PERONEAL. 451 



low down, the vessel should be tied in the middle of the leg. But in aneurism of the posterior 

 tibial high up, it would be better to tie the femoral artery. 



To tie the posterior tibial artery at the ankle, a semilunar incision should be made through 

 the integument, about two inches and a half in length, midway between the heel and inner ankle, 

 but a little nearer the latter. The subcutaneous cellular membrane having been divided, a strong 

 and dense fascia, the internal annular ligament, is exposed. This ligament is continuous above 

 with the deep fascia of the leg, covers the vessels and nerves, and is intimately adherent to the 

 sheaths of the tendons. This having been cautiously divided upon a director, the sheath of the 

 vessels is exposed, and, being opened, the artery is seen with one of the venae comites on each 

 side. The aneurism needle should be passed round the vessel from the heel towards the ankle, 

 in order to avoid the posterior tibial nerve, care being at the same time taken not to include the 

 VCHT3 comitcs 



The vessel may also be tied in the lower third of the leg, by making an incision about three 

 inches in length, parallel with the inner margin of the tendo Achillis. The internal saphenous 

 vein being carefully avoided, the two layers of fascia must be divided upon a director, when the 

 artery is exposed along the inner margin of the Flexor longus digitorum, with one of its venas 

 comites on either side, and the nerve lying external to it. 



To tie the posterior tibial in the middle of the leg, is a very difficult operation, on account of 

 the great depth of the vessel from the surface, and from its being covered in by the Gastrocne- 

 mius a"d Soleus muscles. The patient being placed in the recumbent position, the injured limb 

 should rest on its outer side, the knee being partially bent, and the foot extended, so as to relax 

 the muscles of the calf. An incision about four inches in length should then be made through 

 the integument, along the inner margin of the tibia? taking care to avoid the internal saphenous 

 vein. The deep fascia having been divided, the margin of the Gastrocnemius is exposed, and 

 must be drawn aside, and the tibial attachment of the Soleus divided, a director being previously 

 passed beneath it. The artery may now be felt pulsating beneath the deep fascia, about an inch 

 from the margin of the tibia. The fascia having been divided, and the limb placed in such a 

 position as to relax the muscles of the calf as much as possible, the veins should be separated 

 from the artery, and the aneurism needle passed round the vessel from without inwards, so as to 

 avoid wounding the posterior tibial nerve. 



The branches of the posterior tibial artery are the 



Peroneal. Nutritious. 



Muscular. Communicating. 



Internal calcanean. 



The Peroneal Artery lies, deeply seated, along the back part of the fibular 

 side of the leg. It arises from the posterior tibial, about an inch below the lower 

 border of the Popliteus muscle, passes obliquely outwards to the fibula, and then 

 descends along the inner border of this bone to the lower third of the leg, where 

 it gives off the anterior peroneal. It then passes across the articulation, between 

 the tibia and fibula, to the outer side of the os calcis, supplying the neighboring 

 muscles and back of the ankle, and anastomosing with the external inalleolar, 

 tarsal, and external plantar arteries. 



Relations. This vessel rests at first upon the Tibialis posticus, and, in the 

 greater part of its course, in the fibres of the Flexor longus pollicis, in a groove 

 between the interosseous ligament and the bone. It is covered, in the upper part 

 of its course, by the Soleus and deep fascia : below, by the Flexor longus pollicis. 



PLAN OF THE KELATIONS OF THE PERONEAL ARTERY. 



In front. 

 Tibialis posticus. 

 Flexor longus pollicis. 



Outer side. 

 Fibula. 



Behind. 

 Soleus. 

 Deep fascia. 

 Flexor longus pollicis. 



