U N N I N G H AM S M AN U AL

P R AC TI C A L AN ATO M Y

R EV I S ED AN D ED I TED B Y

ART H U R RO B I N SO N
P RO E R
F A N AT M
SS O OF O Y IN T E U NI ER S I T Y O F E IN U R G
H V D B H

S EV E N T H EDI TI O N

I E FI RS T
V O L U /V

S U P E R I O R E X T R E M IT Y ; IN F E R I O R E X T R E M IT Y

WI TH 2 0 3 I L L U S TR A TI ON S , (! A N Y OF WH I C H A R E C OL O U R E D

N EW Y O R K L

W I LL I A M W O O D AN D C O M P ANY
ED I N B U R G H G L ASG O W AN D L O N D O N
'

. ,

H E N RY F R O W D E AN D HO DD E R S T O U GH T ON
1 9 2 1
P m n t ea in t t in (By LA R LI M I T E D E din o n ng/z
’
Gre a B ri a R 8: R
. . C K , ,
.

1 st Edi ti n
o , 1 89 6 .

3 rd E d iti n o ,
1 90 6 .

5 th E d iti no , 1 91 2 .

6 t /z E di t i n
o ,
1
91 4 .

6 t h Ed iti no ,
2 nd l mfi re ss z o n , 1 9 1 7 .
‘

6 t /z E dit i n
o , 3 rd I mp re ss o , 1 9 1 8 in .

'
A ll rig /i ts resa we d .
 P R E F AC E TO
TH E SE V E N T H ED ITION

I N t his d it io n th e ge n e ral t e xt has be e n r e v ise d man y n e w

e ,

figure s r e p re se n t in g d isse ct io n s se ct io n s an d rad iogra p h s

, , ,

hav e be e n in troduc e d The in struct io n s fo r d isse ct io n hav e

.

be e n p r in t e d in a d ist in ct iv e in d e n t e d ty p e ; in ma n y ca se s
th e y hav e be e n r e wr itt e n an d in so me ca se s a mp lifi e d .

The latt e r cha n g e s t o g e th e r w ith th e add it io n a l figur e s

, ,

hav e cau se d so much in cre a se o f siz e that it has be e n d e e m e d

advisa ble to p u blish t he book in thr e e vo lu me s V o l I . .

Su p e r ior E x tr e m ity an d I n fe r ior E x tr e mity V o l I I Thora x . .

an d A bdo me n ; V o l I I I H e ad an d N e ck
. . .

As was th e ca se in p r e v iou s e d it io n s I am in d e bt e d to ,

D r E B Ja m ie so n fo r m a n y sugg e st io n s fo r h is in va lua ble

. . .
,

h e lp in the re v isio n o f th e t e x t an d fo r the p r e p arat io n o f

t h e I n de x .

M y tha n k s are du e to D r R o be rt K n o x to M ajor A W

.
, . .

P ir ie an d to M aj or T Ra n k in fo r th e u se o f rad io gra p h s
.
,

wh ich th e y v e ry k ind ly p re p ar e d fo r me an d to M r J T ,
. . .

M urray fo r th e n e w draw in g s o f se ct io n s an d d isse ct io n s .

ART H U R RO B I N SO N .

Oct . 1 1, 19 19 .
 CONTENTS

TH E S U P E R I O R E X T R EM IT Y .

A X I LL A
,

D I SSE C T I O N O F T H E BA C K ,

S H O U LD ER — S C A P U L A R R E G I O N ,

T H E F R O NT O F T H E A R M ,

DO RS U M O F T H E A R M ,

S H O U LD ER JO I NT
-
,

FO R EA R M A N D H A N D ,

V O L A R S U R F A C E A N D M E D IA L B O R D E R O F T H E FO R EA R M ,

W R I ST A N D P A L M ,

DO RS U M A ND L A T ERA L B O R D E R O F T H E FO R EAR M ,

DO RSA L A S P E C T O F T H E W R I S T A N D H A N D ,

A R T I C U LAT I O N S ,

TH E I N F E R I O R E X T R EM IT Y .

I NT R O DU C T I O N,

T H E TH IGH ,

T H E ANT ER I O R F E MO RA L A N D M E D IA L F E M O RA L R E G I O N S
A N D T H E ANTE R I O R R E G I O N O F T H E K N E E ,

D E E P D I SSE C T I O N O F T H E ANT ER I O R A N D M E D IA L P A R T S OF
TH E TH IGH ,

M E D IA L S I D E O F T H E T H I G H ,

G LUT EA L R E G I O N ,

P O P L I T EA L S P A C E ,

BACK O F TH E T H I G H ,
 C O N TE N TS
P A E
G

TH E L EG ,
ANT ER I O R C R U RA L R E G I ON A N D
L A T E RA L C R U RA L O R P E R ON E A L
M E D IA L C R U RA L R E G I O N
,

P O S T E R I O R C R U RA L R E G I O N
,

S O L E O F T H E FOO T ,

A RT I C U LAT I O N S
,

I N D EX ,
 A G L O S SA RY

OF TH E

I N T E R N AT I O N A L

A N AT O M I CAL T E R M I N O L O GY

G E N ERA L TER M S .

T ER M S I N D I C ATI N G S I TU ATI ON AN D D I R ECTI O N .

L o n g itu dinalis Lo n gitu dinal R e fe rrin g to the lo n g a is o f t he bo dy x .

R e fe rrin g to th e p o sit io n o f th e lo ng
V e rticalis V e rtical x
a is o f t h e bo dy in the e re c t p o stu re .

R e fe rrin g to the fro n t an d back f th e

[ o

I bo dy o r o f the limbs .

R e fe rrin g to the an te rio r an d

p o st e rio r

as e ct s,
p re spe cti e l v y , o f the bo dy ,
an d to fie x o r an d e te nso r
th e x
asp e c ts o f th e limbs, re s e c t iv e ly
p .

R e fe rrin g to po sitio n n e are r the h e ad

o r th e tai l
e n d o f the lo n g a is x .

U se d o n y in re fe re n ce to parts o f
l
th e h e ad, n e ck , o r t ru n k .

U se d in re fe re n ce to the h e ad, n e ck ,
an d tru n k Equ ivale n t to cran ia
. l
an d cau da re spe c tiv e ly l .

U se d o n ly in re fe re n ce to t he limbs .

P xro im al n e are r th e attach e d e nd .

D istalis D istal D istal n e are r th e fre e e n d .

U se d in re fe re n ce t o plan e s p ara e l ll
Sagittalis Sag it t al
w ith the sagitta su tu re o f the l
Sk u l, i e l v e rtical an te ro p o ste rio r
. .
-

p lan e s .

U se d in re fe re n ce to p lan e s p ara e l ll
F ro n tal is F ro n tal w ith the co ro n al su tu re o f the sku l, l
z e t ran sv e rse v e rt ical
'

. .
p lan es .
 G L OSSARY

H o riz o n talis H o riz o n tal U se d in re fe re n ce to p l an es at righ t

ang le s to v e rtical lan e s
p .

R e fe rrin g to th e m e dian v e rtic al

M e dian u s M e dian
an te ro p o ste rio r
-

p lan e o f th e bo dy .

M e dialis M e dial R e fe rrin g to struct u re s re lativ e l y

n e are r to o rfu rt h e r aw ay f ro m th e

L ate ralis L ate ral me dian p lan e .

R e fe rrin g to struc tu re s situ ate d be

I n t e rm e dius I n te rm e diat e t we e n mo re m e dial an d mo re

late ral stru ctu re s .

R e fe rring to stru c tu re s n e are r to and

fu rth e r aw ay fro m th e su rface .

R efe rrin g , w ith fe w e ce p tio n s, to th e x

walls o f cav itie s an d h o llo w o rg an s .

N o t to be u se d as syn o nymo u s w ith

m e dia] an d late ral .

U se d in re fe re n ce to th e me dial an d
late ral bo rde rs o f th e fo re arm ,
re sp e ctive ly .

U sed in re fe re n ce to the me dial an d

late ral bo rde rs o f the le g, re
F ibu lar F ibu lar sp e c tiv e ly .

TH E B O N ES .

B N A
. . . TER MIN O L OG Y . OL D TER MIN O L OG Y .

Ve rt ebr as V e rt ebr ae
F o v e a co stal is su p e rio r I n co m p le te face t fo r h e ad o f rib,

u e r
p p
F o ve a co stalis in fe rio r I n co m p le te face t fo r h e ad o f rib,

lo we r
F o v e a c o sta l is t ran sve rsal is Face t fo r tu be rcle o f th e rib

R adix arc u s v e rte brae P e dicle

t
A las At las
F o ve a de n tis F ace t fo r O do n t o id p ro c e ss

Ep is tro p h eus Ax is
D e ns O do n to id p ro ce ss

Ste r n um S t e r n um
C o rp u s s t e rn i G l di l
a o us

P ro ce ssu s x iph o ide u s En sifo rm p ro ce ss

I n cisu ra j ugu laris Su p ra st e rn al n o t ch
-

Pl an u m St e rn ale An te rio r su rface

O ssa Cran ii . B o n es o f Sk ull .

osf r o n t ale F r o n t al
Sp ina fro n ta li s N asal sp in e
P ro ce ssu s zyg o maticus x
E te rn al an g u lar p ro c e ss

F acie s ce re bral is I n te rn al su rface

F acie s fro n tal is F ro n ta surface l
P ars o rbital is O rbita l pl at e
 GL OSSARY xi

B N A
. . . TER MIN O L OG Y . OLD TER MI N O L OG Y .

o s p a ie r tale P arietal
L in eae te m p o rale s Te mpo ral rid e s g
Su lcu s t ran sv e rsus G ro o ve fo r late ral sin us
Su lcu s sag it talis G ro o v e fo r sup lo n g sin u s
. .

Os o ccip i ale t O ccip ital

l
C an a is hyp o glo ssi An t e rio r co n dylo id fo ram e n
F o rame n o ccip itale m ag nu m F o rame n m agn u m
C an alis co n dylo ide u s P o ste rio r co n dy lo id fo ram e n

Sulcus t ran sv e rsu s G ro o v e fo r late ral sin u s

Su lcu s sagit talis G ro o ve fo r su p . lo n g . sin us

l
C ivu s M e dian p art f u pp e r su rface
o

basi o c cip ital

-

L in e a hae
nuc sup re ma H igh e st cu rv e d line
L in e a n uch ae su p e rio r S u pe rio r cu rv e d lin e
L in e a n u ch ae in fe rio r I n fe rio r cu rv e d lin e

Os sp h en o idale Sp h en o id
C rista infrate mp o ralis P t yg
er o id ridg e
Su lcus ch iasmatis O p t ic g ro o v e
C rista Sph e n o idalis Eth mo idal c re st
Spina an gu laris Spino u s p ro c e ss
L am in a m e dialis p ro cessu s p te ry I n te rn al p te ryg o id p late
g o ide i
Lamin a late ralis pro ce ssu s p te ry x
E te rn al p te rygo id p late
go ide i
Canalis p te rygo ide us [ V idu ] V idian canal

F o ssa hypo physe o s Pit u itar y fo ssa

Su lcus caro ticu s C av e rn o us gro o v e
Co n ch ae Sp h e n o idale s Sph e n o idal tu rbinal bo n e s
H am ulu s p te rygo ide u s H amu lar pro ce ss
C analis p h ary n ge u s l
P te ry go pa atin e can al
-

Tu be rcu lu m se llae O livary e m in e n ce

F issu ra o rbitalis su pe rio r Sph e n o idal fi ssu re

Os t emp o rale Temp o r al B o n e

C analis facialis [ F allo p u ] A q u e du ct f F allo p iu s
o

H iatu s can alis facia is l H iatu s F allo pii

Vagin a p ro ce ssus sty o ide i l V aginal p ro ce ss o f tympan ic bo n e
I n cisu ra m ast o ide a D ig astric fo ssa
I mp re ssio trig e min i I mp re ssio n fo r G asse rian gan g lio n
Emin en tia arcu a a t Emin e n ce fo r sup . se micircu lar

c anal

Su lcus sig mo ide u s F o ssa sig mo ide a

F issu ra p e tro ty mpan ica G lase rian fissure
F o ssa m andibularis G le n o id ca ity v
Se micanalis tubae au ditiv ae Eu stach ian tu be

os e t hmo idale t
E h mo id
L abyrinth u s e th m o idalis Lat e ral mass
L amina p apy race a O s plan um
P r ce
o ssus u ncina u st U n cifo rm pro ce ss
x ii G L OSSARY

EN A
. . . TER MIN O L OG Y . OL D TER MIN OL OG Y .

Os lac imale r r
Lach y mal B o n e
H am ulu s lacrimalis H amu lar p ro ce ss
C rista lac rim alis p o ste rio r Lach ry ma c re st l
Os a
n sale Nasal B o n e
Su l cu s e t h mo idalis G ro o v e fo r n asal n e r e v
Max illa Sup e io r r M ax illar y B o n e
Facie s ant e rio r F acial o r e x te rn al su rface
F acie s in fra te m po ral is
-
Zygo matic surface
Sinu s m a illaris x An t rum o f H igh m o re
Pro ce ssu s fro n talis N asal p ro ce ss
P ro ce ssu s zyg o maticus M alar p ro ce ss
C anale s alv e o lare s P o s te rio r de n ta l c anals

C an alis n aso lacrimalis -

L ac rimal g ro o ve
O s in cisiv um Pre m a illa x
F o rame n in cisivu m An te rio r p l
a at in e fo ram e n

Os p alatinu m P ala t e Bo n e
Pa p e rpe n dicu laris
rs V e rtical p late
C rista c o n ch alis I n fe rio r tu rbin at e c re st

C rista e th mo ida is l Su pe rio r tu rbin ate cre st

Pars h o ri o n talis z z
H o ri o n ta p ate l l
Os z y go ma icum t Malar B o n e
P
ro ce ssu s te m p o ralis Zyg m atic p ro ce ss
o

P ro ce ssu s fro n to -
sp h e n o idal is F ro n tal pro ce ss
F o rame n zygo m at ico -
o rbita e l Te mp o ra m alar can al -

F o rame n z yg o matico -
facia l e M alar fo ram e n

Man dibu la I nfe io r r Max illary Bo n e

Spin a m e n talis G e n ial tube rcle o r sp in e

L in e a o bliq u a x
E te rn al o bliq u e lin e
L in e a m ylo hyo ide a I n te rn al o bliq u e lin e
I n cisu ra man dibu lae S ig m o id n o tch
F o rame n man dibu lare I n fe rio r de n tal fo ram e n
l
C an a is m an dibu lae I nfe rio r de n tal canal
P ro tu be ran tia m e n alis t M e n tal p ro ce ss

The Sk u ll as a W h o le .

O ssa su tu raru m W o rmian bo nes

F o ve o lae g ranu lare s ( Pacch io n i) P acc h io n ian de p re ssio n s

F o ssa p te ry go p al atina -
Sph e n o m a -
x illary fo ssa
C an alis p te ry go p alatin u s -
Po ste rio r p alatin e can al

F o rame n lace ru m l
F o rame n ace rum m e diu m
C h o an ae P
o ste rio r nare s

F issu ra o rbitalis su p e rio r Sph e n o idal fissu re

F issu ra o rbitalis in fe rio r Sph e no ma illary fi ssure
-
x
 GL OSSARY

U pp e r Ex t re mit y .

EN A
. . . TER MIN O L OG Y . OL D TER MIN O L OG Y .

a
Cl vicu la v
Cla icle
Tube ro sitas c o raco ide a I m p re ssio n fo id lig am e n t
r co n o

Tube ro sitas co sta l is I m p re ssio n fo rr o h mbo id ligam e n t

Scap u la a
Sc p u la
I ncisu ra scap u laris S u p ra ~
scap u lar n o tc h
An g u lu s late ra is l An te rio r o r late ral an g le
An g ulu s me dia is l Su p e rio r an g e l
H umerus H u me u s r
l
Su cu s in t e rtu be rc ularis B icipital gro o v e
C rista tu be rc u i m aj o ris l x
E te rn al lip
C rista tu be rcu li m in o ris I n te rn al lip
Facies ante rio r me dialis I n te rn al su rface
F acie s an te rio r ate ralis l x
E te rnal su rface
M arg o m e dialis I n te rn al bo rde r
M arg o late ralis x
E t e rn al bo rde r
Su lcu s n e rvi radialis M u scu lo spiral g ro
-
o ve
C ap it ulu m C ap ite l u m l
Ep ico n dylu s m e dialis I n t e rn al co n dyle
Ep ico n dylus late ra is l x
E te rn a co n dy lel
U ln a U lna
I n cisura se m ilu naris G re ate r Sig mo id cav ity
I nc isu ra radialis L e sse r sigmo id cav ity
C rista in te ro sse a x
E te rn al o r in te ro sse o u s bo rde r
F acie s do rsa is l P o st e rio r su rfac e

F acie s vo laris An te rio r su rface

Facie s me dialis I nte rn al su rface
M arg o do rsa is l P o st e rio r bo rde r

M arg o v o laris An te rio r bo rde r

Radius
Tube ro sitas radi i B icip ital tube ro sity
I n cisu ra u ln aris Sigm o id cavity
C rist a in te ro sse a I n te rn al o r in te ro sse o us bo rde r
F acie s do rsa is l Po ste rio r su rface

F acie s v o laris An t e rio r su rface

F acie s late ralis x
E te rn a su rface l
M arg o do rsalis Po ste rio r bo rde r

M arg o v o laris An t e rio r bo rde r

Carp us
Os n a i cul ev ar
Os lun a u m t
tr
Os i qu e um tr
t
Os mul an gu lu m m ju s a
Os multan gulum minus
Os cap i um tat
Os h amatum
 i
x v GL O SSARY

L o w e r Ext re mit y .

B N A. . . TER MI NO LOG Y . OLD TER MIN O L OG Y .

Os co x as I n n o min a e B o n e t
L in e a gl u tae t
a an e rio r M iddle curv e d line
L in e a glu taea p o ste rio r Sup e rio r cu rve d lin e
L in e a te rm in alis M argin o f in le t o f t rue p e v is l
Sp in a isch iadica Spin e o f the isch iu m
I n cisu ra isch iadica m aj o r G re at sacro sciatic n o tch -

I n cisu ra isch iadica m in o r L e sse r sacro sciatic n o tch -

l
Tube rcu u m p ubicu m
R amu s infe rio r o ss p u bis
R am us su p e rio r Oss p u bis
R amu s su pe rio r o ssis isch i i
R am u s in fe rio r o ss isch ii
Pe c te n o ssis
p u bis
Sp ine o f pu bis
. D e sce n din g ramu s o f p ubis
. Asce n din g ram u s o f p u bis
B o dy o f isch iu m
. R am u s o f isch iu m
P
u bic
p t
ar o f ilio p e ct in e al lin e -

F acie s sy mphyse o s Sy mphysis p ubis

v
P el i s P el i s v
P
e lv is m aj o r False pe lvis
P
e lv is min o r Tru e p e lvis
Ap e rtu ra p e lv is m in o ris sup e rio r P
e lvic in le t

Ap e rtu ra p e lv is min o ris in fe rio r P

e lv ic o u t e t l
L in e a te rm ina is l M arg in o f in le t o f t ru e p e lv is

F emu r F emur
F o ssa h an te rica
tro c D ig ital fo ssa
L in e a in te rtro ch an te rica Sp iral lin e
C rista in te rtro ch an t e rica P o st . in te rt ro ch an te ric lin e
C o n dylu s m e dialis I yle
nn e r co nd

C o n dy lu s late ralis O u te r co n dy le
Ep ico n dylus m e dialis I n n e r tube ro sity
Epico n dylus late ralis O u te r tu be ro sity

Tibia Tibia
C o ndylu s m e dialis I n t e rn al ube ro sityt
C o n dylu s late ralis x
E t e rn al tu be ro sity
Emin e n tia inte rco n dylo ide a Sp in e
Tu be ro sitas tibiae Tube rcle
M alle o lu s m e dialis I n te rn al malle o lus

F ibula Fibula
M alle o lus late ralis x
E te rn al malle o lu s
Ap e x cap itu li fibulae Sty lo id p ro ce ss

B o n es o f t he F o o t .

Talu s Astr agalus

Calcaneus Os calcis
Tu be r calcan e i Tu be ro sity o f
P
ro ce ssu s m e dialis t u be ris calcan e i I nne r
Pr o ce ssu s late ralis tube ris calcan e i O u te r
Os me p r imum
cu n eif o r I nn e r cun eif o rm
Os cun eif o rme secun du m Middle cu n eif o r m
Os cuneifo rme tertium O uter cun eifo r m
 GL OSSARY xv

TH E L I G A M E N TS .

L ig ament s of t h e Sp ine .

B N A
. . . TER MI NO L OG Y . TER MIN O L OG Y
OL D .

L ig lo n gitu dinale an te riu s

. An te rio r co mmo n ligame n t
l
L ig o n g itu dinale p o ste rius
. Po ste rio r co mm o n l igame n t
L ig fl av a
. L ig am e n ta su bfl ava
M e mbrana te c o ria t P o ste rio r o ccipito ax ial ligame n t -

A rticu latio atlan to -

e p istro ph ica Jo in t be tw e e n the atl as an d the ax is
L ig alaria
. O do n to id o r ch e ck ligam e n ts
L ig ap icis de n tis
. S u sp e nso ry ligame n t

The R ibs .

L ig. c ap itu li co stae radiatu m An te rio r co sto -

v e rte bral o r ste l ate l
lig ame n t
L ig. ste rn o -
co stale in te rartic u lare I n te rartic u l ar c h o n dro -
ste rn al l ig a

men t
L ig. st e rno -
co stalia radiata An te rio r an d
p o ste rio r C h o ndro
ste rn al l ig m ta en

L ig. c o sto x ip ho ide a Cho n dro -

x iph id lig o am e n ts

Th e J aw .

L ig te m p o
. ro -
m an dibu lare x
E te rn al late ral ligam e n t o f th e ja w
L ig. S
p h e no -
m andibu lare ll
I n te rnal late ra igame n t o f the ja w
L ig. sty lo m an dibu lare-
Sty lo ma i ary igam e n t
-
x ll l

U p p e r Ext re mi t y .

L ig. co sto -
clav ic ulat e R h o m bo id ligame nt
L abru m g le n o idale G le n o id lig am e n t
Articu latio radio u ln aris p ro -
x im alis S u p e rio r radio -
u n ar l j o in t
L ig co l ate rale u n are
. l l I n te rn a l late ral ig ame n t l o f e lbo w
j o in t
L ig . co ll t a e rale radiale Ex t e rn al late ra ligame n t l
L ig . an n u lare radii l
O rbicu ar lig am e n t
C h o rda o bliq u a Obliq u e ligam e n t o f u ln a
Articu latio radio u ln aris dista is -
l I n fe rio r radio —u ln ar j o in t
D iscu s articu laris Trian g u lar fibro carti ag e -
l
R e ce ssu s saccifo rm is M e mbran a saccifo rm is
L ig radio carp e u m v o lare
.
-
An t e rio r ligam e n t o f the radio

carp al j o in t

L ig . radio -
carp e u m do rsale P o ste rio r l
ig am e n t o f the radio

carp al j o int

L ig . co ll ate rale carpi u ln are I n t e rnal late ral ligame n t o f th e

w rist j o in t
V OL . I — o
xv i GL OSSARY

B N A . . . TER MIN O L OG Y . OL D TER MIN O L OG Y .

L ig . co llate ra l e carp i radiale x

E te rn al late ral lig am e n t
o f t he

w rist j o in t
A rticu latio n e s in te rcarpae C arp al j o in ts
L ig . acce sso ria v o laria P l l
a m ar ig am e n ts o f th e m e tacarp o

l
p h a an g e al j o in ts
L ig . cap itu lo ru m
( o ss
. m e tacar Tran sv e rse m e tacarp al lig am e n t
p aliu m
) tran s v e rsa
L ig . co llate ralia L ate ral ph alan g e a ligam e n ts l

Th e L o w er Ex t re mit y .

L ig . arc u atu m Su bpu bic ligame n t

L ig . sacro -
t u be ro su m G re at sacro sciatic ligam e n t -

P ro c e ssu s fa l cifo rm is Falcifo rm p ro ce ss

L ig . sacro -
Sp in o su m S mall sacro sciatic lig ame n t
L abru m gle n o idale C o ty lo id ligame n t
Z o n a o rbicu laris Z o n u lar ban d

L ig am e n tu m ilio fe m o rale Y Sh ap e d ligame n t

-

L ig isch io cap su lare

.
-
lsch io capsu ar ban d
-
l
L ig p ubo cap su lare
.
-
P u bo fe mo ra ligam e n t
-
l
L ig p o p lite u m o bliq uu m
. L ig am e n t o f W in s o w l
l
Lig co late rale fibu lare
.
x
L o n g e te rn al late ral lig am e n t
l
L ig co late ra e tibiale
.
l I n te rn al late ral ligam e n t
L ig p o p lite u m arcu atu m
. Arcu ate p o p ite al ligame n l t
M e n iscu s late ralis x
E te rn al se m i u n ar carti ag e l l
M e n iscu s m e dialis I n te rnal se m i u n ar carti ag e l l
P l i y vi li
ca s no a s p ate llaris L ig m uco su m
.

P li a l
c e a are s L igam e n ta alaria
Articu latio tibio fibu laris -
S u p e rio r tibio fibu lar artic u latio n -

L ig cap itu li fibu lae

. A n te rio r an d p o ste rio r su p e rio r
t ibio fibu lar ligame n t s
-

Sy n de sm o sis tibio fi bu laris -

I n fe rio r tibio fibu lar articu latio n -

Lig de lto ide u m

. I n te rnal late ral ligam e n t o f an k le
L ig talo fibu lare an te riu s
.
-
An te rio r fasc icu u s o f e te rn al l x
late ral lig am e n t
L ig talo fibu lare p o ste riu s
.
-
P o ste rio r fascicu lu s o f e te rn al x
late ral lig am e n t
L ig . c alcan e o -
fibu lare M iddle fascicu lu s o f e te rn al late ra x l
ligam e n t
L ig talo
.
-
calcane u m late ra l e x
E te rn al calcan e o astrag alo id lig a -

men t
L ig t alo
.
-
calcan e u m m e diale I n te rn al calcan e o astrag alo id lig a -

me n t
L ig calcan e o n av icu lare p lan tare
.
-
l
I n fe rio r ca can e o n av icu lar ligam e n t -

L ig talo n av icu lare

.
-
l
Astrag a o scaph o id ligam e n t
-

Pars c alcan e o n av icu aris lig -

l . Su p e rio r ca can e o scaph o id lig a l -

bifu r me nt
P ars calc an e o -
cu bo ide a catu m I n t e rnal calcan e o cu bo id lig ame n t -
 G L OSSA R Y x v ii

T HE M U S C L ES .

M u scle s o f t h e B ack .

r
Sup e fi cial .

B N A
. . . TER MIN OLOG Y . OLD TER MIN O L OG Y .

L e vato r scap u lae L e vato r an g u li scap u lae

Muscle s o f t h e Ch e st .

Se rratu s an te rio r Se rratu s m ag n u s

M u sc le s o f U p p e r Ext re mit y .

B ice ps brachn B ice p s

L ace rtus fibro su s B icip ital fascia
B rach ialis l
B rach ia is an t icu s
Trice p s brach n Trice ps
Capu me diale t I nne r h e ad
C apu t late rale O u te r h e ad
P ro n ato r t e re s P ro n ato r radi i t e re s
C ap u t u ln are Co ro n o id h e ad
B rach io radialis-
Su pinato r lo n g u s
Su p inato r Su pinato r bre v is
Ex te n so r carpi radialis lo ng u s x
E t e n so r carp i radialis lo n g io r
x
E te nso r carp i radialis bre vis x
E te n so r ca rp i radialis bre v io r
x
E t e n so r in dicis p ro p rius x
E te n so r indicis
x
E te n so r dig iti q u in ti p ro p rius x
E te n so r m in imi digi t i
Abdu cto r p o l icis lo n gu s l x
E te nso r o ssis m e tacarp i po llicis
Abdu cto r p o llicis bre v is Abducto r p o llicis
x
E te nso r p o l icis bre v is l x
E te nso r p rimi in te rno di i p o licis l
x
E te n so r p o llicis lo n g us x
E te nso r se cun di in te rn o dii po llicis
L ig carpi tran sve rsu m
. An te rio r an n u lar ligam e n t
L ig carpi do rsale
. Po ste rio r ann u lar lig am e n t

M u scles o f L o w e r Ex t re mit y .

Te n so r fasciae latae Te nso r fasciae fe m o ris

C analis addu cto riu s ( H un t e ri) H un te r s can al’

Trig o n u m fe mo ra e ( fo ssa Scarp ae l Scarpa s t rian g le

’

maj o r)
l
C ana is fe m o ralis C ru ral can al
An nu lus fe mo ralis C ru ral ring
M q u adrice ps fe m o ris
.
Qu adrice ps
R e c tu s fe mo ris R e ctu s fe m o ris
V astus late ralis V astus e xt e rn u s

Vastus in te rme dius C rure u s

V astu s me dialis Vastu s in te rn u s
M art icu laris g e n u
. Su bcru re u s
Tibia is l an te rio r Tibialis an ticu s
x v iii GL OSSARY

B N A
. . . TER MI N O L OG Y . OL D TER MIN O L OG Y .

Te n do calcane u s Te n do Ach illis

l
Tibia is p o ste rio r l
Tibia is po sticu s
Q uadratu s
p lan tae Acce sso riu s
L ig tran sv e rsu m cruris
. U pp e r an te rio r an n ular ligam e n t
L ig cru ciatu m c ruris
. L o w e r an te rio r ann ular ligam e n t
L ig lacinia u m
. t I n te rnal ann ular lig am e n t
R e tinaculu m m u scu lo ru m p e ro
na eo ru m su e riu s
p
R e tin acu lu m m usc ulo ru m p e ro
x
E te rnal an n u lar lig ame n t

na e o ru m in fe riu s

Ax ia l M u scles .

Mu scle s of t h e Back .

Se rratu s p o ste rio r Se rratu s po sticu s su p e rio r

Se rratus po ste rio r Se rratus p o sticus in fe rio r
Sp le n ius ce rv icis Sple n ius co lli
Sacro sp in alis
-
Ere cto r Spinae
I lio co stali s
-
I lio co stalis
-

L u mbo ru m Sacro lu mbalis -

D o rsi Acce sso riu s

C e rv icis C e rv icalis asce n de n s
Lo n gi ssimu s Lo n gissimu s
Do rsi D o rsi
C e rv icis Tran sv e rsalis ce rv icis
C ap itis Trache lo masto id -

Sp inali s Sp in alis
D o rsi D o rsi
C e rvicis C o lli
C ap itis C ap itis
Se misp in alis Semi sp in lis a
D o rsi D o rsi
C e rvicis C o li l
C apitis C o m p le us x
M u ltifidus Mu ltifidu s Sp in ae

M u sc le s o f H e ad an d N eck .

Epicran ius O ccip ito fro n alis -

t
G ale a ap o n e u ro tica Ep ic ran ial apo n e uro sis
Pr o c e ru s Pyramidalis nasi
P ars trans v e rsa ( n asalis) C o m p re sso r n aris
P ars alaris ( nasalis) D ilato re s n aris
Au ricu laris an te rio r At trah e n s au re m

Au ricu laris p o ste rio r R e trah e n s au re m

Au ricularis su pe rio r At to lle n s au re m
O rbicularis o cu i l O rbic u laris pa p e brarum l
P
ars lacrimalis Te n so r tarsi
xx GL OSSARY

M u scle s o f t h e Abdo men .

B N A
. . . TE R MIN O L OG Y . OL D TER MIN O L OG Y .

L ig am e n tu m in g u in al e ( P o u part i) P o u
p art s
’
ligam e n t
L igame n tu m lacu nare ( Gimbe rn ati) G imbe rn at s l igame n t
’

F ibrae in te rcru rale s I n te rc o l u m n ar fi bre s

L ig am e n tu m in gu in ale re fl e x u m Trian gu lar fasc ia
( C o lle si)
An n u lu s in g uin a is su bcutan e us l E xt e rn al abdomin a rin g l
C ru s su pe rius I n te rn al p i ar ll
C ru s in fe rius x
E t e rn al p illar
Falx apo n e uro tica ing u in alis C o nj o in e d t e n do n
M tran sv e rsu s abdo min is
. Tran sv e rsa is muscle l
L in e a se m icircu laris ( D o u glasi) l
F o d o f D o uglas
An n u lu s in gu in a is abdo m in a is l l I n te rn al abdo min a rin g l
P e rin eum an d P elvis .

Tran sv e rsu s p e rin e i su p e rfic ialis Tran sv e rsu s p e rin e i

M sp h in cte r u re th rae m e mbran ace ae
. C o mp re sso r u re th rae
D iaph rag ma u ro ge n ita e l D e e p tran sv e rse m u scle an d s
p hin c
te r u re t h rae
F ascia diaph rag m at is u ro g e n ital is D e e p lay e r o f trian g ular lig am e n t
su e rio r
p
F ascia diap h ragm atis u ro g e n italis Su p e rfi cial lay e r o f the trian gu ar l
in fe rio r lig ame n t
A rcu s te n din e u s fasciae p e lvis W h ite lin e o f p e lv is
L ig am e n ta p u bo p ro static a An te rio r an d late ral t ru e ig ame n t s l
o f bladde r

F ascia diap h rag m atis pe lv is su p e rio r V isc e ral lay e r o f p e lvic fascia
F ascia diap h ragmatis p e lv is in fe rio r An al fascia

TH E N ER V O U S SYSTE M .

M e dulla Sp ina lis . Sp in al Co r d .

Fasc iculus an te rio r pro p riu s ( F le ch An te rio r g ro u n d o r basis bun dl e

sis )
F asciculu s late ralis p ro p riu s L ate ral g ro un d bun dle
N u cle u s do rsa lis C l k ’
ar e s co lu mn
P ars tho racalis D o rsal p art o f spin al c o rd
S ulcu s in te rm e diu s p o ste rio r Parame dian fu rro w

C o lu m n ae an te rio re s, e tc . An te rio r g re y co lu mn
F ascicu lu s ce re bro Sp in a is an te rio r-
l D irect py ramidal tract
F ascicu lu s ce re bro sp in a is ate ra is -
l l l C ro sse d py ramida t rac t l
( py ramidalis)
Fascicu lu s ce re be llo spin a is -
l D ire ct c e re be ll ar t ract
F asciculus an te ro late ralis sup e r G o w e rs ’
t rac t
ficialis
 G L OSSAR Y XX I

A a c e
o o f . a

v
o
w
m

z
w 2 2 i
m m
m m
m
u
x x ii G L OSSARY

B ra in .

B N A . . . TER MIN O L O Y G . OL D TER MIN OL OG Y .

R h o mbencep h alo n
Emin e n tia m e dia is l Emin e n tia te re s
Ala c in e re a Trig o n u m v agi
Ala ac ustica Trig o n u m acu sticu m
l
N u c e u s n e rvi abduce n t is l
N u c e us o f 6 th n e rv e
l
N u c e i n acu stic i . Au dito ry n u cle u s
l
F ascic ulus o ng itu din a is m e dialis l Po st e rio r lo n g it u din al bu n d e l
C o rp u s trap e o ide u m z C o rp us t rap e o ide s z
I n cisu ra ce re be li an te rio r l l
Se m i u n ar n o tch ( o f ce re be u m ) ll
I nc isu ra ce re be i p o ste rio r ll M arsup ial n o tch
z
S u lcu s h o ri o n talis ce re be l i l G re at h o riz o n tal fissu re
L o bulu s ce n tra li
s L o bus ce n tralis
F o l ium v e rm is F o liu m cacu minis
Tu be r v e rm is Tu be r v a v u ae l l
L o bu l u s q u adran g u l aris Q uadrate lo bu e l
B rac h iu m c o nj u n ct iv um c e re be ll i Su p e rio r ce re be llar p e du n cle
L o bu l u s se l
m i u n aris su p e rio r P o st e ro su e rio r lo bu le
p
-

L o bu l us se m ilu n aris in fe rio r P o ste ro in fe rio r lo bu le

-

Ce r ebrum
Pd l
e u n cu u s c e re bri C rus ce re bri
C ll i l
o c u u s su p e rio r A n te rio r co rp u s q u adrig e min u m
C ll i l
o in fe rio r
cu u s P o ste rio r co r u s q u adrig e minu m
p
A q u e du ct us c e re bri I te r e te rtio ad q u artum v e n tri
o n lu m , o r a u e d O f Sy lv iu s
q .

F o rame n in te rv e n tricu l are F o ram e n o f M o n ro

H yp o thalamu s Su bth alm ic re gio n
S u l cu s hy p o th alam icu s Su lcu s o f M o n ro
M assa in te rm e dia l
M idd e co mmissu re
Fascicu lus th alamo m am m illaris -
B u ndle o f V ic q d Az y r
’

P ars o p e rcu laris P ars basilaris

Th alamus O p tic th alam u s

P ll
a iu m x
C o rte ce re bri
G y ri tran sitiv i Ann e ctan t gy ri
F issu ra ce re bri l at e ral is F issu re o f Sylv iu s
G yru s te mp o ral is su p e rio r t
F irst e mp o ral gy rus
Gyru s te mp o ral is m e diu s Se co n d t e mp o ral gy rus
G yru s te mp o ral is in fe rio r Th ird te mp o ral gy rus
Su lcu s ce n t ra is ( K o lan di) l F issu re f R o lan do
o

S ulcu s t e mp o ralis su p e rio r Paralle l su lcu s

Su lcu s te m p o ralis m e diu s Se co n d te mp o ral su cus l

S ulcu s circularis L im itin g su cu s o f R e i l l
Su lcu s t e m p o ralis infe rio r O ccip ito te mpo ral su lc us
-

G yru s fusifo rm is O ccip ito te mp o ral c o n vo lu t io n

-

S u lcu s in te rp arie ta is l I n trap arie tal sulcus

l
Su cu s co rp o ris ca o si ll C allo sal su lcu s
l
S u c u s cing u li C allo so m argin al fissu re
-

F issu ra h ipp o camp i D e n tate fissu re

G y rus cing u l i C all o sal co n v o lu tio n
 GL OSSARY xx iii

B N A. . . TER M IN O L OG Y . OL D TER MIN O L OG Y .

St ria t e rm ina is l Tae n ia se m icircii laris

Trig o n u m c o llate rale Trig o n um v e n tricu li
H ipp o cam pus H ip p o campu s m aj o r
D ig itatio n e s h ippo cam p i P e s h ippo campi
F ascia de n tata h ippo cam pi G yru s de n tatus
C o lu mna fo rn icis An t e rio r p illar o f fo rn i x
Se p tu m p e llu cidum S e p tum lu cidu m
I n fe rio r co rn u D e sce n din g h o rn o f l at e ral v e n tricle
C o mm issu ra h ip p o cam p i L y ra
l
N u c e us le n tif o rmis L e n ticu lar n u cle u s
P ars fro n ta is cap su ae in te rn ae l l An te rio r lim b ( o f in e rnal capsu le )t
P ars o cc i italis cap su lae in te rnae
p Po ste rio r limb ( o f in te rnal ca su le )
p
R adiatio o ccip ito th alam ica -
O p tic radiatio n
R adiatio co rpo ris ca o si ll R adiatio n o f c o rp us callo su m
P
ars fro n talis F o rce ps min o r
P
ars o cci ita is
p l F o rce ps maj o r

M e mbran es o f B rain .

C iste rn a ce re be llo me dullaris -

t
C is e rn a mag n a
C iste rna in te rp e du n cularis C iste rn a basalis
G ran u latio n e s arachn o ide ale s Pacch io n ian bo die s

Te la c h o rio ide a v e n tricu li te rti I V e lum in te rpo situ m

Te la ch o rio ide a e n tricu li q uarti v Te la ch o ro ide a infe rio r

Cerebral N erv es .

N . o cu lo mo to riu s Th ird ner ev

N . t ro c h le aris F o u rth ne rv e
N . ge min us
tri F ifth n e rve
G ang l io n se milunare ( C asse ri) G asse rian g anglio n
N . n as o -
ciliaris N asal n e rv e
N ma illaris
. x Sup e rio r m ax il lary n e rv e
N m e n in g e us ( m e diu s)
. R e cu rre n t m e n in ge al n e rv e
N yg o maticu s
. z Te mp o ro malar n e rv e
-

R ami alv e o lare s su p e rio re s po s P o ste rio r su

p e rio r de n tal
te rio re s
R am i v
al e o lare s su pe rio re s me du M iddle su p e rio r
de n ta l
R am i al e o v lare s su
p e rio re s an An te rio r su p e rio r de n ta l
te rio re s

G an g lio n Sp h e no -

p alatinum M e ck e l s ’
gang l io n
N .
p alatin u s me diu s x
E te rn al p alatin e v
ne r e

N man dibularis
. I n fe rio r m a i lary xl n e rv e

N e rvu s spin o sus R e cu rre n t ne r e v

N alv e o laris in fe rio r
. I n fe rio r de n ta l
N . abdu ce n s x
S i th n e rv e
N . facialis Se v e n th n e rv e
N . in te rm e dius P ars in te rm e dia o f W risbe rg

N . acu s icu s t Eigh th o r au dit o ry n e rv e

 xx iv G L OSSARY

B N A. . . TER M I N O L OG Y . OL D TER MI N O L OG Y .

G anglio n su p e rius j guu lar g an g l io n o f

9 th n e rv e
N . re c u rre n s R e cu rre n t laryn g e al n e rv e
G ang l io n j u gu l are G ang lio n o f ro o t
O f v ag u s
G ang l io n n o do su m G ang l io n o f tru n k
Pl x e u s o eso
p hage u s an te rio r
P le x us gulae
Pl x phage u s p o st e rio
e u s o eso r

N e rv u s acce sso riu s Sp inal acce sso ry

R am us in te rn u s Acce sso ry p o rtio n o f S
p in a l
acce sso r y ner e v
R amu s e xt e rn u s Sp in a p o rtio l n

Sp i nal N erv es .

R am i p o ste rio re s P o st e rio r y divisio n s

p rimar

R am i an te rio re s An te rio r p rimary div isio n s

N . cu tan e u s co ll i Sup e rfi cial ce rvic al n e rv e
Nn . su p rac a l vi lc u a re s an te rio re s Su p raste rn al n e rve s
Nn . v icu lare s me dii
su p racla Supraclav icu lar n e rv e s
Nn . su raclav icu lare s p o st e rio re s
p Su p ra acro m ial n e rv e s
-

N . do rsalis scap u ae l N e rv e to th e rh o mbo ids

N n in te rc o sto brach iale s
.
-
I n te rco st o h u m e ral n e rv e
-

N th o racalis lo n g us
. N e rv e o f B e ll
N . do rsa is th o raco -
l L o ng subscap ular n e rv e
N c u tan e u s brach ii m e dia is
. l L e sse r in te rn al c u tan e o u s n e r e v
N cu tan e u s brachn ate ra is
. l l C u tan e o u s bran ch o f circu m fl e x
ner ev
F ascicu lus late ralis O u te r co rd ( o f p le x us )
F ascicu lus m e dialis I nn e r co rd
N . cu tan e u s an tibrach n late ra is l C u tan e o us bran ch o f m u scu lo -
cu ta

n e o us n e r e v
N . c u tan e u s an t ibrachn me dialis I n te rn al cu tan e o u s n e r e v
R am u s vo laris An te rio r branch
R amu s u ln aris P
o ste rio r bran c h

N . cu tan e u s an tibrach n do rsalis x

E te rn al cu tan eo u s bran c h o f m u s
c u lo sp iral
-

N . a x il l aris C ircu m fl e x n e rv e
N in te ro sse us v o aris
. l An te rio r in te ro sse o u s
R amu s palm aris N m e dian i . Palmar cu tan e o us bran ch o f the
m e dian n e rv e
N n dig itale s . v o lare s p ro p ru l
C o late ral p almar dig ital bran ch e s
o f m e dian n e rv e

R amus do rsalis m an us D o rsal c u tan e o u s bran ch o f u ln ar

v
ner e

R am us cu tan e us p maris
al P alm ar cu tan e o u s bran ch o f u ln ar

v
n er e

N . radialis M u scu lo -
Sp iral n e r e v
N . cu tan e u s brach n p o ste rio r I n te rn al cu tan e o u s bran ch . o f
m uscu lo -
sp ira l ner ev
N . cu tan e us an t ibrach u do rsalis x
E te rn a l cu tan e o us bran ch e s o f
I n u sculo -
Sp ira l ner ev
 GL OSSARY XXV

B N A . . . TER MI N O L OG Y . TER MIN OLOG Y

OL D

N . radialis ( co n t a
’
. M u scu lo sp iral n e rve ( co n tra)
-

R amu s su p e rficialis R adial n e rv e

in te ro sse u s do rsa is
N . l P o ste rio r in te ro sse o u s n e r e v
N n dig it ales do rsale s
. Do rsal digita l v
ne r es

l
i io hyp o gas tricu s-
I iol hyp g -
o astric n e r e v
R amus cu tan e us late ralis I liac bran ch o f ilio -
hyp o gastric
v ne r e

R amus cu tan e u s an te rio r H ypo gastric bran ch o f il io

hypo gastric n e rv e
N . ge n ito fe mo ralis
-
G e n ito cru ral n e rve
-

N . lu mbo ing u in a is -
l C ru ral bran ch o f g e n ito cru ral -

n e rv e

N . S
p e rmaticus e xt e rn us G e n ital bran ch o f ge n ito cru ral -

n e rve

N . cu tan e u s fe m o ris late ralis Ex te rn al c u t an e o us n e rv e

N . fe m o ralis An te rio r c ru ral n e rv e
sap h e nus L o n g saph e n o u s n e rv e
R amu s in frap ate llaris P ate llar branch o f lo ng sap h
e n o u s ne rv e

isch iadicus G re at sc iatic n e rv e

p e ro n ae us com m u nis Ex te rnal p o p lite al n e rve
R amu s anasto mo tic u s p e ro N e rvu s co mm unicans fibu laris
nae us

N .
p e ro nae u s s u p e rfic ialis M u scu lo -
cu tan e o us n e r e v
p e ro n ae u s p ro fu ndus
N . An te rio r tibial n e rv e
tibialis I n te rn al p o p lite al n e rv e
N . cu tan e u s su rae me dialis N e rvu s co m m u n ican s t ibialis
N . su ralis Sh o rt saph e n o u s n e rv e
p lan taris m e dia is l I n te rn al p lan tar
p lan taris late ralis x
E te rnal p lan tar
p u de ndu s Pu dic n e rv e

TH E H EART AN D BL OO D V ESSE L S .

H e a rt .

At riu m Au ricle
Au ricu la co rdis Au ricu lar ap p e n di x
I n cisu ra c o rdis N o tch at ap e o f x h e art
Trabe culae c arn e ae C o lum nae carn e ae
Tu be rcu lum in t e rv e no su m I n t e rv e n o ns tu be rc le o f L o w e r
Su lcus lo ngi tu dinalis an te rio r An te rio r in te rve n t ric u lar g ro o v e
l
Su cus co ro n ariu s Au ricu lo ve n tricu lar g ro o
-
ve
L imbus fo ssae o va is l l
Ann u u s o v alis
l
Valvu a v e nae cavae Eustachian v alv e
l l
V a vu a Sinus c o ro n aru Valve o f Th ebe siu s
xx vi GL OSSARY

Art erie s .

B N A . . . TER MIN OL OG Y . TER MIN O L OG Y

OL D .

Sin us ao rtae Sin u se s o f V alsalva

A p ro fu n da in gu ae
. l R an in e arte ry
A ma i aris e te rn a
. x ll x F acial arte ry
A alv e o laris in fe rio r
. I n fe rio r de n tal arte ry
R am u s me ninge u s acce sso riu s Sm al l m e n in g e al arte ry
A bu ccin ato ria
. B u ccal art e ry
l
A a v e o laris su p e rio r p o ste rio r
. P o ste rio r de ntal arte ry
Aa alv e o lare s sup e rio re s an te rio
. re s An te rio r su p e rio r de n tal arte rie s
R amus c aro tic o tym p an icu s -
Ty m pan ic bran ch o f in t caro tid .

A c h o rio ide a
. An te rio r ch o ro idal arte ry
A au ditiva in te rn a
. Au dito ry arte ry
R am i ad p o n te m Tran sv e rse arte rie s ( bran ch e s
B asi l ar arte r y)
A p e ricardiaco p h re n ica
.
-
Arte ria co m e s n e rv i ph re n ici
R ami in te rco sta e s ( A m amm aria l . An te rio r in te rco stal arte rie s
in te rn a)
Tru ncu s thyre o ce rv icalis -
Thy ro id a is x
t ran sv e rsa scap u lae Su p rascap u lar arte ry
in t e rco st a is su p re ma l Su p e rio r inte rco stal
t ran sve rsa co l i
0 l Tran sv e rsalis c o lli
tho racalis su pre m a Su p e rio r th o racic arte ry
th o raco ac ro m ia is -
l A c ro mio th o rac ic arte ry
-

th o racalis late ralis L o n g th o racic arte ry

circ um fl e x a scap u la e Do rsalis sca u la
p e
p ro fu n da brach ii Sup e rio r p ro fu n da
l
co lat e ralis radialis An te rio r bran ch o f su p e rio r p ro fun da
t
co lla e ralis u ln aris su p e rio r I n fe rio r p ro fu n da
l
A c o l ate ralis u lnaris infe rio r
. An asto mo tica m agn a
R am u s carp e us v o laris A n te rio r radial carpal
R am us carp eu s do rsalis P o st e rio r radial car al
p
Aa m e tacarp e ae do rsale s
. D o rsal in te ro sse o u s arte rie s
A . v
o laris indicis radia is l l
R adia is in dicis
Arcu s v o laris su p e rficialis Su p e rficial p almar arch
Arcus v o laris p ro fu n du s D e e p p almar arch
A in te ro sse a do rsalis
. P o ste rio r in te ro sseo u s arte ry

t
A in e ro sse a re cu rre n s
. P o ste rio r in e ro sse o u s t re cu rre n t

a rte r y
A in te ro sse a v o laris
. An te rio r in te ro sse o u s arte ry
R am u s c arp e u s do rsalis P o ste rio r u lnar car al
p
R am u s carp e u s v o laris An te rio r u ln ar carp al
Aa dig itale s v o lare s co mmu n e s
. Palm ar dig it al arte rie s

Aa dig itale s v o lare s p ro p riae

. C o llate ral digital arte rie s
A rte riae in te stin ale s I n te stinal bran ch e s o f su p . m e se n
te ric
A su p rare n alis m e dia
. M iddle c ap su lar arte r y
A hyp o gastrica
. I n te rn al i iac l y
arte r

A u mbi ica is
. l l t
O blite ra e d hyp o g astric
A p u de nda in te rna
. t
I n e rn al p u dic arte ry
A e p ig astrica in fe rio r
. D e e p e p igastric arte ry
xx v iii G L OSSARY

Ly mp hat ics .

E N A
. . . TER MIN O L OG Y . TER MIN O L OG Y
OL D .

C iste rn a c hyl i R e ce p tacu lu m chy li

TH E V I S C ERA .

Digest iv e A p p arat u s .

Arcu s g lo sso p alatin u s -

An te rio r p il ar o f fau ce s l
Arcu s ph ary n g o palatin u s -
Po ste rio r p illar o f fau ce s

G l lin gu alis an te rio r

. G l an d o f N u hn
D u ctus su bma illaris x W h arto n s duc t ’

Gl p aro tis acc e sso ria

. So cia p aro tidis
’
D u ctus p aro tide u s ( Ste n o n is ) Ste n so n s du ct
D e n te s p raem o lare s B icu spid e e th t
D e n s se ro tinu s W isdo m to o th
Pa illae v allata
p e C ircu m v allate pap i lae l
R e ce ssu s ph ary n g e u s L ate ral re ce ss o f p h aryn x
Te la su bmu co sa P h ary ng e al ap o n e u ro sis
P li a c e c ircu lare s l
Valvu ae co nn ive n te s
Gl in te stin ale s
. C ry p ts o f L ie be rk u h n
V alv u la co li I le o cae cal valv e
-

C o lumnae re ctale s l
C o u mn s o f M o rgag n i
Pli a t v l
c e ran s e rsa e s re ct i V alv e s o f H o u sto n
V l v l p i li
a u a s ra s V alve s o f H e ist e r
N d l i l y m p h ati i gg re gat i Py p atch e s
’
o u c a e er s

( P e y e ri)
I n te stin u m j ej u n u m Je j un u m
I n te stinu m ile um I le um
N o du li lym ph atici lie nale s l
M a p igh ian co rp u sc e s l
( M alp ighii)

R e sp ira t o ry A p p ara t us .

La r y nx
P mi
ro n e n tia laryn g e a Adam s ap p le
’

I n cisu ra thy re o ide a su p e rio r Su p e rio r thy ro id n o tch

M ary e p iglo t ticu s
.
-
Ary te n o e pig lo ttidean m uscle
-

M v o calis
. I n te rn al thy ro ary te n o id m u scle -

M tlI y re o e p iglo tticu s

.
-
Thy ro e pig o t tide an m u scle
-
l
x
Ap pe n di v e n tricu li lary n g is L aryn g e a l sac

Pl ica v o ca is l Tru e v o cal co rd

P lica v e n tricu laris F alse v o cal co rd
L ig ame n tum v e n t ricu lare Su pe rio r thyro ary te n o id ligam e n t -

L igame n tu m v o cale I n fe rio r thyro ary te n o id lig am e n t -

G l o ttis G l o t t is v e ra
R im a v e st ibu li G l o t tis spu ria
C artil ago thyre o ide a ,
Thy ro id cart il age
 G L OSSARY i
xx x

B N A
.TER MIN O L OG Y
. . . OLD TER MIN O L OG Y .

M e mbrana hy o thy re o ide a -

Thy ro hy o id m e m bran e
-

C artilag o co rn icu l ata ( San t o rin i) l

C arti ag e o f San to rin i
Tu be rcu lu m e p ig l o tticu m C u sh io n o f e p ig o ttis l
P in te rme mbranace a ( rim ae
ars G o ttis v o ca is
l l
glo ttidis)
arsP in te rcartilagin e a G lo ttis re spirato ria
l
g o ttidis)
C o n us e lasticu s ( m e m bran ae C rico -
t hy ro id me mbran e
e last icae lary n g e s)
G lan du la thyre o ide a Thy ro id glan d
G lo mus caro ticu m I n te rcaro tid g l an d o r bo dy
N o se
C o nch a n asalis su p re ma ( San to rin i) H igh e st tu rbinate bo n e
C o n ch a n asalis su p e rio r Su p e rio r u rbinate bo n et
C o n ch a n asalis m e dia M iddle tu rbin ate bo n e
C o n ch a n asa is in fe rio r l I nfe rio r tu rbin ate bo n e

U ro ge nit a l App a rat u s .

C o rp usc ula re n is M alp igh ian p co r u scle s

Paradidy m is O rgan o f G iraldés

Ap pe ndi t e st is x H ydatid o f M o rgag ni ( ma e ) l
D uctu s de fe re ns V as de fe re ns
Gl u re thrale s
. G ands o f L ittré
l
G lan du la bulbo u re th ralis ( C o wp e ri)-
C o w p e r s g lan d
’

F o llicu li o o pho ri ve sicu lo si G raafian fo llicle s

C u mulu s O o ph o ru s D iscu s p ro ig e ru s l
Tu ba u te rin a F allo p ian tu be
Ep o o p h o ro n P aro v a riu m

Ap pe n dice s v e sicu lo si H y datids o f M o rgagn i ( fe m a l e )

D uc tu s e po o ph o ri lo n gitu dinalis G artne r s duct
’

O rificiu m in te rn u m u te ri I n te rnal 0 5 ( o f u te rus)

O rificiu m e te rnu m x x
E te rn al o s
P ro ce ssu s v ag in alis C an al o f N uck
G andu la m agn a ve stibu i
l l Barth o in s g an d
’
l l
P erit o n e um .

B u rsa m e n talis
o L e sse r p e rito ne a l sac

F o rame n e p ip lo icu m F o rame n W in sl o w o f

L ig p h re n ico co licu m
.
-
C o sto co lic ligam e n t
-

x
E cavatio re cto u te rin a ( cav u m -
P o uch o f D o ug l as
D o ug asi) l
L ig gastro lie n ale
.
-
G astro s ple n ic o me n tu m

S E N SE OR G A N S .

Th e Ey e .

S c e ral Sc le ro t ic co at
L am in a e last ica an te rio r ( B o wm an i) B o w man s m e m bran e
’
x xx GL OS SARY

B N A
. . . TER MIN O L OG Y . OL D TER MIN O L OG Y .

L am in a p o ste rio D e sce me t m e mbran e

’
e last ica r (Des s

ce m e ti )
Spatia an g u i iridis l Space s o f F o n tan a
A n g u lu s iridis I rido co rn e al j u n c tio n
-

Zo n u la c iliaris Z o nu e o fl in n Z
Se p tu m o rbitale P alp e bral lig am e n t

F ascia bu lbi C ap su le o f Te n o n
C o m m issu ra palp e braru m la e ralis t x
E te rnal c an th us
C o mmissu ra p alp e braru m m e dialis I n te rnal can th u s
Tarsus su p e rio r Su p e rio r tarsal p ate l
Tarsus in fe rio r I n fe rio r tarsal p ate l
L ig p alpe bra e m e diale
. l I n te rn al tarsal igam e n t l
l
R ap h e p a p e bra is late ra is l l x
E te rn al tarsal ligam e n t
Tarsal glan ds M e ibo mian glands

Th e Ear .

C analis se m icirc ularis la te ra is l x

E te rnal se micircu ar can al l
D uctus re u n ie n s C an alis re u n ie n s
D uc tu s co ch le aris M e m bran o us co ch le a
R e ce ssu s sp h e ricu s Fo v e a h e m isph e rica
R e ce ssus e lip ticu sl F o ve a h e mi e llip tica -

Pa rie s j u g ularis F lo o r o f tymp an u m

Parie s laby rin t hica I nne r w all

F e n e stra v e stibu li F e n e stra o valis

F e ne stra co ch le ae F e n e stra ro tu nda
Pa rie s m asto ide a Po ste rio r wal l
An trum tym p an ic u m M asto id an t ru m
Parie s caro t ica An te rio r w all
P ro c e ssu s ate ralisl P ro c e ssu s bre v is ( o f malle us )
P ro ce ssus an t e rio r P ro ce ssu s gracilis
 MANUAL

P RAC TI CA L A N A TO M Y .

TH E S U P E R I O R EX T R E M I TY .

I nt ro duc io n t — Th e su p e r ior e x tr e mity co n sist s o f th e

brat /zinm o r arm , wh ich e x t e n d s fro m t h e shou ld e r to t h e
e lbow ; t h e a n tiorat /zin m or f or e ar m, wh ich lie s be tw e e n th e

e lbow an d th e wr ist ; th e wrist, wh ich co n n e ct s th e f or e ar m

w ith the ha n d ; an d th e man ti s or ha n d B e lo n g in g to it.

a lso are th e bo n e s o f the shou ld e r g ird le , the clavic le an d

sca p u la , by me a n s o f wh ich it is art icu lat e d w ith th e sk e le to n

o f th e tru n k ; it is a lso attach e d to t he tru n k by me a n s o f a

n u mbe r o f m u sc le s . The a n g le wh ich lie s be tw e e n the arm

an d t he u p p e r p art o f t he tru n k is th e a x illa or arm p it .

Surf ace An at o my . B e for e co m me n c in g t h e actua l dis

-

se ct io n o i an y r e g io n o f t he body t he stud e n t shou ld be

qu it e fa miliar w ith th e bo n e s o f t he r e g io n , fo r th e y are th e

la n d m ark s by me a n s o f wh ich the p o sit io n s o f t h e so ft p art s
wh ich lie be n e ath the sk in c an be d e fi n e d , both in t h e d e ad
an d in t h e livin g body . Th e out lin e s o f ma n y o f t h e bo n e s
an d t h e p r o j e ct in g p art s o f oth e r s can be se e n , fo r th e y cau se

p ro m in e n c e s o n t h e s ur fac.e M a n y p o rt io n s o f bo n e wh ich
ca n n o t be se e n can be felt qu it e e a sily wh e n th e fi n ge r is
p a ss e d light ly o v e r t h e p lac e s wh e r e th e y l ie s light p r e ssur e

m u st be u se d in oth e r p lac e s wh e r e th e bo n e s lie m o r e

d e e ply So me p art s o f the sk e le to n, how e ve r, c an be n e ith e r
.

se e n n o r fe lt u n t il t h e so ft p art s hav e be e n r e m ov e d .

V OL . I— l
 THE S U P ER I OR E X TRE M I TY
I t is e sse n t ia l th e r e for e that t he stud e n t shou ld train his
, ,

e y e s to se e all that c an be se e n an d his fi n g e r s to fe e l all ,

that can be fe lt an d he mu st r e m e mbe r that a n yth in g wh ich

,

h e can se e or fe e l in th e ca se o f th e body o f a n o th e r p e r so n
h e c an a lmo st e qua lly w e ll se e an d fe e l in t h e ca se o f h is
o wn body .

Th e bo n e s o f t he su p e r io r e x tr e mity are th e clavicle ( co llar

bo n e ) an d t h e scap u la ( shou ld e r blad e ) t h e nu meru s t h e , ,

radiu s an d th e u ln a eiglzt carp al bo n es fi ve met acar

,
pal ao n es , ,

an d fo u rteen p lz alanges ( F ig s 1 z .
, ,

Th e sca p u la an d c lav ic le tog e th e r for m th e shou ld e r gird le

, , ,

by me a n s o f wh ich th e arm is art icu lat e d w ith th e sk e le to n o f

t he tru n k .

Th e c lav ic le can be se e n an d fe lt at th e low e r p art o f th e

fro n t o f the n e ck I t e x t e n d s fro m th e shou ld e r to th e u p p e r
.

e n d o f th e st e r n u m ( br e a st bo n e ) wh ich lie s in th e m idd le ,

p art o f t h e f ro nt o f t h e ch e st B e low t h e j u n ct io n o f.

its in t e r me d iat e an d lat e ra l th ird s is a d e p r e ssio n o f th e

sur fac e t he aelto p ecto ral triangle The so ft p ro min e n c e to
’
-
.
,

t h e m e d ia l sid e o f t h e de lto p e ctora l tr ia n g le is cau se d by th e

-

p o rt io n o f t h e p e ctora l is m ajor mu sc le wh ich is attach e d to

t h e fro n t o f t h e m e d ial ha lf o f the c lav ic le an d t h e p ro min e n c e ,

o n th e lat e ra l sid e o f th e tr ia n g le is due to t h e a n t e r ior p art

o f t h e d e lto id m u sc le wh ich sp r in g s f ro m t h e fro n t o f th e

lat e ra l th ird o f th e c lav ic le I f t he fi n g e r is p r e sse d u p ward s

.

an d backward s at t h e u p p e r p art o f t h e lat e ra l m arg in o f

th e de lt o p e ctora l tr ia n g le a p ro min e n c e o f bo n e ca lle d t h e

-

co raco ia p ro cess o f t he sca p u la w ill be fe lt I t lie s u n d e r cov e r

’
.

o f th e m e d ia l e dg e o f th e d e lto id m u sc le an d is an imp orta n t ,

la n d mark ( F ig s 1 2 5 5 5 6.
, , , ,

B e yo n d an d be h in d t h e lat e ra l e n d o f t h e c lav ic le a m or e
o r le ss quadra n gu lar p lat e o f bo n e c an be fe lt I t is t h e .

acro mio n o f t h e sca p u la I t s me d ia l m arg in art icu lat e s w ith

.

t h e lat e ra l e n d o f th e c lav ic le at t h e acro mio clavicu lar j o in t ,

-
.

I t s lat e ra l m arg in lie s at t he tip of the slzo u laer an d it is t h e

’
,

u pp e r p o in t fr o m wh ich the le n gth o f the su p e r ior e x tr e mity

is me a sur e d .

O n th e p o st e r ior a sp e ct o f th e body ru n n in g m e d ia lly , ,

backward s an d slight ly dow n ward s fro m th e acro mio n is a ,

p ro m in e n t an d e a sily fe lt r idg e o f bo n e I t is t h e p o st e r ior .

bord e r or crest of tlz e spin e of the scap u la .

I n the arm th e r e is o n e bo n e the lzu merus I t exte nd s ,

.
 P LA TE I
C LA I L E
V C Sp i ne
C LA I L E
V C
Acro m i o n
e dia l a n gl e

Med a i l gl
an e
“
Ac ro m i o n

SC A ULAP

SC A ULA
P

I n t e rt u be r

l
.

c u la r su c u s
“

I i
n fe r o r a n g le

I i
n fe r o r a n gl e

H U ER U
M S H U M ERU g Su l cu s fo r rad a i
~

ne r e v

M e dial su p ra
La t e ra l e p ic o n d
y
e
p i co nd yl i dg
ar r e
il p
M ed a
la r r d ig e
pi dy l i dg
su ra

di l p i dy l
e co n ar r
Me a e co n e
e

M di l p i dy l
Ol e c ra n o n
e a e co n e

hl
Co ro n o id p ro c e s s
T ro c ea

C id p
o ro n o ro c e ss

Vl o ar bo ide r'

~
O bli q ue li ne

Vl o ar s urfac e
R A IU D S U LN A
U LNA R A IU D S

D o rsa lb o rde r
D o rsa lb o rde r
.I n t e ro sse o u s c re s t s I n t e ro sse o u s c re s ts

Vl o ar bo rde r
O bli q ue li ne Vl o ar su rfac e

Vl o ar bo rde r
H e a d\

St yl i
o d p ro c e ss
A St yl i d p
o ro c es s St yl id
o

CAR U P S St yl i d po ro c e ss

M e ta c a rp a

M e ta c a rp a l
I ST P H ALA N X

2 N l) P H ALA N X
I St p ha l x
an

FI G . L — B o ne s o f U p per L mb i . FI G . 2 .
— Bo ne s o f U pper L m b i .
‘

P o ste ri o r v i e w .

A n te r o i r V e iw .
 P LA TE II

R dia us

St yl id p
o ro
ce ss o f l
u na

Di l st a ep
ii
p hy
sis o f rad u s

L u n at u m

P i sI fo rm
St y l id p
o ro
c e ss o f radi u s

Na vi l
c u ar

Tr iq u e t ru m
Mu l gl
tan u u m
In a u s j
H am a t u m

C ap i tat u m

FI G .
3 .
— An te ro p o ste r o
-
i r R dia o grap h o f th e Wri st o f a p e rso n o f
1 9 ye ars .

N o te (I ) i li
Th e e p p hyse al n e s o f th e rad u s an d u n a i l .

(2 ) i l l
Th e d ffe re n ce in e ve o f th e sty o id pro ce ss l o f t he l
u na as co n
t raste d w i th th e st yl o i d p ro c e ss o f th e radi u s .

Th e ve rl ap sh ado w s o f adj ac e n t bo n e s
(3) o o f th e .
4 TH E S U P ER I O R E X TRE M I TY

j u st lat e ra l t o t h e sty lo id p roc e ss an d slight ly p r o x im a l t o

it th e r e is a rou n d e d p ie c e o f bo n e ca lle d th e bead of tbe u ln a .

I t is be st se e n an d fe lt wh e n t h e p a lm o f t h e ha n d is tur n e d
dow n ward s .

The rad iu s is m o r e de e p ly bur ie d tha n th e u ln a bu t th e r e ,

is n o d ifficu lty in lo cat in g it s p r o x im a l an d d ista l e n d s Th e .

p r o x im a l e n d ca lle d t h e li co d of ta
, e radiu s lie s a sh o rt d ista n c e
,

d ista l t o the lat e ra l e p ic o n dy le o f the hu me ru s I ts p o sit io n .

is m ark e d o n t h e back o f t h e fo r e ar m by a d imp le o f t h e

sk in . I f a fi n g e r is p lac e d in t h e d imp le t he h e ad o f t h e
rad iu s can be fe lt rotat in g wh e n the p a lm o f t he ha n d is
tur n e d a lt e r n at e ly u p ward s an d d o w n ward s .

Th e d ista l e n d o f t h e rad iu s is t h e quadra n gu lar m a ss o f

bo n e wh ich c an be fe lt at t h e lat e ra l sid e an d t he back o f th e
wr ist I t lie s lat e ra l to th e h e ad o f the u ln a an d it t e rmin at e s
.

o n th e lat e ra l Sid e in a p o in t e d p roc e ss t h e sty lo id p ro cess of

,

The eigbt p bo nes o f the wrist lie in th e in t e rva l

car al

be tw e e n th e sty lo id p roc e sse s o f t h e rad iu s an d u ln a be y o n d ,

wh ich th e y e x t e n d d ista lly fo r a short d ista n c e ( F ig s 3 6 7 .

, ,

The fi ve metacarp al bo n es o f tbc band o n e fo r e ach d ig it , ,

e x t e n d fro m t h e car p u s to t h e p ha la n g e s .

Th e y are n u mbe r e d o n e to fiv e fr o m th e thu mb to the

litt le fi n g e r sid e an d all are e a sily fe lt at th e back o f t he
,

ha n d wh e r e the h e ad s o r d ista l e n d s for m t he p ro min e n c e s

,

k n o w n as th e k n uckle s “
.
!

Th e fo u rteen p /zalanges are in t he fr e e p art s o f th e d ig it s :

t wo in t he thu mb first o r p ro x im a l an d seco n d or d ista l
'

t hr e e in e ach fi n g e r p r o xima l o r first m idd le o r seco nd an d

, , ,

d ista l or tlzird The se co n d p ha la nx o f th e thu m b an d th e

.

th ird p ha la n g e s o f the fi n g e r s are fre qu e n t ly ca lle d t e r min a l

p ha la n ge s .

Th e structur e s co n n e ct e d an d a sso c iat e d w ith all th e

bo n e s m e n t io n e d h av e t o be e x a min e d by th e d isse ct o r o f
th e su p e r io r e x tr e m ity an d wh ilst wa it in g t o c o m m e n c e t h e
,

disse ct io n t h e d isse ctor sh o u ld v e r ify all th e p o in t s a bo v e

m e n t io n e d u p o n h is o wn body w ith th e aid o f h is fi n g e r s an d
a lo o k in g gla ss
-
.

Sin c e m a n y stud e n t s co m me n c e d isse ct in g be fo r e th e y

hav e att e n d e d e ith e r le cture s o r d e m o n strat io n s o n An at o my ,

th e y are u n acqua in t e d w ith t e r m s wh ich m u st be u se d in th e

in struct io n s g iv e n r e gard in g th e d isse ct io n s wh ich are to be
 P E C TORA L RE G I O N 5

mad e F ortu n at e ly m o st o f th e t e r ms u se d , lik e tho se a lr e ady

.

me n t io n e d, r e fe r t o th in g s wh ich can be se e n an d fe lt ; th e y,
th e r e fo r e are e a sily u n d e r st o o d Th e re are how e v e r c e rta in
, .
, ,

t e r ms u se d wh e n bra n ch e s o f Sp in a l n e rv e s are u n d e r c o n
,

sid e rat io n wh ich are n o t se lf e x p la n atory an d it is n e c e ssary

,
-

, ,

th e re for e that the stud e n t shou ld p o sse ss a k n ow le dg e o f the

,

te rms u se d in co n n e ct io n w ith sp in a l n e rve s an d th e ir bra n ch e s

'

be for e th e actu al w o rk o f d isse ct io n is c o mm e n c e d Th e .

fo llo w in g p o in t s shou ld be n ot e d : ( 1 ) Ev e ry sp in a l n e rv e is
attach e d to th e sp in a l m e du lla ( sp in a l c o rd ) by two root s an ,

a n terio r ro o t an d a p o sterio r ro o t Th e a n t e r ior ro o t is n o n .

n lio n ated an d t he p o st e r ior r o ot is

a
g g a
g gn lio n ated
( )
2 A s t h e <
r
é
f
.

root s are le av in g th e v e rt e bra l ca n a l thr o ugh an in t e rv e rt e bra l ,

fo ra me n th e y u n it e to fo r m a tru n k
, (3) I m m e d iat e ly a f t e r .

its e x it fro m t h e in t e rv e rt e bra l fo ra me n th e tru n k d iv id e s in to

a p o sterio r ramus an d an an terio r ramus o f wh ich the a n t e rior
ra m u s is w ith fe w e x c e p t io n s m uch the larg e r ( 4 ) Each
, , .

p o st e r ior ra m u s d iv id e s in t o a medial branc/z an d a lateral

branc/z (5 ). Each a n t e r io r ra mu s d iv id e s in t o a latera l bran ca

an d an an terio r brancti ( F ig .

Ev e ry a n t e r ior r o o t c o n sist s o f n e rve fi br e s wh ich Sp rin g

fr o m n e rv e c e lls in t he sp in a l me du lla an d p a ss to th e m u sc le
fi bre s o f variou s mu sc le s Th e y carry motor imp u lse s t o the .

mu sc le s Each p o st e rio r root co n sist s o f n e rv e fi bre s p a ssin g

.

to an d fro m the n e rv e c e lls o f the ga n glio n o f the p o st e r ior

ro o t The p o st e r io r root fi br e s carry se n so ry imp u lse s such
.
,

as c o ld h e at a in e t c T h e se n so ry im p u lse s p a ss through
p , , ,
.

th e c e lls o f th e ga n g lio n o f th e p o st e r io r root an d th e n o n ward s

to the sp in a l m e dulla .

