REGION OF THE ANKLE. 



147 



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( R. Willis.) 



ANKLE, REGION OF THE, (surgical 

 anatomy), (region tibio-tarsienne, Velp.) The 

 relative positions and other particulars con- 

 nected with the parts found in the region of the 

 ankle, owing to the numerous accidents which 

 occur here, are matters of great interest to the 

 surgeon. The extent and boundaries of this re- 

 gion are by no means so distinctly defined as 

 those of many others ; hence, in isolating it for 

 special description, the surgical anatomist is 

 obliged to assign to it arbitrary or imaginary 

 limits. We propose to adopt the following 

 boundaries for this region, viz. superiorly a hori- 

 zontal line drawn round the leg two inches above 



the malleoli, and inferiorly a line drawn across 

 the dorsurn and sides of the foot at the same 

 distance from those bony prominences. In this 

 space are comprised the ankle-joint and several 

 important vessels, tendons, and other soft parts 

 well worthy of attention. 



In examining the external characters of this 

 region we notice four well-marked prominences, 

 one on either side, termed malleotus, (internus 

 v. externus) ; a third posteriorly, which cor- 

 responds to the tendo Achillis; and a fourth in 

 front, resulting from the projection of the astra- 

 galus. The malleoli do not accurately corres- 

 pond either in situation or shape to each other : 

 the internal lies upon a plane superior and 

 anterior to the external, and in a well formed 

 person is much less sharp and prominent, 

 a fact, the recollection of which is of great im- 

 portance in estimating deformity or dislocation 

 of the joint. The cylindrical prominence be- 

 hind, as it depends upon the tendo Achillis, 

 will of course vary in size and tension accord- 

 ing to the relaxation or contraction of the 

 gastrocnemii muscles. Upon either side of 

 the tendo Achillis, between it and the malleo- 

 lus we meet with a deep groove, called by 

 some the calceo-malleolar furrow : that upon 

 the outside is extremely well marked, and we 

 may here distinctly feel through the integu- 

 ments two of the peronei tendons : the internal 

 calceo-malleolar groove is broader and shal- 

 lower, but of much greater interest, for through 

 it, in addition to certain tendons, we have 

 transmitted the principal vessels and nerves des- 

 tined for the sole of the foot. The anterior 

 prominence, named in popular language, " the 

 instep," is rounded in the transverse direction, 

 and in some individuals projects much more 

 than in others. On throwing the foot and toes 

 into action, as in walking, we can here dis- 

 tinctly recognize the tendons of the tibialis 

 anticus, extensor pollicis, extensor digitorum 

 longus, and peroneus tertius, and almost in 

 the mesial line may be felt pulsating distinctly 

 the anterior tibial artery. 



Having thus examined the landmarks which 

 are to guide us in our anatomical investigation 

 of this region, we may next proceed to inquire 

 into the nature and relations of its constituent 

 parts. Besides the bones, cartilages, and liga- 

 ments which immediately constitute the joint, 

 and form the basis of the region, we have like- 

 wise several other structures entering into its 

 formation ; integuments, muscles, vessels, 

 nerves, and fasciae are here arranged in suc- 

 cessive layers beneath each other. We shall 

 accordingly describe four layers, namely, 

 1. the skin; 2. the subcutaneous cellular 

 tissue; 3. the fasciae; and 4. the tendons, 

 vessels, and nerves, which lie in immediate 

 contact with the articulation. 



1. The skin forms a complete investment 

 for the whole region, but its structure and 

 properties differ considerably in different situ- 

 ations. Upon the inner ankle it i:i smooth and 

 thin, and possessed of but little extensibility ; 

 so that in operating here, if we look forward 

 to union by the first intention, it becomes a 

 matter of great moment to preserve as much 



i. 2 



