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Trabeculae traversing human bursae.

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TRABECULAE TRAVERSING HUMAN BURSAE
CHARLES L. SCHNEIDER
Department of Anatomy, Stanford UniGersity, Calif.
m o
PLATES
(SEVENTEEN FIGURES)
I n the course of routine dissection in the regular class
work in anatomy, discrete strands of tissue were observed
to pass through some of the bursae, especially one on the
plantar aspect of the foot. Finding no adequate account of
such strands, or trabeculae, it seemed desirable t o make a
more careful examination of the bursae that could be studied
in the laboratory. Seventy-nine bodies were wholly or partly
dissected while this study was being made and through the
cooperation of student dissectors it was possible to see a
rather large number of bursae.
Most of the bursae examined were essentially “normal”
although many of them showed tabs or appendices of fatty
or fibrous tissue extending into the lumina, and not infrequently multilocular bursae were encountered. It was generally difficult to determine whether the multilocular bursae
had originally developed in this form or had resulted from
the partial disappearance of tissues separating two or more
bursae that had arisen independently. Bursae presenting
this problem were particularly common in the pre-patellar
region. It is not the purpose to enter into a discussion of
these multilocular bursae but rather to call attention to the
diversity of tissues that are found as free strands crossing
the lumina of existing bursae and to note some of the alterations in these tissues.
It is to be presumed that some of these strands were
originally outside the bursae and subsequently became in151
152
CHARLES L. SCHNEIDER
eluded through investment by the bursa1 “membrane ” and
that others are remnants of originally intervening walls between coalescence bursae. The differences between these two
possible modes of formation may not be very great.
TISSUES COMPOSING THE TRABECULAE
As will become clear below, the composition of a trabecula
is determined by the locus of its bursa. If the bursa develops
in such a way as to include a region of skeletal muscle, the
strands may be made up of muscular fasciculi; if in the region
of blood vessels, they may include arteries or veins; if in
the region of nerves, they may even include nerve bundles.
After study by gross methods, representative trabeculae were
subjected to the usual histological procedures and studied
microscopically.
Collagenous connective tissue (jigs. 1-6). Gross dissection
shows connective tissue trabeculae of two forms : sheet-like
and cord-like. Both types are visible in the pre-tibia1 bursa
shown in figure 1. They are likewise common in the olecranon
bursa, and may occur in other constantly occurring or anomalous bursae.
Sheet-like trabeculae such as can be seen in figure 1, appear
to arise as remnants of the connective-tissue wall between
originally superimposed bursae. They are of the order of
1mm. in thickness and may taper in width from a few centimeters down to fine strands.
The strand trabeculae may be simply dense collagenous
connective tissue as seen in the cross section of the trabecula
shown in figure 2, or may be diffusely infiltrated with fat
cells as in the cross section of the trabecula of figures 3 and 6.
If the strand is of a diameter greater than 1 mm., its
periphery is apt to be capsule-like as seen in figures 2 and 3
(cross sections of strands, 1x 2 and 1x 3 mm., respectively) ;
if on the other hand, the strand is of a diameter less than
1 mm., the capsule is apt to be reduced or lacking as is the
case with the small strand shown in figure 4 and the finer
strands of figure 5.
TRABECULAE TRAVERSING H U M A N BUBSA4E
153
Connective tissue stralnds of special origin (figs. 5 , 6 ) . Not
all of the trabeculae of the bursa shown in figure 1 lend themselves readily to the interpretation of origin by partial destruction of an inter-bursa1 wall. Strands “ D ” and “ E ” of
figure 1, although largely connective tissue, are not mere
remnants of inter-bursa1 wall, but are traced as projections
of the pre-patellar plexus of nerves.
Cross sections of two of the smaller cords whose composition is now largely connective tissue but which probably arose
by a gradual dissection of a once functional structure from
the bursa wall, are shown in figures 5 and 6. The central
structure of figure 5 was probably a small blood vessel,
although it is now so atrophic as to leave some doubt as to
this interpretation. Similarly, the small, central, atrophied
structure of figure 6 is tentatively identified as a small nerve
bundle. Whatever their original structure, even their central
structures are now essentially connective tissue.