The tru n k o f e v e ry Sp in a l n e rv e th e r e fo r e co n ta in s both , ,

mo to r
'

o r e fi erent an d sen so r
y o r a fi eren t n erve fibres ,
an d t h e

p o st e r io r an d a n t e r ior ra m i in to wh ich it d iv id e s a ls o co n ta in

both se t s o f fi br e s Th e bra n ch e s o f th e ra mi may co n ta in

.

e ith e r both se t s o f fi br e s o r o n ly o n e o r th e oth e r se t .

Ev e n tua lly h o we v e r th e p e rip h e ra l p art s o f the fi br e s c o n

, ,

v e yin
g im p u lse s f r o m an d tho s e co n v e y in g im p u lse s t o t h e

sp in a l me du lla se p arat e fro m o n e a n oth e r The fi br e s wh ich .

co n v e y imp u lse s fro m the Sp in al me du lla be co m e th e mo t o r

n e rv e s wh ich e n d in t h e mu sc le fi br e s wh ilst t h e fi br e s w h ich ,

1
Th is div isio n is no w ay s o bvi o us and in ce rtain
t al ,
situ at io n s the
lat e ra l an d an te rio r bran ch e s are calle d re sp e ctiv e ly , , po ste ri o r an d
an t e rio r bran ch e s .

1— 16
 TH E S U P ER I O R E X TRE M I TY
co n v e y se n so ry im p u lse s o n ly are ory n e rv e fi br e s
th e se n s .

The se n so ry n e rv e fi br e s wh ich c o n v e y se n so ry imp u lse s fr o m

th e sk in a re t e r m e d cu ta n eo u s n erves .

Th e d isse ctor o f th e upp e r ex tr e mity m u st be g in work o n

Me d i al c u t an e o u s b ran c h o f me di l di a ii
v s o n o f p o st e r o i r ramus

L ate ral c u tan e o us b ra n c h o f me di l d i

a ii
v s o n o f p o st e r o i r ram u s Me d ld
ia im
i v si o n o f
p o st e ri o r ra us

L ate ral d ii i
iv s o n O f
n to
i
p o st e r o r
t e rm i nal m u
P o st e r o i g gi
r an l o n at e d
ro o t
c u lu s o f
i
P o st e r o r ramu s me d u lla

te n o r g y lum n
A
re co
n t e ri o r ra m us

M u sc u la r b ran c h es

A i
nt e r o r ro o t

l [ R e c urre n t b ran c h
L ate ral d
an t e ri o r ra
iim
iv s o n o
us
f 1
y
S m p at h e ti c g gl
an io n

A n t e ri o r di ii
v s o n o f i
an t e r o r ram u s

M us cu la r b ra n c h es

Me
dm
d i al c u t an e o u s
sr
o n o f
b ran c
an t e ri o r ram us
h o f an t e r o r i
I
L at e ral c ut ane o b us ra nc h o f ant e r o r i d ii iv s o n o f an te r o i r ramu s

FIG .
4 .
— Di g
a ram o f a na N er e Spi l
N o t e t a t th e m e d a d s v . h i l i vi i o ns o f
i
t he p o ste r o r ram u s is re p re se n te d as d s tr bu te d t o sk n st t h e i i i wh il ,l ate ra l
ivi i i
d s o n t e rm n ate s at a de e p e r e e in m usc e I n so m e s t u at o lvl l . i i n s t he

re ve rse co n di t i o n o c c u rs , an d th e me d a i l an d l t l div i i
a e ra s o ns o f all

p o st e r o i r ra mi su p p ly m l
u sc e s .

th e urth day a ft e r t he su bj e ct has be e n plac e d in t he

fo
d isse ct in g ro o m H e w ill fin d the body ly in g u p o n its back
-
. .

Th e thora x w ill be ra ise d to a co n v e n ie n t h e ight by m e a n s o f

blo ck s an d a lo n g bo ard w ill be p lac e d u n d e r the sh o u ld e r s
,

fer t he p ur p o se o f su pp ort in g th e ar ms wh e n th e y are a bduct e d

fro m the sid e s .
 P E C TORA L RE G I O N 7

U ntil the disse ctio n o f the axilla is co mple te d the disse cto rs o f the arm
an d o f th e h e ad an d n e ck w ill fin d it adv an tag e o u s t o arran g e t o w o rk
at diffe re n t h o u rs Th e disse cto r o f the h e ad an d n e ck at th is stag e is
.
, ,

e n g ag e d o n t h e p o st e rio r t rian g le o f th e n e ck an d t h e disse ctio n o f the

,

triang le can n o t be w e ll do n e u n le ss the arm is p lac e d c lo se t o the Side

an d the sh o u lde r de p re sse d F o r t he disse ct io n o f the ax illa th e arm Sh o u ld
.

be stre tch e d o u t at righ t an g le s t o the th o rax A co m pro m ise be t w e e n

.

t h e se t wo p o sit io n s alw ay s re su lts in disco m fo rt t o bo th disse c to rs .

F iv e day s are a llo w e d fo r th e e x a min at io n o f the a xilla

an d t he mu sc le s wh ich p a ss t o t h e u p p e r e x tr e mity fro m t h e

a n t e rior p ort io n o f the thorac ic r e g io n o f th e body The .

fo llow in g ta ble w ill be fou n d u se fu l in r e gu lat in g th e a mou n t

o f w o rk wh ich sh o u ld be carr ie d o u t o n e ach day

First Day .
— m y ( b) re fl e ctio n o f the skin ( c) cu tan e
( a ) Su rface anato
l
o us v e sse s an d n e rv e s o f th e an t e rio r an d late ral asp e ct s o f the th o ra ; x
x
( d) e am in atio n o f the fascia o f the p ecto ralis m aj o r an d the a illary fasc ia x
( c) the c le an ing o f the p e c to ralis m aj o r ( f ) the re fl e ctio n o f the p e ct o ralis
m aj o r .

S eco n d Day . x
—a The e am in atio n o f the c o sto co raco id m e m bran e an d
( ) -

the stru ctu re s p ie rcin g it ( b) the re m o v al o f the co sto co raco id m e m bran e

-

x
an d th e e amin at io n o f th e st ru ctu re s p o ste rio r to it .

T h irdD y a .
—
( a ) The cle an in g o f the p e cto ralis m ino r ( b) the c le an in g
x
o f th e c o n t e n ts o f th e a illa be lo w t h e p ec to ralis m in o r .

F o u rt h Day — ( a ) The re fle ctio n o f the p e cto ralis m in o r ; ( b) the co m

.

p le t io n o f t h e c le an in g o f th e co n t e n t s o f th e a i laxl
( c) the c le an in g o f the
se rratu s an te rio r ; ( d) t h e c le an in g o f th e po ste rio r w all o f t he a i a (e) x ll
th e re fl e ctio n o f t he su bc av iu s ; l x
( f ) the e amin atio n o f the st e rn o
c lav icu lar articu latio n an d t he disarticu latio n o f the c lav icle at t he ste rn o

c lav icu lar j o in t .

x
Fift h Day — ( a ) The brach ial p le u s an d a g e n e ral re v ie w o f the a illa
. x
an d its co n te n ts .

B e for e co mme n c in g t he d isse ct io n o f the a xillary r e g io n

draw your fi n g e r alo n g the clavicle fro m its st e rn a l to its ‘

acro mia l e n d N ot e that in the m e d ia l two th ird s o f its

.
-

le n gth th e bo n e curv e s fo rward s to g iv e r o o m fo r th e p a ssag e

o f v e sse ls an d n e rv e s fro m t h e n e ck t o the a x illa Th e lat e ra l .

th ird is curv e d backward s P lac e your fi n g e r in the de lto

.

p e ct o ra l tr ia n g le b e low t h e ju n ct io n o f t h e in t e r m e d iat e an d

lat e ra l th ird s o f t he c lav ic le an d n o t e that t he gr e at p e ctora l

,

mu scle lie s to it s m e d ia l Sid e an d th e d e lto id mu sc le to its

lat e ra l sid e ; both m u sc le s sp r in g fro m t h e a n t e r io r a sp e ct
o f t h e c lav ic le Pu sh y o ur fi n g e r u ward s an d
( se e F ig
‘

p
backward s in t h e tr ia n g le u n d e r t h e m e d ia l bord e r o f t h e
d e lt o id u n t il the coraco id p roc e ss is d ist in ct ly fe lt N e x t .

e x a min e t h e art icu lat io n s o f th e c lav ic le L itt le o r n o .

p ro min e n c e is for m e d by th e lat e ra l e x tr e mity o f th e bo n e

its su p e r ior sur fac e lie s in the sa m e p la n e as th e su p e r ior
I— lc
8 TH E S U P ER I OR E X TRE M I TY
s urfac e o acro mio n o f t h e sca p u la Wh e n t he u p p e r
f th e .

lim b is m ov e d h o w e v e r th e j o in t c an e a sily be d e t e ct e d
, ,
.

I n stro n g c o n tra st t o t he in c o n sp icu o u s acr o m io c lav icu lar -

j o in t is t h e st e r n o c lav icu lar j o in t wh e r e t he me d ia l e n d o f t h e

-

c lav ic le can be fe lt as a mark e d p r o j e ct io n a lt hough it is ,

m a sk e d to the e ye by t h e st e r n a l p art o f th e st e r n o c le ido

, ,
-

m a st o id mu sc le wh ich cau se s the r idg e lik e p ro m in e n c e at th e -

sid e o f t h e n e ck as it e x t e n d s fro m th e st e r n u m an d c lav ic le t o

t h e sku ll be h in d th e e ar P lac e th e in d e x fi n g e r in the j ugu lar

.

n o tclt o n th e u p p e r bord e r o f th e m a n u br iu m st e r n i be tw e e n ,

t h e c lav ic le s an d carry it d o w n ward s a lo n g th e m idd le o f

, ,

t h e st e r n u m in t h e in t e rva l be tw e e n t h e attach m e n t s o f t h e
,

gr e at p e ctora l m u sc le s Th e p ort io n o f the st e r n u m u n.

cov e r e d by th e t wo gr e at e r p e ctoral m u sc le s is n arrow a bov e ,

bu t it w id e n s o u t be low an d as t he fi n g e r p a sse s a lo n g it a ,

p r o m in e n t r idg e w ill be fe lt T h e r idg e m ark s t he j u n ct io n

.

o f t h e m a n u br iu m st e r n i w ith t h e bo dy o f t h e st e r n u m an d ,

a lso th e le v e l at wh ich t he co sta l cart ilag e s o f the se c o n d

r ibs j o in th e st e r n u m I t is e a sily felt an d can o ft e n be se e n
. .

I t is th e r e for e an e x c e lle n t la n d m ark in d icat in g th e p o sit io n s

, , ,

o f t h e se c o n d p a ir o f r ibs f ro m wh ich t he cou n t in g o f t h e oth e r

,

r ibs Sh o u ld a lway s co m me n c e At th e low e r e n d o f th e body o f .

t h e st e r n u m t h e fi n g e r as it is carr ie d dow n ward s w ill sin k

, , ,

sudd e n ly in to a d e p r e ssio n be tw e e n th e cart ilag e s o f t he ,

se v e n th p a ir o f r ibs an d r e st aga in st t h e x ip h o id p r o c e ss o f
,

t h e st e r n u m Th e d e p r e ssio n is t e r m e d t h e inf rastern alf o ssa

.
,

or p it o f th e sto m ach Th e c o sta l arch e s be low th e first.

, ,

are e a sily r e cog n ise d bu t t h e fir st rib lie s d e e p ly u n d e r th e

,

clavicle an d can be fe lt o n ly in fr o n t at its ju n ct io n w ith

'

, ,

th e m a n u br iu m st e r n i The arm shou ld n o w be a bduct e d

.

a carr ie d lat e ra lly fro m t h e tru n k ) wh e n t he h o llow o f

( i . .
,

th e a x illa an d th e two rou n d e d fo ld s wh ich bou n d it ,

in fro n t an d be h in d w ill be brought in to v ie w , Th e .

a n t e r ior fo ld o f the a x illa is for me d by th e low e r bord e r o f

t h e p e ct o ra lis m aj or an d t o a sm a ll e x t e n t a lso by th e low e r
,

bo rd e r o f th e p e ctora lis min or The p o st e r ior fo ld wh ich is .

,

for me d by th e lat issimu s d o r si as it w in d s rou n d th e t e r e s

major mu sc le is carr ie d dow n ward s to a low e r le v e l tha n the
,

a n t e r io r fo ld Th is as w ill be se e n lat e r is an imp orta n t

.
, ,

p o in t in co n n e ct io n w ith the a n at o m y o f th e a x illa I f t h e .

fi n g e r is p u sh e d u p ward s in to the a x illa the glo bu lar h e ad o f

th e hu m e ru s w ill be fe lt wh e n th e arm is rotat e d , O n e oth e r .
 P E C TOR A L RE G I O N 9

p o in t d e m a n d s t h e att e n t io n o f t h e stud e n t be for e t h e dis

se ct io n is c o mm e n c e d an d that is t h e p o sit io n o f the n ipp le

,
.

As a ru le it lie s su p e rfic ia l to t h e in t e r sp ac e be tw e e n th e
fourth an d fi fth r ibs an d it is situat e d rath e r m or e tha n four
,

in ch e s fro m t he me d ia n lin e .

Th e stud e n t shou ld e x a min e th e se var iou s la n d m ark s n o t ,

o n ly u p o n th e d e a d bo dy bu t a lso u p o n h imse lf an d h is
fr ie n d s u n t il h e is p e rfe ct ly fa m iliar w ith th e m both by touch
, ,

an d Sight an d c an at o n c e p u t h is fi n g e r o n an y g iv e n p o in t
, ,

what e v e r th e p o sit io n o f th e limb may be .

Dis s e c tio n — R e fl e ct io n o f t he Sk in — I n cisio n s z— ( I ) Alo n g .

t h e m iddle lin e o f t h e bo dy f ro m t h e u p p e m arg in o f t h e m an u r

t
briu m s e rn i t o t h e tip o f t h e x ip h o id p ro ce ss ( 2 ) U p ards . w
t
an d la e rally f ro m t h e t ip o f t h e x ip h o id p ro ce ss t o t h e n ip p le .

At th e n ip p le th e in c isio n m u s bifu rca e , t o e n circle t h e dark t t

p a tc h o f s k in a ro u n d t h e n ipp le h ic h is calle d t h e are o la, w
t t t
h e n it m u s be co n in u e d alo n g t h e an e rio r fo ld o f th e ax illa t
t o t h e arm As so o n as it re ac h e s t h e arm it m u s be c arrie d
. t
t
do w n w ards f o r abo u 6 3 mm ( t wo in c h e s an d a h alf ) , an d h e n . t
t v
ra n s e rse ly t o t h e la e ral bo rde r o f t h e arm t (3 ) F ro m t h e t ip .

o f t h e x ip h o id p ro ce ss t ran s e rse ly a c ro ss t h e f ro n v
an d side o f t
t
t h e c h e s t o t h e p lan e o f t h e p o s e rio r f o ld o f t h e ax illa (F ig t .

To m ak e a c le an in cisio n in t h e sk in p lac e t h e p o in o f t h e t
scalp e l o n o n e e n d o f t h e lin e o f in cisio n , an d, h o ldin g t h e sc alp e l
at righ t
an g le s t o t h e su rf ace t o be in cise d, f o rce t h e p o in t
t t
h ro u gh th e Sk in ill it e n e rs t h e so f su p e rfi cial fas cia h ic h t t w
lie s be n e a h t
Th e n in clin e t h e blade t o an an g le o f 4 5 t o
.
°

t h e su rfa ce o f th e sk in , an d, p re ssin g fi rm ly o n t h e back o f t h e

blade wt
i h t h e f o re fi n g e r, c arry it s e adily t o t h e o pp o si e e n d t t
o f t h e lin e o f in cisio n , bu t as t h e e n d o f t h e lin e is app ro a c h e d
brin g t h e blade ag ain t o a righ an g le w i h t h e su rf ace , an d so t t
wt i h dra w it f ro m t h e in cisio n .

t t
To re fl e c t h e S k in ak e h o ld o f o n e o f t h e an g le s o f th e fl ap
r n ark e d o u t by t h e in cisio n s i h t h e f o rce p s ; in t h e c ase o f wt
th e u pp e r fl ap ( 1 , F ig w
h ic h sh o u ld be de al i h fi rs , t h e
. t wt t
su p e rio r m e dial an g le o n t h e righ side an d t h e in fe rio r m e dial t
an g le o n t h e le f S ide , an d t wt
i h t h e e dg e o f t h e scalp e l de ac h it t
f ro m th e so f f at be n e a h t t .

As so o n as t h e an g le se le c e d is su ffi cie n ly de ac h e d disca d t t t r

th e f o rce p s , an d, h o ldin g t h e de ac h e d an g le o f sk in be een t tw
t
th e h u m b an d f o re fi n g e r o f t h e le f h an d, k e e p it e n se an d t t
draw th e e dg e o f th e s calp e l acro ss t h e sk in at its j u n c io n i h t wt
t h e f at f ro m o n e e dg e o f th e fl ap t o th e o h e r, al ay s k e e p in g t w
t h e e dg e o f t h e k n ife a g ain s t h e sk in B e c are fu l n o t t o ak e t . t
an y f at a ay w
i h t h e sk in wt Co n in u e t h e re fl e c io n u n il th e. t t t
t
la e ral bo rde r o f t h e sh o u lde r re g io n is re ac h e d Le a e t h e . v
fl ap h an g in g alo n g t h a bo rde r an d u rn t o fl ap 2 , F ig 5 t Co m t . .

m e n ce at t h e m e dial an g le , p ro ce e d as i h fl ap I , an d c o n wt
t t t
in n e t h e re fl e c io n u n il t h e p o s e rio r f o ld o f t h e ax illa is re ac h e d t .

As t h e S k in fl ap s are re fl e c e d o ards t h e arm an d t h e side t t w

o f th e ch e s t
t h e sm all p a c h aro u n d th e n ipp le m u s be le f
‘

t t t
t
u n o u ch e d .
 THE SUPER I O R EXTRE M I TY
As t h at re fl e ctio n p ro ce e ds n o t t h at
e th e co n n e ct io n be tw een

th e su p e rfi cral f as cia an d t h e sk in is t
s ro n ge r in so m e p laces
t h an in o th e rs . I n th e fe m ale de fi n i te fi bro u s strands w ill be

Ju n c t i o n o f man u br u m i
St e rn a l end o f l vi l
c a c e
W i t h bo d y O f s t e rn u m

Acro m il
a e nd o f c a l vi l c e

H e ad o f h u me ru s

N pp i l e

L o we r e n d o f bo d y o f st e rn u m

L a t e ra l pi e co nd yl e

Me di l p i
a e co n dy l e

An t . su p . i
sp n e o f iliu n

G re a t e r t ro ch an t e r

St yl id p
o ro c e ss o f ra d u si
y l id p
St o ro c e ss o f ul

M ed a il yl f f m
co nd e o e ur

L at e ra l dy l
co n f f m e o e ur
P t ll a e a

L at e ra l dyl f t i bi
co n
e ad o
e o
f fibu l
a
H a

i l ll l
M e d a ma eo us

l
L at e ra m alle o lu L at e ra l m ll l
a eo us

FIG .
5 ,
— Su rface vie w sh o w i n g I ii
n c s o n s an d Bo n y P o i n ts .
1 2 TH E SUPER I OR EXTRE M I TY
be e n t e d the n e rve s an d v e sse ls wh ich p a ss through
no it t o
th e sk in m u st be so ught fo r Th e y are .

N e rv i C u tan e i .

l
Su prac lav icu ar, fro m th e c e rv ical p e u s l x .

An te rio r c u tan e o u s ] fro m th e an te rio r ( in te rco sta ) rami o f th e th o racic l

l
L ate ra cu tan e o u s n e rv e s .

A rte riae C u tan e ae .

C u tan e o u s t w igs fro m th e bran ch e s o f th e th o raco ac ro m ial arte ry -

F ro m the c av icu ar bran ch l l .

F ro m the ac ro m ia bran ch l .

F ro m the de lto id branch .

P e rfo ratin g bran c h e s o f t h e in te rna m a mm ary arte ry l .

B ran ch e s fo rm t h e ate ral th o racic arte ry l

Bran ch e s fo rm t he tran sv e rse sc ap u ar arte ry l .

t
D is s e c t i o n — Cu t h ro u gh t h e su p e rfi c ial f ascia t o t h e de e p
.

f as cia alo n g t h e la e al m arg in o f t h e s e rn u m t r Th e le e l o f t . v

t h e de e p f ascia w ill be re co g n ise d by t h e in cre ase d re sis an ce t
o ffe re d t o t h e k n if e , an d by its blu is h wh i e c o lo u r h e n it is -
t w
e x p o se d As re g ards t h e diff e re n ce o f re sis an ce t h e disse c o r
. t t
t t
mu s e du ca e h is fi n g e rs t o re co g n ise t h e diffe re n “
fe e l o f th e
!
t
v ario u s s ru c u re s t t
As t h e e dg e o f t h e k n ife o u c h e s h e m ,
. t t
su p e rfi c ial f ascia, de e p f asc ia, n e r e s, e sse ls, m u scle s , t h e y all v v
c au se a diffe re n se n sa io n , t t
e co g n isable by t h e e du ca e d o u c h , r t t
w h ic h can o n ly be ac q u ire d by a t e n io n an d p rac ice t t t .

v
As so o n as t h e le e l o f t h e de e p f ascia is re ach e d raise t h e
cu t m arg in o f t h e su p e rfi cial f ascia w i h t h e f o rc e p s o r fi n g e rs t
an d, wt
i h t h e e dg e o f t h e scalp e l, se e r t h e s ran ds h ich a t ac h v t w t
t h e de e p su rf ace o f t h e su p e rfi cial f as cia t o t h e de e p f as cia ,
cu tt t
in g ag ain s th e de e p f asc ia an d re m o in g t h e h o le o f th e v w
su p e rfi cial f ascia As t h e se p ara io n p ro ce e ds p u ll t h e de ac h e d
. t t
su p e rfi c ial f as cia a w ay f ro m t h e s e rn u m , an d as so o n a s t h e t
t t
an e rio r e n ds o f t h e in e rc o s al sp ace s are re ac h e d lo o k f o r t h e t
an te rio r cu tan eo us n e rv es an d t h e p er f o rati ng bran che s of the
i n tern al mamm ary artery , h ic h p ie rce t h e de e p fascia n e ar t h e w
m arg in o f t h e s e rn u m t
I f t h e ar e rie s are w e ll in j e c e d o n e
. t t
s h o u ld be f o u n d in e ac h o f t h e u pp e r six in e rco s al sp ace s It t t .

is n o t p ro bable h a a n e e t t
ill be f o u n d in t h e fi rs sp ace , bu t rv w t
o n e sh o u ld be fo u n d in e a c h o f t h e o h e r fi v e sp a ce s Th e t .

art e rie s w
ill be re co g n ise d by t h e re d in j e c io n h ic h h e y t w t
t
co n ain ; e ac h is a cco m p an ie d by a sm all e in Th e n e r e s v . v
a re w t t
h i ish h re ads, n o t u n lik e h in h i e h re ad Th e y are t w t t .

t
m u c h fi rm e r t o th e o u c h , an d m u c h s ro n g e r h an t h e blo o d t t
v e sse ls .

t v
Trac e bo h th e e sse ls an d n e r e s as far la e rally as p o ssible v t .

t
W h e n th e an e rio r cu an e o u s n e r e s an d t h e a cc o mp an y in g t v
v e sse ls h aV e be e n se cu re d lo o k f o r t h e sup raclavi cu lar n erves ;
t t
t o fi n d h e m cu t h ro u gh t h e fi bre s o f t h e p la y sm a alo n g t h e t
u p p e r bo rde r o f t h e cla icle f ro m t h e s e rn u m t o t h e s h o u lde r, v t
t
an d u rn t h e lo w e r p ar o f th e se e re d m u scle a n d f ascia do t n v w
w t
ards, de a c h in g it f ro m t h e f ascia be n e a h i h t h e e dg e o f t wt
t h e scalp e l . t
As h is is do n e lo o k f o r t h e n e r e s h ic h app e ar v w
as w t t
h i ish s ran ds r n n in g do n ards acro ss th e cla icle an d u w w v
p a ssi n g f ro m t h e de e p e in o t h e m o e s u p e rfi c i r
al lay e r Tw o t r .

t
o r h re e s h o u ld be f o u n d abo u th e middle o f the c la ic le , o n e t v
 PE C TOR AL RE G I O N I 3

n e ar its t it s acro m ial e n d de sce n din g in

s e rn al e n d, an d o n e n e ar
v
t h e f as c ia o e r t h e an e rio r p ar o f t h e de l o id m u scle t F o llo t t . w
v w
t h e n e r e s do w n ards h ro u gh t h e su p e rfi c ial f asc ia as far as t
p o ssibl e ; h e y d e sce n d t ott h e le e l o f t h e se co n d o r h ird rib, v t
t
an d are so m e im e s a cco m p an ie d by sm all bran ches o f the tran s
verse scap u lar artery w h ic h p ie rce t h e de e p f asc ia abo e t h e v
c la iclev t
N e ar t h e s e rn al e n d o f t h e c la icle sm all w i g s o f
. v t
t h e clavicu lar branch o f the tho raco acro m ial artery m ay be -

se e n N e ar t h e a cro m io n
. ig s o f t h e acro mi al bran ch o f t h e tw
t
sam e ar e ry m ay be f o u n d ; an d in t h e de l a p e c o ral
“

rian g le t -
t t
t wig s o f t h e de lto i d bran ch are o cc asio n ally i si ble V .

t
A f e r t h e su p racla icu lar n e r e s h a e be e n f o u n d an d v v v
w t t
f o llo e d t o h e ir e rm in a io n s cu t h ro u gh t h e su p e rfi c ral f as ci a t t
alo n g t h e lin e o f t h e an e rio r f o ld o f t h e ax illa an d t h e lo w e r t
t
m arg in o f t h e p e c o ralis m aj o r As so o n as t h e le e l o f t h e . v
de e p f ascia is re ac h e d u rn t h e an e ri o r p ar o f t h e su p e rfi cral t t .

t
t
f asc ia o w ards t h e m e dian p lan e , an d lo o k f o r t h e an te ri o r
bran ches o f the la te ral cu tan eo us n erves, as h e y u rn ro u n d t h e t t
t
bo rde r o f t h e p e c o ralis m aj o r, p ie rce t h e de e p f asci a, an d ru n
m e dially in th e su p e rfi c ial fascia .

N er v u s c u t an e u s
Acc e s so r y n e rv e C O lll

L e v at o r sc a p u a: l
i l
M dd e su p ra c la v ic u la

P i
o s t e r o r su ra c
p

Sca l e nu s me

FIG . 6 .
-
The S u p ra c l vi l
a cu ar B ran c he s o f the C e r v i c al P l e x u s .

N erv i up raclavic ula re s The supraclavicu lar n erves arise

s —

in the n e ck fr o m t h e th ird an d fourt h c e rv ica l n e rv e s

, Th e y .

sp r e ad o u t as th e y d e sc e n d i rc h d fa c ia ck
p e e t e e e p s o f t h e n e ,
,
an d th e y cro ss t h e c lav ic le u n d e r cov e r o f t h e aty a
p l sm .

Th e y are c la ssifi e d accord in g to th e ir p o sit io n s in t o the

, ,

a n t e r ior the midd le an d the p o st e rior bra n ch e s ( F ig

, , Th e .

a nterio r are t h e sm a lle st o f th e se r ie s

; th e y cro ss t h e m e d ia l
p art o f t h e c lav ic le to e n d in t h e sk in im m e d iat e ly be low .

The middle bran ches p a ss ov e r the midd le o f th e c lav ic le an d

e x t e n d dow n ward s in t he su e rfic ia l fa sc ia ov e r t h e ctora
p ,
p e lis
maj or as far as th e th ird rib
, Th e po sterio r cr o ss the lat e ra l .
1 4 TH E SU PER I OR EXT R E M I TY
th ird o f the c lav ic le an d w ill be a ft e rward s fo llo w e d t o th e
,

sk in o f t h e sh o u ld e r Th e y are fr e qu e n t ly acc o mp an ie d by
.

cu ta n e ou s bra n ch e s o f the tra n sv e r se sca p u lar art e ry .

N e rv i Cu t an ei A n t e ri o res Th e anterio r cu tan eo u s n er ves

.
—

are t h e min ut e t e r m in a l tw ig s o f t h e a n t e r io r ra m i o f t h e

th o rac ic n e rve s Th e y be c o me su p e rfic ial by p ie rc in g th e

.

p e ct o ra lis m ajor m u sc le an d t h e d e e p fa sc ia c lo se t o t h e ,

m arg in o f t h e st e r n u m O n e w ill be f ou n d in e ach in t e r

.

co sta l in t e rva l e x c e p t th e first ; an d th e y are acc o mp a n ie d by

t he cu tan eo u s p er fo rating branches o f the in t e rn a l ma mm ary
art e ry wh ich se rv e as the be st gu id e s to th e n e rv e s The
, .

n e rv e s an d t h e art e r ie s g iv e sle n d e r tw ig s to t h e sk in ov e r

th e st e r n u m an d larg e r bra n ch e s wh ich ru n lat e ra lly an d

,

m ay be trac e d as far as th e a n t e r ior fo ld o f th e a x illa Th e .

cuta n e ou s p e r fo rat in g art e ry wh ich a pp e ars through the th ird

in t e rc o sta l sp ac e is u sua lly t h e larg e st o f t h e se r ie s e sp e c ia lly ,

in th e fe ma le .

N e rv i Cut an e i L a t erales — Th e lateral cu tan eo u s n erves.

,

m uch larg e r tha n th e a n t e r ior ar ise fro m t h e a n t e r io r ra mi o f

,

t he thorac ic n e rv e s an d a p p e ar o n th e sid e o f t h e th o ra x
, , ,

a lo n g a lin e situat e d a litt le be h in d th e a n t e rior fold o f th e

a xilla Th e y p ie rc e th e wa ll o f th e thora x in the in t e r sp ac e s
.

be tw e e n th e r ibs an d d iv id e in to a n t e r io r an d p o st e r ior
,

bra n ch e s u n d e r cov e r o f th e se rratu s a n t e r ior m u sc le At a .

lat e r stag e th e bra n ch e s w ill be fou n d a p p e ar in g be tw e e n t h e

d ig itat io n s o f the se rratu s a n t e r io r Th e an terio r branches .

a pp e ar as a ru le abo u t an in ch in fro n t o f th e corr e sp o n d in g

'

, ,

p o s t e r ior bra n ch e s an d th e n p a ss fo rward s o v e r the lo w e r

,

bo rd e r o f t h e p e ct o ra lis m aj o r m u sc le F r o m t he lo w e r .

m e mbe r s o f th is se r ie s so m e m in ut e tw ig s are g iv e n o ff wh ich ,

e n t e r t h e su p e rfic ia l sur fac e s o f t h e d ig itat io n s o f t h e e x t e r n a l

o bliqu e m u sc le o f th e a bd o m e n wh ich w ill be e x p o se d by

t he d isse ct io n o f t h e a bd o me n Th e po sterio r bra nches ru n .

backward s t o th e dor sa l a sp e ct o f the tru n k o v e r th e a n t e r io r

, ,

bo rd e r o f th e lat issim u s d o r si mu scle ( F ig .

I t is v isable to atte m p t to se cu re
no t ad th e p o ste rio r bran ch e s o f th e
l ate ral cu tan e o u s n e rv e s in the m e antim e . Th e y are be st disse c t e d a o n g l
w ith the o th e r co n te n ts o f the ax ill a .

Th e M a mma ( M a mmar y Glan d o r B r e a st ) I n th e fe m a le .

—

t h e m a m m a fo r m s a r o u n d e d p r o min e n c e o n t h e fr o n t an d
a lso to so me e x t e n t o n the lat e ra l a sp e ct o f the thora x I t
, , , .
 PE C TOR AL RE G I O N 1 5

lie s in the su p e rfic ia l fa sc ia, an d its sm ooth co n tour is larg e ly

du e to th e in va sio n o f its su bsta n c e by th e fatty t issu e o f that
fa sc ia .

A litt le below its mid p o in t , an d at a le v e l wh ich u sua lly -

corr e sp o n d s to the fourth in t e rco stal sp ac e , the ma mma is

sur m ou n t e d by a co n ica l e le vat io n t e r me d t h e papilla mo mma

o r n ipp le The n ipp le sta n d s in th e midd le o f a c ircu lar

.

p atch o f co lour e d sk in wh ich is ca lle d th e m amma .

L at iss mu s i
P e c to rali

L o bu l es

A mp u ll i
a: o r s n u se s o fd
Se rrat u s an t e

i
F bro u s t rabe cu l a o f the gl an d

FIG .
7 .
— Di i
ssec t o n o f the M amm a
.

W ith in th e a lso subjac e n t to the ar e o la th e r e is

n ip p le , an d ,

n o fat A cur iou s cha n g e o f co lour occur s in th is r e g io n in

.

t h e fe ma le durin g t h e se co n d m o n th o f p r e g n a n cy At that .

t ime th e d e licat e p in k co lour o f t h e sk in o f t he n ip ple an d

ar e o la wh ich was p re se n t in the v irgin be co me s co n v e rt e d to ,

brow n by t h e d e p o sit io n o f p ig m e n t an d it n e v e r aga in

, ,

r e su me s its orig in a l a p p e ara n c e .

Th e m a mm a e x t e n d s in a hor iz o n ta l d ir e ct io n fro m , ,

t h e sid e o f th e st e r n u m a lm o st t o t he m id a x illary lin e o n -

th e sid e o f t he thora x an d in a v e rt ica l d ir e ct io n fro m , , ,

th e se co n d co sta l arch a bov e to t he six th co sta l cart ilag e

1 6 TH E SUPER I O R EXTRE M I TY
be low About two th ird s o f the gla n d are plac e d u p o n t h e
.
-

p e ctora lis m ajor m u sc le ,

wh ilst t h e r e m a in in g p art ,
wh ich
corr e sp o n d s to its in fe r ior an d lat e ra l th ird, e x t e n d s be yo n d
t h e a n t e rior fo ld o f the a x illa, an d lie s u p o n t h e se rratu s
a n t e rior mu scle F ro m the p art wh ich lie s in r e lat io n to th e
.

low e r bord e r o f t he p e ctoralis major a p ro lo n gat io n e x t e n d s

u p ward s in to the a x illa, an d r e ach e s as h igh as the th ird rib .

Pr o ce sse s ra d at n i ig o ut
fro m t h e c o rp us mam mae

P e ct o ra li s j
ma o r

S i n us lac t ife ru
D uc t u s l if i
ac t er

F at l o bu l e

F IG . 8 — Se c t
. i o n t h ro u gh a M am m ary G l an d p re p are d by th e m e th o d
re co mm e n de d by S ir H aro d St l il es .

The m a mm a is n o t e n c lo se d in a ca p su le , an d in that
r e sp e ct it d iffe r s fro m m a n y oth e r gla n d s I ts lo bu le s an d .

lo be s are e mbe dd e d be tw e e n stra n d s o f fi brou s t issu e wh ich

p a ss through t h e su p e rfic ia l fa sc ia fro m t h e sk in to t h e d eep

fa sc ia . Th e stra n d s for m th e stro ma or fra me work o f th e

gla n d Th e y su pp o rt an d bin d tog e th e r the vario u s p art s o f
.
 PE C TOR AL RE G I O N 1 7

the tru e gla n du lar t issu e wh ich co n sist s o f c e ll lin e d tu be s

,
-
,

an d th e y attach th e g land both t o t he sk in an d to t h e d e e p

fa sc ia . Th e stra n d s wh ich p a ss to t h e sk in hav e be e n ca lle d

th e ligaments of C o op er .

The stro ma an d th e g la n d t issu e tog e th e r for m a co n ica l

m a ss ca lle d the co rp u s mamma F ro m th e sur fac e s an d bo rd e r s
.

o f t he g e n e ra l ma ss o f t h e cor p u s m a mm a e m a n y p r o c e sse s

o f stro m a an d g la n d su bsta n c e p roj e ct an d in t h e ho llo w s ,

be tw e e n th e p roj e ct io n s is d e p o sit e d th e fat u p o n wh ich th e

sm o oth an d rou n d e d co n tour o f t h e orga n d e p e n d s .

Th e p o rt io n s o f th e tu be s o f t h e g la n d wh ich for m th e
se cr e t io n ca lle d m ilk are grou p e d t o g e th e r in sm a lle r an d

larg e r m a sse s ca lle d lo bu le s an d lo be s in the in t e r st ic e s o f

, ,

the fi brou s stro m a o f th e g la n d Th e p ort io n s o f the tu be s

.

wh ich carry th e se cr e t io n toward s the n ip p le are ca lle d duct s:

The sma lle r duct s fu se w ith oth e r s to for m larg e r duct s u n t il
fi n a lly so m e fi ft e e n o r m or e t e r min a l duct s ca lle d lactifero us ,

ducts co n v e rg e toward s t he ba se o f th e n ip p le
, Su bjac e n t to .

the ar e o la e ach duct e x p a n d s in to a fu sifor m d ilatat io n ca lle d

a lactifero u s sinu s th e n it co n tract s trav e r se s the su bsta n c e
, ,

o f th e n i p le an d O e n s o n it s a p e x g
p p , ( F i s 7 a n d .

I n a w e ll inj e ct e d su bj e ct tw ig s fro m t h e in terco stal arteries

-

an d a lso fro m t h e p er fo rating branches Of the intern al mammary

artery ,
may be trac e d in to th e ma mma an d oth e r v e sse ls ,

calle d the ex ternal mammary branches Of th e lateral tho racic

arter y ,
m a y b e se e n w in d in g rou n d t h e e dg e o f t h e p e ctora lis

maj or or p ie rc in g it s low e r fi br e s to r e ach t he gla n d

, ,
.

B y me a n s o f ly m p h v e sse ls wh ich issu e fro m it in t h e

n e igh bourhood o f t h e ar e o la an d fro m its bord e r s an d its ,

d e e p sur fac e the m a mmae is co n n e ct e d w ith the a x illary the

, ,

st e r n a l an d t h e in frac lav icu lar ly mp h g la n d s an d w ith t h e ,

ly mp h v e sse ls o f th e a bdo me n ( F ig s 9 Th e ly mp h v e sse ls

.
,

are n o t as a ru le
,
visible in an ord in ary d isse ct in g roo m
,
-

su bj e ct fo r Sp e c ia l me thod s o f p r e p arat io n are n e c e ssary fo r

,

th e ir p ro p e r d isplay bu t th e y m u st be r e me mbe r e d be cau se

, ,

th e y are o f th e gre at e st imp orta n c e in co n ne ct io n w ith th e

sp r e ad o f an y m a lig n a n t d ise a se wh ich h as co mm e n c e d in

t h e m a m ma .

I n th e m ale th e m a mm a ( ma mm a vir ilis) is qu it e rud i

m e n tary Th e n ipp le is sma ll an d p o in t e d an d the ar e o la
.
,

is surrou n d e d by Sp ar se ha ir s wh ich are n e v e r p r e se n t in th e

,

fe m a le .

V OL . 1— 2
1 8 TH E SUPER I O R EXTRE M I TY
D i s s e c t io n — t
I f th e su bj e c is a fe m ale th e disse c o r sh o u ld
. t
e n de a o v u
r t o m ak e o u t so m e o f th e de ails de scribe d abo e t v .

t
Th e s ran ds calle d th e lig am e n s o f Co o p e r e re n o e d, as t h e t w t
sk in w as re m o v
e d f ro m t h e su rf ace o f t h e g lan d (p No w .

t h e sk in o f t h e are o la m u s be de ac h e d f ro m t h e su rf ace o f t t
t h e glan d, an d re fl e c e d t o ards t h e n ip p le t w
As h a is do n e . t t
t ry t o m ak e o u t t h e la ct ife ro u s sin u se s (F ig 7 ) an d th e e rm in al . t
t t t t t
,

du c s . I f p o ssible p ass a bris le in o o n e o r o h e r o f t h e du c s

at t h e ap e x o f t h e n ip p le an d race t h e du c t o a lac ife ro u s t t t
t
sin u s, an d f ro m t h e sin u s ra ce t h e de e p e r p art o f t h e du c in o t t
t
t h e su bs an ce o f th e g lan d N ex t , i h t h e aid o f th e scalp e l,
. wt
t
g radu ally de ach the glan d f ro m th e de ep f ascia B e g in at .

r
t h e u pp e bo rde r, an d, as th e g lan d is disp lace d, n o e t h e s ran ds t t
o f t h e s ro m a t w
h ic h co n n e c its de e p su rface wi h th e de e pt t
f ascia t t
I t is alo n g h o se s ran ds h a blo o d e sse ls an d ly m p h
. t t -
v
v e sse ls, w h ich p ie rce t h e su bs an ce o f t h e p e c o ralis m aj o r, t t
t
e n e r an d le a e v
t h e g lan d Trace a p ro ce ss o f th e la e ral
. t
t
m arg in o f th e g lan d in o th e ax illa be h in d t he an e rio r ax illary t
f o ld . v
F in ally , re m o e th e g lan d by cu in g t h e m amm ary tt
t t
bran ch e s o f t h e la e ral h o racic art e ry at th e la e al m arg in , t r
a n d t h e m amm ary bran ch es o f t h e an e rio r p e f o a in g a e rie s t r r t rt
at t h e m e dial m arg in , t
h e n ex am in e th e de e p f ascia o f th e
p e c otr a l a n d ax illa ry re g io ns .

De e p F ascia — The d e e p fa sc ia o f the p e ctora l r e g io n is

a th in me mbra n e wh ich c lo sely in v e st s th e p e ctoralis m aj or .

I t is attach e d a bov e to t he c lav ic le , an d me d ia lly to t he

fro n t o f t h e st e r n u m B e low, it is co n t in uou s w ith th e d e e p
.

fa sc ia cov e r in g th e a bdo min a l m u sc le s, an d, at t he low e r

bord e r o f t he p e ctoralis m aj or m u sc le , it is co n t in uou s w ith
t h e a x illary fa sc ia At th e de lto p e ctora l tr ia n g le a p roc e ss
.
-

fro m it s d e e p sur fac e d ip s in , be tw e e n t h e d e lto id an d

p e ctora lis major m u sc le s, to j o in t h e co sto coraco id m e mbra n e , -

wh ilst , furth e r lat e rally, it be co me s co n tin uou s w ith the fa sc ia

cov e r in g th e d e lto id m u sc le Th e co sto coraco id me mbra n e .
-

w ill be d e scr ibe d lat e r ( p .

F ascia A x ill a ri s — Th e a x illary fa sc ia is a d e n se fe lt e d

.

m e mbra n e wh ich e x t e n d s acro ss the ba se o f t he a x illa It .

is co n t in uou s a n t e r ior ly w ith th e d e e p fa sc ia ov e r th e

p e ctora lis m aj or , p o st e r ior ly w ith t he f a sc ia ] sh e ath s o f t he

lat issim u s dor si an d th e t e r e s m aj or m u sc le s, m e d ia lly w ith

th e d e e p fa sc ia o n th e sur fac e o f th e se rratu s a n t e r ior,
wh ilst lat e ra lly it is co n tin uou s w ith t he d e e p fa sc ia o n
th e me d ial sur fac e o f th e p ro x im a l p art o f t h e arm I t is .

draw n u p toward s th e ho llow o f th e a xilla , an d th e

e le vat io n is du e ch ie fly to t h e c o n n e ct io n o f it s d e e p sur fac e
w ith the fa sc ial sh e ath o f the p e ctora lis min or, an d p art ly
to its attach me n t to t h e ar e o lar tissu e wh ich fi lls th e a xillary
 TH E SUPER I OR EXTRE M I TY
an d fro m t he
hou ld e r by ly mp h v e sse ls wh ich acc o mp a n y
s

t h e c e p ha lic v e in an d th e y tra n sm it it to ly mp h v e sse ls wh ich

,

c o n n e ct th e de lto p e ct o ra l gla n d s w ith th e in fraclav icu lar -

gla n d s ( se e F ig s 9
.

.
,

M P e ct o ra lis M ado n — Th e p ow e r fu l p e ctora lis m aj o r

.

m u sc le e x t e n d s fro m th e a n t e r io r a sp e ct o f t h e th o ra x t o th e
hu me ru s I t is d iv id e d by a d e e p fi ssur e in to a c lav icu lar an d
.

li v i
C e p ha c e n
l xill y g l
I C e n t ra a ar an ds
gl an d
gl an ds
c ial to co st o -
co ra co id in e mbrai
c t o ra l gl a n ds
h v e sse s l p ig
a ss n to
s t e rna l gl an ds

y v
L m p h e sse s fro m l m ar

l xill y g l d
"
L a t e ra a ar an s

o s t e rio r o r su bsc a p l xill y g l d

u ar a ar an s

i
An t e r o r o r p l xill y g l d
e c t o ra a ar an s

y
L mph v e sse s l fro m de e p p arts o f m am ma
p a ss i gt
n o i l
n t e rp e c t o ra , i n fra c a i c u ar lv l
a nd a l so t o s u p rac a cu ar l vi l gl
an ds

y
L mp h v e sse s l p ass ig j i n to o n o t he r l ymp h
ve sse s l i x p n e
.

t ra e ri t o n e a l t i ssu e

FI G .
9 .
— The L y mp h G l an ds an d Ve sse l s o f the xill
A a an d M amm a .

a st e r n oco sta l p ort i o n Th e fi ssur e p e n e trat e s through the .

e n t ir e th ick n e ss o f th e m u sc le the c lav icu lar an d st e r n oc o sta l ,

p o rt i o n s be in g d ist in ct e x c e p t c lo se to th e ir in se rt io n s T h e ,
.

clavicu lar po rtio n ar ise s by short t e n d in o u s an d m u scu lar fi br e s

fro m an im p r e ssio n o n t h e m e d ia l ha lf o f th e a n t e r ior sur fac e

o f t h e c lav ic le Th e su p e rfic ia l p art o f th e stern o co stal p o rtio n
.

tak e s orig in by fl e shy fi br e s ( r) fro m th e a n t e rio r sur fac e o f

, ,

t h e st e r n u m ( 2 ) fro m th e a p o n e uro sis o f th e e x t e r n a l o bliqu e

,

m u sc le an d ( 3 ) o cca sio n a lly fro m th e six th rib n e ar it s

,
 AX I L LARY SP AC E 2 r

cart ilag e Th e d e e p e r p art ar ise s by a var ia ble n u mbe r o f

.

m u scu lar slip s fr o m th e cart ilag e s O f the u

pp e r six r ibs .

Th e m u sc le is in se rt e d , by a flatt e n e d bila min ar t e n do n ,

in to th e lat e ral lip o f t h e in t e rtu be rcu lar su lcu s o f t h e
hu me ru s, an d the fi br e s o f th e m u sc le u n d e rgo a r e arra n g e
me n t as th e y c o n v e rg e u p o n t h e t e n do n Th e gr e at e r .

p art o f t h e c lav icu lar p ort io n j o in s the a n t e r ior la min a o f the

co mm o n t e n do n ; so m e o f the m o st me d ia l c lav icu lar fi br e s,
how e v e r, are in se rt e d d ir e ct ly in to the hu me ru s, d ista l to -

t h e t e n do n , wh ilst a fe w ga in attach m e n t to t h e d e e fa sc ia
p
o f th e arm, an d oth e rs be co m e adh e r e n t to t h e adj ac e n t

p art o f t he d e lto id .

The fi br e s o f t h e ste r n oco sta l p ortio n o f th e m u sc le d o

n o t all p a ss in th e sa m e d ir e ct io n bu t t h e y all j o in t h e la min a e

C o st o -
l vi l li g
c a c u ar a me n t
Co no i d li g ame n t

FIG . I o .
-
I n fe rio r Surface o f t he C l v i l w i th th
a c e e Attach me n ts o f t he
M u sc l es m ap p e d o ut .

o f th e t e n do n o f in se rt io n
u p e r ior fi br e s d e sc e n d . Th e s

slight ly t h e in t e r me d iat e fi br e s p a ss horiz o n ta lly wh ilst th e

, ,

in fe r io r fi br e s a sc e n d an d at t h e sa m e t ime ga in th e d e e p
, , ,

sur fac e o f t h e r e st o f t h e m u sc le A smooth fu ll an d rou n d e d .

, ,

low e r bord e r o f t he m u sc le is thu s for me d ; it co n st itut e s t he

a n t e r ior fo ld o f t h e a xilla Th e attach me n t s o f th e m u scle .

to the hu me ru s w ill be stud ie d in d e ta il at a lat e r stag e

o f t he d isse ct io n ( p .

Th e p e ct o ra lis m aj or is su pp lie d by th e medial an d la teral

a nterio r tho racic nerves I t is an adductor o f t h e su p e r io r
.

e x tr e mity an d a m e d ia l rotator o f t h e hu m e ru s .

Axilla — The a xilla is th e ho llow o r r e c e ss be tw e e n t h e

u p p e r p art o f t he sid e o f th e thora x an d th e p ro xima l p art
o f t h e arm W h e n th e arm is a bduct e d fro m th e tru n k
.
,

an d th e are o lo fatty t issu e wh ich occu p ie s the a x illa is

-

r e m ov e d th e sp ac e d isc lo se d has th e for m o f a four sid e d

,
-

p yra m id T. h e a p e x o r n arrow p art o f

,
t h e s p ac e lie s ,
2 2 TH E SUPER I O R EXTRE M I TY
imme d iat ely to th e me d ia l sid e o f th e coraco id p roc e ss, an d
is d ir e ct e d u p ward s toward s t h e root o f the n e ck , wh ilst the
w id e r p art or ba se o f the sp ac e look s dow n ward s Th e .

me d ia l wa ll, fo r m e d by t h e thora x, is o f gr e at e r e x t e n t tha n

th e lat e ra l
wa ll wh ich is for m e d by t h e arm I t fo llow s .
,

th e r e fo r e that the a n t e r ior an d p o st e rior wa lls c o n v e rg e as

,

th e y p roc e e d lat e ra lly an d be cau se the p o st e rior wa ll is

, ,

lo n g e r fro m a bov e d o w n ward s tha n t h e a n t e r ior t h e p o st e r ior

, , ,

bord e r o f th e ba se is low e r tha n th e a n t e r ior .

B e fo be g in n in g the disse ctio n o f th e sp ac e , th e disse cto r sh o u ld h av e

re
a g e n e ral k n o w le dg e o f its bo u n darie s an d o f th e man n e r in wh ich th e
co p l
n te n ts are dis o se d in re at io n t o th e bo u n darie s .

B o un daries o f t h e Axilla — The fo ur wa lls o f the a x illa are

( ) a
i n t e r ior , ( )
2
p o st e r ior , (3) m e d ia l,
an d ( )
4 lat e ra l Th e .

a nterio r w all is for m e d by th e two p e ctora l mu sc le s, t h e

su bc lav iu s an d th e fa sc ia wh ich surrou n d s t he p e ctora lis
min or an d attach e s its u p p e r bord e r to th e c lav ic le an d it s
lo w e r bord e r to the fl o or o f the axilla an d to th e d e e p fa sc ia ,

o n th e m e d ia l sid e o f t h e arm Th e p e ct o ra lis maj o r fo r m s

.

t h e su p e rfic ia l stratu m an d is sp r e ad o u t ov e r th e e n t ir e
,

e x t en t o f t h e a n t e r io r wa ll Th e p e ctora lis m in or lie s

.

p o st e r ior t o th e p e ct o ra lis major an d tak e s p art in th e ,

for mat io n o f th e midd le th ird o f th e a n t e r io r bou n dary Th e .

fa sc ia wh ich fi lls t h e gap be tw e e n th e p e ct o ra lis min o r an d

th e c lav ic le is ca lle d t he co st o corac o id me m bra n e ; it sp lit s -

a bov e to e n c lo se t he su bc lav iu s m u sc le an d a lo n g th e lo w e r ,

bord e r o f that mu sc le it is str o n g e r tha n e lse wh e r e Th e .

lo w e r bo rd e r o f t h e a n t e r io r wa ll is th e an terio r fo ld o f th e
a xilla I t is for me d by th e low e r bo rd e r o f the p e ctora lis
.

m aj or str e n gth e n e d m e d ia lly by t h e low e r bord e r o f th e

, , ,

p e ctora lis m in or wh ich p

,
roj e ct s be yo n d t h e m ajor n e ar t h e

sid e o f th e thora x .

Th e p o sterio r wall o f th e a x illa is for me d by th e lat e ra l

p art o f t h e s u b sca p u lar is m u sc le b a
y p o rt io n o f t h e lat
,
issi m u s

dor si an d its t e n d o n an d by th e t e r e s m ajor m u scle Th e

,
.

su bsca p u lar is cov e r s th e co sta l sur fac e o f th e sca p u la Th e .

lat issim u s dor si w in d s fro m t h e back rou n d t h e m e d ia l p art ,

o f t h e lo w e r bord e r o f t h e t e r e s m aj o r to ga in its a n t e r ior

s ur fac e ; thu s t he low e r bord e r o f th e p o st e r io r wa ll wh ich ,

co n st itut e s th e p o sterio r fo ld o f th e a xilla is fo r me d in its ,

me d ia l p art by t he lat issimu s dor si an d lat e ra lly by t h e ,

in fe r ior marg in o f th e t e r e s maj or .

 AX I L L ARY SP AC E 2 3

I n the medial wall are p art s o f t he u p p e r fiv e r ibs w ith

th e in t e rv e n ing in t e rco sta l m u sc le s th e y are cov e r e d by th e
corr e sp o n d in g d ig itat io n s o f th e se rratu s a n t e r ior mu sc le .

The lateral wall is for me d by t h e hu me ru s an d th e co nj o ine d

p ro x ima l p art s o f th e coraco brach ia lis an d t h e short h e ad o f -

the bic e p s brach ii m u sc le s .

At the apex o f the sp ac e is t h e n arrow tr ia n gu lar in t e rva l

through wh ich the a x illa co mm u n icat e s w ith th e n e ck ; it is
fr e qu e n t ly ca lle d th e cervico ax illary canal I t is bou n d e d -
.

a n t e r ior ly by t he c lav ic le, m e d ia lly by t he out e r bord e r O f

t h e fir st rib, an d p o st e r ior ly by th e su p e rior m argin o f t h e
sca p u la ; through it p a ss the a x illary v e sse ls an d th e big
n e rv e cord s o f th e brach ia l p le x u s o n th e ir way fro m t h e

i . P ro x ima l e nd o f
3 . A xill ary arte r y .

ll u mc ru s .

9 . Lo n gh e ad o fb i ce p s .

2 . 5 0 13 0 15“
3 10 . Co n o j i ne d o r ig i n o f
i
i fiég
he ad o f b ce p s
sh o rt
i mu o s ma j o r
an d c o raco - brach i
5 . Se rrat u s an t e r o r i .

a s li .

l l scap ll laf ls

ii
6
f 1 3 B rachialn e rv e s
v
. .

7 . i llary ein .

FIG . I r .
— Di g a ram o f i
se c t o n t hro u gh t he A xill a o f th e L e ft S de i .

ne ck to the arm The w id e base o r floor o f th e Sp ac e is

.

c lo se d by the vau lt e d a xillary fa sc ia .

Co nt e nt s o f t h e Axilla — Th e a x illary art e ry an d v e in .

,

w ith th e larg e brach ial n e rv e s wh ich su pp ly th e su p e r ior ,

e x tr e mity an d t h e a ,
x illary ly m p h v e sse ls an d ly m h g la n d s
p ,

are t h e m o st imp orta n t co n t e n t s o f t h e a x illa Th e y are .

all e mbe dd e d in th e so ft a x illa ry fat E x c e p t at th e a p ex .

o f t h e sp ac e th e gr e at v e sse ls an d n e rv e s lie c lo se to th e
,

lat e ra l wa ll an d fo llow it in all th e m ov e me n t s o f the arm

, .

D ss e c t o
i i n — C t t h r u gh t h lav ic lar fi bre o f t h p e ct o ralis
u o e c u s e
m aj o r im m e diat e ly b lo w t h ir att ac h m e n t t t h e clav icl an d
,
e e o e,
t rn t h e m t o w ard t h ir in se rtio n At th sam e t im s re t h e
u s e . e e, e cu
bran ch e f t h lat r al an t rio r t h o racic n rv e w h i h p ass in t o
s o e e e e c
t h e d e p s rf ac o f t h e m scle
e u F o ll w t h
e p h alic v e in an d u . o e ce
t h e de lt o id bran c h o f t h e t h o ra o acro m ial a rt ry m dially u n de r c -
e e ,

ve r o f th clavic lar p art o f th p ct o rali m aj o r an d se r th e

co e u e e s ,
cu e
a r m ial an d p
c o t ral bran ch s f th latt r art e ry Cl an t h
ec o e o e e . e o se
ve s ls an d dir ctly b lo w t h lavi l disp lay t h co sto
se ,
e e e c c e, e
co raco id membrane an d m o re in f e r io rly an d lat e rally t h e f as cia
, , ,
2 4 TH E SUP ER I OR EXTRE M I TY
o n t h e la t e ral p art
f th e p e c o ralis m in o r o Cu t h ro u gh t h e t . t
t
s e rn o c o s o t al p art f
t h e p e c o ralis m aj o r abo u t wo in c h es f ro m t t
t
t h e la e ral bo rde r o f t h e s e rn u m t
Tu rn t h e m e dial p ar o ards . tt w
t h e m e dian p lan e e rify it s a ac h m e n v
t o t h e co s al c a ilag e s tt t t rt
t
an d t o t h e s e rn u m an d t o t h e ap o n e u ro sis o f t h e e x e rn al o bliq u e t
m u scle o f t h e abdo m e n Tu n t h e la e ral p ar o f t h e m u scle
. r t t
t w
o ards t h e arm w
h ils do in g h a , se cu e th e m e dial an e io t t t r t r r
t v
h o racic n e r e , w h ic h p e rfo ra e s th e p e c o alis m in o an d e n ds t t r r
in t h e p e c o ralis m aj o r t Ex am in e t h e in se rt io n o f t h e p e c o ralis
. t
t t t t
m aj o r N o e h a t h e e n do n o f in se rt io n co n sis s o f tw o lam in a
. t
w t t
h ic h are u n i e d o g e h e be lo t r
in o h e r o rds, th e e n do n is w t w t
f o lde d o n i se lf t an d be tw
e e n t h e tw o lam in a a mu co us bu rsa
t
is f re qu e n ly in e rp o se d t Th e c la icu lar fi bre s an d t h e u pp e r
. v
t t tt
s e rn o c o s al fi bre s are a ac h e d t o t h e an e rio r lam in a, t h e lo er t w
t t r
s e rn o co s al fi b e s t o t h e p o s e rio r lam in a B o h lam in a are t . t
t t
a t ac h e d t o t h e la e ral lip o f t h e in e r u be rcu lar su lcu s o f t h e t t
r
h u m e u s, bu t t he de e p lam in a asce n ds to a m o re p ro x im al le e l, v
t
an d be co m e s co n in u o u s w i h a lay e r o f f as cia w h ic h is a ac h e d t tt
t
t o t h e le sse r u be rcle o f t h e h u m e ru s Th e in f e rio r bo rde o f t h e . r
t t
e n do n o f in se r io n is c o n in u o u s t
i h th e de e p f as c ia o f th e arm wt .

t
W h e n t h e p e c o ralis m aj o r is co m p le e ly re fl e c e d a c o n in u o u s t t t
sh e e t
o f f ascia is e xp o se d, h ic h ex e n ds f ro m th e cla icle w t v
r
su p erio ly t o t h e ax illary f asc ia in f e rio rly , an d f ro m t h e all o f w
t
t h e h o rax m e dially t o t h e arm la e rally t h e sh e e o f f ascia is t t
t h e so calle d clavip ecto ral f asci a o r susp e nso ry ligamen t of the
-

axi lla I t is be cau se o f th e a t ac h m e n o f h a f asc ial s h e e t o

. t t t t t
v
t h e c la icle su p e rio rly an d t o t h e ax illary f ascia in fe rio rly h a t t
t h e fl o o r o f t h e ax illa is raise d as t h e a rm is abd ct e d f ro m th e u
side an d t h e cla icle is e le a e d vTh e p e c o ralis m in o r m u scle , v t . t
p assin g o bliq u e ly f ro m its o rig in o n t h e h o racic all t o its t w
t r
in se rt io n in o t h e c o ac o id p ro ce ss o f t h e sc ap u la, ru n s h ro u gh t
t
t h e su bs an ce o f t h e cla ip e c o al f asc ia an d di ides it in o h re e v t r v t t
p ar s t v
( 1 ) t h e p art abo e t h e m scle , (2 ) th e p ar h ic h e n clo se s u tw
t h e m u scle , an d (3 ) t h e p art be lo w t h e m u scle Th e u pp e rm o s . t
p a rt i s t h e c o s o t
- co raco id m e m bran e
,
t h e in e rm e dia e p art is t h e t t
t
s h e a h o f t h e p e c o ralis m in o r t
No sp e cial t e rm is app lie d t o .

w t
t h e lo e s p art , bu t it s h o u ld be n o e d h a it lie s p o s e io r t o t h e t t t t r
w t t
lo e r p ar o f t h e p e c o ralis m aj o r, an d h a it co e rs t h e dis al t t v t
rt
p o io n s o f t h e ax illary e sse ls an d n e r e s v v .

M embran a Co st o co raco ide a co sto coraco id me m .

-
Th e -

bra n e occu p ie s the gap be tw e e n th e c lav ic le an d th e p e ctora lis

min or I t e x t e n d s fro m th e fir st rib m e d ia lly t o the corac o id
.

p roc e ss lat e ra lly a n d f ro m t h e c lav ic le

,
a bo v e to t h e p e ctora lis
m in or be low I t s u pp e r p art is sp lit in to t wo lay e r s an
.
,

a n t e r ior an d a p o st e rio r wh ich are attach e d to th e c o rr e ,

sp o n din g bord e r s o f t h e c lav ic le E n c lo se d be tw e e n th e m is .

t h e su bc lav iu s m u sc le Th e stro n g e st p art o f t h e m e mbra n e

.

is that wh ich e x t e n d s a lo n g t h e low e r bord e r o f t h e su b

c laviu s fro m th e fir st rib to the c o raco id p roc e ss that p ort io n
,

is fr e qu e n t ly ca lle d th e co sto co raco id ligamen t Th e m e mbra n e -

.

is co n t in uou s be low w ith th e fa sc ia l sh e ath o f the p e ctora lis

 AX I L L A RY SP A C E 2 5

m in or p o st e r ior ly w ith th e fa sc ia l S h e ath o f t he a x illary

an d

v e sse ls ( F ig . I t is p e r fo rat e d , a bov e the u p p e r bo rd e r

o f the
p ctora lis m in or, by the c e p ha lic v e in , t h e thoraco
e

acro mia l v e sse ls, an d the lat e ra l a n t e r ior thorac ic n e rv e .

N ot e ( I ) that the fibres of the membran e ru n medio laterally, -

( )
2 t hat th
ey a re pu t o n the stretch w hen the arm is a bdu cted
,
an d 3 ) that they are relax ed w hen the a rm is by the side Th e .

s urg e o n tak e s adva ntag e o f th e se fact s wh e n he is ligatur in g

t h e fir st p art O f th e a x illary art e ry .

C l vi l
a c e

S u bc l vi
a us

Tho raco ac ro
-
m il
a a rte r y
Fi rst rib

Co sto -
co raco id
m e mbran e

A xill y ar art e r y

A xill y
ar sh e a th

ary fasc i a

FIG . 1 2 .
— Di g
a ra m o f th e C o sto -
co raco id M e m bran e .

t r u
D is s e c ti o n — Cu t h o gh t h e an e rio lay e r o f t h e u p p e r p ar t r t
o f th e t
co s o c o raco id m e m bran e
-
an d e x p o se t h e su bcla iu s v
m u scle P
ass t h e h an dle o f a k n ife be lo
. t h e lo e r bo rde o f w w r
v w r
t h e su bcla iu s an d u p a ds be h in d t h e m u scle an d de m o n s ra e t t
t
t h e p o s e rio r lay e r o f t h e u pp e r p art o f t h e m e m bran e Cle ar a w ay .

r
t h e e m ain s o f t h e m e m bran e an d f o llo t h e ce p h alic e in t o it s w v
t wt v
j u n c io n i h th e ax illary e in , th e h o raco acro m ial art e ry t o t -

t t
t h e ax illary ru n k , an d t h e la e ral an e rio r h o rac ic n e r e t o t h e t t v
t r
la e al co rd o f t h e brac h ial p le xu s Cle an t h e p ro x im al p art s o f .

t v
t h e ax illary ar e ry an d e in an d t h e la e ral co rd o f t h e bra c h ia l t
p lex u s t t t
N o e h a th e ax illary e in lie s t o t h e m e dial side o f t h e
. v
t t
ar e ry , o n a so m e wh a an e rio r p lan e , an d h a a s t h e arm is t t t
t
abdu c e d f ro m t h e side t h e v
e in p asse s m o re an d m o re in f ro n t
o f t h e art e ry t r
Th e la e ral co d o f t h e p le xu s lie s t o t h e la e ral
. t
side o f t h e art e ry an d o n a p o s e rio r p lan e t
B e h in d t h e u p p e r .

t
bo rde r o f t h e p e c o ralis m in o r fi n d t h e m e dial an e rio r h o rac ic t t
v
n e r e , an d n o e t t t
h a a co mm u n ica io n is f o rm e d be t e e n th e t w
t t
m e dial an d la e ral an e rio r h o acic n e r e s , acro ss t h e f ro n o f t r v t
t
t h e ax illary ar e ry an d be h in d th e co s o co raco id m e m bran e t - .
2 6 TH E SUPER I OR EXTRE M I TY
t r
Cle an t he p e c o alis m in o r m scle i h o u u wt t inj urin g th e m e dial
an t t
e rio r h o racic n e e, hich p ie rce s it rv w .

M P ect o ra lis M in o r The p e ctora lis m in or mu sc le is

. .
-

tria n gular in out lin e I t arise s ( 1 ) fro m th e a n t e rior e n d s .

o f t he th ird fourth an d fi fth r ibs c lo se to th e ir ju n ct io n s

, , ,

w ith th e ir cart ilage s an d ( 2 ) fro m the fa sc ia cov e rin g the ,

in t e rco stal m u sc le s in th e in t e rv e n ing sp ac e s I t s fi br e s p a ss .

u p ward s an d lat e ra lly an d its t e n do n o f i n se rt i o n i s attach e d ,

to t he u p p e r sur fac e an d the a n t e ro m e d ia l bord e r o f th e -

horiz o n tal p art o f the coraco id p roc e ss n e ar its lat e ra l ,

e x tr e mity W h e n the mu sc le is in act io n it draw s th e sca p u la

.

dow n ward s an d forward s an d d e p r e sse s th e shou ld e r It , .

is su p p lie d by t he medial an terio r tho racic n erve Th e gr e at e r .

p ort io n o f t h e p e ctora lis m in or is co n c e a le d by t h e p e ctora lis

m ajor bu t th e low e r an d me d ia l p art o f its in fe r ior bord e r
,

a pp e ar s o n the lat e ra l wa ll o f the thora x be lo w the pe ctora lis

major ; its in se rt io n is co n c e a le d by th e a n t e r ior fi br e s o f the
d e lto id .

D is s e c t i o n — Cle a a ay t h e cla ip e c o al f ascia be lo

. r w th e v t r w
v t r
le e l o f t h e p e c o alis m in o r an d o p e n u p t h e lo e r p ar o f t h e w t
ax illa v
re m o e also t h e de e p f ascia o f t h e arm in t h e e g io n o f r
t
t h e la e ral bo u n dary o f t h e ax illa .

Co mm e n ce at t h e la e ral p art o f t h e are a be lo t

t h e p e c o ralis w t
m in o r an d cle an t h e c o raco b ac h ialis an d t he s h o h e ad o f th e -
r rt
t
bic e p s, as h e y de sce n d in o t h e arm f ro m th e t ip o f t h e c o rac o id t
p ro c e ss t
F in d t h e dis al p ar o f th e ax illary ar e ry at t h e m e dial
. t t
bo rde r o f t he co raco brac h ialis Th e ru n k o f th e m e dian n e r e
-
. t v
lie s be tw t
e e n t h e a r e ry an d t h e m u scle , an d at t h e lo e r bo rde r w
t
o f t h e p e c o ralis m in o r t h e m e dial h e ad o f t h e n e r e c ro sse s t h e v
r t
f o n o f t h e ar e ry t
P u ll t h e co rac o brac h ialis la e rally an d fi n d
.
-
t
t
t h e m u scu lo cu an e o u s n e r e e n e rin g its de e p su rf ace , j u s
-
v t t
be lo w
t h e p e c o ralis m in o r t Abo e an d t o t h e la e ral side o f t h e . v t
t ru n k o f t h e m u scu lo cu an e o u s n e r e fi n d t h e bran c h f ro m it -
t v
w h ic h su p p lie s t h e c o raco brac h ialis Th e ax illary e in lie s alo n g -
. v
t h e m e dial side o f t h e ar e ry , an d in t h e in e r al be w e e n t h e t t v t
t v t
ar e ry an d e in , an e rio rly , is t h e m e dial cu an e o u s n e r e o f t h e t v
f o re arm ( O T in e rn al cu an e o u s)
. . t
R u n n in g alo n g t h e m e dial t .

s ide o f t h e v
e in is t h e m e dial cu an e o u s n e e o f t h e arm ( O T t rv . .

t r
le sse r in e n al cu an e o u s n e r e ) t
se cu re it an d f o llo it u p w a ds v w r
t
t o th e co m m u n ic a io n w h ic h it re ce i e s f ro m t h e in te rco st o v
brac h ial n e r e (F ig I v At t h e sam e t im e ide n if y an d
. t
v t
p re se r e t h e la e ral g ro u p o f ax illary ly m p h g lan ds, h ic h lie w
alo n g t h e m e dial side o f t h e ax illary e in Se cu re th e in t e rco st o v .

brac h ial n e r e an d f o llo v it m e dially , t o t h e p o in w h e re it w t

e m e rg e s f ro m t h e se co n d in e rco s al sp ace , an d la e rally t o t h e t t t
m e dial an d p o s e rio r asp e c o f t h e arm , t h e re it is dis ribu e d t w t t .

I n o rde r t o disp lay t h e dis ribu io n o f t h e in te rco st o brac h ial t t -

v v
n e r e , an d t o g i e be e r a c ce ss t o t h e m e dial an d p o s e rio r tt alls t w
o f t h e ax illa, t h e ax illa y fascia m s be se p ara e d f o m t h e f as cia r ut t r
2 8 TH E SUPER I O R EXTRE M I TY
o t
f t h e p e c o ralis m in o r, fi n d t h e la e ral h o rac ic ar e ry cle an t h e t t t
art e ry an d t h e m e dial g ro u p o f ax illary ly m p h g lan ds, h ich lie w
alo n g its c o u rse .

t
At t h e j u n c io n o f t h e p o s e rio r h ird an d an e rio r tw o h irds t t t t -

o f t h e m e dial w
all o f t h e ax illa fi n d t h e lo n g h o ra cic n e r e , h ic h t v w
t
su p p lie s t h e se rra u s an e rio r an d de s ce n ds alo n g it s la e ral t t
su rf a ce , f ro m t h e ap e x t o t h e base o f t h e ax illa Af e t h e n e r e . t r v
h as be e n se cu re d t h e se rra u s an e rio r m u s be cle an e d t
W hen t t .

t t
h a h as be e n do n e t h e disse c o r sh o u ld cle an t h e dis al p ar s o f t t t
v
t h e larg e e sse ls an d n e r e s an d h e ir bran c h e s an d ribu arie s v t t t .

t
W i h c h ain an d h o o k s p u ll t h e ax illary ar e ry an d t h e m e dial t
t
cu an e o u s n e r e o f t h e f o re arm v o w ards t h e a rm an d disp lace t
v
t h e ax illary e in in t h e o pp o si e dire c io n t h e n fi n d t h e u ln ar t t
ne r e v w h ic h lie s in t h e p o s e rio r p ar o f th e in e r al be e e n t h e t t t v tw
art e ry an d v
e in ; p u ll t h e u ln ar n e r e la e rally , an d be h in d t h e v t
t
a r e ry fi n d t h e larg e radial n e r e ( O T m u scu lo sp iral
) u ll it v . .
-
. P
m e dially an d f o llo w it s la e ral bo rde r u p ards At t h e lo e rt w . w
bo rde r o f t h e su bsc ap u laris m u scle o n t h e la e ral side o f t h e t
v
radial n e r e se cu re t h e ax illary n e r e as it u rn s back ards in o v t w t
t
t h e p o s e rio r all o f t h e ax illa w N e ar t h e ax illary n e r e is t h e . v
larg e su bscap u lar bran c h o f t h e ax illary ar e ry a cc o m p an ie d by t
t h e co rre sp o n din g e in v
Th e su bscap u lar ar e ry sp rin g s f ro m
. t
t h e m e dial side o f t h e ax illary ar e ry A sh o rt dis an ce be lo its t . t w
v t
o rig in it di ide s in o tw o bran c h e s, t h e c i cu m fl ex s cap u lar an d r
t r
t h e h o aco do rsal Th e circu m fl e x sc ap u lar p asse s back ards
-
. w
t t
in o t h e p o s e rio r all o f t h e ax illa wTh e h o raco do rsal ar e ry . t -
t
de s ce n ds alo n g t h e lo w e r bo rde r o f t h e su bscap u laris m u scle t o
t h e an g le w h e re t h e p o s e rio r t
all j o in s t h e m e dial w all o f t h e w
ax illa w
F o llo th e art e ry do n ards , ak in g c are n o t t o in j u re
. w w t
t h e in t e rco st o brac h ial n e r e an d t h e p o s e rio r bran c h e s o f t h e
-
v t
t
la e ral ram i o f t he 3 rd, 4 th , an d sth in e co s al n e r e s h ic h c ro ss t r t v w
in f ro n o f it t t
N o e t h e p o s e rio r g ro u p o f ax illary ly m p h g lan ds
. t
w h ic h lie alo n g it s co u rse , an d n e ar its lo e r e n d se cu re t h e w
t r v w
h o aco do rsal n e r e , h ic h cro sse s in f ro n o f th e art e ry , o n it s
-
t
w ay t o t h e la issim u s do rsi, t h ich it su pp lie s R e u n t o th e w . t r
v
di isio n o f t h e su bscap u lar ar e ry D isse c in t h e an g le be w e e n t . t t
it s c ircu m fl e x s cap u lar an d its h o ac o do rsal bran c h e s an d t r -

se cu re t h e se co n d su bsc ap u lar n e r e , h ic h su pp lie s t h e e re s v w t

m aj o r m u scle f o llo w it t o th e m u scle .

t
R e u rn t o t h e radial n e r e an d fi n d sp rin g in g f ro m its m e dial v
bo rde r n e ar t h e lo w e r m arg in o f t h e su bs cap u laris t h e p o s e rio r t
t v
brac h ial c u an e o u s n e r e , an d bran ch e s t o t h e lo n g an d m e dial
t
h e ads o f t h e rice p s m u scle No t u n co mm o n ly all h o se bran ch e s . t
are co n j o in e d at t
h e ir o rig in , an d se p ara e as h e y p ass t o h e ir t t t
t
de s in at io n s t
Th e p o s e rio r brac h ial cu an e o u s n e r e , o n its
. t v
w ay t o t h e m iddle o f t h e p o s e rio r asp e c o f t h e arm , p asse s t t
be h in d t h e in te rc o st o brac h ial n e r e Th e n e r e t o t h e lo n g
- v . v
h e ad o f th e t rice p s e n e rs t h e p ro x im al p ar o f h a m u scle t t t t .

