Anatomy and pattern of tibial periosteal circulation: implications for tibial plating

Abstract

Aims

The significance of periosteal vessels in the healing of tibial shaft fractures is well-established. However, the gross anatomical patterns and differential distribution of these vessels on the medial versus lateral surface of the tibial shaft have not been thoroughly described. This study aimed to illustrate the comparative anatomy of periosteal circulation on the medial versus lateral surface of the tibial shaft, where tibial plates are commonly applied.

Methods

Ten adult fresh cadavers underwent aortic injection with coloured silicone to investigate the vascular system of the lower limbs, including the tibial extraosseous circulation. Following material fixation, the medial and lateral tibial surfaces were dissected extraperiosteally from the knee to the ankle joint to visualize the gross anatomy of periosteal vessels running along the medial and lateral surfaces of the tibial shaft.

Results

In all specimens, periosteal vessels on the lateral tibial consisted of six to eight main trunks in 17 out of 20 specimens. These vessels were evenly distributed, horizontally oriented, and exhibited variable side branching. Most of these vessels crossed the anterior tibial crest, terminating on the medial side. The extensor muscles on the lateral tibial surface made negligible contributions to the periosteal circulation. The medial tibial surface received its periosteal blood supply partly from the terminal branches of the traversing vessels from the lateral surface and partly from branches of the posterior tibial artery. These vessels were shorter, smaller, sparsely scattered, randomly distributed, and exhibited greater variability in number and size compared to their lateral counterparts.

Conclusion

Periosteal circulation to the anterior two-thirds of the tibial shaft is mainly delivered through the lateral tibial surface. When periosteal circulation is a concern, lateral plating may be more disruptive compared to medial plating.

Cite this article: Bone Joint Res 2025;14(9):769–776.

Article focus

• Gross extramedullary circulation of the medial and lateral surface of tibial shaft.

• Vascular impact of medial versus lateral side diaphyseal plating.

Key messages

• Periosteal vessels running on the lateral surface of tibial shaft play a dominant role in extramedullary circulation of the anterior two-thirds of tibial shaft.

• Lateral side muscles make a negligible contribution to the periosteal circulation of tibial shaft.

• Medial surface plating can be a vascular-sparing approach in tibial shaft plating.

Strengths and limitations

• The study was done using very fresh cadavers early after death and before any postmortem soft-tissue degradation.

• Fills the gap in the literature about the comparative periosteal anatomy of the medial versus lateral surface of the tibial shaft.

• Provides more clarification about the gross anatomy, origins, and pattern of tibial shaft periosteal circulation.

• The study shows the static situation of the periosteal vessels in postmortem limbs; in live and physiological conditions, the diameter and patency as well as the number of functioning vessels may differ from those of the postmortem limbs.

• The posterior surface of the tibia was not included in the study, although that side is not typically used for plating.

• Lack of cross-sectional image of the specimens.

Introduction

The blood supply of long bones, including the tibia, and its role in fracture healing, have been extensively studied in both animal and human research.^1-12 Human long bones including the tibia receive blood from three primary sources: the metaphyseal-epiphyseal arteries, the endosteal (nutrient) artery, and the periosteal arteries.^1-6 The tibial shaft, like other long bones, derives its blood supply from two main sources: the endosteal (intramedullary) circulation, supplied by the nutrient artery, and the periosteal (extramedullary) circulation, supplied by the periosteal vessels.^1-16 Both circulations, particularly the endosteal supply, are vulnerable to damage following a displaced diaphyseal fracture. Additionally, surgical fixation techniques such as medullary nailing and plating can further compromise the endosteal and periosteal blood supplies, respectively.^13-15 Several studies have emphasized the critical role of periosteal vessels in the repair of tibial shaft fractures when medullary circulation is compromised.^13-18

Currently, closed medullary nailing is the preferred treatment for tibial shaft fractures, although plating techniques remain commonly indicated.^19-28 The trend in plating has shifted towards less invasive techniques to minimize periosteal circulation damage, thereby enhancing the healing potential of bone fragments.^28-34 The decision to apply plates on the medial or lateral tibial surface typically depends on factors such as the condition of the superficial soft-tissues, ease of access, and the surgeon’s preference, rather than on the status of periosteal circulation.