A d i p o s e connective tissue. Besides the fatty component of
the strands mentioned above, such as in figures 3 and 6,
there are occasional bursae in which tabs of adipose tissue
project into the spaces between trabeculae. The origin of
these tabs is not clear. They measure up to a few mm. in
diameter, are lipoma-like in gross appearance, are composed
of large f a t cells, and have a thin but well defined capsular
covering of connective tissue.
B o a e (fig. 7). Since anomalous calcification and bone formation under various conditions is not unusual, it is perhaps
not surprising to find ossification in relation to these trabeculae. One case was found in an enlarged trochanteric bursa
which perhaps had been inflamed. The ossified portion of
the trabecula made up a terminal knob, a flattened ovoid
mass of almost 1 em. in its greatest diameter, on a peduncle
of dense connective tissue. There were several smaller strands,
apparently similar to the peduncle, extending entirely through
the bursa.
The bony structure is surrounded by a 1-mm. zone of dense
irregularly arranged connective tissue. This grades into a
154
CHARLES L. SCHNEIDER
thinner, irregular zone of callus-like bone, within which is a
sharply but irregularly limited zone of compact bone of about
7 x 2 mm. cross section. Not only are Haversian systems
with their central canals, concentric lamellae and lacunae
to be seen, but even interstitial lamellae. Circumferential
lamellae external to this typical compact bone are lacking ;
instead there is the layer of callus mentioned above.
Skeletal muscle (figs. 8 , 9 ) . Trabeculae consisting of skeletal muscle fasciculi were found extending through two bursae
below the ischial tuberosity. The more superficial bursa involved the gluteus maximus and the deeper involved the head
of the semitendinosus muscle. The muscle fasciculi were
separated one from the other and from the bursal walls by
dissection of the bursal space within connective tissue layers ;
i.e., by separations within the perimysium and within the
epimysium. Some of the fasciculi were converted to connective
tissue strands over a good part of their length; others were
apparently still functional skeletal muscle throughout. Strands
from the coarse-grained gluteus maximus were mostly of
1-t o 3-mm. diameter, but reached widths of as much as 7 mm.
A cross section of one of the trabeculae from the semitendinosus muscle is shown in figure 8 and a longitudinal section
from the same trabecula in figure 9. A good vascular supply
and striations typical of skeletal muscle are clearly visible.
Nerve-artery tra-beculae (figs.%?, 16,17,table 1 ) . The deep,
fascia1 bursae (not the occasional bursa within the plantar
fat pad) on the plantar aspect of the fifth metatarso-phalangeal joint had compound nerve-artery trabeculae in about
half of the cases in which bursae were found; the data from
those bodies dissected in 1942 on which the bursae of both
feet could be studied, twenty-five in all, are collected in table 1,
and can be summarized as follows:
The bursae were found in 40% of the bodies and the trabeculae in 20% ; less than half of these, i.e., less than 10% of all
the bodies showed the trabeculae extending as completely free
strands across the bursae. The incidence of bursae and of
trabeculae tended to be symmetrical with slightly greater
155
TRABECULAE TRAVERSING H U M A N BURSAE
development on the right side; they were perhaps more frequent on feet with some toes removed and on one legged
bodies. As seen in table 1,the incidence of comparable bursae
and trabeculae at the first metatarso-phalangeal joint is low;
it is rare in relation to the other digits.
Figure 16 (retouched outside the bursa to bring the nerve
and artery into relief) shows a trabecula that is free from
the wall as it traverses the cavity. Figure 17 (not retouched,
but with the nerve, artery and trabecula colored in the dissection before the body was photographed) shows a trabecula
which is attached throughout its length t o the lateral bursa1
wall by a thin sheet of connective tissue. I n one case, only,
TABLE 1
Incidence of compound nerve-artery trabeculae in the bursae on the plantar aspect
of the metatarscu-phalangeal joints. Data f r o m 50 feet (twenty-five bodies).
