586 THE BLOOD-VASCULAR SYSTEM. 



PLAN OF THE RELATIONS OF THE ANTERIOR TIBIAL ARTERY. 



In front. 



Integument, superficial and deep fasciae. 

 Anterior tibial nerve. 



Tibialis anticus (overlaps it in the upper part of the leg). 

 Extensor longus digitorum ) / i . r i,, \ 

 Extensor proprius hallucis } ^ overla P lt sll ht1 ^ 

 Anterior annular ligament. 



Inner side. /^ Outer side. 



Tibialis anticus. / Anterior \ Anterior tibial nerve. 



Extensor proprius hallucis ( TiWai r Extensor longus digitorum. 



(crosses it at its lower V Extensor proprius hallucis. 



part). 



Behind. 



Interosseous membrane. 

 Tibia. 

 Anterior ligament of ankle-joint. 



Peculiarities in Size. This vessel may be diminished in size, may be deficient to a greater 

 or less extent, or may be entirely wanting, its place being supplied by perforating branches from 

 the posterior tibial or by the anterior divisjon df the peroneal artery. 



Course. The artery occasionally deviates in its course toward the fibular side of the leg, 

 regaining its usual position beneath the annular ligament at the front of the ankle. In two 

 instances the vessel has been found to approach the surface in the middle of the leg, being 

 covered merely by the integument and fascia below that point. 



Surface Marking. Draw a line from the inner side of the head of the fibula to mid- 

 way between the two malleoli. In this line take a point one inch and a quarter below the 

 head of the fibula, and the portion of the line below this point will mark the course of the 

 artery. 



Surgical Anatomy. The anterior tibial artery may be tied in the upper or lower part of 

 the leg. In the upper part the operation is attended with great difficulty, on account of the 

 depth of the vessel from the surface. An incision, about four inches in length, should be made 

 through the integument, midway between the spine of the tibia and the outer margin of the 

 fibula, and the deep fascia exposed. The wound must now be carefully dried, its edges retracted, 

 and the white line separating the Tibialis anticus from the Extensor longus digitorum sought 

 for. When this has been clearly defined, the deep fascia is to be divided in this line, and the 

 Tibialis anticus separated from adjacent muscles with the handle of the scalpel or a director until 

 the interosseous membrane is reached. The foot is to be flexed in order to relax the muscles, and 

 upon drawing them apart, the artery will be found lying on the interosseous membrane with the 

 nerve on its outer side or on the top of the artery. The nerve should be drawn outward, and 

 the venae comites separated from the artery and the needle passed around it. 



To tie the vessel in the lower third of the leg above the ankle-joint an incision about three 

 inches in length should be made through the integument between the tendons of the Tibialis 

 anticus and Extensor proprius hallucis muscles, the deep fascia being divided to the same extent. 

 The tendon on either side should be held aside, when the vessel will be seen lying upon the 

 tibia, with the nerve on the outer side and one of the venae comites on either side. 



The branches of the anterior tibial artery are the 



Posterior Recurrent Tibial. Muscular. 



Superior Fibular. Internal Malleolar. 



Anterior Recurrent Tibial. External Malleolar. 



The posterior recurrent tibial is not a constant branch, and is given off from 

 the anterior tibial before that vessel passes through the interosseous space. It 

 ascends beneath the Popliteus muscle, which it supplies, and anastomoses with the 

 lower articular branches of the popliteal artery, giving off an offset to the 

 superior tibio-fibular joint. 



The superior fibular is sometimes given off from the anterior tibial, sometimes 

 from the posterior tibial. It passes outward, round the neck of the fibula, through 

 the Soleus, which, it supplies, and ends in the substance of the Peroneus longus 

 muscle. 



The anterior recurrent tibial branch arises from the anterior tibial as soon as 

 that vessel has passed through the interosseous space ; it ascends in the Tibialis 

 anticus muscle, and ramifies on the front and sides of the knee-joint, anastomos- 



