hand, perforate both epiphyseal and apophyseal plates. The vessels arising in the periosteum are most abundant in the metaphyseal regions. The growth zones of the metaphyses are richly vascular and their blood supply us secured from diaphyseal metaphyseal and epiphyseal vessels. The vessels of the epiphyses give off branches not only to the omification centre but also to the cartilage via vascular canals containing both artery and vein Branches of the central veins of the epiphytes perforate the epiphyseal plates, and the vedous system of a long bone forms a continuous network which has anastomoses with the veins of the soft parts, chiefly via vena nutraa of the diaphysis, the metaphyseal veins, and the epiphyseal veins. The veins are much larger than the arteries. Within the bone they have no valves, there appearing immediately outade the foramina. Thus it is proved that the epiphyseal plates do not constitute a barrier to the blood vessels dunog growth. The epiphyseal vasels penetrate them, and vascular connexions between the epiphysis and diaphysis exist from an early stage of growth Nor do the apophyseal plates form a barner Tuberositas abize thus has vascular connexions with both epiphyns and metaphysis. In the cow vasa nutricia of the diaphysis remain the main vessels of the long bone. The arterial branches that in the calf supplied the growth zones diminish with increasing age, and are not found in the adult animal In the metaphyses of the cow there is considerable anastomou of epiphyseal, metaphyseal and diaphyseal vessels, as has also been demonstrated by earlier researchers. In the human material I have demonstrated that the vascular anatomy of the long bonos is similar in prinaple to that of the calf In children there are vascular canals perforating the epiphyseal plates, and vascular connexions between the epiphyses and diaphyres are present from an early stage By means of histological studies I have confirmed the presence in calves and human fetuses of vascular canals perforating the epiphyseal places. Dunng growth the epiphyseal arulage contains abundant vascular anals, and these develop at an early stags long before the appearance of the ossificaçon centres.

·Zusammenfassung Es bestehen divergerende Auffassungen über die Blutgefassverbāloosse in langen Röhrenknochen während des Wachstums Altere Forscher wie LANGER, Luxex und BIDDER sind der Ansicht, dass die Gefisse in den Epiphysen und der Diaphyse bereits wahrend des Wachstums mtander anastomosieren Die meisten späteren Forscher sind doch der Ansicht, dass die Epiphyseni fogen eine Barriere für die Blutgefasse bilden so dass die Gefässysteme der Epiphysen vom Gefassystem der Diaphyse getrennt wären Dieser Auffassung nad NUSSBAUM, RUBASCHETA, PRINES DE MARNETTE, DALE, HARRIS U. 2. Auch TRUETA erachtet die Epiphysenfuge als Barriere, doch mit einer Aus nahme er fand dass bei Neugeborenen die Epiphysenfuge mm proximalen Femur von Metaphysengefassen durchbohrt wird. Diese Gefässe verschwinden relativ rasch so dass bereits im Alter von 4 Jahren die Epiphysenfuge cine isolierende Barrite bildet, die nicht vor dem Abschluss des Wachstums durchbrochen wird Bisher wurde das Gefässystem der Apophysen nur wenig beachtet. Bidder vermutet doch, dass Gefasse cristieren die die Apophysenfugen perforieren Das Problem der Epiphysengefässe wahrend des Knorpelstadiums ist eine wichuge Frage. Viele sind der Meinung, dass die Epiphysengefasse erst ent stehen, wenn die Knochenkerne angelegt werden LANGEN, BIDDEN L. a. haben doch gezeigt, dass im Knorpel Gefässkanale lange Zeit vor der Entwicklung des Knochenkernes bestehen. Meine Untersuchungen wurden ausgeführt an separierten Gliedmassen von Kälbern, kühen und an aner kleinen Serie menschlichen Materials wahrend der Wachstumsperiode Das hauptsächlich verwendete Objekt war die Tibia. Fur die Röntgenuntersuchung verwendete ich folgende Methoden 1 Dhe selekave Angiographie mit der Kandle oder Katheter in der Anteria oder Vena nutricia sowohl der Diaphyse wie auch der Epiphyse. Als hontrast mittel wurde Urokon (Pharmaca) verwendet. Es passiert ohne Schwierigkeit durch das hapıllarsystem so dass ber arterieller Injektion auch die drainieren den Venen kontrasgefüllt werden Mittels raschen Film wechsels konnte die Kontrastpassage durch die Blutgefasse verfolgt werden 2 Injektion von Micropaque in die Antena rop Vena femoralis, danach Varersuchung des Rohrenknochens sowohl mit wie obac Periost und Perichon drum.