NUJIBER W I T H TRABECULAE
BIDE
AND
LOCATION
NUMBER
HAVING
BURSAE
Separation
Total
Partial
Complete
First metatarso-phalangeal joint
11
Right ........
Left .........
5
1
0
0
0
1
0
Fifth metatarso-phalangeal joint
11
Right ........
10
Left . . . . . . . . .
4
4
2
1
5
6
did the plantar nerve and artery t o the fifth digit traverse
the bursa as separate trabeculae. In the typical case, the nerve
and artery made up a compound trabecula as shown in figures
10, 16, 17. The structures of the nerve and artery are described below.
Arteries (figs. 20, 21, 16, 17). The artery of the trabecula
traversing the bursa of the plantar aspect of the fifth metatarso-phalangeal joint is indicated in the cross section of
figure 10 by letter “A” and is shown enlarged in figure 11.
At this level, i.e., within the bursa, the lumen is completely
obliterated and the walls much reduced. The extensive
changes in the wall and the apparent obliteration of the lumen
156
CHARLES L. S C H S E I D E B
would make the artery almost unrecognizable and might lead
to confusion with the artery supplying the nerve bundle were
it not for its continuity proximally and distally with the artery
supplying the lateral part of the fifth digit. This is in contrast with the hypertrophy of the portions just proximal and
distal to the bursa, the wall alone being as thick there as this
entire remnant within the bursa (fig. 11);proximally and
distally it is especially the intima that is hypertrophied, but
not t o the extent of closing the lumen. I n the region, within
the bursa1 wall, where there is the maximum connective tissue
development around the vessel, the lumen is for the most part
obliterated by a combination of hypertrophy and contraction
of the vessel wall.
Veim. Although it would seem probable that veins should
form the basis of trabecnlar structures just as do arteries,
their more superficial position places most of the larger ones
beyond the outer walls of most bursae. With smaller vessels,
the distinction between veins and arteries in microscopic
preparations is made doubtful because of modifications of
the vessel walls within the trabeculae; hence although many
of the smaller vessels seen in sections probably were veins,
their identification is not certain. Only one vein serving as
the basis of a trabecula was found. This was a minor branch
of the great saphenous (anomalously enlarged with a lumen
over 1 mm. in diameter) traversing a pre-tibia1 bursa just
below the knee joint. This trabecular vein was patent as
could be seen by exerting intermittent pressure which caused
small bubbles to move back and forth within the lumen. Small
functional veins incidental to the vascular supply of trabecula e
are, of course, much in evidence (cf. fig. 6).
Capillaries (fig. 9 ) . As might be expected, capillaries are
readily visible in many of the sections. One is indicated in
longitudinal section in figure 9.
Nerves (figs.2 , 22-27). Figure 1 shows branch trabeculae,
“ D ” and “E”, which were traced back to the saphenous
nerve, and figures 16 and 17 show trabeculae of which the
nerve component can be traced proximally to the lateral
TRABECULSE THAVE1;SING HUMAX BURSAE
157
plantar nerve and distally to the distribution of the lateral
border of the fifth digit. As can be seen even in these photographs of gross dissections, there is a marked hypertrophy of
the connective tissue components.
The histological interpretation would be far less certain
if it were not for the possibility of comparison with a nerve
from a similar region but not involved in a bursa. Figures
12-15 are presented for this purpose, figures 12 and 13 being
enlargements of a nerve bundle from the trabecula shown in
figure 10, figures 14 and 15 being enlargements of a normal
nerve from a similar region not in a bursa (a branch of the
medial plantar nerve at the level of the second metatarsophalangeal joint).