Most anatomical studies describe the general pattern and distribution of tibial periosteal circulation at the microangiographic and histological levels.^1-8 However, reports on the gross anatomical pattern are limited,^7,8 and no studies have documented the differential distribution of periosteal vessels on the medial and lateral surfaces of the human tibia. This cadaveric vascular study aims to provide a macroscopic display of the anatomical pattern and distribution of periosteal vessels on these surfaces, where tibial plates are commonly applied.

Methods

This study was part of a more extensive vascular anatomy study of the lower limbs and pelvis. Formal institutional review board approval was not required, but the study had the support and approval of the orthopaedic department of the Iran University of Medical Sciences and the postmortem department of the Legal Medicine Organization. Ten fresh adult cadavers (7 males, 3 females) aged 30 to 65 years were selected. For bilateral lower limb examination, the aorta was accessed via a standard laparotomy approach commonly used in medicolegal investigations. All 20 specimens were intact, with no signs of previous damage or surgery.

To clear any remaining blood, the arterial system was irrigated with water. Subsequently, a green-coloured, doughy silicone mixture lubricated with oil was injected using a large irrigation syringe. A catheter was fixed to the aorta before its bifurcation, and steady, continuous hand pressure was applied for five to ten minutes to ensure a controlled injection. Injection continued until either the sole of the foot turned green, or the material leaked from a small skin incision made at the tip of the toes. All injections were performed by the senior author (MK).

After the silicone had cured overnight, the legs were accessed through a long anterior incision extending from the tibial tuberosity to the ankle joint (Figure 1). The medial and lateral tibial surfaces were exposed extraperiosteally. On the medial surface, the skin and subcutaneous tissue were carefully dissected from the periosteum to preserve the vessels running along the bone’s surface (Figures 2a, 3a, and 4a). A similar technique was used to expose the lateral tibial surface by separating the tibialis anterior fascia from the anterior tibial crest and gently dissecting from the periosteum on the lateral surface (Figures 2b, 3b, and 4b). Dissection continued to the interosseous membrane until the anterior tibial artery was visible (Figure 5).

Fig. 1.

Extent of the approach and subcutaneous exposure of the anterior aspect of the right leg, from the knee to the ankle. Long arrow shows the diaphyseal portion of tibia. TAM= tibialis anterior muscle, T.T.= tibial tuberosity.

Fig. 2.

Extraperiosteal exposure of the medial (a) and lateral (b) surfaces of the right tibia in the same specimen after separating the skin and muscles from the periosteum, highlighting the sparsity of periosteal vessels on the medial side. ant.= anterior, post.= posterior, TAM= tibialis anterior muscle, T.T.= tibial tuberosity.

Fig. 3.

Extraperiosteal exposure of the medial (a) and lateral (b) surfaces of the lef tibia of the same specimen, demonstrating the poorly perfused medial surface, as in Figure 2. TAM= tibialis anterior muscle, T.T.= tibial tuberosity.

Fig. 4.

Extraperiosteal exposure of the a) medial (med.) and b) lateral (lat.) surfaces of a right tibia after separation and retraction of the overlying skin and muscles, revealing a) the better perfusion of the medial side in this case. b) The magnified inset shows effective filling of the small vessels by the injected material. Arrow shows the tibial tuberosity (T.T.). TAM, tibialis anterior muscle.

Fig. 5.

Extraperiosteal exposure of the lateral surface of right tibia after separation and retraction of the overlying muscles showing the interosseous membrane and the anterior tibial artery (white arrows). Yellow arrow shows the lateral malleolus. Ant.= anterior, Post.= posterior, TAM= tibialis anterior muscle, T.T.= tibial tuberosity.

Periosteal vessels along the diaphysis were visually examined, traced, and documented using digital photography. The presence of fine capillaries and visible vessels on the surface of dissected muscles confirmed effective arterial system filling (Figure 4b). The true size of the periosteal arteries could not be defined, concerning the variability of their size and the effect of injection pressure on the diameter of the main supplying vessels. All specimens were selected by the forensic medicine specialist (JG) and all dissections were performed by one of the authors (MK).

