European Journal of Cardiovascular Medicine

Nutrient foramen is small opening present in most of bones of human body to transmit the nutrient artery which supplies nutrition to different parts of bone^1,2.Long bones get their blood supply from the nutrient, periosteal, metaphyseal and epiphyseal arteries. Long bones consist of outer cortex and inner medulla. Outer cortex and metaphysis are supplied by periosteal and metaphyseal arteries. The medulla and inner half of the cortex of the shaft of long bones are supplied by nutrient artery. The nutrient artery enters the shaft through the nutrient foramen leading into nutrient canal. The knowledge of nutrient artery of long bone is important in surgical procedures like bone grafting and bone transplantation. In day today life we are seeing increased number of cases with fracture of long bones. This is due to road traffic accidents, injuries in sports, industrial hazards, osteoporotic pathological fractures.4+

The nonunion of a fractured bone can be a complication of a closed or open reduction. Humerus is the largest and longest bone of upper limb. When blood supply is not established well, it can be complicated by a delayed union or a nonunion of the fracture and this reveals that the medullary arterial system plays an important role in revascularization of the necrotizing cortex and the uniting callus at the fracture site³. On the basis of this knowledge, the number, location of nutrient foramen is important for surgeons in preventing the intra operative injury of nutrient artery and also in medicolegal practice.

Study Design:

This study was a cross-sectional observational study conducted over a period of three months, from August 2024, to analyze the variations in the nutrient foramen of the humerus. The study took place at the Department of Anatomy and the Department of Forensic Medicine at Guntur Medical College, Guntur, India.

Study Sample:

The study sample consisted of 120 dry adult humerii (bones of the upper arm). These bones were selected based on specific inclusion and exclusion criteria:

Inclusion Criteria:

Only dry adult humerii were included in the study.

A total of 64 right humeri and 56 left humeri were included for the analysis.

Exclusion Criteria:

Broken bones: Humeri with fractures or signs of damage were excluded to ensure the integrity of the bones.

Pathological bones: Any humeri showing signs of disease or abnormal conditions, such as deformities, infections, or tumors, were excluded to avoid skewing the results.

Parameters Observed:

The main variables studied were the nutrient foramen (the small holes through which the blood vessels enter the bone), specifically focusing on the following aspects:

Number of Nutrient Foramina:

The humeri were examined for the number of nutrient foramina present. The following categories were considered:

Single foramen: One nutrient foramen.

Double foramen: Two nutrient foramina.

Triple foramen: Three nutrient foramina.

Location of Nutrient Foramina:

The location of the nutrient foramen(s) on the humeral shaft was recorded based on the surface of the bone. The locations were classified as:

Anteromedial surface: The front and middle portion of the shaft.

Anterolateral surface: The front and lateral portion of the shaft.

Posterior surface: The back portion of the shaft.

Direction of Nutrient Foramen:

The direction of the nutrient foramen was determined by inserting a pin into each foramen. This pin helped observe the direction in which the nutrient foramen was pointing, typically towards the center of the bone. The direction was assessed to understand the orientation of the foramen and its relevance to blood supply in the humerus.

Data Collection and Analysis:

The data related to the number, location, and direction of nutrient foramen in the humeri were observed, recorded, and compiled systematically. The results of these observations were organized into categories (single, double, triple foramen) and analyzed to detect patterns or variations in the presence and positioning of the nutrient foramen on the humeral shaft. This data will later be used to explore the clinical implications of these variations, particularly in surgical procedures or the understanding of bone health.

Ethical Considerations:

The study was approved by the Institutional Ethics Committee, ensuring that ethical guidelines were followed throughout the research process. Since the study involved dry bones and did not pose any harm to living individuals, it complied with ethical standards for anatomical and forensic research.

In the present study out of 120 humerus 85 are from the department of Anatomy and 35 are from the department of Forensic medicine Guntur Medical College, Guntur. In 104 humerus bones, single nutrient foramen is seen and out of which 56  are right humerii and 49 are left humerii. Double nutrient foramen is seen  in 14 bones, out of which 7 are right humerii & 7 are left humerii. Triple nutrient foramen is seen 2 bones,  out of which one  is right humerus & one is left humerus. Table  number 1 shows the number of nutrient foramen in humerus bones.

Table No.1 Number of nutrient foramen in  humerus bones

In 108 humerus  bones nutrient foramen is seen on Antero medial surface, out of which,  60 are right side & 48 are left side. In 1 humerus bone that is left side the nutrient foramen is seen on Anterolateral surface. In 11  humerus bones  the nutrient foramen is located on Posterior surface, out of which 4 are right side & 7 are left side.

Table No.2 Location of nutrient foramen in humerus bones

All nutrient foramina are directed downwards towards the lower end of humerus that is  away from growing end obeying the rule of law of ossification.

In the process of healing of a fracture , the blood supply of bone plays an important role. When blood supply is not established well, it can be complicated by a delayed union or a nonunion of the fracture. Outer cortex and metaphysis are supplied by periosteal and metaphyseal arteries. The medulla and inner half of the cortex of the shaft of long bones is supplied by nutrient artery.

The knowledge of nutrient artery of long bone is important in surgical procedures like bone grafting and bone transplantation. On the basis of this knowledge the number, location of nutrient foramen is important for surgeons in preventing the intra operative injury of nutrient artery and also in medicolegal practice.  Laing⁴ studied that the vascularity of the humerus must be protected from injuries during operations  which are done on the humerus shaft.

