thigh, as the biceps is of the arm, and the sterno-cleido-mastoideus of
the neck. Its direction and borders may easily be traced by asking the
patient to raise his leg, a movement which puts the muscle in action.
The same action defines the boundaries of the triangle (of Scarpa)
formed by Poupart’s ligament, the adductor longus and sartorius.
=Line of femoral artery.=--To define the course of the femoral artery,
draw a line from midway between the anterior superior spine of the
ilium and the symphysis pubis to the (spur-like) tubercle for the
adductor magnus on the inner side of the knee. The femoral artery lies
under the upper 2/3 of this line.
The sartorius begins to cross the artery, as a rule, from three to
four inches below Poupart’s ligament. The point at which the profunda
artery arises is about one and a half or two inches below the ligament.
Therefore the incision for tying the femoral in Scarpa’s triangle
should commence about a hand’s breadth below Poupart’s ligament, and be
continued for three inches in the line of the artery.
To command the femoral in Scarpa’s triangle, the pad of the tourniquet
should be placed at the apex, and the direction of the pressure should
be, not backwards, but outwards, so that the artery may be compressed
against the femur.
In the middle third of the thigh the femoral artery lies in Hunter’s
canal, overlapped by the sartorius. About the commencement of the lower
third the artery leaves the canal through the oval opening in the
adductor magnus, and, under the name of popliteal, enters the popliteal
space. The line for finding the artery in Hunter’s canal has been
already traced (102). The incision to reach the artery in this part of
its course would fall in with the outer border of the sartorius.
To command the femoral artery in Hunter’s canal, the pressure should be
directed outwardly, so as to press the vessel against the bone.
_THE BUTTOCKS._
103. =Buttocks.--Bony landmarks.=--The bony landmarks of the buttocks
which can be distinctly felt are: 1, the posterior superior spines of
the ilia; 2, the spines of the sacral vertebræ; 3, the two tubercles of
the last sacral vertebra; 4, the apex of the coccyx in the deep groove
leading to the anus; 5, the tuberosities of the ischia on each side of
the anus.
The posterior spines of the ilia are about the level of the second
sacral spine, and correspond with the middle of the sacro-iliac
symphysis.
The third sacral spine marks the lowest level to which the membranes of
the cord and the cerebro-spinal fluid descend in the spinal canal.
The tuberosities of the ischia, in the erect position, are covered by
the gluteus maximus. In the sitting position they support the weight of
the body, and are only covered by a thick pad of coarse fat. Between
this pad and the bones there is a bursa, which becomes occasionally
enlarged and inflamed in coachmen.
The prominence of the nates is one of the characteristics of man in
connection with his erect attitude. ‘Les fesses n’appartiennent qu’à
l’espèce humaine.’ They are formed of an accumulation of fat over the
great muscle of the buttock (gluteus maximus). From their appearance
we may gather some indication of the state of the constitution. They
are firm and globose in the vigorous; loose and flaccid in the infirm.
Wasting and flattening of one, compared with the other, is an early
symptom of disease in the hip.
104. =Fold of the buttock.=--The deep furrow, termed ‘the fold of
the buttock,’ which separates the nates from the back of the thigh,
corresponds with the lower border of the gluteus maximus. Its altered
direction in disease of the hip is very characteristic. This is the
best place to feel for the great ischiatic nerve. We find it by
pressing deeply between the trochanter and the tuber ischii, rather
nearer to the latter. When we sit upright, the nerve is not liable to
pressure; but it becomes numbed when we sit long sideways.
105. =Gluteal artery.=--To find at what point the gluteal artery comes
out of the pelvis, draw a line from the posterior superior spine of the
ilium to the top of the trochanter major, rotated inwards. The junction
of the inner with the middle third of this line lies over the artery as
it emerges from the upper border of the great ischiatic notch.
The point of exit of the ischiatic artery from the pelvis is about half
an inch lower than that of the gluteal.
106. =Pudic artery.=--The pudic artery crosses the spine of the
ischium. To find it, draw a line from the outer side of the tuber
ischii to the posterior superior spine of the ilium. The junction of
the lower with the middle third gives the position of the artery. The
ischiatic artery lies close to it, but nearer the middle line.