The boundaries of tibial diaphysis were defined intraoperatively based on the visual anatomical landmarks: proximally by the distal margin of the tibial tuberosity and the Pes anserinus attachment, where metaphyseal flaring ended, and distally, it was marked by the point where distal flaring started, and where the anterior tibial crest turned medially toward the medial malleolus and where it lost its anterior sharpness.

Results

In all specimens, the periosteal vessels on the lateral tibial surface originated directly from the anterior tibial artery and ran transversely from the posterolateral border towards the anterior tibial crest (Figure 4a and Figure 5). These vessels were transversely oriented and regularly spaced along the tibial shaft. In 17 out of 20 specimens, the number of these vessels varied between six and eight along the shaft (Figures 2b, 3b, 4b, 5, and 6). About 60% to 75% of these vessels traversed the tibial crest and ended on the medial side, contributing to the medial surface periosteal circulation (Figure 7). Smaller and shorter vessels branched off from each side of the transverse arteries along their course on the lateral surface of the shaft. The number, size, and length of these side branches were highly variable (Figure 8). Toward the proximal metaphysis, the periosteal vessels were more densely populated and irregularly scattered.

Fig. 6.

Lateral surface of the right tibia, illustrating the dense network and fine branching of periosteal arteries, as well as the more uniform and dominant periosteal circulation on this side compared to the medial side. Ant.= anterior, Post.= posterior; TAM= tibialis anterior muscle, T.T.= tibial tuberosity.

Fig. 7.

Extraperiosteal exposure of the lateral (a) and medial (b) surfaces of the right tibia, showing the contributing periosteal vessels traversing the anterior tibial crest from the lateral to the medial surface (short white arrows).

Fig. 8.

Lateral surface of the left tibia, showing periosteal vessels. The magnified inset (A) highlights the side branching of a transverse artery. TAM= tibialis anterior muscle, T.T.= tibial tuberosity.

The tibialis anterior and the other extensor muscles on the lateral tibial surface contributed negligibly to the periosteal circulation of the tibial shaft.

The medial surface periosteal vessels originated partly from the lateral surface traversing vessels (Figures 2, 4, and 8), and partly from the posterior tibial artery, which ran from the posteromedial border anteriorly along the surface of the bone. These vessels were smaller, shorter, sparsely scattered, and randomly distributed along the diaphysis compared to the lateral side periosteal vessels (Figures 2a, 3a, 4a, and 7b). Compared to the medial side, the lateral side vessels were more prominent in size, consistent in number and distribution pattern (Figures 2 to 7). In the proximal metaphyses, especially on the lateral side, the vessels were more densely populated compared to the diaphysis and distal metaphysis.

Discussion

The vascular anatomy of the tibia and its relationship to fracture healing has been extensively studied by many authors.^1-9 Several studies have emphasized the role of periosteal circulation in the healing of tibial shaft fractures.^8-18 This human cadaveric study illustrates the macroscopic anatomy and distribution pattern of periosteal vessels on the medial and lateral surfaces of the tibial shaft, where tibial plates are typically applied. Most prior anatomical studies, conducted using microangiography and histology, focused on animal models.^1,4-11 Our findings confirm many of the conclusions drawn in these earlier studies, with some additional insights.

Consistent with some of the previous research, we observed that the periosteal vessels on the tibial shaft predominantly originate from the main arteries of the leg. In contrast to the previous studies, we demonstrated that the overlying muscles contributed minimally to the periosteal circulation of the tibial shaft. Additionally, most of the terminal branches from the main lateral periosteal vessels terminate on the medial side, by traversing the anterior tibial crest. The size, number, and distribution pattern of these vessels vary between the medial and lateral surfaces. Specifically, periosteal vessels on the lateral side are more consistent in their number, size, and pattern, playing a dominant role in the extramedullary perfusion of the anterior two-thirds of the tibial shaft (Figures 2b, 3b, 4b, 5, 6, 7a, and 8). These vessels are uniformly distributed and run transversely along the tibial shaft, with many terminating on the medial side after traversing the anterior tibial crest, contributing to the medial periosteal circulation (Figure 7).

