1458 



CLINICAL AND TOPOGRAPHICAL ANATOMY 



surface-marking of the upper part of the vein is a line drawn from the posterior border of the 

 sartorius or the adductor tubercle to the lower part of the fossa ovalis. The small saphenous 

 vein passes behind the lateral malleolus, runs upward over the middle of the calf, and joins the 

 popliteal by perforating the deep fascia in the lower part of the pophteal space. This vein is 

 accompained by the medial sural cutaneous (external saphenous) nerve throughout its course. 



The popliteal artery bifurcates at the lower border of the popliteus, about on 

 a level with the tuberosity of the tibia. About 5 cm. (2 in.) lower down the pero- 

 neal artery comes off from the posterior tibial (fig. 1173). 



The course of the posterior tibial corresponds mth a line drawn from the centre 

 of the lower part of the popliteal space to a point midway between the tip of the 

 medial malleolus and the medial edge of the calcaneus. 



In the lower third, the artery becomes more superficial, passing from beneath the calf 

 muscles, lying between the tendo Achillis and medial border of the tibia, and covered only by 

 the skin, deep fascia, and, lower down, by the laciniate (internal annular) ligament. It is here, 

 in its close relation to the tendons of the tibialis posterior and flexor digitorum longus, that it 

 is Uable to be injured in the older methods of tenotomy. The nerve is medial above, lateral 

 below (fig. 1173). 



Ligature of the posterior tibial in the middle of the leg. — The following are the chief points 

 in the technique. An incision, 7.5 to 10 cm. (3 to 4 in.) long, is made 1.2 cm. (J in.) behind the 



Fig. 1174. — Upper Segment of a Section of the Right Leg in the Upper Third. (Heath.) 



Tibialis anterior 

 Extensor digitorum longus 



AAnterior tibial vessels and 

 deep peroneal nerve 



Peroneus longus 



Flexor hallucis longus 

 Soleus with fibrous intersection 



Gastrocnemius 



Tibialis posterior 

 Flexor digitorum longus 



Saphenous vein 



Lateral sural cutaneous nerve 



Tendon of plantaris 



Peroneal vessels I Posterior tibial vessesls and tibial nerve 

 Small saphenous vein and medial sural cutaneous nerve 



\ 



medial.border of the tibia, to avoid the trunk of the great saphenous. The deep fascia being 

 freely opened, the medial head of the gastrocnemius is drawn backward. The tibial attachment 

 of the soleus, thus exposed, is cut through carefully, so as to allow of identification of its central 

 membranous tendon, which must not be confused with the deep intermuscular septum over 

 the flexor. Any sural vessels are now tied. The above-mentioned special septum is next 

 made out, passing between the bones (vertical line descending from oblique line of tibia and 

 oblique Une of fibula). On division of this septum the nerve usually comes into view, the artery 

 lying more laterally. The needle is passed from the nerve; the vena? comitantcs may be in- 

 cluded. The muscles should now be fully relaxed by flexion of knee and plantar flexion of foot. 

 The ligature will be placed below the peroneal artery. 



The course of the anterior tibial artery corresponds with a line drawn from a 

 point midway between tlu; lateral condyh" of the head of the tibia and the head of 

 the fiV)uhi to one on the centre of tlie ankle-joint. 



This line corresponds to the lateral border of the tibialis anterior and the interval between it 

 and the exten.sor digitorutn longus (figs. 1170 and 1171). This is shown when the first of these 

 muscles is thrown iiitf) action. The accoin))aiiying nerve is in front in the middle third of the 

 leg, lateral above and below. 



Ligature of the anterior tibial artery at the junction of the upper and middle thirds of the 

 leg. The limb being flexed and rotated medially, an incision is made, 7.5 to 10 cm. (3 to 4 in.) 

 long, in the line of (he artery, distant 2.5 cm. (1 in.) or more (according to the size of the leg) 

 from the crest, and beginning about 5 cm. (2 in.) below the head of the tibia. If, on exposure 

 of the deep fascia, the intermuscular septum between the tibialis and long exten.sor of the toes 