Th e re are u su ally tw o bran c h e s t o t h e m e dial h e ad o f t h e rice p s t

t
o n e e n e rs t h e p ro x im al p ar o f t h e m u scle , an d t h e o h e r, k n o t n t w
as t h e u ln ar co llateral, bec au se it ru n s by t h e side o f t h e u ln ar
v
n e r e , p asse s t o t h e dis al art
p I t ill be r a c e t
d t o it s e rm in a . w t t
t io n at a la e r p e rio d t .

Th e an e rio t r t
an d p o s e rio r h u m e ral c ircu m fl e x bran c h e s o f
t h e ax illary ar e ry t w
ill be f o u n d sp rin g in g f ro m t h e ar e ry a t
sh o r t t t
dis an ce dis al t o t h e su bscap u lar bran c h , t h e f o m e r r
 AX I LLA RY SP AC E 2
9

arisin g f ro m t h e an t e rio r , an d t h e t
la t e r f ro m t h e p o t r io r a
s e sp e c t
o f t h e ax illary ru n k t .

t w
Af e r t h e lo e r p art o f th e ax illa h as be e n h o ro u gh ly cle an e d, t
t
t h e p e c o ralis m in o r m u s be di ide d, abo u m id ay be t
e e n it s v t w tw
t
o rig in an d in se r io n , a n d t h e tw o p art s m u s be u n e d aside t t r .

t t
W h e n h a h as be e n do n e t h e u pp e r su bscap u lar n e r e m u s be v t
t
f o u n d as it e n e rs t h e u p p e r p ar o f th e su bsc ap u laris , an d h e n t t
t
t h e re m ain in g are o lar issu e m u s be re m o e d f ro m t h e ax illary t v
t
sp ace , t h e ru n k s an d bran c h e s o f t h e ax illary e sse ls an d n e r e s v v
t t r
mu s be h o o u gh ly cle an e d, an d t h e co n e n s o f t h e sp ace m u s t t t
t
be s u die d in de ail t .

R lgh t j u u 1ar
'

g I f i d
n er o r e e p cer vi ca l
ly
mp h t ru n k l y mp h g l an ds

I l v i l l y mp h
n fra c a c u ar
gl an ds

i
Su p e r o r a n t e rio r
i i l ly
m e d as t na mp h an ds gl I n t e rpe c t o ra l l y mp h
gl a nd

Tho rac i c du c t

S t e rn a l l y mp h g l d an s

f i gh id ‘
o r t s e

l l y mph gl
St e rn a an ds o f l e ft s id

i l
N pp e

mamma
Are o l a

y
L mp h v e sse s l gig ji
o n to o n
ly
mp h v e sse s o l f abdo me n

FI G . I 4 .
— Di g a ram o f the C o n n e c t o ns i o f th e L y m p h Ve sse l s O f
t h e M am m a .

Ly mp h o glan dula Ax illa res ( Axillary Ly mp h Glan ds) .

The ly mp h gla n d s in th e a x illary r e g io n are sp ok e n o f,

co lle ct iv e ly, as the a x illary gla n d s, bu t fo r co n v e n ie n c e o f
d e scr ip t io n , an d to fac ilitat e a m or e p r e c ise k n ow le dg e o f
th e ir co n ne ct io n s an d a ssoc iat io n s, th e y are su bd ivid e d in to
se v e ra l su bord in at e grou p s So m e o f th e g la n d s hav e be e n .

r e mov e d as th e d isse ct io n p roc e e d e d, an d oth e r s are so sm a ll

that th e y m ay have e sca p e d the att e n t io n o f the d isse ct o r ;
bu t if h e h as fo llow e d th e d ir e ct io n s g iv e n a bov e h e w ill
hav e n ot e d at le a st four grou p s o f gla n d s ( 1 ) A lat e r al o r .

brach ia l gro u p co n sist in g o f six o r m or e gla n d s, wh ich lie

3 0 TH E SUPER I O R EXTRE M I TY
a lo n g the a x illary v e sse ls Th e y r e c e iv e the ly mp h v e sse ls
.

fro m th e gr e at e r p art Of th e u pp e r e x tr e mity an d tho se at t h e ,

u p p e r p art o f the cha in also r e c e iv e ly mp h fro m th e d e e p

p art o f t h e m a m ma
'

( ) p
2 A e.ctora l gr o u p o r a n t e r ior grou p , ,

wh ich lie s in the a n gle be tw e e n th e a n t e r ior an d me d ial wa lls

O f t h e a x illa Th is is su bd iv isible in to two p art s : ( a) an
.

u pp e r grou p o f two or thre e sm a ll gla n d s wh ich lie be h in d

th e p e ctora lis m ajor in th e r e g io n o f th e se co n d an d th ird
in t e rco sta l sp ac e s th e se r e c e iv e ly mp h fro m the a n t e r io r wa ll
—

o f t h e thora x an d fro m the lat e ra l two th ird s o f th e m a m m a -

n in fe r ior grou p wh ich lie s a lo n g th e p o st e r ior bord e r o f

( )
b a

th e lat e ra l thorac ic art e ry an d r e c e iv e s ly m p h fro m t h e lat e r al

,

wa ll o f the thora x ( 3 ) A p o st e r ior o r su bsca p u lar gr o u p

.
,

wh ich lie s a lo n g the su bsca p u lar art e ry o n the p o st e r ior wa ll o f

th e a x illa an d r e c e iv e s ly mp h v e sse ls fro m the back
, ( )
4 T h e .

de lto p e ctora l g la n d s a grou p o f two o r thr e e sma ll g la n d s

-
,

wh ich lie in t he de ltO p e ctoral tr ia n gle an d r e c e iv e ly mp h

-

fro m t he p ro x ima l an d lat e ra l p art s o f t he arm .

I n add it io n to th e ly mp h g la n d s wh ich are u sua lly se e n in

an ord in ary d isse ct io n th e r e are thr e e o th e r grou p s o f g la n d s
,
.

nterp ecto ral gla n ds fr o m o n e to thr e e or four wh ich lie

( )
a I -

, ,

o n th e a n t e r io r sur fac e o f th e e ct o ra lis m in or ; th e y r e c e iv e

p
ly mp h fro m t h e d e e p p art o f th e m a mm a by ly m p h v e sse ls
wh ich pie rc e the p e ctora lis m aj o r ( b) Th e central glands .
,

wh ich are v e ry varia ble th e y lie e ith e r o n the surfac e o f th e

a x illary fa sc ia in a p ock e t o f its su bsta n c e o r d e e p to it
, ,

in th e fat o f t h e midd le p art o f th e a x illa th e y hav e n o

a ff e r e n t s fro m an y d e fin it e r e g io n bu t are co n n e ct e d w ith
,

t he oth e r grou p s ()
c .Th e infraclavicu lar gla n ds wh ich lie ,

in th e a p e x o f th e a x illa be h in d t h e co sto c o raco id me mbra n e -

.

Th e y r e c e iv e e ffe re n t s fro m all the low e r grou p s an d th e ir ,

e ffe r e n t s u n it e to for m a su bc lavia n ly mp h tru n k wh ich

t e r min at e s o n th e le ft sid e in the tho racic du ct an d o n th e ,

right sid e in t he right ly mph du ct ( F ig .

R ami Lat era les ( O T Lat eral Cut an e o u s Bran ch e s) o f t he

. .

Ant erio r Bran ch es o f t he Seco n d an d Third Th o racic N erv es .

— As a ru le th e fir st thorac ic n e rv e do e s n o t g iv e o ff a lat e ra l
,

bra n ch . That wh ich sp rin g s fro m the se co n d th o rac ic n e rv e

is th e larg e st o f th e se r ie s an d d iffe r s fro m th e oth e r s in n o t
,

d ivid in g in to an a n t e r ior an d a p o st e rior bra n ch I t is t e r me d .

th e interco sto brachial n erve o n accou n t o f its be in g d istr ibut e d

-

to the sk in o n the me d ial an d dor sa l a sp e ct s o f the p ro x ima l

 AX I L L ARY SP AC E

p art o f t h e arm To r e ach th is d e st in at io n it cro sse s th e

.

ax illa an d p ie rc e s the d e e p fa sc ia B ut be for e p ie rc in g the .

fa sc ia it e sta blish e s co m mu n icat io n s an d f or m s a p le x ifor m

arra n g e me n t in the a xilla w ith the m e d ia l cuta n e ou s n e rv e o f
t he arm an d th e lat e ra l bra n ch o f th e th ird thorac ic n e rv e
, .

The p le x u s so for me d may be j o in e d by a n oth e r tw ig wh ich

D id b h h mi y e lt o f t al arte r
A i ran c o o ra co - ac ro
y lla r
A
arte
C hm i m
O laCO ld
’

y p ro ce ss
x
n t e ri o r u e ral c rc u fle x art e r
A mi b h
c ro al ran c o f th o

T h o raco - ac ro i
m al art e r y
t h
C lavic u la r
o rac o - ac ro
b
mi
ran c
al art e r
h o
y
f

e ral
C i rc u m tle x a rt e r y
Su b sca p u lar a rt e r y
C i rc um fl e x y
sc ap u lar art e r

Su b i
c lav u s

o rac o -
d o rsal a rt e r y
S e rrat u s ant e r o i r

L a te ral t h i
o rac c art e r y

FIG . 1 5 .
— Di i
sse c t o n o f the A i x ll y A t y
ar r er and its B ran ch e s .

is occa o a
si n lly p r e se n t viz th e m in ut e lat e ra l cuta
,
n e ou s .
,

bra n ch o f th e fir st thorac ic n e r ve .

Th e lateral branch o f the th ird thorac ic n e rv e d iv i d e s i n to

a t r
n e i or o
an d p s e t r ior art wh ich a re d i s tr ib ut e d in th e
an p ,

ordin ary way F ro m the p o st e r ior bran ch tw ig s are giv e n to

.

k a
th e s in o f the x ill a a dn t h e t e r m in a l tw ig s a r e d is tr ib ut e d
,

to the in t e gu me n t o n the p ro x imal p art o f the me d ial a sp e ct

'

o f th e arm .

Art eria Ax illaris .

— Th e a x illary art e ry is th e ch ie f art e ry
 TH E SUPER I O R EXT R E M I TY
Of u p p e r limb I t e n t e r s th e ax illa at its a p e x at the
the .
,

out e r bord e r o f the first rib co mme n c in g as th e c o n t in ua ,

t io n o f th e su bclav ia n art e ry I t lie s fo r a short d ista n c e .

, ,

P i i mfl x y A i i mfl x y o s t e r o r c rcu e art e r n t e r o r c rcu e arte r

S b p l y li m j to ta s a o r
h l
u sc a u ar art e r
M C u sc
b o ra c o -
rac ia is

Axill y (O ar n e rv e .

C ph e

A mi l c ro a ar
L l i h i
a t e ra an t e r o r t o ra c c n e rv e

L l
at e ra d fb
co r h o ra c
Th mi l
o rac o -
a c ro a
Axill yar ya rt e r ,
1

i
M e d al a n t e r o r i
t ho rac c i

ial cu tan e o us ne r e o v f the a

n e rv e ( O T m u s cu lo
.
-
sp rai l
ap u a l (O T . .

n o f a l at e ra l cu t ane o u s n e r e v

I
v
er e ( O T m dd e
. . i l su bscap u lar )

Lo ng t h o rac c ne r i ve
I n te rco st o brach a n e r e
-
il v
An te ri o r li f afl Ch Of a l
L at e ra tho rac c art e r i y
l a t e ra l c u t an e o u s n e r e v l g
( O T o n t ho rac i c)
. .

FI G . 1 6 — The
. f the A
co n te n ts o xill
ary S p ace e p o se d by t h e re fl e c t o n o f th e x i
li j j
P e ct o ra s M a o r an d t he su b ace n t fasc a, an d t he re mo va o f the fat an i l
l
t h e y m p h g an ds l
P art o f t he a ary v e n h as be e n re m o ve d to e p o se
. xill i x
i l
t h e me d a c u tan e o u s ne rve o f th e fo re arm an d th e u n ar n e rve l .

o n me d ia l wa ll o f th e a x illa , cro sse s th e fat in th e a n g le

th e
be tw e e n th e me d ia l an d p o st e r ior wa lls, an d th e n ru n s a lo n g
the lat e ra l wa ll t o th e low e r bord e r o f th e t e r e s m aj or th e r e it
 AX I L L ARY SP AC E 33

le av e s th e a xilla an d p a sse s in to the arm wh e r e it be co me s th e ,

brach ia l art e ry F o r co n v e n ie n c e o f d e scr ip t io n it is u sua lly

.

d ivid e d in to thr e e p art th e p art a bov e t he p art be h in d an d

s—
, ,

t h e p art be low t h e p e ctora lis min or wh ich are k n ow n ,

r e sp e ct iv e ly as the first se co n d an d th ird p art s , Th e , .

d ir e ct io n wh ich the ar te ry tak e s varie s w ith the p o sit io n o f

th e limb Wh e n th e arm is at a right a n gle w ith th e body
.
,

th e d ir e ct io n is that o f a stra ight lin e fro m t he c e n tr e o f t h e

c lav ic le to the midd le o f the be n d o f t he e lbo w Wh e n t h e .

arm is by th e sid e th e art e ry d e scr ibe s a curv e w ith th e

,

co n v e xity d ir e ct e d lat e ra lly ; an d if the arm is ra ise d a bo v e

t h e h e ad th e curv e fo r m e d by th e art e ry is co n v e x in th e
r e v e r se d ir e ct io n .

The first part o f th e a xillary art e ry lie s v e ry d e e p ly I t is .

cov e r e d a n t e r ior ly by th e skin su p e rfic ia l fa sc ia d e e p fa scia

, , , , ,

th e c lav icu lar p art o f t he p e ctora lis maj or t h e co sto coraco id ,

-

m e mbra n e an d the v e sse ls an d n e rv e s su p e rfic ia l to it

,
Ev e n .

wh en tho se are r e mov e d the v e sse l is n o t co mp le t e ly e x p o se d ,

be cau se it is e n v e lo p e d a lo n g w ith th e a x illary v e in an d gr e at

,

n e rv e s by a fu nn e l sha p e d Sh e ath wh ich is p ro lo n g e d u p o n

,
-

th e m fro m th e d e e p c e rv ical fa sc ia ( F ig an d it is .

cr o sse d by the I oo p o f co mmu n icat io n be tw e e n th e two

a n t e r ior thorac ic n e rv e s wh ich lie s in fro n t O f the sh e ath .

B ehin d th is p art o f the v e sse l are t h e fir st in t e rco sta l sp ac e

an d th e fir st d ig itat io n o f t h e se rratu s a n t e r ior m u sc le ; th e

lo n g thorac ic n e rv e an d th e me d ia l cord o f t h e brach ia l

p le x u s a lso cro s s b e h in d it To it s m edia l s ide a n d s o. m e ,

what ov e rla pp in g it is th e a x illary v e in wh ilst abo ve an d to

, ,

it s lateral side are th e lat e ra l an d p o st e r ior cord s o f t h e

brach ia l p le x u s .

Th e seco nd p art o f th e a x illary art e ry is p lac e d be h in d

th e two p e ctora l mu sc le s an d has th e thr e e cord s o f th e ,

brach ial p le x u s d isp o se d arou n d it The me d ia l cord lie s .

u p o n its me d ia l sid e th e lat e ra l cord u p o n its lat e ra l sid e

, ,

an d t he p o st e r ior cord be h in d it Th e a x illary v e in is st ill .

u p o n its me d ia l sid e bu t is se p arat e d fro m the art e ry by th e

,

me d ia l n e rv e cord -
Str ict ly sp e ak in g it is n o t in a pp o sit io n
.
,

w ith any mu scle p o st e r iorly be in g se p arat e d fro m t h e su b ,

sca p u lar is m u sc le by are o lo fatty t issu e -

.

The third an d lo ngest part o f th e a x illary art e ry is su p e rfic ial

in its d ista l ha lf be cau se th e a n t e r ior wa ll o f t h e a x illa d o e s
,

n o t e x t e n d so far dow n as th e p o st e r ior wa ll Th e r e for e .

,

—
V OL . 1 3
34 TH E SUPER I O R EXTRE M I TY
wh ilst the th ird p art o f th e a xillary art e ry is cov e re d in its ,

p ro x ima l ha lf by the p e ctora lis m ajor its d ista l ha lf is c o v e r e d

, ,

o n ly by th e sk in an d fa sc ia B e h in d it p r o x imo d ista lly are .

,
-

,
th e su bsca p u lar is the t e n do n o f the lat issim u s d r i
, o s an d ,
th e t e r e s m aj or
; bu t it is se p arat e d fr o m th e su bsca p u lar is
m u sc le by the a x illary O T c ircu m fl n d rad ia l
( e x
) a
( O T . .
.

mu scu lo sp ira l) n e rv e s an d fr o m the lat issim u s dor si an d t h e

-

t e re s maj or by the rad ia l n e rve To its lat e ra l sid e is the .

L a t e ra l c o rd

P i
o st e r o r c o rd o f brac h i l pl
a exus

Med a il c o rd

M u sc u lo -
c u t an e o u s n e r e v

M e d an i ne r e v ( l a te ra lh e ad )

d ani n e rv e ( me d a i lh e ad )

M ed a il c u t an e o u s n e r e o v f t h e fo re arm

M ed ail c u t an e o u s n e r e o v f the arm

M e d an i v
ne r e

Ul nar n e r e v
R di l i l)
l

a (O T m
a n c rv e . . u sc u lo -
sp ra

FI G . 1 7 .
-
Di g m t h w l t i
a ra o s o re a o ns o f Axill y Var e sse ls an d N e rv e s .

coraco brach ia lis mu sc le bu t be tw e e n th e m u scle an d th e art e ry

-

are t h e m u sc u lo cuta n e ou s an d t h e m e d ia n n e rv e s
-
To th e .

me d ia l sid e o f th e art e ry is th e v e in w ith th e m e d ia l ,

cuta n e ou s n e rv e o f th e for e ar m in th e a n t e r io r a n g le be tw e e n
th e art e ry an d v e in an d t h e u ln ar n e rv e in t h e p o st e r io r a n g le
,

be tw e e n t h e art e ry an d v e in The m e d ia l cuta n e ou s n e rv e .

o f th e arm lie s a lo n g t h e m e d ia l Sid e o f t h e v e in

( g
F i .

The branch es o f t h e ax illa ry art e ry hav e be e n see n at

d iffe r e n t stage s o f the d isse ct io n Th e y shou ld n o w be e x .

amin e d m or e fu lly ( F ig Th e y are .

3 6 T H E SU PER I O R EXTRE M I TY
Alar Th o racic .
-
Th is sm all arte r y su pp lie s ly m ph g lan ds
th e fat an d

in the a i la, xl bu t it is rare ly pre se n t as a se p arate bran ch , an d its p ace is l

l
u su a ly t ak e n by t w ig s fro m th e su bscap u lar an d lat e ral th o racic arte rie s .

Art e ria Subsca p ulari s — Th e su bsca p u lar bra n ch o f th e

.

a x illary is a r e lat iv e ly larg e an d co mp arat iv e ly short bra n ch

wh ich sp rin gs fro m th e p ar e n t tru n k at th e low e r bord e r o f
t h e su bsca p u lar is m u sc le I t d e sc e n d s, fo r a bout o n e in ch ,
.

a lo n g the lo w e r bo rd e r o f the su bsca p u lar is, an d th e n d iv id e s

in to two t e r m in a l bra n ch e s, t h e a circu m fl e x a sca p u la , an d.

t h e a thorac o dor sa lis

.
-
Th e circu mflex scap u lar branch turn s
.

rou n d t he a x illary bo rd e r o f th e sca p u la o n it s way t o the

in fra sp in ou s fo ssa o f that bo n e , wh e r e it a n a sto m o se s w ith
bra n ch e s O f th e tra n sv e r se c e rv ica l an d tra n sv e r se sca p u lar
art e r ie s . I t g iv e s n u m e rou s bra n ch e s to t h e adjac e n t
m u sc le s Th e tho raco do rsal branch d e sc e n d s a lo n g th e lo w e r
.
-

bord e r o f t h e su bsca p u lar is t o t h e in fe rior a n g le o f t h e

sca p u la .I t g iv e s bra n ch e s t o t h e adjac e n t m u sc le s an d
a n a sto m o se s w ith the lat e ra l thorac ic art e ry an d w ith
bra n ch e s fro m t h e in t e rc o sta l art e r ie s I t se n d s bra n ch e s
.

a lso in to the su bsca p u lar fo ssa wh ich a n a sto m o se w ith tw ig s

o f th e tra n sv e r se an d c ircu m fl e x sca p u lar art e r ie s, an d
w ith bra n ch e s o f th e d e sc e n d in g bra n ch o f the tra nsv e r se
c e rv ica l art e ry .

Aa Circumfl ex a H u meri, An t erio r et P o st e rio r ( O T

. . .

Ant e rio r a n d P o st e ri o r i
C c r um fl ex Art e e s)
ri — Th e a n t e r ior .

an d th e p o st e r ior hu m e ra l c ircu m fl e x art e r ie s both ar ise fro m

th e a x illary at th e sa m e le v e l, a short d ista n c e d ista l to th e

orig in o f the su bscap u lar art e ry The po sterio r hu meral cir .

cu mfl ex ar t ery is m uch th e larg e r o f the two O n ly a sma ll .

p ort io n o f it c a n b e se e n at t h e p r ese n t stag e I t sp r in g s .

fro m th e p o st e r ior a sp e ct o f t h e a x illary art e ry, an d at o n c e

p a sse s b ackward s ,
w i th t h e a x illary n e rv e , in t h e in t e rva l
be tw e e n th e su bsca p u laris an d t e r e s m ajor m u sc le s o n th e
m e d ia l sid e o f t he surg ica l n e ck o f th e hu m e ru s The .

sma lle r anterio r hu meral circu m flex artery tak e s orig in fro m th e
lat e ral a sp e c t o f th e a x illary art e ry, an d ru n s lat e ra lly , in fro n t
o f t h e surg ica l n e ck o f th e hu me ru s, u n d e r cov e r o f th e
coraco brach ia lis an d short h e ad o f the bic e p s brach ii
-
.

R e ach in g the in t e rtu be rcu lar sulcu s, it d ivid e s in to two

bra n ch e s O n e o f th e two is d ir e ct e d p ro x ima lly , a lo n g th e
.

lo n g h e ad o f th e bic e p s brach ii, to th e sh o u ld e r j o in t ; t h e -

oth e r p a sse s lat e ra lly, to th e d e e p surfac e o f the d e lto id , an d

 AX I L L ARY SP AC E 37

fi n a lly a n a sto mo se s w ith so m e o f the t e r min a l tw igs o f th e

p o st e r io r c ircu m fl e x art e ry o f t h e hu m e ru s .

V e n a Axillaris — The a xillary v e in has the sa m e e x t e n t

.

as t h e art e ry I t be g in s at t h e low e r bord e r o f t h e t e r e s

.

m ajor as t h e p ro x ima l cont in uat io n o f the ba silic v e in o f th e

,

arm an d it be co mes th e su bc lav ia n v e in at the out e r marg in

,

o f t he fir st rib At th e low e r m arg in o f t he su bsca p u lar is

.

it r e c e iv e s the two vena co mites o f the brach ia l art e ry an d ,

abov e the le v e l o f t h e p e ctora lis m in or it is jo in e d by the

c e p ha lic v e in I ts oth e r tr ibutar ie s corr e sp o n d m or e o r
.
,

le ss c lo se ly to th e bra n ch e s o f th e a x illary art e ry

, .

M Subclav ius
. Th e su bc lav iu s is a sm a ll m u sc le wh ich
.
—

lie s imm e d iat e ly be low t h e c lav ic le e n c lo se d be tw e e n t h e ,

two lay e r s o f th e co sto coraco id m e mbra n e I t take s or ig in -

.
,

by a short r o u n d e d t e n do n fro m the su p e r ior sur fac e o f ,

t h e fir st co sta l arch at th e ju n ct io n o f t h e bo n e w ith th e

,

cart ilag e an d the fl e shy be lly is in se rt e d in to th e sha llow

,

groov e o n the in fe rior sur fac e o f th e c lav ic le The n e rv e o f .

su p p ly is d e r iv e d fro m t h e fi fth an d six th c e rv ica l n e rv e s an d

e n t e r s the p o st e r ior sur fac e o f t h e m u sc le W h e n th e mu sc le .

co n tract s it d e p r e sse s t he c lav ic le an d draw s it Slight ly

forward s .

D is s e c t i o n — W h e n t h e su b lav iu s h as be n
. am in d it m st c e ex e u
be di id d h riz o n t lly an d w h n t h at h as b n do n e t h e c st
v e o a ,
e ee o o
clav i lar lig am e t w ill be f o n d be h in d t h m e dial n d o f t h e
cu n u e e
m u scle .

t
At h is s ag e , t wt t
i h t h e assis an ce o f t h e disse c o r o f t h e h e ad t
v
an d n e ck , t h e cla icu la r p art o f t h e s e rn o cle ido m as o id m u scle t - - t
t t
m u s be de ac h e d f ro m t h e su p e rio r bo rde r o f t h e cla icle an d v
t
t li e s e rn al p art o f t h e m u scle m u s be p u lle d o ards t h e m e dian t t w
p lan e .

Art icula t io St ern o clavic ula ris — Th e st e r n o c lav icu lar j o in t .

-

is a d iarthrod ia l jo in t , for m e d by th e st e r n a l e n d o f th e
c lavic le , the lat e ra l p art o f th e su p e rior bord e r o f th e
m a n u br iu m st e r n i, an d th e su p e r ior sur fac e o f th e st e r n a l
e n d o f t h e cart ilag e o f th e fir st rib I t h e lp s to in cr e a se .

th e ra n g e o f th e f orward , backward , an d u p ward m ov e m e n t s

o f th e arm The c lav ic le is attach e d to the st e r n u m an d t h e
.

first rib by a stro n g fi brou s ca p su le W ith in th e ca p su le is an .

art icu lar d isc wh ich se p arat e s t he j o in t cav ity in to two p art s .

I t is attach e d to t h e su p e r ior bord e r o f t h e st e r n a l e n d o f t h e

c lav ic le , t o th e su p e rior sur fac e o f th e fir st c o sta l cart ilag e , an d
to the a n t e rior an d p o st e rior p art s o f the ca p su le On th e .
 38 TH E SU PE R I OR EXTRE M I TY
lat e ra l a sp e ct o f the ca p su le th e r e is a str o n g acc e sso ry
liga m e n t t h e co sto clavicu lar ligament wh ich lie s be h in d t h e
,
—
,

o r ig in o f t h e su bc lav iu s m u sc le an d a sse s u p ward s back

p ,

ward s an d lat e ra lly fro m the fir st rib to th e c o sta l tu be rc le o n

,

the low e r sur fac e o f t he c lav ic le I n th e ca p su le it se lf th e r e .

are thr e e th ick e n e d ba n d s an a n t e r io r a p o st e rior an d a , , ,

su p e r io r an d as so m e o f t h e fi br e s o f th e latt e r p a ss fr o m
,

o ne c lav ic le to the oth e r it is ca lle d th e in terclavicu lar ,

Jo i n t c ap su

Jo i n t ca vi t y

I n t e rart ic u la
lg
i a me n t

Jo i n t ca vi t y An t e r o i h d
rC o n ro
s t e rn a l li g m a e nt

FI G . 1 8 — S te rn o
.
-
l vi l
c a cu ar an d C o s to -
s te rn a lj i o n ts .

D is s e c t i o n — t P u ll th t
le id e s e rn al h e ad o f the s e rn o -
c o
m a t id m s l
s o m dian p lan
u c e t o w ard t h
C t t h r gh t h s e e e . u o u e
an t ri r p rt
e f t h c ap s l
o f th j i t l
a o t th t r m e u e o e o n c o se o e s e nu .

P a s t h k if b h i d t h cap l av idin g t h e a t ri r j g lar

s e n e e n e su e , o n e o u u
v in w h i h r n lat rally b h i d t h pp r b rd r f t h j i t
e ,
c u s e e n e u e o e o e o n ,

an d de t a h t h fi br f rig in f t h st rn hy id m s l w h i h
c e es o o o e e o -
o u c e c
sp rin g f ro m t h ba k o f t h ap s l C t t h r gh t h p t ri r
e c e c u e . u o u e o s e o
lig am e t a d p ll t h n lav i l lat rally
n Th art i lar di c i
u e c c e e . e cu s s
no w p d D t ac h it f r m t h fi r t rib
ex o se . t h n rry th k if
e o e s e ca e n e

lat rally b l w t h
e lav i l a d e o t t h r gh t h l w r p art e f c c e n cu o u e o e o
th e ap l an d t h
c t lavi lar lig am n t Th lavi l
su e e co s o -
c cu e . e c c e
can n o w be di p la d ffi i n t ly p w ard a d l t rally t bri g
s ce su c e u s n a e o n
th ew h l o f t h bra h ial p l
o e i t Vie w B f r t dy i g
e c ex u s n o . e o e s u n

th epl s th di t r h o u ld n o t e t h at b h i d t h t rn o
exu ,
e sse c o s e n e s e
 AX I L L ARY SP AC E
39
clavi lar j i t t h r ar t h l w r fi br f th t r hy o id
cu o n e e e e o e es o e s e no -

an d t rn t hyr id m l w h i h i t rv righ t
s e o n th eo id u sc e s
-
c n e ene, o e s e,
b tw n t h
e ee c ap l f t h e j in t a d t h
e bif r at i f th
su e o o n e u c o n o e
inn m at
o art ry in t
in it righ t emm o n ar t id an d s b lav ian
e o s co c o u c
bran h a d
c t h l f t ide b tw n t h j o in t an d t h l f t
e s, n , o n e e s e ee e e e
mm n ar t id art ry
,
co o c o e .

P lex us B rach ialis ( Brachia l Plex us) .

— Th is imp o rta n t

gcAvut n n ew !

A N N R I OR
‘
u r e a“
n annc cc “ N i

U S n e rv e

l
L a t e ra cu t a n e o u s n e r ve
M ED I AN N ER

S u bsc ap u l ar n e rv e I
I n t e rc o st o bra c h i a n e r e
-
l v
Ul n ar n e rv e M e di a l c u t a n e o u s n e rv e o f arm
M e di a l c u t a n e o u s n e rv e o f fo re arm

FIG . 1 9 .
— Di agra m o f B rac h i a l P l e x u s an d its B ran c he s .

le xus is for m e d by t he a n t e r io r ra mi o f th e lo w e r fo ur
p
c e rv ica l n e rv e s an d th e gr e at e r p art o f t h e a n t e r io r
ra mu s o f th e fir st thorac ic n e rv e Th e p le x u s is furth e r .

r e in fo rc e d a bov e by a sm a ll tw ig o f c o m mu n icat io n wh ich

, ,

p a sse s f ro m t h e f ourth t o t h e fi fth c e rv ica l n e rv e wh i lst b e low , , ,

a similar c o n n e ct in g tw ig n o t in fr e qu e n t ly p a sse s u p ward s in ,

fro n t o f t h e n e ck o f t h e se co n d rib fr o m the se co n d to ,

 4 0 TH E SUPER I O R EXT R E M I TY
th e fir st thorac ic n e rv e The ma n n e r in wh ich the n e rv e s
.

j o in to fo r m the p le x u s is v e ry co n sta n t The fif th an d six th .

cervical n erv es u n it e t o for m an upper tra nh th e seventh r e m a in s

sin g le an d p roc e e d s d ista lly as a tranh ; wh ilst the

U pp er t ru nk

Sca l i
e n u s a n t e r o r an d o n l g u s co lli
Sca l e nu s me diu s an d i
p o st e r o r

P hr i
e n c ne r e v
l i
Sc a an t e r o r an d o n u s co l g lli
l i i
.

S c a me d u s an d p o st e r o r
i l
.

M dd e t ru nk

N Tno aA C A u s A fl fl i mo
.

i n AN S
Sc al i l g
an t e r o r an d o n u s co lli
l i
.

Sc a . me di u s an d p o st e r o r

Sca l e n u s an t e r o r an d i l g
o n u s co lli
Sc a l e nu s m e di u s an d p o st e r o i r

L o we r t ru nk

N I N T£ R C O $ TA U 3
.

F IG . 20 .
— Di g
a ram o f t h e B rac h i al P l e x u s . P ate rso n .

an d first jo in to co n st itut e a third O r

tho racic n erves ,

lo wer tran h A Short d ista n c e a bo v e th e c lav ic le e ach o f th e

.

thr e e tru n k s sp lit s in to an anterio r an d a po sterio r divisio n .

W h e n t he thr e e a n t e rior d iv isio n s are ra ise d o n th e ha n d le

o f a k n ife t h e thr e e p o st e r ior d iv isio n s w ill be se e n u n it in g to
,

for m t h e po sterio r co rd o f th e p le x u s I t shou ld be n o t e d that

.

t he low e st o r m o st m e d ia l o f t h e p o st e r ior d iv isio n s is m uch

 AX I LL ARY SP AC E 4 1

s ma lle r tha n th e oth e r two Of th e thr e e a n t e r ior d iv isio n s

.

th e two upper j o in to c o n st itut e t h e lateral co rd wh ilst t h e ,

lo wer p a sse s d ista lly by it se lf as t h e medial co rd o f t h e p le x u s

,
.

F ro m th e thr e e cord s o f th e p le x u s t h e bra n ch e s are giv e n

o ff wh ich su p p ly t h e su p e rio r e x tr e m ity g
( F i s 1 9 20 .
, ,

F ro m th e a bov e d e scr ip t io n it w ill be se e n that t he p le x u s

may be d iv id e d in to four stag e s

F iv e se parate n e rve s ( v iz lo w e r fo u r ce rv ical an d fi rst.

,

th o racic ) .

Th re e n e rv e tru nk s ( v iz an u pp e r middle an d lo w e r)
-
.
, , , .

Th re e an te rio r div isio n s an d th re e po st e rio r div isio n s .

Th re e n e rv e co rds ( v iz a lat e ral a m e dial

-
an d a
.
, , ,

po s t e rio r ) .

Th e p le x u s t d s fro m the lat e ra l bord e r o f th e sca le n u s

ex e n

a n t e r ior to th e low e r bord e r o f the p e ctora lis m in or an d it ,

lies in th e low e r an d me d ia l p art o f t h e p o st e r ior tr ia n g le o f

t he n e ck be h in d t he midd le th ird o f t h e c lav ic le an d in t h e
, ,

a x illa As a ru le the fir st two stag e s are in the n e ck the

.
, ,

th ird stag e is be h in d th e c lav ic le an d th e la st stage is in the ,

a x illa ( F ig s 2 1 .
,

I t h as be e n cu sto mary to d iv id e t h e bra n ch e s o f the

p l e x u s in to su p rac lav icu lar a n d in frac lav icu l ar grou p s b u t ,

such a d iv isio n is n e ith e r sc ie n t ifica lly accurat e n o r O f p ract ica l

imp orta n c e Th e bra n ch e s o f t he p le x u s sp r in g e ith e r fro m

.

it s root s or its tru n k s or it s cord s

, ,
.

Th p t
e f th pl x
ar s o e b v th
e l vi l
us a d th b
o eh g iv e c a ff i c e , an e ranc es en o n

th e v icu lar re gio n mu st be fo u n d an d cle an e d by the disse cto r o f

su p racla ,

t he h e ad and n eck ; the re m ainin g p arts o f th e p le x u s an d its bran ch e s

sh o u ld be dis lay e d b
p y th e disse c t o r o f th e u pp e r e x t re m ity bu t the t wo ,

disse cto rs m u st co mbin e to e x am in e th o ro u gh l y th e g e n e ral re latio n s an d

the bran ch e s o f th e p le x u s .

The R elat io n s o P le x u s Sup erfi cial to the c e rv ica l

f the —

p art o f t h e p le x u s lie t h e Sk in t h e su p e rfic ia l f

,
a sc ia t h e ,

p laty sm a t h e, d e e p fa s c ia t h e e x t e,
r n a l jugu lar v e in t h e tra n s ,

v e r se c e rvica l an d tra n sv e r se sc ap u lar v e in s th e p o st e rior ,

be lly o f t h e o mo hyo id m u scle an d th e tra n sv e r se c e rv ica l

-

art e ry B ehin d it is the scale n u s m e d iu s m u sc le ( F ig

. .

I n th e in t e rva l be tw e e n th e n e ck an d t h e a x illa t h e c lav ic le ,

an d th e tra n sv e r se sca u lar art e ry an d v e in are in fro n t o f

p
it an d t he th ird art o f t h u b c lav i a n art e ry is a n t e r ior to
p e s

its low e st tru n k .The sca le n u s m e d iu s is st ill be h in d it .

I n t h e a x illa it h as in fro nt of it th e in t e gu me n t th e fa sc ia , ,
 4 2 TH E SUPER I OR EXTR E M I TY
th e pl aty sma th e p e ct o ra lis m ajor th e p e ct o ra lis m in or the
, , ,

co st o coraco id me mbra n e the c e p ha lic v e in an d t he a x illary

-
, ,

art e ry ; behind it lie the u p p e r se rrat io n o f th e se rratu s

a n t e rior th e fa sc ia fille d in t e rva l be tw e e n th e me d ia l an d
,
-

p o s t e r io r wa lls o f th e a x illa an d th e su bsca p u lar is m u sc le ,

( g
F i .

Th e B ranch es
P le x u s — The bra n ch e s fr o m th e
o f the
root s o f the p le x u s are ( I ) B ra n ch e s t o th e sca le n u s
a n t e rior th e lo n gu s co lli the sca le n u s m e d iu s an d th e
, , ,

sca le n u s p o st e r ior ( fro m C v VI VII ( )

2 A co m . .
,
.
,
.
,

m u n ic at io n to th e p hr e n ic n e rv e ( fro m C v o r v an d . .
,
.

L e v at o r scap u la

S t e rn o hy i d m
-
o usc le

D o rsal scap u lar n e rv e

E x t e rnal ju g u la r v e n i
S cale n u s me d ius S t e rn o q n as t o id
i i i u sc le

T ran s v e rse c e rv i
c al art e r

lav i au
S u p rasc ap u l

FI G . an —
c Di i
sse c t o n O f th e l o we r p art P o ste ri o r Tri angl e o f
o f t he th e N e ck ,

ho w i n g
s the S u p rac l av i c u l ar P art o f the B rac h i al P l e x u s .

3) dor
Th e sa lis sca p u la n e rv e wh ich su
pp l ie s t h e rho m b o id ,

mu sc le s ( fr o m C ( )
4 T h e lo n g th o rac ic n e rv e wh ich
.
,

su pp lie s t h e se rratu s a n t e r ior ro m

( f C v VI . .
, .
,

Th e bra n ch e s fro m t h e tru n k s o f the p le x u s are : ( I ) Th e

n e rv e to th e su bc laviu s fro m t h e u p p e r tru n k fr o m C v
( ,
. .
,

I t h as a lr e ady be e n se e n p ie rc in g t he p o st e r io r sur fac e o f t he

co sto coraco id me mbra n e an d e n t e r in g the p o st e rio r a sp e ct
-

o f t h e su bc lav iu s ( p ( )
2 T h e su p ra sca p u lar
. n e rv e ,

fro m t h e u p p e r tru n k ( fro m C v I t w ill be fou n d . .

,

cr o ssin g the lo w e r p art o f the p o st e rio r tria n g le d e e p t o ,

t h e p o st e r io r be lly o f t he o m o hy o id m u sc le an d d isa p p e ar -

in g through th e sca p u lar n otch o n its way to th e dor su m

sca p u la
( g
F i .
44 TH E SUPER I O R EXTRE M I TY

p a sse s d o w n ward s a n d lat e ra lly g iv e s bra n ch e s to ,

the low e r
p art O f t h e su bsca p u lar is th e n p a sse s thr o ugh ,
t he a ngle
23 24 25

FI G . 1 6 .
— Di sse c t o n i to s o h w t h e G e n e ra l R l ti
e a o ns o f t he B rac h i al P l e x u s .

1 Acce sso ry n e rv e M di l
e a cu t an e o u s n e r e o v f a rm .
lv l il
. .

v
N e r e t o e at o r sc ap u a I n t e rc o s t o bra c h a n e r
-
v e.
l L i im i
.

v
L e a t o r sca p u a a t ss u s do rs
D l l l
. .

o rsa sc a p u a r n e r e . v Tho rac o -

do rsa n e r e v
i i
.

g
L o n t ho rac c n e r e v Lo n g th o ra c c n e r e v
l i I lj g l
. .

Sca e n u s me d u s n t e rn a u u ar ve in.
l S p i id y
.

Su p ras cap u ar n e r e v u hy
er o r t re o a rt e r
i S bm xill y g l d
. .

Se rra t u s a n t e r o r u a ar an
l Ex lj g l v i
. .

U p p e r su bsc a p u ar n e rv e t e rn a u u ar e n

l i S l
. .

S u bsc ap u ar s m d
c a e nu s e i u s.
li m i hi l pl x
.

P e c t o ra s no r Up p k fb
er t ru n o rac a e us.
i li M i ddl hi l p l x
.

N er v e t o c o raco -
brach a s. k f b
e t ru n o rac a e u s.
Axill y ar n e rv e E igh h ti l v c e rv c a ne r e .
Om hy id
.

M l
u sc u O - c u t an e o u s n e r e v o -
o
Rd l v b l vi
. .

a ia ne r e N e rv e t o su c a us

M di l i h i v
. .

e a n n e rv e . L at e ra ante r o r t o rac c n e r e
M di l M di l i h i v
.

e a cu t ane o us n e r e o v f fo re arm
. e a an t e r o r t o rac c n e r e .

be tw e e n th e thoraco dor sa l -
an d c ircu mfl e x sca p u la art e r ie s
an d e n d s in t he t e r e s m ajor, wh ich it su p plie s .
 AX I L L ARY SP AC E 45

N . Th o ra co do rsa li s ( O T L o ng Su bsca p ular N erv e)

. . Th e .
-

thoraco dor sa l n e rv e sp rin g s fro m the p o st e rior c o rd o f th e

-

le x u s, a sse s o bliqu e ly dow n ward s a d lat ra lly through t h

p p n e , e

a x illa, an d jo in s the thoraco dor sa l art e ry n e ar the low e r p art

-

O f t h e lat e ra l bo rd e r o f t h e su bsca p u lar is mu sc le Aft e r cro ss .

Scal e n us i
me d u s
l
Sc a e n u s an t e r o r i
p a rt o f Se rrat u s

i l
M dd e p o rt i o n o f
Se rrat u s a n t e ri o r

FIG . 2 3 .
—Se rratu s i
An te r o r m u sc l e an d o r g n o i i f the E te rn a O b q u ex l li
m u sc l e the l
sc ap u a is draw n away fro i
m th e s de o f the ch e st .

in g in fro n t f t h e art e ry it t e r min at e s in th e lat issim u s dor si,

o

wh ich it su p plie s .

N Tho racalis Lo ngu s ( O T P o st e rio r Tho racic o r Ex

. . .

t er na l i
R sp a o ry
e r t N e rv e o f B e ll) — T h e lo n g thorac ic .

n e rv e m ay n o w be studie d in its who le le n gth I t p a sse s .

dow n ward s o n th e lat e ra l surfac e o f the se rratu s a n t e rior, an d

is th e n e rv e o f su pp ly to that m u sc le I t ar ise s, in the ro o t o f .
 TH E S UPER I OR EXTRE M I TY
th e n eck fro m th e brach ial ple x u s by thr e e root s The u pp e r
, , .

two ro o t s ( o n e fro m th e fi fth c e rvica l an d th e oth e r fr o m the

six th c e rv ica l n e rv e rc ca u d u u t g
) p ie e t h e s le n s m e i s an d n i in , ,

C o ra co
brac hi a l i s and

P e c t o ra li s m i no r

O mo h
-
y id
o

2 4 .
— C o sta l asp e c t o f t he Scap u l w ith th
a e At tach m e n ts
o f M u sc l es m ap p e d o ut .

in t o o ne t
s em, g iv e o ff bra n ch e s t o
u p p e r p art o f th e the
se rratu s a n t e r ior Th e th ird root tak e s or ig in fro m t he se v e n th
.

c e rv ical n e rv e p a sse s in fr o n t o f th e sca le n u s me d iu s an d ru n s

, ,

dow n ward s fo r a co n sid e ra ble d ista n ce o n t he Surfac e o f

 AX I L L A RY SP AC E 47

th e rratu s a n t e rior be for e it u n it e s w ith the oth e r p art o f

se ,

th e n e rv e The e n t ir e n e rv e can be fo llo w e d to th e lo w e r

.

p art o f t he se rratu s a n t e r ior g iv ing tw ig s to e ach o f it s ,

d igitat io n s .

M Serra t us An t erio r ( O T Serrat u s M agnu s) — Th e

. . . .

se rratu s a n t e r ior ar ise s by fl e shy d ig itat io n s fro m t h e u p p e r

e ight r ibs a bout m idway be tw ee n th e ir a n g le s an d cart ilag e s

, .

The slip s are arra n ge d o n th e ch e st wa ll so as to p r e se n t a

g e n t le curv e co nv e x fo rward s The low e r thre e in t e rd ig itat e .

w ith the e x t e rn al o bliqu e mu scle o f the a bdo m e n The .

se rratu s a n t e r ior is in se rt e d in to t he e n t ir e le n gth o f t h e

a n t e rior lip o f th e v e rt e bra l m arg in o f the sca p u la an d it fa lls ,

n atura lly in t o thr e e p art s ( a) The upp er part co m p o se d o f .

,

t h e larg e fir st d ig itat io n a lo n e ar ise s fro m th e fir st an d se co n d ,

r ibs an d fro m a t e n d in ou s arch be twe e n th e m Th e fi br e s

, .

co n v e rg e to be in se rt e d in to a so me what tria n gu lar surfac e o n

,

th e co sta l a sp e ct o f th e m e d ia l a n g le o f t h e sca p u la ( )
b T h e .

middle part co n sist s o f two d ig itat io n s wh ich tak e or ig in fro m

th e se c o n d an d th ird r ibs The u pp e r Slip is v e ry broad an d
.
,

sp r in g s fro m th e low e r bord e r o f th e se co n d rib Th e fi bre s .

o f t h e m idd le p art d iv e rg e to for m a th in m u scu lar sh e e t ,

wh ich is in se rt e d in to th e a n t e rior lip o f the v e rt e bra l m arg in

o f th e sca p u la be tw e e n th e in se rt io n s o f t h e u p p e r an d low e r
,

p o rt io n s
()
c .T h e lo w er p art is for m e d b
y t h e r e m a in in g

d igitat io n s o f the m u scle Th e y co n v e rg e to fo r m a th ick .

m a ss wh ich is in se rt e d in t o a r o ugh sur fac e u p o n t h e c o sta l

,

a sp e ct o f the in fe rior a n gle o f the sca p u la The d e e p surfac e .

o f th e se rratu s a n t e r ior is in co n tact w ith th e ch e st wa ll .

I t is th e m o st p ow e r fu l p rotract o r o f th e wh o le u p p e r
e x tr e m ity .

D I SSE C T I ON OF TH E B AC K .

D i s s e c t i o n — At t h e e n d o f t h e fi f h day , af e r t he disse c o r t t t
t
h as e x am in e d t h e se rra u s an e rio r an d c are fu lly re ise d t h e t v
t t
co n e n s o f t h e ax illa, h e m u s re p lace t h e cla icle , p ack t h e t v
ax illa wt i h t o w o r rag s s e e p e d t
i h p re se r a i e so lu io n an d wt v tv t
fi x t h e sk in fl ap s t o t h e all o f th e w
h o rax i h a f e w s it c h e s t wt t .

t
W h e n h e re u rn s o n t h e sixt h day h e ill fi n d h a t h e bo dy h as w t t
be e n p lace d u p o n it s f ace , wt
i h blo ck s su pp o r in g th e c h e s an d t t
t h e p e l is v
I t w ill re m ain in h a p o si io n f o r fi v e day s , an d
. t t t
t t
du rin g th e fi rs tw o o f h o se t h e disse c o r o f t h e u pp e r e xt re m i y t t
t t t
mu s e x am in e t h e s ru c u re s h ic h co n n e c t h e lim b w i h t h e w t t
t
p o s e rio r asp e c o f t h e ru n k t t .
 48 TH E SU PER I O R EXTRE M I TY
Surf ace An at o my — I n th e me d ia n lin e o f the back th e r e

i
S u p e r o r n u c ha l li ne

M ast o i d p ro ce ss
x t e rn al o c c ipi l p
ta ro t u be ran c e

Sp i ne o f l
sc a p u a
e o f se v
e n th ce r vi ca lve rt e bra

Ac ro m i o n

I i
nfe r o r an gl e o f sc ap u a l

M ed a i l pi
e co n d yl e
Ol e c ran o n

e ad o f i
rad us

P i
o st e r o r su p e r o r i
sp i n e o f 1 1mm

St yl i d p
o ro ce ss o f u na l
G re at e r t ro c h an t e r
St yl i d p
o ro ce ss o f rad u s i
Tu be ro s i y f i hi
t o sc u m

Med a il yl
co n d
f fe mu r e o
l
L at e ra co n dy l
e o f fe m u r
L at e ra c o nl dy l
e o f t b a ii
H e ad o f fibu a l

e dial ma e o ll l us
L a t e ra ma l ll l eo us

FIG . 2 5 .
— Surface V i e w sh o w i n g I nc ii
s o n s an d Bo n y P o i n ts .

is litt le d iffi cu lty in r e cognisin g th e t ip s o f the Sp inou s p roc e sse s

 D I SSE C T I ON O F TH E B AC K 49

o f t he v e rt e br a ( F ig Th e y fo llow e ach oth e r in co n

.

se cu t ive ord e r an d it may be n ot e d wh e n th e fi n g e r is p a sse d

, ,

ov e r th e m that all o f th e m do n o t lie in t h e m e d ia n p la n e ;

,

so m e m ay be d e fl e ct e d in a slight d e gr e e t o o n e S id e o r th e
, ,

oth e r The spin e s o f the v e rt e br a are the o n ly p art s o f

.

th e sp in a l c o lu m n wh ich co m e to t h e sur fac e ; th e y a lo n e

y ie ld d ir e ct in fo r m at io n by touch to the surg e o n as to th e
, ,

c o n d it io n o f th e Sp in e At the low e r e n d o f t he n e ck th e
.
,

Sp in e o f t h e se v e n th c e rv ica l v e rt e bra ( vertebra p ro min ens)

mak e s a v isible p roj e ct io n ; an d th e sp in e s o f the fir st
two thorac ic v e rt e bra lik e w ise are v e ry p ro min e n t AS .

a ru le the m o st e v id e n t o f the thr e e is that o f the fir st

,

th o rac ic v e rt e bra At a lo w e r le v e l in su bj e ct s o f g o od
.
,

mu scu lar d e v e lo p me n t a me d ia n furrow is p roduc e d by th e

,

p ro m in e n c e o f t h e sacro sp in a lis m u sc le o n e ach s id e an d ,

t h e sp in e s o f t h e v e rt e br ae m ay be fe lt at t h e bott o m O f
t h e gr o o v e Th e furrow atta in s its gr e at e st d e p th in t h e
.

u pp e r p art o f t he lu mbar r e g io n an d it fad e s away be low , , ,

at the le v e l o f the Sp in e o f t he th ird sacra l v e rt e bra The .

fi n ge r shou ld n e x t be p a sse d d o w n ward s fro m th e th ird sacra l

sp in e be tw e e n t h e buttock s a lo n g t h e low e r p art o f th e tu be r
, ,

c u lat e d p o st e r io r sur fac e o f t h e sacru m an d a lo n g t h e p o st e r ior ,

sur fac e o f t h e coccy x t o th e t ip o f t he coccy x wh ich is t he ,

in fe r ior e x tr e m ity o f t h e v e rt e bra l c o lu m n A ft e rward s the .

fi n g e r should be carr ie d a lo n g the cr e st o f t h e iliu m I t .

co mme n c e s at th e p o st e r io r su p e r ior sp in e o f th e iliu m wh ich

can e a sily be d e t e ct e d be cau se it s p o sit io n is in d icat e d by

a small bu t d istin ct d imple wh ich lie s at th e le v e l o f th e

se co n d sacra l sp in e F ro m the p o st e r ior su p e r ior sp in e t h e
.

cr e st o f the iliu m p ursu e s a sig m o id course lat e ra lly an d ,

fo rward s .Th e h igh e st p o in t it r e ach e s is o n a le v e l w ith

t h e sp in e o f t h e fo urth lu mbar v e rt e bra an d it t e r m in at e s ,

in fr o n t in a p ro min e n c e ca lle d th e a n t e r ior su p e r ior

sp in e .

ca p u la o r shou ld e r blad e is fo r the m o st p art th ick ly

Th e s , , , ,

cov e re d by mu sc le s ; bu t in sp it e o f that its g e n e ra l out lin e

, ,

c an be m ad e o u t F ig I cov e r s a co n sid e ra ble ar e a o f

( t .

th e u pp e r p o rt io n o f t h e p o s t e r ior a sp e ct o f t h e th o ra x W ith .

t h e ha n d by th e sid e it s m e d ia l a n gle lie s o v e r t h e se c o n d

rib t h e r o o t o f its sp in e is p lac e d o p p o sit e t h e sp in e O f t h e
,

th ird thorac ic v e rt e bra wh ilst it s in fe r io r a n gle r e ach e s

,

down as far as th e se v e n th o r e v e n the e ighth rib Th e , ,

.

V OL . 1— 4
50 TH E SUPE R I OR EXTRE M I TY
sca p u la is v e r y m o bile an d move s t o a gr e at e r or le ss
,

d e gr e e w ith e v e ry m ov e me n t o f th e limb Th e sp in e an d .

acro mio n o f the sca p u la are su bcuta n e ou s thr o ugh o ut

‘

B e lo w t he sca p u la th e low e r five r ibs c an be d ist in gu ish e d ,

an d t h e tip o f t h e la st rib c an be fe lt at a p o in t a bo ut t wo

in ch e s o r le ss a bo v e th e iliac cr e st .

As th e back is d isse ct e d th e fo llow in g are the p art s wh ich

mu st be e x a m in e d .

The cu tan e o u s v e sse ls an d n e rv e s o f the back .

The trape iu s mu sclez . I st day .

The latissim u s do rsi mu scle .

The rh o m bo id m u scle s an d th e ir n e rv e .

l
The e v ato r sc apu la m u scle .

The ac c e sso ry n e rv e an d th e n e rv e s fro m the ce r v ical p l e x u s

wh ich su p p l y the trap e iu s z . 2 n d day .

The tran sv e rse c e rv ic al arte ry an d its t wo t e rmin al bran ch e s .

The p o ste rio r be lly o f the o m o hyo id m u scle -

.

The tran sv e rse scapu lar arte ry an d the su p rascapu lar n e rv e .

Th is d isse ct io n m u st be co mp le t e d in two day s in o rd e r that ,

t h e d isse ctor o f t he h e ad an d n e ck m ay be e n a ble d t o c o n

t in u e t h e d e e p e r d isse ct io n o f the back Th e first day s w o rb ’
.

sh o u ld co mp r ise ( I ) the r e fl e ct io n O f the sk in ( 2 ) th e

—

d isse ct io n o f the cuta n e ou s n e rv e s an d v e sse ls ; an d ( 3 ) the

c le a n in g o f the lat issimu s dorsi an d tra p e z iu s m u sc le s The .

r e ma in d e r o f th e d isse ct io n can be u n d e rtak e n o n the seco nd

day .

D is s e c ti o n —
. f t h e Sk im— Th e f o llo in g in c isio n s
R e fl e ct io n o w
are n e ce ssary — 1 F ro m t h e t ip o f th e c o ccyx , at t he lo e r e n d
. w
o f the v
e rt e bral co lu m n , u p w ards , alo n g t h e m e dian lin e o f t h e
bo dy , t o t h e sp in e o f t h e se e n h c e rv ic al e rt e bra v t
2 F ro m v . .

t v
t h e u p p e r e n d o f 1 ran s e rse ly , t o t h e t ip o f th e a c ro m io n o f t h e
scap u la 3 F ro m t h e lo w e r e x re m i y o f t h e m e dian in cisio n
. . t t
v t t
in a cu r e d dire c io n la e rally an d f o rw ards, alo n g t h e cre s o f t
t h e iliu m , t o wt
i h in tw o in c h e s o f t h e an e rio r su p e rio r iliac sp in e t .

4 An o bliq u e in c isio n f ro m t h e sp in e o f t h e fi rs lu m bar e rt e bra,

. t v
t t
u p w ards an d la e rally , t o t h e p o s e rio r f o ld o f t h e ax illa , an d a lo n g
t
t h e la t e r t o t h e arm Th e tw o larg e fl ap s ( 1 7 an d 1 8 , F ig 2 5 )
. .

w h ic h are n o w m app e d o u t u p o n t h e back m u s be care fu lly t

raise d f ro m t h e su bj ac e n fa y issu e Re fle c t tt
t h e u pp e r t . t
t rian gu lar fl ap fi rs , an d h e n t h e lo t e r fl ap t w .

P anniculus A dip o sus ( Sup erficial P ascia) I n su bj e ct s .

-

wh ich hav e be e n a llow e d to lie fo r so m e t im e o n the back

th e su p e rfic ia l fa sc ia is u sua lly m or e o r le ss in fi ltrat e d w ith
flu id wh ich has grav itat e d in to it s m e sh e s ; oth e rw ise it has
t h e ord in ary charact e r s o f su p e rfic ia l fa sc ia ( p I I ) . .
 TH E SUPER I OR EXTRE M I TY
m arg in o f the acro sp in a lis m u sc le a short d istan c e a bove th e
s ,

iliu m . Th e y are t he t e r min a l tw i g s o f th e lat e ra l d i vi si o n s

o f t he p o st e r ior ra m i o f th e u p p e r thr e e lu mbar sp i n a l n e rv e s

G re a t e r o c c ip i lta n er e v m isp in alis c ap t s ii (O T . . co mp lxe us )

Th rd o cci ip i lta ne r e v
St e rn o mast o d
-
i S t o t rap e z m s

ner e v
L e sse r o cc ip i lta n e r e v in gb r o . f t ra n s ve rse c e r i ca v l art

Trap e z i us

us m i no r

D l id
e to

e re s ma j o r

Te re s m a j o r

Se rra t u s an t e r o r i

Se rra t u s p o s t e r o r i i n fe r o r i
Lat i ssi mu s do rSI L at i im
ss us do rs i ( c u t)

Ex t e rn a l bli q m l
o ue u sc e

L a te ra d l iii v s o ns o f
p o st e ri o r ra m i o f T ig
r o nu m l mb l ( P i i ) et t
l u mba r n e r v es
u a e

G lu t a u s me d u s i
G lu ta u s ma xi m us

F IG . 2 6 .
— Di i
sse c t o n o f t he Su p e rfic i l
a M usc l e s an d N er v e s o f t he B ack .

an d th e y d iff e r fro m the n e rve s a bov e in a sm uch as th e y turn ,

dow n ward s ov e r the cre st o f the iliu m to su p ply the sk in o f

th e g lut e a l r e g io n ( F ig .

Th e cutaneo us arteries wh ich acco mp a n y th e cuta n e ou s

n e rv e s o f t h e back are d e r iv e d fro m th e o st e r ior bra n ch e s
p
o f th e in t e rco sta l an d lu mbar art e r ie s .
 D I SS ECTI ON O F TH E B AC K 53

M uscle s c o nn ect ing t h e Limb t o t h e Do r sal Asp e ct o f t he

Trunk — Th is grou p c o n sist s O f fiv e m u sc le s an d th e y are ,

arra n g e d in two strata Two fo r m th e superficial stratu m v iz .

, .
,

t h e tra p e z iu s an d th e lat issim u s d o r si B oth are broad flat .

,

m u sc le s wh ich c o v e r th e gr e at e r p art o f th e d o r sa l a sp e ct o f
the tru n k fr o m t h e occ ip ut a bo v e to t h e iliu m be lo w
,
Th e .

tra p e z iu s lie s ov e r th e back o f the n e ck an d th e thora x .

Th e lat issim u s d o r si is p lac e d lo we r dow n The deep er .

stratu m o f m u sc le s co mp o se d o f t h e le vat o r sca p u la an d t h e

,

t wo rho mbo id m u sc le s is u n d e r cov e r o f t h e tra p e z iu s , .

Se m s p i i li na s c ap t s ii
R e c t u s c ap ii t s p o st e r i
R ii
e c t us c ap t s i
p o st e r o r m aj

S t e rn ol id m id
-
c e o -
ast o

Sp l i pi i
e n u s ca t s

O bli q ii
u u s c ap t s s u e r o r
p i

R e c t u s ca
p ii l t s a t e ra li s

R e c t u s ca
p t s an t e ii
Lo n g us
Su p e ri o r c o nstr cto r o i f p har) r
I lX

FIG . 2 7 .
— M usc l e - At t ac h m e n ts to the O cc p i it l a Bo ne .

D is s e c ti o n — . Af t t
e rt h e cu an e o u s n e r e s an d v v e sse ls h ave be e n
disp lay e d an d f o llo w e d t o h e ir e rm in a io n s, cle an t t t a w ay t h e
tt
re m ain s o f t h e f a y su p e rfi c ial f ascia in t h e a re a o f t h e rap e iu s , t z
bu t do n o t in j u re t h e de e p f as c ia o r t h e c u an e o u s n e r e s ; h e n t v t
p ro ce e d t o c le an t h e rap e iu s, w h ic h is t h e m o s su p e rfi c ial t z t
m u scle o f t h e bac k Th e rap e iu s be lo n g s o n ly in p ar t o t h e
. t z t
t
disse c o r o f t h e u pp e r e xt re m i y Th e p o r io n o f it wh ic h lie s t . t
v t
abo e t h e p ro m in e n sp in e o f t h e se e n h ce r ical e r e bra is t h e v t v v t
t
p ro p e r y o f t h e disse c o r o f t h e h e ad a n d n e ck , an d m u s be t t
t
disse c e d by h im Th e tw o disse c o rs sh o u ld o rk in c o n ju n c
. t w
t io n wt
i h e ac h o h e r ; an d t
h e n t h e e n ire m u scle is e x p o se d, w t
v
e ac h s h o u ld g i e t h e o h e r an o pp o r u n i y o f s u dy in g it in it s t t t t
t t
e n ire y .

t
I f t h e disse c io n is be in g m ade o n t h e righ s ide , p lace t h e arm t
clo se t o t h e t
ru n k an d dra g t h e s cap u la f o r a rds o e r t h e e n d o f w v
t h e blo ck w h ic h su p p o r s t h e h o rax Cu t h ro u gh t h e de e p t t . t
1— 4b
54 TH E SUPER I OR EXTRE M I TY
v t v
f asc ia f ro m th e s e e n h c e r ical sp in e t o t h e ac ro m io n ; t h e
in c isio n w
ill c o rre sp o n d wt
i h t h e dire c io n o f t h e fi bre s o f th e t
v t
m u scle at t h e le e l se le c e d W o rk g radu ally do w n w ards, raisin g
.

t
t h e f ascia in a c o n in u o u s lay e r f ro m t h e su rf a ce o f th e m u scle .

w
Al ay s c arry t h e s calp e l in t h e dire c io n o f t h e m u s cle fi bre s , t
t v
an d ak e c a re t o le a e n o n e o f t h e f as c ia o n t h e su rf ace o f t h e
m u scle t
As t h e dire c io n o f t h e m u scle fi bre s c h an g e s , al e r t h e
. t
t
p o si io n o f t h e a rm t o k e e p t h e fi bre s wh ic h are be in g cle an e d o n
t h e s re c ht t I n th e c ase o f t h e lef t trap ez i u s t h e p re lim in ary
. ,

t t
in c isio n h ro u gh th e f ascia m u s be m ade alo n g t h e lo w e r m arg in
o f t h e m u scle , an d t h e su rf a ce o f t h e m u scle m u s be cle an e d, t
w v
f ro m be lo w u p ards, t o t h e le e l o f t h e se e n h ce r ical e rt e bra v t v v .

v
As t h e de e p f asc ia is re m o e d f ro m t h e rap e iu s, an d in de e d t z
t t w t
h ro u gh o u t h e h o le disse c io n o f t h e back , t h e cu an e o u s t
v
ner e s mu s t v
be c are fu lly p re se r e d, in o rde r h a t h e disse c o r t t t
v
o f t h e h e ad an d n e ck m ay h a e an O p p o rt u n i y o f e s ablish in g t t
t r t t wt t
h e i co n in u i y i h t h e ru n k s f ro m h ich h e y arise w t .

M Tra p ez ius — Th e
. . tra p e z iu s i s a flat tria n gu lar m u sc le
, ,

wh ich lie s, in its e n t ir e e x t e n t imm e d iat e ly su bjac e n t to t he

,

S t e rn o h -
y ido

FIG . 2 8 — U p p e r Su rface
. o f th e R ight C l v i l
a c e.

d e e p fa sc ia I t has a v e ry lo n g orig in wh ich e x t e n d s a lo n g

.
,

th e m e d ia n p la n e fro m th e o cc ip ut a bov e to th e le v e l o f th e
,

la st thorac ic v e rt e bra be low I t ar ise s fro m . the m e d ia l

th ird or le ss o f th e su p e r ior n ucha l lin e o f th e occ ipita l bo n e
an d th e e x t e r n a l occ i ita l rotu ra c ga m tu m
p p b e n e ( )
2 t h e li e n

n uch a an d t h e sp in e o f t h e se v e n th c e rv ica l v e rt e bra ; 3 ) th e

t ip s o f the Sp in e s o f all th e thorac ic v e rt e bra as w e ll as th e ,

s u p ra sp in ou s liga m e n t s wh ich br idg e acro ss th e in t e rva ls

be tw e e n th e m ( F ig s 2 6 .
,

I n th e lo w e r ce rv ical an d u p p e r th o racic re gio n s th e t e n din o u s fibre s by

wh ich the mu scle arise s le n g th e n o u t so as to fo rm a fl at te n do n , wh ich ,
t ak e n in co nj u n ctio n w ith th e co rre sp o n din g ap o n e u ro sis o f the o pp o sit e
x
side , e h ibits an o v al o u tlin e .

As th e fi br e s o f th e tra p e z iu s p a ss lat e ra lly t h e y co n v e rg e

t o th e ir in se rt io n s in t o th e two bo n e s o f th e sh o u ld e r g ird le -
.

Th e o ccipital an d upper cerv ical fibres in clin e dow n ward s, an d,

 D I SSE C T I O N O F TH E B AC K 55

turn in g forward s o v e r the sh o u ld e r are in se rt e d in to th e ,

p o st e r ior b ord e r o f t h e lat e ra l th ird o f t h e c lav ic le ( F ig .

t he lo wer cervical an d upper tho racic fibres p a ss m or e o r le ss

tra n sv e r se ly to ga in an in se rt io n in to the me d ia l bord e r o f
t h e acr o m io n an d the u pp e r m arg in o f t h e p o st e r ior bord e r
o f t h e sp in e o f t h e sca p u la wh ile the lo w er tho racic fibres are
dir e ct e d u p ward s an d at the v e rt e bra l bo rd e r o f t h e sca p u la
, ,

e n d in a flat tr ia n gu lar t e n do n wh ich p lay s ov e r th e sm ooth

, ,

sur fac e at t h e a p e x o f t h e sca p u lar s in e an d is in se rt e d

p ,

in t o a rough tu be rc le o n t h e sp in e im me d iat e ly be yo n d that

sur fac e To ac tat m ov m t
( g 3 p
F i 8 . f ,ili e t.h e e e n o f t h e

t e n do n u po n the bo n e a sma ll bursa m uco sa is in t e rp o se d

be tw e en th e m .

The tra p e z iu s is su p plie d by the accesso ry nerv e an d by

twig s fro m t he third an d fo urth cervical nerves I t is an .

e le vator an d d e p r e ssor o f t h e sh o u ld e r ; an d a rotator an d

adductor o f the sca p u la .

i
D s e c tio n
s — Th lat i im u s do r i is n o w t o b di
. ect d It ss s e sse e .

is a diffi c lt m cl t u le an n t n ly n a c
us nt e f t h v ary i g
o c ,
o o o c o u o e n
dir ct i n o f it fi bre b t al o b a e its pp r p art is g
e o s s, rallyu s ec us u e ene
v ry t h i an d it u pp r b rd r ill d fi d N ar t h p i
e n, s ef o e -
e ne . e e s nes o
t h v rt bra it u pp r p rt i n is v e rlapp d by t h t rap z i
e e e s e b t o o o e e e u s, u
in it g r at r p art t h e m
s e ecle i bcu t an e s B t h th p r us s su o u . o e su e
fi ial a d t h de p f a ia sh o u ld b rai e d at t h sam t im f ro m
c n e e sc e s e e e
it s r f ace a d it s fi br s m ay b st re t h d by rai in g t h arm
s u ,
n e e c e s e
an d f o ldin g it u n de r t h e n e c k .

On t h e right s i de cu t h ro u gh t h e f as cia alo n g t h e u p p e r bo rde r t

o f t h e m u s cle f ro m t h e p o in h e re h a m arg in disapp e ars u n de r tw t t
t z
t h e rap e iu s t o t h e p o s e rio r f o ld o f t h e ax illa , an d w o rk do n t w
w ards D e fi n e c are fu lly t h e a t ac h m e n t o t h e su p e rfi c ial lay e r
. t t
o f t h e lu m bo do rs al f asc ia Cle an h a f ascia, bu t do n o t in j u re it
-
. t t
it is t h e p ro p e rt y o f t h e disse ct o r o f t h e h e ad an d n e ck Nex . t
tt t
de fi n e t h e a ac h m e n o f t h e lo w e r e n d o f t h e m u scle t o t h e c re s t
o f t h e iliu m ; an d wh e n t h e lo e r p art o f t h e la e ral bo rde r o f t h e w t
m u scle is re ac h e d, c le an t h e slip s o f t h e la issim u s h ic h are t w
t
a t ac h e d t o t h e lo w e s tt
h re e o r fo u r ribs, an d cle an also t h e slip s
o f t h e e x t e rn al o bliq u e m u scle o f t h e abdo m e n w h ic h in e r t
dig i a e t t wt
i h t h e co s al slip s o f t h e la issim u s do rsi t t .