In the present study, single nutrient foramen is seen in 86.66%,Double nutrient foramen is seen in 11.66% and triple nutrient foramen is seen in 1.66% of bones. Asha rani⁵ et al, single nutrient foramen is seen in 87% , Double nutrient foramen is seen in 11% and  no triple nutrient foramen is seen.Ramyasree⁶ et al, single nutrient foramen is seen in 81.19% , Double nutrient foramen is seen in 18.35% and triple nutrient foramen is seen in 0.45% of bones. .Govula Subramanyam⁷ et al, single nutrient foramen is seen in 61% , Double nutrient foramen is seen in 31% and triple nutrient foramen is seen in 8% of bones. Vikram singh⁸ et al, single nutrient foramen is seen in 61% , Double nutrient foramen is seen in 31% and triple nutrient foramen is seen in 8% of bones. Sobia ali⁹ et al, single nutrient foramen is seen in 60%, Double nutrient foramen is seen in 23.3% and triple nutrient foramen is seen in 11.6% of bones.

Number of humerus examined in Asha Rani study and present study are equal number i.e.,120.Out of which single foramen  present in same number in both study, double foramen are less in present study compared to other studies.

Table-3 Number of Nutrient Foramen

In the present study, the  nutrient foramen is seen on anteromedial surface  in 90%, on anterolateral surface in 0.83% and on posterior surface in 9.16% .Sanjay Kumar¹⁰ et al the  nutrient foramen is seen on anteromedial surface  in 89.02%, on anterolateral surface in 9.76% and on posterior surface in 1.22% .S. Chandra sekharan¹¹ et al  the  nutrient foramen is seen on anteromedial surface  in 89.92%, on anterolateral surface in 1.55% and on posterior surface in 8.53%.C.D.Sukumar¹² et al the  nutrient foramen is seen on anteromedial surface  in 85.24%, on anterolateral surface in 6.56% and on posterior surface in 10.65%.D.Mansur¹³ et al the  nutrient foramen is seen on anteromedial surface  in 88.86%, on anterolateral surface in 6.52% and on posterior surface in 4.62%.Yaseen¹⁴ et al (2014) the  nutrient foramen is seen on anteromedial surface  in 88.5%, on anterolateral surface in 3.5% and on posterior surface in 8.53%.

Table-4 Location of Nutrient Foramen

The Present study concludes that most of the humerus bones consist of single nutrient foramen on antero-medial surface of shaft of humerus. Deviation to normal, nutrient foramen is also seen on antero-lateral surface, posterior surface of shaft of humerus. In some humerus double or triple nutrient foramen is also seen. So, the anatomical knowledge regarding the number, location, direction of nutrient foramen is helpful for Orthopedic surgeons in internal fixation, fracture repair, bone graft, joint replacement therapy and vascularized bone micro surgery and decreases the chances of damage to nutrient artery. In fractures of humerus damage to nutrient artery leads to non-union or delayed union of bone. All foramina are directed downwards towards the lower end of humerus, that is away from growing end obeying the rule of law of ossification.

1. Datta AK. General Anatomy: General consideration. 4th ed. Kolkata: Current Books International; 1997. p. 75-7.
2. Standring S, Williams P, Warwick W, Bannister D. Gray's Textbook of Anatomy: Pectoral girdle, Axilla. 37th ed. London: Elsevier Churchill Livingstone; 1993. p. 299-300, 759.
3. Rhinelander FW. The normal microcirculation of diaphyseal cortex and its response to fracture. J Bone Joint Surg Am. 1968 Jun;50(4):784-800. doi: 10.2106/00004623-196850040-00016. PMID: 5658563.
4. LAING PG. The arterial supply of the adult humerus. J Bone Joint Surg Am. 1956 Oct;38-A(5):1105-16. PMID: 13367086.
5. Asharani SK., Ajay Ningaiah. A study on the nutrient foramen of humerus. Int J Anat Res. 2016; 4 (3): 2706-2709
6. Ramya Sree. A, Udaya Kumar P, Kalpana. T, Vinayaka Naik. I.MorphometricAnd Morphological Study Of The Nutrient Foramina In Dry Human Humerus Bones Of Telangana Region. Int J Anat Res 2019;7(1.3):6302-6306. Doi: 10.16965/Ijar.2019.104
7. Govula Subramanyam, Chittinarasamma, Ch Jayamma, Somasekhar. A study on variations of nutrient foramen of humerus in Kurnool, Andhra Pradesh, India and its clinical relevance. Int J Med Res Prof. 2021;10(23):1-4.
8. Vikram S, Amit Kumar S, Prachi SA, Pawan M. A study on variations of nutrient foramen of humerus and its clinical significance. Int J Med Res Prof. 2018;4(5):255-8.
9. Sobia Ali Chalkoo, Parvaiz Ahmad Lone, Shaheen Shahdad, Ghulam Mohammad Bhat. Nutrient foramen of humerus. Int J Med Sci. 2023 Oct 11;10(10):3681-4.
10. Kumar S, Sinha S, Akhtar M, et al. Morphometric study of the nutrient foramen of the humerus in the population of Bihar. Cureus. 2022 Dec 23;14(12):e32856. doi: 10.7759/cureus.32856.
11. Chandrasekaran S, Shanthi KC. A study on the nutrient foramina of adult humerii. J Clin Diagn Res. 2013;7:975-7.
12. Sukumar CD. A study on the anatomical variations in diaphyseal nutrient foramina of humerus and its clinical implications. Int J Cur Res Rev. 2019;11(15):16-22.
13. Mansur DI, Manandhar P, Haque MK, Mehta DK, Duwal S, Timalsina B. A study on variations of nutrient foramen of humerus with its clinical implications. Kathmandu Univ Med J (KUMJ). 2016;14(53):78-83.
14. Yaseen S, Nitya W, Ravinder M. Morphological and topographical study of nutrient foramina in adult humerii. Int J Innovat Res Develop. 2014;3(4):7-10.