·102 3 Intraossöse und intracartaginäre Injektionen mit Urokon als Kontrastmittel Die histologischen Untersuchungen dienten dem Nachweis von Gefässkanälen in den Epiphysen beim Kalb und bei rafen und unreifen menschlichen Fetus. Die Röntgenuntersuchungen am Kalb zagten, dass Arterien und Venen cinander begleiten Sowohl in den Epiphysen wie auch in den Draphysen bestehen teils zentrale, tals periphere Gefäse Die zentralen Gefässe kommen von den grossen Foramina nutricia und verzweigen sich strahlenförmig in alle Richtungen. In den Diaphysen darstellen die eigentlichen grossen Vana nutncia die zentralen Gefässe, während in den Epiphysen ebenfalls grosse Vasa nitraa vorkommen, die durch an oder mehrere grosse Foramina nutricia in des Epi physenzentrum gelangen Die penpheren Diaphysengefässe en uspringen aus dem periostalen Gefässetz, die periphere Epiphysengefixe aus den perichondralen Gefāsnetz Die zeitralen und peripheren Gefässe anastomosieren miteinander Die Arteria nutriaa in der Draphyx des Kalbes erreicht mit siden Verzwegungen die Apo- und Epiphysenfugen, ohne diese sichtbar zu perforieren. Die Artena nutricu in den Epiphyxen perforiert hingegen mit longitudinal verlaufenden Verzwegungen sowohl die Epiphysenfugen, wie auch bei der proximalen Tibia, die Apophysenfuge. Die vom Periost ausgehenden Gefässe nod an reichlichsten in den Metaphysenzonen vorhanden. Die Wachstum.czonen der Metaphysen sind reich vascularisiert, ihre Blutgefässversorgung ist gesichert durch diaphysäre, metaphysäre und epiphysäre Gefässe. In den Epiphysen verzweigen sich die Gefasse nicht nur im Koochenkern sondern auch in Gefiakanälen des Knorpels, in welchen sowohl Arterien wie auch Venen verlaufen Verzweigungen der zentralen Venen der Epiphysen perforieren die Epı physenfugen so dass die Venensysteme eines langen Rõbrenknochens ein zosammenhängendes Netz bilden. Dieses Venennetz steht mit den Weichteilvenen in Verbindung hauptsächlich via die Veni nutrice der Diaphyse, die Meta physenvenen und die Epiphysenvenen die durch die grossen Foramina nutriai der Epiphysen gehen. Die Venen haben ein weites kalıbet im Verhältnis zu deo Arterien. Die Venen innerhalb des Koochens haben keine Klappen, doch sobald sie die Foramina outricia verlassen, sind sie mit Klappen verschen. De Epiphysenfugen bilden infolgedessen keine Barnere für Blutgefässe während der Wachstumsperiode. Die Epiphysengefisse perforieren die Fugen und bilden eine Gefistverbindung zwischen Epiphysen und der Diaphyss, die bereits wahrend der Wachstumspenode asert. Auch nicht die Apophysenfugen bilden aine solche Barriere. Dr Tuberositas ubiae hat infolgedessen Gefäsverbindungen sowohl zur Epiphyxe wie auch zur Metaphyse Bom erwachsenen Rınd bewahren die Vasa nutricia der Draphyse due Rolle ·103 des grössten Gefasses des Röhrenknochens. Mit zunehmendem Alter des Kalbes verden die Artenen verzweigungen die zu den Wachstumszonen verlaufen, zuoctuend rückgebildet und fehlen beim erwachsenen Rind. Beim Erwachsenen Rund anastomosieren die Epiphysen Metaphysen und Diaphysengefasse rachlich. Dies wurde auch durch frühere Untersuchungen gezeigt. Am menschlichen Material konnte ich zeigen dass die Gefisverhältnisse prin piel mit denen beim Kalbe übereinstimmen Bei Kindern bestehen durch die Epiphysenfugen perforierende Gefässkanäle, also bereits während der Wachstumsperiode vorhandene Verbindungen zwischen den Gefässystemen der Epıphysen ond der Diaphyse Durch histologische Untersuchungen konnte ich die perfonierenden Gefasskanale durch die Epiphysenfugen venfizieren und zwar sowohl beim Kalb wie auch ber reifen und uprafen Menschenfetus. Der Epiphysenknorpel entbālt wahrend der Wachstumsperiode reichlich Gefässkanäle. Diese werden während and frühen Stadiums angelegt, lange Zat vor der Entwicklung der Epiphysen knochenkerne.

