The vascularity of the scaphoid bone

The extraosseous and intraosseous vascularity of the carpal scaphoid was studied in 15 fresh cadaver
specimens by injection and clearing techniques. The major blood supply to the scaphoid is via the radial
artery. Seventy to eighty percent of the intra osseous vascularity and the entire proximal pole is from
branches of the radial artery entering through the dorsal ridge. Twenty to thirty percent of the bone, in
the region of the distal tuberosity, receives its blood supply from volar radial artery branches . There is all
excellent collateral circulation to the scaphoid by way of the dorsal and volar branches of the anterior
interosseous artery. An explanation for the cause of scaphoid necrosis 0 11 the basis of the vascular
allatomy is proposed. The volar operative approach would be least traumatic to the proximal pole's blood
supply .

Richard H. Gelbennan, M.D., and Jayasanker Menon , ¥.D., San Diego, Calif.

T he high frequency of avascular necrosis of the prox-

imal pole of the carpal scaphoid following fracture has
been noted by several authors. Scaphoid fractures ac-
count for less than 2% of all fractures, but the scaphoid
is second only to the femoral head in its incidence of
posttraumatic avascular necrosis . I Whereas several fac-
tors have been related to scaphoid avascular necrosis,
the only consistent finding has been a correlation of
fracture location and avascular necrosis of the proximal
pole. 2 Thirty percent of middle third fractures and al-
most 100% of proximal fifth fractures have been asso-
ciated with avascular necrosis of the proximal pole of
the scaphoid. 3
The first study designed to determine the anatomical
basis for avascular necrosis of the scaphoid was per-
formed by Preiser and Lexer in 1910. 4 They investi-
gated the scaphoid's vascularity in an experiment
which utilized vascular injection and dissection tech-
niques . The most recent of a group of studies using
injection and clearing techniques was performed by
Talesnik and Kelley4 in 1966. They injected the radial Fig. 1. Schematic drawing of the volar external blood supply
of the scaphoid. (S, scaphoid; I, radial artery; 2, volar
artery with India ink and barium sulfate and dissected
scaphoid branches; 3, ulnar artery; 4 , anterior division of the
the scaphoid's blood vessels under magnification. They
anterior interosseous artery.)
then cleared the bone by the Spalteholz method and
visualized the internal vascularity. Despite the con- orientation and clinical significance of the intraosseous
tribution of this study, considerable differences of opin- vascular patterns.
ion have persisted about the origin and relative con- The purpose of this study is to demonstrate the exter-
tribution of the scaphoid's nutrient arteries, and the nal and internal vascularity of the carpal scaphoid by
nondissection techniques. The radial, ulnar, and in-
terosseous arteries were injected to define the precise
From the Division of Orthopedic Surgery, University Hospital Medi-
contribution of the major blood vessels supplying the
cal Center, University of California, San Diego, Calif.
Received for publication Dec. 14, 1980; revised March 14, 1980.
scaphoid and determine the extent of its collateral circu-
Reprint requests: Richard H. Gelberman, M.D., University Hospital
lation . The entry vessels and internal vascularity were
Medical Center, University of California, San Diego, 225 Dickin- studied to provide a better understanding of scaphoid
son SI., San Diego, CA 92103. avascular necrosis and to help determine the least de-