Looking at the course of these arteries it appears that when we sit
on hard seats the pressure is sustained by the bones; when we recline
on soft seats the pressure is sustained more by the soft parts, and
reaches the arteries; hence the tendency of modern modes of reposing
to drive the blood into the interior of the pelvis and favour the
production of piles and uterine disorders. A celebrated French
accoucheur used to say that the fashion of high waists, tight lacing,
and easy chairs brought him many thousands a year.
_THE KNEE._
107. =Bony points.=--The patella; the tuberosities of the two condyles;
the tubercle of the tibia for the attachment of the ligamentum patellæ;
another (the lateral) tubercle, on the outer side of the head of the
tibia; and the head of the fibula are the chief bony landmarks of the
knee.
Observe that the head of the fibula lies at the outer and back part of
the tibia, and that it is pretty nearly on a level with the tubercle
for the attachment of the ligamentum patellæ.
We can also feel the adductor tubercle or spur-like projection of bone
above the internal condyle which gives attachment to the tendon of the
adductor magnus. This spur-like projection corresponds with the level
of the epiphysis of the lower end of the femur, and also with the level
of the highest part of the trochlea for the patella: facts worth notice
in performing excision of the knee.
‘In reducing a dislocation of the hip, it is important to bear in mind
that the inner aspect of the internal condyle in every position of the
limb faces nearly in the direction of the head of the femur.’ (100)
The tubercle on the outer side of the head of the tibia gives
attachment to the broad and strong aponeurosis (tendon of the tensor
fasciæ), which, acting like a brace for the support of the pelvis,
is well seen in emaciated persons down the outer side of the thigh.
This tubercle indicates the level to which the condyles of the femur
descend, and the lower level of the synovial membrane.
The patella, in extension of the knee, is nearly all above the
condyles; in flexion, it lies in the inter-condyloid fossa (more on the
external condyle), and thus protects the joint in kneeling. Its inner
border is thicker and more prominent than the outer, which slopes down
towards its condyle.
108. =Ligamentum patellæ.=--The line of the ligamentum patellæ is
vertical. Hence any deviation from this line, one way or the other,
indicates more or less dislocation of the tibia. There is a pellet of
fat under the ligament, which answers a ‘packing’ purpose--sinking in
when the knee is bent; rising when the knee is extended, and bulging
on either side of the tendon, almost enough to give the feel of
fluctuation.
In a well-formed leg the ligamentum patellæ, the tubercle of the
tibia, and the middle of the ankle should be in the same straight line.
A useful point in the adjustment of fractures.
Behind the upper half of the ligamentum patellæ is the synovial
membrane of the knee-joint; behind the lower half is a synovial bursa
and a pad of fat. It is well to remember this in cases of injury to the
ligamentum patellæ.
109. =Patellar bursa.=--The patellar or housemaids’ bursa is situated
not only over the patella, but over the upper part of the ligament.
This is plain enough when the bursa becomes enlarged. There is another
subcutaneous bursa over the insertion of the ligament into the tubercle
of the tibia. This is quite independent of the deep bursa between the
tendon and the bone.
110. =Synovial membrane of knee.=--The synovial membrane of the knee,
when the joint is extended, rises like a cul-de-sac above the upper
border of the patella about two inches. It ascends, too, a little
higher under the vastus internus than the vastus externus--a fact
very manifest when the joint is distended. When the knee is bent
this cul-de-sac is drawn down--hence the rule of bending the knee in
operations near the lower end of the femur.
The lower level of the synovial membrane of the knee is just above the
level of the upper part of the head of the fibula. The tibio-fibular
synovial membrane is, with rare exceptions, independent of that of the
knee.
111. =Popliteal tendons.=--The tendons forming the boundaries of the
popliteal space can be distinctly felt when the muscles which bend the
knee are acting. On the outer side, we have the biceps running down
to the head of the fibula. On the inner side we feel three tendons,
disposed as follows:--nearest to the middle of the popliteal space
is the semitendinosus, very salient and traceable high up the thigh;
next comes the thick round tendon of the semimembranosus; still more
internally is the gracilis. The sartorius, which forms a graceful
muscular prominence on the inner side of the knee, does not become
tendinous until it gets below it.
