THE POSTERIOR TIBIAL ARTERY 



837 



I. The artery is best approached from the inner side of the leg. The leg being- 

 flexed, the limb is laid on its outer side, and an incision three and a half or four inches 

 in length is made along the inner 



margin of the tibia, beginning two 

 and a half inches from the upper end of 

 that bone. The skin being divided, 

 care must be exercised in opening 

 the superficial fascia not to injure the 

 internal saphenous vein or nerve, both 

 of which lie directly in the track of the 

 wound. These structures being dis- 

 placed, the deep fascia must be slit up 

 to the full extent of the incision. It 

 should also be cut transversely, so as 

 to allow a freer access to the intermus- 

 cular parts. The next step consists 

 in detaching the origin of the soleus 

 muscle from the tibia. It is at this 

 stage of the operation that one of two 

 errors is often committed, — the inter- 

 muscular space between the inner 

 head of the gastrocnemius and the 

 soleus muscle is opened, or all the 

 muscular tissue is separated from the 

 bone, the tibialis posticus muscle be- 

 ing raised along with the soleus. 

 The first mistake leads the operator 

 above the vessel and the second leads 

 him underneath. There is, however, 

 a guide which will afford important 

 assistance. If the soleus has been 

 properly detached and raised, its 

 under surface will present a white, 



Fig. 



Fig. 737. 



Gastrocnemius, 



outer head 



Venae comites 



Flexor longus 



digitoruni 



Post, tibial artery 



Post, tibial nerve 



Cut edge of 



soleus muscle 



Tendon of 



plantaris 



/ 



■\ 



Dissection of back of right leg, showing relations of pos- 

 terior tibial vessels and nerve ; gastrocnemius and soleus 

 muscles have been cut and drawn aside. 



shining sheet of tendinous material, beneath 



which will be seen a 

 layer of fascia (inter- 

 muscular) covering the 

 tibialis posticus muscle. 

 If search is now made 

 externally and towards 

 the middle of the leg, 

 the artery will be found 

 covered by the inter- 

 muscular fascia, the 

 nerve lying to its outer 

 side. After the vessel 

 has been separated 

 from the investing con- 

 nective tissue and the 



accompanying veins, 

 the needle must be 

 passed from without 

 inward (Agnew). 



2. At the middle 

 third the artery is 

 reached through an 

 incision parallel with 

 the inner edge of the 

 tibia and a half inch from its border. Avoiding the saphenous vein and nerve, the 

 superficial fascia and the deep fascia (with its fibres running transversely) are 



Tendon of flex, 

 long, digitorum 



Tendon of 

 tibialis posticus 



Post, tibial artery 



Post, tibial nerve 

 Tendo Acllillis 

 Flex. long, hallucis 



Venae comites 



Dissection of inner side of right ankle, showing relation of tendons, vessels 

 and nerves as they pass between calcanium and internal malleolus. 