On t h e lef t s i de cu t h ro u gh t h e f as c ia f ro m t h e c re s o f t h e t t
t
iliu m t o t he p o s e rio r f o ld o f t h e ax illa, an d w o rk m e dially an d
u p w ards an d w
h e n t h e m ain p art o f t h e m u scle h as be e n cle an e d,
re tu
rn t o t h e lo w e r p art o f t h e la e ral bo rde r an d disp lay t h e t
t t t
co s al a t ac h m e n s o f t h e m u s cle an d t h e in e rdig i a io n s o f t h e t t t
e xt e rn al o bliq u e .

t t
Af e r t h e co s al slip s o f t h e m u scle h a e be e n de fi n e d, e e r v v t
t h e u pp e r m arg in o f t h e m u sc le , a s it c ro ss e s t h e in f e rio r a n g le o f
t h e sc ap u la , t o disp lay t h e slip o f fi bre s w h ic h sp rin g s f ro m h a t t
a n g le an d j o in s t h e de e p asp e c o f t h e u p p e r bo rde r o f t h e m u scle t
t
it is ap t t o be m is ak e n f o r a p ie c e o f t h e e re s m aj o r u p o n w h ic h t
it lie s .

1— 4 0
56 THE SUPER I OR EXTRE M I TY
M L at issimus Do rsi — Th e lat issimu s
. dor si is a w id e flat ,

mu sc le wh ich cov e r s th e back fro m the le v e l o f th e Six th

,

th o rac ic v e rt e bra d o w n to the cre st o f t he iliu m ( F ig 2 6 p .

,
.

I t ar ise s— ( I ) fro m th e t ip s o f th e Sp in ou s p roc e sse s o f th e

low e r six thorac ic v e rt e br a an d t h e su p ra sp in ou s liga me n t s in
co n n e ct io n w ith th e m ( 2 ) fro m th e su p e rfic ial la me lla o f
t h e lu mbo dor sa l fa sc ia F ig 2 6 )
-

( 3) yb a th in t e n d in ou s or ig in .

fro m a sma ll e x t e n t o f th e out e r lip o f th e cr e st o f t he iliu m in ,

FIG 9 . Di g
2 .
— a ram o f t h e L u m bo do -
rsa lF asc a i .

1 . S e rra t u s
p i if i
o st e r o r n e r o r. 6 . F i a sc a t ran s e rsa v li s.

2 . L i im
at ss d i
us o rs .
7 . Sac ro sp n a i li s.

3 . T v
ra n s bd m i i
e rsu s a o n s. 8 .
Q uadrat u s l u mbo ru m .

4 . O bli q i u us n t e rn u s .
9 . P so a s ma j o r.

5 . O bli q x
uus e t e rnu s .

fro n t o f t h e lu mbo
dor sa l fa sc ia ( F ig 2 6 p 5 2 ) ( 4 ) by thr e e
-
.
,
.

o r four d ig itat io n s fro m the lo w e r thre e o r fo ur r ibs ; an d 5 )

by a fl e shy slip fro m t h e d o r sa l a sp e ct o f t he in fe r ior a n g le
o f t he sca p u la m a or g r
( F ig 3 8 p B y e n
. s o f it s i in f
, o m
.

t he p o st e r ior la me lla o f lu mbo d o r sa l fa sc ia it atta in s an in -

d ir e ct attach m e n t to th e spin e s O f the lu mbar an d u p p e r sacra l

v e rt e br a an d a lso to the p o st e rior p art o f t h e cre st o f the
,

iliu m . Th e c o sta l Slip s o f or ig in in t e rd ig itat e w ith t h e low e r

d ig itat io n s o f the e x t e r n a l o bliqu e mu sc le o f t he a bdo min a l
wa ll.

Th e fi br e s o f th e lat issim u s d o r si co n v e rg e ra p id ly as
 D I SSE C T I O N O F TH E B AC K 57

th e y a pp roach the low e r p art o f th e sca p u la The h igh e st .

fi bre s p a ss a lm o st h o riz o n ta lly toward s that p o in t the lo w e st

fi br e s a sc e n d a lmo st v e rt ica lly ; wh ilst t he in t e r me d iat e
fi br e s Show vary in g d e gr e e s o f o bliqu ity As a r e su lt Of th e .

c o n v e rg e n c e o f fi bre s t he m u sc le is gre at ly r e duc e d in w idth

,

an d it sw e e p s ov e r th e in fe r io r a n g le o f th e sca u la in th e
p
for m o f a th ick fl e shy ba n d wh ich w in d s rou n d t h e low e r
, ,

marg in o f t he t e r e s m ajor mu sc le an d t e r m in at e s in a
'

n arr o w ,flat t e n d o n wh ich is in se rt e d in to the fl o or o f th e

,

in t e rtu be rcu lar su lcu s o f t he hu m e ru s ( F ig 4 5 p The .

,
.

in se rt io n ca n n ot be stud ie d at p r e se n t bu t w ill be se e n lat e r ,

.

With the t e r e s major m u sc le t he lat issim u s dor si for m s the,

p o st e r ior fo ld o f t he a xilla At first it is p lac e d o n the dor sa l

.

a sp e ct o f t he t e re s m aj o r th e n it is fo ld e d rou n d its low e r

,

bo rd e r an d fi n a lly it is in se rt e d in fro n t o f it
, To the .

p e cu liar r e lat io n sh ip o f the two m u sc le s is du e th e fu ll ,

rou n d e d a pp e ara n c e o f t he p o st e r ior ax illary fo ld .

The lat issim u s d o r si is su pp lie d by the tho raco do rsal n erv e -

.

I t is an adduct o r r e tract o r an d m e d ia l r o tator o f th e u p p e r

, ,

e x tr e m ity .

Tw o I nt e rmuscular Sp aces ( )
I A tr ia n gu lar
— sp ac e

m a pp e d o u t by t h e in fe r ior bord e r o f the tra p e z iu s the su p e r ior ,

bord e r o f t h e lat issim u s d o r si an d th e ba se o f the sca p u la, ,

Shou ld n o w be n ot ic e d i W ith i im i t
( g
F 2 6 p . n ,
t h e .l s Of

that tr ia n g le a sma ll p ort io n o f t he rho mbo id e u s major c an be

se e n an d a lso a vary in g a m o u n t o f t he wa ll o f th e thora x — a
,

p art o f t h e s ix th in t e rc o sta l S p ac e an d t h e b ord e r s o f t h e r ib s

wh ich bo u n d it a bo v e an d be lo w I t is w e ll to n ot e that .

th is is th e o n ly p art o f the th o rac ic wa ll o n the p o st e r io r

a sp e ct o f t h e tru n k wh ich is n o t cov e re d by mu sc le s ( 2 ) .

B e t we e n th e la st rib an d t h e cr e st O f t h e iliu m th e a n t e r io r
bo rd e r o f t h e lat issim u s d o r si g e n e ra lly ov e r la p s t h e
p o st e r ior bord e r o f th e e x t e r n a l O bliqu e m u sc le o f t he
a bd o min a l wa ll So me t ime s how e v e r a n arrow tria n gu lar
.
, ,

in t e rva l e x ist s be tw e e n th e t wo m u sc le s in wh ich is se e n a ,

sm a ll p art o f t h e in t e r n a l o bliqu e m u sc le That Sp ac e is .

t e r me d the trrgo nu m lu mbale ( P etiti) ( F ig 2 6 p I t is a .

, .

w e ak p art o f the wa ll o f th e a bd o me n an d occa sio n a lly so m e ,

O f t h e c o n t e n t s O f t h e a bdo me n are r o trud e d thr o ugh it

p ,

fo r min g a lu mbar hern ia .

D is s e c t i o n — R e fl e ct io n
. of t h e Trap e z m s —On t h e seco n d day
t
t h e disse c o r m u s be g in by t re fl e c in g t h e t
rap e iu s , t z w ki g
o r n ,
it
5 8 TH E SU PER I OR EXTRE M I TY
p o ssible , in c o n j u n c io n t wt
i h t h e disse c o r o f t h e h e ad an d n e ck t .

v t
D i ide t h e m u scle abo u t w o in c h e s f ro m t h e sp in e s o f t h e e rt e v
t t
bra , an d h ro w it la e rally , t o w ards it s in se rt io n Th e rap e iu s . t z
v t
is e ry h in at its o rig in , an d t h e g re a e s c are m u s h e re f o re be t t tt
tak e n n o t t o in j u re t h e su bj a ce n rh o m bo id m u s cle s Th e sm all t .

t
bu rsa be tw e e n t h e e n do n o f in se r io n o f t h e lo e r p ar o f t h e t w t
t z tt
rap e iu s an d t h e fl a e n e d ap e x o f t h e sp in e o f t h e s c ap u la m u s t
v
n o t be o e rlo o k e d, an d t h e n e r e s an d e sse ls o n t h e de e p su rf ace v v
o f t h e m u scle m u s t
be cle an e d an d p re se r e d Th e y are t h e v .

v
a c ce sso ry n e r e an d branc h e s o f t h e h ird an d f o u r h ce r ical t t v
v
n e r e s, t h e as ce n din g bran c h o f t h e ran s e rse ce r ical ar e ry , t v v t
an d bran c h e s o f t h e de s c e n din g bran c h o f t h e ran s e rse c e r ic al t v v
ar e ry t tt
Th e la e r p ass in o t h e rap e iu s f ro m be w e e n t h e
. t t z t
m u scle s o f t h e se co n d lay e r .

N e rv e s an d V e sse lsf Su p p ly t o t h e Trap e z i us — A dis

o .

se ct io n o f the d e e p sur fac e o f the r e fl e ct e d m u sc le w ill r e ve a l

t h e fo llo w in g structur e s

a The acce sso ry n e rv e

. .

b Two o r th re e n e rv e s fro m the c e rv ical ple u s

. x .

c The asce ndin g bran ch o f the t ran sv e rse ce rv ical arte ry

. .

d Tw ig s o f the de sc e n ding bran ch o f the tran sv e rse ce rv ic al

.

arte r y .

Th e se co n st itut e th e n e rvou s an d va scular su p ply o f th e

tra p e z iu s .

The n e rv e s hav e alr e ady be e n d isplay e d by the d isse ctor o f

t h e h e ad an d n e ck as th e y cro ss th e p o st e rior tr ia n g le o f th e
,

n e ck .Th e bra n ch e s fr o m th e c e rvica l p le x u s co me fro m th e

third an d fo urth cerv ical nerves On th e d e e p sur fac e o f th e .

tra p e z iu s th e y j o in w ith bra n ch e s Of the acc e ssory n e rv e to

for m t he su btrap ez ial plex u s fro m wh ich tw ig s p roc e e d in to t h e ,

su bsta n c e O f t h e m u sc le Th e t e r min a l tw ig o f th e accesso ry

.

nerve c an be trac e d n e arly to the low e r margin o f the

tra p e z iu s .

Th e ascen ding branch of the transverse cervical artery wh ich ,

acco mp a n ie s the acc e ssory n e rv e m u st be fo llow e d to the ,

a n t e rior bord e r o f the tra p e z iu s wh e r e it will be se e n t o ,

sp r in g fro m th e tru n k o f t he art e ry at t h e p o in t wh e r e it

d iv id e s in t o it s a sc e n d in g an d d e sc e n d in g bra n ch e s .

Th e t wigs fro m the descen ding branch of the transverse

cerv ical a rter y p ie rc e th e m u sc le s o f t h e se co n d lay e r or p a ss
be tw e e n th e m c lo se t o th e v e rt e bra l bo rd e r o f th e sca p u la
,
.

D is s e c t i o n — t
Th e p o s e rio r be lly o f t h e o m o hy o id, t h e ran s -
t
ve rse s cap u lar art e ry , an d su p ras c ap u lar n e r e m u s n o w be v t
v
disp lay e d, an d t h e cla icu lar an d sc ap u lar in se rt io n s o f t h e
t z
rap e iu s m u s be e x am in e d t
D i ide t h e rap e iu s in o an u p p e r . v t z t
60 THE S U P ER I O R EXTRE M I TY
ba n d wh ich ru n s p ara lle l to the u p p e r bo rd e r o f th e m ajor
rho mbo id I t sp rin g s fro m the lo w e r p art O f th e liga me n tu m
.

n uch a the Sp in e o f t h e se v e n th c e rv ica l v e rt e bra an d fr e qu e n t ly

, ,

a lso fro m th e sp in e o f t he fir st th o rac ic v e rt e br a I t is .

in se rt e d in t o t h e v e rt e bra l m arg in o f t h e sca p u la o p p o sit e

t h e tr ia n gu lar sur fac e at t h e flatt e n e d a p e x o f it s sp in e

( g 3 p
F i . 8 8 ,
I t is e.n t ir e l y cov e r e d b y t h e tra p e z iu s .

Th e rho mbo ideu s maj o r arise s fro m th e u pp e r fo ur o r fiv e

thorac ic sp in e s an d the corr e sp o n d in g p art s o f the su p ra spin ou s
,

liga m e n t s I t s fi br e s ru n o bliqu e ly d o w n ward s an d lat e rally

.
,

an d e n d in a t e n d in ou s arch wh ich is attach e d to th e ,

v e rt e bra l marg in o f the sca p u la fro m th e in fe rior a n gle to ,

t h e a p e x o f t h e sp in e Th e m a in attach m en t o f t he fi brou s .

arch is to th e in fe r ior a n gle bu t it is bou n d t o th e v e rt e bra l ,

bo rd e r fro m that p o in t to t h e sp in e by fa ir ly fi rm ar e o lar

t issu e ( F ig 3 8 p 8 . Th e gr e at e r p art o f th e rho mbo id e u s
,
.

m ajor is cov e r e d by t h e tra p e z iu s o n ly a sma ll p ort io n n e ar

th e in fe r ior a n g le o f t he sca p u la lie s im m e d iat e ly su bjac e n t
to th e d e e p fa scia .

M L ev at o r Sc ap ula — Th e le vator sca p u la is an e lo n

.

gat e d mu sc le wh ich ar ise s by four m o r e or le ss t e n d in ou s , ,

slip s fro m t h e p o st e r ior tu be rc le s o f t h e tra n sv e r se p roc e sse s

o f t h e u p p e r four c e rv ica l v e rt e br a I t p a sse s dow n ward s .

an d backward s to be in se rt e d in to t h e v e rt e bra l m arg i n O f

th e sca p u la fro m t h e m e d ia l a n g le to th e sp in e
,
I t is su pp lie d .

by bra n ch e s fro m th e third an d fo u rth cervical n erves .

D is s e c t i o n — Cl an t h l v at r s ap la t k in g ar n o t t o e e e o c u ,
a c e
in j r t h
u e rv w h ich s p p ly it Th m u cl b l n g p art ly to
e ne es u . e s e e o s
t h di e t r f th h e ad a d n k n d p a tly t th di ct r o f
sse c o o e n ec a r o e sse o
the p ri rsu t r m it y W h n b t h f t h m h av st di d its
e o ex e . e o o e e u e
att a h m n t an d n rv
c e pp ly t h m s l m u t b div id d at
e e - Su ,
e u c e s e e
th e m iddl f it l g t h Th l w r h alf i t h n t b t rn e d
e o s en . e o e s e o e u
do w w rd a d lat rally t o it i
n a s rt i
n a d th d rsalis cap la
e s n se o n, n e o s u
n rve a d th
e d di g bra h
n ef th t ra v r c rvical
e sce n n nc o e ns e se e
art ry w h i h li
e , d p to th m c l ar to b p r
e ee rv d a d e u sc e , e e e se e n
f ll w d t t h
o o pp r m rg i o f t h rh m b ide s m i
e o e u e r a n e o o u no .

N t t t h r u gh t h rh m b id fr m b v do w n w ard
ex cu o e o o s, o a o e s,
m idw ay b tw e th s ap la a d t h
e pi
en f t h v rt bra ;
e c u n e s nes o e e e
r m m b r t h at t h y ar v ry t h i
e e e n d t ak ar e t t i j u r th e e n, a e c e no o n e e
s rrat
e p st ri r us p rio r wh i h i imm di t ly s bj a
o e o su t to
e ,
c s e a e u ce n
t h m Tu r th m dial p rt f h m s l t w ards th v rt bral
e . n e e a o e ac u c e o e e e

sp in a d v rify it
e att a h m
n t T r t h lat ral p art t o w ards
e s c en . u n e e s
th c ap u la an d f ll w t h
e s d r alis ap la n rv o n d tho e o s sc u e e a e

de din g bra c h
sc e n f th t ra v rs rv i al art ry t
n ot h ir e ns e e ce c e o e
t rm in at i n s Th n rv g iv bran h t o th l v t r ap la
e o . e e e es c es e e a o sc u

an d t b t h t h rh m b id m
o o l an d t h art ry
e oo t n ly p p li
o u sc e s , e e n o su es

t h e rh o m bo id b t al t h adj a n t m s cl un th s ap la so e ce us es o e c u .
 D I SSE C T I ON OF TH E B AC K 61

N e rvu s Do rs a li s Sca p ula ( O T N e rv e t o t h e Rh o mbo ids) . . .

Th is lo n g sle n d e r n e rv e arise s, in th e n e ck, fro m the fi fth

c e rv ica l n e rv e , u sua lly in co mm o n w ith t he u p p e r r o ot o f
th e lo g thorac ic n e rv e
n I t p ie rc e s th e sca le n u s m e d iu s
.
,

an d p a sse s dow n ward s u n d e r c o v e r o f the le vator sca p u la

, ,

to th e d e e p surfac e o f the rho mbo id e i mu sc le s I t e n d s in .

tho se mu sc le s bu t it su pp lie s a lso o n e or two tw ig s to the

, , ,

le vator sca p u la .

Th e root tw ig s o f o r ig in o f t h e d o r sa lis sca p u la n e rv e

so m e t ime s p ie r ce t he le vator sca u la se p arat e ly a n d th e n
p ,

u n ite in a ple x ifor m m a n n e r .

R amus Desc en de n s o f t h e Art Tran sv e rsa Co lli ( O T . . .

P o st erio r Sca p ular Art e ry ) — The d e sc e n d in g bra n ch o f the .

tra n sv e r se c e rv ica l art e ry tak e s or ig in in the low e r p art o f

t h e n e ck c lo se to t h e lat e ra l m arg in o f t h e le vator sca p u la .

At fir st it ru n s m e d ia lly u n d e r cov e r o f th e le v at o r sca p u la

.
,

bu t it so o n cha n g e s it s d ir e ct io n an d th e n ru n s dow n ward s

a lo n g th e v e rt e bra l bord e r o f the sca p u la u n d e r cov e r o f the ,

rh o mbo id mu sc le s ( F ig 2 6 p I t g iv e s n u me r o u s bra n ch e s
.
,
.

t o bo th t h e c o sta l an d dor sa l a sp e ct s o f th e sca p u la an d it s ,

t e r min a l tw ig s m ay e n t e r the lat issim u s dor si O n e larg e .

bra n ch u sua lly p a sse s backward s in th e in t e rva l be tw e e n t he ,

rho mbo id mu sc le s o r through th e gr e at e r rho mbo id to r e ach ,

th e tra p e z iu s m u sc le ; an d a n oth e r bra n c h t he sup rasp z n al

’

, ,

is g iv e n to t h e su p ra sp in atu s m u sc le an d t h e stru ctur e s

su p e rfic ia l t o it .

D is s e c ti o n — R e fl e ct io n o f t h e L a issim u s D o rsi an d t h e t
v
re m o al o f t h e Su p e rio r Ex t re m i y —D iv ide t h e la issim u s do rs i t . t .

v
Co mm e n ce t h e di isio n at t h e u p p e r bo rde r h re e in c h e s f ro m t h e t
v e rt e bral sp in e , an d c arry t h e k n ife o bliq u e ly do w n ards an d w
t
la e rally t o a p o in j u s be lo t t
w h e re t h e las dig i a io n o f t h e w t t t
m u scle sp rin g s f ro m t h e las rib t
R e m e m be r h a t h e m u s cle is . t t
t h in an d do n o t in j u re t h e p art s su bj ace n t o it Tu rn t h e t .

t
m e di al p o rt io n o w ards t h e e rt e bral sp in e s, ak in g c are n o t t o v t
t t
in j u re t h e se rra u s p o s e rio r in f e rio r in t h e re g io n o f th e lo w e r
v
f o u r ribs , an d e rif y th e o rig in o f t h e m u scle f ro m t h e sp in e s
an d s u p rasp in o u s lig am e n s , lu m bar f ascia an d iliac c re s t t .

Th ro w t t
t h e la e ral p ar o f t h e m u s cle la e rally an d f o r ards , t w
cle an t h e de e p su rfa ce s o f t h e slip s a a c h e d t o t h e lo w e r h re e tt t
o r f o u r ribs, an d n o t e t t t
h a h e y in e rdig i a e w i h t h e e x t t t t
t e rn al o bliq u e m u scle o f t h e abdo m e n At t h e in f e rio r an g le .

o f t h e s cap u la fi n d t h e t
h o raco do rsal n e r e an d t h e h o raco -
v t
do rs al a r e ryt Th e y su pp ly t h e m u s cle an d e n e r its de e p
. t
su rf ac e .

v
Th e R e m o al o f t h e Su p e rio r Ext re m i y D i ide t h e t v
v
t ran s e rse scap u lar a rt e ry an d t h e su p rascap u lar n e r e an d t h e v
62 THE SUP ER I OR EXTRE M I TY
t
p o s e rio r be lly o f the o mo -
hy o id at th e u pp e r bo rde r o f th e
scap u la .

( ) 2 D i id e t h e v d o r s a l s c a p u la r n e r e a n d t h e d e s ce n d in g v
t v
bran c h o f th e ran s e rse ce r ic al ar e ry n e ar t h e m e dial an g le o f v t
t h e s cap u la .

P v
(3 ) u ll th e e rt e bral bo rde r o f t h e scap u la a w ay f ro m t h e
t
ribs t o e x p o se t h e p o s e rio r p ar o f t h e se rra u s an e rio r o n t h e t t t
t
c o s al su rf a ce o f t h e s c ap u la .

(4 ) C u t h r o u gh t t
h e p o s e ri o r p a r o f t h e se rra u s a nt e r io r f ro m t t t
its u pp e r t o its lo w e r bo rde r abo u o n e in c h f ro m t h e e rt e bral t v
m arg in o f t h e s cap u la .

( 5 ) P u ll th e scap u la s ill fu r h e r a ay f ro m th e h o rax an d t t w t

v v
di ide t h e ax illary e sse ls an d n e r e s at t h e o u e r bo rde r o f t h e v t
t
fi rs rib .

( 6 ) D e a c h t h e t a n e r i o r s k i t
n fl ap p re io u sly s i c h e d t o t h e v tt
t
an e rio r all o f t h ew t
h o rax , an d ak e t h e lim b to th e able t t
p r ov id e d ,
h e re t hwe f u r t h e r di sse c io n is t o b e c o m p le ed t t .

v
Tie th e di ide d ax illary e sse ls an d n e r e s t o a p ie ce o f o o d, v v w
abo u t m m ( 1 5 in c h e s) lo n g , in h e ir p ro p e r o rde r ( a p ie ce o f
. t
a bro k e n p e n h o lde r w ill se r e t h e p u rp o se ) , an d h e n by m e an s v t
o f a lo o p fi x t h e w
o o d t o t h e co ra co id p ro c e ss ; by h a m e an s t t
v
t h e e sse ls an d n e r e s v w
ill be re aine d in h e ir p ro p e r re la io n t t t
s h ip s du rin g t h e fu rt h e r s ag e s o f disse c io n , an d t
h e y can be t t
re le ase d f ro m t h e c o raco id p ro c e ss w h e n it is n e ce ssary t o
e x am in e an y h in g t
h ic h lie s be h in d h e m w t .

t
A f e r t h e su p e rio r e xt re m i y h as be e n se p ara e d p ro ce e d t o t t
v
re m o e t h e w h o le o f t h e sk in h ic h co e rs it h ils t h e su b w v w t
t t
cu an e o u s issu e s are s ill in g o o d co n di io n , an d in o rde r h a t a t t t
v
g e n e ral ie w o f th e cu an e o u s e in s an d n e r e s m ay be o b ain e d t v v t .

t
Th e m ain cu an e o u s e in s c arry blo o d t o t h e ax illary e in , an d v v
t v
t h e cu an e o u s n e r e s are e i h e r dire c bran c h e s o f t h e brac h ial t t
p le xu s o r h e y sp r t
in g f r o m t h e m a in e rm in al bran c h e s o f t h e t
p le x u s Th e fo llo win g s e p s m u s be ak e n t
( I ) p lac e t h e lim b t t

"
.

t t
o n it s p o s e rio r asp e c ; ( 2 ) m ak e an in cisio n alo n g t h e an e rio r t
asp e c t
f ro m t h e re g io n alre ady de n u de d t o t h e t ip o f t h e m iddle
fi n g e r (F ig ( 3 ) m ak e a ran s e rse in cisio n at th e
. ris t v w t
t v
(4 ) a ran s e rse in c isio n at t h e p ro x im al e n ds o f t h e fi n g e rs ;
.

( 5 ) an o bliq u e in cisio n f ro m t h e m iddle o f w ris to t h e t ip t

o f the t
h u m b ; ( 6 ) in cisio n s alo n g t h e m iddle o f th e in dex ,
t h e rin g , an d t h e li le fi n g e r tt
Tu rn t h e la e ral fl ap s 3 an d 5 . t
t
(F ig 5 ) la e rally , t h e m e dial fl ap s 4 an d 6 m e dially ro u n d t h e
.

tv
re sp e c i e m arg in s o f t h e lim b, an d h e n disse c h e m fro m t h e t tt
do rsal asp e c t t
Tre a t h e fl ap s 5 an d 7 an d h o se o f t h e fi n g e rs
. t
in t h e sam e w ay , an d disse c fl ap 6 dis ally t o t h e an g le be tw e e n t t
t
th e h u m b an d t h e in de x fi n g e r .

Tak e g re a c are t w
h ils re m o in g the fl ap s n o t to in j u re t h et v
t
cu an e o u s v
e sse ls an d n e r e s v
h ic h lie in th e su p e rfi cial f ascia w
t
im m e dia e ly su bj ac e n t o t h e sk in t .

t t
N o e t h a t h e sk in is re adily se p ara e d f ro m th e su p e rfi c ial t
f asc ia in t h e arm an d f o re arm an d o n t h e do rsal asp e c o f t h e t
t
h an d I t is sligh ly m o re adh e re n o e r t h e e p ico n dy le s o f th e
. t v
h u m e ru s an d t h e O le cran o n I n t h e re g io n s o f t h e p alm an d th e .

v t
o lar asp e c s o f t h e dig i s. t h e sk in t
an d su p e rfi c ial f asc ia are
'

t t
c lo se ly adh e re n , f o r h e re t h e sk in is bo u n d t o t h e de e p f ascia
t w
by fi bro u s s ran ds h ic h p ass h ro u gh t h e su p e rfi c ial f ascia t
In .

th e u ln ar p art o f th e p alm , abo 2 5 mm dis al t o t h e ris , ut . t w t

D I SSE C T I O N O F SU PER F I C I AL STRU C T U RE S 63

so m e m u scle fi bre s w ill be bro u gh t in t o v ie w ; t h e y co n n e ct the

s k in o n t he u ln ar m arg in o f t h e p alm w it h t h e de e p f as cia ,

an d co n st it t e th p almaris bre is m uscle

u e v .

W h n t h e k in i
e m p l t ly r m v d it m u t n t be t h r wn
s s co e e e o e s o o
aw ay b t m st b u k p t to be w rapp d r n d th p art wh r e t he
u e e e o u e e
dis ct io n i n o t p r o
se di g
s ce e n .

Cu t a e o u s V e in s o f t h Su p rio r Ext re m it y — Af t r t he sk in
n e e . e
h as b n r m o v d p r c d t o di p lay t h
ee e e t an o s v in s be a
o ee s e cu e u e ,
c u se
t h y ar
e p t h r an d t h r t h m st s p e rfi cial st ru ctu re
e, e x ce e e e e, e o u s,
b t b car f l t p r s rv an y n e rv s m e t w it h as t h e v i
u e e u o e e a re e e e ns
be in g cle an e d (F ig s 3 1 , .

t v
Co mm e n ce at t h e in e r al be tw e e n t h e p e c o ralis m aj o r an d t
t
t h e de l o id an d f o llo w
t h e ce p h alic e in dis ally , be in g care fu l t o v t
v t
p re se r e t h e ribu arie s w h ic h j o in it t At t h e be n d o f t h e e lbo . w
se cu re a larg e c o m m u n ica in g bran c h calle d t h e me di an cu bi tal t
ve i n ; it ru n s o bliq u e ly , p ro x im ally , an d m e dially , an d j o in s th e
t
bas i li c ve i n , abo u 3 0 mm p ro x im al t o t h e le e l o f th e m e dial . v
e p ico n dy le Th e m e dian cu bi al e in is j o in e d at its dis al
. t v t
bo rde r by a e in v w
h ic h p ie rce s t h e de e p fascia an d co n n e c s t h e t
t v wt
m e dian cu bi al e in i h t h e de e p e in s o f t h e f o re arm Af e r v . t
t v
t h e m e dian cu bi al e in an d its co n n e c io n s h a e be e n disp lay e d, t v
v
f o llo w t h e ce p h alic e in dis ally , alo n g t h e f o re a m an d ro u n d its t r
radial m arg in , t o t h e do rsu m o f t h e h an d h e re it co m me n ce s, w
t t
do rsal t o t h e fi rs m e acarp al bo n e , in t h e radial e xt re m i y o f t h e t
do rsal ven o us arch Th e do rsal e n o u s arc h c o sse s t h e do rsu m
. v r
o f t h e h an d, f ro m t h e r
adial t o t h e u ln ar side , an d at its u ln a r
e n d, w t
h ic h lie s Opp o si e th e in e rsp ace be e e n t h e f o u rt h an d t tw
t t
fi f h m e acarp al bo n e s, t h e basi li c vei n co mm e n ce s F o llo . w
t h e bas ilic e in p ro x im allyv I t p asse s at fi rs alo n g t h e do rsal . t
t
asp e c o f t h e u ln ar bo rde r o f t h e f o re arm , h e n u rn s ro u n d t h e t t
u ln ar bo rde r t o th e fro n , an d asce n ds t o t h e arm , t
h e re it is w
j o in e d by th e m e dian cu bit al e in alre ady disse c e d F o llo t h e v t . w
bas ilic v
e in p ro x im ally be y o n d its j u n c io n i h t h e m e dian t wt
cu bi al t v
e in t o t h e m iddle o f t h e a rm h e re it p ie rces t h e w
v
de e p f ascia, at t h e le e l o f th e in se rt io n o f t h e c o raco - brac h ialis
m u scle As y o u cle an it , in t h e lo e r p art o f t h e arm , lo o k f o r
. w
so m e su p e rfi cial cu bi al lym p h g lan ds t
h ic h lie in th e su p e rfi cial w
t
f ascia ; a li t le p ro x im al t o t h e e lbo w h e y re ce i e lymp h f ro m th e t v
t r
fi n ge rs, p alm , an d t h e an e io r asp e c o f th e f o re arm , an d are ap t t
t o be co m e in flam e d an d p ain fu l h e n o u n ds o f h o se p art s w w t
be co m e se p ic t
Th e ce p h alic an d t h e basilic e in s re ce i e ribu
. v v t
t arie s , w v
h ic h ary in n u m be r an d si e , bo h fro m the do rsal an d z t
v
t h e o lar su rf ace s o f t h e f o re arm an d h an d .

W h e n t h e ce p h alic an d basilic e in s an d h e ir m ain ribu arie s v t t t

v r t
h a e be e n cle an e d, e u rn to th e do rsu m o f th e h an d, cle an th e
v
do rsal e n o u s arc h an d t h e ribu arie s h ic h p as s t o it f ro m t h e t t w
t t
dig i s ; h e y are ( I ) three do rsal m e tacarp al vei n s , o n e o pp o si e t
e ac h o f t h e t
h re e m e dial in e rdig i al cle f s ; (2 ) t h e h radial do rsal t t t
t v
dig i al e in f ro m t h e in de x fi n g e r On t h e do rsu m o f e ac h dig i . t
lo o k f o r t wo do rsal digi tal vei ns , o n e alo n g t h e radial an d o n e
alo n g t h e u ln a r bo rde r Th e do rsal dig i al e in s o f t h e h u m b
. t v t
v
j o in t h e ce p h alic e in t h e u ln ar do rsal dig i al e in o f t h e li t le t v t
fi n ge r u su ally j o in s th e basilic e in ; t h e o t h e r do rsal digi al v t
v t t
e in s e rm in a e in t h e do rs al m e acarp al e in s Th e tw o do rsal t v .

t v
dig i al e in s o n e ac h fi n g e r are u n i e d by m an y c h an n e ls h ic h t w
f o rm a se rie s o f arc ades, t h e do rsal digi tal ven o u s arche s Th e .
 TH E SUPER I OR EXTRE M I TY
su p e r c ial fi v t h e do rsu m o f th e h an d c o m m u n ica e h ro u gh
e in s o n t t
t h e in t t t
e rdig i al c le ft s w i h t h e de e p an d su p e rfi cial e in s o f t h e v
p alm .

The su p e rfic ial v e in s o n t he v o ar aspe c ts o f the fin g e rs an d in the p alm l

are sm a ll
a n d c an n o t as a ru le be disp ay e d in an o rdin ary disse c tio n , bu t ,
, l
sprin gin g fro m a n e t w o rk in th e su p e rfi cia fascia o f th e p a m , o r ap p e arin g l l
in the s u p e rfic ial fascia of t he v o lar asp e c t o f the w rist , t h e re is o cc asio n a y ll
a m edia n a n tebrac/z z a / v e in wh ic h p asse s p ro im al y , a o n g t he m iddle
’

x l l
o f t h e v o lar as pe c t o f t he fo re arm , t o w ards t h e e lbo w A sh o rt distan c e .

l l
dista to t he e bo w it e ith e r j o in s the m e dian c ubital v e in o r it div ide s
in to t wo bran ch e s, the m e dian basi ic an d the m e dian ce p h alic , wh ich l
t e rm in at e re spe c tiv e ly in th e basilic an d c e ph alic v e in s .

Acco m p any ing t he v ario u s su pe rfi cial v e in s o f the su pe rio r e t re m ity x

t h e re are n u me ro u s ly m ph v e sse s wh ic h co le c t ly mp h fro m t he re g io n s l l
drain e d by t he v e in s Th o se wh ich ac co mp an y the p ro im al part o f the
. x
c e p h alic v e in , an d wh ich are de riv e d p art y fro m the do rsu m o f th e l
l
fo re arm an d p art y fro m t he do rsu m o f t he arm an d the late ral part o f
th e sh o u lde r, p ass to the de lto p e c to ral an d in fraclav icu lar ly m ph g lan ds ;
-

l
so m e o f th e y m ph v e sse ls wh ic h acco m pany the basi ic v e in e n d in the l
su p e rfic ial c u bital g lan ds, abo v e the m e dial e p ico n dy le t h e re m ain de r, an d
t h e e ffe re n ts o f t h e su p e rfi cial c u bital g lan ds, ac co m p an y t he pro im a p art x l
l
o f the basi ic v e in , an d, afte r p ie rc in g t he de e p fasc ia , th e y te rm in at e e it h e r

l
in the brach ial g an ds o r the a te ra g ro u p o f a il ary g lan ds ( F ig l l x l .

l
The su pe rfic ia ly m ph g lan ds c an o fte n be fo u n d by a c are fu l disse cto r,
ll
bu t t h e su p e rfic ia y mp h v e sse ls are diffic u lt t o de m o n strat e in an o rdin ary
disse c tin g ro o m T h e y app e ar as fi n e wh it e stran ds, an d are m o st
“
art
p
-
.

l
e asi y distin g u ish e d as th e y e n te r o r le av e th e g an ds l .

V ena Ce p h a lic a
c e p ha lic v e in co mme n c e s at t he
.
— Th e
rad ia l e n d o f th e v e n ou s arch o n t he dorsu m o f th e ha n d .

I t r e c e iv e s th e t wo dor sa l d ig ita l v e in s fr o m the thu mb an d ,

th e n tur n s rou n d the rad ia l bo rd e r o f the d ista l p art o f the

fo r e ar m an d a sc e n d s to t he r e g io n o f th e e lbo w ; th e r e t h e
gre at e r p art o f t he blo od wh ich it carr ie s is tra n sm itt e d to the
ba silic v e in by t h e larg e m e d ia n cu bita l v e in Pro x ima l to .

t h e le v e l o f th e m e d ia n cu bita l v e in th e c e p ha lic v e in a sc e n d s ,

e ith e r a lo n g t h e lat e ra l p art o f t h e bic e p s o r in t h e gr o o v e ,

at the lat e ral bord e r o f the bi c e p s t o the low e r bo rd e r o f th e ,

p e ct o ra lis m ajor ; th e r e it p ie rc e s t h e d e e p fa sc ia F ig
( an d .

th e n co n t in u e s p ro x imally in the gr o ove be tw e e n the p e ct o ra lis

major an d th e d e lto id t o the de lto p e ct o ra l tr ia n g le I n t he -
.

de lto p e ctora l tr ia n g le it cr o sse s the lat e ra l p art o f th e p e ctora lis

-

min o r an d tur n s me d ia lly be tw e e n th e clav icu lar p art o f the

,

p e ct o ra lis m aj or an d t h e co sto corac o id me m bra n e I n th is -

.

t e r min a l p art o f its c o ur se it lie s a n t e r io r to th e a x illary art e ry ,

bu t is se p arat e d fro m the art e ry by t he c o st o coraco id me m -

bra n e F in a lly it p ie rc e s t h e c o sto corac o id m e m bra n e an d

.
-

j o in s the a xillary v e in I t r e c e iv e s ( r) th e dor sal d ig ita l v e in s

.
 D I SSE C T I O N O F SU PER F I C I A L STR U C TU R E S 65

f th e thu mb, ( 2 ) t ribu tarie s f ro m th e vo lar an d d o r sa l a sp e ct s

‘

o f t h e fo r e ar m, tr utar ro m at ra dor a
(3 ) ib ie s f t h e l e l an d s l
a sp e ct s o f the arm, ( 4 ) a tributary fro m t he sid e o f the shou ld e r,
an d imm e d iat e ly be fo r e it p ie rc e s th e co sto c o rac o id -

me mbra n e , it is j o in e d by t he v e n a c o mit e s o f th e d e lto id an d

acro mia l bra n ch e s o f th e thoraco acr o mia l art e ry I t is -
.

acc o mp a n ie d by ly mp h v e sse ls fro m t h e dor su m o f the ha n d ,

an d t h e lat e ra l an d d o r sa l sid e s o f t h e for e ar m an d arm ;

tho se v e sse ls t e r min at e in th e de lt o p e ct o ral ly mp h gla n d s

-
.

Ve na B asili ca — Th e ba silic
v e in c o mme n c e s at th e u ln ar
e n d o f th e dor sa l v e n ou s arch o f t h e ha n d I t r e c e iv e s t h e
.

dor sal d ig ita l v e in fro m th e u ln ar sid e o f the lit t le fi n g e r an d

th e n a sc e n d s o n the u ln ar p art o f t he dorsa l sur fac e o f t he
fo r e ar m B e low th e e lbow it tur n s rou n d th e u ln ar bo rd e r
.

o f t he for e ar m an d a s c e n d s t o t h e gro o v e a lo n g t h e m e d ia l

bord e r o f t h e bic e p s brachn Abo ut 3 0 mm a bov e t h e

. .

m e d ia l e p ico n dy le it is jo in e d by th e m e d ia n cu bita l v e in ,

th e n it co n tin u e s p ro xima lly to the le ve l o f t he midd le o f t he

arm wh e r e it p ie rc e s t h e d e e p fa sc ia
, Aft e r it has p ie rc e d
.

t h e d e e p f a sc ia it ru n s a lo n g t he m e d ia l sid e o f t h e brach ia l
,

art e ry to the low e r bord e r o f the t e r e s major wh e r e it be co me s ,

t h e a x illary v e in ; o n ly t he t e r m in at io n o f th is p art o f t h e
v e in can be se e n at p r e se n t the r e ma in d e r w ill be dis
,

p l ay e d in a lat e r d is se ct io n T h e
. tr ibutar ie s o f t h e ba silic

v e in are ( I ) the u ln ar dor sa l d ig ita l v e in o f th e litt le fi n g e r ,

( )
2 tr ib utar ie s fro m t h e vo la r an d d o r sa l a sp e ct s o f t h e fo r e

arm , (3) t h e m e d ia n cu b ita l v e in

( )
4 tr
, ib utar ie s f r o m t h e

m e d ia l an d p o st e r ior p art s o f th e arm I t is acco mp a n ie d

.

by ly mp h v e sse ls fro m th e d o r su m an d pa lm o f t h e ha n d
an d t h e vo lar an d dor sa l a sp e ct s o f th e for e ar m So me .

o f t h e acco m p a n y in g ly m h v e sse ls e n d in t h e su p e rfic ia l

p
cu bita l g la n d s wh ich lie p ro x ima l t o the me d ia l e p ico n dy le
,
.

O th e r s p a ss d ir e ct ly to the brach ia l an d the lat e ra l a x illary

gla n d s .

V e n a M e dian a Cubit i — The m e d ia n cu bita l v e in is a

. .

larg e co m mu nicat in g v e in wh ich sp r in g s fro m t he c e p ha lic

v e in a bout 2 5 mm be low th e be n d o f the e lbo w an d
.
,

t e r min at e s in the ba silic v e in 3 0 mm a bov e the m e d ia l .

e p ico n dy le As it cr o sse s fro m t h e c e p ha lic t o t h e ba silic

.

v e in it r e c e iv e s tr ibutar ie s fro m th e vo lar a sp e ct o f t h e

fo r e ar m it is se p arat e d fro m t h e d ista l p art o f th e brach ia l
,

art e ry by a th ick e n e d p ort io n o f d e e p fa sc ia ca lle d the

V OL . 1— 5
66 TH E SU P ER I O R EXTRE M I TY
lacertu s fi bro su s,
1
an d it is cr o sse d th e r d e e p ly o r su p e r
ei

fi cially by th e v o lar bra n ch o f t he m e d ia l cuta n e ou s n e rv e o f

t h e for e ar m ( F ig .

Th e Ly mp h V e sse ls an d L y mp h Glands o f t h e Su p e rio r Ex t re mit y .

x
W ith the e ce p tio n o f a fe w ym p h v e sse s wh ic h the disse cto r m ay h av e l l
Ju g u l l y mp h
ar

l vi l
S u bc a an
I n frac a l v i l l y mp h g ]
cu ar '
I n t e rn a lj g l v i
u u ar e n

S u bc lav ia n v e in
’

I i
nn o m n a t e v e n i
l l y mp h g l di as t m a l
gfigi p
‘

h
’

D e lt o p e c t o
-
ra an ds,
r

y
L mp h v e sse s l i
wh ch ac c o m p a n y
t he ce p h a c e n
‘
li v i

A xill y l y mp h gl
ar a n ds

L y mp h v l whi
e sse s c h ac c o mp a n y
h b ili v i
t e as c e n

l y mp h gl an ds

FIG .
3o .
—
Di agra m o i l
f th e S u p e rfic a L ym p h Ve sse s l an d L ym ph G l an ds o f
t he Ri i
gh t Su p e r o r E tre m ty x i .

fo und
p assin g t o an d fro m th e a il ary lym p h g lan ds ( p x l . th e l m p y
h
v e sse ls o f the su p e rio r e tre m ity can n o t be di sp ay e d in x l an o rdin ary
disse c tin g ro o m
p t,
a r
!
an d it is o n ly o cc asio n al y in th e
-
l h o spital , th e
p o st -
mo rte m ro o ll
m , an d in sp e cia y p re p are d su bj e c t s th at an o
pp o rt u n ity
fo r se e in g t he l ym ph v e sse ls w ill o ccu r I t is u n fo rtu n ate th at th is sh o u d
. l
1
Th e st re n gt he n i ng fi bre s f theo l ace rt u s fibro su s are de r iv ed fro m t h e
t e n do n o f i i
n se rt o n o f th e i
b ce p s brac h ii .
68 TH E SU PER I OR EXTRE M I TY
The sup erfi cia l ly ncp /z gla n ds are t he su pe rficial cu bital glan ds wh ich lie
in the fat o f the fro n t o f t he m e dia side o f th e arm imm e diate ly p ro im al l x
l
to the m e dia e pico n dy le ( se e p .

The lym ph fro m the sk in an d su bcu t an e o u s tissu e s o f the su p e rio r

x
e t re m ity fo rm s t w o m ain stre am s ( ) F ro m the pa m , the u n ar bo rde r . I l l
an d the u ln ar art o f the do rsal su rface o f the h an d, the g re ate r art o f th e
p p
fro n t , the u ln ar bo rde r, an d th e u nar p art o f the do rsa su rfac e o f the fo re l l
arm , it fl o w s th ro u gh a se rie s o f su e rficia
p y m p h v e sse ls wh ich acco m p an y ll
th e tribu tarie s an d t he dist a part o f the tru n k o f the basi ic v e in t o the l l
l
su p e rfic ia c u bital g lan ds The e ffe re n t v e sse ls fro m the su pe rfi cial cu bital
.

g lan ds, re in fo rce d by ym ph v e sse s fro m the m e dia part o f the arm , l l l
ac c o m an y the
p p ro im a p a x l
rt o f th e basilic v e in t h ro u gh the de e p fascia ;

so m e o f th e m e n d in the brach ia g an ds, bu t th e m aj o rity pass to the l l

x l
late ral a il ary g an ds l
( 2 ) The se co n d st re am flo w s fro m the radial part
.

o f th e do rsal as e ct o f t he h an d, t he radial bo rde r, an d th e radial

p p art o f
t he p o ste rio r su rfac e o f th e fo re arm an d the lat e ra p art o f the arm , th ro u gh l
p l
a se rie s o f y m h v e sse ls wh ic h ac co m any th e ce ph a ic v e in
p T h ey e n d l .

l
in the de lto pe c to ral g an ds, wh ic h re ce iv e lym ph a so fro m the re g io n
-
l
o f the sh o u lde r Th e lym p h fro m the late ral a illary g lands an d the
. x
de lto pec to ral g lan ds p asse s t o th e in fraclav icu lar g lan ds , an d th e n ce o n the
-

p l
righ t side t o t he righ t y m h du c t , an d o n th e le ft side to t he th o racic du ct .

The ly mph fro m th e de e p an d su pe rficial p arts o f the scapu ar re g io n l

flo w s mainly to the po ste rio r a i ary g lan ds, an d th ro ugh th e m to the in fra x ll
c lav ic u la r g lan ds Th e su p e rficia an d de e p ly m ph v e sse ls o f the an te rio r
. l
x l
a il ary re gio n h av e a re ady be e n trac e d l
Th e y c arry ly m ph p artly to the .

x
an t e rio r a illary a n d in t e r e c to ral g an ds, wh e n ce it p asse s t o t he in fra
p l
c lav icu lar g lan ds , an d
p l
art y dire c t y to th e in frac lav icu lar g lands, bu t th e y l
also co n v e y it t o the st e rn a ly m h g lan ds, an d th e y co mm u n ic ate w ith th e
p l
l
ly mph v e sse s o f t he u pp e r an d an te rio r p art o f the abdo m e n ( se e p 1 7 .

an d F ig .

Wh en u p e rfic ia l v e in s an d th e ir co n n e ct io n s hav e
the s

be e n c le a n e d an d stud ie d th e cuta n e o u s n e rv e s o f th e ,

su p e r ior e x tr e m ity m u st be fo u n d an d c le an e d ; th e y are

'

v
- The po ste rio v icu lar n e rv e s
r su prac la .

p The in te rco sto brach ial n e rv e -

.

o
a The m e dial cu tan e o u s n e rv e o f the arm
To th e sk in o f the arm
g
.

-
The late ra l brach ial cu t an e o u s n e rv e
.

F- .

n
L
Th e po ste rio r c u t an e o u s n e rv e o f t h e
arm .

The m e dial cu t an e o u s n e rv e
\
0 o f th e
fo re arm . To th e sk in o f th e arm an d

v The do rsal cu tan e o u s n e rv e o f t he t h e fo re arm .

fo re arm .

8 Th e late ral c u tan e o u s n e rv e

. o f th e To the fo re arm an d ba l l o f
fo re arm . th e t h u mb .

9 The p almar c u tan e o u s bran ch

. o f th e
m e dian n e rv e
To sk in o f the p alm
.

the
The palm ar cu tan e o us bran ch f the
.

10 . o

u ln ar n e r e v .

11 . The dig ital bran ch e s o f the m e dian n e rv e .

12 . The dig ital bran ch e s o f t he u lnar n e rv e .

13 . The su pe rficia l bran ch o f the radial n e rv e an d its do rsal dig ital

bran ch e s .

14 . The do rsa branc h l o f t he ulnar n e r e an d v it s do rsal dig it al bran ch e s .

D I SSE C T I ON O F SU PER F I C I AL STR U C T U R E S 6 9

i
D se ct o n
s i — Tu rn t o t h e p ro x im al e n d o f t h e limb an d co m
m e n ce wt
i h t h e i n terco sto brachial n erve , w h ic h w as se e re d v
w h e n th e su p e rio r e xt re m i y w as re m o e d f ro m th e ru n k I t t v t .

t
lie s in t h e p o s e rio r p art o f t h e m e dial side o f t h e arm , an d is at
t
fi rs de e p t o th e de e p fascia N o e th e p o in at h ic h it p ie rce s . t t w
t h e de e p f as cia ( F ig s 3 1 , 3 2 ) an d race it t o its e rm in a io n n e ar
. t t t
t h e e lbo w B y m e an s o f its ario u s bran c h e s it su p p lie s th e sk in
. v
o n t h e m e dial s ide o f t h e p o s e rio r p art o f t h e arm ( F ig s 3 1 , t .

F in d, n e xt , th e me di al cu tane o u s ne rve of the arm I t p ie rce s .

t h e de e p o f t h e fas c ia p ro x im al h ird o f t h e arm o n t h e m e dia l t

side , an d its bran c h e s su p p ly t h e sk in as f ar as t h e e lbo w in an
are a an e rio r t o t t t
h a su p p lie d by t h e in te rco sto brac h ial n e r e -
v .

t t
Af e r t h e m e dial cu an e o u s n e r e o f t h e arm h as be e n cle an e d, v
lo o k f o r t h e bran c h e s o f t h e me di al cu taneo us nerve of the f o re
arm , w
h ic h su p ply th e m e dial p art o f th e sk in o f t h e arm Th e y .

v ary in n u m be r an d si e , bu t z
h e y u su ally p ie rce th e de e p fas cia t
alo n g t h e lin e o f t h e me dial bo de r o f t h e bic e p s brac h ii an d h e y r t
co mm u n ica e t wt
i h o n e an o h e r (F ig t .

t
Th e ru n k o f t h e m e dial cu an e o u s n e r e o f t h e f o re arm t v
t
e i h e r p ie rce s t h e de e p f asc ia clo se t o t h e bas ilic e in , o r it p asse s v
t h ro u gh th e s am e o p e n in g as th e e in , an d di ide s in o its vo lar v v t
an d u lnar te rmma l bran ches Th e o lar bran c h p as se s e i h e r . v t
de e p o r su p e rfi c ial t o t h e m e dian cu bi al e in an d h e n de sce n ds t v t
t o t h e w ris t
I t su p p lie s t h e sk in o f t h e u ln ar h alf o f t h e o lar
. v
asp e ct o f t h e f o re arm Th e u ln ar bran c h p asse s e i h e r an e rio r
. t t
t
o r p o s e rio r t o t h e m e dial e p ic o n dy le an d h e n alo n g t h e u ln ar t
m arg in o f t h e f o re arm I t su p p lie s t h e sk in o f t h e u ln ar m arg in
.

r t
an d o f t h e u ln a p ar o f t h e do rsu m o f t h e f o re arm as f ar as t h e
w t ris .

t t
Af e r t h e m e dial cu an e o u s n e r e o f t h e f o re arm h as be e n v
t
disse ct e d, race t h e re m ain s o f t h e p o s e rio r su p racla icu lar n e r e s t v v
t v
h ro u gh t he f at o e r th e p ro x im al p art o f t h e de l o id h e y su p p ly t t
v
t h e sk in o e r t h e p ro x im al h alf o f t h e de l o id m u scle W he n t .

t v t
h e y h a e be e n race d t o h e ir e rm in a io n s m ak e an in cisio n t t t
t h ro u gh th e f at alo n g t h e dis al h alf o f t h e p o s e rio r bo rde r o f t het t
t
de l o id an d se cu re t h e la teral cu tan eo u s n erve o f th e arm I t is a .

v
bran c h o f t h e ax illary n e r e an d w ill be f o u n d u rn in g ro u n d t h e t
p o s e t
r io r b o d e r o f t h r
e d e l o id a t t h e j u n t
c io n o f t h e p ro x im al t
tw o t h irds
-
wt t t
i h t h e dis al h ird o f th e m u scle ( F ig s 3 1 , 3 2 ,
-
.

w
I t ru n s f o r ards a cro ss t h e m u s cle an d su pp lie s t h e sk in o e r it s v
t
dis al h alf .

To fi n d t h e p ro ximal an d dis tal branc hes o f t h e do rsal cu tane

o us n erve of the f o rearm disse c in t h e f at be w e e n t h e la e ral t t t
e p ico n dy le o f t h e h u m e ru s an d t h e in se rt io n o f t h e de l o id t .

Th e y are bran c h e s o f t h e radial n e r e an d bo h are o ccasio n ally v t

diffi cu l t o fi n d t Th e p ro x im al bran c h u su ally p ie rc es t h e de e p
.

tt t
f ascia a li le dis al t o t h e in se rt io n o f th e de l o id ( F ig s 3 1 , t .

I t su p p lie s t h e sk in o f t h e la e al p art o f t h e an e rio r asp e c o f t r t t

t h e arm as f ar as th e e lbo Th e dis al bran c h w ill be f o u n d
. t w
abo u t
o n e in c h n e are r t h e la e ral e p ico n dy le t
I t p asse s be h in d .

t
t h e la e ral e p ico n dyle an d h e n de sce n ds alo n g t h e do rsal asp e c t t
o f t h e f o re arm t o t h e w ris t .

t t
Af e r t h e dis al bran c h o f th e do rsal cu t an e o u s n e rv e o f t h e
f o re arm h as be e n t race d t o it s e rm in a io n , fi n d t h e late ral t t
cu tan eo u s nerve o
f t he f o r e a r m I t is t h e c o n inu a io n o f t h e . t t
m u scu lo cu an e o u s n e r e
- t v
I t app e ars at t he late ral; bo rde r o f
. , ,

1— 5 6
70 TH E SU PER I OR EXTRE M I TY
the bic e p s u n de r co e r O f t h e ce p h alic v
e in , abo u 2 5 mm v t .

v
abo e t h e p o in tw
h e re th e m e dial cu bi al e in le a e s t h e c e p h alic t v v
v e in . t
So o n af e r it e n e rs t h e su p e rfi c ial f ascia it di ide s in o t v t
a v o lar an d a do rsal bran c h Th e o lar bran c h de sce n ds alo n g . v
v
t h e radial p art o f t h e o lar asp e c o f t h e f o re arm t o th e ball o f t h e t
t h u m b, an d th e do rsal bran c h m ay be t race d dis ally o n t h e do rsal t
t
asp e c o f t h e radial s ide o f t h e f o re arm as f ar as t h e ris w t .

Th e p o steri o r cu tan eo us n erve o f the arm w as fo u n d du rin g

t
t h e disse c io n o f th e ax illa sp rin g in g f ro m t h e p ro x im al p art o f
t h e radial n e r e v
No w it m u s be race d alo n g th e do rsal asp e c
. t t t
o f t h e arm t o t h e e lbo w
I t su p p lie s t h e sk in O f t h e do rsu m o f
.

t h e arm f ro m th e ax illa t o t h e e lbo w (F ig .

t t
Af e r t h e p o s e rio r cu an e o u s n e r e O f t h e arm h as be e n t v
c le an e d, p lace t h e lim b o n it s do rs al su rf ace an d lo o k f o r t h e
t
p alm ar c u an e o u s bran c h e s o f t h e m e dian an d u ln ar n e r e s v .

t
Th e y bo h p ie rce th e de e p f as cia o f t h e f o re arm abo u 3 0 t
m m p ro x im al t o t h e w ris
. Th e p alm ar cu tane o u s bran ch o f t .

the m edi an n erve lie s in t h e lin e o f t h e m e dial bo rde r o f t h e

p ro x im al e n d o f t h e ball o f th e h u m b ( h e n a e m in e n ce ) an d it t t r
e x t e n ds t o t h e m iddle o f t h e p alm Th e p almar cu tan eo u s .

bran ch of the u ln ar n erve lie s in t h e lin e o f t h e m iddle o f t h e

t
ball o f th e li t le fi n g e r ( hyp o h e n ar e m in e n ce ) it also e x t e n ds t o t
v
t h e le e l o f t h e m iddle o f t h e p alm (F ig .

t t t
A f e r t h e dis ribu io n o f t h e p alm ar cu an e o u s n e r e s h as t v
w
be e n se e n cle ar a ay t h e su p e rfi cial f asc ia o f t h e p alm f ro m t h e
t v
in e r al be e e n the tw t
h e n ar an d hyp o h e n ar e m in e n ce s t o th e t
t
base s o f t h e dig i s t o e xp o se t h e in e rm e dia e p ar o f t h e p almar t t t
ap o neu ro sis ,
t t
h a is, th e de e p fascia o f t h e p alm N o e h a t h e . t t t
su p e rfi c ial f asc ia in t h e are a u n de r c o n side ra io n is de n se I t is t .

v t
di ide d in o sm all lo bu le s by fi bro u s se p a h ic h p ass f ro m th e t w
sk in t o t h e p alm ar ap o n e u ro sis W h e n t h e in e rm e dia e p art O f . t t
t h e p alm ar ap o n e u ro sis is ex p o se d it w ill be f o u n d t o be rian gu lar t
in o u lin e tTh e ap ex lie s at th e ris
. h e re it is co n in u o u s i h w tw t wt
t h e de e p f ascia o f t h e f o e a m The base is at t h e le e l o f t h e r r . v
t t
dis al e n ds o f t h e m e acarp al bo n e s, an d it di ide s in o fi v e p ie ce s, v t
o n e f o r e a c h fi n g e r an d a le ss de fi n i e slip f o r t h e hu mb A t t .

bu n dle o f t ran s e rse fi bre s w ill be m e t v i h in t h e f o ld O f sk in wt

w h ic h c ro sse s th e p ro x im al e n ds o f th e in e rdig i al cle f s I t is t t t .

t h e sup erfi ci al tran sverse ligame n t o f t h e h an d, an d it m u s be t

v t
di ide d Opp o si e t h e cle f s in o de r h a t h e o lar dig i al n e r e s t r t t v t v
w h ic h su pp ly t h e adj ace n side s o f the cle f s m ay be f o llo e d t t w .

v t
Th e o lar dig i al n e r e s are se e n in n u m be r Th e fi rs an d v v . t
se c o n d p ass t o t h e t
h u mb, o n e to its radial an d o n e t o its u ln ar
side Th e y are a c co m p an ie d by b an c h e s o f th e p rin ce p s p o llic is
. r
t
ar e ry w
Th e y ill be f o u n d at t h e m e dial m arg in o f t h e h e n ar
. t
e m in e n ce an d m u s be race d t o t h e e n d o f t h e h u m b t t
Th e h ird t . t
t
app e ars at th e la e ral m arg in o f t h e slip o f t h e p alm ar ap o n e u ro sis
t o t h e in de x - fi n ge r I t ru n s alo n g t h e radial side o f t h e fi n g e r
.

acco m p an ie d by t h e o lar radialis in dic is art e ry v

Th e fo u r h , . t
t w
fi f h , an d sixt h ill be fo u n d be e e n t he slip s o f t h e in e r tw t
t t
m e dia e p ar o f t h e p alm ar ap o n e u ro sis in lin e w i h t h e fi rs , t t
t
se co n d, an d h ird in e rdi g i al c le f s re sp e c i e ly t
Eac h is ac t t tv .

co m p an ie d by a v
o lar dig i al art e ry , an d lik e t h e a r e ry it di ide s t t v
t
t o su p p ly t h e adj a ce n side s o f t h e fi n g e rs wh ic h bo u n d t h e cle f t
t
O p p o si e w h ic h it lie s Th e se e n h su pp lie s th e u ln ar s ide o f
. v t
tt
th e li le fi n g e r I t app e ars at th e dis al bo rde r o f t h e p alm aris
. t
 P L ATE IV

Nn . su p ra c a l vi l c u a re s

N . c u t an e u s brach n l a t e ra li s

N . c u ta n e u s brac h ii
p o st e ri o ri s

N . in t e rco st o brach ia lis

N c u t a n e u s a n t ibra c h i i do rsa li s ram u s su p e r o r i

N . c u t a n e u s a n t ibrach ii do rsa li s, ra mu s i n fe r o r i
c u t a ne u s bra c h n m e d a i li s

N cu t an e u s an t ibra c h i i me d a i li s,
4
l
.

ra m u s u n ari s

c u t a n e u s a n t ibra c h ii l a t e ra li s

V . bas ili c

V . bas ili c

rad a i li s su p e rfi c al s i i

c e p ha li ca

l i
u n a r s , ra m us do rsa l si man u s

FIG .
32 .
— i
Su p e rfic ial V e n s an d N e rve s o f t h e P o ste ri o r Asp e ct
o f th e S u p e r o r E tre m ty i x i .
 D I SSE C T I ON O F SU PER F I C I AL STR U C TURE S 7 1

v
bre is m u scle an d is ac co m p an ie d by a dig i al art e ry Th e fi v e t .

t t t v
m o s la e ral dig i al n e r e s are bran c h e s o f t h e m e dian n e r e , t h e v
t
t w o m o s m e dial a re bran c h e s o f t h e u ln ar n e r e , h e re f o re t h e v t
v t
m e dian n e r e su pp lie s h re e an d a h alf dig i s , t h e h u m b, th e t t
in de x , t h e m iddle an d h alf t h e rin g dig i , an d t h e u ln ar su pp lie s t
t h e re m ain in g o n e an d a h alf , v iz , t h e li le fi n g e r an d h alf t h e . tt
rin g fi n g e r .

As t h e bran ch e s o f t h e m edian n e r e t o t h e fi n g e rs are f o llo w e d v

t
alo n g t h e fi n g e rs h e y w ill be f o u n d t o se n d bran c h e s n o t o n ly t o
v
t h e o lar su rf ace s bu t a lso t o t h e do rs al su rf ace s in t h e re g io n s
o f t h e se co n d an d e rm in al p h alan g e s t .

The c are fu l disse cto r w ill n o te th at so m e o f the fi n e r bran ch e s o f th e

digital ne r e s v t e rmin at e in m inu te o v o id bo die s e m be dde d in the fat .

Th e y a re the P ac in ian to u ch c o r u sc le s an d are asso ciate d w ith th e se n se

p
o f to u ch .

Tw o h e r cu t an e o u s n e rve s h av e st ill t o be disse ct e d ; t h e y are

o t

t h e do rsal bran c h o f t h e u ln a r n e rv e an d t h e su p e rfi cial div isio n

o f t h e radial n e rv e B o t h are dist ribu t e d t o t h e do rsu m o f t h e
.

h an d an d t o th e do rs al asp e ct s o f t h e dig it s .

Th e do rsal bran ch of the u ln ar n erve m u st be s o u gh t f o r as

it t u rn s ro u n d t h e u ln ar bo rde r o f t h e w rist im m e diat e ly dist al
t o t h e st y lo id p ro ce ss o f t h e u ln a I t g iv e s a bran c h t o t h e u ln ar.

s ide o f t h e litt le fi n g e r an d a bran c h t o su pp ly t h e a dj ace n t s ide s

o f t h e rin g an d litt le fi n g e rs ; t h e latt e r co m m u n icat e s w it h t h e
m o st m e dial bran c h o f t h e su p e rfi c ial div is io n o f t h e radial n e rv e .

Th e sup erfi ci al bran ch of the radi al n erve w ill be f o u n d at

t h e radial bo rde r o f t h e f o re arm I t ap p e ars f ro m u n de r co e r . v
o f th e t
e n do n o f th e bra c h io radialis abo u 8 cm (3 1 in c h e s) -
t .

abo e t h e v w t
ris , an d, as it de s ce n ds t o t h e h an d, it bre ak s u p
t
in o fi v e bran c h e s — o n e t o e ac h s ide o f t h e h u m b, o n e t o t h e t
radial s ide o f t h e in de x - fi n ge r, o n e t o t h e adj ace n side s o f t h e t
in de x an d m iddle fi n g e rs, an d o n e t o t h e adj ace n side s o f t h e t
m iddle an d rin g fi n g e rs Th e las bran c h is co n n e c e d w i h t h e
. t t t
j
ad a ce n t ram u s o
f t h e do rsal bran c h o f t h e u ln ar n e r e by a v
co m m u n ica in g ig t tw
A p alm ar cu an e o u s bran c h is dis ribu e d
. t t t
t t
t o t h e ball o f t h e h u m b e i h e r f ro m t h e ru n k o f t h e su p e rfi c ial t
p a r o t
f t h e ra dial n e r e o r f ro m t h e bra n c h t v
o t h e radia l s id e

o f th e t
h u m b Th e do rsal dig i al n e r e s o f t h e h u m b can be
. t v t
t race d t o t h e e n d o f t h e t
h u m b, h o se o f t h e in de x dig i t o th e t t
p ro x im al e n d o f t h e se co n d p h alanx , h o se o f t h e m iddle fi n g e r t
t o t h e m iddle o f t h e se co n d p h alan x a n d h o se o f t h e rin g an d t
tt
li le fi n g e rs t o t h e p ro x im al e n d o f t h e e rm in al p h alan x Th e t .

t
re m ain in g p ar s o f t h e do rsal asp e c s o f t h e fi n g e rs a re su p p lie d t
by t h e v
o lar dig i al n e r e s t v
Th e im p o rt an p rac ic al p o in is
. t t t
t t
h a p art s O f t h e do rsal su rface o f th e in de x , m iddle , an d rin g
t
dig i s are su p p lie d n o t by t h e radial bu t by t h e m e dian n e r e v .

The g e m e n t o f the n e rv e s o n the do rsu m o f the h an d is v e ry

arran

v ariable Th at de scribe d abo v e is u su ally m e t w ith bu t n o t u n co m mo n l y

.
,

th e u lnar n e rv e su pp l ie s a larg e r an d the radial n e rv e a sm all e r are a .

The re v e rse arran g e m e n t is also fo u n d .

W hen t h e disse c iot n o f th e t

cu an e o u s n e r e s o v f th e su p e r o r
i
e x t re m ity is co mpl t e e d re m o ve t h e re m a in s o f th e f a t y t su p e rfi c ral
f asc ia an d p ro ce e d t o th e s udt y o f the de e p f ascia.
1— 5 a
72 TH E SU PER I OR EXTRE M I TY
D ee p F a sc ia — Th e d e e p fa sc ia o f the su p e rio r e x tre mity
c o n sist s ch ie fly o f tra n sv e r se fi br e s wh ich are bo u n d t o g e th e r
,

by o bliqu e an d lo n g itud in a l fi br e s The o bliqu e an d lo n g i

.

tu din al fi br e s be co me sp e c ia lly d e v e lo p e d in c e rta in situat io n s

wh ich w ill be n o t e d lat e r The d e e p fa sc ia is fa irly str o n g in
.

th e r e g io n o f t h e sh o u ld e r ov e r t h e d e lt o id m u sc le Ov e r .

t h e p o st e r io r p art o f th e d e lt o id an d t h e adj o in in g p art o f t h e

in fra sp in atu s wh ich c o v e r s th e low e r p art o f t h e back o f t h e
,

sca p u la it be c o m e s d e n se an d it is c lo se ly attach e d by d e e p
, ,

p r o c e ss e s t o t h e a x illary bo rd e r o f t h e sca p u la Ov e r t h e .

fr o n t o f th e arm wh e r e it c o v e r s t h e bic e p s m u sc le it is th in
, , ,

bu t it is m uch str o n g e r at t h e back o f th e arm o v e r t h e tr ic e p s , .

O n e ach sid e e x t e n d in g p ro x im a lly fr o m th e lat e ra l an d the

,

m e d ia l e p ico n dy le s d e e p e x p a n sio n s bin d it to th e lat e r al

an d m e d ia l su p ra e p ic o n dy lar r idg e s o f t h e h u m e ru s
-
Th e .

e x p a n sio n s are k n o w n as the latera l an d medial in termu scu lar

sep ta be cau se th e y se p arat e t h e m u sc le s o n t h e fr o n t f r o m

,

th o se at th e back o f t h e arm At the e lbo w it is th ick e n e d.

an d str e n gth e n e d by t e n d in o u s fi br e s wh ich p a ss t o it fr o m ,

t h e bic e p s an d tr ic e p s m u sc le s an d it is c lo se ly attach e d to
,

t h e lat e ra l an d m e d ia l e p ic o n dy le s o f t h e hu me ru s an d t o
t h e O le cra n o n o f t h e u ln a A sp e c ia l th ick e n in g ca lle d th e
.

lacertu s fibro su s ( F ig 3 1 ) is fou n d at t h e fr o n t o f t h e e lbo w

. .

I t e x t e n d s fro m th e m e d ia l bo rd e r o f t h e p r o x im a l p art o f
t h e bic e p s t e n do n an d th e adjac e n t p art o f t he m u sc le to t h e
m e d ia l sid e o f th e p r o x ima l p art o f t he for e ar m I t se p arat e s .

t h e m e d ia n cu bita l v e in wh ich lie s su p e rfic ia l t o it fro m t h e

,
.
,

brach ia l art e ry wh ich is d e e p t o it

, Th e v o lar bra n ch o f .

t h e m e d ia l cuta n e o u s n e rv e o f t h e fo r e ar m u sua lly p a sse s

be tw e e n th e lac e rtu s fibro su s an d t h e m e d ia n cu bita l v e in .

I n t h e fo r e ar m t h e d e e p fa sc ia is stro n g ov e r t h e p r o x im a l
p art s o f t h e m u sc le s wh ich sp r in g fr o m t h e m e d ial an d th e

lat e ra l e p ic o n dy le Th e n it be c o me s th in e sp e c ia lly o n the

.
,

v o lar a sp e ct O n th e d o r sa l a sp e ct it is bou n d t o the wh o le

.

le n gth o f t he p o st e r io r bo rd e r o f t h e u ln a by a d e e p
e x t e n sio n wh ich in t e rv e n e s be tw e e n the m u sc le s o n t he
dorsa l an d vo lar p art s Of the m e d ia l sid e o f the fo r e ar m .

A t the wr ist t he tra n sv e r se fi br e s o f th e d e e p fa sc ia

be c o me v e ry o bv iou s an d th e y fo r m t wo m ark e d tra n sv e r se
,

ba n d s ; o n e o n t he v o lar a sp e ct ca lle d t he transverse carp al

liga men t an d o n e o n th e dor sa l a sp e ct ca lle d t h e do rsal carp al
liga ment .
74 TH E SUPER I OR EXTRE M I TY
o f the p a lm Th e d ista l m arg in o r ba se lie s at th e le v e l o f
.

t h e h e ad s o f th e me tacar p a l bo n e s, an d it d iv id e s in t o fiv e
r
p c o e ss e s o,
n e fo r e ach fi n g e r a n d a m o r e sle n d e r p r o c e ss fo r

t h e thu m b Each p r o c e ss p a sse s to the c o rr e sp o n d in g d ig it

.

wh e r e it ble n d s w ith t he vo lar surfac e o f the sh e ath o f th e

fl e x o r t e n d o n s an d it se n d s a p roc e ss o n e ach sid e o f th e
,

d igit wh ich j o in the d e e p fa sc ia o n the d o r sa l sur fac e .

Th e do rsal carpal ligamen t is attach e d o n t h e rad ia l sid e

to th e vo lar m arg in o f t h e sty lo id p roc e ss o f t h e rad iu s an d
o n t h e u ln ar sid e t o t he fa sc ia o n th e m e d ia l sid e o f th e
wrist Th e sp ac e be tw e e n it an d th e d ista l e n d s o f th e
.

rad iu s an d u ln a is d iv id e d in t o six c o mp art m e n t s by se p ta ,

wh ich p a ss fr o m its d e e p sur fac e t o the r idg e s o n t he rad iu s

an d t o t h e h e ad an d s ty lo id p roc e ss o f the u ln a .Th e co m
p a rt m e n t s tra n s m it t h e t e n do n s wh ich p a ss f r o m t h e d o r su m
o f t h e for e ar m t o t h e dor su m o f t h e ha n d an d t o t h e dor sa l

a sp e ct s o f t he fi n ge r s I ts su p e rfic ia l sur fac e is cro sse d by

.

th e t e r min a l bra n ch e s o f t h e S U p e rfic ial d iv isio n o f t h e

rad ia l n e rv e an d by the c e p ha lic an d ba silic v e in s The .

d ista l bord e r o f t he d o r sa l carp a l liga me n t is c o n t inuou s

w ith th e th in d e e p fasc ia o f t he ha n d wh ich is p ro lo n g e d
,

in t o t h e d o r sa l a sp e ct s o f t h e d ig it s .

Wh e n th e study o f the d e e p fa sc ia o f the su p e rio r

e x tr e mity has be e n c o mp le t e d r e tur n t o t h e sh o u ld e r r e g io n ;

v e r ify aga in the attach me n t s o f th e m u sc le s wh ich c o n n e ct e d

th e sca p u la an d th e c lav ic le w ith t he tru n k ; a ft e rward s cut
away th e su p e r flu o u s p art s o f t h e m u scle s le av in g a bo ut o n e
,

in ch o f e ach fo r r e v isio n . Th e n p roc e e d t o th e g e n e ra l

study o f th e sh o u ld e r r e g io n .