112. =Popliteal bursa.=--The precise position of the bursa in the
popliteal space, which sometimes enlarges to the size of a hen’s
egg, is between the tendon of the inner head of the gastrocnemius and
the tendon of the semimembranosus, just where they rub one against
the other. The bursa is from one and a half to two inches long. When
enlarged, it makes a swelling on the inner side of the popliteal space,
which bulges and becomes tense when the knee is extended, and _vice
versâ_. I examined 150 bodies with a view to ascertain how often this
bursa communicates with the synovial membrane of the knee. There was
a communication about once in five instances. This should make us
cautious in interfering too roughly with the bursa when enlarged.
113. =Popliteal artery.=--The popliteal artery can be felt beating
and can be compressed against the back of the femur, close to which
it lies. But pressure, sufficient to stop the blood, should be firm,
and should be made against the bone nearer to the inner than the outer
hamstrings. The line of the artery corresponds with the middle of the
ham. It lies under cover of the fleshy belly of the semimembranosus,
and the outer border of this muscle is the guide to it. An incision
down the middle of the ham would fall in with the vessel just above the
condyles.
114. =Peroneal nerve.=--The peroneal nerve runs parallel with and close
to the inner border of the tendon of the biceps. It can be felt in thin
persons. There is a risk of dividing it in tenotomy of the biceps,
unless the knife be carefully introduced from within outwards. Below
the knee the nerve can be felt close to the fibula just below the head,
and when pressed upon in this situation causes a sensation to run down
its branches to the foot.
_THE LEG AND ANKLE._
115. =Bony points.=--The tubercle of the tibia (for the attachment of
the ligamentum patellæ), the sharp front edge called the shin, and the
broad flat subcutaneous surface of the bone can be felt all the way
down. The inner edge can be felt too, but not so plainly. The lower
third is the narrowest part of the bone and the most frequent seat of
fracture.
The head of the fibula is a good landmark on the outer side of the leg,
about one inch below the top of the tibia and nearly on a level with
the tubercle. Observe that it is placed well back, and that it forms no
part of the knee-joint, and takes no share in supporting the weight.
The shaft of the fibula arches backwards, the reverse of the shaft of
the tibia. The fact of the bones not being on the same plane should be
remembered in flap amputations. The shaft of the fibula is so buried
amongst the muscles, that the only part to be distinctly felt is the
lower fourth. Here there is a flat triangular subcutaneous surface,
between the peroneus tertius in front, and the two peronei (longus and
brevis) behind. Here is the most frequent seat of fracture.
116. =Malleoli.=--The shape and relative position of the malleoli
should be carefully studied, as the great landmarks of the ankle. The
inner malleolus does not descend so low as the outer, and advances more
to the front: at the same time, owing to its greater antero-posterior
depth, it is on the same plane as the outer behind. The lower border of
the inner malleolus is somewhat rounded, and the slight notch in it for
the attachment of the lateral ligament can be felt. The outer malleolus
descends lower than the inner, thus effectually locking the joint on
the outer side. Its shape is not unlike the head of a serpent. Viewed
in profile, it lies just in the middle of the joint.
In Syme’s amputation of the foot at the ankle, the line of the incision
should run from the apex of the outer malleolus, under the sole to the
centre of the inner.
In a well-formed leg, the inner edge of the patella, the inner ankle,
and the inner side of the great toe, should be in the same vertical
plane. Look to these landmarks in adjusting a fracture or dislocation,
keeping at the same time an eye upon the conformation of the opposite
limb.
There are several strong tendons to be seen and felt about the ankle.
117. =Tendo Achillis.=--Behind is the tendo Achillis. It forms a high
relief, with a shallow gutter on each side of it. The narrowest part
of the tendon, where it should be divided in tenotomy, is about the
level of the inner ankle; below this it expands again to be attached to
the lower and back part of the os calcis. Seen in profile, the tendon
is not straight,but slightly concave--being drawn in by an aponeurosis
which forms a sort of girdle round it. This girdle proceeds from
the posterior ligament of the ankle; and, though most of its fibres
encircle the tendon, some of them adhere to and draw in its sides. All
this disappears when the tendon is laid bare by dissection.