It is at once clear that both of these nerves are different
from those most often seen in sections and figured in text
books. The difference lies in the excessive development nf
the connective tissue components, including an increase in
endoneurium as well as perineurium and epineurium. The
extent of the connective tissue development appears to be a
function of the exposure to mechanical stress, the development
being greatest in these plantar nerves which are subjected to
greatest pressure from the weight of the body, intermediate
in the superficial nerves of the arm (some of which were
examined in this connection), and relatively little in the deeply
buried sciatic nerve.
The staining properties of nervous tissues from these dissecting room bodies, while not all that might be desired, are
adequate for ready identification of individual fibers in nerve
bundles that are devoid of collagenous connective tissue as
is shown by the clear figures of Corbin and Gardner ( '37).
They examined spinal roots from within the spinal canal.
The staining qualities of at least the larger nerve fibers of
the plantar nerves, whether normal or in bursa1 trabeculae,
are likewise adequate f o r identification, as can be seen in
figures 13 and 15, it being only necessary to recognize the
iiiterrening tissue as endoneurium.
158
CHARLES L. SCHNEIDER
The hypertrophy of connective tissue elements of these
plantar nerves that pass through bursae as trabeculae, is not
limited to any one layer. Thus, from figures 12 and 14, which
compare equal magnifications of normal and bursa1 nerve
bundles with roughly similar cross sectional areas, it will be
seen that the perineurium of the trabecular nerve is more
than twice the normal thickness. Similarly in figures 13 and
15 it will be apparent that the endoneurium of the trabecular
nerve greatly exceeds that of the normal nerve. Even the
epineurium is much hypertrophied as seen in figure 10. As a
result of the obscuring effect of the dense connective tissue,
only the larger myelin sheathed axones can be easily identified
in these preparations. Presumably they are functional.
Besides the nerve-artery trabeculae associated with the
fifth and first digits, there was one case (fifth digit) in which
the nerve traversed the bursa as a trabecula by itself separate
from that of the artery. There were also occasional cases in
which a minor nerve branch traversed this bursa, and one
similar. case in an uncommon plantar bursa at the second
metatarso-phalangeal joint.
Other nerve trabeculae with excessive connective tissue
dcvelopment occurred not only in the pre-patellar bursa of
figure 1, but also in pre-tibia1 bursae, one outstanding case
being that of a leg with an amputation 10-15 em. below the
knee joint. Thickening of the nerves in this instance was
apparently due to increased pressure caused by a n artificial
limb, the bursa mas highly developed and branches of the
infrapatellar plexus occurred as trabeculae.
All of the trabeclar nerves studied were of largely cutaneous
distribution ; none, with deep distrihution were encountered.
DISCUSSION
P r o s s u r e O H trabeculac. Since bursae are subjected to unilateral pressure at right angles to the plane of the bursa, it
follows that the trabeculae woulct also be subjected to midirectional pressure and this, perpendicular to the lengths of
the strands. The nnidirectional nature of the pressure would
TRABECULAE TRAVERSINQ H U M A N BURSAE
159
lead to special strains on the strands which would not be
expected were the pressure equal in all directions, as it tends
to be, e.g., when the cavities are distended with fluid. This
unidirectional pressure may be directly or indirectly responsible for some of the changes observed; e.g., the high development of the connective tissue components of nerve
bundles. Under severe working conditions the undirectional
nature of the pressure may be modified to more nearly the
conditions of equal pressure in all directions by accumulation
of fluid within the bursae, but these conditions are the exception rather than the rule.
BursaE membrame. A bursal membrane, like a synovial
membrane of a joint cavity, is not a true membrane, for far
from being covered by epithelium, its surface is even made
up in part of non-cellular components, the fibers of the connective tissue. The bursal membrane has even fewer connective tissue cells on its surface than does the synovial membrane. This is perhaps in line with the unidirectional nature
of the pressure to which it is subjected. The membrane is
nevertheless different than a mere surface of a connective
tissue cleft for the opposite walls of the bursa do not ordinarily form adhesions, and those bursae arising in the fetus,
a t least, arise from a peculiarly arranged tissue which cleaves
easily in layers (Whittaker, '10).