M u scle s in se rt e d int o t h e Cla i cle v

Scap u la — The in se rtio n s o f
an d
t h e m u scle s wh ic h h av e alre ady be e n div ide d m u st fi rst e n g ag e the
atte n tio n o f th e stu de n t . l
Th e y sh o u ld be c are fu ly de fin e d an d th e
p re c ise e x
t e nt o f e ac h stu die d B e gin
. w it h th e o mo hy d, wh ich
o i -

sp rin g s fro m th e su p e rio r bo rde r o f th e scap u la ; th e n de al in th e sam e

way w ith th e lev ato r scap u la , rho m bo ideu s m in o r an d m aj o r, wh ich

are att ach e d to th e v
e rte bral bo rde r o f th e bo n e , an d th e serrat u s an te rio r,

wh ich is in se rte d in to the co stal asp e ct o f the m e dial an d in fe rio r an gle s,

an d th e in te rv e n in g p o rtio n o f the v e rt e bral bo rde r o f the sc ap u a Thel .

in se rtio n o f the pecto ralis m ino r in to th e co raco id p ro ce ss, an d o f the

t rap ez i u s in to bo th clav icle an d sc ap u la, sh o u ld also be th o ro u gh ly re
x
e am in e d .
 S HO U L D ER — SC APU L AR RE G I O N 75

SH O U L ER
D — SC A PU L AR RE GI O N .

I n t he d isse ct io n o f th is r e g io n th e fo llow in g p art s m u st be

s tud ie d :
H C u tan e o u s n e rv e s o f the sh o u lde r .

N D e e p fascia .

C
O l
N D e to id mu scle .

P- Su b acro m ial bu rsa

-
.

L
F An te rio r an d po st e rio r circu m fl e v e sse ls o f the h u me ru s x .

xl
Q A i lary ( circu m fl e ) n e rv e x .

V C ircu m fl e x scapu ar art e ry l .

O
O Subscapu aris m u scle l .

S i t i fra i tu s, t e re s min o r, an d t e re s m aj o r m u scle s

O u
p r asp n a u s, n sp n a .

10 B u rsa in c o nn e c tio n with the sh o u lde r j o in t

.
-
.

11 Su p rascapu lar n e rv e an d tran sv e rse scapu lar arte ry

. .

I 2 Acro mio clavicu lar j o in t , an d the co raco acro mial arch

.
- -
.

N e rv i C u t an e i ( Cu t an e o us N e rv es) — The n e rv e s wh ich lie .

in t he su p e rfic ia l fa sc ia o f the shou ld e r r e g io n are d e r iv e d

fro m two d iffe r e n t sou rc e s Th e y are : .

I P t i
.
p l vi l
o s e r o r su rv f m th th ird a d f
rac a th
cu ar n e vi l es ro e n o ur ce r ca
v
ner e s .

2 . C u tan e o u s bran ch e s fro m the x ill y v ( i mfl x ) a ar ner e c rcu e .

Th e y hav e a lre ady be e n se cur e d an d c le a n e d .

The po sterio r sup raclavicu lar n erves cro ss the lat e ra l th ird
o f th e c lavic le an d th e in se rt io n o f t h e tra p e z iu s u n d e r cov e r ,

o f t h e p laty s ma Th e y w e r e d iv id e d wh e n the lim b was

.

r e mov e d an d t he d ista l e n d s have be e n f o llow e d ov e r the

,

p ro x im a l h a lf o f t h e d e lt o id .

Th e cu taneo u s bran ches o f t he ax illary n erve co n sist

a ) o f a larg e bra n ch th e lateral cu tan eo u s n erve of the a rm
( , ,

wh ich tur n s rou n d th e p o st e r ior bord e r o f the d e lto id m u scle ,

an d ( h) o f se v e ra l fin e fi la m e n t s wh ich p ie rc e t he su bsta n c e

o f t he d e lto id m u sc le an d a p p e ar at irr e gu lar in t e rva ls o n

,

it s sur fac e ( F ig The latt e r are difli cu lt to se cur e bu t th e

.
,

lat e ra l brach ia l cuta n e ou s n e rv e h as a lr e ady be e n fo u n d an d

c le a n e d ( se e p I t tur n s rou n d t h e p o st e r ior bord e r
.
,

an d is d istr ibut e d ov e r t h e d ista l p art o f t h e d e lt o id r e g io n .

De ep F ascia — I t h as a lr e ady be e n n ot e d that t he d e e p

fa sc ia ov e r t he d e lto id is fa ir ly stro n g an d that as it p a sse s ,

fro m t h e d e lt o id to t he mu sc le s wh ich sp rin g fr o m t h e low e r

p art o f t h e p o st e r ior a sp e ct o f t h e sca p u la i t be co m es stro n g ,

an d d e nse ov e r th e in f ra sp in atu s t he t e r e s m in or an d th e ,

t e re s m aj or I n the lo w e r sca p u lar r e g io n it is fir mly attach e d

.

to the limit s o f the in fra sp in ou s fo ssa in wh ich the in fra

76 TH E SUPER I O R EXTRE M I TY
sp in atu s tak e s or ig in an d it , p r e se n t s oth e r v e ry a p p ar e n t

co n n e ctio n s . Thu s a stro n g

,
se p tu m p r o c e e d in g fr o m its
,

ral e n d o f c a l vi l c e

M ar gi n o f a c ro m i o n

t o ralis ma j o r

C e p ha li v i c e n

D l id
e to

C u t an e o us bra n c he s oxill y
f a ar

(O T c i rcu m fl x) e v pi i g
ne r e e rc n

l i
. .

de t o d

L at e ra bra ch l il a c u tane o u s

bran c h o f a i x ll y ar v
ner e

B i ce p s

L at e ra he ad l Of i
t r ce p s

i li
B ra ch a s

P xi m l b
ro a ra n c h o f do rsa l
c u t an e o u s n e rv e o f fo re arm

C p h li v i
e a c e n

Di l b hs ta ra n c o f do rsa l c u t an e o u s
ne r e o v f fo re a rm

B rac h i o -
rad a i li s

Te n do n o f tr ce i p s

Ol e c rano n

E x t e nso r carp i rad a i li l gs o n us

FIG .
33 .
—The D l t id M
e o l
u sc e an d th e l at al
er asp e c t o f the Arm .

d e e p sur fac e w ill be n ot ic e d to dip in b e tw e e n the in fra

,

sp in atu s an d t e r e s mino r m u sc le s an d th en as it p r o c e e d s
, ,

forward s it g iv e s a th in
, minor t e r e s ,

majo r an d th e d e lto id
, ,
I n dee du i t may ibfe sa id t o sp lit in to
.
78 TH E SUPER I O R EXTRE M I TY
an d Sp in e o f the sc ap u la, an d tu rn it t w ard
o s its in se rt io n in to
th e h u m e ru s , t ak in g
t t o in j u re t h e c ircu m fl e x h u m e ral
c are no
t
a r e rie s an d t h e ax illary n e rv e N o e t h e e n din o u s in e rse c io n s . t t t t
w t r
h ic h ru n h o u gh th e su bs an ce o f th e mu scle , h e n cle an t he t t
ve s se ls an d n e r es v w h ich are ex p o se d. Th e ax illar y ne r e v
ent t h e ba ck p art o f t h e sh o u lde r re g io n h ro u gh t h e p o s e rio r
e rs t t
p art o f t h e u adran g u lar sp ac e , ac co m p an ie d by th e p o s e rio r
q t
h u m e ral circu m fl e x e sse ls, an d at o n ce di ide s in o an an e rio rv v t t
an d a p o s e rio r di is io n tB e f o re it di ide s , v
h ils it is in t h e . v w t
q u adran gu la r sp ace , im m e dia e ly be lo w t h e s h o u lde r j o in , it t -
t
v t
g i e s o ff an ar icu lar ig t o th e j o in , h ic h sh o u ld be se cu re d tw t w .

t v
Th e an e rio r di isio n acco mp an ie s t h e p o s e rio r h u m e ral c ir t
t
cu m fl ex ar e ry ro u n d t h e su rg ical n e c k o f t h e h u m e ru s It .

t
su pp lie s t h e de l o id an d se n ds bran c h e s h ro u gh it t o t h e s k in o n t
its su p e rfi c ial su rf ace Cle an bo h t h e n e r e an d t h e e sse l ; . t v v
t t
h e n u rn t o th e p o s e rio r bran ch an d se cu re th e ig to the e re st tw t
m in o r up o n w h i h t h e re is a gan glif rm e n larg m t
m u scle , c o e en .

Th p o t rio r bran c h t rm in at
e s e as t h lat e ral c t an o u rv o f
e es e u e s ne e

t h arm w h ic h t r
e r
, d t h p o t rio r b rd r f t h d lt o id
u ns o un e s e o e o e e

t o g ain its s p r fi ial s rfa I t h as alr ady b e n disse t d

u e c u ce . e e c e

( s ee p Cl.a n t h e t r s m aj o r a d m ei r m le w h i h e e n no u sc s c

s p rin g f ro m t h e p o t ri r s r fa f t h a illary bo rd r f t h
s e o u ce o e x e o e

s ap la an d p as
c u t ,
th h u m r an d n o t t he t r g
s o pt m e e u s, e s o n se u

o f d p f asc ia w h i h s p arat e s t h m
ee Cle an t h l n g h ad f
c e e . e o e o

t h e t ri e p s w h i h ari
c f r m t h u p p r p art o f t h a illary
c se s o e e e x
bo rde r o f t h e scap u la Th e n ex am in e t h e su bacro m ial bu rsa,
.

w t
h ic h lie s dire c ly be lo t h e acro m io n , o n th e in se r io n o f t h e w t
su p rasp in a u s t
I f t h e w all O f t h e bu rsa is q u i e e n ire a blo
. t t w
p pi e m ay b e h r u s in o it t
I t c a n h e n t b e dis e ntd e d ,
a n d if . t t
u n ilo c u lar it m ay be in fl a e d t o abo u t h e a e rag e s i e o f a h e n s t ’
t v z
e gg It
. v
aries m u c h in si e , h o e e r, in diffe re n su bj e c s z wv t t .

Op e n t h e bu rsa an d ex am in e its e xt e n i h the fi n g e r o r a t wt

blu n
p t
ro be t
I ts in e rio r is so m e im e s di ide d by fi bro u s p art i
. t v
t t
io ns i n o two o r m o re lo cu li No w u rn th e lim b o n t o its . t
p o s e rit
o r a sp e c an d c le an t h e p r t
o x im a l p a r s o f t h e c o ra c o t
r
b ac h ialis an d t h e sh o r h e ad o f th e bice p s brac h ii w h ic h sp rin g , t
t
by a co mm o n e n do n , f ro m t he t ip o f t h e c o raco id p ro ce ss o f t h e
s cap u la P u ll t h e sh o r h e ad o f t he bice p s an d t h e co rac o
. t
brac h ialis m e dially an d e x p o se th e e n do n o f t h e lo n g h e ad o f th e t
t rt
bice p s ly in g i n t h e in e u be rcu lar su lcu s o f t h e h u m e ru s, bu t do
n o t disp lace it at p re se n t
No w p u ll t h e s h o rt h e ad o f t h e bice p s
.

an d t h e c o raco brac h ialis la e rally an d cle an t h e in se r io n o f t h e

-
t t
s u b s ca p u la i s — it is inrse r e d in o t h e le ss e r u b e rcle o f t h t
e t t
h u m e ru s o n th e m e dial side o f th e in e r u be rcu lar su lcu s Cle an t t .

t
also t h e an e rio r h u m e ral c ircu m fl e x art e ry , race it t o its di isio n t v
t
in o an asce n din g bran c h , h ic h ru n s t o th e s h o u lde r j o in w t
t t
alo n g t h e in e r u be rcu lar su lcu s, an d a ran s e rse bran c h , h ic h t v w
an as o m o ses t wt
i h t h e p o s e rio r h u m e ral c ircu m fl e x art e ry , an d t
t h e n re ex am in e t h e s ru c u re s h ic h lie dire c ly u n de r co e r o f t t w t v
t
t t t
t h e de l o id an d n o e h e ir re la i e p o si io n s tv .

P A RTS U N D ER C O V ER O F TH E D ELTO ID The d e lto id .

—

c o v e r s t h e p ro x ima l p art o f the hu me ru s an d e n v e lo p s t h e ,

r e g io n o f th e sh o u ld e r j o in t be h in d lat e ra lly an d in fr o n t -

, ,
.

I t a lso cov e r s th e coraco id p roc e ss o f th e sca p u la I t is .

 S HO U L D ER — SC A P U L A R RE G I O N 79

se p arat e d fr o m t h e sh o u ld e r j o in t by th e m u sc le s wh ich are

-

attach e d to t he p r o x im a l e n d o f t he hu m e ru s an d by t h e
su bacro m ia l bur sa The fu ll r o u n d e d ap p e ara n c e o f the
.
,

shou ld e r is du e to t h e d e lt o id p a ssin g ov e r t h e p ro x im a l e n d

o f t h e hu m e ru s an d th e m u sc le s attach e d t o it Wh e n t h e .

h e ad o f the hu me ru s is d islo cat e d the mu sc le p a sse s v e rt ica lly

D di g b h f v vi l
e sc e n y n ra n c o t ra n s e rs e c e r ca a rt e r
S p p l v d v u ra sca u ar ne r e an t ran s e rse
p l y sca u a r a rt e r

C p l f h ld j i a su e o s o u e r- o nt

d f p pi o n o su ras nat u s

T d f i f en o n o n ra
i na t u s

Su bsc
I l
n fra sc a p u a r bra n ch

C irc u mfl e x l sc ap u a arte

P i i mfl x
o s t e r o r c rc u y d e a rt e r an
v
xill y v a ar ne r e
N er e t o t e re s m i no r

F G 34
I Di t i
. .
— sse c o n o f th e P o ste ri o r Scap u l ar R e g i o n .

fro m it s or ig in t o it s in se rt io
d islocat io n is n, an d th e
r e cog n ise d by the s uar e n e ss o r flat n e ss o f t h e shou ld e r
q .

U n d e r cov e r o f the p o st e r io r p art o f the d e lto id are p o rt io n s

o f t he m u sc le s wh ich s rin g fro m t h e p o st e r io r sur fac e o f t he
p
sca p u la v iz,
t h e in fra sp in atu s t e re s m ajor an d t e r e s m in or
.
, , , ,

an d t he p ro x im a l art o f th e lo n g h e ad o f t h e tr ic e p s wh ich
p ,

arise s fro m t he u p p e r p art o f the a x illary bord e r o f the

sca p u la U n d e r it s m idd le p art lie th e in se rt io n o f th e
.
 TH E SUPER I OR EXTRE M I TY
su pra sp in atu s c o v e r e d by t h e su bacro mia l bursa an d th e
, ,

u pp e r p ort io n o f the lat e ra l a sp e ct o f t he bo dy o f t he .

hu me ru s I ts a n t e rio r p art c o v e rs t he c o rac o id p roc e ss an d

.

Sp i f p l S p p l v ne o s ca u a u rasca u ar n e r e
T v ra n sp l y e rse s c a u ar art e r

(O T p p l )
. . su ra sca u ar
S u p ra s

m ial bu rsa
'

u ba c ro

I i
n fras p n at u s mu sc l e

Su bsca p u l i ar s

L a t e ra brac h l il a

c u t an e o u s n e r e v
Tri
Qu adra ng u l a r sp ace

i
Tr c e p s , o n h e ad l g La t e ra he ad 0 f l
R di l i l t r1c e p s
.

a a ne r e v ( O T m usc u lo sp ra )
. .
-

i rac h ia l art e ry R di l
a a ne r e v (O T . .

m u sc u lo sp t ral
-
)
i
Tr ce p s, l lh
a t e ra e ad

N . i
t o t r ce p s, m di l h
e a e ad
brfi
fiiéls
r
an
m
d p ro fu n da

N . t o an c o n a u s
P o stbran ch o f p ro fu n da
.

art e r o f a rmy
i
Tr ce p s, me d h e ad D l
o rsa an t i brach i a l
.

cu t a ne o u s n e r e v
B rac h i lia s

Ul n ar n e r e v
M ed a i l pi e co n dy l e

N . to fl e x . c a rp . u lm
.

Ol e cran o n

35 .
— Di i
sse c t o n o f t h e do rsa asp e c t o f t he Arm l . Th e l ate ra lh e ad o f
t he Tric e p s h as be e n d de d an d tu rn e d as de t o ivi i e xp o se t h e l
su c u s o n

th e H u me ru s fo r th e ra d a n e r e i l v .

the m u sc le s an d liga m e n t s
wh ich are attach e d to it t he lo n g ,

h e ad o f the bic e p s mu sc le d e sc e n d in g in the in t e rtu be rcu lar

su lcu s an d t h e in se rt io n o f t h e su bsca p u lar is in to t h e le sse r
,

tu be rc le o f th e hu me ru s The m u sc le a lso cov e r s th e gre at e r .

82 THE SUPE R I OR EXTRE M I TY
bord e r o f th e sca p u la, a n t e r ior to the t e r e s m in or, an d e n t e r s
t h e in fra sp in o u s fo ssa .

Th e bo u n dar ie s o f th e quadra n gu lar sp ac e , as se e n fro m

th e fro n t , are t he su bsca p u lar is a bov e , t h e t e r e s major
be lo w, t h e lo n g h e ad o f t h e tric e p s m e d ia lly, an d t he
surg ica l n e ck o f th e hu me ru s lat e ra lly A t t h e back th e .

t e re s min or r e p lac e s t he su bsca p u lar is as the u p p e r bou n d ary .

B e tw e e n t h e su bsca p u lar is a n t e r ior ly , an d t he t e r e s min or

p o st e r io r ly ,
t h e in fe r ior surfac e o f t he ca p su le o f th e shou ld e r
j o in t fo r ms the u pp e r bo u n dary o f the sp ac e , an d through the
sp ac e , d ir e ct ly be low t h e ca p su le , a ss t h a illary rv e an d
p e x n e

t he p o st e r ior hu m e ra l c ircu m fl e x v e sse ls .

A rt eria Circumfl ex a H u meri ( O T Circumfl e x Art eries) . . .

Th e po steri o r hu meral circu mflex artery has be e n a lr e ady

H . Tran sve rse se c t o n i o f t he

i
hu me ru s m me d at e i l y di l s ta

t o t he t u be rc l e s.

A A . . A xill y ar y art e r .

P C . . P i i mfl x
o ste r o r c rc u e art e r y
of h h m
t e u e ru s .

A C . . A i i mfl x
n t e r o r c rc u e art e r y o f
th h m
e u e rus.

CJ V . Axill y v
ar ne r e .

a . A i l b
rt cu ar h ran c .

TM
. . B h
ran c mi
t o t e re s n o r.

C . C u tan e o u s bran che s .

F IG .
37 .
— Di g a ram o f th e C ircu mfl e x Ve sse l s an d the A xill y N v
ar er e .

o bse rv e d to ar ise w ith in the ax illa fro m the p o st e rior a sp e ct

, ,

o f th e a x illary art e ry a short d ista n c e d ista l to th e su bsca p u lar

,

bra n ch I t at o n c e p a sse s backward s through th e quadr i

.
,

lat e ra l sp ac e an d w in d in g rou n d th e surg ica l n e ck o f t he

, ,

hu me ru s it is d istribut e d in n u m e rou s bra n ch e s to the d e e p

,

sur fac e o f th e d e lto id mu sc le Se v e ra l tw ig s are g iv e n a lso t o

.

th e shou ld e r jo in t an d th e in t e gu m e n t
-
I t a n a sto mo se s w ith .

t h e acro mia l bra n ch o f t h e th oraco acro mia l art e ry an d w ith -

th e a n t e r ior hu m e ra l c ircu m fl e x art e ry an d a lso by o n e o r , ,

m or e tw ig s wh ich it se n d s d istally to th e lo n g h e ad o f the

,

tric e p s w ith th e p ro fu n da bra n ch o f the brach ia l art e ry

,
.

Th e t e r min at io n o f th e anterio r hu meral circu mflex artery

c an n o w be m or e sat isfactor ily stud ie d an d its a n a sto m o sis ,
 S HOU L D ER — SC AP U L AR RE G I O N 83

w ith th e p o st e r ior hu me ra l c ircu m fl e x art e ry e stablish e d if th e ,

inj e ct io n h as flow e d w e ll B y th e a n a sto m o sis th e art e ria l

.

rin g wh ich e n circ le s th e p r o xima l p art o f the hu me ru s is

co mple t e d .

N e rvus Axillaris ( O T Circumfl e x N e rv e ) — Th e a x illary

. . .

M i
tr c e p s
l gh
.

( o n e ad )

G ro o v
fo r c rc u m
e i flx e

a rt e r y
o f sc a p u a l
( O T do rsa s li
l
. .

sc ap u a )

l i im
at ss us do rs i( scap u ar s l li p)
F IG .
3 8
.
— D o rsu m o f Sc ap u l w i th t h
a e A tt ach m e nt s o f th e M u sc l es m app e d o u t .

ne rv e acco mp a n ie s the p o st e rior hu me ral c ircu m fl e x art e ry .

I t su p p lie s : ( 1 ) an articu lar twig to th e shou ld e r jo in t ( 2 ) -

mu scu lar branches to th e d e lto id an d t e r e s min o r ; an d ( 3 )

cu taneo u s branches to t he sk in ov e r t h e d ista l p art o f th e
84 TH E SUPER I OR EXTRE M I TY
d e lto id I t sp r in g s fro m the p o st e r ior cord o f the brach ia l
.

p l e x u s , tur n s rou n d t h e lo w e r bord e r o f th e su bsca u lar is

p ,

an d p a sse s backward s w ith t he o st e r i r hu m ra l c ircu m fl

p
, o e ex

art e ry thr o ugh the quadrilat e ra l sp ac e t o the back o f the limb

, .

Th e r e it d ivid e s in t o an a n t e r io r an d a p o st e rio r d ivisio n

‘

Th e articu lar bran ch tak e s or ig in fro m the tru n k o f th e n e rv e

in t h e quadr ilat e ra l sp ac e an d e n t e r s th e jo in t fro m be low
, .

Th e po sterio r divisio n g iv e s o ff the bra n ch to th e t e r e s min or ,

an d a ft e r fur n ish in g a fe w tw ig s to t h e o st e r i r art f t h

, p o p o e

d e lto id is c o n t in u e d o n ward s as th e lateral cu taneo u s nerve

, ,

of the arm wh ich has a lr e ady be e n d isse ct e d in th e su e rfic ia l

, p
fa sc ia ov e r t h e d ista l p art o f th e d e lto id ( F ig s 3 1 3 2 .
, ,

Th e n e rv e to th e t e r e s m in or is d ist in gu ish e d by th e p r e se n c e
o f an ova l ga n g lifor m sw e llin g u p o n it
, .

Th e anterio r divisio n p roc e e d s rou n d t he hu m e ru s w ith th e

p o s t e r io r c ircu m fl e x art e ry o f t h e hu m e ru s an d e n ds n e ar t h e ,

a n t e rior bord e r o f the d e lto id I t is d istr ibut e d by ma n y .

,

bra n ch e s to the d e e p sur fac e o f the m u sc le wh ilst a fe w

, ,

fin e fi la m e n t s p ie rc e t h e d e lto id an d r e ach th e sk in .

D i s s ec t i o n — Cle an t h e c o raco acro m ial lig am e n , h ich -

t w
t
e x e n ds f ro m t h e co ra co id p ro ce ss t o t h e a cro m io n No e ha . t t t
t h e c o raco id p ro ce ss , t h e co raco acro m ial lig am e n , an d t h e
-
t
ac ro m io n f o rm a n arc h — t h e co raco acro mial arch Th e arc h -
.

v t
lie s abo e t h e s h o u lde r j o in , bu t is sep ara e d f ro m it by th e
-
t
su bac ro m ial bu rsa, an d t h e h u m e ra l e n ds o f t h e su p rasp in a u s , t
tu
t h e in frasp in a s, a n d t h e su bscap u laris .

Arcus C o raco acro mialis — acro mia l arch shou ld

. Th e \
c o raco -

be e x a m in e d at th e p r e se n t stag e in ord e r that its r e lat io n ,

sh ip to t h e su bacro mia l bur s a an d t he su p ra sp in atu s may be

a p p re c iat e d I t is th e arch wh ich o v e rha n g s the shou ld e r

.

jo in t an d p rot e ct s it fro m a bov e I t is for m e d by the .

coraco id p roc e ss the acro mio n an d a liga m e n t — the coraco

, ,

acro mial— wh ich str e tch e s be tw e e n th e m .

Th e co raco acro mial ligament is a stro n g ba n d o f a so m e

-

what tria n gu lar sha pe B y its ba se it is attach e d to the lat e ra l

.

bord e r o f th e coraco id p roc e ss wh ilst by its a p e x it is attach e d

,

to the e x tre mity o f th e acr o mio n ( F ig s 5 1 5 2 .

, ,

Th e c o raco acro m ia l arch p lay s a v e ry im p orta n t p art in

-

th e me cha n ism o f th e shou ld e r ; it might a lm o st be sa id t o

for m a se co n dary sock e t fo r the hu m e ru s The larg e su b .

acro m ia l bur sa wh ich in t e rv e n e s be tw e e n the acro mio n an d

,

th e m u sc le s imm e d iat e ly cov e r in g th e ca p su le o f the shou ld e r

86 TH E SUPER I OR EXTRE M I TY
wh ich lie s a lo n g the low e r bord e r o f the in fra sp in atu s I t .

arise s fro m an e lo n gat e d flat imp r e ssio n o n the dor sa l a sp e ct o f

t h e a xillary bord e r o f th e sca p u la an d fro m the fa sc ia l se p ta ,

wh ich in t e rv e n e be tw e e n it an d the two m u sc le s be tw e e n

wh ich it lie s viz th e in fra sp in atu s an d t e r e s maj o r I t is
,
. .

in se rt e d in to th e low e st o f the thr e e imp r e ssio n s o n th e

gr e at e r tu be rcle o f the hu m e ru s an d a lso by fl e shy fi bre s , , ,

in to t he bo dy o f th e bo n e fo r a bout 1 2 5 mm ( ha lf an in ch ) . .

d ista l to th e tu be rc le ( F ig 4 8 p A s it a pp roach e s it s
.
,
.

in se rt io n it is se p arat e d fr o m t h e t e r e s m aj o r by t he lo n g
h e ad o f the tric e p s brach ii The t e r e s min or is su pp lie d by.

a bra n ch fro m the ax illary n erve I t is an adductor an d .

lat e ra l rotator o f t h e arm .

M Tere s M ado n
.
— Th e p art wh ich th e t e r e s m aj o r play s in
t he for m at io n o f t h e quadr ilat e ra l an d tr ia n gu lar sp ac e s h as
a lre ady be e n se e n I t arise s fro m the ova l sur fac e o n the
.

d o r su m o f the sca p u la c lo se to the in fe rior a n gle o f the bo n e

( g 3 p
F i. 8 ,
a
. n d a lso fro m the se tu m wh ich the in fra
p
Sp in ou s fasc ia se n d s in to se p arat e it fro m th e in fra sp in atu s

an d t e r e s m in or m u sc le s I t is in se rt e d in to t h e me d ia l
.

lip o f th e in t e rtu be rcu lar su lcu s o n the p ro x im a l p art o f t h e

hu m e ru s ( Fig 4 5 p .
,I t is su pp lie d by t h e lo w e r
.

su bsca p u lar n e rv e an d it is an adductor

,
a me d ia l r o tat o r ,

an d an e x t e n sor o f t h e arm

M Subscap ularis — The su bsca p u lar is m u sc le ar ise s fr o m

. .

the who le o f t h e su bsca p u lar fo ssa w ith the e x c e p t io n o f ,

a sm all p o rt io n n e ar the n e ck o f th e sca p u la ; it tak e s ‘

o r ig in a lso fr o m t h e gr o ov e wh ich is p r e se n t o n th e c o sta l

a sp e ct o f t he a x illary bord e r o f t he bo n e ( F ig 2 4 p .
,
.

I ts or ig in is str e n gth e n e d by t e n d in ou s in t e r se ct io n s wh ich ,

are attach e d to th e r idg e s o n th e co sta l sur fac e o f th e

sca p u la Th e fl e shy fi br e s thu s d e r iv e d co n v e rg e u p o n a
.

stout t e n do n wh ich is in se rt e d in t o the le sse r tu be rc le o f

,

t h e hu me ru s ; a fe w o f th e low e r fi br e s h o w e v e r ga in , ,

in d e p e n d e n t in se rt io n in t o th e body o f t h e hu me ru s d ista l
t o th e tu be rc le ( F ig .

As t h e mu sc le p r o c e e d s lat e ra lly to its in se rt io n it p a sse s ,

u n d e r an arch fo r me d by t h e c o rac o id p r o c e ss an d the c o n

j o in e d o rigin o f the sh o rt h e ad o f th e bic e p s brac hii an d the
c o raco brach ia lis The su bsca p u laris is su pp lie d by th e upper
-
.

an d lo wer su bscap u lar n erv es I t is an ad duct o r an d me d ia l

.

rotator o f the arm .

 S HO U L D ER — SC AP U L AR RE G I O N 87

P
D is s e c t i o n — u ll t h e lo n g h e ad O f t h e bice p s o u t o f t h e
t
in e rtu be rcu lar su lcu s Se p ara e t h e
. e n do n o f in se r io n o ft t t
t
t h e la issim u s do rsi f ro m t h e an e rio r su rfa ce o f t h e t e re s m aj o r, t
t
n o in g t h e sm all fi bro u s slip h ic h p asse s f ro m its in fe rio r w
m arg in t o t h e fas cia o n t h e lo n g h e ad o f t h e rice p s m u sc le t
(F ig . t
h e n fo llo w th e e n do n o f t h e la issim u s t o its t t
t
in se rt io n in o t h e fl o o r o f t h e in e rt u be rcu lar su lcu s Th e t .

t t
e n do n o f t h e la issim u s is m o re o r le ss adh e re n t o t h e e re s t t
m aj o r, bu t n e ar t h e h u m e ru s a sm all bu rsa fre q u e n ly in e r e n e s t t v
be tw
e e n t h e tw o e n do n s t
No w e x am in e c are fu lly t h e in se rt io n s
.

t
o f t h e p e c o ralis ma j o r, t h e la issim u s do rsi an d t h e t
e res m aj o r t .

I n se rt io n s P e ct o ralis M ajo r and Lat issimu s Do rsi

o f t he .

AS th e p e ct o ra lis m aj o r p a sse s to it s in se rt io n in to t h e lat e ra l

lip o f t h e in t e rtu be rcu lar su lcu s it lie s a n t e r ior t o t he gr e at
v e sse ls an d n e rv e s o f the a xilla t o th e t wo h e ad s o f t he bic e p s,

hu m e ri an d to the c o rac o brach ia lis wh ilst t he lat issimu s dor si

,
-

lie s be h in d tho se structur e s The t e r e s m aj o r acc o m p a n ie s

.

t h e lat issim u s d o r si as far as t h e m e d ia l lip o f t he in te rtu be r

c u lar su lcu s I t th e r e fo r e d o e s n o t p a ss be h in d th e lo n g h e ad
.

o f t h e bic e p s hu m e r i .

Th e t e n d o n o f th e pecto ralis maj o r c o n sist s o f two la min a .

A se p arat io n o f th e c lav icu lar an d st e r n a l p o rt io n s o f th e

m u sc le w ill br in g bo th la min a in t o V ie w an d the fo llo w in g ,

p o in t s shou ld be n o t e d in c o n n e ct io n w ith th e m :
( )
a that
th e y are c o n t in u o u s w ith e ach o th e r be lo w o r in oth e r w o rd s , , ,

that t h e t e n do n is simp ly fo ld e d u p o n it se lf ; ( b) that t he

p o s t e r io r la m ina exte nd s to a m o r e p r o x ima l le v e l o n t h e

hu me ru s tha n the a n t e r ior an d that a fi br o u s e x p a n sio n p ro

,

c e e ds p r o x ima lly f r o m its s u p e r io r bo rd e r t o se e k attach m e n t ,

to the ca psule o f t h e sh o u lde r j o in t an d the le sse r tu be rc le o f -

t h e hu m e ru s c that t h e lo w e r bo rd e r is co n n e ct e d w ith t h e
()
fa sc ia o f t h e arm .

Th e n arr o w th in flat ba n d lik e t e n d o n o f the latissimu s

, , ,
-

do rsi lie s in fr o n t o f t h e in se rt io n o f t h e t e r e s m aj o r bu t do e s ,

n o t e x t e n d so far d o w n ward s Th e r e for e t he t e r e s maj o r is

.

th e lo w e st mu sc le in t h e lat e ra l p art o f t h e p o st e r io r wa ll o f t h e
axilla an d c o n se qu e n tly the la st mu sc le o f the p o st e r io r a x illary
,

wa ll u p o n wh ich t he a x illary art e ry r e st s The slip o f fa sc ia .

wh ich p a sse s fr o m the lo w e r marg in o f th e t e n do n o f th e

lat issimu s t o t h e fa sc ia o n t h e lo n g h e ad o f t h e tr ic e p s is o f
in t e r e st in a sm uch as it r e p r e se n t s t he d o r si e p it ro c hle aris -

m u sc le o f o th e r a n im a ls .

D is s e c t i o n — D e p re ss t h e u p p e r bo rde r o f the su bs cap u laris

as it p asse s be lo w
t h e co raco id p ro ce ss , an d e xp o se t h e su bs cap u lar
88 THE SUPER I OR EXTRE M I TY
bu rsa t
I n fl at e t h e bu rsa w i h a blo w p ip e , an d n o ice h a , as air
. t t t
w
is blo n in , t h e c ap su le o f t h e s h o u lde r j o in is dis e n de d If -
t t .

the w
all o f t h e bu rsa h as be e n in j u re d in t h e co u rse o f p re io u s v
t
disse c io n s , o p e n it wt
i h t h e sc alp e l an d e x am in e t h e in e rio r t
t t t
w i h a blu n p ro be N o e its e xt e n an d its co n in u i y i h t h e
. t t t wt
t
in e rio r o f t h e s h o u lde r j o in h ro u gh a larg e ap e rt u re in th e
-
t t
t t
an e rio r p ar o f t h e ar icu lar cap su le t .

B u rsa Su bsca p u u bsca p u lar bur sa is for m e d

laris — . Th e s

by th e p ro lo n gat io n o f t he sy n o v ia l stratu m o f t h e ca p su le o f
t h e sh o u ld e r j o in t thr o ugh an a p e rtur e in t h e u pp e r an d
a n t e rior p art o f the fi brou s stratu m I t e x t e n d s lat e ra lly .

be tw e e n t he su bsca p u lar is an d th e m e d ia l p art o f t h e art icu lar

ca p su le m e d ia lly be tw e e n the su bsca p u lar is an d the a n t e r io r
,

sur fac e o f th e n e ck o f t he sca p u la an d t h e ro o t o f th e c o rac o id

p r o c e ss an d it fac ilitat e s t h e m ov e me n t o f t h e su bsca u lar is

, p
o n t h e fr o n t o f th e h e ad an d n e ck o f t h e sca p u la .

t
D is s e c t i o n — Cu t h ro u gh t he su bscap u laris e r ically be lo w v t
t
t h e co ra co id p ro ce ss, an d de ac h f ro m its de e p su rfa ce t h e bu rsa ,
w tw
h ic h lie s be e e n it an d t h e scap u la an d t h e cap su le o f t h e
s h o u lde r Tu rn t h e m e dial p ar o f t h e m u scle o w ards t h e
. t t
v e rt e bral bo rde r o f t h e s cap u la, an d as y o u de ac h it f ro m t h e t
t t
bo n e n o e t h e e n din o u s in e rse c io n s by t
h ic h it is co n n e c e d t w t
wt i h t h e ridg e s o n t h e co s al su rf ace o f t h e scap u la t N o e also . t
t t
t h e an as o m o sis be w e e n bran c h e s o f t h e su bscap u lar a n d ran s t
v t
e rse s c ap u lar ar e rie s w h ic h ram if y o n its de e p su rf ace Tu rn .

t t w
t h e la e ral p o rt io n o ards t h e h u m e ru s , de ac h in g it f ro m t h e t
t t
la e ral p art o f t h e f ro n o f t h e cap su le o f t h e sh o u lde r t o w h ic h
t v
it is adh e re n , an d e rify it s a ac h m e n to t h e le sse r u be rc le o f tt t t
t h e h u m e ru s an d to t h e bo n e imm e dia e ly dis al t o t h e u be rcle t t t .

t t t
D o n o t f ail t o n o ice h a , as it cro sse s t h e sh o u lde r j o in t o its -
t
t
in se r io n , it lie s be h in d t h e c o raco brac h ialis an d t h e s h o rt h e ad -

o f t h e bice p s .

v t
D i ide t h e su p rasp in a u s m e dial t o t h e c o ac o id p ro cess r .

t w
Tu rn t h e m e dial p art o ards t h e e rt e bral bo rde r o f t h e scap u la v
v tt t
an d e rif y its a a c h m e n t o t h e sp in e an d t o t h e do rsal su rf ace
o f t h e sc ap u la, an d disse c o u t t h e bran c h e s o f t h e tran s e rse t v
sc ap u lar art e ry an d t h e su p rascap u lar n e r e h ic h p ass to its v w
de e p su rf ace Tu rn t h e la e ral p art o ards t h e h u m e ru s,
. t t w
t
f o rcin g it be n e a h th e co raco acro m ial arc h , an d as y o u do h a -
t t
v
a o id in j u ry t o t h e ran s e rse s cap u lar t v
e sse ls an d t h e su p ra v
s cap u lar n e r e v w
h ic h lie be n e a h it N o t e h a as t he e n do n t . t t t
o f t h e m u scle c ro sse s t h e t o p o f t h e s h o u lde r j o in it is fi rmly -
t
tt
a ac h e d t o t h e cap su le be f o re it re ac h e s its in se r io n in o t h e t t
su p e rio r f ace t
o n t h e g re a e r u be rcle o f t h e h u m e ru s t t D i ide . v
t
t h e in f rasp in a u s m e dial t o t h e la e ral bo rde r o f t h e sp in e o f t
t h e scap u la tt
V e rif y t h e a ac h m e n o f t h e m e dial p ar t o t h e
. t t
in f e rio r su rf ace o f t h e sp in e an d t h e do rsal su rface o f t h e bo dy
o f t h e sc ap u la , disse c in g o u t t h e t
e sse ls an d n e r e s f ro m it s v v
de e p su rf ace w
F o llo t h e la e ral p art to its in se rt io n in o t h e
. t t
t t t
m iddle f ace o n t h e g re a e r u be rcle o f t h e h u m e ru s an d, as t h e
t
m u scle is disp lace d, ak e care n o t t o in j u re t h e ran s e rse scap u lar t v
9 0 TH E SU P ER I OR EXTRE M I TY
D is s e c ti o n R e ise t h e art e rie s v
h ic h lie in re la io n i h
-
w t wt
t h e bo rde rs an d su rf ac e s o f t h e scap u la , an d disse c o u t t h e t
t
an as o m o sis be w e e n t t
h e ir bran c h e s D e sce n din g alo n g th e .

v e rt e bral bo rde r is t h e de sce n din g bran c h o f t h e ran s e rse t v

v
ce r ical art e ry Cro ssin g t h e su p e rio r bo rde r is t h e su p ra
.

s cap u lar ar e ry t
Th e su bscap u lar art e ry w as se e n du rin g t h e
.

t
disse c io n o f t h e ax illa ; it sp rin g s f ro m t h e h ird p ar o f t h e t t
ax illary , de s c e n ds f o r abo u 2 5 3 0 m m alo n g t h e in f e rio r bo rde r t -
.

o f t h e su bscap u laris , an d h e n di ide s in o circu m fl e x scap u lar t v t

t
an d h o raco do rsal bran c h e s Th e circu m fl ex scap u lar at o n ce
-
.

t u rn s ro u n d t h e ax illary bo rde r o f t h e s cap u la an d p as s e s, de e p

t
t o t h e e re s m in o r, t o t h e in f rasp in o u s f o ssa F o llo w the ram i .

t
fi c at io n s o f bo h bran c h e s t o h e ir an as o m o se s i h t h e adj ace n t t wt t
ar e ries t .

Th e An ast o mo sis
n a a
A n imp o rta n t an d
ro u d t h e Sc p ula —

fr e e a n a sto m o sis tak e s p lac e be tw e e n th e bra n ch e s o f thr e e

art e r ie s wh ich lie in c lo se r e lat io n with t he sca p u la v i z ( 1 ) ,

t h e d e sc e n d in g bra n ch o f t he tra n sv e r se c e rv ica l art e ry ; ( 2 )

th e tra n sv e r se sca p u lar art e ry 3) t h e c ircu m fl e x sca p u la an d
thoraco dorsal bra n ch e s o f t he su bsca p u lar art e ry
-
.

Th e Desce n din g B ran c h o f t h e Tr an sv e rse Cervi ca l

Art ery was se e n wh e n t h e le vator sca p u la an d th e rh o mbo id s
w e r e r e fl e ct e d I t ru n s d o w n ward s a lo n g the ve rt e bra l bord e r
.

o f t he sca p u la in t he a n g le be tw e e n t h e le vator sca p u la an d

t h e rh o mbo id s wh ich a re be h in d it an d t h e in se rt io n o f t h e
, ,

se rratu s a n t e r io r wh ich is in fro n t o f it ,

I t se n d s bra n ch e s .

in to t he su bsca p u lar fo ssa an d in to t he su p ra an d in fra sp in o u s

fo ssa wh ich a n a sto mo se in all thr e e r e g io n s w ith bra n ch e s o f
,

t h e tra n sv e r se sca p u lar an d su bsca p u lar art e r ie s an d at th e ,

infe r io r a n g le o f t h e sca p u la it a n a sto m o se s w ith th e t e r m in a l

bra n ch e s o f t h e thorac o dor sa l bra n ch o f t h e su bsca p u lar -

art e ry .

Art e ria Tran sv ersa Sc ap ula ( O T Su p rasca p ula r Art e ry ) . . .

— Th e tra n sv e r se sca p u lar art e ry e n t e r s t h e su p ra sp in o u s

fo ssa by p a ssin g ov e r th e liga me n t wh ich br idg e s acr o ss t he
sca p u lar n o tch I t d iv id e s u n d e r cov e r o f the su p ra sp in atu s
.
,

mu scle in t o a supraspin o us an d an infraspin o u s bran ch

,
Th e .

for me r su p p lie s t h e su p ra sp in atu s m u sc le an d g iv e s o ff t h e ,

ch ie f n utr ie n t art e ry to the sca p u la t h e latt e r p roc e e d s dow n

ward s through the gre at scap u lar n otch u n d e r cov e r o f the ,

in fe r io r tra n sv e r se sca p u lar liga me n t to r e ach th e d e e p sur fac e ,

o f t h e in fra sp in atu s m u sc le t o wh ich it is d istr ibut e d ,

.

At the su p e r ior bord e r o f t h e sca p u la t h e tra n sv e r se art e ry

o f t h e sca p u la g iv e s o ff a su bscap u lar branch wh ich e n t e r s t h e ,

su bsca p u lar fo ssa u n d e r cov e r o f t he su bsca p u lar is m u sc le

,
.
 S HO U L D ER — SC AP U L AR RE G I O N 9 1

Art eria Circum fl ex a Sca p ula ( O

. T . Do rsa lis Sca p ula
Art ery ) Th e c ircu m fl e x sca p u lar art e ry, as a lr e ady n ot e d ,
.
—

ar ise s fro m th e su bsca p u lar bra n ch o f th e a x illary an d e n t e r s

th e t rian gu lar sp ac e ‘

Wh ile th e re it su p p lie s o n e o r t wo
.

ven tral bran ches, wh ich p a ss, u n d e r cov e r o f th e su bsca p u lar

m u sc le , to th e su bsca p u lar fo ssa , an d a larg e r infrascap u lar

branch, wh ich ru n s d o wn ward s, in t h e in t e rva l be tw e e n t h e t e r e s
major an d t e r e s mm o r, to t he in fe r ior a n g le o f th e sca p u la
( F ig s 3 4
.
, 3 5 , p p 7 9 ,
A.ft e r th o se bra n ch e s are g iv e n

o ff, t h e c ircu m fl e x s ca p u lar art e ry le av e s th e tr ia n gu lar sp ac e

by tur n in g rou n d th e a x illary bord e r o f th e sca p u la , u n d e r

cove r o f th e t e r e s min o r I t n o w e n t e r s the in fra sp in o u s
.

fo ssa, wh e r e it ramifie s, an d su p p lie s bra n ch e s to t he in fra

s in at u s m u sc le
p .

Art e ri a Th o rac o do r sa lis — Th e th o rac o dor sa l bra n ch o f -

t h e su bsca p u lar art e ry ru n s a lo n g t h e a x illary bord e r o f t h e

sca u la o n t h e lo w e r m arg in o f t h e su bsca p u lar is I t se n d s
p .

bra n ch e s in t o t h e su bsc ap u lar fo ssa wh ich su pp ly t he su b

sca p u lar is an d a n a sto m o se w ith bra n ch e s o f t h e d e sc e n d in g

bra n ch o f t h e tra n sv e r se c e rv ica l art e ry, an d th e tra n sv e r se

sca p u lar an d c ircu m fl e x sca p u la art e r ie s .

Wh e n the d isse ctor has follo w e d the bra n ch e s o f th e fo ur

art e r ie s ju st c o n sid e r e d , h e w ill re a lise that t he art e r ia l
a n a st o mo sis arou n d the sca p u la is v e ry co mp le t e I n the .

su p ra sp in ou s fo ssa bra n ch e s o f t h e d e sc e n d in g bra n ch o f th e

tra n sv e rse c e rv ica l art e ry an d t he tra n sv e rse sca p u lar art e ry

a n a sto mo se I n t h e in fra sp in o u s fo ssa bra n ch e s o f t h e
.

d e sc e n d in g bra n ch o f the tra n sv e rse c e rv ica l, th e tra n sve r se

sca p u lar, an d th e su bsca p u lar art e ry a n a st o m o se , an d bra n ch e s

o f t h e sa m e thr e e art e r ie s a n a st o m o se in t h e su bs ca p u lar

fo ssa . Th e imp o rta n c e o f th e se fr e e co mm u n icat io n s is

m a n ife st wh e n it is r e me mbe r e d that two o f th e m a in art e rie s,
v iz , t h e d e sc e n d in g bra n ch o f t h e tra n sv e r se c e rv ica l art e ry
.

an d t h e tra n sv e r se art e ry o f t he sca p u la sp r in g in d ir e ct ly fr o m

,

th e fir st p art o f t h e su bc lav ia n ; wh ilst t h e th ird , viz , th e .

s u bsca p u lar arise s fr o m th e th ird p art o f th e ax illary Wh e n

,
.
,

th e r e fo r e a ligature is a pp lie d t o an y p art o f t he gr e at art e r ia l

,

tru n k o f th e u p p e r limb be t we e n t he first stag e o f t he su b

,

c lav ian an d th e th ird p art o f t h e a x illary t h e a n a st o mo sis ,

r o u n d the sca p u la a ffo rd s a mp le m e a n s o f re e sta blish in g th e -

c irculat io n .

N e rvus S u p ra sc ap u lari s — Th e s u p ra
. s ca p u lar n e rv e
9 2 T H E SU PER I O R EXTRE M I TY
acc o mp a n ie s the tra n sv e r se arte ry o f the sca p u la bu t it ,

e n t e r s t h e su p ra sp in ou s fo ssa by p a ssin g thr o ugh th e sca p u lar

n otch ,
u n d e r cov e r o f the u p p e r tra n sv e r se liga me n t o f the
sca p u la I t su p p lie s t h e su p ra sp in atu s an d e n d s in th e in fra
.
,

Sp in atu s m u sc le I t u sua lly se n d s two articu lar tw igs to th e

.

p o s t e r ior a sp e ct o f t h e shou ld e r jo in t v iz o n e wh ile in t h e -

,
.
,

su p ra sp in ou s fo ssa an d th e se c o n d as it lie s in th e in fra

Sp in o u s fo ssa .

The liga m e n t s wh ich co n n e ct th e c lav ic le w ith t h e sca p u la

shou ld n o w be e x a m in e d ; th e y are c o rac o c lav icu lar
( )
1 t h e -

liga m e n t wh ich is fo u n d be tw e e n th e c lav icle an d t h e coraco id

,

p roc e s s o f t h e s ca p u la an d t he ca su le
p o f t h e acro m io
c lavicu lar j o in t .

Dis s e c ti o n — Cle an t h e su rface s an d bo rde rs o f t he co raco

v
cla icu lar lig am e n , an d n o e t
h a it c o n sis s o f tw o se gm e n s t t t t t
a m e dial se g m e n t
c alle d t h e co n o i d ligame n t a n d a la e ral t
se g m e n c alle d t h et trap ez o id ligame n t Th e tw o se gm e n s . t
t
m ee at an an g le w h ic h is O p e n in fro n , an d in t h e an g le a sm all t
bu rsa is so m e im e s f o u n d t
A f e r t h e co rac o cla icu lar lig am e n
. t -
v t
h as be e n f u lly de fi n e d, re m o e t h e re m ain s o f t h e de l o id an d v t
t z
rap e iu s m u scle s f ro m t h e c ap su le o f t h e ac ro m io cla icu lar -
v
t
j o in an d cle an t h e e xt e rn al su rface o f th e cap su le .

Lig Co raco clav iculare — Th e coraco c lav icu lar liga m e n t

. .
-

is a p ow e rfu l liga m e n t wh ich bin d s th e in fe r ior sur fac e o f t h e

c lav ic le to the coraco id p roc e ss I t co n sist s o f two p art s, .

wh ich are t e r me d th e co n o id
trap e z o id liga m e n t s an d t h e .

The liga men tu m co n o ideu m lie s p o st e r ior an d me d ia l to

t h e lig tra p e z o id e u m
. I t is broad a bov e wh e r e it is attach e d
.
,

to the coraco id tu be rc le o f the c lav ic le ( F ig 1 0 p an d .

,
.

so m e what n arrow e r be low at it s attach me n t to th e be n d o f ,

t he corac o id p roc e ss Th e ligamentu m trap ez o ideu m is a

.

flatt e r ba n d Abov e it is attach e d a lo n g the tra p e z o id lin e

.
,

o f t he c lav ic le wh t ow fi x e d to th e
( g
F i 1 0
p ils be l . it is , .

u pp e r a sp e ct o f the coraco id p roc e ss .

Th e coraco c lav icu lar liga me n t h e lp s to p r e v e n t d islocat io n

-

o f t h e acro mia l e n d o f t h e c lav ic le an d to a c e rta in e x t e n t , , ,

it lim it s the mov e me n t s o f t he acro mio c lav icu lar jo in t It -

.

is th e r e for e an acc e ssory liga m e n t o f that jo in t I t is th e .

m a in m e d iu m by wh ich th e sca p u la an d in d ir e ct ly th e oth e r , , ,

p art s o f t h e su p e r ior e x tr e m ity are su s p e nded f ro m t h e ,

clavic le I f it is o u t wh e n the body is e r e ct the su p e rior

.
,

e x tr e mity as a who le at o n c e fa lls an d th e sa m e th in g occur s ,

94 TH E SUPE R I OR EXTRE M I TY
Th e brach ia l art e ry an d it s bra n ch e s .

Th e m e d ia n , u ln ar, rad ia l an d mu scu lo cuta n e ou s n e rv e s -

.

Th e bic e p s, coraco brach ia lis an d brach ia lis m u sc le s

-
.

I t is co n v e n ie n t to study at th e sa m e t im e the cu bita l

fo ssa in fro n t o f th e ow e lb .

Th e Sk in has a lr e ady be e n r e m ov e d an d th e cuta n e ou s ,

v e in s an d n e rv e s hav e bee n se e n ( se e p p 6 2 N ow th e y
.
,

m u st be re stud ie d an d t h e m a in p o in t s o f the sur fac e a n ato my

-
,

o f th e r e g io n m u st be r e v ise d .

Surf a ce A n at o my — I n a m u scu lar limb t h e p ro m in e n c e

.

for m e d by t h e bic e p s mu scle a lo n g t h e fro n t o f th e arm is

v e ry a p p ar e n t Ev e ry o n e is fa miliar w ith the rou n d e d sw e llin g
.

wh ich the mu scle p roduc e s wh e n p ow e rfu lly co n tract e d in the

liv in g su bj e ct . O n e ach sid e o f th e bic e p s th e r e is a fe e bly
m ark e d furrow an d a sc e n d in g in e ach o f th e se th e r e is a
,

larg e su p e rfic ia l v e in I n th e lat e ra l su lcu s is th e c e p ha lic

.

ve in in the d ista l p art o f the m e d ia l su lcu s is the ba silic v e in .

I n the p ro x ima l p art o f th e m e d ia l bic ip ita l su lcu s is an

e lo n gat e d bu lg in g p roduc e d by th e su bjac e n t coraco brach ia lis -

m u sc le ; it is u se fu l as a gu id e to t h e d ista l p art o f the

a xillary an d th e p ro xima l p art o f the brach ia l art e rie s wh ich ,

lie im m e d iat e ly be h in d an d to t h e me d ia l sid e o f it Th e .

hu me ru s is th ickly c loth e d by m u scle s ; bu t toward s it s d ista l

p art t h e two e
p ico n dy lar r idg e s le ad in g to t
,
h e e p i co n dy lar
e min e n c e s ,
may be fe lt The lat e ra l r idg e is th e m or e
.

sa lie n t o f t h e two an d th e r e for e

,
t h e m or e e v id e n t to
touch .

The bo n y p o in t s arou n d th e e lbow m u st be stud ie d w ith

e sp e c ia l car e . I t is by a p ro p e r k n ow le dg e o f th e n or m a l
r e lat iv e p o sit io n s o f th e m that the surg e o n is a ble to dis
t in gu ish be tw e e n t h e d iffe r e n t for m s o f fractur e an d dis
locat io n wh ich so fr e qu e n t ly occur in t he e lbow r e g io n F ir st .

n ot e t h e m e d ia l e p ico n dy le o f th e hu m e ru s I t co n st itut e s .

a p ro min e n c e a pp re c ia ble to the e ye ; gra sp it be tw e e n th e

fi n g e r an d thu mb an d n ot e that it in c lin e s p o st e riorly as
,

w e ll as me d ially I n a w ell d e v e lop e d fu lly e x t e n d e d arm

.
-

, ,

th e lat e ra l e p ico n dy le do e s n o t for m a p roj e ct io n o n t h e

sur fac e bu t can be fe lt at th e botto m o f a slight d e p r e ssio n
,

o n t h e dor sa l a sp e ct o f th e lim b I t be co m e s a pp ar e n t to
.

th e e y e as a p ro min e n c e wh en t h e e lbow is se mi fl e x e d Th e -
.

O le cra n o n p roduc e s a mark e d p roj e ct io n o n the dor su m o f

t h e e lbow be tw e e n th e two e p ico n dyles I t is p lac e d slight ly
.
 TH E F R O N T O F TH E AR M 95

ne ar e r to the m e d ia l tha n to th e lat e ra l e p ico n dyle The .

lo o se sk in wh ich cov e r s t he O le cra n o n mov e s fr e e ly ov e r it s

su bcuta n e o u s sur fac e ow in g t o th e in t e r p o sit io n o f a bur sa
,
.

Th e diff e r e n t p o sit io n s wh ich are a ssu m e d by th e o le cra n o n ,

in r e lat io n to t h e e p ico n dyle s o f th e hu me ru s in th e m ov e

m e n t s o f the fo re ar m at th e e lbow j o in t m u st be car e fu lly
-
,

e x a min e d That can be do n e be st by plac in g th e thu mb o n

.

o n e e p ico n dy le t h e m idd le fi n g e r o n t h e oth e r an d th e for e

, ,

FIG .
40 .
-
R l ti
e a f th
o n o e

Bo ne s o f th eEl b w t th
o o e

su rf ace . D l i w;
o rsa V e

F IG .
39 .
— R l ti
e af B o ne s
o n o e lb w b
o e nt .

o f E bo l w t o the su rface .

D o rsa l i
v e w ; e bo w fu yl ll
ex te nde d .

fi n g e r o n the O le cra n o n The limb shou ld th e n be a lt e rn at e ly

.

fl e xe d an d e x t e n d e d so as to mak e c le ar the e xt e n t o f th e
,

e x cur sio n p e r for m e d by th e O le cra n o n I n fu ll e x t e n sio n .

at th e e lbow j o in t th e thr e e p ro min e n c e s lie in the sa m e

-

h or iz o n ta l p la n e ; wh e n th e for e ar m is be n t at a right a ngle

t he thr e e bo n y p o in t s are p lac e d at t he a n g le s o f an e qu ilat e ra l
tria n gle o f wh ich o n e a n g le p o in t s d ista lly
, .

Wh e n t h e for e ar m is e x t e n d e d a m ark e d d e p r e ssio n o n the

dor sa l a sp e ct o f the e lbow in d icat e s the p o sit io n o f th e art icu la
9 6 TH E SU P ER I OR EXTRE M I TY
t io n be tw e e n th e rad iu s an d th e hu m e ru s I m me d iat e ly d ista l .

to it th e h e ad o f th e rad iu s lie s n e ar to the sur fac e an d can ,

r e ad ily be fe lt e sp e c ia lly wh e n it is m ad e to ro ll u n d e r t h e
,

fi n g e r by in duc in g a lt e r n at e ly th e m ov e me n t s o f p ro n at io n
an d su p in at io n Th e h e ad o f the rad iu s is p lac e d a bout
.

2
5 m m (.o n e in ch ) d is ta l to t h e lat e ra l e p ico n dy le .

V e n a Su p erficiales — Port io n s o f two larg e cuta n e ou s

.

v e in s are m e t w ith in th e arm th e c e p ha lic v e in an d th e ,

ba silic v e in Th e y w e re d isse ct e d an d stud ie d wh e n the

.

cuta n e ou s n e rv e s o f th e su p e rio r e xtre mity w e r e e x a m in e d

( se e p . Th e ir p o sit io n s in th e arm sh o u ld n o w be

r e v ise d B o th a sc e n d fr o m the back o f the ha n d an d th e y

.
,

co mm u n icat e w ith o n e a n o th e r acro ss th e fa scia l r o o f o f the

cu bita l fo ssa at th e fro n t o f th e e lbow by me a n s o f th e ,

m e d ia n cu bita l v e in .

I n th e arm th e cephalic vein a sc e n d s a lo n g t h e gr o o v e at

th e lat e ra l bord e r o f t he bic e p s o r a lo n g th e lat e ra l p art o f
th e e min e n c e cau se d by t he bic e p s m u sc le to th e de lto ,

p e ctora l su lcu s Th e r e. it p ie rc e s t h e d e e p f a sc ia an d it ,

co n t in u e s u pward s t o the de lto p e ctora l tria n g le wh e r e it -

turn s m e d ia lly cro sse s su p e rficia l to th e p e ct o ra lis m in or

, ,

p ie rc e s t h e c o sto coraco id m e mbra n e-

u n d e r cov e r o f t h e
,

p e ctora li s m ajor a n d t e r m in at e s in t h e a x illary v e in

,
.

The p ort io n o f th e basilic vein wh ich lie s in t h e arm

a sc e n d s in th e groov e a lo n g th e m e d ia l bo rd e r o f th e bic e p s
m u sc le . At th e m idd le o f t h e arm it p ie rc e s th e d e e p fa sc ia ,

an d ru n s a lo n g t h e me d ia l Sid e o f th e brach ia l art e ry to th e

a x illa wh e r e it be co m e s t he a x illary v e in
,
.

N e rv i Cu t an e i — The cuta n e o u s n e rv e s fo u n d in t h e
.

r e g io n o f the arm at a p r e v iou s stag e o f the d isse ct io n w e r e

Nn . s u p rac lav icu lar e s ( the p o st e r ior grou p ) fro m the

c e rvica l p le x u s .

2 cuta n e u s brach ii lat e ra lis fro m th e a x illary n e rv e .

2 in te rco sto brach ia lis fr o m t h e se c o n d

-
in t e rco sta l
n e rv e .

2 cuta n e u s brac h n me d ia lis fro m the brach ia l p le x u s .

2 cuta n e u s an tibrac hi i me d ia lis fr o m th e brach ia l p le x u s .

2 cuta n e u s brach ii p o st e rior fro m the rad ia l n e rv e .

2 cuta n e u s an tibrac h ii d o r sa lis fr o m the rad ia l n e rv e .

2 cuta n e u s an tibrac h ii lat e ra lis fr o m t h e m u scu lo

cuta n e ou s n e rv e .
98 T H E SUP ER I OR EXTRE M I TY
to the d ista l p art o f th e arm both o n th e a n t e rior an d ,

p o s t e r io r a s p e ct s an d th e n d e sc e,n d s t o su pp l y t h e sk i n

o f t h e m idd le o f t h e back o f t h e fo r e ar m as far as th e

wrist ( F ig s 3 1 .
,

Th e latera l cu ta n eo u s n erve of the fo rearm p ie rc e s th e d e e p

fa sc ia p r o x im a l to t h e e lbow p a sse s d e e p to th e c e p ha lic ,

v e in an d su pp lie s th e sk in o n t he lat e ra l p art s o f th e vo lar

,

an d d o r sa l a sp e ct s o f th e for e ar m as far as t h e wr ist It .

a lso su pp lie s the Sk in o f the p ro x ima l p art o f the th e n ar

e m in e n c e ( F ig s 3 1 .
,

F ascia B rachii Aft e r th e cuta n e ou s n e rv e s h av e be e n

.
—

r e v ise d re e x a m in e th e d e e p fa sc ia o f th e arm N o t e
-
.

that it co n sist s larg e ly o f tra n sv e r se fi bre s ; ( 2 ) its c lo se

attach me n t to th e bo n y p ro min e n c e s at th e e lbo w an d
to the d ista l p art s o f t h e me d ia l an d lat e ral bo rd e r s
o f t he hu me ru s ; ( 3 ) its c o nn e ct io n w ith th e mu sc le s
wh ich Sp r in g fro m t he me d ia l an d lat e ra l e p ico n dy le s o f the
hu me ru s ( 4 ) th e th ick e n e d ba n d o f fi br e s ca lle d th e lacertus
fi b r o su s wh ich p a sse s fr o m t h e d ista l p art o f t h e m e d ia l
bord e r o f th e bic e p s to th e m e d ia l sid e o f t h e p r o x im a l
p art o f t h e f o r e ar m ( F ig s 3 1 I t is a lso co n n.e ct e d ,

w ith th e t e n do n s o f in se rt io n o f the d e lto id th e p e ctoralis ,

maj o r an d th e lat issim u s dor si bu t tho se co n n e ct io n s w e r e ,

se v e r e d wh e n th e m u sc le s w e r e c le a n e d .

D is s e c tio n Cu t h ro u gh the de e p fascia alo n g t he t

t
p ro x im al an d dis al bo rde rs o f t he lace r u s fi bro su s, f ro m t h e t
m e dial m arg in o f t h e bice p s t o t h e m e dial m arg in o f t h e f o re
v
arm , an d le a e t h e lace rt u s fibro su s in p o si io n h e n t h e re t w
m ain de r o f t h e de e p f ascia is re fl e c e d ( 2 ) M ak e a lo n g i u din al t . t
t
in cisio n h ro u gh t h e de e p fascia alo n g t h e m iddle lin e o f t h e
bice p s . v
(3 ) At t h e le e l o f t he ep ico n dyle s m ak e a ran s e rse t v
in cisio n t h ro u gh e ac h o f t h e fl ap s m ark e d o u t by t h e lo n g i u din al t
t
in cisio n , an d ( 4 ) re fl e c e ac h o f t h e tw o fl ap s t o its o wn side .

t
As t h e re fl e c io n p ro ce e ds it ill be co m e e ide n h a se p a p ass w v tt t t
f ro m t h e de e p su rface o f t h e de e p f ascia be e e n th e ario u s tw v
mu scle s t
Th u s a se p u m p asse s ran s e rse ly f ro m side t o side
. t v
be t we e n t he bice p s an d brac h ialis m u scle s ( F igs 4 2 , I n it .

is e m be dde d t h e m u scu lo cu an e o u s n e r e A se p u m dip s back

-
t v . t
w ards be tw
e e n t h e bra c h ialis an d t h e m u scle s h ic h sp rin g f ro m w
t
t h e an e rio r lip o f t h e dis al h alf o f t h e la e ral bo rde r o f t h e t t
h u m e ru s Th e radial n e r e an d an e rio r bran ch o f t h e p ro
. v t
f u n da art e ry are e m be dde d in it (F ig bu t t h e s ro n g e s . t t
an d mo s t t
im p o rt an se p a are t h e la e ral an d m e dial in e r t t t
t w
m u scu lar se p a h ic h se p ara e t he s ru c u re s at t h e back o f t h e t t t
arm f ro m t h o se at t h e f ro n Eac h is att ac h e d t o t he h o le t . w
le n gt h o f t h e co rre sp o n din g bo rde r O f t h e bo dy o f t h e h u m e ru s,
t
bu t t he dis al h al e s are t h e s ro n g e s p ar s v Th e m e dial in e r t t t . t
 TH E F RO N T O F TH E A R M 99

m u scu lar sep tu m is st ro n g e r t h an t h e lat e ral I t is e asily t race d .

f ro m th e m e dial e p ico n dy le t o t h e in se rt io n o f t h e co raco

bra ch ialis m u s cle Th e dist al h alf o f t h e lat e ral in t e rm u scu lar
.

se p t u m is q u it e de fi n it e f ro m t h e lat e ral e p ico n dy le t o t h e in se t

t io n o f t h e de lt o id m u scle Th e t wo sep t a, t o g e t h e r w it h th e
.

h u m e ru s, divide th e arm in t o an an t e rio r an d a p o st e r io r o st e o

fascial co mp art m e n t .

St ruct ures in t h e , An t e ri o r Co mp art me n t — Th e a n t e rior

o st e o fa sc ia l co mp art me n t h as be e n o p e n e d by the r e fl e ct io n
-

o f t h e a n t e r io r p art o f t h e d e e p fa sc ia ; t h e r e lat iv e p o sit io n s

o f its co n t e n t s m u st n o w be e x a m in e d The co n t e n t s are : .

Thr e e m u sc le s wh ich be lo n g ma in ly to th e arm th e bic e p s , ,

Med a i li nte r
mu sc u l ar se p t u m
L a te ra li n te r
m u sc u lar se p t u m

FI G 4 1.
— . Di g
a ram ( aft e r Tu rn e r) t o s o h o w t h e Arm h w
iv i i l
is d de d by t h e n te rm u scu ar se p t a an d t he bo n e n t o an i
i i
an t e r o r an d a p o st e r o r c o m p art m e n t T e se co mp artm e n t s
. h
are re p re se n t e d in t ran s e rse se c t o nv i .

th e coraco brach ia lis an d t h e brach ia lis ; p art s o f two

-
,

m u sc le s wh ich be lo n g ch ie fly t o t h e for e ar m th e brach io —

rad ia lis an d the e x t e n sor carp i rad ia lis lo n gu s p art s o f the

t er min a l bra n ch e s o f all th e cord s o f the brach ia l p le x u s
exce pt th e a x illary n e rv e ; t h e brach ia l art e ry its v e n a ,

c o mit e s p art o f th e ba silic v e in with acco mp a n y in g ly mp h

, ,

v e sse ls an d a fe w small brach ia l ly mp h g la n d s wh ich lie

a lo n g th e cour se o f the brach ia l art e ry .

Th e bic e p s brach ii is th e m o st a n t e r ior m u sc le ; u n d e r

c o v e r o f its d ista l ha lf an d c lo se ly app lie d to t he an t e r io r
a sp e ct o f th e hu m e ru s is the brach ia lis wh ilst the sle n d e r ,

c o rac o brach ia lis lie s a lo n g th e me d ial sid e o f the p ro x ima l

-

ha lf o f the bic e p s Th e brach io rad ia lis an d th e e x t e n so r

.
-

I— 7a
1 0 0 TH E SU PE R I OR EXTRE M I TY
carp i rad ia lis lo n gu s lie in the d ista l p art o f th e c o m p art m e n t
a lo n g the lat e ra l sid e o f t he brach ia lis t o wh ich th e y are ,

c lo se ly a pp lie d The brach ia l art e ry an d its v e n a c o mit e s

.

trav e rse the wh o le le n gth o f th e c o mp art m e n t in r e lat io n

w ith t h e me d ia l bord e r o f the bic e p s The m e d ia n n e rv e .

a lso ru n s thro ugh the wh o le le n gth o f the co mp art m e n t

ly in g in t h e p ro x im a l ha lf lat e ra l t o t h e brach ia l art e ry an d
, , ,

in t h e d ista l ha lf me d ia l to it Th e ba silic v e in e n t e r s th e
,
.

co mp art me n t at th e midd le o f the arm wh e r e it p ie rc e s the ,

d e e p fa sc ia an d th e n a sc e n d s a lo n g the me d ial sid e o f th e

,

brach ia l art e ry .

D is s e c ti o n — I f t h e p ie ce o f o o d, t o h ic h t h e ax illary ar e ry w w t
an d t h e n e r e s v w v
e re p re io u sly fi x e d, h as be e n de ac h e d f ro m t h e t
c o ra co id p ro ce ss, re ie it t o t t t
h a p ro ce ss an d p ro ce e d t o cle an th e
t
brac h ial ar e ry an d its bran c h e s, it s e n ae c o m i e s , t h e de e p v t
p ro x im al p art o f t h e basilic e in , an d t h e a c co m p an y in g n e r e s v v .

I t is im p o r an t t t t
h a t h e ar e ry sh o u ld be dis u rbe d as li le as t t tt
p o ss ible be fo re it s re la io n s are s u die d t
Th e re fo re c o m m e n ce t .

t
t h e disse c io n by cle an in g t h e n e r e s an d t h e e in s , an d ak e v v t
c are n o t t o in j u re t h e bran c h e s o f t h e ar e ry B e g in i h th e t . wt
t v
m e dial cu an e o u s n e r e o f t h e arm , race it alo n g t h e m e dial t
s ide o f t h e basilic v t
e in an d h ro u gh t h e O p e n in g in t h e de e p f ascia
t
to its e rm in a io n t
As a ru le it g i e s o ff n o bran c h e s o f dis
. v
t ribu t io n be f o re it p ie rce s t h e de e p f as cia, bu t it co mm u n ica e s t
wt i h t h e in te rco st o brac h ial n e r e (F ig -
N ex t f o llo w t h e v .

t v
m e dian cu an e o u s n e r e o f t h e f o re arm alo n g t h e g ro o e be e e n v tw
t
t h e an e rio r bo rde r o f t h e basilic e in an d t h e bra c h ial a r e ry , an d v t
t h ro u gh t h e o p e n in g in th e de e p fascia t o t h e be n d o f t h e e lbo w .

v v
I t g i e s O ff se e ral bran c h e s be fo re it p ie rce s t h e de e p f asc ia (p .

v
No w cle an th e basilic e in , disp lace it f o rw ards an d f o llo w t h e
v
u ln ar n e r e , w h ic h de sce n ds , alo n g t h e p o s e rio r an g le be w e e n t t
t h e brac h ial art e ry an d t h e basilic e in , t o t h e m iddle o f t h e arm v .

v
Th e n , at t h e le e l o f t h e in se r io n o f t h e co rac o brac h ialis, it t -

p asse s backw a rds, a cco m p an ie d by t h e su p e io r u ln ar c o lla e ral r t

bran c h o f th e brac h ial art e ry , p ie rc e s t h e m e dial in e rm u s cu lar t
t t
se p u m , an d e n e rs t h e p o s e rio r co m p ar m e n t
o f t h e arm , w h e re t t
t
it w ill be disse c e d at a lat e r p e rio d Th e m e dian n e r e s h o u ld . v
n ex tbe c le an e d F o llo w it alo n g t h e la e ral m arg in o f th e
. t
t
p ro x im al p a r o f t h e bra c h ial a rt e ry to t h e m iddle o f t h e a rm ,
t t
h e re it c ro sse s an e rio r to t h e art e ry an d t h e n de sce n ds, o n its
m e dial side , t o t h e cu bi al f o ssa no e t
h a th e n e r e g i es o ff t t t v v
t
n o bran c h e s ill t h e c u bi al f o ssa is re a c h e d t
Af e r t h e m e dian . t
v
n e r e h as be e n cle an e d, c le an t h e e n a c o m i e s o f t h e ar e ry v t t .

No t e t h a tt t
h e y an as o m o se acro ss t h e ar e ry fre q u e n ly , an d h a t t t t
at t h e lo w e r bo rde r o f t h e su bscap u laris h e y e n d in t h e ax illa y t r
v e in No w disp la ce th e p ro x im al p ar o f th e brac h ial ar e ry
. t t
f o rw ards an d f o llo w t h e radial ( m u scu lo sp iral) n e r e be h in d it , -
v
t o t h e p ro x im al e n d o f t h e su lcu s f o r t h e radial n e r e a t th e v
back o f th e h u m e ru s Th e radial n e r e is a c co m p an ie d by t h e
. v
p ro fu n da b r a n c h o f t h e b rac h ial a r e ry C le an t h e bra n c h e s t .

t
w h ic h p ass f ro m t h e la e ral side o f th e art e ry t o t h e bice p s ,
1 0 2 TH E SUP ER I OR EXTRE M I TY
an d th e u ln ar art e r ie s I n th e p ro ximal p art o f the arm it lie s
.

to the me d ia l sid e o f the hu me ru s but as it a p p r o ach e s th e ,

e lbow it p a sse s to th e fro n t o f t h e hu m e ru s .