·Résumé Les opinions sur la vascularisation des os longs pendant la croissance sont divergentes. Des auteun anacns comme LANGEL, LLXEk et BIDDEx pensent que les vals seaur des épiphyses et de la diaphyse sont déjà anastomoses entre eux pendant la croimance. La plupart des chercheurs plus récents sont cependant d avis que les cartilages de conjugaison épiphysaures opposent une barrière aux ruisseaux, de sorte que le système vasculaire des épiphyxs est séparé du système vasculaire de la dia phyłe Cat I opinion de NUSSBAUM, RUDASCHEVA, PRIVES, DE MARNEFFE, DALE, HANNs et plusieurs autres. TRUETA aussi pense que le carulage de conjugaison épiphysaire est une barndre, avec une exception chez le nouveau né et pendant les quatre premières années de la vie, des vaisseaux métaphysaires perforent le carulage de con jugason épıphywure de laxtrémité supérieure du fémur Le système vasculaire des apophyses ne semble pas avoir été étudié en détail jusqu à présent. BIDDER suppose cependant qu'il existe des vaisseaux perforant le cartilage de conjugaison des apophyses Une question importante est celle des vawcaur des épiphyses pendant le rade de formaaon du cartilage. Plusicurs auteurs pensent que les vaisseaux des épiphyses n apparaissent qu en méme temps que se forment les centres d osnfica tion. LANGER, BIDDar et plusieurs autres opt cependant montré qu'il existe des Angus vasculaires bien avant le développement du centre d orification Mon matériel d étude se compose de veaux de vaches et d une petite série de sujets humans en période de croissance. Los recherches ont porté prinapalement sur le abra. Pour l aumen radiologique j'u cu recours aux méthodes muiyantes 1 Angiographie selective par une canule ou up cathéter dans l artère ou la reine noomadre de la diaphyse ou de l&piphyse. Comme moyen de contraste, je me suis servid Urokon (Pharmaan) Par changement rapide des films, il at possible de suivre le passage du contraste dans les vaisseaan 2 Injection de Micropaque dans lastdre ou la venne fémorale suve daamen dos os longs avec et sans périotte et péruhondre. 3 Injections intra-osseuses et intracarulagineuses d Urokon Los études hustologiques ont eu pour but de montrer les canaus vasculara des épıphyses chez le veau et chez des foetus humains à terme et avant terme Laanen radiographique du vau a prouvé que les artères et les vanas ·105 ct saccompagnent. Dans les épiphytes ainn que dans la diaphyse il y a des valseaux centraux et des vaisseaux pénphériques. Les raskaus centraus se dinget vert le centre et se ramifient dans toutes les directions. Dans les dia physes, la gros puisseau nourriciens constituent les paisseaux centraux dans les épiphyses il y a de gros vaisseaux nournciers que par un ou plusieurs trous vasculaires du canal nourraer se dingent vers les parties centrales de 1 épiphysc. Los vaisseaux périphériques des diaphyses viennent du réseau va sculare perrostal et ceux des épiphyses du réseau vasculaire pénichondral La Vaisseaux contraux et les vaisseaux pénphériques s anastomosent entre eux Chez le vean, l artère nourricière de la diaphyse se ramifie jusqu aur carta lages de conjugaison epiphysure et apophysaire, mais ne semble pas les perforer Lartre nourricidre des épiphyses par contre, perfore aussi bien los cartilages de conjugaison épıphytures que les caralages des conjugaison apophysares par de peats rameaux longitudinaux. Cest dans les zones métaphysaures que les vanscaur venant du périoste sont le plus nombreur. Les zones de croissance des métaphyses ont une riche vascularisation assurée par des vaisseaux diaphysaires, métaphywires et épiphysires. Dans les épiphyses, les vaisseau se ramifient non seulement dans le centre dossification mais auoi dans le caralage, à linténeor de canaus vasculaires ou passent des artères et des veines. Des petits rameaux des veines centrales des épiphyses perforent les cartilages de conjugaison et le système veineux d un os long forme un réseau ininterrompu de vane. Celui-a communique avec les veines des parties molles par la veine noumaière de la diaphyse, les venes métaphysaires et les venes épiphysaires par les grands orifices vasculaire du canal nourraer des épiphyses. Le calibre des veines est grand en comparaison de celui des artères. Dans los, les veines nont pas de valvules, mau il