If the trabeculae are thought of as surrounded by the bursal
membrane, they may be considered to be outside the bursa
proper. This would be the case especially if the trabeculae
develop by dissection from the bursal wall with investment
by the membrane. Just how f a r this would apply in the case
of trabeculae formed by wearing away of an interbursal wall
is not clear; however, the final result is much the same, for
the surface of even these strands can not be distinguished
from the adjacent bursal membrane; the similarity is as great
physiologically as histologically for the trabeculae remain as
discrete strands rather than fusing, even though they abut
upon one another.
7 60
C H A R L E S L. S C H N E I D E I :
Coinposition of tr-ahccdac. Although tlie trabeculae may be
of almost any tissue, some tissues are more common than
others. Bursae most commonly form within or between fascial
layers ; thus, the bursae lie within connective tissue ; incidentally, connective tissue strands are the most frequent trabeculae. Similarly, when anomalous bursae form in subcutaneous tissues rather than in fascial layers, as e.g., in the
plantar pads of fatty subcutaneous tissues, tough irregular
connective tissue strands are apt to make up the trabeculae.
Arteries and nerve bundles, lying mitliin the fascia, form
perhaps the next most frequently encountered trabeculae ;
however, for the most part they pass around bony eminences
where bursae are apt to form and are not common as trabeculac. Consistent with the position of the larger superficial
veins in the subcutaneous layers rather than in the fascia,
and with their courses around bony prominences, no large
veins other than one pathologically enlarged one, were found
as trabeculae. Muscular fasciculi as trabeculae are also rare
and then appear to arise’by extension of bursae from fascia
into muscular regions.
Chaizges in trabeculae. Changes in the tissues of the trabeculae may be either atrophic o r hypertrophic. Some of the
trabeculae apparently undergo fragmentation and destruction
by attrition in a manner comparable to the “use destruction”
occurring in joints and bursae as described by RIeyer (’24,
’37; cf. also Codman, ’34).
For trabeculae of specialized tissues, there is commonly
hypertrophy of the connective tissue elements even though the
specialized tissue itself may undergo atrophy. In the case
of nerves and blood vessels, the connective tissue development
may serve for a time, at least, to protect the functional elements from mechanical distortion and even in the case of
atrophic muscle trabeculae the connective tissue development
may facilitate functioning of the remaining intact ends of the
fasciculi. When the atrophy has become complete in the case
of nerves, or the functional state lost as in the occlusion of
;I
blood vessel, the reinfoi-ced i ~ m i i a i i tmay persist as a “coiitive ti \sue st i-and’ ’
t r c‘c
STJMRIARY
Sti-aiids occuriirig as trabeculae in human bursae probably
arise in two cliffel ciit ways, through fenestration of tlie wall
h t w e e n su1)crimposctl bni.sac and tl1r~ougli gradual iiivest~ the end that structures
mciit by the bursa1 “ ~ i i c m b r a n e ’to
adjaceiit to the bursae finally become included as t~*abeculac.
T3otlr from gross dissection and from microscopic csarnina1ion, it n-as fourid that the trnheculae may be of variable cwmlmitioii, tlic tissues being those of the re:;ions of the bursae.
Tissues and structures found were : collagenous connective,
ildiposc, compact bone, skeletal muscle fasciculi, arteries,
veins anid nerves.
111 tlic ti-aheculae of specialized structures, there is commonly liypei$ropli~-of the supporting components arid often
atimphy of tlie essential elements. In tlie event of sucli atrophy
c:f tlic spx*ializecltissue, the whole structure may he converted
swoiida1~i1~into -1vlint would ai11)car to hc a simple c.onnective
tissuo tralxcnla.
The autlioi. mislrc~sto cxprcss appreciation to the Anatomy
l)epai*tmciit, aiicl especially to George Scott, t o Prof. H.