508 THE JOURNAL OF HAND SURGERY 0363-5023/801050508+06$00.6010 © 1980 American Society for Surgery of the Hand
Vol. 5, No.5
September 1980
Fig. 2. Schematic drawing of the dorsal blood supply of the scaphoid. (S, scaphoid; 1, radial artery;
2, dorsal scaphoid branch; 3, dorsal division of the anterior interosseous artery; 4, intercarpal
artery.)
structive operative approach to the bone. Fifteen
cadaver forearms were studied and form the basis of
this report.
Material and methods
The brachial, radial, and ulnar arteries of 15 cadaver
arms were isolated at the elbow and in the proximal
forearm. None of the extremities had any known previ-
ous trauma or disease. The radial artery was cannulated
with a polyethylene catheter. A second catheter was
inserted into the brachial artery and passed into the
ulnar artery proximal to the origin of the common in-
terosseous artery. Both arteries were irrigated with
normal saline until the venous return was clear. Trans-
verse incisions were made over the distal phalanges of
all digits. Ward's blue latex solution (30 to 50 cc) was
then injected into both arteries under firm manual pres-
sure. The adequacy of injection was determined by the
appearance of blue latex through transverse incisions in
the fingertips.
The injected specimens were refrigerated for 12
hours to insure consolidation of the latex. The speci-
mens were then fixed in formalin for 48 hours. After
fixation, the skin and subcutaneous tissue of the dorsal
and volar aspects of the forearm and hand were ex-
cised. The flexor tendons and lumbrical muscles were
severed at the level of the distal palmar crease and
gently withdrawn into the proximal forearm. The ex-
tensor tendons were removed in a similar manner. This
was done to reduce the amount of material to be di-
gested and to obtain uniform digestion of tissues on the
dorsal and volar aspects of the forearms, wrists, and
hands.
Extraosseous vascularity. Each specimen was
Vascularity of scaphoid bone 509
5 3
........_iii_
placed on a metal tray and immersed in full strength
bleach (sodium hypochlorite). The tray could be lifted
in and out of the solution for inspection without directly
handling the specimen. The latex resisted digestion by
bleach. The specimens were inspected every half hour
to observe the extent of soft tissue clearance. Total soft
tissue clearance in full strength bleach generally took 2
to 3 hours. With the soft tissue digested, the latex-filled
vessels stood out prominently. The specimens were
then rinsed gently in distilled water. The dorsal and
volar external vascularity to the scaphoid was then
graphically recorded and photographed.
Intraosseous vascularity. After observations on the
external vascularity had been made, the scaphoids were
removed. The number and location of the entry vessels
were recorded. The scaphoids were then cleared by a
modified Spalteholz technique. They were fixed in
formalin for 12 to 18 hours, washed for 1 hour in run-
ning water, and decalcified in 30% formic acid. The
solution was changed two to three times with the pro-
cess taking approximately 1 week. The scaphoids were
again washed in running water and then immersed in
hydrogen peroxide for 3 days. They were dehydrated in
70% and 95% ethanol overnight, followed by 100%
ethanol for 1 week in a vacuum. The specimens were
immersed in chloroform for 3 days and then placed in
oil of wintergreen until the bones were completely
transparent. Photographs of the internal vascularity
were taken with the specimens immersed in a mixture
of oil of wintergreen and benzyl benzoate 50.
Results
External vascularity. The scaphoid receives its
blood supply primarily from the radial artery. Two

510 Gelberman and Menon
Fig. 3. Dorsal external blood supply in an injected specimen.
(S, scaphoid; C, capitate; R, radius; I, radial artery; 2, dorsal
scaphoid branch; 3, intercarpal artery; 4, dorsal division of
the anterior interosseous artery; 5, superficial palmer branch
of the radial artery .)