Th is cha n ge o f p o sit io n m u st be bor n e in min d wh e n

p r e ssur e is a pp lie d to t h e v e sse l w ith t h e v ie w o f co n tro llin g

th e flow o f blood through it I n the p ro x im a l p art o f th e arm

.

t he p r e ssur e m u st be d ir e ct e d lat e ra lly an d backward s an d in ,

t he d ista l p art d ir e ct ly backward s .

C e p ha li v i
c e n

M u scu lo c u t ane o u s n e r e
-
v

M e d ani v
ne r e f

P ro fu n da art e r y
o f t h e arm

R di l
a a ne r e v
Brachi o -rad a i li s
m l
u sc e

L at e ra li n te r muscu l ar
se p t u m

FI G .
42 .
— Transve rse i h gh th D i t l Thi d
se ct o n t ro u e s a r o f th e
R i ght A m r .

R e lat io n s — The brach ia l

art e ry is su p e rfic ia l in t he
who le o f its le n gth To e x p o se it th e r e fore it is n e c e ssary
.
, ,

to r e fl e ct o n ly th e sk in an d th e fa sc ia ; bu t it is ov e rla pp e d ,

fro m t h e lat e ra l sid e by th e me d ia l marg in s o f t h e c o raco

,

brach ia lis an d bic e p s brach ii ( se e F ig s 1 0 At th e be n d .

,

o f the e lbow it is cro sse d su p e rfic ia lly by th e lac e rtu s fibro su s ,

wh ich in t e rv e n e s be twe e n it an d th e m e d ia n cu bita l v e in .

The ba silic v e in lie s to th e me d ia l sid e o f the art e ry an d

o n a so me what p o st e r ior p la n e I n th e d ista l p art o f the
.

arm it is se p arat e d fro m t he art e ry by th e d e e p fa sc ia ; bu t

in th e p ro x ima l p art a ft e r the v e in has p ie rc e d th e fa sc ia

, ,

it co m e s in to c lo se r r e lat io n sh ip w ith the art e ry Th e two .

v e n a co mit e s are c lo se ly a p p lie d to the sid e s o f the art e ry ,

 TH E F RO N T O F TH E AR M 1 0
3

an d the u me rou s co n n e ct in g bra n ch e s wh ich p a ss be tw e e n

n

th e m both in fro n t o f an d be h in d th e art e ry m ak e t he

, ,

r e lat io n sh ip st ill m ore in t im at e .

B e h in d th e brach ia l art e ry th e r e are four m u sc le s .

Pro ximo d istally th e y are

-
th e lo n g h e ad o f th e tr ic e p s
, ,

wh ich is se p arat e d fr o m th e art e ry by th e rad ia l ne rv e an d the

p ro fu n da v e sse ls
( )
2 t h e m e d ia l h e ad o f t h e tr ic e p s 3) t h e

in se rt io n o f t h e coraco brach ia lis ; ( 4 ) in th e r e ma in d e r o f

it s cour se the brach ia lis for ms the p o st e r ior r e lat io n .

N . m u scu lo
c u tan e u s

N me d an i

M c o raco
i li
.

brach a s

i
‘

D o rsa l cu t an e o us n e r e o v f arm (O T
x l l
. .

e t e rn a c u t an . o f mu sc u lo -
sp i ra )

FIG .
43 .
— Tran sv e rse i
se c t o n t hro u gh M dd ei l o f th e Arm .

W ith the e x e p c t io n
f th e m u scu lo cuta n e ou s n e rv e , all
o -

th e t e r min a l bra n ch e s o f the brach ia l p le x u s lie in r e lat io n to

th e brach ia l art e ry Th e m e d ia n n e rv e lie s o n th e lat e ra l sid e
.

an d s o me what a n t e riorly in t he p ro x ima l half o f the arm ; it

cro sse s a n t e rior to th e art e ry at th e le v e l o f the in se rt io n o f
th e coraco brach ia lis an d in t h e d ista l ha lf o f t he arm an d
-
,

in th e cu bita l fo ssa it is to the m e d ia l sid e o f th e art e ry Th e .

u ln ar n e rve an d th e m e d ia l cuta n e o u s n e rv e o f t he for e ar m

lie c lo se t o t he me d ia l Sid e o f t h e art e ry as far as t h e
in se rt io n o f th e corac o brach ia lis th e n th e y le av e it-
Th e .

uln ar n e rve in c lin e s backward s p ie rc e s th e me d ia l in t e r ,

1 0 4 TH E SUPER I OR EXTRE M I TY
mu scu lar tu m an d p a ssin g be h in d th e m e d ia l e p ic o n dy le
se p , , ,

e n t e r s th e for e ar m Th e m e d ia l cuta n e ou s n e rv e o f t he
.

fo r e ar m in c lin e s forward s an d m e d ia lly p ie rc e s t h e fa sc ia ,

brachn an d be co m e s su p e rfic ia l The rad ia l n e rv e is .

be h in d th e p ro xima l p art o f t he art e ry bu t it soo n le av e s it ,

by p a ssin g d ista lly an d lat e ra lly in to t h e su lcu s fo r t h e

rad ia l n e rv e be tw e e n the m e d ia l an d the lat e ral h e ad s o f the
,

tr ic e p s .

B ran ch e s o f t h e Brachial Art ery — Se v e ra l bra n ch e s ar ise .

fro m t h e brach ia l art e ry Tho se wh ich arise fro m its lat e ra l

.

a sp e ct are irr e gu lar in n u mbe r o r ig in an d siz e Th e y are , ,

.

t e r me d the lateral branches an d are d istribut e d to the mu sc le s

,

an d in t e gu m e n t o n t he fro n t o f t h e arm Th e se r ie s o f .

medial branches wh ich p roc e e d fro m th e m e d ia l an d p o st e r ior

a sp e ct o f the p ar e n t tru n k are n a me d as follow s as th e y ar ise
p ro x imo d ista lly -

I . A pro fu n da brach n
. .
3 . A . nu t ricia hum e ri.

2 A co llate ralis u lnaris su p e rio

. r
.
4 . A . co llate ralis u ln aris in fe rio r .

The profu nda artery ( O T su p e rior p ro fu n da ) is th e . .

larg e st o f the bra n ch e s wh ich Sp r in g fro m t he brach ia l tru n k .

I t tak e s or ig in a bout 2 5 mm ( o n e in ch ) or so d ista l to t he .

low e r marg in o f t he t e r e s maj or an d a ssoc iat e s it se lf w ith the ,

rad ia l ( mu sculo sp iral) n e rv e wh ich it acco mp a n ie s to the

-

back o f th e arm C o n se qu e n t ly o n ly a short p art o f th e

.
,

v e sse l is se e n in the p r e se n t d isse ct io n I t soo n d isa pp e ars .

fro m V ie w be tw e e n th e lo n g an d m e d ia l h e ad s o f th e tr ic e p s .

The superio r u ln ar co llateral artery ( O T in fe r ior p ro fu n da ) . .

is a lo n g sle n d e r art e ry wh ich c an be r e cog n ise d fro m th e

,

fact that it fo llow s c lo se ly th e cour se p ur su e d by t he u ln ar

n e rv e I ts or ig in is so me what var ia ble
. As a g e n e ra l ru le it .
,

issu e s fro m the brach ia l art e ry o pp o sit e th e in se rt io n o f th e

coraco brach ia lis bu t v e ry fr e qu e n t ly it ar ise s in co mm o n
-

w ith the p ro fu n da brach ii I t p ie rc e s the me d ia l in t e r .

mu scu lar se p tu m w ith th e u ln ar n e rv e an d d e sc e n d s be h in d

, ,

that fa sc ia l p a rt it io n to the in t e rva l be tw e e n the O le cra n o n

an d t he m e d ia l e p ico n dy le o f th e hu m e ru s .

The n u trient artery may ar ise d ir e ct ly fro m the brach ia l

tru n k or tak e or ig in fro m the su p e r ior u ln ar co llat e ra l
,

art e ry I t shou ld be sought fo r at the d ista l bord e r o f

.

t h e in se rt io n o f t he c o raco brach ia lis an d t he d isse ct o r -

shou ld no t be sat isfi e d u n t il he has trac e d it in to t h e

1 0 6 TH E SUP ER I O R EXTRE M I TY
vo lar u ln ar r e curr e n t art e ry Th e po steri o r branch p ie rc e s
.

th e m e d ia l in t e r m u scu lar se p tu m an d w ill be se e n at a lat e r

, ,

stag e in th e p o st e r ior co m p art me n t o f t h e arm

, .

D is s e c ti o n — Cle an t h e bice p s brac h a Cle an th e co raco .

t
brac h ialis ; se p ara e it care fu lly f ro m th e sh o r h e ad o f th e t
t
bice p s, an d fi n d t h e m u scu lo cu an e o u s n e rv e as it le a e s t h e
- v
t
la e ral su rface o f t he c o raco brac h ialis F o llo w the mu scu lo
-
.

t v
cu an e o u s n e r e , be tw
e e n t h e bice p s an d t h e brachialis , t o t h e

p o in tw r t
h e e it e m e rg es at the la e ral bo rde r o f t h e e n do n o f th e t
t ut
bice p s an d be co m es t he la e ral c an e o u s n e r e o f th e f o re a m v r .

Cle an t h e brac h ialis as far as th e be n d o f th e e lbo , bu t do n o t w

in j u re t he lace rtu s fi bro su s .

N e rvu s M usculo cut an e us The m u scu lo cuta n e ou s n e rv e

.
— -

ar ise s fro m th e lat e ra l cord o f the brach ia l ple x u s, at the

low e r bord e r o f the p e ctora lis m in or I n c lin in g lat e rally , .

it p e r forat e s th e coraco brach ia lis, an d p a sse s be tw e e n t he

-

bic e p s brachn an d the brach ialis I t p roc e e d s o bliqu e ly

.

d ista lly, be tw e e n tho se mu scle s, u n t il it re ach e s th e be n d

o f t h e e lbow , wh e r e it co m e s to t h e sur fac e at th e lat e ra l

bord e r o f th e t e n do n o f th e bic e p s brach ii F r o m that .

p o in t o n ward s it h a s a lr e ady b e e n trac e d a s t h e lat e ra l

cuta n e ou s n e rv e o f the for e ar m ( p .

I n th e arm th e mu scu lo cuta n e ou s n e rv e su p p lie s bra n ch e s

-

to thr e e m u sc le s o f t h e r e gio n The bran ch to the coraco .

brach ia lis is g iv e n o ff be for e th e p ar e n t tru n k e n t e r s t h e

su bsta n c e o f t h e m u scle ; th e bra n ch e s to th e bic e p s brach n

an d brach ia lis issu e fro m it as it lie s be tw e e n th e m .

M Co raco brachia lis —The coraco brach ia lis is an e lo n gat e d

. .
-

mu sc le , wh ich tak e s o r ig in fro m th e t ip o f t h e c o raco id

p roc e ss ,
in co n j u n ct io n w ith t h e short h e ad o f t h e b ic e p s

brach ii I t p roc e e d s d istally , alo n g th e me d ia l marg in o f the

.

bic e p s brach ii, an d o bta in s in se rt io n in to a lin e ar ridg e

situat e d u o n t h e me d ia l a s e ct o f t he body o f t h e hu m e ru s,
p p
a bout its m idd le .

M Bicep s B rach 11 — Th e bic e p s brach n mu sc le ar ise s

. .

fro m t h e sca p u la by two d ist in ct h e ad s o f or ig in Th e sho rt .

or medial head sp r in gs fro m the t ip o f the corac o id p roc e ss in

co nju n ct io n w ith the coraco brach ialis ( F ig 2 4 , p
-
Th e . .

lo ng or lateral head is a rou n d e d t e n do n wh ich occu p ie s the ,

in t e rtu be rcu lar su lcu s o f t he hu m e ru s I ts or ig in ca n n ot be .

stud ie d at th is stag e o f th e disse ct io n be cau se it is p lac e d w ith ,

in t he ca p su le o f t h e shou ld e r jo in t wh e r e it ar ise s fro m an

-
,

imp r e ssio n o n t h e sca p u la imm e d iat e ly abov e th e gle n o id cav ity .

 TH E F RO N T O F TH E AR M 1 0 7

B oth h e ad s sw e ll out in to
e lo n gat e d fl e shy be llie s Su bsc ap u l i ar s
, Su p rasp i na t u s

wh ich at fir st are me r e ly
, ,

clo se ly a pp lie d to e ach

oth e r but a ft e rward s are
,

u n it e d in the d istal th ird

o f t h e arm Toward s the .

'

be n d o f th e e lbow t h e C re st f t heo
l l
- !

fl e shy fi br e s co n v e rge u p o n e sse r t u be rc e

a stout short t e n do n wh ich

, ,

is in se rt e d in to the dor sa l P e c to ra li s maj o r

p art o f t h e tu be ro sity o f
t h e rad iu s Th e in se rt io n
.

w ill be mor e fully e x amin e d

at a lat e r p e r iod but it ,

may be n ot ic e d in th e ,

me a n t ime that the t e n do n

,

is tw ist e d so as to p r e se n t D l id e to

it s marg in s to th e fro n t
an d dor sa l a sp e ct o f th e C o rac o brach -
i li
a s

lim b an d furth e r that a

, , ,

bur sa muco sa is in t e r p o se d
be tw e e n it an d t h e smooth ,

vo lar p art o f the rad ia l

tu be ro sity
i i li
.

B rach rad a
The d isse ctor h as al
o - s

r e ady tak e n n ot ic e o f th e
lacertu s fi bro has
su s, an d

se p arat e d it, art ific ially,

fro m th e d ee p fa scia o f t h e
arm, an d o f th e fore ar m .

O bse rv e n o w that it Sp r in gs
fro m th e a n t e rior marg in
o f th e t e n do n o f the bic e p s

brach ii, an d a lso fro m th e

s hort h e ad o f the m u scle .

I t is su pp lie d by th e mu s
cu lo cuta n e ou s n e rv e an d Ex
-
t e n so rs

is a su p in ator o f th e f or e Pr o n at o r t e re s
an d fl e x o rs
arm an d a fl e x o r o f t he
e lbow j o in t
F G 45 A I . .
— i
n t e r o r asp e c t o f H u me ru s w i th
l
-

M Att ach m e n ts m app e d o u t

.

uscu ar
M
.

. B rac h i a li s ( O T . .
1 0 8 TH E SUPER I OR EXTRE M I TY
B rachialis An t icu s) — Th e brach ialis arise s fro m th e e n t ir e
.

w idth o f the a n t e r ior a spe ct o f th e dista l half o f the body o f

t h e hu m e ru s, fro m th e m e d ia l in t e r m u scu lar se p tu m, an d fro m
a sma ll p art o f th e lat e ra l in t e r mu scu lar se p tu m p ro x im al to
t h e brach io rad ia lis Th e or ig in fro m th e bo n e is p ro lo n g e d
-
.

p ro x ima lly in two sli s wh ich

p p art ia lly e mbrac e th e in se rt io n

o f t h e d e lto id The fi br e s co n v e rg e to be in se rt e d in to th e
.

ba se o f th e coro n o id p roc e ss o f th e u ln a by a short , th ick

t e n do n The m u sc le lie s p artly u n d e r cov e r o f th e bic e p s
’

brach n , bu t p roj e ct s be yo n d it o n e ach sid e I t is ov e r .

la pp e d o n it s me d ial sid e by t he p ro n ator t e r e s, an d o n th e

lat e ra l sid e by th e brach io rad ia lis an d e x t e n sor car p i rad ia lis
-

lo n gu s I ts d e e p su rfac e is c lo se ly co n n e ct e d to th e a n t e r ior
.

p art o f t h e ca p s u le o f t h e e lbow j o in t I t s ch ie f n e rv e o f
-
.

su p p ly , fro m t he mu scato cu taneo u s, h as a lr e ady be e n se cur e d ,

-

bu t it r e c e iv e s a lso o n e or two sm a ll twig s fro m t h e rad ia l

u scu lo —sp iral n e rv e wh ich are g iv e n O ff u n d e r cov e r o f th e
( m )
brach io rad ia lis -
I t is a fl e x o r o f t he e lbow jo in t
.
-
.

D is s e c ti o n 4 e p arat e t h e brac h io radialis f ro m t h e brach ialis

.
-

t
m u scle , an d disse c o u t t h e radial n e r e , w i h t h e ant e rio r v t
t e rm in al bran ch o f t h e p ro fu n da brac h ii art e ry , w hic h lie de e p ly
v
in t h e in te r al be twe e n t h e m u scles Th e re also , in a w ell .

t
in j e ct e d su bj e c , t h e an as o m o sis be t
ee n t h e p ro fu n da brach ii tw
art e ry an d t h e radial re cu rre n t
art e ry m ay be m ade o u t ; an d
v
th e tw ig s w h ich are gi e n by t h e radial n er e to t h e brac h ialis , v
t h e brac h io radialis, an d t h e e xt e n so r carp i adialis lo n gus, sh o u ld
- r
be lo o k e d f o r.

F o ssa Th e cu bital fo ssa is th e ho llow in

Cubit alis — .

fro n t o f t h e e lbow I t is tr ia n gu lar in out lin e an d it

.

corr e sp o n d s ge n e rally w ith the p o p lit e a l fo ssa at the back

of t he k n e e .

I t p o sse sse s a roo f or su p e rfic ia l bou n dary ; a floor o r

d e e p bou n dary ; m e d ial an d lat e ra l bou n dar ie s ; a ba se an d
an ap ex .

The roo f is for me d by the d e e p fa sc ia in wh ich lie s

th e th ick e n e d ba n d ca lle d th e lac e rtu s fi bro su s I t is .

p ie rc e d by a co m m u n icat io n fro m th e d e e
p v e in s o f t h e

for e ar m to th e m e d ia n cu bita l v e in I t is cov e r e d by t he .

Sk in an d su p e rfic ia l fa sc ia an d u p o n it in th e su p e rfic ial , ,

fa sc ia lie a p ort io n o f t h e c e p ha lic v e in a p o rt io n o f th e

, ,

ba silic v e in th e m e d ia n cu bita l v e in th e vo lar bra n ch o f

, ,

th e m e d ia l cuta n e ou s n e rv e o f th e fo r e ar m an d th e lat e ra l ,

cuta n e ou s n e rv e o f the for e arm .

 1 1 0 THE SU PER I O R EXTRE M I TY
the p ro n ator t e re s The fl o or is for m e d by th e d istal p art
.

o f th e brach ia lis m u sc le an d t h e a n t e r io r p art o f the su p in ator .

With in the fo ssa are th e t e r min at io n o f th e brach ia l art e ry ,

an d t h e p ro x im a l p art s o f th e rad ia l an d u ln ar art e r ie s in t o ,

wh ich it d iv id e s To the lat e ra l sid e o f th e ma in v e sse l

.

M ed a il c u t ane o u s n e rv e
l
L at e ra cu t ane o u s n e r e o f v
re arm
f o t he fo
vl
t he fo re a rm , o a r bran ch
F i
‘
v

arm
p h li v i
as c a o f the
Ce a c e n

B as ili c ve i B rac h i li a s

l
L at e ra c u t an e o u s n e r e o f v
B rach il
a art e r y t h e fo re arm , do rsa bran c h l
M ed a il c u t an e o u s
R di la a n e rv e

v
ne r e o f t he fo re arm L fib
ac e rt u s ro su s

i v
R di l v
a a ne r e ,

p fi i l b
M e d an ne r e
su er c a ran ch

Vl l
o ar u n ar re c u rre n t
R di l va a ner e ,
de e p bran ch
a rt e r y
N er v
e t o p ro nat . t e re s Te ndo n o f b i ce p s brach n

Ul n ar art e r y
L ace rt u s fibro
R di l
a a re c u rre n t art e r y
su s
-
0

Su p 1n ato r m u sc l e

P ro n at o r te re s, de e p he ad B ra ch i o -
rad a i li s mu sc l e

Fl x e o r carp i i li
rad a s

R di l
a a art e r y
P a lm i l g
ar s o n u

Med a il cu ta n e o u s n e rv e
L at e ra l c u t an e o u s
f t he fo re arm
o
v f t he fo re arm ,
B as ili v i
c e n
ne r e o
v o l ar bran c h

C e p ha li v i
c e n

M e d an i i
ve n

FI G .
47 .
— Di i
sse c t o n o f t h e L e ft C u bi t l F
a o ssa.

is p ac e d
l t e n do n o f th e bic e p s brachn and to its
th e ,

me d ial sid e th e m e d ia n n e rve, A qua n t ity o f loo se fat a lso .

is p r e se n t The u ln ar art e ry le av e s t h e sp ac e by p a ssin g

.

u n d e r cov e r o f the p ro n ator t e r e s the rad ial art e ry is c o n

t in ne d d ista lly be yo n d the a p ex o f th e fo ssa ov e rla pp e d by ,

the brach io rad ia lis Th e m e d ia n n e rv e d isa p p e ar s be tw e e n

-
.

th e two h e ad s o f th e p ro n ator t e r e s an d t he t e n do n o f ,

t h e bic e p s brachn in c lin e s p o st e r ior ly be tw e e n the two bo n e s ,

o f t h e f or e ar m to r e ach it s in se rt io n in to t h e rad ia l tu be ro sity

,
.
 TH E F RO N T OF TH E AR M 1 1 1

Oth e r structure s wh ich are u n d e r cov e r o f th e bo u n darie s

bu t are n o t str ict ly w ith in t h e fo ssa are t h e t e r m in at io n —

o f t h e rad ia l n e rv e an d
p art s o f it s d e e p an d su p e rfic ia l
d iv isio n s ; th e a n t e rior t e r m in a l br an ch o f t h e p ro fu n da
art e ry ; th e rad ia l r e curr e n t art e ry ; t h e v o lar an d d o rsa l
u ln ar r e curr e n t art e rie s an d tw ig s o f t h e su p e r io r an d in fe rio r
u ln ar c o llat e ra l art e r ie s .

D is s e c ti o n — Th f a ial r f f t h bit l f a w a p art ially e sc o o o e cu a o ss s

d tr y d w h
es o th d p f
e ia f th fr t f t h arm w a
en e ee as c o e o n o e s
r fle t d b t th la rt fi br
ec e , i t ill i p sit i n N w
u e ce us o su s s s n o o . o
cu t a r th l
c o ss rt ar t h bi p (Fig e a d r fl
a ce t it us ne e ce s . n e ec
t w ard th m dial b rd r f th f r arm t h n p r d t l an
o s e e o e o e o e , e o ce e o c e
th e t t f th f a P ll a id t h m dial an d lat ral
co n e n s o e o ss . u s e e e e
bo dari
un w it h h k a d t h es mm w it h th m dia o o s n en co e n ce e e n
n rv
e F ll w it f r m ab v d w w rd t t h p i t w h r it
e . o o o o e o n a s o e o n e e
disapp ar b t w n t h tw
e h d f t h p r at r t r
s e ee an d e o ea s o e o n o e e s,
se cu re t h e bran c h e s wh ic h sp rin g f ro m its m e dial side an d p ass
to the m u scle s wh ic h arise f ro m t h e m e dial e p ic o n dy le o f t h e
h u m e ru s .

N e xt c le an t h e bra c h ial a rt e ry , also f ro m abo e do n w ards v w .

v
I f its e n a co m i e s are in t h e w ay re m o e h e m t F o llo th e v t . w
v
a rt e ry t o it s di isio n in o it s radial an d u ln ar bran c h e s , hen t t
f o llo w t h e radial art e ry t o t h e ap e x o f t h e f o ssa, an d t h e u ln ar
art e ry t o t h e p o in tw
h e re it disap p e ars be h in d th e de e p h e ad o f
t h e p ro n a o r e re s t t
D o n o t in j u re t h e radial re cu rre n bran c h
. t
w h ic h sp rin gs fro m th e la e ral side o f t h e radial art e ry , o r t h e t
v o lar an d do rsal u ln ar re cu rre n bran c h e s wh ic h arise f ro m t h e t
m e dial side o f t h e u ln ar ar e ry N o w cle an t h e t e n do n o f t h e t .

bice p s bra c h ii an d f o llo w it t o its in se rt io n in o t h e p o s e rio r p ar t t t

o f the t
u be ro si y o f t h e radiu s, an d n o e t
h a , as it p asse s t o its t t t
in se rt io n , it w is s so t t
h a its an e rio r su rface be co m e s la e ral, t t t t
an d its p o s e rio r su rf ace t
be co m e s m e dial Th e e n do n is . t
t
se p ara e d f ro m t h e a n e rio r p art o f t h e u be ro si y by a sm all t t t
bu rsa w
h ic h m ay be o p e n e d i h t he p o in o f t h e scalp e l wt t .

t t
To f acili a e t h e c le an in g o f t h e fl o o r an d t o e x p o se s ru c u re s t t
t t
w h ic h are n o t s ric ly co n e n s o f th e fo ssa, bu t w h ic h lie clo se t t
v
t o it , u n de r co e r o f it s m e dial an d lat e ral bo u n darie s, fl e x t h e
e lbo w t
S ligh ly , an d p u ll t h e m e dial an d la e ral bo u n darie s o f t h e t
f o ssa s ill w ide r ap artt F in d t h e e rm in a io n o f t h e radial n e r e ,
. t t v
t t
an d t h e an e rio r e rm in al bran c h o f t h e p ro f u n da art e ry at t h e
v
le e l o f t h e la e ral e p ico n dy le be t
e e n t h e brac h io radialis a n d tw -

th e bra c h ialis F o llo w t h e de ep an d su p e rfi cial e rm in al bran ch e s

. t
O f t h e n e r e , do n w ards in f ro n v w
o f t h e la e ral p art o f t h e t t
c ap su le o f t h e e lbo w j o in Th e de e p bran c h disap p e ars in o t h e
-
t . t
t
su bs an ce o f t h e su p in a o r Th e su p e rfi c ial di isio n de sce n ds t . v
be tw
e e n t h e brac h io radialis an d t h e su p in a o r, e i h e r su p e rfi c ial
-
t t
o r de e p t o t h e bran c h e s o f t h e radial re cu rre n art e ry Th e t .

t t
e rm in a io n o f t h e su p e rfi cial di isio n h as alre ady be e n disse c e d v t
o n t h e do rsu m o f t h e h an d w h e re it s u p p lie s t h e la e ral h re e t t
an d a h alf dig i s (se e p
- -
t
N ex t f o llo w t h e radial re cu rre n . t
t
a rt e ry t o t h e la e ral e p ico n dy le , w h e re it an as o m o se s w i h t h e t t
t t
an e rio r e rm in al bran c h o f t h e p ro fu n da art e ry Th e n race . t
th e v
o lar an d do rsal re cu rre n t bran ch e s o f t h e u ln ar art e ry t o
1 1 2 TH E SU PER I OR EXTRE M I TY
the m e dial e p ico n dy le w h e re
‘

th y a
e n as o t m o se w it h t he su p e rio r
an d in f e rio t ral bran h f th br h ial art ry
r u ln ar c o lla e c es o e ac e .

Aft e r th e r e lat ive p o sit io n s o f t h e c o n t e n t s o f th e cu bita l

fo ssa hav e be e n stud ie d t ur n to th e d isse ct io n o f t h e back o f
t h e arm .

D OR SU M O F TH E AR M .

In th is r e g io n in add it io n to th e cuta n e o u s n e rv e s the

fo llow in g are t he structur e s wh ich m u st be stud ie d
m The tric e p s m usc le .

u The p ro fu n da brachn arte ry , an d the radia n e rv e l .

n
g l ll
The su p e rio r u n ar co ate ral art e ry , an d the u n a r n e rv e l .

a The po ste rio r bran ch o f the in fe rio r u ln ar co llate ral arte ry .

m The su ban c o n a u s m u scle .

Th e sk in an d t he su p e rfic ia l fa sc ia hav e a lr e ady be e n

r e mo v e d bu t the cuta n e o u s n e rv e s are st ill p r e se n t, an d
t h e d isse ctor shou ld r e v ise th e m be fo r e p r o c e e d in g w ith th e
d isse ct io n .

O n th e me d ia l sid e are bra n ch e s o f t he in t e rco sto brach ia l -

n e rv e lat e ra l t o th e m lie s t h e p o st e r io r brach ia l cuta n e o u s

bra n ch o f t he rad ia l n e rv e , an d, a lo n g t h e lat e ra l m arg in o f
t h e arm, is t h e dor sa l cuta n e ou s n e rv e o f t h e for e ar m, a lso
a bra n ch o f t he rad ia l n e rv e .

v t
D is s e c t io n — M ak e a e r ical in cisio n hro u gh t h e de e p f ascia t
as f ar as t h e O le cran o n o f t h e u ln a, an d a ran s e rse in cisio n t v
ac ro ss t h e O le cran o n f ro m o n e e p ico n dy le t o t h e o h e r, ak in g t t
c are n o t t o in j u re t h e do rsal cu an e o u s n e r e o f t h e fo re arm t v .

t
R e fl e c t h e fl ap s o f de e p f as cia t o h e ir re sp e c i e S ide s u n il t tv t
t t t t
h e ir co n in u i y w i h th e m e dial an d la e ral in e rm u scu lar se p a t t t
tv
re sp e c i e ly is de m o n s ra e d t t
As t h e m e dial fl ap is re fl e c e d,
. t
v
a o id in j u ry t o t h e u ln ar n e r e v w
h ic h de sce n ds o ards th e t w
m e dial e p ico n dy le o n t h e m e dial h e ad o f t h e ric e p s I t is t .

a cco m p an ie d by t h e su p e rio r u ln ar co lla e ral art e ry W hen t .

t
t h e re fl e c io n o f t h e fl ap s is co m p le e d cle an t h e rice p s m u scle t t
t t
an d de fi n e care f u lly it s a t ac h m e n s t o t h e sc ap u la, t o t h e h u m e ru s,
an d t o t h e u ln a .

M Tric e p s Brach ii
. tric e p s m u sc le occu p ie s t he
.
-
The
e n t ir e p o st e r ior o st e o fa sc ia l co m p art m e n t o f th e arm
-
It .

arise s by a lo ng head fro m the sca p u la an d by two short e r ,

h e ad s lateral an d medial fro m th e hu me ru s The fl e shy

, ,
.

fi br e s o f the thr e e h e ad s j o in a co mm o n t e n d o n wh ich is ,

in se rt e d in to t he p ro x ima l sur fac e o f th e O le cra n o n o f the

1 1 4 TH E SUPER I O R EXTRE M I TY
Th e lateral head o f th e tr ic e p s arise s fro m th e lat e ra l an d
p o s t e r ior a sp e ct o f t h e b ody o f th e hu m e ru s , p
ro x im a l to t h e

su lcu s fo r th e rad ia l n e rv e . I t tak e s or ig in , by S h o rt t e n d in

o u s fi br e s, a lo n g a lin e wh ich p a sse s d ista lly fro m t h e in se rt io n

o f th e t e r e s min or to t h e p ro x ima l bord e r o f t h e su lcu s fo r

th e rad ia l n e rv e . B u t it d e r iv e s fi br e s a lso fr o m a stro n g

fa sc ia l br idg e or arch wh ich is throw n ov e r t h e groov e so as
to g iv e p rot e ct io n to the p ro fu n da brachn art e ry an d th e
rad ia l n e rv e The str e n gth an d p o sit io n o f th is arch c an be
.

e st imat e d by thru st in g t h e ha n d le o f t h e k n ife d ista lly an d

lat e ra lly in th e su lcu s fo r th e rad ia l n e rv e , an d a lo n g th e

course o f the n e rv e an d art e ry, u n d e r the lat e ra l h e ad o f
the tr ic e p s . B y its d ista l e n d t h e arch is co n n e ct e d w ith th e
lat e ra l in t e r mu scu lar se p tu m .

The medial head o f the tr ic e p s is p lac e d d ista l to the su lcu s

fo r t h e rad ia l n e rv e . I t s p ro x im a l e n d, wh ich is n arrow an d
p o in t e d ,
lie s c lo s e to t h e d i s ta l e n d o f t h e i n se rt i o n o f t h e

t e r e s major The orig in gradua lly w id e n s as th e su lcu s fo r

.

t h e rad ia l n e rv e p a sse s toward s the lat e ra l bord e r o f t h e

hu m e ru s, an d in the d istal th ird o f the arm it cov e r s t he
p o s t e r i or s ur f ac e o f t h e hu m e ru s f ro m t h e lat e ra l to t h e m e d ia l
bord e r ( F ig . I t sp r in g s a lso fro m t he p o st e r ior sur fac e
o f t h e m e d ia l in t e r mu scu lar se p tu m, an d fro m th e d ista l p art

o f th e corre sp o n d in g surfac e o f the lat e ral in t e r mu scu lar

se p tu m . The me d ia l h e ad o f th e tr ic e p s, th e r e for e , h as v e ry
m uch the sa me or ig in fro m th e p o st e r ior sur fac e o f th e bo n e
that the brach ia lis has fro m the a n t e rior a sp e ct .

Th e d isse ctor shou ld n o w study th e co mmo n tendo n of

insertio n o f the tr ic e p s The lo n g an d th e lat e ra l h e ad s e n d
.

in a broad , flat t e n do n , wh ich is in se rt e d in to th e back p art

o f the p ro x im a l sur fac e o f th e o le cra n o n , an d at th e sa m e

t ime g iv e s o ff, o n t he lat e ra l Sid e , a stro ng e xp a n sio n t o the

fa sc ia o f th e for e ar m as it cov e r s th e an c o n a u s mu sc le . Th e
short fl e shy fi br e s o f t h e m e d ia l h e ad are , fo r th e m o st p art ,

in se rt e d in to the d e e p sur fac e o f th e co mmo n t e n do n , bu t a

co n sid e ra ble n u mbe r fin d d ire ct attach men t to the o le cra n o n ,
wh ilst a fe w o f the d e e p e st fi bre s are in se rt e d in to the loo se
p o s t e r ior p art o f t h e ca p su le o f t h e e lb ow
-
jo int . T h e latt e r

fi br e s have be e n d e scribe d as a se p arat e mu scle u n d e r th e

n a m e o f su banco n a us . The tr ic e p s is su pp lie d by bra n ch e s
f ro m th e radial n erve . I t is an e x t e n sor o f t h e e lbow j o in t -

an d an adductor o f th e arm .
 D OR SU M O F TH E AR M 1 1
5

D is s e c ti o n — I n o de r rt t
h a the radial n e r e an d th e p ro fu n da v
brach ii art e ry m ay be fu lly e x p o se d, t h e la e ral h e ad o f t h e t
trice p s mu s be di ide d t v r t
Th u s t h e h an dle o f a k n ife alo n g t h e
.

su lcu s f o r t h e radial n e r e , an d u n de r t h e m u scle v Th e h an dle .

w t
ill h e n g i e t h e dire c io n in v t w
h ic h th e la e ral h e ad o f th e t
trice p s s h o u ld be se e re d v
B e y o n d cle an in g t h e n e r e an d its. v
bran c h es, an d t he p ro fu n da brach ii art e ry , as h e y lie in t h e t
v t
g ro o e , n o fu r h e r disse c io n is n e cessary t .

n s R a dia lis ( O T M u sculo Sp iral N erv e ) — The rad ia l

N e ry . .
-
.

n e rv e is th e d ir e ct co n t in uat io n o f th e p o st e r io r c o rd o f t h e

brach ia l p le x u s aft e r it has fur n ish e d in th e a x illa th e t wo , ,

su bsca p u lar n e rv e s t h e thoraco d o r sa l n e r ve an d t h e a x illary

,
-

n e rv e I n th e fir st in sta n c e t h e rad ia l n e rv e p roc e e d s d ista lly

.
, ,

be h in d th e d ista l p art o f the a x illary art e ry an d t h e p ro xima l

p art o f t h e b rach ia l art e ry I t soo n le av e s t h e a n.t e r ior a s p e ct
o f th e arm how e v e r an d in c lin in g backward s w ith t h e pro
, , , ,

fu nda brachii artery e n t e r s th e in t e rva l be tw e e n th e lo n g an d

,

t he m e d ia l h e ad s o f t h e tr ic e p s an d r e ach e s th e su lcu s fo r t h e ,

rad ia l n e rv e I n that it p a sse s rou n d the back o f the body o f

.

t he hu m e ru s u n d e r c o v e r o f t h e lat e ra l h e ad o f th e tr ic e p s an d
, ,

o n t h e lat e ra l sid e o f th e limb it p ie rc e s th e lat e ra l in t e r m u scu lar

se p tu m an d p a sse s in to th e a n t e r io r co mp art me n t o f th e arm ,

wh e r e it has a lr e ady bee n d isse ct e d Th e r e it lie s d e e p ly in .

,

th e in t e rva l be tw e e n t h e brach ia lis o n t h e m e d ia l Sid e an d

t h e brach io rad ia lis an d e x t e n sor car p i rad ia lis lo n gu s o n t h e
-

lat e ra l sid e an d it e n d s at th e le v e l o f t h e lat e ra l e p ico n dy le o f

,

th e hu me ru s by d iv id in g in to two t e r min a l bra n ch e s v iz th e ,

.
,

ra m u s sup e rfic ialis ( O T rad ia l) an d t he ra m u s p r o fu n du s. .

( O T
. .
p o s t e r ior in t e ro sse ou s
) T h e rad ia l n e rv e p r e
. se n t s ,

th e r e fo r e v e ry d iffe r e n t r e lat io n s as it is trac e d fro m its origin

,

i ts t e r m in at io n : ( 1 ) be tw e e n th e su bsca p u laris lat issimu s

t o ,

dor si t e r e s major an d lo n g h e ad o f the tric e p s wh ich su pp o rt

, , ,

it be h in d an d th e a x illary an d brach ia l art e r ie s wh ich are

,

p lac e d in fro n t o f it ( )
2 b e tw e e n th e lo n g an d th e me d ia l h e ad s

o f t h e tric e p s ; 3) in t h e su l cu s fo r t h e rad ia l n e rv e be tw ee n ,

th e bo n e an d t h e lat e ra l h e ad o f th e tr ic e p s ( )
4 in the

in t e rva l be tw e e n th e brach ia lis o n th e m e d ial Sid e an d th e ,

brach io rad ialis an d e x t e n sor car p i rad ia lis lo n gu s o n th e

—

lat e ra l sid e .

Th e bra n ch e s wh ich p r o c e e d fr o m th e rad ial n e rv e are

mu scu lar, cu taneo u s, articu lar an d termin al .

Th e cu taneo u s branches are two in u mbe r an d hav e a lr e ady

n ,

be en trac e d . Th e y are th e p o st e r ior cuta n e o u s n e rv e o f

 THE SUPER I OR EXTRE M I TY
t h e arm, an d ( ) 2 an d 3) th e dor sal cutan e ou s ne rv e s o f th e
for e ar m .

The mu scu lar branches are d istr ibut e d to th e thr e e h ead s

Sp i ne o f sc ap u a l S p up lrascav u ar ne r e
Tran s v e rse scap u ar art e r l y
(O T . . su p rascap u ar l ) D l id e to
Su p rasp i n at u s

Su bacro m i lb
a u rsa

I i
n fras p n a t u s mu sc l e

o f sh o uld er

t e re s mi no r

Su l) scap u l ar1 s
( inf bran ch)
.

L at e ra brac h l il
a

c u t ane o u s n e r e v

ric e p s, l g o n h e ad
La te ra he ad o f l
R di l i l) t r1c e p s
.

a a ne r e v ( O T m usc u lo sp ra

i rac hia l arte r y R di l

a a ne r e v (O T
l)
. .

m u sc u lo -
sp i ra

i
Tr ce p s, l lh
at e ra e ad

N . i
t o t r ce p s, m di l h
e a e ad
2:2}32 5
1 3 “ h 0 f p ro fu n da
3 rm

N . t o an co na u s
P branch o f p ro fu nda
o st .
y
art e r o f arm

i
Tr ce p s, me d he ad D l
o rsa an t brach a i il
.

c u t ane o u s n e r e v
B rach i lia s

Ul n ar ne r e v
Med a i l pi e co n dy l e

N . to fl e x . c arp . u ln.

Ol e cran o n

FIG .
49 .
— Di i
sse c t o n o f th e do rsa asp e c t o f t h e Arm l . The l ate ra lh e ad o f
i
t h e Tr ce p s h as be e n d de d an d t u rne d as de t o ivi i e xp o se t he l
su c u s o n

t he H u me rus fo r t he ra di l a ne r e v .

of th e tr ic e p s, to t h e an co n a u s, to th e lat e ra l fi br e s o f th e
brach ia lis, to th e brach io rad ia lis, an d to th e e x t e n sor car p i -

rad ialis lo n gu s The bra n ch e s to th e thr e e la st n a me d

.
-

mu sc le s sp r in g fro m the tru n k o f t h e n e rv e a ft e r it has

1 1 8 TH E SU PER I OR EXTRE M I TY
also be disse c e d o u t t As a ru le , a ran s e rse an as o m o sin g
. t v t
t tw t tv
w ig p asse s be e e n h a e sse l an d th e p o s e io e rm in al p ar t r rt t
o f t h e p ro fu n da brac h ii ar e ry t
I t lie s u p o n t h e p o s e rio r asp e c
. t t
t
o f th e h u m e ru s, imm e dia e ly p ro x im al t o t h e e lbo j o in , an d w -
t
c an be e x p o se d b v t
y di idin g t h e rice p s m u scle a sh o r dis an ce t t
p ro x im al t o t h e O le cran o n At t h e sam e im e t h e fl e shy fi bre s
. t
o f t h e m e dial h e ad o f t h e rice p s , t
h ic h are in se r e d in o t h ew t t
t t
p o s e rio r p ar o f t h e cap su le o f t h e e lbo j o in , an d co n s i u e w -
t tt t
t h e su ban co naeu s mu scle , s h o u ld be ex am in e d L as ly , raise . t
t t
t h e dis al p ie ce o f t h e rice p s f ro m t h e e lbo w j o in , an d lo o k -
t
f o r a sm all bu rsa m u co sa be tw
e e n t h e de e p su rf ace o f t h e rice p s t
t t
e n do n an d t h e an e rio r p art o f t h e p o x im al asp e c o f th e r t
O le cran o n rv
Th e n e ise t h e m e dial an d la e ral in e rm u scu lar
. t t
t w
se p a h ich are n o w fu lly e xp o se d .

Th e M e dial an d L at eral I n t ermu scu lar Se p t a — The .

m e d ia l in t e r m u scu lar se p tu m is th e stro n g e r ; it se p arat e s th e

m e d ia l p art o f th e me d ia l h e ad o f th e tr ic e p s fro m th e
brach ia lis, g iv e s attach me n t to both t he m u sc le s, an d e x t e n d s,
as a stro n g me mbra n e , f ro m t h e m e d ia l e p ico n dy le to t h e in

se rt io n o f th e coraco brach ia lis -

Th e n it be co m e s le ss d ist in ct,
.

bu t it can be trac e d p ro x ima lly to th e low e r p art o f th e m e d ia l

lip o f th e in t e rtu be rcu lar su lcu s At t he le v e l o f th e in .

se rt io n o f th e coraco brach ia lis it is ie rc e d b t h e u ln ar n e rv e

p y
-

an d t he su p e r ior u ln ar co llat e ra l art e ry , wh ich d e sc e n d p o st e r ior

to it to th e m e d ia l e p ico n dy le A sh o rt d ista n c e a bo v e the.

m e d ia l e p ico n dy le it is p ie rc e d by th e p o st e r ior bra n ch o f

t h e in fe r ior u ln ar co llat e ra l art e ry .

Th e lat e ra l in t e r m u scu lar se p tu m is w e ak e r tha n t he

m e d ia l . I t e x t e n d s fro m th e lat e ra l e p ico n dy le to th e ih
se rt io n o f th e d e lt o id mu sc le , w ith wh ich it ble n d s, an d it

se p arat e s t he lat e ra l p art o f t h e m e d ia l h e ad o f th e tr ic e p s,

wh ich is attach e d to its p o st e rior sur fac e , fro m the u p p e r

lat e ra l p art o f t he brach ia lis, t h e brach io rad ia lis an d t h e -

e x t e n sor car p i rad ia lis lo n gu s wh ich sp r in g fro m it s a n t e r io r

sur fac e . At t h e j u n ct io n o f th e m idd le an d d ista l th ird s

o f t h e arm it is p ie rc e d b t h e rad ia l n e rv e an d t h e a n t e r io r
y
bra n ch o f th e p r o fu n da art e ry, wh ich a ft e rward s d e sc e n d
a lo n g its a n t e r ior a sp e ct, be tw e e n the brach ia lis me d ia lly an d
t h e brach io rad ia lis an d th e e x t e n sor car p i rad ia lis lo n gu s
-

lat e ra lly .
 S H OU L D ER -
J OI NT I I 9

ART I C U L AT I O H U M ER I ( SH OU L D ER J O I N T ) -
.

Aft e r th e structur e s situat e d in th e arm hav e be e n e x a m in e d

th e d isse ct io n o f th e sh o u ld e r j o in t sh o u ld be co mme n c e d , in -

o rd e r that t h e liga me n t s ma b e e x a m in e d be fo r e th e y hav e

y
be co m e to o dry .

Th e shou ld e r jo int be lo n g s t o th e e n arthr o d ia l o r ba ll an d

-

C a p su l e o f Jo m t
S u p rasp i n at u s

H u me rus

D l id e to Scap u l a

F ld f p l
o o ca su e
fj i o o nt

Su bscap u l i
ar s

P i
o s t e r o r c rc u i m flx
e art e
o f h u me ru s an d

(O T . . C i rcu m fl e

Te re s m a j o r

R di l ( O T
a a . . m uscu lo -
i l)
sp ra
ne r ev Se rrat u s an t e ri o r

L at issimu s do rs i
FI G .
50 .
— F ro n tal o r ve rt i cal v i h h
t ran s e rse se c t o n t ro u g t h e L e ft
S ho u l de r j o i nt-
.
( V i e we d fro m be h i n d
.
)

so ck e t su b grou p o f th e d iarthr o d ial o r c o mple t e ly m o va ble

-

j o in t s Th e so ck e t is fo r m e d by th e gle n o id cav ity o f th e

.

sca p u la an d t h e ba ll is t h e sp h e ro ida l h e ad o f t h e hu m e ru s .

I n n o j o in t in t h e bo dy are t h e m o v e m e n t s so fr e e an d so
varie d in th e ir charact e r as in t h e sh o u ld e r j o in t Th is is -
.

r e n d e r e d n e c e ssary by the ma n y fu n ct io n s wh ich are p e r fo r me d

by th e u p pe r limb F r e e do m o f m o v e m e n t is p r o v id e d fo r in
.

t wo way s 1
) y
b t h e larg e siz e o f t h e h e ad o f t he hu me ru s ,

in co mp ar iso n w ith t h e sm a ll d im e n sio n s an d sha llow charact e r

1 2 0 TH E SUPER I O R EXTRE M I TY
o f th egle n o id cavity ( 2 ) by th e gr e at la x ity o f the liga me n t
o us structur e s wh ich co n n e ct t h e hu me ru s w ith t he sca p u la .

Th e se p rov isio n s fo r a llo w in g an e x t e n siv e ra n g e o f m ov e me n t

at th is articu lat io n might at fir st sight le ad o n e to dou bt th e , ,

se cur ity o f th e jo in t I t s str e n gth c e rta in ly do e s n o t lie in

.

th e ada p tat io n o f t h e bo n y sur fac e s t o o n e a n o th e r n o r in ,

t he str e n gth o f it s liga m e n t s I t lie s ( r) in t h e p ow e r fu l .

—

m u sc le s by wh ich it is c lo se ly surr o u n d e d ; ( 2 ) in th e o v e r
ha n g in g coraco acro mia l arch wh ich for ms as it w e r e a
-

, , ,

C mi l o ra co -
acro a
lg m A m i a e nt c ro io n

Co raco -
h u me ra l
lg i am e n t

Su bsc ap u l i ar s
scle

C ap su l e o f j i
o nt

F IG .
5 1 .
— S o h u ld j i
e r- o n t as se e n fro m th e fro nt .

se co n dary sock e t fo r the h e ad o f th e hu me ru s an d e ff e ctua lly ,

p r e v e n t s an
y d isp lac e m e n t in an u p ward d ir e ct io n ; an d 3)
in at mo sp h e r ic p r e ssur e wh ich e xe rc ise s a p ow e rfu l in flu e n c e
,

in k e e p in g th e O p p o se d sur fac e s in co n tact w ith e ach oth e r .

O n all a sp e ct s e x c e p t ov e r a sma ll ar e a be low th e loo se

, , ,

liga me n tou s ca p su le wh ich e n v e lo p s t h e shou ld e r jo in t is -

su pp ort e d by m u sc le s th e t e n do ns o f wh ich are m or e o r le ss

,
(

in t im at e ly co n n e ct e d w ith it A le ne it is cov e r e d by t he .
,

su p ra sp in atu s éenz n a the in fra sp in atu s an d t e r e s m in or are

'
’
,

a p p lie d to it ; in fro nt is the su bsca p u laris B elo w th e .

,

ca p su le is to a c e rta in e x t e n t u n su p p ort e d by mu sc le s an d ,
 1 2 2 TH E SUPER I O R EXTRE M I TY
the art iculat io n o n all sid e s I t is attach e d to t he sca p u la .

arou n d the m arg in o f t he gle n o id cavity bu t is attach e d ,

d ir e ct ly to the bo n e o n ly at the u pp e r p art ; e lse wh e re it

ble n d s w ith t h e out e r sur fac e o f th e la bru m g le n o ida le wh ich ,

is attach e d to th e m arg in o f th e cav ity fo r th e p u rp o se o f

in cr e a sin g its d e p th L at e ra lly th e ca p su le is attach e d to .

C o raco h u me ra -
l li g ame n t

M b
. i ce p s brach n

i
Su p e r o r gle no
llg
h u m e ra i a me n t
I i
n fra sp n at us bu rsa

M i ddl gl e e no

hu m l li g m
e ra a e

L abru m gl e no id l a e

I n fe r o r i gle no
h u me ra l li g am e n t

N . m u sc u lo -
cu ta n e u s

N ax ill i
ar s

l i l i i
.

N u n ar s ] A et v c rc . hu me r
l l
. .
.

N c u t an e us an t i brac h i i m e di a i s radi a i s
x ll
.

A a i ari s e di an us

V ill i
.

. ax ar s

FI G .
5 2 .
— Se m i d ag ramm at
-
i i c re p re se n t at o n i o f a d i sse c tio n o f a i
S ag ttal
se c t o n t h ro u gh th e R i ght Sh o u l de r The su bsc apu l ar bursa is sh o w n
i .

c o n n e c te d w i th t h e c av i ty o f t h e j o i n t be tw e e n t h e su p e ri o r an d m i ddl e

gle n o h u m e ral ban ds o f t he art i cu l ar cap su l e

-
.

the a n ato mica l n e ck o f th e hu me ru s an d to the tra n sv e r se

liga me n t o f th e hu me ru s wh ich br idg e s acro ss th e t o p o f t he ,

in t e rtu be rcu lar su lcu s fro m th e gr e at e r to the le sse r tu be rc le .

Th e attach me n t o f th e u pp e r p art o f th e fi brou s stratu m to

t h e hu m e ru s is qu it e c lo se t o t h e art icu lar sur fac e o f t he
h e ad bu t the attach me n t o f the low e r p art is so me d ista n c e
,

( 1 2 1 6 mm -

) fro m t h e art i cu lar sur fac

. e ; co n se qu e nt ly a co n

side rable
p art o f t h e low e r p ort io n o f t h e a n ato m ica l n e ck is

in sid e th e fi brou s stratu m o f t h e ca p su le an d is cov e r e d by

 S HO U L D ER -
JO I N T I 2
3

t he y via l stratu m ( F ig 5
s no Th is ca n n ot be se e n u n t il
.

t h e ca p su le has be e n o e n e d
p .

Th e fi br o u s stratu m o f th e ca su le is n o t co m le t e at all
p p
p o in t s I t s co n t in u ity is a lway s br o k e n b two an d so m e
.

y
t ime s by t hr e e o r fo ur a p e rtur e s an d wh e r e the lat e ra l marg in,

o f t h e fi brou s stratu m is attach e d to t h e tra n sv e r se liga m e n t

o f th e hu m e ru s th re i a rtur b low h m arg i

e s an
p e e e t e n .

Prolo n gat io n s o f the sy n ovia l stratu m are p rotrud e d thr o ugh

’

C ap su l i l i
a art cu ar s

Tu be rc u l u m

L abru m gl e no id l
a e

C ap su l i l i
a art c u ar s

P i hm l
o st e r o r u e ra
xill i
C i rc u mfl v l
ex e sse s
N . a ar s

an d a x ll y v
i ar ne r e

P i
o st e r o r h u me ra l
c 1 rc u m fl e x v l
e sse s

FI G 5 3 . .
— Di agra m o f a F ro n ta l S tiec o n o f th e R i gh t Sh l d o u er

all th e a p e rtur e s wh ich are p r e se n t Th e larg e st o p e n in g is .

in t he a n t e ro me d ia l p art n e ar t h e root o f t h e c o raco id

-

p r o c e ss a n d,t h e p ro lo n gat io n o f t h e sy n o v ia l stratu m wh ich

p a s se s through it f or m s t h e su bsca p u lar bur s a wh ich se p arat e s ,

t h e su bsca p u lar is fro m t h e fro n t o f th e ca p su le an d fr o m t h e

fro n t o f th e n e ck o f th e sca p u la Th e d isse ctor shou ld n o t e
.

car e fu lly th e siz e an d t he p o sit io n o f th is O p e n in g be cau se

the h e ad o f t h e hu m e ru s is o cca sio n a lly dr iv e n through it ,

in st e ad o f through th e low e r p art o f t h e ca p su le wh e n th e ,

jo in t is d islo cat e d .
1 2 4 TH E SUPE R I OR EXTRE M I TY
The se c o d co n sta n t a p e rtur e is that be lo w the tra n sv e rse
n

liga m e n t o f t h e hu m e ru s at th e t o p o f th e in t e rtu be rcu lar

su lcu s . I t is m uch sm a lle r tha n t h e a p e rtur e in fro n t an d ,

through it th e t e n d o n o f th e lo n g h e ad o f the bic e p s wh ich ,

sp r i n g s fro m t h e a p e x o f t he g le n o id cav ity e m e rg e s fro m t h e,

j o in t Th e t e n do n is e n clo se d in a tu bu lar p r o lo n gat io n o f

.

t h e sy n o v ia l stratu m wh ich surrou n d s it an d lin e s t he in t e r

tu be rcu lar su lcu s ( F ig . I t is n o t o ft e n that a th ird
o p e n in g is fou n d in the fi brou s stratu m I t is situat e d wh e n .
,

p r e se n t in
,
t h e p o st e ro l at
-
e ra l p art o f t h e ca p su le a n d
p e r m i t s t h e p rotru s io n o f t h e s y n ov ia l stratu m to for m a bur sa
u n d e r cov e r o f th e in fra sp in atu s m u sc le ( Fig St ill .

mo r e rar e ly th e su bacro m ial bur sa co mmu n icat e s w ith th e

cavity o f th e j o in t through an O p e n in g wh ich is situat e d
be tw e e n th e su p ra sp in atu s an d su bsca p u lar is m u sc le s .

I n four situat io n s the fi brou s stratu m o f t h e ca p su le is

th ick e n e d by lo n g itud in al ba n d s o f fi br e s wh ich p a ss fro m
t h e sca p u la t o t h e hu m e ru s . O n e o f t h e th ick e n in g s t h e ,

co raco nu meral lzg

-
amen t c an be se e n fro m t h e e x t e r io r ; th e
,

oth e r thre e th e gleno lzu meral ligamen ts are th ick e ning s o f

,
-
,

t h e in n e r sur fac e o f th e fi brou s stratu m o f th e ca p su le an d

c an be se e n o n ly fro m t h e in t e r ior o f t h e jo in t .

Liga me n t um Co raco humerale — Th e coraco hu m e ra l liga

.
-

m e n t is p lac e d u p o n th e su p e r ior a sp e ct o f th e jo in t I t is .

a broad ba n d Of gr e at str e n gth wh ich is m or e o r le ss c o m

,

p le t e ly in cor p orat e d w ith t h e ca p su le Pro x

. im a lly it is fi xe d ,

to th e root an d lat e ra l bord e r o f t h e coraco id p roc e ss o f th e

sca p u la an d it p a sse s th e n c e o bliqu ely d ista lly an d lat e ra lly
, , ,

to ga in attach me n t to the two tu be rc le s o f the hu me ru s an d ,

t o th e tra n sv e r se hu m e ra l liga m e n t wh ich for m s a stro n g arch

,

ov e r th e u p p e r p art o f the in t e rtu be rcu lar su lcu s .

Ligame nt a G1en o humera1ia — Th e r e are thr e e gle n o

.

hu me ra l liga me n t s To se e th e m the p o st e r ior p art o f th e

.

ca p su le mu st be d iv id e d by a v e rt ica l in c isio n an d th e h e ad
o f t h e hu m e ru s m u st be tu r n e d a sid e o r r e m ov e d Th e .

sup erio r glen a nu mera l lig -

a ment s r in g s fro m t h e m arg in O f
p
t h e g le n o id cav ity im m e d iat e ly a n t e r ior to t h e t e n do n o f t he
lo n g h e ad o f t h e bic e p s brach ii an d it p a sse s to a sm a ll
,

it situat e d o n th e p ro x im a l e x tr e mity o f t h e hu m e ru s c lo se
p
to th e t o p o f th e int e rtu be rcu lar su lcu s The middle gleno .

lcu meral ligamen t is attach e d to t h e sca p u la im me d iat e ly

abov e t he n otch o n t he a n t e rior marg in o f the gle n o id cav ity ,
1 2 6 THE SUPER I OR EXTR E M I TY
an d attach e d t o it s rim I t d e e p e n s an d at the sa m e
is .
,

t im e se rv e s to e x t e n d the articu lar sock e t o f the sca p u la

, .

Th e in t im at e co n n e ct io n wh ich it p r e se n t s w ith th e ca p su le
o f t h e jo in t c an n o w be stud ie d Two t e n do n s are a lso .

c lo se ly a sso c iat e d w ith it viz th e lo n g h e ad o f the tr ic e p s

, .

brach ii be low an d th e lo n g h e ad o f th e bic e p s brach ii a bov e

, .

L o ng H e a d o f t h e Bic e p s — Th e t e n do n o f t h e lo n g
h e ad o f th e bic e p s is an imp orta n t factor in th e m e cha n ism
o f th e shou ld e r j o in t I t e n t e r s th e ca p su le through t h e
.

o p e n in g be tw e e n t he two tu be rc le s o f th e hu me ru s an d ,

is p r o lo n g e d ov e r the h e ad o f th e bo n e to th e a p e x o f th e
gle n o id cav ity I ts attach me n t to the sca p u la shou ld n o w be
.

e x a m in e d The t e n do n d iv id es in to thr e e p ort io n s v iz a

.
,
.

larg e in t e r me d iat e p art wh ich o bta in s d ir e ct attach me n t to

,

t h e sca p u la an d two sma lle r co llat e ra l p art s wh ich d iv e rg e

, ,

fro m e ach oth e r an d ble n d w ith t h e la bru m g le n o ida le Th e .

lo n g h e ad o f t h e bic e p s brach n by it s p o sit io n w ith in th e ,

ca p su le an d in the d e e p su lcu s be tw e e n the tu be rc le s o f the

hu me ru s se rv e s to k e e p th e h e ad o f the bo n e in p lac e an d
, ,

to st e ady it in the var iou s m ov e m e n t s at the shou ld e r jo in t -

.

Th e sy n o vial stratu m lin e s the fi brou s stratu m o f t h e

ca p su le o f th e jo in t an d is r e fl e ct e d fro m it u p o n th e a n ato mica l
,

n e ck o f t h e hu m e ru s as far as th e art icu lar m arg in o f th e

h e ad o f the bo n e Th e bur sal p rotru sio n o f th e bursa suo

.

scap u laris u n d e r t h e t e n do n o f th e su bsca u lar is mu sc le has

, p ,

a lr e ady be e n n ot ic e d Th e t e n do n o f th e bic e p s as it
.
,

trav e r se s th e jo in t is e n v e lo p e d in a tu bu lar sh e ath o f th e

,

m e mbra n e ; th is sh e ath bu lg e s out through th e O p e n in g o f the

ca p su le in the for m o f a bur sa wh ich lin e s the in te rtu be r
c u lar su lcu s F i
( g 5 .

Art ic ula r Surf ac e s — The sm ooth g list e n in g art icu lar ,

cart ilag e wh ich c o at s th e h e ad o f th e hu m e ru s is th ick e st

in th e c e n tr e an d th in s as it p a sse s t o ward s th e e dg e s
,
In .

t he ca se o f th e gle n o id cav ity t h e r e v e r se o f th is w ill be

n ot ic e d .

M o v eme nt s at t he Sh o ulder jo int — The shou ld e r is a -

.

ba ll an d so ck e t jo in t ( e n arthro sis) an d co n se qu e n t ly m ov e
- -

me n t in e v e ry d ir e ct io n is p e r mitt e d v iz fl ex io n o r , .
,

fo rward m ov e m e n t ; ( 2 ) ex tensio n o r backward m ov e m e n t ,

( ch e ck e d in its e x t e n t by t h e coraco hu m e ra l liga me n t ) ; ( 3 ) -

aoau ctio n
’
or lat e ra l m o v e m e n t ( ch e ck e d by th e coraco
,

acro mia l arch ) ; ( 4 ) aacluctio n o r me d ia l mo v e m e n t ( limit e d

’
,
 P L AT E Vl

G re ate r t u be rc e l Acro mi o
o f hu me ru s Acro mi o n c l l
av i c u ar j o m t Co raco i d

Su p rasc ap u l ar
no t ch

Sp i ne o f scap u a l

i
G le n o d fo ssa

FIG .
5 6 a .
— R di g
a o rap h o f S h o u l de r R e gi o n w i th Ar mf lly abd
u u c te d .

Co no id l
t u be rc e Acro m oi
lv l lv l
.

o f c a ic e Lo racm d c a i c u a r io m t Ac ro m i o n

H e ad o f h u me ru s

S u p rascap u l ar
no t c h

Sp i ne o f sc ap u a l L o w e r mar n gi o f
gle n 0 1 d fo ssa

t e ral m ar gi n o f
p i ne o f scap u a l

FIG .
5 66 .
-
i h
R ad o grap o f S o u de r e h l R g i w i th A m p tly bd
o n r ar a u c te d .

N o te ) 1 h l i
T at t he g e n o d f o ssa is a lw y di t d li ght ly pw
a s re c e s u ards .

(2 ) l iv ii
Th e re at e p o s t o n s o f th e he ad o f t he hu me ru s an d the
1 2 8 TH E SUPER I O R EXTRE M I TY
s u p plie d by t/ze distal branclc of tbe do rsal cu tan eo u s n erve of
tbe fo rearm wh ich is a bra n ch o f th e rad ia l n e rv e
, .

F o u r n erves su p p ly t h e sk in o f th e p a lm o f t h e ha n d : in
th e r e g io n o f t h e hy p oth e nar e m in e n c e t/z e p almar cu tan eo us
bran cb of ibe u ln ar n erve in th e r e g io n o f t h e th e n ar e m in
,

e n c e t/z e lateral cu tan eo u s n erve o f m a tw g r o m

f t be o rear a n d i f ,

t he sup erficial divisio n of tbc radial n erve wh ilst th e in t e r ,

m e d iat e p art is su pp lie d by tbc palmar cu ta n eo u s branclc of tbe

median n erv e .

Tw o nerves u pp ly bra n ch e s t o the sk in o f t h e dor su m o f

s

t he ha n d : o n t h e lat e ra l p art t/ze sup erficial bra n c/z of tbc

radial n erve an d o n t h e m e d ia l art
, p t/ze do rsa l bran cic of tbe

u ln ar n erve .

Two n erves s u p ply k in

v o lar a sp e ct s o f the
t he s o f th e
d ig it s : tllo median an d t/ze u lnar Thr e e an d a ha lf d ig it s fa ll .

to th e d ig ita l bra n ch e s o f t h e m e d ia n n e rv e : t h e thu mb t h e ,

in d e x th e midd le an d t h e lat e ra l ha lf o f th e r in g fi n g e r an d
, ,

o n e an d a ha lf to th e d ig ita l bra n ch e s o f t h e u ln ar n e rv e t h e ,

litt le fi n g e r an d th e m e d ia l ha lf o f t h e r in g fi n g e r .

Taree n erves su p p ly th e sk in o f th e dor sa l a sp e ct s o f t h e

d ig it s Sp e ak in g g e n e rally the p ro xima l ha lv e s o f th e thu mb
.
, ,

t h e in d e x m idd le an d ha lf th e r in g fi n g e r are su pp lie d by

, ,

bra n ch e s o f tbc superficial divisio n of tbc radial nerve Th e .

d ista l ha lv e s o f th e in d e x midd le an d half the r in g fi n g e r

, ,

are su pp lie d by tw ig s o f tbe digi tal bran c/zes o m

f tb e edia n n erv e ,

an d t h e r e ma in in g ha lf o f t h e r in g fi n g e r an d th e litt le fi n g e r

r e c e iv e tw ig s fr o m tbc u ln ar n erve .

Aft e r t h e cuta n e ou s v e in s an d n e rv e s hav e be e n re

e x a min e d t h e d e e p fa sc ia o f th e fo r e ar m shou ld be thor o ugh ly

c le a n e d if that h as n o t a lr e ady be e n do n e an d it s sp e c ia l
, ,

p o in t s shou ld b e re stud ie d -
.

Fa sc i a Ant b achii ( F ascia o f t h e F o re a ) Th e d e e p

i r rm — .

fa sc ia wh ich e n v e lo p s t h e for e ar m is o f co n sid e ra ble str e n gth

an d d e nsity M or e p art icu lar ly is that th e ca se o n th e d o r sa l
.

a sp e ct o f th e limb I n its p ro x ima l p art it r e c e iv e s an

.

acc e ssio n o f fi br e s fro m t he t e n do n o f th e bic e p s brach ii in ,

t h e for m o f th e lac e rtu s fibro su s So me fi br e s are g iv e n to

.

it by the t e n do n o f th e tr ic e p s a lso N e ar th e e lbow it .

se rv e s as a sur fac e o f o r ig in fo r t h e n u m e rou s m u sc le s wh ich

Sp r in g fr o m t he e p ico n dy le s o f t h e hu m e ru s an d fro m it s ,

d e e p a sp e ct d e n se se p ta p a ss be tw e e n t he fl e shy be llie s The .

se p ta l p art it io n s are in d icat e d o n the sur fac e by a se r ie s o f

 F ORE A R M AN D H AN D 1 2 9

wh it e lin e s At the wr ist it be c o me s c o n t in u o u s a n t e r ior ly

.

, ,

w ith the vo lar carp al ligamen t an d th e tra nsverse carpal liga

men t ( O T an t a n n u lar . wh ilst p o st e rio rly it fo r ms an
. .

o bliqu e ly p lac e d th ick e n e d ba n d the do rsal carp al ligament

, ,

(p o st a n n u
. lar

V O L AR SU R FAC E AN D M EDI A L B O R D E R OF TH E F O R EA R M .

In th is d isse ct io n t he fo llo w in g tructur e s w ill

s be dis
p ay e d
l
I . The radial an d u ln ar arte rie s an d th e ir bran ch e s .

2 . The m e dian an d u n ar n e rv e s an d th e ir bran ch e s l .

3 . The de e p bran ch an d the su p e rficial bran ch o f the radial n e r e v .

4 . The g ro u p o f p ro n ato r an d fl e x o r m u scle s .

D is s e c ti o n — The de e p fascia m u s
w be re m o e d fro m t h e t no v
f o re arm M ak e tw o in c isio n s h ro u gh it, ( I ) a ran s e rse
. t t v
in cisio n at t he p ro x im al bo rde r o f t h e t ran s e rse c arp al lig a v
t t
m e n ; ( 2 ) a lo n g i u din al in cisio n f ro m t h e ap ex o f t h e cu bi al t
f o ssa t o t h e t ran s e rse in c isio n v
As t h e t ran s e rse in cisio n is . v
r
m ade be c a e fu l n o t t o in j u re t h e p alm ar cu an e o u s bran c h es t
o f t h e m e dian an d u ln ar n e r e s, t h e e n do n o f t h e p alm aris v t
lo n g u s, t h e u ln ar n e r e an d art e ry, an d t h e m u co u s sh e a h s v t
o f t he fl ex o rs Th e tw o p alm ar cu an e o u s n e r e s an d t h e
. t v
t e n do n o f t h e p alm aris lo n gu s an d t h e u ln ar n e r e an d a r e ry v t
p ie rce t h e de e p f asc ia p ro x im al t o t h e ran s e rse lig am e n an d t v t
p ass acro ss its su p e rfi cial su rf ace , bu t t h e u ln ar n e r e an d a r e ry v t
are bo u n d do w n t o t h e lig am e n by a m o re su p e rfi cial ban d t
c alle d t h e co lo r carp al ligamen t, h ic h p asse s fro m th e p isifo rm w
bo n e t o t h e f ro n o f th e ran s e rse carp al lig am e n t Th e o lar t v t . v
c arp al lig am e n t
is ap t t o be m is ak e n f o r t h e t ran s e rse lig a t v
t t
m e n , bu t t h e m is ak e s h o u ld n o t be m ade , be c au se t h e o lar v
c arp al lig am e n t
lie s su p e rfi cial t o t h e u ln ar art e ry an d n e r e , v
w t t
h ils t h e ran s e rse lig am e n is de e p to h o se s ru c u re s v t t t t .

t v
R e ain t h e o lar c arp al lig am e n in t h e m e an im e Th e m u co u s t t .

sh e a h s o f t h e t e n do n s lie im m e dia e ly su bj a ce n t t o t h e de e p t t
f ascia Tu rn t h e tw o fl ap s m ark e d o u t by th e in cisio n s t o h e ir
. t
tv
re sp e c i e s ide s, di idin g t h e se p a v
h ic h p ass fro m h e ir de e p t w t
su rf ace s be een t h e adj a ce n tw
m u scles B o h fl ap s c an be t . t
f o llo w e d t o t h e do rsal bo rde r o f t h e u ln a , t o t h e h o le le n gt h o f w
w h ic h the de e p fascia is a ac h e d, bu t fo r t h e p re se n do n o t tt t
t
re fl e ct t h e la e ral fl ap be y o n d t h e radial bo rde r o f t h e fo re arm .

N e ar t h e e lbo w t h e m u scle s h ic h sp rin g f ro m t h e m e dial an d w

t
la e ral e p ico n dy le s g ain addi io n al o rig in f ro m t h e de e p su rf ace t
o f t h e f asc ia W h e re t h a is t h e case t h e f ascia m u s be le f
. t t t
i n si tu , f o r a e m p t s t o re m o e it tt
ill o n ly re su l in lace ra io n o f v w t t
t h e m u scle s .

M uscles A sp e c t o f t h e F o re a rm — Th e
o f t he Vo la r
m u sc le s o f t h e v o lar a sp e ct o f th e for e ar m are arra n g e d in a
su p e rfic ia l an d a d e e grou p Th e y c o m p r ise t h e fl e x o rs o f
p .

t h e wr ist an d d ig it s, an d a lso t h e p ro n at o r s o f t h e fo r e ar m .

V OL . 1— 9
1 3 0 TH E SU PER I OR EXTRE M I TY
I n t he p erficial gro up are t h e brach io rad ia lis p r o n at o r t e r e s
su -

, ,

t h e fl e x o r car p i rad ia lis t h e p a lmar is lo n gu s an d t h e fl e x o r

, ,

carp i u ln aris in that o rd e r fr o m t he lat e ra l t o th e m e d ia l

,

sid e . O n a d e e p e r p la n e lie s t h e fl e shy be lly o f t h e fl e x o r

d ig itoru m su blimis wh ich o n ly p art ia lly c o me s t o th e sur fac e .

Th e deep gro up is c o mp o se d o f thr e e m u sc le s p lac e d in c o n ,

tact w ith t he bo n e s an d in t e r o sse ou s m e mbra n e o f th e fo r e

arm v iz ,
t h e fl e x o r d ig it o ru m p r o f u n du s in r e lat io n t o t h e
.
, ,

u ln a th e fl e x o r p o llic is lo n gu s in r e lat io n to th e rad iu s an d

, , ,

t h e p ro n at o r quadratu s c lo se ly a p p lie d to t h e d ista l e n d s o f

,

bo th bo n e s Th e brach io rad ia lis lie s a lo n g the lat e ra l bo rd e r

.
-

o f t h e v o lar a sp e ct .

Th e brach io rad ia lis e x t e n d s fr o m t h e lat e ra l su p ra c o n

- -

dylar r idg e o f t h e hu me ru s t o t he d ista l e n d o f t h e rad iu s .