I<ii*kmaiiand to Piwf. ( I . H. T)aiifoi*tlifor advicc aiid criticism
; i i r d f o r iira!<iny tlri i i ~ v ( l . t i ~ a t i possible.
~ii
1,IT k X 1 T TTRI.: C‘ITE 1,
1924 TIIC slioulder. 13cil)tiiw of the s:ip~:isl~iii:itiis tciidon and
otllcr lcsimis i n (11’ :ibout tlie sub:~croniinl liursa. T1iom:is ‘I’odd Co.
( ‘ o I > ~ I . ~1.;x
. ,
130
toll.
B E D E. I). (:ARDXF.IL
1937 Ikcrcasc i n nuiiibt~r of myclinated
filicrs i n I i u i i i a i i qiiii:il roots witli age. Anat. Hcc., r o l . 68. 1’11. (i3-74.
-1. \V. 19% F:irtllcr rridrnce of attrition i n t h e 1ium:in body. Am. J.
Anat., vol. 34, 1)p. 241-26i.
~.
~1!13i I‘se des?ruc.tion in the human body. Calif. and Western Mrd.,
n i l . 47, pii. 37.7-383.
\ ~ ~ I ~ T T A ~ c C’.
E R R.
,
1910 The arrangeinnit of the bursae i n the superior extrrniity of the full-time foetus. J.. Anat. and Physiol., Ser. 3, rol. 44.
111). 133-1.16.
I<. E.,
PLATE I
TRABECULAE TRAVERSING H U M A N BURSAE
CllAR1.68 L. SCWNEIDAR
1
1’rq)utcll:tr bursa.. A , Cord trabeeula; R, sheet trabeeula ; C, cotton plncccl in deep bursa;
E, niwes. 1 X.
Dciise councwtive tissue tmbceula. C, (Japsulc. 18 X.
Fatty tr:ibeculn. F, f a t cbcll;C , enpsulc. 15 X .
I)PIIRC
coiincc4irc tissuc tnihecula. No enpsule. 15 X.
I)iww cwiwct.iw tissue trabwulrr. V, probable central vcsscl, (atrophied). S o capsule. 15 X.
P:itty tr:ibeculn. N, l~rohublecentral nerve (atrophied) ; A, artcry; V, vein; C, capsule.
1) :rntl
-
15
x.
Bonib. €1, 1Itivorsi:in r:iii:il 11, Hnversinri 1:imellae; I, iiiterstit.ia1 lamellnr ; C, callus. 30 X.
R Skeletal inusclr, Cross swtiun. F, muscle fiber. 15 X.
al
Ioiigitiidiiial section. c, c a p i h r y wit.1) r h x . ; F,striated musclc fiber. 90 X.
9 H k ~ l ~ t rniisclc,
I
162
T R A B E C U L A E TRAVERSING H U M A N B U R S A E
PLATE 2
C H A R L E S L. S C H N E I D E R
10 P l a n t m bursa1 traliecula, cross sectioii. A, artery (atrophied) ; N, nerve huntlle; P, ti&
neurium; E, epineuriuni; C, capsule. 13 x.
11 Degenerated arteiy of fig. 10. Note u a v y elastic fibers. L, position of obliterated lumen.
200 x.
13 Nerve bundle of trabecula shown in fig. 10. Compare periiieuriuui, P, with periiieurium of
normal nerve of fig. 14. GO X.
13 Enlargement of nerve from traheculn of fig. 10. N, nerve axone; E, endoneuriuni. Conipare with normal nerve of fig. 1.7. 300 X.
14 Nerve bundle of normal planter nerve. Compare perineurium, P, with trnhccular nerve of
fig. 12. 60 x.
15 Enlargement of nornial nerve of fig. 14. N, nerve axone; E, mdoneuriuni. Compare with
trabecular nerve of fig. 13. 30 X .
IF, 17 Plantar bursae at the fifth metstarso-phalangeal joint and their trabeculae. A,
artery; N, nerve; T, trabeculn in bursa. 1 X.
163
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