major blood vessels enter the scaphoid, one through its
dorsal surface and one through its volar surface. All of
the vessels entered the bone through nonarticular sur-
faces in areas of ligamentous attachment.
The volar vascular supply to the scaphoid accounts
for 20% to 30% of the internal vascularity of the bone,
all in the region of the distal pole. The volar aspect of
the scaphoid is concave, ending distally in a rounded
elevation called the tubercle . The tubercle is the area of
entry for the volar distal blood supply of the scaphoid.
The radial artery lies between the brachioradialis and
the flexor carpi radialis at the wrist before coursing
dorsally to enter the palm through the first dorsal in-
terosseous space. At the level of the radial-scaphoid
joint the radial artery gives off its superficial palmar
branch (Fig. 1). Just distal to the origin of the superfi-
cial palmar branch, several smaller branches course
obliquely and distally over the volar aspect of the bone
to enter the scaphoid through the region of the tubercle.
These branches, the volar scaphoid branches, divide
The Journal of
HAND SURGERY
into several smaller branches just prior to penetrating
the bone . In 75% of the specimens these arteries arose
directly from the radial artery. In the remaining speci-
mens they arose from the superficial palmar branch of
the radial artery. Consistent anastamoses were noted
between the volar division of the anterior interosseous
artery and the volar scaphoid branch of the radial artery
when the latter arose from the superficial palmar branch
of the radial artery (Fig. I). There were no apparent
communicating branches from the ulnar artery to the
volar branches of the radial artery supplying the
scaphoid. There were several very small vessels seen
running over the volar scapholunate ligament, but they
did not penetrate the bone and did not contribute to the
vascularity of the scaphoid in that region. The volar
cartilagenous areas of the scaphoid were devoid of any
blood vessels.
On the dorsum of the scaphoid, there is a ridge which
lies obliquely between the articular surfaces for the
radius and for the trapezium and trapezoid. The major
dorsal vessels to the scaphoid enter the bone through
small foraminae located on this dorsal ridge (Fig. 2). At
the level of the intercarpal joint the radial artery gives
off the intercarpal artery which immediately divides
into two-a transverse branch to the dorsum of the
wrist and a branch that runs vertically and distally over
the index metacarpal (Fig. 3). Approximately 0.5 cm
proximal to the origin of the intercarpal vessel at the
level of the styloid process of the radius, another vessel
is given off which runs over the radiocarpal ligament to
enter the scaphoid through its waist along the dorsal
ridge. In 70% of the specimens the dorsal vessel arose
directly from the radial artery. In 23% the dorsal branch
had its origin from the common stem of the intercarpal
artery . In 7% the scaphoid received its dorsal blood
supply from branches off both the intercarpal artery and
the radial artery directly. There were consistent major
anastamoses between the dorsal scaphoid branch of the
radial artery and the dorsal branch of the anterior in-
terosseous artery in each specimen (Figs. 2 and 3).
There were no vessels seen entering the proximal-
dorsal region of the bone through the dorsal scapholu-
nate ligament, and there were no vessels entering
through dorsal cartilaginous areas.
Both the dorsal and volar blood vessels entered the
scaphoid through the distal half of the bone. The an-
terior interosseous artery appeared to significantly en-
hance the blood supply of the scaphoid through its
communication with both the dorsal and volar scaphoid
branches of the radial artery.
Internal vascularity. In 79% of specimens, one to
two dorsal vessels entered the scaphoid through
foraminae located on the dorsal ridge at the level of the
Vol. 5, No.5
September 1980 Vascularity of scaphoid bone Sl1

