THE LEG. 



and sacculated and thrombi may form and suppurate. The treatment consists in ligat- 

 ing and excising as many of the affected veins as possible. The internal saphenous is 

 especially to be excised, beginning a short distance below the saphenous opening and 

 extending for the greater portion of its length (Fig. 563). 



The operation of Max Schede, of circular incision around the leg just below the 

 knee, dividing everything down to the deep fascia, is usually effective, but we have seen 

 recurrences even after it, due to regurgitation from the deep veins. In fat people the in- 

 ternal saphenous may lie imbedded in the superficial fat some distance beneath the skin. 



A varicose condition of the veins of the leg is a causative factor in chronic leg 

 ulcer; hence, in order to cure it, the necessity of elevating the limb in its treatment, 

 or excising the veins. 



LYMPHATICS OF THE LEG. 



Sometimes there are one or two lymphatic nodes at the upper extremity of the 

 anterior tibial artery but usually the first to be encountered are around the popliteal 

 vessels, below that point are only 

 lymphatic radicles or vessels. 



FRACTURES OF THE LEG. 



Fractures of the bones of the leg 

 are most often due to direct violence, 

 but sometimes to indirect. The tibia 

 is rarely broken alone, but either it 

 or the fibula may be fractured by a 

 direct blow. On account of the tibia 

 being subcutaneous these fractures 

 are frequently compound. The shafts 

 of the bones, being of compact tissue, 

 are usually broken obliquely. When 

 the fibula is broken above its lower 

 fourth there is usually little displace- 

 ment because the attached muscles 

 hold it in place. 



Fractures of the tibia whether 

 accompanied or not by fracture of the 

 fibula most often occur at the junction 

 of the middle and the lower thirds. 

 The line of fracture is downward, for- 

 ward, and inward. The displacement 

 of the lower fragment is backward, 

 upward and slightly outward. It is 

 produced mainly by the muscles of 

 the calf pulling on the tendo calcaneus 

 (Achillis). The upper fragment is 

 pulled forward by the quadriceps fem- 

 oris (Fig. 564). 



The difficulty usually encountered 

 in treatment is a persistent projecting 

 forward of the upper fragment with 

 a drawing up and turning outward of 

 the lower fragment and foot. The 

 displacing action of the tendo cal- 

 caneus (Achillis) is more powerful 

 than that of the quadriceps. On this 

 account the first attempt at correc- 

 tion should be to place the leg in the 

 ' ' Pott' s position. ' ' This consists in flexing the knee to a right angle and placing the 

 leg on its outer side. This relaxes the gastrocnemius and plantaris and is sufficient 



Plantaris 



Tendo calcaneus (Achillis) 



Posterior tibial 



Flexor longus digitorum 



Flexor longus hallucis 



FIG. 564. Fracture of the tibia with displacement of 

 the upper fragment forward and lower fragment backward 

 and upward. 