Brookes,¹ Rhinelander,⁵ and Trueta⁴ have previously described the general anatomical circulation of the tibia in animal models.^6,17 Our study, however, offers a macroscopic comparison of the periosteal vessels on both the medial and lateral surfaces of the human tibial shaft. In a human cadaveric study, Nelson et al² described the pattern of periosteal circulation of tibia more like to our study. They observed that periosteal vessels of varying diameters, entering or leaving the cortex, represent either capillaries or small venules, but not arteries. The current study confirms the existence of the periosteal arteries and their terminal ramifications as capillaries.

The tibial shaft receives blood supply from two main sources: the endosteal and periosteal circulations. Of these, the endosteal vessels are more prone to disruption in fractures, particularly in displaced diaphyseal fractures, as they run longitudinally along the medullary canal. In contrast, the periosteal vessels, especially on the lateral surface, run more transversely along the shaft and are less likely to be significantly damaged in closed or simple open fractures.^1-6,18 Periosteal stripping and medullary reaming during surgical treatment can further damage the already compromised circulation in the bone.^9,18 Several authors have investigated the importance of periosteal circulation for cortical perfusion and fracture healing.^{1-5,7,9,35,36} Kowalski et al,³⁶ using sheep tibiae, found a 20% reduction in cortical perfusion after stripping the periosteum along the medial tibial surface. This reduction might have been more pronounced if the experiment had been conducted on the lateral tibial surface, given the higher concentration and richer distribution of periosteal vessels on this side.

Modern plating techniques aim to preserve periosteal circulation to maintain the healing potential of the bone fragments. The vascular impact of different plating techniques and plate designs on tibial periosteal circulation has been extensively studied.^30-35,37 However, the difference in vascular impact between medial and lateral tibial plating has yet to be addressed in the current literature.

In a cadaveric study, Borrelli et al³¹ found that open plating techniques significantly compromised periosteal circulation on the medial surface of the distal third of the tibia, compared to newer subcutaneous methods. Kregor et al³³ studied the effect of three types of plates with varying bone contact on cortical bone perfusion in immature sheep tibiae, finding no difference in perfusion after medial side plating. Conversely, Swiontkowski et al,³² in a vascular study on sheep tibiae, concluded that plate design does affect cortical perfusion.

Surgeons typically choose either the medial or lateral side for tibial fixation based on local soft-tissue conditions or the surgeon’s preference when no other factors dictate the choice. However, most experimental studies have focused solely on the medial side, raising questions about the applicability of these findings to lateral side plating procedures.

Despite concerns about potential vascular complications, many surgeons prefer lateral side plating due to its advantage of better soft-tissue coverage. Initially, adverse vascular effects associated with lateral tibial plating were attributed to muscle detachment from the bone. However, our study reveals that the periosteal vessels on the lateral surface originate directly from the main leg arteries, with minimal contribution from overlying muscles. Therefore, if muscle detachment from the lateral tibial surface is performed carefully, it has a minimal negative impact on periosteal bone circulation. The primary concern with lateral plating should be the potential for direct periosteal damage, rather than muscle detachment.

In terms of tibial periosteal circulation, lateral tibial plating may be more invasive due to the potential for greater periosteal damage, as opposed to muscle detachment. However, the advantages of better soft-tissue conditions in lateral plating should be weighed against the increased risk of vascular damage.

This study has some limitations. The posterior tibial surface, which is not commonly used for plating, was not included. Additionally, the study reflects a static pattern of periosteal circulation in intact bone and does not account for dynamic bone perfusion or clinical outcomes. Further research, including studies on bone perfusion and clinical outcomes, is needed to confirm these anatomical findings.

In conclusion, the periosteal vessels on the lateral surface of the tibial shaft are more consistent in number, size, and distribution compared to those on the medial side. These vessels originate directly from the main arteries, with minimal contribution from the overlying soft-tissues. While lateral tibial plating offers better soft-tissue coverage, medial plating, when performed carefully, may better preserve periosteal circulation. Further studies are needed to validate these findings in clinical settings.

Data Availability

The data that support the findings for this study are available to the researchers from the corresponding author upon request.