Part 12

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.