Th e p r o n ator t e r e s e n d s at t h e midd le O f t he rad iu s Th e .

fl e x o r car p i rad ia lis p a sse s t o t h e ba ll o f th e thu mb wh e r e ,

its t e n d o n d isa p p e ar s in t o a c le ft in t h e lat e r al bo rd e r o f

th e tra n sv e r se car p a l liga m e n t Th e t e n d o n o f t h e p al .

m ar is lo n gu s lie s m e d ia l to th e t e n do n o f th e fl e x o r car p i
rad ialis it p a sse s a n t e r io r t o t he tra n sve r se carp a l liga me n t
to jo in th e in t e r me d iat e p art o f t h e p a lmar a p o n e uro sis .

St ill m or e m e d ia l d e sc e n d in g t o t h e p isifo r m bo n e is th e
, ,

t e n d o n o f the fl e xo r carp i u ln ar is Th e t e n d o n s o f t he fl e x o r .

d ig itoru m su blimis e n c lo se d in th e ir muc o u s sh e ath lie d e e p

, ,

t o t he p a lmar is lo n gu s be tw e e n t h e fl e x o r car p i rad ia lis an d

t h e fl e x o r carp i u ln ar is .

D is s e c tio n — Cl an t h e brac hio r adialis f r m its o rig i f ro m

e -
, o n
t h e h m e ru t o its i
u rt io n in t o t h e bas
s f th
n se tylo id p ro s e o e s ce s
f t h e radi s
o To p se t h i
u . rt i it w ill b n e ary t
ex o e n se o n e e c ss o

p h ba k w ards t h t d
us c f t h abd t r p lli i l g
e en an d
o ns o e uc o o c s o n us

th e t e n o r p o llicis br vis w h ich o ve rlap it p o t ri rly P ll

ex s e s e o . u

th e bra h i radiali a id an d l an t h
c o -
s radial art ry an d it s
s e c e e e
bran c h a d th p rfi ial bran ch f t he radial n e rve
es n e su e c o .

Art eria R a dialis — Th e rad ia l art e ry is th e sm a lle r o f th e

two t e r min a l bra n ch e s o f th e brach ial art e ry bu t its d ir e ct io n ,

g iv e s it th e a p p e ara n c e o f be in g the co n t in uat io n o f th e

p ar e n t tru n k in t h e for e ar m I t tak e s o r ig in in th e cu bita l
.

fo ssa O p p o sit e th e n e ck o f t h e rad iu s an d it p roc e e d s d ista lly

, , ,

in t h e lat e ra l p art o f th e fr o n t o f t h e limb u n t il it r e ach e s ,

t h e d ista l e n d o f the rad iu s Th e r e it turn s r o u n d the .

lat e ra l bord e r o f t he wr ist an d le av e s t h e p r e se n t d isse ct io n .

At fir st it lie s be tw e e n t h e p r o n ator t e r e s an d the brach io

rad ia lis an d is o v e rla p p e d to so m e e x t e n t o n th e lat e ra l sid e
,
 1 32 TH E SUPER I O R EXTRE M I TY
bra n ch e s o f t h e rad ia l n e rv e , an d g iv e s O ff se v e ra l tw ig s fo r
th e su pp ly o f th e m u sc le s ar isin g fr o m the lat e ra l e p ico n dy le
o f th e hu m e ru s So me what r e duc e d in siz e , it n o w tur n s
.

p r o x ima lly , in th e in t e rva l be tw e e n th e brach io rad ia lis an d -

brach ia lis, an d e n d s, in fro n t o f th e lat e ra l e p ic o n dy le o f th e

hu me ru s, by a n a sto m o sin g w ith the a n t e r ior t e r min a l bra n ch
o f t h e p ro fu n da brach ii art e ry I t m ay be r e p r e se n t e d by
.

t wo o r m or e v e sse ls .

The sup erficia l vo lar artery is a s ma ll, var ia ble bra n ch ,

wh ich ar ise s a short d ista n c e p r o x ima l to th e wr ist, an d ru n s
d ista lly to e n d in the mu sc le s o f the ba ll o f th e thu mb So me .

t ime s, how e v e r, it atta in s a larg e r siz e an d a sp e c ia l imp orta n c e ,

be cau se it is co n t in u e d in t o t h e p a lm to co mp le t e t he su p e r
fic ial vo lar arch , o n th e lat e ra l sid e .

Th e vo lar radial carpal a rtery is a m in ut e tw ig wh ich sp r in g s

fro m t he rad ia l at the d ista l bord e r o f th e p r o n ator quadratu s
mu sc le I t ru n s m e d ia lly , u n d e r c o v e r o f th e fl e x o r t e n do n s,
.

an d j o in s w ith th e corr e sp o n d in g bra n ch o f th e u ln ar art e ry

to for m th e vo lar carp al arc/z .

Th e R amu s Su p e rficialis an d t h e R a mu s Pr o f un du s o f
t h e N e rv u s R a dia lis ( O T R a dial an d P o st e r io r I nt ero s
. .

seo u s N e rv e s) — I t h as a lr e ady be e n n ot e d th at th e rad ia l

.

n e rv e e n d s p ro x ima l to t h e e lbo w , u n d e r cov e r o f t h e brach io

rad ia lis m u sc le , by d iv id in g in to two t e r min a l bra n ch e s,

t h e su p e rfic ia l bra n ch an d t he d e e p bra n ch B oth bra n ch e s .

may n o w be stud ie d in so far as th e y lie in th e v o lar

p art o f t h e for e ar m T h e rd m u s p rofu ndu s
. soo n d is

a pp e ar s fr o m v ie w by p a ssin g backward s, o n t he lat e ra l

sid e o f t h e rad iu s, thr o ugh th e fi br e s o f t h e su p in ator
mu sc le .

Th e p erficial brancb p r o c e e d s d ista lly u n d e r cov e r

su ,

o f t h e fl e shy be lly o f t h e brach io rad ia lis I n th e m idd le -

.

th ird o f th e for e ar m it lie s a lo n g th e lat e ra l sid e o f th e rad ia l

art e ry th e n it le av e s t h e art e ry an d w in d s r o u n d th e lat e ra l
marg in o f t h e lim b u n d e r cov e r o f th e t e n do n o f t he
,

brach io rad ia lis -

I t h as be e n trac e d in th e r e st o f it s
.

cour se ( p The su p e rfic ia l bra n ch is a p ur e ly cuta n e o u s

.

n e rv e ; an d it g iv e s o ff n o bra n ch e s u n t il it ga in s the dor sa l

a sp e ct o f the d ista l p art o f the for e ar m .

D is s e c ti o n B e fo re t he cle an in g o f t h e su p e rfic ial fl e x o r

.

tt t
m u scle s is co m m e n ce d an a e m p s h o u ld be m ade t o de m o n s ra e t t
u t
th e m co u s sh e a h s o f th e fl e x o r e n do ns t
Th e y are th e co mm o n .
 F ORE AR M AN D H AN D
s h e at h
f th e fl ex o r dig i o ru m su blim is an d th e fl ex o r dig it o ru m
o t
p ro fu n du s, t h e s h e a h o f t h e fl e x o r p o llic is lo n g s an d t h et u
t
s h e a h o f t h e fl ex o r c arp i radialis .

t
I f t h e s h e a h s are u n in j u re d h e y c an be dis e n de d i h air t t wt
by m e an s o f a blo wp ip e , o r by fl u id f o ce d in h ro u gh a sy rin g e r t .

v
I f tl e y h a e be e n in j re d t h e y can st ill be e xp lo re d i h a blu n u wt t
p ro ge .

t
Ex amin e , fi rs , t h e co m m o n sh e a h o f t h e fl e x o r e n do n s o f t t
th e fi n g e rs P ick u p a f o ld o f t h e m e dial p art o f its an e rio r
. t
t
wall wi h in th e fo rce p s, an d in ro du ce t h e blo wp ip e o r th e t
n e e dle o f t h e sy rin ge in t o t h e base o f t h e f o ld N o ice h a as . t t t
R di l a a arte r y
C e p ha li c M ed a il c u t an e o u s n e rv e
L ate ra l c u ta ne o u s n e rv é o f h f
t e o re arm
M di e an n e r e v
B rach i o
P al m ari s l g
o n us

! Ul n ar art e r y
x i
!

E
U l na
t e n so r c arp
rad a i li l g
s o n us
r ner e v
Med a il c u ta n e

F le x o r carp i
l
a

u nari s

B as ili v i
c e n

D o rsa li n t e ro sse o u s n e r

E x t e n so r d ig i t o ru m c o mm u n i s
i
Su p n at o r mu sc e l An co n a u s
i
Su p n at o r mu sc l e Te n do n o f b i ce p s brac h ii
D o rsa l v f th f
c u t an e o u s n e r e o m e o re a r

F IG .
57 .
— Tran sv e rse se ct i o n t hro u gh t h e P ro xi m al Th i rd o f th e

l e ft Fo re arm .

t r
t h e air o r fl u id e n e s it th e sh e a h is dis e n de d, at fi rst p o x im ally , t t -

r
t
t o abo u 2 5 m m abo e t h e t ran s e rse carp al lig am e n , t h e n t h e
. v v t
t t
dis e n sio n p asse s dis ally , be h in d t he ran s e rse carp al lig am e n , t v t
t o th e m iddle o f t h e p alm an d alo n g t h e li le fi n ge r, as far as tt
the t e rm in al p h alan x , sh o in g h a t h e co m m o n fl ex o r s h e a h w t t t
is co n in u o s t u wt
i h t h e fl e x o r s h e a h o f the li le fi n g e r I t m ay t tt .

als o e xt e n d alo n g t h e h u mb, fo r, in a ce rt ain n u m be r o f cases, t

t wt
t h e sh e a h o f t h e fl e x o r p o llicis lo n gu s co mm u n ica es i h th e t
co m m n fl exo r h e at h o s .

Th e sh e at h o f t h fl e o r carp i radialis is n o t e a ily di t e n de d

e x s s
be cau se it i e n clo se d f o r t h e g re at r p art o f its e t n t in an
s e x e
o st e o fi bro u c an al
- It t n ds f r m a s h o rt di t an ce p ro im al
s . ex e o s x

to t h t ran sv r e arp al lig am e n t t o t he base o f th e m tacarp al

e e s c e

bo n e o f th e in de fi n ge r Op e n it at t h e p r o im al bo rde r o f t h e
x . x

1— 9a
 1 34 T H E SU P ER I OR EXTRE M I TY
t v t
ligam e n an d in e s ig a e its co u rse an d dire c io n t i h t h e aid o f t wt
a blu n t p ro be .

t
I f t h e sh e a h o f t h e fl e x o r p o llicis lo n g u s h as n o t alre ady
t
be e n dis e n de d by t h e air o r fl u id h ro n in o t h e co m m o n t w t
t
fl ex o r s h e a h , p u ll t h e te n do n o f t h e fl ex o r carp i radialis m e dially ,
t
fi n d t h e e n do n o f t h e fl ex o r p o llicis lo n gu s h ic h lie s be h in d w
t t
it, an d e i h e r dis e n d its s h e a h in t he m an n e r in dica e d o r t t
ex am in e it i h a p ro be wt I t ex t e n ds f ro m o n e in c h abo e th e
. v
t v
ran s e rse carp al lig am e n t
t o t h e base o f th e e rm in al p h alanx t
o f t he hu mb t .

No w tu rn t o t h e m iddle fi n g e r an d mak e a sm all lo n g i u din al t

t
in cisio n h ro u g h t h e fl ex o r s h e at h o pp o si e th e m iddle o f t h e t
se c o n d p h alanx t r
A blu n p o be in ro du ce d h ro u gh t h e in cisio n
. t t
c an be p asse d dis ally t o t h e base o f t h e t e rm in al p h alan x an d t
v
p ro x im ally t o t h e le e l o f t h e h e ad o f th e m e acarp al bo n e Th e t .

t
c o n di io n s are t h e sam e in t h e c ases o f t h e in de x an d rin g fi n g e rs ,
t t t
h e re fo re th e dig i al sh e a h s o f t he in dex , middle , an d rin g fi n g e rs
do n o t co m m u n ica e t wt
i h t h e c o mm o n fl e x o r s h e a h I f the t .

t t t
dig i al s h e a h o f t h e li t le fi n g e r is o p e n e d in a sim ilar m an n e r
n o diffi cu lty w
illbe exp e rie n ce d in p assin g a p ro be alo n g it in o the t
t
co mm o n fl ex o r s h e a h , an d if t h e dig i al s h e a h o f t h e h u m b is t t t
t
o p e n e d an d a li t le c are ex e c ise d a p ro be can be p asse d alo n g it , r
v
an d be h in d t h e t ran s e rse carp al lig am e n , t o t h e p o x im al li m i t r t
u t
o f t h e m co u s s h e a h o f t h e fl ex o r p o llicis lo n g s e n do n u t .

M u c o us Sh e a t hs o f t h e F lex o r Te n t e n do n s do n s — . As t he
o f t he fl e x o r d ig itoru m su blimis th e fl e x o r d ig itoru m ,

p r o fu n du s a n d t
,
h e fl e x o r p o llic is lo n gu s p a ss be h in d t h e

tra n sv e r se carp a l liga me n t th e y are acco mp a nie d by the

me d ia n n e rv e an d th e y are e n v e lo p e d in two mucou s
sh e ath s n e Sh e ath surrou n d s t h e fl e x o r p o llic is
( g
F i O .

lo n gu sf th e o th e r surrou n d s t he t e n do n s o f both t h e fl e x o r
su blimis an d th e fl e x o r p r o fu ndu s an d it m ay e n c lo se ,

a lso th e me d ia n n e rv e The sh e ath s th e r e for e lin e a

’

.
, ,
“
carp al tu n n el wh ich is bou n d e d su p e rfic ia lly by th e
!

tra n sv e r se car p al liga me n t an d dor sa lly by th e car p a l bo n e s ,

an d th e y gr e at ly fac ilitat e t h e fr e e p lay o f t h e t e n do n s be tw e e n

t h e tra n sv e r se car p a l liga me n t an d t h e car p u s As a lr e ady .

stat e d th e sh e ath s are two in n u mbe r

,
B oth sh e ath s are p ro .

lo n g e d p ro x im a lly in to th e for e ar m fo r 2 5 mm ( o n e in ch ) o r
, ,
.

m or e an d both are carrie d d ista lly in to th e p a lm in th e for m

,

o f d iv e rt icu la u p o n t h e d iv e rg in g t e n do n s The d iv e rt icu la in .

r e lat io n to the t e n do n s wh ich go to the in d e x m idd le an d rin g , ,

fi n ge rs e n d n e ar th e m idd le o f the p a lm Tho se u p o n t h e .

t e n do n s o f the thu mb an d little fi n ge r how e ve r are p ro lo n ge d , ,

d istally in to the d ig it s an d lin e th e fi brou s sh e ath s wh ich ,

co n fi n e the t e n do n s u p o n the vo lar a sp e ct s o f the p ha la n g e s

( g 5 7)
F i .
1 3 6 THE SUP ER I O R EXTRE M I TY
a p e rtur e n e ar th e p ro ximal bord e r o f th e tra n sve r se carp al
li ga me n t W i th , t he m ucou s sh e ath Of the t e n do n o f the fl e xo r
p o llic is lo n gu s .

B rach i o -
rad a i li s

M abdu c t o r po lli i
c s
l g
.

o n us
A radialis
r
.

M . e x t e n so r p o ll b v
ic is re is

M . e x t e n so r p o lli i l g
c s o n us

She a th lli i l g o f fl ex o r po c s o n u sr
'

L ig am e n t u m carp id o rsa e l
Sh h f fl pi
eat di li o e x o r c ar ra a s
f x
M uc o u s sh e ath o e te n s o r
Sh h f bd
e at
p ll l g u ct o r i li l g i rad a o n us
'

o a o ic i s o n us c arp s

Sh h f x
e at
p lli i b
o e t e n so r o c s r A i l p l fw i
rt cu ar ca su e o r st

A di li ra a s

p lli i b v i h f x pi
.

M bd a u c to r o c s re Sh e at o e t e n so r c ar
di li b v i
.

ra a s re s

Sh h x p lli i I
e at e t e n so r o c s o n gus

Sh h f x di g i
e at o e t e n so r t o ru m
comm i un s

M . i n t e ro s se u s do rs a li s

p ri m u s

M .
‘
addu ct o r po lli ic s

FI G .
59 .
— Di sse c t o n oi f t he L ate ra S de l i o f t h e L e ft W ri st an d H an d
ho wi n g
s M u co u s S e at s h h o f Te n do n s .

The Co n st it ut io n o f M u c o u s Sh e at h s o f Te n do n s.
— Th e
stud e n t shou ld u n d e rsta n d th e n ature o f mucou s sh e ath s
wh ich surrou n d t e n do n s wh e re th e y p a ss through fa sc ial or ,

o st e o fa sc ia l ca n a ls Th e majority o f the mucou s sh e ath s

-
.
 F ORE AR M AN D H AN D 1 37

are dou ble wa lle d tu be s At th e ir e x tr e mit ie s th e out e r an d

-
.

in n e r wa lls are bou n d tog e th e r an d t h e sp ac e be tw e e n t h e ,

t wo wa lls t h e so ca lle d cav ity o f t h e sh e ath is thu s c lo se d

,
-

, .

Th e cav ity o f t h e sh e ath is a p o t e n t ia l cav ity o n ly an d ,

it co n ta in s m e r e ly su ffic ie n t m uc o u s flu id to lu br icat e t h e
ad j ac e n t sur fac e s an d fac ilitat e th e ir fr e e p lay ov e r o n e
,

a n oth e r .

Th e in n e r wa ll o f th e tu be surrou n d s t h e t e n do n an d
adh e r e s to its sur fac e The out e r wa ll lin e s th e ca n a l
:

thr o ugh wh ich t he t e n do n p a sse s an d adh e r e s to it B ut .

th e e n d s o f t h e sh e ath s p r o j e ct be yo n d t h e limit s o f th e
ca n a ls wh ich th e y lin e ; th e r e for e as the t e n d o n s m ove ,

T v p l li g m T d ffl
ran s e rse c ar a di g i m bli m i a e nt en o ns o exo r t o ru su s

M di e an n e rv
T d
en f fl
o n o p lli exo r o

Te n do n o f fle x o r
c a rp i r

Te n do ns o f fl exo r dig i t o ru m p ro fu n du s

FI G . 6o .
— Di g a ram ill i g th
u strat n e re at o n o l i f th e Syn o v i al Sh e ath s to th e
Fl x e o r Te n do ns a t th l v l
e e e o f t he tran s ve rse c arp al li g am e n t .

p ro x im a lly d ista lly the o pp o sit e e n d s o f the sh e ath s

an d ,

c an be i n vag i n at e d an d e vag in at e d thu s a llow in g fo r th e ,

f r e e p lay o f t he t e n do n s .

Wh e n a sh e ath be co m e s in fla m e d th e adj ac e n t surfac e s

o f it s two wa lls are at fir st rough e n e d an d wh e n t h e t e n do n ,

m o v e s fr ict io n wh ich c an be h e ard an d fe lt occur s an d

, , ,

p a i n is cau s e d Th e n t h e flu.id b e tw e en t h e two wa lls

in cr e a se s in a m ou n t t h e sh e ath be co m e s d ist e n d e d as if it
,

had be e n inj e ct e d an d its p o sit io n be co me s a p p ar e n t At

,
.

th e sa me t im e t h e fr ict io n c e a se s bu t t h e d ist e n sio n o f ,

t h e wa lls str e tch e s t h e n e rv e s an d p a in is st ill fe lt ,

.

So me mucou s sh e ath s fo r e x a mp le th e m ucou s sh e ath ,

o f th e fl e x o rs o f th e fi n g e r s are n o t co mp le t e tu be s bu t , ,

me r ely in vag in at e d sac s ( F ig .

1 3 8 TH E SUPER I OR EXTRE M I TY
—
D is s e c ti o
n The su p e rfi cial m u scle s w h ich a ise fro m th e r
m e dial e p ico n dy le o f t h e h u m e ru s m u s n o w be c le an e d t .

t t
Co mm e n ce w i h t h e m o s lat e ral o f t h e g ro u p , t h e p ro n a o r t e re s , t
an d f o llo w it f ro m it s o rig in t o it s in se rt io n in o t h e m iddle o f t
t h e lat e ral su rf ac e o f t h e radiu s To e x p o se t h e in se rt io n t h e .

brac h io radialis an d t h e lo n g an d sh o rt radial e xt e n so rs o f t h e

-

c arp u s w h ic h co e r it m u s be p u lle d a side v As t h e dis al p art o f t . t

t h e p ro n at o r t e re s is be in g cle a n e d be c are fu l n o t t o in j u re t h e h in t
radial o rig in o f t h e fl e x o r dig it o ru m su blim is h ic h lie s be h in d w
it . t
Se p ara e t h e p ro xim al p art o f t h e p ro n a o r e re s f ro m t h e t t
fl ex o r carp i radialis by di idin g t h e in e rm u scu lar se p tu m v t
be tw
e e n hem t v
D i ide t h e su p e rfi c ial h e ad o f t h e p ro n a o r e re s ,
. t t
t u rn th e p ro x im al p ar o t t w
ards t h e m e dial e p ic o n dy le an d t h e
t t w
dis al p art o ards th e radiu s an d f o llo t h e de e p h e ad be een w tw
v
th e m e dian n e r e an d t h e u ln ar art e ry t o its o rig in fro m t h e
co ro n o id p ro ce ss o f t h e u ln a Af e r t h e p ro n a o r e re s h as be e n . t t t
e x am in e d c le an t h e fl e x o r c arp i radialis , bu t do n o t f o llo w it s
t e n do n o f in se rt io n be y o n d t h e p ro x im al e dg e o f t h e ra n s e rse t v
t
c arp al lig am e n , wh e re it e n e rs a sp e c ial o s e o fi bro u s c an al t t -

t w
h ro u gh w h ic h it ill be race d in a la e r disse c io n No w cle an t t t .

t h e p alm a ris lo n gu s ; rac e it s e n do n t o th e in e rm e dia e p art t t t t

o f t h e p alm ar ap o n e u ro sis , an d n o e h a as it cro sse s t h e t t t
t v
ran s e rse carp al lig am e n its de e p su rf ace is a ac h e d t o th e t tt
lig am e n t .
1

t
Th e m o s m e dial m u scle o f th e g ro u p , th e fl ex o r carp i u ln aris,
t
m u s n o w be cle an e d No e h at its e n do n o f in se rt io n lie s
. t t t
alo n g t h e v
o lar bo rde r o f t h e dis al p art o f t h e m u s cle Th is is t .

t t
a p o in o f p rac ic al im p o rt an ce f o r t h e e n do n is u se d as a gu ide , t
t
du rin g o p e ra io n s u p o n t h e u ln ar n e r e an d art e ry in t h e dis al v t
p ar t o f t h e f o re arm C le a n b o h h e ads o f o rig in o f th e fl ex o r
. t
carp i u ln aris , o n e f ro m t h e m e dial e p ico n dy le an d o n e f ro m t h e
m e dial bo rde r o f t he O le cran o n o f t he u ln a, an d n o e h a t h e t t t
v
u ln ar n e r e , a cco m p an ie d by t h e su p e rio r u ln ar c o lla e ral a rt e ry , t
disap p e ars be w e e n h e m t t
Se p arat e th e p ro x im al p art o f t h e .

fl ex o r carp i u ln aris f ro m t h e adj ace n p art s o f t h e p alm aris lo n gu s t

t
an d t h e fl e x o r dig i o ru m su blim is by sp li t in g t h e se p a be een t t tw
t h e m ; se cu re t h e u ln ar n e r e an d its bran c h e s t o t h e fl ex o r v
carp i u ln aris an d t h e fl e x o r dig i o ru m p ro fu n du s o n t h e dee p t
su rf ace o f t h e fl ex o r c arp i u ln aris F o llo w t h e u ln ar n e r e . v
dis ally t At t h e j u n c io n o f t h e p ro x im al an d m iddle t h irds
. t
o f t h e f o re arm it is j o in e d by th e u ln ar a rt e ry , w h ic h ap p e ars
vr
f ro m u n de r co e o f t h e m e dial bo rde r o f th e fl e x o r dig i o r m t u
su blim is Cle an t h e art e ry an d n e r e , as f ar as th e la e ral
. v t
side o f t h e p isif o rm bo n e , an d fi n d t h e o rig in s o f t h e do rsal
an d p alm a r
bran c h es o f th e n e r e , w h ic h w e re se e n h e n th e v w
su p e rfi cial st ru ctu re s o f t h e p alm an d o n t h e do rsu m o f t h e
w
h an d e re disse ct e d (p Se cu re also th e o lar carp al. v
bran c h o f t h e art e ry w h ic h arise s n e ar th e p o x im al bo rde r o f r
t v
th e ran s e rse carp al lig am e n t .

v
To ge t a g o o d ie w o f t h e fl e x o r dig i o ru m su blim is di ide t v
t h e p alm aris lo n gu s an d t h e fl e x o r carp i radialis at t h e m iddle
o f t h e f o re arm Tu rn t h e p ro x im al p art s o f bo h th e mu scle s
. t
u pw ards a n d se p ara e t t
h e m f ro m th e p ro n a o r e re s an d th e t t
tt
fl ex o r su blim is by sp li in g t h e in e r e n in g in e rm u scu lar se p a t v t t .

1
Th e p a m ar s l i l g o n us is n o t unco m mo n ly abse nt .
1 4 0 TH E SUPER I O R EXT R E M I TY

p . Th is attach m e nt is p lac e d o n the su mmit o f th e

ch ie f curv e o f th e rad iu s an arra n g e m e n t wh ich e n a ble s th e
,

mu sc le to e x e rc ise its p r o n at in g act io n at a gr e at adva n tag e .

C lo se to its in se rt io n t h e p ro n ator t e r e s is cro sse d by th e

rad ia l art e ry an d it is cov e r e d by t h e brach io rad ia lis mu sc le -
.

I t is su pp lie d by th e median nerve I t is a p ro n ator o f the .

for e ar m an d ha n d an d a fl e x o r o f the e lbow .

M Flexo r Carp i Radialis — The fl e x o r carp i rad ia lis arise s

.

fro m t he co mm o n t e n do n fro m t h e fa sc ia o f t h e fo r e ar m
,

an d t h e fi brou s se p ta wh ich in t e rv e n e be tw e e n it an d t h e

adjac e n t m u sc le s I ts fl e shy be lly g iv e s plac e a short d ista n c e

.
,

d ista l to t h e m idd le o f th e for e ar m to a lo n g flatt e n e d t e n do n , ,

wh ich at th e wrist trave r se s t he groov e o n th e fro n t o f the

, ,

o s mu lta n gu lu m m aju s in a sp e c ia l co mp art m e n t o f t h e tra n s

,

v e r se car p a l liga me n t ( F ig 6 0 p I t is in se rt e d in to
.
, .

th e vo lar asp e ct o f th e ba se o f th e m e tacarp al bo n e o f th e

in d e x an d slight ly a lso in to t h e ba se o f th e m e tacarp al bo n e
,

o f t h e midd le fi n g e r I ts r e lat io n s to th e tra n sv e rse car p al

.

liga m e n t an d a lso it s attach me n t to the me tacarp u s w ill be

, ,

e x p o se d an d stud ie d at a lat e r stag e o f th e d isse ct ion It .

is a fl e x o r o f th e wr ist an d e lbo w j o in t s an d a ssist s in

‘

p roduc in g a bduct io n o f th e ha n d I t is su p p lie d by the .

median nerve.

P almaris L o ngus — The p a lmaris lo n gu s is a lo n g sle n d e r

M .

mu scle wh ich is n o t a lway s p r e se n t

,
I t sp r in g s fro m th e .

co mmo n orig in th e fa sc ia l in v e st m e n t o f th e for e arm an d the

,

fi brou s sep tu m o n e ach sid e o f it I ts t e n do n p ie rc e s the ‘

d e e p fa sc ia imme d iat e ly p ro x imal to the wr ist an d th e n p a sse s ,

d istally su p e rfic ial to th e tra n sv e r se carp al liga me nt to jo in the

, ,

stro n g in t e r me d iat e p ort io n o f th e p a lmar a p o n e uro sis V e ry .

fr e qu e n t ly it g iv e s a slip to th e a bductor p o llic is br e v is I t is .

su pp lie d by th e me dian n erv e an d is a fl e x o r o f t h e rad io

,

carp a l an d e lbow j o in t s .

M F lexo r Carp i U a
. ln ri s — The u ln ar fl e x o r Of t h e car p u s
.

m u sc le ar ise s by two h e ad s O n e o f th e m is in corp orat e d

.

w ith the co mmo n or igin fro m the me d ial e pico n dy le ; the

oth e r sp r ing s fro m the me d ial bo rd e r o f th e O le cra n o n o f the
u ln a an d a lso by an a p o n e urot ic attach m e n t fro m th e dorsa l
,

bord e r o f the sa me bo n e in its p ro x im a l two th ird s F ibr e s -

.

are d e riv e d a lso fro m t h e in v e st in g fa sc ia an d th e in t e r

m u scu lar se p tu m o n its lat e ra l sid e The two h e ad s o f orig in .

o f th e fl e x o r carp i u ln ar is br idg e acro ss the in t e rva l be tw e e n

 P L ATE
'

VII

il
Med a c u t an e o u s n e r e o v f fo re a rm

B i ce p s brach 1 1 m u sc le B ili v i
as c e n

D pf i
,

ee asc a o f a rm

M ed a i li n te r m u sc u l a r se p t u m

L a t e ra l c u t a n e o u s n e rv e o f fo re
B rac h i li l
a rm ( m u sc u lo c u tan e u s ) a s m u sc e
il
-

B rac h a a rt e r y
B ra c h i li
a s m u sc l e
D eep f a sc i a o f fo re arm ( re fl e c te d)
M e d an i n e rv e :

B rac h i o -
ra d a i li s m u sc l e

Te n do n o fb i ce p s brac h i i
P ro n a t o r t e re s m u sc l e

Ul n a r art e r y
R di l a a art e r)
L ace rt u s fi o ro su s

F le x o r c arp i rad a i li s m u sc l e

P a lm i l g ar s o n us mu sc l e

E x t e nso r c arp i rad a i li s bre v i s

m u sc l e
Fl x e o r c a rp i l i
u n ar s m u sc l e

Te n do n o f e x t e n so r c a rp i ra d a i li s

l g
o n us

R di l a a a rt e r y
F le x o r d igi t o ru m su b li m i s m u sc l e

Te ndo n s
l o f flexo r d igi t o ru m su b li m i s
F le x o r po lli i l g
c s o n us mu sc l e

Su p e rfic i lb
a ra n c h o f rad a il n e rv e

P ro na t o r q u a dra t u s m u sc l
Te n do n o f abdu c t o r lli i l g
e
M e d an i n e rv e
po c s o n us

Te n do n o f fle x o r po lli i l g
c s o n us

R di a us

R di l ya a art e r Ul n ar a rt e r y .

Te n do ns o f abdu c t o r p lli i l
o
g c s o n us
Ul n ar n e rv e

an d e x t e n s o r
p lli i b o i c s re v s ‘
Tran s v e rse c arp a l li g am e n t

Su p e rfic i lv l
a o ar a rt Pi i
s fo rm bo ne

FI G . 61 .
-
Su p e rfic ial Di i
sse c t o n o f t he M u sc l
es, Art e r e s i , an d N er ve s o f t he
A n te ri o r A sp e c t o f th e F o re ar m .

P art o f t he ra d a i l arte r y was re m o ve d to Sho w so m e o f its de e p l i

re at o n s .
 P L AT E V I I I

i ii m l
!

M ed il a c u t a ne o u s n e r e o v f fo re arm
B ce p s

h i li m
brac h u sc e
o n basi l v ic ein
B ra c l a s u sc e

P a rt o f brac h i o -
ra di li m
a l s u sc e ‘

M e d an i
hi di li
n e rv e
N er v e to bra c o -
ra a

B il
ra c h a art e r y
—
Me di l ia n t e rmu sc u ar s e t u m l
p

fo
L a te ra l c u t an e o u s n e r e o v f L ac e rt u s fibro su s
re ar m ( m u sc u lo -
c u tan e u s
)
R a di a l n e rv e

N e rv e t o ex t e n so r c a r
p
i ve t o p ro n a t o r t e re s

ra di a i s l l g o n us
ro n a t o r t e re sm u sc l e

Su p e rfic i lb
a ran c h o f ra di l va ne r e
u p e rfi c ia l h e a d

v
)
N e r e t o fl e x o r c ar i
p
Do rsa li
n t e ro sse o u s n e r e v i li
ra d a s ,
p a m ar s o n l i l g
R l
adi a re c u rre n t ar y and fl e x o r d t o ru m igi u s,

te r
su b m s li i
N e rv e t o ex t e n s o r c ar i
radi a i s l p
bre v i s N e rv e t o fl e x o r d t o ru m ig i
S up i l su b i m s l i
n ato r m u sc e
D e e p h e ad o f
p ro n a t o r t e re s
m u sc e l
il
Su p e rfic a he ad o f p ro n a t o
Vl i o ar n t e ro ss e o u s n e r t e re s mu sc e l i

ve

i P l i l g
a mar s o n u s m u sc e l
Ex t e n so r ca rp
l g m l i li ra d a
o n us u sc e
s
e ro -
l
u n ar p art o f flexo r
E x t e n so r c ar i ra
p di li a li mi s mu sc l e
b i m l
re v s u sc e
s

P ro n a to r t e re s m l R di l p f fl
a a art o exo r d igi to ru m
bli m i m l
u sc e
su s u sc e

R di l a y a art e r a
Ul v
n ar n e r e

Fl x e o r d ig i t o ru m su b m li i s m u sc l e

F le x o r p o lli i l g
c s o n us m u sc l e Ul n ar arte r y
Te n do n o f brac h i o -
ra d a i li s

Fl x
e o r d ig i t o ru m p ro fu n du s m u sc l e

M e d an i n e rv e w ih
t a cc o mp an yi g n
art e r y
Te n do n o f a bdu c t o r
po l c li i l g
P ro n a t o r q u a dra t u s
s o n

m u sc
us
l e
Te n do ns o f flexo r d i g i m bli m i
t o ru su s

S u p e rfic ia l bra n c h o f ra d a il v ne r e Te n do n o f fl e x o r c ar pi l i
R di a
u nar s

Ul
us
Te n do n o f fle x o r c ar pi di li
ra a s
n a r a rte r y
Te n do
Ul
i l g
n o f p a mar s l o n us

Su p e rfic i lv l
a o a r art e r y T v
ran s
n a r n e rve

p l li g m
e rs e c ar a a e nt
P f mb
i si o r o ne

P l m i b vi m l
a ar s re s u sc e

FI G . 62 ,
— D eep Di sse c t o n o i f the M u sc l e s, V e sse l s, an d N er ve s o f th e
fro nt o f th e F o re arm .
1 42 TH E SU PER I OR EXTRE M I TY
t
D is s e c t io n — Cu t h ro u gh t h e radial p art o f t h e fl e x o r dig i
to ru m su blim is at its u n io n i h t h e h u m e ral p o rt io n wt u ll . P
t h e m ain m ass o f t h e m u s cle o w a rds t h e m e dial s ide o f th e t
t
f o re arm , an d u rn t h e radial p o r io n o w ards its o rig in Th e n t t .

v
c le an t h e m e dian n e r e , t h e bran c h o f t h e an e rio r in e ro sse o u s t t
a r e ry t w
h ic h a c co m p an ie s t h e n e r e , an d t h e an e rio r su rface v t
o f t h e fl e x o r p o llic is lo n g u s w
h ic h sp rin gs fro m th e o lar su rface v
o f t h e radiu s ; an d t h e fl e x o r dig i o ru m
p ro fu n du s , h ic h arise s t w
v
f ro m t h e o lar an d m e dial su rf a ce s o f t h e u ln a Th e n se cu re t h e .

v t
o lar in e ro ss e o u s bran c h o f t h e m e dian n e r e I t sp rin g s f ro m v .

v
t h e m e dian n e r e as t h e la e r e m e rg e s f ro m be w e e n t h e tw ott t
t t
h e ads o f th e p ro n a o r e re s F in d also t h e co m m o n in e ro sse o u s
. t
bran c h o f t h e u ln ar art e ry I t arise s in , o r im m e dia e ly dist al
. t
t t
t o , t h e cu bi al f o ssa , an d m u s be lo o k e d f o r be h in d th e de e p h e ad
o f t h e p ro n a o r e re s t t
Alm o s at o n c e it di ide s in o
. t
o lar an d v t v
t
do rsal in e ro sse o u s bran c h e s Th e do rsalbran c h p asse s backw ards
.

v t
abo e t h e in e ro sse o u s m e m bran e t o t h e do rsal p ar o f t h e f o re t
arm , w t
h e re it w ill be disse c e d la e r N o w se p ara e th e adj ace n t . t t
bo rde rs o f t h e fl ex o r p o llic is lo n g u s an d t h e fl e x o r dig i o ru m t
p ro fu n du s an d f o llo th e w v
o lar in e ro sse o u s ar e ry an d n e r e t t v
t
t o t h e p o in wh e re t h e y disapp e ar be h in d t h e p ro n a o r q u adra u s t t
t t
in t h e dis al h ird o f t h e f o re arm Cle an t h e p ro n a o r q u adra u s ,
. t t
t t
h e n p ro ce e d t o s u dy t h e s ru c u re s e xp o se d t t .

Art e ria U lna ris — Th e u ln ar art e ry is th e larg e r o f th e

.

two t e r min a l bra n ch e s Of t he brach ia l tru n k I t tak e s o r ig in , .

in th e cu bita l fo ssa , at th e le v e l o f th e n e ck o f th e rad iu s In .

t h e p ro x im a l th ird o f th e fo r e ar m it in c lin e s o bliqu e ly d ista lly

an d m e d ia lly , an d th e n it p roc e e d s stra ight d o w n to th e

wrist I t e n t e r s the p a lm by p a ssin g a n t e r ior to the tra n sv e r se

.

carp a l liga me n t I n the p ro xima l o bliqu e p ort io n o f its c o urse

.

the v e sse l i s d e e p ly p lac e d , an d i s cro sse d by both h e ad s o f t h e

p r o n ator t e r e s, t h e fl e x o r car i rad ia lis, t h e

p p a lm ar is lo n gu s,

t h e fl e x o r d ig itoru m su blimis an d t he m e d ia n n e rv e I ts d ista l, .

v e rt ica l p art is o v e r la pp e d o n the me d ia l sid e by th e fl e x o r

car p i u ln ar is, bu t a short d ista n c e p ro x ima l to the wr ist it
be co m e s su p e rfic ia l, an d lie s in th e in t e rva l be tw e e n t h e
t e n d o n o f the fl e x o r carp i u ln ar is o n the m e d ial sid e an d the
t e n do n s o f th e fl e x o r su blimis o n the lat e ra l sid e As it lie s .

o n t h e tra n sv e r se car p a l liga m e n t it is se p arat e d fro m th e

lat e ra l sid e O f t h e p isifo r m bo n e by t h e u ln ar n e rv e , an d is

c o v e r e d by a stro n g ba n d o f fa sc ia, the v o lar car p a l liga me n t
( pp . 1 2 9, wh i ch lie s su p e rfic ia l t o t h e tra n sv e r se liga

me n t Thr o ughout it s e n t ir e cour se it is acco mp a n ie d by

.

two vence co mites I t has im p orta n t r e lat io n ship s w ith the

.

m e d ia n an d u ln ar n e rv e s The median n erve, wh ich lie s.

u p o n its m e d ia l sid e at its or igin , so o n cro sse s it, bu t at

th e p o in t o f cr o ssin g th e n e rv e is se p arat e d fro m th e art e ry
 F ORE A R M AN D H AN D 1 43

by t h e d e e p h e ad o f t he p ro n ator t e r e s The u ln ar n erve in .

t h e p r o x im a l th ird o f t he for e ar m is se p arat e d fro m th e

v e sse l by a w id e in t e rva l, bu t in th e d ista l two th ird s o f th e -

fo r e ar m it c lo se ly acc o mp a n ie s th e art e ry an d lie s o n its ,

m e d ial sid e .

I n t h e cu bita l fo ssa t h e u ln ar art e ry r e st s u p o n t h e

brach ia lis ; m or e d istally it is in co n tact p o st e r io r ly w ith t he
fl e x o r d ig itoru m p ro fu n du s wh ilst at th e wr ist t h e art e ry lie s
u p o n the su p e rfic ia l sur fac e Of th e transverse carpal ligament .

B ran ch e s o f t h e U ln ar Art e ry I n t h e fo r e ar m t h e u ln ar .
—

art e ry g iv e s o ff the fo llow in g bra n ch e s

I . A . re cu rre n s u ln aris v o l aris .
4 A c arp e a v o laris
. . .

2 . A . re c u rre n s u n ari s l do rsali s .

5 A c arp e a do rsalis
. . .

3 . A . i n te ro sse a co mm u n i s . 6 R am i m u sc u lare s
. .

Th e mu scu lar bra n c/zes are o f sm a ll co me o ff at

siz e , an d

varia ble p o in t s fo r the su p p ly o f t he n e igh bo ur in g m u sc le s .

Th e vo lar u lnar recu rren t a rter

y ( O T . . anterio r u ln ar re

s t h e sma lle r O f t h e two r e curr e n t bra n ch e s ru

cu rren t
) i I t ns .

p ro x im a lly , a n t e r io r t o t h e m e d ia l e ic o n dy le o f th e hu m e ru s,
p
in th e in t e rva l be tw e e n t he p ro n ator t e r e s an d the brach ia lis
m u sc le s, a n a sto m o se s w ith th e a n t e rior t e r min a l bra n ch
an d it
o f t h e in fe r ior u ln ar co llat e ra l art e ry .

The do rsa l u ln a r recu rren t artery ( O T po sterio r u ln a r . .

recu rrent p a sse s m e d ia lly u n d e r cov e r o f t h e fl e x o r d ig itoru m

) ,

su blimis an d th e n tur n s p r o x im a lly be tw e e n th e t wo

,
h e ad s ,

o f or ig in o f t h e fl e x o r car p i u ln ar is to ga in the in t e rva l ,

be tw e e n the m e d ia l e p ico n dy le o f t h e hu m e ru s an d th e
o le cra n o n o n th e d o r sal a spe ct o f the limb Th e re it be co me s
,
.

a ssoc iat e d w ith th e u ln ar n e rv e an d a n a st o mo se s w ith th e ,

p o s t e r ior t e r m in a l bra n ch o f th e in fe r io r u ln ar c o llat e ra l art e ry

an d w ith th e su p e r ior u ln ar c o llat e ra l art e ry .

I t is n o t u n c o mm o n t o fi n d t he two r e curr e n t art e r ie s

ar isin g fro m the u ln ar tru n k by a short c o mmo n st e m .

Th e co mmo n in tero sseo u s artery is a short w id e tru n k wh ich , ,

tak e s or ig in im m e d iat e ly d istal t o the r e curr e n t bra n ch e s ,

abo ut 2 5 m m ( o n e in ch ) fr o m the co mm e n c e m e n t o f th e u ln ar
.

art e ry I t p a sse s dor sa lly t o th e p r o x im a l m arg in o f the

.

in t e r o sse ou s m e m bra n e wh e r e it d iv id e s in to two t e r m in a l

,

bra n ch e s v iz th e vo lar ( O T an terio r) an d t h e do rsal ( O T

,
.
,
. . . .

po sterio r) intero sseo us arteries .

Th e arteria in tero ssea do rsa lis p a sse s backward s a bov e

1 44 TH E SU P E R I O R EXTRE M I TY
th e p ro x im a l bord e r o f t h e in t e ro sse o u s m e m bra n e to t h e

dor sa l p art o f the fore ar m wh e re it w ill be d isse ct e d at a

,

lat e r p e r iod .

Th e arteria in tero ssea vo laris d e sc e n d s o n t he a n t e r io r

sur fac e o f th e in t e r o sse o u s m e m bra n e be tw e e n th e adjac e n t ,

m arg in s o f t h e fl e x o r p o llic is lo n gu s an d th e fl e x o r d ig itoru m

p ro f u n du s
,
wh ich m u s t be s e p arat e d as th e art e ry is fo llo w e d .

At t h e p r o x im a l bord e r o f the p ro n ator quadratu s it p ie rc e s

t h e in t e r o sse o u s m e m bra n e an d p a sse s t o th e dor sa l p art
o f t h e fo r e ar m wh e r e its t e r min a l p art w ill be se e n at a
,

lat e r p e r io d . As it d e sc e n d s o n t he vo lar sur fac e o f t h e

in t e ro sse ou s m e m bra n e it g iv e s tw ig s t o th e adjac e n t m u sc le s ,

an d the fo llow in g n a m e d bra n ch e s

:

I A rt e ria m e dian a
. .

2 an d 3 N u trie n t to radiu s
. an d u ln a
.

4 V o lar co m mu nic at in g
. .

Th e arteria median a is a lo n g sle n d e r v e sse l wh ich

acco mp a n ie s t he me d ia n n e rv e t o the p a lm o f the ha n d ,
wh e r e it so me t ime s t e r min at e s in t h e su p e rfic ia l v o lar arch .

Th e n u trient arteries e n t e r th e n utr ie n t fo ra min a o f th e

rad iu s an d u ln a The vo lar co mmu nicating artery d e sc e n d s
.

o n t h e v o lar sur fac e o f t he in t e ro sse ou s m e m bra n e , d e e p to

t h e p ro n ator quadratu s, to th e car p u s, wh e r e it t e r m in at e s in

t he vo lar carp a l arch .

The u ln ar carp al arteries are two sm a ll art e r ie s wh ich \

,

p art ia lly e n c irc le t h e wr is t T h e v o

. lar u ln ar car p a l arter
y
ru n s lat e ra lly u n d e r cov e r o f the t e n d o n s o f the fl e x o r d ig i
,

toru m p ro fu n du s an d a n a sto m o se s w ith the vo lar carp a l

,

bra n ch o f t h e radia l art e ry F ro m th e arch thu s for me d

.
, ,

s ma ll tw ig s are g iv e n to t h e vo lar a sp e ct o f t h e car p a l bo ne s

an d j o in t s. Th e do rsal u ln ar carpal artery ga in s th e dor sa l

a sp e ct o f th e carp u s by w in d in g rou n d th e me d ia l marg in o f
t h e limb imm e d iat e ly p ro x ima l to t he p isifor m bo n e an d ,

u n d e r c o v e r o f the t e n do n o f the fl e x o r carp i u ln aris .

u
N e rv s U lna ris — Th e u ln ar n e rv e wh ich was trac e d in
.
,

th e d isse ct io n o f t h e arm as far as t he in t e rva l be tw e e n t he

O le cra n o n an d me d ia l e p ic o n dy le o f the hu me ru s e n t e r s the ,

for e ar m be tw e e n t h e t wo h e ad s o f th e fl e x o r car p i u ln ar is It .

p roc e e d s d is ta lly o n t h e v o lar su r fac e O f th e fl e x o r d ig it o ru m

,

p r o fu n du s a n d u n d e r cov e r o f t h e fl e x o r car p i u ln ar is in t h e ,

v o lar p art o f the m e d ia l sid e o f the fore ar m C lo se t o .

1 46 TH E SUPER I O R EXTRE M I TY

p a ssi n g su p e rfic ia l to t h e tra n sv e r se car p a l liga m e n t I n t he .

p ro x im a l th ird o f t he fo r e ar m th e u ln ar n e rv e is se arat e d fro m

p
t h e u ln ar art e ry by a c o n sid e ra ble in t e rva l bu t in t h e d ista l ,

two th ird s it is clo se ly a pp lie d to the me d ial sid e o f the

-

ve sse L

I n the for e ar m th e u ln ar ne rv e g iv e s o ff
I . R am i articu lare s .

t o the fl e x o r c arpi u lnaris an d the m e dial p art

2 R am i M u scu lare s,
f the fl e x o r dig it o ru m p ro fu n du s
.

o .

R am i t
cu an e i,
l
ram u s cu tan e u s p a m aris .

3 .

ram u s do rsalis m anu s .

The articu lar rin g fro m the u ln ar n e rv e as it

brane/res sp

lie s in t he in t e rva l be tw e e n t h e O le cra n o n an d th e m e d ia l

e p ico n dy le o f th e hu m e ru s an d p a ss to t h e e lbow j o in t
,
-
.

The muscular brane/res are g iv e n o ff im me d iat e ly d ista l to

t h e art icu lar bra n ch e s Th e y su p p ly the fl e x o r carp i u ln aris
.

an d t he me d ia l p art o f th e fl e x o r d ig itoru m p ro fu n du s .

Th e palmar cutaneo u s bran cic is a min ut e tw ig wh ich h as

a lre ady be e n se e n p ie rc in g the fa sc ia o f the for e ar m im ,

me d iat e ly p ro x im a l to the tra n sv e r se carp a l liga m e n t I t ar ise s .

a bout the midd le o f the for e ar m an d p roc e e d s d ista lly u p o n

th e u ln ar art e ry to be d istr ibut e d in t he p a lm o f t h e ha n d
, .

The do rsal bran clz is a n e rv e o f so m e siz e wh ich sp rin g s

fro m t he u ln ar t ru n k a bout 6 7 5 c m ( two an d a ha lf or —
.

thr e e in ch e s) p ro x ima l to the wr ist I t w in d s rou n d the

.

me d ia l marg in o f the for e ar m u n d e r cov e r o f the fl e x o r car p i

,

u ln ar is an d r e ach e s the dor su m o f the ha n d imm e d iat e ly

,
.

d ista l to the p ro min en c e forme d by the d istal e n d o f th e u ln a .

F ro m that p o in t o n ward s it h as be e n trac e d in t he su p erfic ia l

d isse ct io n ( p .

N e rv us M e dian us — As its n a me implie s th e me d ia n n e rv e

.
,

p a ss e s dow n t h e m idd le o f t h e for e ar m .

I n the p ro x ima l p art o f th e for e ar m the m e d ia n n e rv e lie s in

the cu bita l fo ssa u p o n t h e m e d ia l sid e o f th e u ln ar art e ry .

I t le av e s the fo ssa by p assmg be tw e e n the two h e ad s o f th e

p ro n ator t e r e s a n d,
as it do e s so it cro sse s the u ln ar art e ry ,

bu t is se p arat e d fro m it by the u ln ar h e ad o f t he m u sc le .

F ro m that p o in t t he m e d ia n n e rv e ru n s d ista lly be tw e e n t h e

fl e x o r d ig itoru m su blim is su p e rfic ia lly an d th e fl e x o r d ig it o ru m
p ro f u n du s d e e p l y N e ar t.h e wr ist it be co m e s su p e rfic ia l an d ,

lie s in t h e in t e rva l be tw e e n th e t e n do n s o f t he p a lm ar is lo n gu s ,

o n th e me d ia l sid e an d t h e fl e x o r car p i rad ia lis o n the lat e ra l

, ,
 F ORE AR M AN D H AN D 1 47

d
si e . F in a lly it le av e s the
for e ar m by p a ssin g d e e p
to the tra n sv e rse car p a l
liga m e n t A sm a ll art e ry
.
,

th e a media n a a bra n ch o f
.
,
B i ce p s br

the v o lar in t e ro sse o u s art e ry ,

acco mp a n ie s the m e dia n

n e rv e So m e t im e s th is v e sse l
.

attain s a co n sid e ra ble siz e .

As the me d ia n n e rv e
e n t e r s th e for e ar m it g iv e s

o ff n u me rou s bra n ch e s fo r

th e su pp ly o f m u sc le s an d ,

n e ar t h e wr ist it su p p lie s

a p almar brancb wh ich has ,

a lr e ady be e n d isse ct e d ( p .

Th e muscu lar branclzes

su p p ly all th e m u sc le s wh ich

sp r in g fro m th e me d ia l
e p ic o n dy le o f th e hu m e ru s,

w ith the sin gle e x c e p t io n o f

th e fl e x o r carp i uln ar is v iz , .

t he p ro n ator t e r e s the fl e x o r ,

carp i rad ia lis th e p a lm ar is ,

lo n gu s an d t h e fl e x o r d ig i
,

toru m su blimis .

I t su pp lie s a lso a lo n g
sle n d e r twig — vo lar inter
o sseo u s n erve — wh ich go e s
to the d e e p mu scle s o n th e
volar a sp e ct o f the for e
arm .

Dee p St ruct ures on t he

fro nt o f t he F o re a rm .

Th e co n n e ct io n s o f the
d e e p m u sc le s m u st n o w be
stud ie d
V o l ar asp e c t o f B o ne s o f
.

FIG 64 —
Th e fl e x o r d ig itoru m p ro
. .

F o re arm with M uscu l ar Attach m e n ts

fu n du s is t h e larg e m u scle m ap p e d o ut .

wh ich c loth e s the v o lar an d

m e d ia l sur fac e s o f th e u ln a ; the fl e x o r p lli o c is lo n gu s is p lac e d
1— 10 a
 1 48 TH E SU PER I OR EXTRE M I TY
u p o n the vo lar surfac e o f the rad iu s ; wh ile the p r o n ator
quadratu s is a quadrat e fl e shy lay e r c lo se ly a pp lie d to both
bo n e s im m e d iat e ly p ro x im a l to th e wr ist Th e v o lar in t e r .

o sse ou s art e ry an d n e rv e p roc e e d d istally in the in t e rva l

be tw e e n th e fl e x o r p ro fu n du s an d fl e x o r p o llic is lo n gu s .

M F lex o r Digit o ru m P ro f un dus — Th e d e e p fl e x o r o f

. .

t h e fi n g e r s sp r in g s fr o m t h e vo lar an d me d ia l sur fac e s o f

t h e u ln a in it s p ro x im a l thr e e fourth s I t d e r iv e s fi br e s
-
.

a lso fro m t he v o lar sur fac e o f the in t e ro sse ou s me mbra n e

an d t h e a p o n e uro sis by wh ich t h e fl e x o r car p i u ln ar is tak e s

O r ig in fro m the dor sal bord e r o f th e u ln a The fl e shy m a ss

'

g iv e s p lac e to four t e n do n s fo r th e m e d ia l four d igit s bu t ,

o n ly o n e o f th e m — that fo r th e in d e x fin ge r be co me s m

se p arat e an d d ist in ct in th e fo r e ar m The t e n d o n s p roc e e d .

d istally deep to the tra n sv e r se car p a l liga m e n t in to the p a lm

, , .

Th e fl e x o r d ig itoru m p r o fu n du s is su pp lie d by th e vo lar

in tero sseo u s bran e/z of tire median by th e u ln ar n erve
an d It .

is a fl e x o r o f all t h e j o in t s o f th e fi n g e r s, an d o f the wr ist .

M F .le x o r P o llic is L o n gu s — Th e fl e x o r p o llic is lo n gu s

arise s fro m the p r o x ima l t wo th ird s o f th e v o lar sur fac e o f
-

the rad iu s I t tak e s or ig in a lso fro m t h e adjac e n t p art o f

.

t h e v o lar sur fac e o f th e in t e ro sse ou s me mbra n e A rou n d e d .

t e n do n issu e s fro m the fl e shy be lly , an d p roc e e d s in to the

p a lm ,
d e e p to t h e tra n sv e r se car p a l liga m e n t .

I n m a n y ca se s t he fl e x o r p o llic is lo n gu s h as an add it io n a l
sle n d e r h e ad o f or ig in , wh ich sp r in g s fro m th e m e d ia l bord e r

o f th e coro n o id p roc e ss O f t h e u ln a , or th e m e d ia l e p ico n dy le

o f t h e hu m e ru s Th e fl e x o r p o llic is lo n gu s is su pp lie d by
.

the vo lar in tero sseo u s n erve I t is a fl e x o r o f all th e j o in t s

.

o thu mb an d o f th e wr ist
f th e .

M P ro n at o r Q u a dra t u s — Th e quadrat e p r o n at o r m u sc le
.

tak e s orig in fro m th e d istal fourth o f the volar su rfac e o f

th e u ln a an d is in se rt e d in to t h e d ista l th ird o f th e vo lar
,

sur fac e O f t h e rad iu s I t is su pp lie d by th e vo lar in tero sseo us

.

n erve .I t is p ro n ator o f t h e f or e ar m an d ha n d .

v
D is s e c ti o n —Di ide t h e p ro n at o r q u ad
. rat us ve rtically an d
cle an t h e p ar o f t h e o la t
in e o sse o u s v r t r art e ry w h ic h lie s
be h in d it .

W R I ST AN D P AL M .

I n th is d isse ct io n t he fo llow in g structur e s w ill be fou n d

 I
5 0 TH E SUPER I OR EXTRE M I TY
ha n d A se co n d cro sse s th e p a lm tra n sv e rse ly C o mme n c in g
. .

at t h e midd le o f the lat e ra l bo rd e r o f the ha n d wh e r e the ,

first furrow e n d s it ru n s me d ia lly bu t as a g e n e ra l ru le

, , , ,

v o l i i di i
ar s n c s rad a i li s

P i
r n ce p s po lli i
c s

B ra n ch t o m u sc l es

Ul nar n e r e v o f t h u mb

Su p e rfic i lv l
a o ar arte r y
Ul nar arte r y
i
M e d an v ne r e

R di l
a a y arte r

FI G . 65 .
— Di g
a ra m o v e s an d Ve sse l s o f
f N er H an d i l ti t
n re a o n o Bo ne s

i g an d Sk i n M ark n s
.

it fad e s away u p o n t he hy p o th e n ar e min e n c e Th e th ird .

furrow be g in s n e ar t h e c le ft be tw e e n t h e in d e x an d midd le
fi n g e r s an d p roc e e d s m e d ia lly w ith a g e n t le curv e acro ss
, ,

t h e hy p oth e n ar e min e n c e t o t h e m e d ia l m arg in o f t h e ha n d

,
.

The tra n sv e r se cuta n e ou s furrow s at t h e root s o f th e fi n g e r s ,

 F ORE AR M AN D H AN D
an d o n t h e p a lm ar a s e ct s o f t h e in t e rp ha la n g e a l j o in t s shou ld
p ,

a lso be n ot ic e d The furrow s at th e root s o f the fi n g e r s are

.

lm i l g
P a ar s o n us
Fl x
e lim i
o r su b s

Fl x e pi l i
o r c ar u nar s
Brac hi di li
o -
ra a s

Fl x
e pi
o r c ar di li ra a s

R di l
a a y
art e r

Ul n ar art e r y M di
e v
an n e r e

Trans v e rse c a rp a l li g ame n t Abd p lli i l

u cto r g o c s o n us

Pi s if o r m bo n e S p fi i l v l
u er c a y o a r art e r

lm i l g P a ar s o n us
p lli i
ne us o c s

P lm i b a ar s
bd p lli i u cto r o c s bre vi s

Abd di g i i q
uc to r t u

Fl x di g i i q i i
e o r t u nt Fl x e o r p o llic ishre v is
bre v 15

P a lm ar a p o n e u ro s s i
( i n t e rme d at e i p art )

S u p e rfic il
a t ra ns v e rse
lg
i ame n t

rs t l u mbr ca i l wi h t
gt l
,

di i a v
n e r e an d
i art e r a i ndi c i s radi a i s l
2n d l mb i l w i h di g i l
u r ca ,
t ta
y
a rt e r and n e r e v

FIG . 66 .
— Su p e rfi c ia l Di i
sse c t o n o f th e P l
a m . i
Th e n t e rme d ate p art o f th e i
l
p a m ar a p o n e u ro s s i h l ii
as be e n e ft in p o s t o n , wh il l
st th e at e ra an d me d a l i l
i
p o rt o n s hav e be e n v
re m o e d to i ly h l
d sp a th e s o rt m u sc e s o f t h e t u mb h
an d l t t e fi n ge r i l .

p lac e d ove r
ar a sp e ct s o f th e p ro x im a l p ha la n g e s
th e p lm a ,

a bout 2 5 mm ( o n e in ch ) d ista l to t h e m e tacarp o p ha la n ge a l

.
-

j o in t s The p ro x im a l o f th e two furro ws o n the fro n t o f a

.

1— 10 6
I 52 TH E SU PER I O R EXTRE M I TY

p ro x im a l in t e r p ha la n g e a l j o in t is p lac e d imm e d iat e ly ov e r

t h e art icu lat io n wh ilst in th e ca se o f th e d ista l in t e r
,

p ha la n g e a l j o in t s t h e sin g le cr e a se wh ich is u sua lly

p r e se n t
is situat e d imm e d iat e ly p ro x ima l to th e art icu lat io n On .

th e back o f t he ha n d t h e m e tacar p a l bo n e s c an be r e ad ily

fe lt wh ilst th e ir d ista l e x tr e mit ie s o r h e ad s fo r m t h e p ro m in
, , ,

e n c e s k n ow n as th e k n uckle s “ !
.

M Pa lma ri s Bre v is
. Th is sma ll cuta n e ou s m u sc le c o n .
—

sist s o f a se r ie s o f fa sc icu li wh ich are fr e qu e n t ly se p arat e d

fro m o n e a n oth e r by d ist in ct in t e rva ls As a who le it .

fo r ms a th in fl e shy lay e r wh ich cov e r s th e d e e p fa sc ia o n th e

p ro x ima l o n e an d a ha lf in ch e s o f t h e hy o th e n ar e m in e n c e
p .

I t sp r i n g s fro m t h e d ista l m arg in O f t he tra n sv e r se car p a l

liga m e n t an d t h e me d i a l bord e r o f the stro n g in t e r me d iat e
p art o f t he p a lm ar a p o n e uro sis an d it i s i n se rt e d in to t h e ,

sk in o f th e m e d ia l bord e r o f t h e ha n d I t lie s su p e rfic ia l .

t o th e u ln ar art e ry th e su p e rfic ia l p art o f th e u ln ar n e rv e an d

, ,

t o th e d e e p fa sc ia cov e r in g t he m u sc le s o f t h e hy p oth e n ar
e min e n c e I t is su p p lie d by th e su p e rfic ia l d iv isio n o f
.

t h e u ln ar n e rv e .

D is s e c t io n — R e fl e t t h e p alm ar i br v i t o its o rig in f ro m c s e s

t h e i t rm diat
n e p arte f t h p alm ar ap o n
e ro is an d se u r
o e eu s ,
c e
th e bran ch f r m t h e s p e rfi cial div i io n o f t h e u ln ar n e rv wh i h
o u s e c

s pp li s it
u e R m v e t h e m dial p art f t h e p alm ar ap n e ro is
. e o e o o u s
f ro m t h e m scle s o f t h e h yp o t h n ar m i n c
u Cle an t h u ln ar e e ne e . e
art e ry t o t h e p in t w h re it disapp e ars o n d r o v r o f th e i te r
e u e c e n
m diat e p art f t h e p alm ar ap o e ro sis
e o N o t e t h at as it p asses n u .
,

by t h e m edial si de o f t he h k f t h o h am atu m it n ds a o o o e s ,
se
d p bra
ee h in t th
nc b t an ce Of th e p alm
o Cl an t h
e su ln ar s . e e u
n e rv as it lie
e o n t h e m dial id o f t h e bo o k
s f t h e h am atu m e s e o
an d se cu re it tw o t rm i al bran h e
s ( 1 ) A s p e rfi ial bran c h
e n c s u c ,

w h ich divide s in t th dig ital br n ch f r the m dial side f t he

o e a o e o

litt l fi n g r an d a bra c h w h ic h divid s t o s pp ly th adj ace n t

e e ,
n e u e
side s o f t h e litt le a d ri g fi n g rs ; a d ( 2 ) a d n p bran h w h ic h n e n ee c
ac m p an ies t h d e p bran c h f t h e ln ar art ry i t t h d p t h s
co e e o u e n o e e

o f t h e p alm F in d th bran h w h i h the d p div i i n o f t h e

. e c es c ee s o

u ln ar n rv e g iv s t o t h
e s h rt m scl f t h litt le fi n g e r ; t h e n
e e o u es o e
in rt t h h a dl o f t h scalp l i t o t h e cle ft in t o w h i h th e de p
se e n e e e n c e
div is i n s f t h art e ry a d n rv p ass a d carry it di t ally t o
o o e n e e ,
n s

s p arat
e t h e abd ct o r dig it i q in t i m
e l u o th m e dial ide u u sc e , n e s ,

fr m th fl
o er dig it i q in t i br vis a n d t h
ex o o pp s dig it i q i t i
u e e o nen u n

o n th lat e ral side

e Th e o p p n e n s li s o n a d p e r p lan e t h an
. o e ee
th e s h o rt fl o r ex .

Sh o rt M u scle s o f t h e Litt le Finge r — Th e r e are thr e e .

short m u sc le s o f t h e litt le fi n g e r : t h e a bductor t h e short ,

fl e xo r an d t h e O pp o n e n s
,
Th e y are all su p p lie d by t he d e e p .

bra n ch o f th e u ln ar n erve .
i
54 TH E SUP ER I OR EXTRE M I TY
w h ich g o es to t he t hu mb tak in g id in j u ry t o t he
,
c are to a o v
dig ital n rv s
e ef tho t h mb N
e u ex t se p ara e t h e ap ex o f t h e
. t
in t e rm diat p art f t h e p alm ar ap
e e o o n eu ro sis f ro m t h e t e n do n o f
t h e p alm aris lo n gu s an d f ro m t h e ran s e rse carp al lig am e n , t v t
an d re fl e c t t t
t h e in e rm e dia e p ar o f t h e ap o n e u ro sis dis ally t o t t
t
th e ro o s o f t h e fi n g e rs D o n o t fail t o n o e h a , f ro m its m e dial
. t t t
t t
an d la e ral m arg in s, se p a p ass do rs ally in o t h e p alm se p ara t t
t
in g t h e m u scle s o f th e h e n ar an d hyp o h e n ar e m in e n ce s f ro m t
t
th e e n do n s o f th e lo n g fl e x o rs o f t h e fi n g e rs Th e se p ta m u s . t
v
be di ide d as t h e ap o n e u ro sis is re fl e c e d Co n in u e t h e re fl e c io n t . t t
t
u n il t h e de e p su rf ace s o f t h e p ro ce sse s wh ic h p ass t o t h e fi n g e rs
are fu lly ex p o se d t t t
N o e h a , at t h e ro o s o f t h e fi n g e rs, e ac h
. t
r v
p o ce ss di ide s in o tw o slip s t
As t h e tw o slip s p ass do rsally .

v
t h e y f o rm an arc h o e r t h e tw o fl ex o r e n do n s w h ic h p ass in o t t
t
th e t e n do n sh e a h o f t h e fi n g e r, an d h e y be co m e att a c h e d t o t
t t
t h e sh e a h o f t h e e n do n s , t o th e ran s e rse lig am e n h ich bin ds t v tw
t
t h e h e ads o f th e m e a carp al bo n e s o g e h e r, an d to t h e dee p t t
f ascia o f th e do rsu m o f t he fi n g e r D e fi n e t h e dis al bo rde r o f . t
v
th e t ran s e rse c arp al lig am e n , bu t le a e in p o si io n th e p ar t v t t
o f th e v
o lar c arp al lig am e n tw
h ic h bin ds th e u ln ar art e ry an d
v v
n e r e t o t he t t v t
o lar asp e c o f t h e ran s e rse c arp al lig am e n .

The structur e s e x p o se d by th e r e fl e ct io n o f t h e in t e r
me d iat e p art o f the p a lmar a p o n e uro sis are t h e co n t e n t s o f
t h e in t e r m e d iat e co mp art me n t O f t h e p a lm Th e y are : .

1 . The co n t in uat io n o f th e u ln ar art e ry as the su p e rfic ia l

vo lar arch .

2 . Th e d ig ita l bra n ch e s fro m th e arch to th e c le ft s be tw e e n

th e fi n g e r s an d to t h e m e d ia l sid e o f t he litt le fi n g e r .

The t e r m in a l bra n ch e s o f th e m e d ia n n e rv e .

Th e bra n ch o f th e su p e rfic ia l d ivisio n o f th e u ln ar n e rv e

to t he adjac e n t sid e s o f the r in g an d litt le fi n g e r s ,
.

Th e fl e x o r t e n do n s surrou n d e d by th e ir m uc o u s sh e ath
,
.

The p ro x ima l p art s o f t h e mucou s sh e ath s o f th e in d e x ,

midd le an d r in g fi n g e r s
,
.

Th e four lu mbr ica l m u sc le s .

F a scial Co mp a rt me nt s o f t h e Pa lm — Th e two se p ta wh ich

p a ss f ro m t h e m arg in s o f t h e in t e r m e d iat e p art o f t h e p a lm ar
a p o n e uro sis in t o t he d e p th s o f th e p a lm hav e be e n n ot e d
as th e y w e r e d iv id e d Th e y j o in a lay e r o f fa sc ia wh ich
.

lie s o n th e vo lar sur fac es o f t h e in t e ro sse ou s m u sc le s an d

t h e adductor o f t he thu mb an d t he d e e p v o lar art e r ia l
arch Th e re are th e r e fo r e in th e p alm t h r e e fa sc ial
.
, , ,

co mp art me n t s wh ich lie d e e p to th e p a lmar a p o n e uro sis

,
.

n in t e r me d iat e co m p art me n t wh ich c o n ta in s th e fl e x o r

( )1 A
t e n do n s the lu mbr ica l mu sc le s the su p e rfic ia l v o lar arch
, ,

an d its bra n ch e s an d th e t e r m in al bra n ch e s o f t h e me d ia n

,
 P L A TE IX

Ul n a r a rt e r y

D ee p bra n c h
o fu l n ara rt e r)

De e p v
o l ar

FI G . 68 — . R di
a o grap h o f a H an d in wh i c h th e i w
Arte r e s e re i j n e c te d .

No te )1 Th a t t h e i j ti
n ec o n is i nco mp l e te .

( )
2 Th at t he i vl
su p e rfic al o ar arc h is fo rm e d by t h e a n asto m o s s i
f h
o t p fi i l b
e su er c a ran c h o l
f t h e u n ar arte r w t y t he ih
p i p p lli i
r n ce s t y o c s ar e r .

3) Th t t h v l
a e di l o t ar ra a ar e r y o f the i n de xfi g
n e r is a bran c h
f th
o p fi i lv l
e su er c a o ar arc h .

( 4) Th l t i f th d p v
e re a o n o e ee o l ar arc h to t he m e t ac arp a bol nes .
 1 5 6 TH E SUPE R I OR EXTRE M I TY
th e m e d ia l sid e
f t h e a p e x o f th e hook o f t h e o s ha matu m
o .

A sh o rt d ista n c e d ista l to th e bo o k o f t he O S ha m atu m it

tur n s lat e ra lly, p ie rc e s t he se p tu m wh ich se p arat e s the m e d ia l
fro m th e in t e r m e d iat e fa sc ia l co mp art m e n t o f t he p a lm, an d
cr o sse s th e in t e r me d iat e c o mp art m e n t , ly in g be tw e e n th e
in t e r m e d iat e p art o f th e p a lm ar a p o n e ur o sis, wh ich is su p e r
ficial t o it, an d t he t e r min a l bra n ch e s o f t h e m e d ia n n e rv e
an d th e fl e x o r t e n do n s, wh ich are d e e p t o it At th e lat e ra l .

bord e r o f th e in t e r me d iat e fa sc ia l c o m p art m e n t it u n it e s w ith

a bra n ch o f th e rad ia l art e ry e ith e r the su p e rfic ial volar O r
, ,

th e rad ia lis in d ic is o r the p,

r in ce s
p p o llic is T h e arch .

lie s th e r e fo r e in the me d ia l an d in t e r m e d iat e fa sc ia l c o m

, ,

p a rt me n ts o f t h e
p a lm I n t h e m e
. d ia l co m p art m e n t it lie s

u p o n t h e fl e xo r br e v is an d o pp o n e n s d ig it i qu in t i mu sc le s an d
is cov e r e d by th e p alm ar is br e v is I n th e in t e r me diat e .

co mp art m e n t it lie s u p o n the fl e x o r t e n do n s an d the d ig ita l

bra n ch e s o f t h e me d ia n n e rv e an d it is c o v e r e d by the ,

in t e r m e d iat e p art o f th e p a lmar a p o n e uro sis .

As the u ln ar art e ry lie s o n t he tra n sv e r se car p a l liga m e n t ,

be for e it be c o me s th e su p e rfic ia l v o lar arch it g iv e s O ff a p ro ,

n da bran clc wh ich a d y to a m w th

f u
p sse s e e p l in t h e p l i t h e ,

d e e p d ivisio n o f the u ln ar n e rv e be tw e e n the a bductor ,

d ig it i qu in t i m u sc le m e d ia lly an d the fl e x o r d ig it i qu in t i
br e v is lat e ra lly That bra n ch w ill be trac e d in the d e e p
.

d isse ct io n o f the p a lm F ro m the su p e rficia l arch it se lf

.

sma ll tw ig s are g iv e n o ff to th e adjac e n t t e n do n s an d fas c ia ,

bu t t h e ch ie f bra n ch e s are t he fo u r digital arteries wh ich

Sp r in g fro m t h e co n v e x ity o f th e arch The fir st o f t h e four .

r e ma in s u n d ivid e d I t ru n s t o th e m e d ia l bord e r o f t h e
.

litt le fi n g e r a lo n g wh ich it p a sse s to t h e t e r min a l p ha la n x

,
.