..
Fig. 4. Photograph of a cleared specimen showing the internal vascularity of the scaphoid . [I. dorsal
scaphoid branch of the radial artery; 2, volar scaphoid branch (The vessels in the dorsal and volar
scapholunate ligaments do not penetrate the bone .).]

Fig. 5. Photograph of a specimen showing the internal vascularity of the scaphoid . (I , dorsal
scaphoid branch of the radial artery; 2. volar scaphoid branch .)

waist. In 7% the vessels entered proximally, and in
14% just distal to the waist. In one specimen four sepa-
rate vessels entered the waist, two of which ran in a
horizontal direction supplying the waist and two of
which extended into the proximal pole . In most speci-
mens the dorsal vessels divided into two to three
branches soon after entering the bone. These branches
ran volarly and proximally , dividing into smaller
branches supplying the proximal pole as far as the prox-
imal subchondral region (Figs. 4 and 5) . In two speci-

512 Gelberman and Menon
Fig. 6. The proximal 70% to 80% of the bone is supplied by dorsal vessels (shaded area). The distal
20% to 30% is supplied by volar branches of the radial artery (white area).
mens the dorsal vessels entered through the most distal
portion of the dorsal groove and coursed from the distal
to the proximal segment . In these specimens 85% of the
scaphoid was supplied by the major dorsal vessels. In
the other specimens a slightly smaller percentage of the
intraosseous vascularity (70% to 75%) supplying the
proximal portion of the bone came from the dorsal
vessels .
The tubercle of the scaphoid was supplied by volar
vessels . Two to three vessels entered the tubercle and
divided into several smaller branches which supplied
the distal portion of the bone as far proximally as the
waist in a few specimens (Figs. 4 and 5). There were no
apparent intraosseous anastamoses between the dorsal
and volar vessels. Several small vessels were noted on
the surface of soft tissue attachments in the region of
the proximal pole , but no vessel was seen penetrating
the bone in that region.
Discussion
The proximal 70% to 80% of the scaphoid is
supplied by branches of the radial artery entering along
the narrow, oblique dorsal ridge (Fig. 6). The distal
scaphoid is supplied by direct branches of the radial
artery or its superficial palmar branch. Those branches
enter the tuberosity and supply the distal 20% to 30% of
the bone. While the ulnar artery makes no apparent
contribution to the scaphoid's vascularity, the dorsal
and volar branches of the anterior interosseous artery
make significant contributions. The dorsal branch of
the anterior interosseous artery anastamosed with radial
branches prior to their entering the bone in each speci-
men. In 33% of the specimens there was a similar
The Journal of
HAND SURGERY
communication between the volar branch of the an-
terior interosseous and the volar radial branches.
Our review of the literature yielded conflicting re-
ports on the vascularity of the scaphoid. In Talesnik
and Kelley's study4 of 11 cadaver specimens, three
major vessels to the scaphoid-the laterovolar, dorsal,
and distal vessels-were found. They concluded that the
laterovolar vessels were the largest and provided most
of the blood supply to the proximal two thirds of the
bone. The intraosseous vascular patterns in their study
were particularly well demonstrated, due to the use of
freshly amputated limbs. On studying the major vessels
of their cleared specimens, it was apparent that their
lateral-volar vessels were analogous to our dorsal ridge
vessels, and their distal vessels similar to our tuberosity
vessels. They thought that the lateral-volar vessels en-
tered the bone just proximal to the tubercle on the volar
surface of the bone, however, whereas we consistently
found the major vessels entering the ridge on the dorsal
surface of the scaphoid. Barber5 studied the internal
vascularity of eight specimens by injecting barium sul-
fate and clearing by the Spalteholz technique. He noted
three groups of vessels entering at various intervals
along the dorsal ridge and branching to supply the
tuberosity and the proximal pole. He did not find any
vessels entering the scaphoid through its volar surface .
Grettve, 6 based on a study of five specimens , stated that
there were small vessels entering the scaphoid through
the radiovolar aspect. He concurred with our findings,
however, and those of Barber that the major blood
supply came from the dorsum. We confirmed our orien-
tation several times , recorded our findings with the
scaphoid in situ, and photographed each specimen prior
Vol. 5, No.5
September 1980
to dissection. Using this method we were able to iden-
tify two consistent entry vessels-the dorsal ridge ves-
sels and the volar tubercle branches of the radial artery.
The dorsal nutrient vessels consistently provided the
vascularity to the proximal portion of the bone.
Lutzeler 7 described vessels entering the scaphoid
through the volar and dorsal scapholunate ligaments
supplying the proximal pole directly. Travaglini 8 also
noted vessels entering the proximal pole through the
scapholunate ligament, and Barber5 noted a tiny vessel
directly supplying a small area of the proximal cortex.
We studied the proximal cortex for any direct vessel
entry and, although we consistently found vessels in
both the volar and dorsal scapholunate ligaments, none
of these vessels penetrated the cortex. The proximal
segment always received its vascularity from vessels
entering through the dorsal ridge.
In a study of scaphoid nutrient foramina by Obletz
and Halbstein,9 13% of 297 scaphoids were lacking
foramina proximal to the waist. In 14% of our speci-
mens the dorsal vessels entered distal to the waist. In
27% the vessels entered just proximal to the waist but
within 2 to 3 mm of the midsection of the bone, and in
the remaining 59% entered directly over the waist. A v-
ascular necrosis of the proximal pole of the scaphoid is
due to an interruption of the proximal intraosseous vas-
cularity, which in our specimens were noted to enter
along the dorsal ridge. Fourteen percent of our speci-
mens would have had a significant interruption and
59% a partial interruption in the proximal pole's vascu-
larity following a fracture through the waist. The more
proximal the fracture the higher the incidence of total
avascularity.
These findings may have clinical importance in other
areas. It appears that a volar operative approach to the
scaphoid would injure less of the vascularity to the
proximal pole than would a dorsal approach. This con-
curs with the observations of Bohler l l and Russe,10
who recommend grafting through a volar operative
approach. The bone grafts would theoretically be vas-
cularized and incorporated more quickly by preserva-
tion of the dorsal ridge vasculature. Finally, the consis-
tent rich collateral circulation to the scaphoid by way of
the dorsal and volar branches of the anterior interosse-
ous artery would ensure the scaphoid's vascularity in
the event of a segmental loss of the radial artery at the
wrist. It is unlikely that a simultaneous injury to the
radial artery and a fracture of the scaphoid would cause
Vascularity of scaphoid bone 513
any increased incidence of scaphoid avascular necrosis
over the fracture occurring alone.
Conclusions
1. The major blood supply to the scaphoid is from
the radial artery. The proximal pole and 70% to 80% of
the bone receives their blood from vessels entering
through the dorsal ridge.
2. The tuberosity and the distal 20% to 30% of the
bone are supplied by volar branches of the radial artery
and its superficial palmar branch. There were no sig-
nificant intraosseous anastamoses between dorsal and
volar branches.
3. The collateral circulation to the scaphoid is by
way of the dorsal and volar branches of the anterior
interosseous artery anastamosing with dorsal and volar
branches of the radial artery.
4. The vascularity of the proximal pole of the
scaphoid would be traumatized least by a volar opera-
tive approach.
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