118. =Tendons behind inner ankle.=--Above and behind the malleolus
internus we can feel the broad flat tendon of the tibialis posticus and
upon it that of the flexor longus digitorum. The tendon of the tibialis
posticus lies nearest to the bone and comes well up in relief in
adduction of the foot. It lies close to, and parallel with, the inner
edge of the tibia, so that this edge is the best guide to it. Therefore
in tenotomy the knife should be introduced first perpendicularly
between the tendon and the bone, and then turned at right angles to cut
the tendon. The tendon has a separate sheath and synovial membrane,
which commences about one inch and a half above the apex of the
malleolus, and is continued to its insertion into the tubercle of the
scaphoid bone. The proper place, then, for division of the tendon, is
about two inches above the end of the malleolus.
In a young and fat child, where the inner edge of the tibia cannot be
distinctly felt, the best guide to the tendon is a point midway between
the front and the back of the ankle. An incision in front of this
point might injure the internal saphena vein; behind this point, the
posterior tibial artery.
119. =Tendons behind outer ankle.=--Behind the malleolus externus we
feel the two peroneal (long and short) tendons. They lie close to the
edge of the fibula, the short one nearer to the bone. In dividing these
tendons, the knife should be introduced perpendicularly to the surface,
and about two inches above the apex of the ankle, so as to be above the
synovial sheaths of the tendons.
=Tendons in front of ankle.=--Over the front of the ankle, when
the muscles are in action, we can see and feel, beginning on the
inner side, the tendons of the tibialis anticus, the extensor longus
pollicis, the extensor longus digitorum, and the peroneus tertius. They
start up like cords when the foot is raised, and are kept in their
proper relative position by strong pulleys formed by the anterior
annular ligament. Of these pulleys the strongest is that of the
extensor communis digitorum. When the ankle is sprained, the pain and
swelling arise from a stretching of these pulleys and effusion into
their synovial sheaths. A laceration of one of the pulleys and escape
of the tendon is extremely rare.
The place for the division of the tendon of the tibialis anticus, so as
to divide it below its synovial sheath, is about one inch before its
insertion into the cuneiform bone. The knife should be introduced on
the outer side, so as to avoid the dorsal artery of the foot.
Now trace the lines of the arteries, and the landmarks near which they
divide.
120. =Popliteal artery.=--About one inch and a quarter below the head
of the fibula, or say one inch below the tubercle of the tibia, the
popliteal artery divides into the anterior and posterior tibial. The
peroneal comes off from the posterior tibial about three inches below
the head of the fibula.
Consequently we may lay down, as a general rule, that, in amputations
one inch below the head of the fibula, only one main artery, the
popliteal, is divided. In amputations two inches below the head of
the fibula, two main arteries, the anterior and posterior tibial,
are divided. In amputations three inches below the head, three main
arteries, the two tibials and the peroneal, are divided.
121. =Anterior tibial artery.=--The anterior tibial artery comes in
front of the interosseous membrane, one inch and a quarter below the
head of the fibula, and here lies close to this bone. Its subsequent
course is defined by a line drawn from the front of the head of the
fibula to the middle of the front of the ankle. This line corresponds
pretty nearly with the outer border of the tibialis anticus all
the way down. If this muscle be put in action, its outer border
(the intermuscular line) is plainly seen, and the incision for the
ligature of the artery in any part of its course may be defined with
the greatest precision. The artery can be felt beating and can be
compressed where it crosses the front of the tibia and ankle.
122. =Posterior tibial artery.=--The posterior tibial commences about
one inch and a quarter below the head of the fibula. Its subsequent
course corresponds with a line drawn from the middle of the upper part
of the calf to the hollow behind the inner ankle, where it can be felt
beating distinctly about half an inch behind the edge of the tibia. A
vertical incision down the middle of the calf would reach the artery
under cover of the gastrocnemius and soleus. A vertical incision along
the middle third of the leg, about half an inch from the inner edge of
the tibia, would enable the operator to reach the artery sideways, by
detaching from the bone the tibial origin of the soleus.
123. =Saphena veins.=--The subcutaneous veins on the dorsum of the foot
form an arch convex towards the toes (as on the back of the hand),
from which issue the two main subcutaneous trunks of the lower limb,
the internal and external saphena veins. The internal saphena vein can
be always plainly seen over the front of the inner ankle. Its further
course up the inner side of the leg, knee, and thigh to its termination
in the femoral is not in all persons manifest.
The external saphena vein runs behind the outer ankle and up the middle
of the calf to empty itself (generally) into the popliteal vein.
