Ligation of Anterior Tibial Artery 493 



Its course is marked by a line from the inner side of the head of 

 the fibula to the middle of the front of the ankle. 



Relations. The artery is covered by skin, superficial and deep 

 fasciae, by the muscles between which it passes, and especially by the 

 extensor proprius hallucis, which, descending from the front of the 

 fibula to the great toe, crosses the artery a little above the ankle. 

 The anterior tibial nerve sometimes rests upon the artery. 



On the inner side are the tibialis anticus, the tibia, and, near the 

 ankle, the tendon of the extensor proprius hal'ucis. On the outer side 

 are the extensor longus digitorum, the extensor proprius hallucis 

 (in the middle third of the leg), and the anterior tibial nerve. 



Branches. Recurrent, which ascends through the tibialis anticus 

 to the front of knee-joint, where it anastomoses with the lower arti- 

 cular branches of the popliteal, and perhaps with the anastomotica 

 magna. Muscular twigs, which, in addition, supply the skin. The 

 internal malleolar descends obliquely under the tendon of the 

 tibialis anticus, to anastomose near the inner ankle with twigs of the 

 posterior tibial (calcanean) and internal plantar. The external 

 malleolar passes beneath the tendons of the extensor longus digito- 

 rum and peroneus tertius to anastomose with the anterior peroneal, 

 and with tarsal branches of the dorsalis pedis. The supply of the 

 ankle-joint is partly derived from these branches. 



A ligature may be applied in the upper or in the lower part of 

 the leg, but in the middle, where the great toe extensor is passing on 

 to, or is crossing over, the artery, it is obviously inconvenient to 

 attempt to secure the vessel. 



X > the upper part of tha ley it is by no means easy to find the 

 vessel, on account of the depth at which it lies between the tibialis 

 anticus and the extensor longus digitorum. An incision having been 

 made through the skin and superficial fascia from the inner side of 

 the head of the fibula for three or four inches down the course of the 

 artery, the strong, deep fascia is exposed. Search is made for the 

 interval between the two muscles just mentioned. This is best 

 accomplished by working with the director, or handle of the scalpel, 

 in the lower part of the incision, where the space between the muscles 

 is commencing. Thus the muscles are parted from below upwards, 

 and are afterwards held asunder by spatulae. The finger may then 

 be passed upwards between the muscles, so as to make more room. 

 The artery is found on the interosseous membrane, with a com- 

 panion vein on either side. The anterior tibial nerve will probably be 

 seen coming through the origin of the long extensor of the toes, and 

 approaching the ou er side of the artery. The ligature, therefore, 

 may best be passed from the outer side. 



Just abovj tn*^ ankle the vessel is expos 3d by an incision of 

 two inches and a half through the skin, superficial fascia, and deep 

 fascia. The deep fascia is here thickening into the anterior annular 