y en a juste à la porte de lonfice vasculaire du canal nourriar Les cartilages de conjugaison épiphysaires ne consutuent donc pas unc bartidre pour les veuseaux poudant la croissance Les vaisseaur épiphyraires les perforent, de sorte qu il y a déjà pendant la croissance communication entre la diaphyx a les épiphyse. Los carulages de conjugaison apophysires ne constituent pas non plus une barrière. La tubérosité abiale antérieure a des communicacions vasculaires avec 1 épiphyse ainsi qu avec la métaphyse Chez la vache, les vaisseaux nournciers de la diaphyse conuduent 3 role de vaisseau principal de los long Los ramifications anténelle qu chez le reat se dingent vers les zones de croissance se sont considérablement réduites aree lige et font detaut hez la vache. Dans les métaphyses da chez rache une riche formation anastomosque de vaisseaui epiphysire, meta phytures et diaphysaires fut déjà constaté par d autres auteurs Jouet le ·106 Sur le matériel hunain ja pu mettre en évidence que la disposition de rapporo vasculaires at en principe analogue à celle du veau. Chez lefant, il existe des canaur vasculaires perforant les cartlages de conjugaison épı physaires, de sorte qu il y a déjà pendant la croissance communication catre le système vasculare de 1 épiphyx et celui de la diaphyse. Par des cramens histologiques j ai pu vérifier I existence de canaux vasculaires perforant les cartilages de conjugaison épıphymiros 20851 bien chez le veau que chez da foetus humains à terme et avant terme. Le cartilage des épiphyses est pendant la croissance abondamment pourvu de canaux vasculaires et ceux-a existent à un stade précoce, bient avant le développement des centres dossifica tion des épiphyses ·References Bucu, T. Hustolople und Ateroskopisebe Anatomie des Menschen Gront Thorne Stutt furt 1956 Bova, A : Ortcobxologle. Arch. Antt. 64 (1906) 137 Broer, O: Histologie ood Alikroskopische Anatoor da Mekheo. H Huber Bero/Stutt Part 1956. DALE, GG HARLA, R: Prognose of epiphyrual separation AA capenmetal mody J Boot 10d Jount Surt. 40-D (1954) 116 DOAM C. The apullares of the booe marrow of the adult picron Bull. Jobs Hopkins Hosp 33 (1927) 222. ECO J Pro D GUETTE, & & CATACH, D Etude da rtsetu Tancur dans los os long du lapun Ardures d lostomi I (1997) 101 GDL), A. Developexor of apparatus and metbode for rorotgrn stadies no harmodysamol Aca riduol Suppl. 130 (1956) Guico, R. Cantu, C. Circulation inenele mort-onctie de femur et du abu. L A# der Anatom. 16 (1921) 179 HASHIMOTO 11. Ober das grobert Blogger dssystena da kanischenknochenmark. Fukuoka Acta Media 23 (1935), 371 -- Ober das kapitäne Blutgefissytem des Keomebek Docbeomark. Transaction Societuin Patholopcae Japonia 26 (1936) 300 HAURIS, H A.: The muscular ropply of bone with special refereixe to the epiphysul anılago. Journal of Anatomy 64 (1930), 3 Hatu, A. Intr-ochronS venographies of medal fracture of the femoral neck. Acta Chir Scanbaru Suppl. 214 (1956) LANGEL, hir Ober das Gefamyhen der Rohreokoocha. Depkachnha der koberlichen Aka derme der Virenschaften, 36 (1976) 1 LEVILO J: The blood opply of developing long bones vith specul reference to be pers phykel | Bone and Jorat Sort 38-B (1956), 925 Lu Unterschungen siber Knochenartenen mittelst RBotgrosofnahmen IDJOITUKO hoocben. A Hirschnld, Berlin 1934 De Market L: Recherche morpbologiques et expérenule sur la pixolamuare on: Arta chir Bele 50 (1951) 469 568 681 MARTWOT and Bloom A Tenbook of Histology WB Samders Coropady PhDidelphu 1997 Numan Anatomie der Kpoche ancien Arbre for llon Chur 126 (1923) 40. Line As AGUZILA, MARLY A. Ostromedullografia. Atti del xix Congresso pazronale Vol II Sociech Italiana di Radiologu Meda. Bane Editon, Roma 1956 Koch, GLADSTONE, H: Vikular foramina and artenal supply of the disul cod of the femar J Bone and Jount Sore 32-A (1950) 167 RURAICHEUL, A, PUTEL ÁLG Blutvenorgung der langso Robrealoochen der Honden z aut 91, 3 (1932) 261 SPELH: Die hoocomarkinuskon mi hontruflutuskot Rontgenbilder Monatuhr f huderbet unde 7 (1980) 117 TAUTTAJ HARRISOY ALH AL The normal akalar 10pmy of the femoral head in adalt in J Bone and Joint S 635-B (1993) 442. T ti, J Tbc poreul Tikular anatomy f the human femoral bed daring growth. J Barme IN Jonat Sart 19-D (1937) 351

·No text on this page.

·No text on this page.