_THE FOOT._
What are the bony landmarks which guide us in the surgery of the foot?
124. =Points of bone.=--Along the inner side of the foot, beginning
from behind, we can feel--1, the tuberosity of the os calcis; 2, the
projection of the internal malleolus; 3, the projection of the os
calcis, termed ‘sustentaculum tali,’ about one full inch below the
malleolus; 4, about one inch in front of the malleolus internus, and a
little lower, is the tubercle of the scaphoid bone; the gap between
it and the sustentaculum tali being filled by the calcaneo-scaphoid
ligament and the tendon of the tibialis posticus, in which there
is often a sesamoid bone; 5, the internal cuneiform bone; 6, the
projection of the first metatarsal bone; 7, the sesamoid bones of the
great toe.
Along the outer side of the foot we can feel--1, the external
tuberosity of the os calcis; 2, the external malleolus; 3, the peroneal
tubercle of the os calcis, one inch below the malleolus, with the long
peroneal tendon below it, and the short one above it; 4, the projection
of the base of the fifth metatarsal bone.
125. =Lines of joints.=--In fat persons the following rules for finding
the joints may be of service as regards the surgery of the foot:--
The level of the ankle joint lies about half an inch above the end of
the inner malleolus. This is worth remembering in performing ‘Syme’s’
amputation.
The tubercle of the scaphoid bone is the best guide to the
astragalo-scaphoid joint which lies immediately behind it; and the
plane of this joint is in the same line as that of the calcaneo-cuboid.
Thus a line drawn transversely over the dorsum of the foot, behind
the tubercle of the scaphoid, would strike both the joints opened in
‘Chopart’s’ operation.
Place your thumb on the tubercle of the scaphoid, and measure about one
inch and a half in front: here you find the joint between the internal
cuneiform bone and the metatarsal bone of the great toe. This point is
useful in Lisfranc’s operation, which consists in the removal of the
metatarsal bones.
The line of the calcaneo-cuboid joint lies midway between the external
malleolus and the (tarsal) end of the metatarsal bone of the little toe.
The projection of the fifth metatarsal bone is the guide to the joint
between it and the cuboid.
Notice that the line of the joints between the metatarsal bones and the
first phalanges lies a full inch farther back than the interdigital
folds of the skin. This is a point to be remembered in amputating the
toes.
126. =Dorsal artery.=--The line of the dorsal artery of the foot is
from the middle of the ankle to the interval between the first and
second metatarsal bones. The artery can be felt beating over the bones
along the outer side of the extensor longus pollicis, which is the best
guide to it.
127. =Bursa.=--The synovial sheath of the extensor longus pollicis
extends from the front of the ankle, over the instep (apex of the
internal cuneiform bone) as far as the metatarsal bone of the great
toe. There is generally a bursa over the instep, above, or it may be,
below, the tendon.
There is often a large irregular bursa between the tendons of the
extensor longus digitorum, and the projecting end of the astragalus,
over which the tendons play. There is much friction here. It is well to
be aware that this bursa sometimes communicates with the joint of the
head of the astragalus.
128. =Plantar arteries.=--The course of the external plantar artery
corresponds with a line drawn from the hollow behind the inner ankle
obliquely across the sole nearly to the base of the fifth metatarsal
bone; from thence the artery turns transversely across the foot, lying
(deeply) near the bases of the metatarsal bones, till it inosculates
with the dorsal artery of the foot in the first interosseous space.
The course of the internal plantar corresponds with a line drawn from
the inner side of the os calcis to the middle of the great toe.
129. =Plantar fascia.=--To divide the plantar fascia subcutaneously,
the best place is about one inch in front of its attachment to the
os calcis. This is the narrowest part of it. The knife should be
introduced on the inner side; and the incision will be behind the
plantar artery.
The subcutaneous section of the tendon of the abductor pollicis should
be made about one inch before its insertion.
_THE ARM._
130. =Clavicle.=--The line of the clavicle and the projection of the
joint at either end of it can always be felt, even in the fattest
persons. Its direction is not perfectly horizontal, but slightly
inclined downwards, when the arm hangs quietly by the side. When the
body lies flat on the back, the shoulder not only falls back, but rises
a little, the weight of the limb being taken off. Hence the modern
practice of treating fractures of the clavicle (in the early stage) by
the supine position.