Th e o th e r thr e e bra n ch e s z u d 3 rd 4 t h p a ss toward s th e

, , , ,

in t e rd ig ita l c le ft s wh e r e e ach d iv id e s at th e le v e l o f th e
, ,

ba se s o f the fir st p hala n g e s in to two bra n ch e s wh ich su p p ly

, ,

t h e sid e s o f t he adjac e n t fi n g e r s t he se c o n d su pp ly in g th e ,

litt le an d r in g fi n g e r s t h e th ird the r in g an d midd le an d th e

, ,

fo urth t h e m idd le an d in d e x fi n g e r s ( F igs 6 8 .

,

Th e r e are c e rta in p ract ica l p o in t s to be n o t e d in a ssoc ia

t io n w ith th e d ig ita l art e rie s The fir st cro sse s the lat e ra l
.

bra n ch o f th e su p e rfic ia l d iv isio n o f t h e u ln ar n e rv e an d t h e

sh o rt mu sc le s o f t h e litt le fi n g e r Th e u n d iv id e d p art s o f
th e se co n d ,
th ird an d fo urth lie in lin e w ith th e in t e r
,

d ig ita l c le ft s be tw e e n the fi n g e r s e ach is situat e d be tw e e n

 F ORE A R M AN D H AN D 1
57

a p a ir o f fl e x o r t e n do n s an d is su p e rfic ial t o a d ig ita l

n e rv e an d a lu mbr ica l m u sc le As the bra n ch e s ru n a lo n g
.

t h e sid e s o f th e fi n g e r s th e ir r e lat io n sh ip to t h e n e rve s is

Fl x e o r carp i l i
u n ar s

F le x o r d ig i to ru m su b li m i s

Ul n ar art e ry Fl x e o r c arp i rad a i li s

i
M e d an v
ne r e

D o rsa lb l
ran c h o f u n ar n e r e v R di l
a a art ry e

Su p e rfi c i lv l
a o ar art e r y
Ul nar n e r ev Trans v e rse c arp a l li g m a ent

D pb h f l
ee ran c o u n ar n e r e v Abdu c t o r p o lli i l g
c s o n us

Abd di g i i q
u ct o r t i i
u nt

D pb h f l
ee ran c o u n ar

S p fi i lp
u er c a f l art o u na

O pp di g i i
o n e ns t

Abd di g i i
uc to r t o r po lli i
q i i
c s
u nt

Su pe rfic i lv l
a o ar a rc h

Addu c t o r p lli io c s,

l
4 t h u m br c a i l v
t ra n s e rse p art .

3 rd l u mbr cal i

rst l u mbr ca i l

2n d l u mbr ca i l

FIG . 6 9 — Th e p arts in t he
. a m l wh i h
P
c i y
are d sp la e d by t he re m o a o f t h e v l
P l
a m ar Ap o n e uro s s i i
I n th e sp ec me n fro m
. c wh i h
the dra n w as tak e n wi g
t he art e r a o ar s i v l i i ii i li i
n d c s rad a s an d t h e arte r a p r n ce p s p o i
c s to o k lli i
o r i gi
n fro m th e su p e rfic a i lv l
o ar arc h .

cha n ge d ; the n e rv e s be c o me su p e rfic ia l o r v o lar an d the

art e rie s lie be h in d the n e rve s O p p o sit e the t e r min a l
.

p ha la n x t h e two art e r ie s o f e ach fi n g e r jo in to for m an arch

fro m wh ich a gr e at n u mbe r o f fin e bra n ch e s are d istr ibut e d
1
5 8 TH E SUP ER I OR EXTRE M I TY
to the p pu l o f t h e fi n g e r an d t o th e be d u p o n wh ich t h e

n a il r est s .

At t h e c le ft o f t he fi n g e r i m m e d iat e ly be for e it d iv id e s ,

e ach d ig ita l art e ry is j o in e d by the corr e sp o n d in g v o lar

m e tacar p a l art e ry f r o m t h e d e e p vo lar arch ; an d as t h e ,

bra n ch e s ru n a lo n g th e sid e s o f t he fi n g e r s th e y g iv e o ff ,

n u m e rou s tw ig s to su p p ly t h e sk in t he fl e x o r t e n do n s an d
,

t h e jo in t s o f t h e fi n g e r s .

The fi v o lar arch is n o t u n co mmo n ly abse n t in wh o l e

su p e r cial o r in
p art . I n su c h case s the dig ital arte rie s are re lace d by the v o lar
p m e ta
carp al bran ch e s o f the de e p v o lar arch .

N ervus M e dianu s
The me d ia n n e rv e was trac e d to th e
.
—

p ro x ima l bord e r o f t h e tra n sv e r se car a l liga me n t wh e n t h e

p
fro n t o f t h e for e ar m was d isse ct e d As it p a sse s f r o m t he
.

for e ar m to t he p a lm o f t he ha n d it lie s be h in d t h e tra n sv e r se

car p a l liga m e n t at th e lat e ra l marg in o f the t e n do n s Of the
fl e xo r d ig itoru m su blimis ( F ig 6 0 ) an d in c lo se re lat io n
.

w ith t he m ucou s sh e ath wh ich surrou n d s tho se t e n do n s .

N e ar t h e d istal bord e r o f the tra n sv e r se carp a l liga me n t it is

fir st flatt e n e d a n t e ro p o st e r iorly an d th e n it d iv id e s in to a
-

sma lle r lat e ra l an d a larg e r m e d ia l d iv isio n

, Th e lateral
.

divisio n g iv e s o ff a bra n ch wh ich su p p lie s t he short a bductor t h e ,

O p p o n e n s an d the sh o rt fl e x o r o f th e thu mb ; th e n it d iv id e s
in to t hr e e d ig ita l bra n ch e s o f wh ich two go to th e sid e s o f
,

t h e thu mb an d th e th ird to t h e rad ia l sid e o f t h e in d e x

fi ng e r . Th e d ig ita l bra n ch e s su p p ly the sk in t e n d o n s
x
, ,

liga m e n t s an d jo in t s o f t h e r e g io n s to wh ich th e y are dis

tr ibut e d I n add it io n th e bra n ch e s to the m e d ial sid e o f
.

t he thu mb an d th e rad ia l sid e o f th e in d e x d ig it g iv e bra n ch e s

to th e fo ld o f in t e gu me n t wh ich str e tch e s be tw e e n th e ro o t s
o f tho se d ig it s an d t h e n e rv e to th e in d e x fi n g e r a lso g iv e s
,

a bra n ch to the fir st lu mbrical m u scle .

The larg e r m e d ia l d iv isio n d iv id es in to two bra n ch e s On e .

ru ns toward s th e c le ft be twe e n the in d ex an d midd le fi n g e rs

an d d iv id e s to su pp ly th e adjac e n t sid e s o f tho se fi n g e r s be fo r e
it d ivid e s it g iv e s a m u scu lar bra n ch to the se c o n d lu m br ica l
m u sc le .Th e se co n d bra n ch o f the m e d ia l d iv isio n d iv id e s ,

in a similar m a n n e r to su p p ly th e adjac e n t sid e s o f the

,

midd le an d rin g d ig it s bu t be fo r e it d iv id e s it giv e s a

,

co mmu nicat in g tw ig to the lat e ra l bra n ch o f the su p e rfic ia l

d iv ision o f th e u ln ar n e rv e I t so me t ime s giv e s a mu scular
.
1 60 TH E SU PER I OR EXTRE M I TY
Th e sup erficial brancb p a sse s d ista lly , u n d e r cov e r o f th e
p a l m ar is b r e v is,
t o wh ich it g iv e s a t wig o f su p ply Wh ilst .

u n d e r c o v e r o f the p a lmar is br e v is it d ivid e s in t o two d ig ita l

bra n ch e s The m e d ia l o f t h e two bra n ch e s p a sse s t o th e
.

m e d ia l sid e o f th e litt le fi n g e r Th e lat e ra l bra n ch p ie rc e s .

t h e se p tu m wh ich p a sse s d o r sa lly fr o m t he m e d ia l bord e r o f

t h e in t e r m e d iat e p art o f th e p a lm ar a p o n e uro sis, an d e n t e r s
t he in t e r me d iat e co mp art m e n t o f t h e p a lm Th e r e it is j o in e d .

by a co mm u n icat in g bra n ch fro m t h e fir st m e d ial d ig ita l

bra n ch o f t he m e d ia n n e rv e , an d th e n it d ivid e s in to t wo
bra n ch e s wh ich su pp ly t h e adjac e n t sid e s o f t h e r in g an d
litt le fi n g e r s .

t
D is s e c ti o n — Af e r t h e bran c h e s o f t h e m e dian an d u ln ar
v v
n e r e s h a e be e n ex am in e d, re m o e t h e la e ral p ar o f t h e p alm ar v t t
ap o n e u ro sis f ro m t h e m u scle s o f t h e h e n ar e m in e n ce , bu t t
v t
p re se r e h e ir n e r e o f su pp ly , v
h ic h h as alre ady be e n f o u n d w .

As so o n as t h e ap o n e u ro sis is re m o e d tw o m u scle s are e x p o se d v

t t
h e y are th e abdu c o r p o llicis bre is an d t h e su p e rfi cial h e ad o f v
t h e fl e x o r p o llicis bre w s Th e abdu c o r is th e la e ral m u scle ;
. t t
p ass t h e h an dle o f t h e s cap e l be h in d its la e ral bo rde r a n d lif t t
t h e m u scle f ro m th e su bj ace n o p p o n e n s p o llic is , t h e n di ide t v
t t
t h e abdu c o r abo u t h e m iddle o f it s le n gt h ; u rn t h e p ro x im al t
tt w r
p ar o a ds it s o rig in , an d t h e dis al p ar o w ards its in se rt io n t tt .

t t
W h e n h a h as be e n do n e t h e Opp o n e n s ill be ex p o se d, an d w
t
m u s be cle an e d N ex di ide t h e sh o r fl ex o r at it s m iddle an d
. t v t
re fl e c t w
it t o ards it s ext re m i ie s Th e re fl e c io n o f t h e s h o rtt . t
w
fl e x o r ill brin g in o ie t v w
p a r s o f t h e addu c o r o f t h e h u m b, t t t
e m e rg in g f ro m be h in d t h e fl e x o r e n do n s o f t h e fi n g e rs, an d t
alo n g t h e m e dial bo rde r o f t h e o pp o n e n s p o llicis t h e e n do n o f t
t h e fl ex o r p o llicis lo n gu s ill be se e n w
it is e n clo se d in its m u co u s
t
s h e a h , wh ic h s h o u ld n o t be in j re d u .

t t
At h is s ag e t h e m u c o u s sh e a h s o f t h e fl e x o r e n do n s m ay t t
be re ex am in e d (se e p 1 34 ) by in fl a io n o r w i h t h e aid o f a
-
. t t
t
blu n p ro be .

t t
N o e t h a t h e co mm o n s h e a h h ich e n e lo p s t he e n do n s o f t w v t
t
t h e fl e x o r dig i o ru m su blim is an d th e fl ex o r dig i o ru m p ro fu n du s t
t t
e xt e n ds , f ro m t h e dis al p ar o f t h e f o re arm , be h in d t h e ran s e se t vr
t
carp al lig am e n , t o t h e m iddle o f t h e p alm I ts p ro x im al lim i . t
t
is abo u 2 5 mm abo e t h e ran s e rse lig am e n . v t
At its dis al v t . t
lim i , t w h ic h is at t h e m iddle o f th e p alm , p rac ically at th e sam e t
v t t
le e l as t h e m o s dis al p ar o f t h e su p e rfi cial o lar arc h , it t v
t t t
e rm in a e s , o p p o si e t h e in de x , m iddle an d rin g fi n g e rs , in blu n t
t
p ro tu sio n s o n t h e e n do n s o f t h e co rre sp o n din g fi n g e rs, bu t o n
its u ln ar side it is p ro lo n g e d in o an d is c o n in u o u s i h th e t t wt
t t tt
fl ex o r dig i al sh e a h o f t h e li le fi n g e r, wh ic h is p ro lo n g e d t o t h e
t
base o f t h e e rm in al p h alan x o f th e li le fi n g e r (F ig Th e tt .

t t
co n in u i y is e as ily de m o n s ra e d, if in fl a io n f ails , by m ak in g t t t
t
a sm all in cisio n in o t h e fl e x o r sh e a h o f t h e li le fi n g e r an d t tt
t
p assin g a p ro be h ro u gh t h e in cisio n an d alo n g t h e s h e a h t .

v t
Th e sy n o ial sh e a h o f t h e fl e x o r p o llicis lo n gu s re ac h es t h e
v
sam e p ro x im al le e l as t h e co m m o n fl e x o r s h e a h , an d it is p ro t
 F O RE A R M AN D H AN D
lo ndist ally , to t h e base o f t h e e rmin al p h alan x o f t he h u mb
ge d , t t .

t t t
Th e ex e n o f h is s h e a h can be in es ig a ed by a blu n p ro be t v t t t
t t
in ro du ce d h ro u gh a sm all o p e ning m ade o p p o si e t h e fi s t rt
p h alanx o f t h e h u mb t .

In so m uco us sh e ath wh ic h e n sh e ath s th e fl e x o r te n do n s o f

me case s t he
the fi n g e rs is divide d in to a m e dial and a ate ral c o m p artm e n t by a fi bro u s l
se p t u m , an d th e late ral co m art m e n t ma
p y c o m m u n ic at e w ith t h e sh e at h
o f t he fl e x o r po llicis lo n g u s by m e an s o f a sm a ap e rtu re situ ate d at ll
x
th e p ro im al m arg in o f the t ran sv e rse c arpal lig am e n t .

Lig a me n t um Ca rp i Tran sv ersum ( O T An t erio r A nn ular . .

Ligame nt ) — Th e tra n sv e r se car p a l liga m e n t shou ld n o w be

.

P lm l g a ari s o n us
M d v T v p l l g m e i an n e r e ran s e rse car a i a ent
Fl x p l e
Ul o r y o n ar a rt e r
S p fi i l v l u er c a
P l m i b vi
o ar
a ar s re s
Fl x pi edi li o r c ar ra a s

Sh o rt mu scl

Abdu c t o r p o lli ic
l g o n u

E x lli i
t e n so r p o c s
b i re v s

R di l y
a a art e r i l i
so r carp u n ar s

Ex p lli i l
t e n so r dg q i i i ti u int
o c s o n
i
p ro p r u s
Ex pi di li l g
t e n s o r ca r ra a s o n us
al bran c h f h lo v
t e u n ar n e r e
R di l v p fi i l
a a n e r e , su er c a
b h ran c

Ex pi di li t e n so r car ra a s bre vi s E x t e n so r d igi to ru m co mm u n i s an d e x t e n so r

i n di c i s p ro p ri u s

FI G .
7o .
-
Tran sve rse se c t o n i h gh
t ro u th e W ri st at t h e lvl
e e of th e Di t l s a

Ro w o f C arp a B o l ne s to sh o w t h el C arp a Tu nn e l . Th e Te n do ns o f the

Fl x Di gi te o r o ru m Su bli m i Fl x Di gi t
s, e o r o ru m P ro fu n du s , an d F x le o r
P lli i L g
o c s o n us are se e n w i th i th T l
n e u n ne .

thoroughly e x a min e d be for e it is d ivid e d t o e xp o se the

p ort io n s o f t h e fl e x o r t e n do n s wh ich lie be h in d it I t is a ,
.

th ick d e n se fi brou s ba n d wh ich str e tch e s acro ss th e v o lar

, , ,

a sp e ct o f the co n cav ity o f the ca rp u s an d co n v e rt s it in t o an ,

o st e o fibro u s tu n n el fo r th e p a ssag e o f the fl e x o r t e n do n s in t o

-

th e p a lm O n e ach sid e it is attach e d to t h e p ie r s o f

.

t h e car p a l arch v iz o n t he lateral side to t h e tu be rc le o f

,
.
,

th e n av icu lar bo n e an d t h e r idg e o f th e gr e at e r m u lta n gu lar

bo n e an d o n t h e medial side to th e p isifor m bo n e an d t h e
,

bo o k o f t h e o s ha m atu m I t s p r o x im a l m arg in is co n t in uou s .

w ith th e d e e p fa sc ia o f th e for e ar m o f wh ich it m ay be ,

V OL . 1— 11
 1 62 TH E SUPER I O R EXTRE M I TY
co n sid e r e d to be a th ick e n e d p art ; wh ilst d ista lly it is c o n
n e c t e d with t h e p a lm ar a o n e uro sis
p .

U p o n the vo lar sur fac e o f the tra n sv e r se carp a l liga me n t the

e x p a n d e d t e n do n o f th e p a lm ar is lo n gu s is p ro lo n g e d d ista lly

to the in t e r me d iat e p art o f the p almar a p o n e uro sis wh ilst ,

fro m its sid e s so m e o f th e short m u sc le s o f th e thu mb an d

litt le fi n g e r tak e or ig in C lo se to its m e d ia l attach m e n t th e
.

u ln ar art e ry an d n e rv e fin d th e ir way in to th e p a lm by p a ss
in g su p e rfic ia l to it an d d e e p to a m or e su p e rfic ia l fa sc ial
ba n d t h e vo lar carpal ligamen t wh ich is attach e d o n the
, ,

m e d ia l sid e to t he p isifo r m an d th e hook o f th e o s ha m atu m ,

an d o n t h e lat e ra l sid e to th e vo lar sur fac e o f t h e tra n sv e r se

carp al liga me n t .

The tu nn e l wh ich t h e tra n sv e r se car p a l liga m e n t for ms

w ith th e vo lar co n cav ity o f the car p u s is tra n sv e r se ly ova l in
sha p e an d it O p e n s d ista lly in to t h e in t e r m e d iat e co m art me n t
, p
o f t h e p a lm Through it p a ss the t e n do n s o f the fl e x o r
.

d ig itoru m su blimis the fl e x o r d ig itoru m p ro fu n du s the t e n do n

, ,

o f th e fl e x o r p o llic is lo n gu s an d t h e me d ia n n e rv e Th e .

re lat io n Of the t e n do n o f th e fl e x o r carp i rad ia lis to the

tra n sv e r se car p a l liga me n t is p e cu liar I t p ie rc e s th e lat e ra l .

attach m e n t o f t he liga me n t and p roc e e d s d ista lly in th e, ,

groov e o f the o s mu lta n gulu m maju s in a sp e c ia l co mp art me n t ,

p rov id e d w ith a Sp e c ia l m ucou s s h e ath .

D is s e c t io n — Cle an t h e fi bro u s h e at hs o f t h e fl ex o r t e n do n
s s
o f t h e fi n g rs an d t h e t h u mb
e Th e y lie im m e diat e ly su bj ace n t
.

to th e p rfi cial f ascia an d t h e d ig ital v e s e l an d n e rve s an d

su e s s ,

t h e y bin d t he t n do n s to t he vo lar asp e cts o f t he p h alan ge s an d

e
t h e in t e rp h alan g e al j o in ts .

Flex o r Sh e at hs — I mm e d iat e ly su bjac e n t to t h e sk in ,

t he su p e rfic ia l fa sc ia an d t h e vo lar d ig ita l art e r ie s an d

n e rv e s lie t h e fi brou s sh e ath s wh ich bin d t he fl e x o r t e n do n s
,

to the vo lar surfac e s o f the p ha la n g e s an d to t he vo lar ,

acc e ssory liga me n t s o f t h e me tacarp o p ha la n g e a l an d in t e r -

p ha la n g e a l jo in t s Each fi brou
. s s h e ath co n sis t s o f a n u m b e r
o f p art s o f wh ich th e two stro n g e st t he digital vagi n al ,

ligaments lie o pp o sit e th e bod ie s o f an d are attach e d to the

, ,

m arg in s o f t h e fir st an d se co n d p ha la n g e s
,
Such stro n g ba n d s .

p lac e d O pp o sit e t h e m e tacar o

p p ha la n g e a l a n-
d in t e rp ha la n ge a l
jo in t s wou ld se riou sly in t e r fe r e w ith th e ir mo ve m e n t s ; th e r e for e ,

in tho se r e g io n s w e ak e r tra n sv e r se ba n d s t he ann u lar liga

, ,

ments are fo r m e d
, I n add it io n cruc iat e ba n d s
.
,
t h e cru ciate —
1 64 TH E SUPER I O R EXTRE M I TY

p ha l a n g e a l jo ints f or m s ,
in e
, ach fi n g e r a n o st e o fibro u s ,
-

ca n a l in wh ich are e n c lo se d t he t e n d o n s o f the fl e x o r

,

d ig it o ru m su blim is an d the fl e x o r d ig itoru m p ro fu n du s

t o g e th e r w ith th e ir surr o u n d in g m uc o u s sh e ath .

L e av e the fi brou s sh e ath o f t h e m idd le fi n g e r in tact

fo r r e v isio n bu t O p e n th e o th e r fi br o u s sh e ath s by lo n g i
,

t u din al in c isio n s Th e y w ill be se e n to be lin e d w ith a

.

m ucou s sh e ath wh ich is r e fl e ct e d ov e r the e n c lo se d t e n d o n s

so as to g iv e e ach a se p arat e in v e st m e n t E x a min e the e x t e n t .

o f e ach m uc o u s sh e ath w ith t h e aid o f a blu n t p r o be The .

m ucou s sh e ath O f t h e litt le fi n g e r h as be e n se e n to be a d ir e ct

p ro l o n gat i o n fro m th e co mm o n m ucou s sh e ath o f the fl e x o r

t e n do n s the oth e r thr e e are d ist in ct fro m that bu t th e y are ,

carr ie d p ro x ima lly in to the p a lm Th e y e n v e lo p th e t e n do n s

.

O f th e r in g in d e x an d m idd le fi n g e r s as far as a lin e draw n

, ,

acr o ss the p a lm imme d iat e ly p r o xima l to the h e ad s o f the

m e tacar p a l bo n e s .

I f t h e fl e x o r t e n d o n s are ra ise d fro m th e p ha la n g e s c e rta in ,

m ucou s fo ld s w ill be n ot ic e d c o n n e ct in g th e m to th e bo n e s .

Th e se are t e r me d the vincu la ten din u m Two k in d s o f .

th e m are d ist in gu ish e d v iz v in cu la br e v ia an d lo n ga I n the

,
.
,
.

acc o mp a n y in g illu strat io n ( F ig 7 2 ) th e c o n n e ct io n s o f th e se

.

m ay be se e n . Th e vin cu la brevia are tr ia n gu lar fo ld s

wh ich c o n n e ct the t e n d o n s n e ar th e ir in se rt io n s to the
, ,

v o lar a sp e ct o f th e m o r e p ro x ima l p ha la n x The vincu la .

lo nga are n o t in var ia bly p r e se n t Th e y are p lac e d m o r e

.

p ro x im a lly ,
a n d are n arrow w e ak s tra n d s wh ich p a ss be tw e e n
,

t h e t e n do n s an d th e bo n e s .

I n se rt io n s o f t h e F lex o r Te n do n s Th e in se rt io n s o f the
.
—

two fl e xo r t e n do n s c an n o w be stud ie d O n the vo lar sid e o f .

t h e fir st p ha la n x t h e t e n d o n o f th e fl e x o r su blim is be c o m e s
flatt e n e d an d fo ld e d r o u n d the su bjac e n t cy lin drica l t e n d o n
Of t h e fl e x o r p r o fu n du s I t th e n sp lit s in to two p art s
.
,

wh ich p a ss dor sa l to t he t e n do n o f the fl e x o r p r o fu n du s ,

an d a llow th e latt e r t o p roc e e d o n ward s be tw e e n th e m .

D o r sa l t o t h e d e e p t e n do n t h e t wo p o rt io n s o f t h e t e n do n
O f t h e fl e x o r su blim is f u se t o g e th e r an d th e n aga in th e y
, , ,

d iv e rg e to be in se rt e d in to th e bo rd e r s O f th e body o f th e
,

se co n d p ha la n x . B y th is arra n g e m e n t t h e flatt e n ed t e n do n
o f t h e fl e x o r su blim is for m s a r in g o r short tu bu lar p a ssag e, ,

through wh ich the t e n d o n o f th e fl e x o r p r o fu n du s p roc e e d s

o n ward s t o t h e ba se o f th e u n gua l p ha la n x in to wh ich it is ,
 F ORE A R M AN D H A N D

in se rt e d I n e ach o f th e fo ur fi n g e r s t h e sa m e arra n g e m e n t
.

is fou n d ; t h e t e n d o n o f the fl e x o r su blimis is in se rt e d by two

slip s in to t h e m arg in s o f t h e v o lar sur fac e o f th e se co n d

p ha la n x , wh ilst th e t e n do n o f t h e fl e x o r p r o fu n du s is in
se rte d in to t h e vo lar a sp e ct o f the ba se o f th e t e r m in a l
p ha lanx .

D iss e c t i o n — Op e n t h e carp al u n n e l by m ak in g a e rt ical t v

t
in cisio n h ro u gh t h e m iddle o f t h e ran s e rse carp al lig am e n t v t .

t
Cle an t he m u c o u s s h e a h s f ro m t h e fl ex o r e n do n s , a n d se p ara e t t
t
t h e e n do n s f ro m o n e an o h e r, bu t be c are fu l n o t t o in j u re t h e t
lu m brical m u scle s w
h ic h sp rin g fro m t h e e ndo n s o f t h e fl ex o r t
t
dig i o ru m p ro fu n du s B e c are fu l also n o t t o in j u re t h e n e r e s
. v
Co ll at e ra li n te rp ha la n
o r sh e a t h
g l li g
ea

m e t a carp o
p ha l g l li g
an ea ame n t

bre v i a
Vi n cu a l l g o n a

FI G .
7 2 .
— Fl x e o r Te n do ns o f t he Fi g w i th V i
n er l
n cu a te n d n u m i .

of Su p p ly fro m th e la e ral tw o lu m bric als Th e y are t ig s f ro m . tw

t
t h e dig i al bran c h e s o f t h e m e dian n e r e , an d h a e alre ady be e n v v
fo u n d . v
Th e n e r e s t o t h e m e dial tw o lu m bricals are fro m t h e
v
de e p di isio n o f t h e u ln ar n e r e Th e y ill be f o u n d at a la e r v . w t
t
s ag e o f t h e disse c io n t
Cle an t h e lu m brical m u scle s an d h e n
. t
e x am in e t h e arran g e m e n t
o f t h e fl ex o r e n do n s an d t h e o rig in s t
an d in se rt io n s o f t h e lu m brical m u scle s .

Flex o r Te n do ns ur t e n do n s o f the dex o r sublimis

.
— The fo
are arra n g e d in p a ir s d e e p t o t h e tra n sv e r se car p a l liga m e n t ;

tho se fo r the litt le an d t h e in d e x fi n g e r s lie dorsal to tho se

fo r th e r in g an d m idd le fi n g e r s O f th e t e n do n s o f th e .

u ndus o n ly that fo r t h e in d e x fi n g e r is d ist in ct an d

fl e x o r p f
ro ,

se p arat e t h e o th e r thr e e as a ru le r e m a in u n it e d u n t il th e y , ,

e me rg e fr o m u n d e r cov e r o f t h e d ista l bord e r O f t h e tra n sv e r se

carp a l liga me n t .

I n t h e in t e r m e d iat e co mp art m e n t o f th e p a lm t he fl e x o r
t e n do n s d iv e rg e fro m e ach oth e r an d two v iz o n e fro m the , , .
,

fl e x o r su blim is an d o n e fro m t h e fl e x o r p r o fu n du s go to e ach

, ,

o f t h e fo ur fi n g e r s F ro m th e t e n do n s o f th e fl e x o r p ro fu n du s
.

th e lu m br ica l m u sc le s tak e o r ig in an d th o se m u sc le s an d t h e , ,

vo lar d ig ita l n e rv e s an d art e r ie s w ill be se e n o ccu p y in g th e ,

1— 11 b
 1 66 TH E SU PER I OR EXTRE M I TY
in t e rva ls be tw e e n t h e t e n do n s as th e y app r o ach t h e r o o t s o f
the fi n g e r s .

I n t h e fingers th e t wo fl e x o r t e n d o n s ru n d ista lly, u p o n

t h e vo lar a sp e ct s o f t h e p ha la n g e s, an d are h e ld in p o sit io n
by th e fl e x o r sh e ath s, wh ich hav e a lr e ady be e n stud ie d .

Th e t e n d o n O f t h e fl ex o rp o llicis lo ngu s occu p ie s th e lat e ra l

p art o f t h e tu n n e l an d ga in in g t h e p a lm tur n s lat e ra lly to
, , ,

r e ach th e t e r min a l p ha la n x o f th e thu mb .

Te n do n o f t h e F lexo r P o llicis L o ngu s — The t e n do n o f

t h e lo n g fl e x o r o f t h e thu mb p roc e e d s d ista lly in t h e in t e rva l ,

be tw e e n two o f t h e sh o rt m u sc le s o f the thu mb ( viz t he .

,

su e rfic ia l h e ad o f t h e fl e x o r p o llic is br e v is an d t h e o bliqu e

p
p art o f t h e adduct o r p o llic is
) an d a lso in t h e in t e rva l be tw e e n ,

th e two se sa mo id bo n e s wh ich p lay u p o n th e h e ad o f t he

m e tacar p a l bo n e At t h e ba se o f t h e p r o x im a l p ha la n x it
.

e n t e r s a fi brou s fl e x o r sh e ath co n struct e d u p o n a sim ilar

p l a n to tho se o f t h e fi n g e r s an d p a sse s a lo n g it to t h e ba se ,

o f t h e t e r min a l p ha la n x in to wh ich it is in se rt e d ,
Th e .

m uc o u s sh e ath wh ich surr o u n d s th e t e n do n dur in g it s

p a ss ag e thr o ugh t h e car p a l tu n n e l is co n t in u o u s w ith t h e

sh e ath wh ich in v e st s t h e t e n do n in f ro n t o f t h e p ha la n g e s .

M m Lumbrica les
.
— The lu m br ica l mu sc le s are four sle n d e r
.

fl e shy be llie s wh ich arise fr o m the t e n d o n s o f the fl e x o r

d ig itoru m p ro fu n du s as th e y trav e r se t he p a lm The first .

lu mbrical ar ise s fro m th e lat e ra l sid e o f th e t e n d o n fo r t h e

in d e x fi n g e r ; t h e seco n d lu mbrical sp rin g s fro m t h e lat e ra l
bord e r o f th e t e n d o n fo r th e m idd le fi n g e r ; wh ilst t h e t/zird
an d f o u rtlc lu mbricals tak e O r ig in fr o m t h e adjac e n t sid e s o f

t h e t e n d o n s be tw e e n wh ich th e y lie ( v iz t h e t e n do n s fo r .
,

th e midd le r in g an d litt le fi n g e r s)
, ,
Th e litt le m u sc le s p a ss .

d ista lly an d e n d in d e licat e t e n d o n s o n th e lat e ra l sid e s o f

,

th e fi n g e r s Each t e n do n is in se rt e d in t o the lat e ra l margin

.

o f t h e e x p a n sio n O f t h e e x t e n so r t e n do n wh ich lie s u p o n t h e ,

d o r sal a sp e ct o f the p ro x im a l p ha lan x .

D iss e c ti o n — D iv id t h fl o r dig it r m p r f n d s in t h e e e ex o u o u u
f r arm a d t r t h di t l p rt t w ard t h fi g rs
o e ,
n u n e As t h e
s a a o s e n e .

t do a d t h l m bri al m l w h i h ar attach d t t h m
en ns n e u c u sc e s c e e o e
ar erai d s c r t h fi n tw ig
se , e uf pp ly w h i h p a
e e t th e s o su c ss o e
m dial tw l m bri al fr m t h d p div i i n f t h
e o u c s l ar o rv e ee s o o e u n ne e.
Th y e r a ily f o
a e d if o rdi ry
e s a ti n i un b rv e d Th na c u o s o se . e
d p v lar ar h a d t h d p div i i
ee o c f th
n ln ar n rv ar n w
e ee s o n o e u e e e o
ex po d se Cl an b t h t h
. e ar h a d t h orv an d t ra eth e c n e ne e, ce
br n h a c f t h n rv t t h i t r s i m u cl an d t t h add t r
es o e e e o e n e o s e s es o e uc o

p lli is a d t h e de p h ad f t h e fl
o c n r p lli is br vi
e e Th e n o exo o c e s .
1 68 TH E SUP ER I OR EXT R E M I TY
d e e p to the fl e x o r t e n do n s N e ar the lat e ra l bord e r o f th e
.

p a lm t h e d e e p b ra n ch o f t h e u ln ar n e rv e br e ak s u p in to

t e r min a l tw ig s wh ich su pp ly the adductor p o llic is an d the first

dor sa l in t e ro sse ou s mu scle I n its cour se acro ss the p a lm it
.

lie s a lo n g t h e co n cav ity o r p ro x ima l bord e r o f th e d e e p vo lar

arch an d se n d s thr e e fin e bra n ch e s d ista lly in fro n t o f the
,

thr e e in t e ro sse ou s Sp ac e s Th e y su pply the in t e ro sse ou s

.

mu sc le s in th e sp ac e s wh ile th e me d ia l two g iv e bra n ch e s

,

O pi m O l m s ca t at u s u n at u

O s h a ma t u m
Os t riq u e t ri i m
Opp i l i
g
o n e ns le x p r carp u n ar s
Abdu c to r po 11le i s l s p i s i fo rme

igi i q i i
Abdu c t o r d t u nt
x igi i
e o r d t
q i i vi
u nt bre s
Fl x
e
p l o r c ar i u n ari s

Fl x
e o r c arp i i li
rad a s

O pp o n e ns d igi i q i i
t u nt

a lm i
ar n t e ro sse i

Addu c t o r po lli i
c s

FI G .
73 .
— Vo l ar asp e c t o f th e B o ne s o f th e C arp u s an d M e tacarp u s
w i th M u scu l ar Attach m e n ts m app e d o u t .

also to th e me d ia l two lu mbrica l mu sc le s The th ird .

lu mbr ica l h as fr e qu e n t ly a dou ble n e rv e su p p ly ; it r e c e iv e s

a bra n ch fro m the d e e p p art o f the u ln ar n e rv e an d no t , ,

u n co m mo nly a se co n d tw ig fro m the m e d ia n n e rv e e n t e r s

,

its vo lar a sp e ct .

The d e e p bra n ch o f the u ln ar n e rv e m ay th e r e fo r e be sa id , ,

to su pp ly all th e mu sc le s o f the p a lm wh ich lie to t he me d ia l

sid e o f t h e t e n do n o f t he fl e x o r p o llic is lo n gu s wh ilst th e ,

me d ia n n e rv e su p p lie s th e thr e e m u sc le s w h ich lie to th e

lat e ra l sid e o f that t e n do n Th e r e are two e x c e p t io n s to th is
.

g e n e ra lisat io n v iz the lat e ra l two lu mbr ica l mu sc le s wh ich lie

,
.
, ,
 F ORE A R M AN D H AN D 1 69

upon t he me d ia l sid e o f th e t e n do n ,
an d are y e t s u pplie d
by t he m e d ia n ne rv e .

D iss e c ti o n — Cle an t h e . addu c o r o t f th e th u mb an d then

ex am in e t h e s h o rt m u scle s o f th e t h u mb an d re vi e s th e sh rto
m u scle s o f t h e litt le fi n g e r .

Th e Sh o rt M uscle s o f t h e Thumb Thr e e o f th e short -

m u sc le s o f t h e thu mb hav e a lr e ady be e n d isse ct e d All four .

are n o w d isp lay e d , w ith t h e e x c e p t io n o f t h e d e e p h e ad o f

th e s hort wh ich ca n n ot be se e n u n t il th e adduct o r

fl e xo r,

h as be e n r e fl e ct e d Th e ir r e lat io n s an d attach m e n t s
.

shou ld n o w be stud ie d Thre e o f the four the a bduct o r

.
,

p o llic is b r e v is t h e su p,e rfic ia l h e ad o f th e fl e x o r p o llic is

br e v is an d th e O pp o n e n s p o llic is lie o n th e lat e ra l sid e O f

the t e n do n o f t he fl e x o r p o llic is lo n gu s the fourth m u sc le ,

t h e adductor p o llic is is o n t h e m e d ia l sid e o f that t e n do n

,
.

The abdu cto r po llicis brevis for m s th e m o st p ro m in e n t an d

lat e ra l p art o f t h e ba ll o f th e thu mb The superficial bead .

of fire fi ex o r p o llicis brevis is imm e d iat e ly m e d ia l t o t h e

a bduct o r ; the oppo n ens is d e e p to both o f th e m an d is
e x p o se d wh e n th e y are p u lle d a p art o r wh e n th e y are ,

r e fl e ct e d The fan sha p e d addu cto r po llicis lie s d e e p ly i n

.
-

th e p a lm I t is imp e r fe ct ly se p arat e d in to a p ro x im a l o r
.

O bliqu e p ort io n an d a d ista l or tra n sv e r se p ort io n Th e .

se p arat io n is p roduc e d by t he rad ia l art e ry as it e n t e r s t h e

p a lm through the fir st in t e ro sse o u s sp ac e The d e e p h e ad .

o f t h e fl e x o r p o llic is br e v is is co n c e a le d b t h e adductor
y ,

an d ca n n ot be se e n at th is stag e o f t h e d isse ct io n .

The bra n ch o f th e m e d ia n n e rv e wh ich su p p lie s t he

thr e e mu sc le s wh ich lie lat e ra l to the t e n do n o f the
fl e x o r p o llic is lo n gu s h as a lr e ady be e n f ou n d ( p .

an d th e tw ig s to t h e adductor wh ich are d e r iv e d fr o m th e

d e e p bra n c h o f the u ln ar n e rv e hav e a lso be e n trac e d ( p .

M Abduc t o r P o llic is B re vi s
. Th e short a bductor o f t h e —

thu mb ar ise s fro m th e v o lar a sp e ct o f the tra n sv e r se carp a l

liga me n t an d fro m th e r idg e o n t h e o s m u lta n gu lu m
maju s I t is in se rt e d in to th e lat e ra l se sa m o id bo n e o f
.

th e thu mb in t o t h e lat e ra l sid e o f t he ba se o f t h e fir st

,

p ha la n x a n d, t o a sl ight e x t e n t in to t h e e x t e n sor t e n do n

o n t h e dor su m o f t h e fir st p ha la n x I t is su p p lie d by t h e .

median n erve .

M . F le x o r P o llic is B re vis ( C a p u t Sup e rfi cialis) .

— The
1 7 0 TH E SUP ER I OR EXTRE M I TY
s u p e rfic ia l h e ad o f the short fl e x o r o f th e thu mb tak e s orig in
fro m t h e tra n sv e r se car p a l liga me n t I t is in se rt e d in to t he
.

lat e ra l se sa m o id bo n e o f t h e thu mb an d in to t h e lat e ra l sid e ,

o f t he p ro x im a l p ha la n x an d it is su p lie d by th e median
, p
o r th e d e e p h e ad se e be lo w
n erve .
( F ) .

M O pp o n e n s P o llicis
. Th e O p p o n e n s m u sc le o f t h e
—

thu mb sp rin g s fro m the tra n sv e r se car p a l liga me n t an d the

r idg e o n the vo lar surfac e o f th e O S m u lta n gu lu m maju s I ts .

fi br e s sp re ad o u t as th e y a p p roach th e ir in se rt io n in to th e
wh o le le n gth o f t he rad ia l bord e r an d the adjac e n t p art o f the
v o lar surfac e o f the m e tacarp a l bo n e o f the thu mb I t is .

su p p lie d by t h e median n erve .

M Addu ct o r P o llic is
. The adductor Of th e thu mb
—

co n sist s o f an o bliqu e an d a tra n sv e rse p art The o bliqu e .

p art ar is e s f ro m t h e o s ca p itatu m a n d t h e ba se s o f,
t h e

se c o n d an d th ird m e tacar p a l bo n e s n so m e
( g
F i I .

ca se s it has a slip o f orig in fro m the o s m u lta n gu lu m min u s .

The tra n sv e r se p art sp r in g s fro m th e d istal two th ird s Of th e -

vo lar bord e r o f the th ird m e tacarp a l bo n e The two p art s .

c o n v e rg e as th e y p a ss to th e ir in se rt io n in to the me d ia l
se sa m o id bo n e o f t he thu m b an d t h e m e d ia l sid e o f it s

p ro x im a l p ha la n x I n m a n.y ca se s a slip o f m u s c le fi b r e s le av e s

t he lat e ra l sid e O f t he O bliqu e p art o f t h e adductor p a sse s ,

dor sa l t o the t e n do n o f t he fl e x o r p o llic is lo n gu s an d fu se s ,

w ith the su p e rfic ia l h e ad O f the fl e x o r p o llic is bre v is B o th .

p art s o f t h e m u sc le ar e s u pp lie d by tw ig s fro m t h e d e e p

d ivisio n O f the u ln ar n erve .

At th is stag e o f the d isse ct io n t h e short m u sc le s o f th e

litt le fi n g e r t he ,
a bductor t he short fl e x o r an d th e
,

o pp o n e n s shou ld be r e v ise d ( se e p
,
.

D is s e c ti o n — To disp lay th e bran c h e s o f th e p alm ar p art s o f

r
t h e adial a rt e ry an d t h e de e p h e ad o f t h e fl e x o r p o llicis bre is, v
cu t t t
h ro u gh th e tw o p ar s o f th e addu c o r p o llicis m idw ay t
be tw
ee n t t
h e ir o rig in s an d in se r io n s, an d u rn t he se p ara e d t t
p o rt io n s aside Th e de e p h e ad o f t h e fl ex o r p o llicis bre is lie s
. v
alo n g t h e u ln ar bo rde r o f t h e m e ac arp al bo n e o f t h e t h u mb, t
a n d t h e radial ar e ry t w
ill be f o u n d e n e rin g t h e p alm be ee n t tw
t
th e tw o h e ads o f t h e fi rs do rsal in e ro sse o u s m u scle at t h e t
p r o x im a l e n d o f t h e fi rs in e rot t
sse o u s S p a c e I ts las t w o bra n c h e s , . t
t h e p rin ce s p o llic is an d t h e
p v
o lar radial a rt e ry o f t h e in de x
fi n g e r, sp ri n g fro m it as so o n as it e n e rs t h e p alm , an d h ils t w t
t
it s ill lie s be h in d t h e o bliq u e p art o f t h e addu c o r p o llicis t .

Th e De ep H e ad f t h e Fle x o r
o P
o llici s Bre i s — This v w e ak sli
p f o

m u scle lie s alo n g t he m e dial side o f th e m e t acarp al bo n e o f th e th u m b

1 7 2 THE SU PER I OR EXTR E M I TY
is e v ide n t at th at e v e l l l
The lin e s a o n g wh ic h in cisio n s sh o u d be m ade
. l
in to the v o lar c o m p art m e n ts o f the p alm an d the m u co u s sh e ath s o f the
fl e x o r t e n do n are sh o w n in F ig 7 1 . .

The fi n g e rs are su bj e c t t o an in fl am mato ry p ro ce ss, t e rm e d w bit lo w ,

an d, in co nn e c tio n w ith th is, it is e sse n tia t o re m e m be r th at th e fl ex o r l
fibro u s sh e ath e n ds o n th e base o f the distal p h alan in e ach dig it x .

l
W h e n the wh itlo w o ccu rs m o re dista ly , in the p u lp o f the fin g e r, the v ita ity l
o f t h e dist al p art o f th e u n gu al p h alan x
is e n dan g e re d, bu t the fl e x o r
t e n do n s m ay be re g arde d as be in g t o le rab y safe l
W h e n th e in fl am matio n .

o ccu rs m o re
p ro im allx
y , an d in v o lv e s the fl e x o r sh e ath , as it g e n e ra y do e s, ll
slo u gh in g o f t he t e n do n s is t o be app re h e n de d, u n le ss an im m e diate
o p e n in g is m ade N o sligh t su p e rfi cial incisio n w ill su ffi ce
. The .

kn ife m u st be carrie d de e p in to the ce n tre o f the fin g e r, so as to fre e ly

lay o p e n the sh e ath co n t ain in g the t e n do n s Early in t e rfe re n ce in c ase s.

o f wh itlo w o f th e t h u m b an d little fin g e r is e v e n m o re u rg e n t ly re q u ire d

t h an in t he c ase o f th e o t h e r th re e digit s, be c au se the digit al m u co u s

sh e ath s o f th e fo rm e r are , as a ru le , co n n e ct e d w ith th e g re at co m m o n

m u co us sh e ath o f the fl e x o r te n do n s, an d so o ffe r a re ady m e an s fo r the

x x
p ro im al e t e n sio n o f the in flam m ato ry actio n .

x
Ev e ry am pu tatio n o f th e fin g e rs p ro im al to the in se rtio n o f th e te n do n s
o f th e fl e x o r p ro fu n du s in v o lv e s t he O p e n in g o f th e fl e x o r sh e ath s, an d n o

x
do u bt e p lain s th e o ccasio n al o c cu rre n ce o f p alm ar t ro u ble afte r o p e ratio n s
o f t h at kin d The o p e n tu be s o ffe r a re ady p assag e by m e an s o f wh ich
.

x
se p tic m at e rial m ay t rav e l p ro im ally in to t h e p a m , an d, in th e c ase o f l
t he t h u m b an d litt le fi ng e r, in to the c arp al tu n n e l an d distal p art o f t he
fo re arm .

D O R SU M AN D L ATER A L B O R D ER OF TH E F O R EA R M .

Th e structur e s wh ich st ill r e ma in to be d isse ct e d in th is

r e g io n are
I . Th e su pin ato r an d e te n so r mu scle s x .

2 . l
The do rsa in te ro sse o u s arte ry .

3 . The p e rfo ratin g o r t e rmin al bran c h o f t he v o lar in te ro sse o u s arte r y .

4 . The do rsal in t e ro sseo u s n e rv e .

B e fo re d isse ct io n
is p roc e e d e d w ith , t h e cuta n e o u s
th e
v e in s an d n e rv e s an d the d e e p fa sc ia , p r e v iou sly d isp lay e d ,
shou ld be re e xa m in e d Th e two m a in cuta n e ou s v e in s
-
.

are se e n B oth a sc e n d fro m t h e v e n o u s p le x u s o n t h e

.

d o r su m o f th e ha n d , an d both turn rou n d a bo rd e r o f th e

fo r e ar m to ga in it s vo lar sur fac e , bu t wh ilst t he c e p ha lic
v e in turn s rou n d t he d ista l th ird o f t h e rad ia l bord e r the ,

ba silic a sc e n d s to a m uch m o r e p ro x ima l le v e l be for e it

tur n s rou n d the u ln ar bo rd e r .

The cuta n e ou s n e rv e s are four in n u m be r Th e

dor sa l bra n ch o f the lat e ra l cuta n e ou s n e rv e o f the for e ar m
, ,

o n t h e lat e ra l sid e ; ( 2 ) t h e dor sa l bra n ch o f t h e m e d ia l

cuta n e ou s n e rv e o f th e fo r e ar m o n th e m e d ia l sid e ( 3 ) in the

 F ORE A R M AN D H AN D 1 73

in t e r m e d iat e ar e a the d ista l bra n ch o f the dor sa l cuta n e o u s

n e rv e o f t h e fo r e ar m e su p e rfic ia l d iv isio n O f t h e rad ia l
( )
4 t h
n e rv e a e ar i n g fr o m u n d e r cov e r o f th e brach io rad ia l i
pp s -

a bout 8 c m in ch e s) p ro x im a l t o t he wr ist
. Thu s thre e O f .

t h e t e r m in a l bra n ch e s o f t he brach ia l p le x u s are r e p r e se n t e d

o n t he dor su mo f t he fo r e ar m t h e m u scu lO cuta n e ou s n e rv e — -

by the lat e ra l cuta n e ou s n e rv e o f t h e fo r e ar m ; t h e m e d ia l

cuta n e o u s n e rve o f the fo r e ar m ; an d th e rad ia l n e rv e by
it s su p e rfic ia l d iv isio n an d by t he dor sa l cuta n e o u s n e rv e
,

O f t h e for e ar m

I n t he dor su m o f th e ha n d t he d istr ibut io n o f t h e su p er

ficial bra n ch o f th e rad ia l n e r ve an d t h e dor sa l bra n ch O f
t h e u ln ar n e rve hav e a lre ady bee n e x a m in e d ( p p 7 1 .
,

t h e rad ia l n e rv e su pp lie s t h e gr e at e r p art o f t h e sk in o f

t h e dor su m O f t h e ha n d an d thr e e an d a ha lf d ig it s t he —

thu mb an d the p ro x ima l p art s o f the in d e x the m idd le

, , ,

an d ha lf t h e r in g fi n ge rs wh ilst the d o r sa l bra n ch O f the

—

u ln ar n e rv e su pp lie s th e r e ma in in g ha lf o f the r in g fi n g e r an d
t h e litt le fi n g e r Th e sk in o f t h e d ista l p art s o f t h e in d e x
.
,

t h e m idd le an d ha lf t h e r in g fi n g e r s is su p p lie d as a lr e ady

, ,

n ot e d tw g d g ta ra ch
(p . b y i s o f t h e i i l b n e s o f t h e

me d ia n n e rv e .

D is s e c t i o n — R m v e t h c t an o . e v l an d n rves fro m
o e u e us e sse s e
t h do r u m o f t h f re arm a d h an d t h n r v i
e s e o t h d e p f ascia
n ,
e e se e e .

Th e De ep F a sc ia — Th e d e e p fa sc ia o f t h e d o r su m o f th e
.

fo r e ar m is stro n g e r tha n t h e d e e p fa sc ia o f t h e vo lar a sp e ct .

I ts p r o x ima l p art is str e n gth e n e d by e x p a n sio n fr o m t he

tric e p s an d n e ar the e lbo w it is in t im at e ly co n n e ct e d w ith
,

t he m u sc le s o f th e back o f t h e for e ar m wh ich tak e p art

O f th e ir o r ig in fro m it s d e e p sur fac e I t is c lo se ly attach e d .

to t h e who le le n gth o f th e d or sa l bord e r O f t he u ln a an d ,

in th e r e g io n s o f th e d ista l e n d s o f the rad iu s an d u ln a an d

t h e back o f t he car p u s it is th ick e n e d by n u m e rou s tra n s
v e r se fi br e s wh ich c o n st itut e th e liga me n tu m carp i d o r sa le .

D is s e c t io n — Th e d r al carp al lig am t m t b l ft i n s i t
o s en us e e u

u t il t h
n di e t io n f t h e d r al p art o f th f arm a d h an d
sse c o o s s e o re n

i
s co mp l t d T e e r it. re t oti i a se cu e i j r d dit i
s en o n n n un n u e co n o n,

i l t it by c tt i g ar f lly t h r gh th d p f
so a e u n c i p ar ll l w it h
e u o u e ee as c a a e

it p ro im al b rd r
s x W h il t m ak i g t h i i i
o e . ar m s tb n e nc s o n, c e us e

tak n t e av id in j ry t o t h
o o m co u h at h f t h t er u us s e s o e e x e n so
t do w h i h li im m di t ly bj
en ns c e t t th d p fa ia
e a e su a ce n o e ee sc .

Wh t h f ro n t
en f t h f re rm w a di
e o t d th radi l fl ap f
e o a s sse c e , e a o

de e p fascia w as re fl e ct e d o n ly as f ar as t he radial bo rde r o f the

1 74 T H E SU PER I OR EXTRE M I TY
f o re arm t
N o w co n in u e t h e re fl e ct io n u n il t h e a t ac h m e n o f
. t t t
t
t h e fl ap t o t h e p o s e rio r bo rde r o f t h e u ln a is re ac h e d As t h e .

t
re fl e ct io n p ro ce e ds , t h e in e rm u scu lar se p a h ic h p ass fro m th e t w
de e p su rf ace o f t h e de e p f ascia be tw
e e n t h e m u scle s o f t h e do su m r
o f t h e f o re arm m u s be di ide d t v .

Su p e rfi c ia l M u scle s Th e m u sc le s in th is r e g io n co n sist
—

O f a su p e rfic ia l an d a d e e p grou p Th e superficial muscles, .

n ame d fro m t h e lat e ra l t o th e m e d ia l bord e r o f t h e

fo r e ar m, ar e z — ( r) t h e brach io rad ia lis ; ( 2 ) the e x t e n sor -

carp i rad ia lis lo n gu s ( 3 ) t he e x t e n sor car p i rad ia lis bre v is ;

x t e n sor d ig itoru m co mm u n is t n sor d ig it i
( ) h 5) h
'

4 t e e t e e x e

qu in t i p ro p riu s ( 6 ) t he e x t e n sor carp i u ln ar is an d ( 7 ) th e

an c o n a e us .Th is gr o u p th e r e fore c o m p rise s o n e fl e x o r O f
t h e e lbow , thr e e e x t e n sor s o f t h e wr ist , t wo e x t e n so r s o f t h e
fi n g e r s, an d a fe e ble e x t e n sor o f the for e ar m at the e lbow
j o in t, v iz , the an co n aeu s I n the d ista l p art o f the fore ar m
. .

t h e e x t e n sor d ig it o ru m c o m m u n is is se p arat e d fro m t h e

e x t e n sor car p i rad ia lis br e v is by a n arrow in t e rva l, in wh ich

a p p e ar two m u sc le s be lo n g in g to th e d e e p grou p The t wo .

m u sc le s in qu e st io n tur n rou n d th e lat e ra l m arg in o f t he fore

arm , su p e rfic ia l t o t h e rad ia l e x t e n sor s o f t h e wr ist , an d e n d in

t e n do n s wh ich go to the thu m b The p ro x im a l o f the two .

m u sc le s is the a bductor p o llic is lo n gu s, th e d ista l is t h e

e x t e n so r p o llic is br e v is, bu t th e y lie in such c lo se co n tact ,

an d so in t im at e ly are th e ir t e n do n s co n n e ct e d , that in m a n y

ca se s th e y ap p e ar , at first sight, to be ble n d e d t o g e th e r by th e ir

m arg in s . Aft e r th e y hav e be co me su p e rfic ia l, t he a bduct o r
p o llic is lo n gu s an d th e e x te n so f p o llic is br e v is tur n rou n d

t h e rad ia l bord e r O f t h e for e ar m su p e rfic ia l to t h e rad ia l

e x t e n sor s O f t h e wr ist , an d as th e y d e sc e n d to t h e thu m b

th e y lie in th e gro o v e o n the lat e ra l sur fac e o f th e sty lo id

p r o c e ss o f th e rad iu s in wh ich th e y are r e ta in e d by t h e

m o st lat e ra l p art o f t h e dor sa l car p a l liga m e n t ( F ig .

A short d ista n c e p ro x im a l to t he dor sa l car p a l liga m e n t

o n t h e rad ia l sid e o f th e t e n do n s o f t h e e x t e n sor d ig itoru m

a th ird m u scle o f th e d e e p grou p a lso co m e s in t o v ie w ; it is ‘

t h e e x t e n sor p o llic is lo n gu s I t s t e n d o n cr o sse s t h e rad ia l

.

e x t e n sor s o f th e wr is t at th e d ista l bord e r o f t h e d o r sa l

car p al liga m e n t .

D is s e c t i o n. — Th e s k in o f t he do rsu m o f the h an d h as alre ady

be e n re m o ve d ,
an d th e t
cu an e o u s n e r e s v an d ve in s h ave be e n
disp lay e d . t
Th e t h in dee p f ascia is s ill in p o si io n , bu t it ill t w
no t p re v nte t t
a su ccessfu l de m o n s ra io n o f t h e m u co u s s h e a h s t
 F ORE AR M AN D H AN D 1 75

o f th e t
t e n do n s w h ich sh ld be att mp te d be fo re th e
e x e n so r ,
o u e
al e t n so r m u scles a re n t ro d ce a blo w
su
fi
pe r CI le a e d I
x e c n . u

p pei t o e ach mu co u s sh e at h imm e diat ly p ro im al to th e

in e x

B rach i o -
rad a i li s

M abdu c t o r po lli i c s
l g
.

A . rad a i li s
“

‘
o n

M . e
us

x t e n so r p o lli i b vi
c s re s

M . e x t e n so r p o lli i l g
c s o n us

Sh e a t h o f fle x o r polli i l g
c s o n u s?
L ig ame n t u m c arp id o rsa e l
Sh e a t h o f fi e x o r car pi di li ra a s
f x
M uco u s she at h o e te nso r
She at h f abdu c t o r p lli i l g i li l g i rad a
‘

o o c s o n us c arp s o n us

Sh e a t h o f e x t e n so r p o lli i bc s r A i l p l fw i
rt c u ar c a su e o r st

A di li ra a s

h f x pi
.

M abd uc t o r p o lllC lS bre v i Sh eat o e te n so r c ar

di li b v i
.

ra a s re s

Sh h x p lli i l
e at e t e n so r o c s o n gu s

Sh h f x e at di g i o e t e n so r t o rum
comm i un s

M . i n t e ro sse u s do rsa li s

p ri m u s

M . addu c t o r po lli i
c s

FI G .
75 .
— Di sse ct o n oi f th e L ate ra S de l i o f t h e L e ft W ri st an d H an d
sh o w i gMn uco u s Sh e ath s o f Te n do ns .

do rsal carp al lig am e n an d h e n in fl a e t h e s h e a h t

Co mm e n ce t t t .

t
W i t h t h e s h e a h o f t h e abdu ct o r p o llicis lo n gu s an d th e ext e n so r
p l
o l i e s br e is ; h e n in fl at e iv
n s u cc e ssio n t
t h e s h e a h s o f t h e t
radi al e xt e n so rs o f t h e w
rist , t h e co m m o n ex t e n so r o t t h e fi n g e rs ,

t
t h e ext e n so r dig i i q in i, an d th e ex t e n so r carp i uln aris u t A .

tt t
be e r de m o n st ra io n o f th e m u co u s sh e a h s m ay be m ade by t
1 76 TH E SUP ER I O R EXTRE M I TY
t t
in j e c in g h e m , by m e an s o f a larg e hyp o de rm ic sy rin ge , i h a wt
t t
h in so lu io n o f co lo u re d s arc h I f th e sh e a h s h a e be e n t . t v
in j u re d, an d it is n o t p o ssible to dis e n d t h e m , h e n o p e n e ac h an d t t
ex amin e its ex t e n t
wit h t h e aid o f a blu n p ro be t .

The M u c o u s Sh e at hs o f t h e Ext e n so r Te n do n s — Se v e n .

m uc o u s sh e ath s surrou n d t h e t e n do n s wh ich p a ss u n d e r cov e r

O f t h e dor sa l car p a l liga m e n t Two lie a lo n g th e d ista l p art .

o f t h e rad ia l bo rd e r o f t he for e ar m ; th e y are th e sh e ath s o f

t h e a bduct o r p o llic is lo n gu s an d t he e x t e n sor p o llic is br e v is .

Th e y may co m m u n icat e w ith o n e a n oth e r F ro m the rad ia l .

to t he u ln ar bord e r th e r e ma in in g five sh e ath s are arra n g e d

in t h e fo llow in g o rd e r : th e sh e ath o f th e e x t e n sor car pi
rad ia lis lo n gu s the sh e ath o f th e e x t en sor car pi rad ia lis
,

br e v is a sh e ath co m mo n to th e e x t e n sor d igitoru m co m

,

m u n is an d t h e e x t e n sor in d ic is the sh e ath o f th e e x t e n sor ,

d ig i t i qu in t i an d the sh e ath o f the e x t e n sor car pi u ln ar is

, .

Th e p ro x im a l limit o f the sh e ath s lie s at or slight ly p ro x i ,

mal t o t he d o r sa l car p a l liga me n t

, Th e sh e ath s o f th e .

a bduct o r p o llic is lo n gu s an d the rad ia l an d u ln ar e x t e n sor s

o f t h e car p u s are p ro lo n g e d d ista lly to th e in se rt io n s O f t he

t e n d o n s o f th e se mu sc le s As re gard s the sh e ath s o f t h e .

e x t e n sor s o f t h e fi n g e r s an d thu mb it m a be s a id sp e ak in g
y , ,

g e n e ra lly that th e y t e r min at e d istally a bo ut the le v e l o f th e

,

mid le n gth o f th e ha n d ( F ig s 7 5
-
.
,

D is s e c ti o n —
The brac h io radialis h as alre ady be e n disse c e d - t
t
t h e o h e r su p e rfi cial m u scle s m u st n o w be cle an e d an d, as f ar
t
as p o ssible , iso la e d fro m o n e a n o h e r Th e iso la io n o f t h e dis al t . t t
t t
p ar s is n o t diffi cu l , bu t t h e p ro x im al p ar s sp rin g n o t o n ly f ro m t
th e h u m e ru s an d t h e su p e rj ace n dee p f ascia, bu t also f ro m t
t
s ro n g in t e rmu w h ic h in e r e n e be
s cu lar se p a t
e e n adj ace n t v tw t
m u scle s t
To iso la e t h e p ro x im al p art s o f t h e m u scles, h e re fo re ,
. t
t t t
t h e disse c o r m u s sp li t h e in e rm u scu lar se p a i h t h e scalp e l t t wt
t
an d so iso la e e ac h m u scle as f ar as its bo n y o rig in .

M . Brachio radialis
( O T -
S u p in at o r L o ng )
u s — T h.e brach io. .

rad ia lis m u sc le lie s m or e o n the vo lar tha n o n th e dor sa l

sur fac e o f th e fo r e ar m I t tak e s or ig in , in th e arm, fro m
.

th e p r o x im a l two th ird s o f th e lat e ra l e p ico n dy lar r idg e o f th e

-

hu me ru s an d fro m the lat e ra l in t e r mu scu lar se p tu m N e ar .

th e m idd le o f th e for e ar m a flat t e n do n e me rg e s fro m its

fl e shy be lly, an d p roc e e d s d ista lly to ga in in se rt io n in t o th e
lat e ra l a sp e ct o f t h e e x p a n d e d d ista l e x tr e mity o f t h e rad iu s,
at t h e ba se o f th e stylo id p roc e ss The n e rv e o f su p ply is .

a bra n ch o f the radial n erve ( O T mascu lo spiral), wh ich . .

-
1 78 TH E SU P ER I OR EXTRE M I TY
w t
be f o llo e d t o th e h u m b, t h a o f t he abdu c o r p o llicis lo n g s t t u
t
t o t h e bas e o f t h e m e a carp al bo n e , h a o f t h e ex t e n so r p o llicis t t
v
bre is t o t h e bas e o f t h e fi rs p h alanx , an d t h e e n do n o f t h e
' '

t t
ex t e n so r p o llicis lo n gu s t o t h e base o f t h e e rm in al p h alanx t .

t
Th e re are f o u r e n do n s o f t he e x e n so r dig i o ru m c o m m u n is , t t
o n e f o r e ac h fi n g e r Eac h o f t h e f o u r ex p an ds, o n t h e do rsu m
.

o f t h e fi rs t
p h alanx o f th e fi n g e r t o h ic h it be lo n gs, in o an w t
ex te n so r exp an si o n w v
h ich co e rs th e h o le o f th e do rsu m o f th e w
p h alanx .

t t
N e ar t h e dis al ext re m i y o f t h e fi rs p h alanx t h e ex t e n so r t '

ex p an sio n di ides in o v t t
h re e p ie ce s, an in e rm e dia e p ie ce an d t t
t
two co lla e ral p ie ces w
Th e e ak e r in e rm e dia e p ie ce is in se rt e d
. t t
t
in o t h e base o f t h e se co n d p h alanx Th e lat e ral p ie ce s u n i e . t
t t
wi h o n e an o h e r o n t h e do rsu m o f th e se co n d p h alanx be fo re
t t
h e y are in se rt e d in o t h e base o f th e e rm in al p h alanx Care t .

fu lly de fi n e t
h is arran g e m e n o n at le as o n e fi n g e r Th e t t .

t e n do n o f th e e x t e n so r in dic is p asse s alo n g t h e u ln ar side o f th e

t
t e n do n o f t h e ex t e n so r dig i o ru m co m m u n is t o j o in th e e xt e n so r
ex p an sio n o f t h e in de x fi n g e r, an d t h e two e n do n s o f t h e ex t e n so r t
t t
dig i i q u in i j o in t h e e xt e n so r e xp an sio n o f t h e li t le fi n g e r t .

Cle an t h e m arg in s o f t he e xt e n so r e x p an sio n o f o n e o r m o re

fi n g e rs, an d p ass th e h an dle o f a scalp e l be w e e n t he ex p an sio n t
an d th e m iddle o f t h e fi rs p h alan x , t
h e n n o te , as t h e e x p an sio n t
t t t t t
is p u t o n t h e s re c h , h a , j u s be y o n d t h e m e ac arp o p h alan g e al t -

t
j o in , t h e e x p an sio n is j o in e d, o n e ac h side , by stru c u re s w h ich t
t
p ass t o it h ro u gh t h e in e ro sse o u s Sp ace s t
On t h e radial side .

t
it is j o in e d by t h e e n do n o f a lu m bric al m u scle an d by a slip
t t
f ro m t h e e n do n o f an in e ro sse o u s m u scle , an d, o n th e u ln ar
t
side s , by a slip f ro m a e n do n o f an in e ro sse o u s m u s cle , ex ce p t t
tt w
in t h e case o f t h e li le fi n g e r h e re t h e re is, o f co u rse , n o in e r t
o sse o u s m u scle o n t h e u ln ar side Th e disse c o r w ill h a e n o . t v
t
diffi cu l y in display in g t h e ass o cia io n o f t he lu m brical m u s cles t
wt i h t h e ext e n so r e xp an sio n s at t h e p rese n s ag e o f th e dis t t
t
se c io n . t
Th e c o n n e c io n s o f t h e in e ro sse i can n o be p ro p e rly t t
t t t
de m o n s ra e d u n il a la e r s ag e t t
Th e Ext en so r Ex p an sio n s d isse ctor
on t he F i ge rs n Th e —

who has car e fu lly fo llow e d th e a bov e w ill hav e in struct io n s

r e cog n ise d that by me a n s o f t he e xt e n sor e xp a n sio n s a
co m m o n e x t e n sor t e n d o n a lu mbrica l an d o n e or mo r e in t e r
, ,

o sse i ga in in se rt io n in to th e d o r sa l a sp e ct s o f th e ba se s o f
th e se co n d an d t e r min a l p ha la n g e s o f e ach fi n g e r an d ,

through th e sa m e me d iu m t he se co n d an d t e r mina l p ha la n g e s
o f th e in d e x an d litt le fi n g e r s are attach e d to t h e sp e c ia l

e x t e n so r s o f tho se d ig it s Th e d isse ctor shou ld n o w n ot e

.

t h e m ov e me n t s h e c an m ak e w ith h is o wn fi n g e r s : ( I ) by u se
o f the fl e x o r mu sc le s a lo n e he c an fl e x all thr e e j o in t s o f t he

fi n g e r s the m e tacarp o p ha la n g e a l an d th e p ro xima l an d d istal

,
-

in t e r p ha la n g e a l j o in t s ; ( 2 ) by u se o f th e e x t e n sor m u sc le s a lo n e
h e c an e x t e n d all thre e jo in t s ; ( 3 ) by u se o f t h e fl e x o rs an d
e x t e n sor s simu lta n e ou sly h e can fl e x t h e in t e r p ha la n g e a l an d
 F ORE AR M AN D H AN D
t d
ex en th e m e tacar p o p ha la n g e a l
jo in t s ; ( 4 ) he can a lso fl e x
-

t he m e tacar p o p ha la n g e a l j o in t s an d e x t e n d t h e in t e rp ha la n g e a l
-

jo in t s The la st c o mbin at io n o f m ov e me n t s is ca lle d p utt in g

.
“

t h e fi n g e r s in t h e wr it in g p o sit io n I t is du e m a in ly to t h e
!
.

act io ns o f the lu mbr ica ls an d in t e r o sse i wh ich p a ss fro m the ,

vo lar t o th e dor sal a sp e ct acro ss t h e m e tacarp o p ha la n g e a l -

jo in t s an d so are e n a ble d to fl e x tho se jo in t s wh ilst by v irtu e

, ,

o f th e ir attach m e n ts t o the e xt e n sor e x p a n sio n s th e y can

e x t e n d t h e in t e r p ha la n g e a l jo in t s .

O l m s u n a tu

O pi m s ca ta t u
O q m
s t ri u e t ru
O v l m s na i cu are a nu s
O p i if [
Ex pi di li b v i
s s
t e n so r ca r ra a s re s

Os hama t u m

carp i a
r dia li l g
s o n us
u ct o r p o lllC lS l g
o n us

x
E te n so r c arp i l i
u n ar s

FIG .
77 .
— D o rsa l as p e c t o f th e Bo nes o f th e C arp us an d M e tac arp u s ,
w i th M u scu l ar Att ach m e n ts m appe d o u t .

M . Ext e nso r Ca rp i R a dia lis L o ngus — The lo n g rad ia l

e x t e n so r o f t h e car p u s is p lac e d dor sa l to th e brach io rad ia lis -
.

I t ar ise s fro m t h e d ista th ird o f the lat e ra l e p ico n dy lic r idg e

o f th e hu me ru s, an d fro m th e lat e ra l in t e r m u scu lar se p tu m .

F ro m th e fl e shy p ort io n O f t h e mu sc le a lo n g t e n do n p ro
cee ds, wh ich p a sse s u n d e r cov e r o f th e dor sa l car p a l liga m e n t ,

an d is in se rt e d in to th e dor sa l a sp e ct o f th e ba se o f th e

m e tacar p a l bo n e o f th e in d e x fi n g e r Th e m u sc le is su p p lie d .

by a bra n ch o f th e tru n k o f t h e radial n erve ( O T mu scu lo . .

sp iral wh ch n t e r s it ro x ima l t o ow o ng
) i e p t h e e lb T h e l .

I — l2 a
 1 80 TH E SUP ER I OR EXTRE M I TY
rad ia l e x t e n so r o f the wr ist h e lp s to e x t e n d an d a bduct t he
ha n d at th e wr ist jo in t an d it a ssist s in fl e xio n o f the e lbow
-
,

( F ig s 74 .
7 5 7 6 )
. .

M Ex t e n so r Carp i R a dialis Bre vis — Th e e x t e n sor car p i

. .

rad ia lis bre vis is c lo se ly a ssoc iat e d w ith the p r e c e d in g mu sc le .

I t ar ise s by th e co mm o n e x t e n sor t e n d o n fro m th e lat e ra l

, ,

e p ico n dy le o f th e hu m e ru s ; it d e r iv e s fi br e s a lso fro m t h e

rad ial c o llat e ral liga me n t o f the e lbow jo in t fro m the ih -

,

v est in g d e e p fa scia an d the fi brou s se p ta in co n n e ct io n

,

w ith it The t e n do n o f t he m u sc le acco mp a n ie s that o f

.

th e lo n g rad ia l e x t e n sor u n d e r cov e r o f the dor sa l car p a l

liga me n t an d is in se rt e d in to th e dor sa l a sp e ct o f the ba se
,

o f th e th ird m e tacar p a l bo n e im m e d iat e ly be yo n d the root ,

o f its sty lo id p roc e ss Th is m u sc le is su pplie d by the deep

.

brancb of tire radial nerve by a tw ig g iv e n O ff be for e t h e n e rv e

p ie rc e s t h e su p in ator m u sc le I t is an e x t e n so r o f t h e wr ist
.

an d th e e lbow an d an abductor o f t h e ha n d at t h e wr ist jo in t

,
-
.

M Ex t e nso r Digit o rum Co mmunis

.
— The e x t e n sor d ig i .

toru m co mmu n is tak e s orig in by the co m mo n t e n do n , ,

fro m the lat e ra l e p ico n dy le o f t he hu m e ru s Th e d e e p .

fa sc ia an d th e in t e r mu scu lar se p ta in r e lat io n to it a lso

co n tr ibut e fi bre s I ts fl eshy be lly in the d ista l p art o f the
.
,

for e arm e n d s in four t e n do n s wh ich p a ss u n d e r cov e r o f

, ,

th e dor sa l car p a l liga me n t O n the dor su m o f the ha n d .

th e y d iv e rg e an d p roc e e d o n ward s to the four fi n g e r s Th e ir .

arra n ge me n t an d attach m e n t s o n the dor su m o f t he ha n d an d

fi n g e r s hav e alr e ady be e n co n sid e r e d( p 1 Th e mu sc le is .

su pplie d by the do rsal intero sseo u s n erv e I t is an e x t e n sor o f .

all th e jo in t s o f t h e fi n g e r s o f th e wr ist an d o f t h e e lbow, , .

M . Ext e n so r Digit i Q uin t i P ro p rius ( O T Ex t e n so r . .

M in imi Digit i) — The e x t e n sor d ig it i qu in t i p ro p r iu s is a

.

sle n d e r fl e shy be lly wh ich at fir st sight a p p e ar s to be a p art o f

th e p r e c e d in g m u sc le bu t it s t e n do n p a sse s through a sp e c ia l
,

co mp art me n t in the dorsal carp al liga me n t I t ar ise s in .

co mm o n w ith the e x t e n sor d igitoru m co mm u n is I ts t e n do n .

o f in se rt io n split s in to two p art s Th e lat e ra l o f the two .

j o in s the t e n do n o f the e x t e n sor d ig itoru m c o m mu n is wh ich ,

p a ss e s t o t h e litt le fi n g e r an d t h e m e d ia l p art e n d s in th e
,

e x t e n sor e x p a n sio n o n t h e dor su m o f t h e fir st p ha la n x o f t h e

litt le fi n g e r The m u sc le is su pp lie d by th e do rsal in tero sseo u s

.

n erve . I t is an e x t e n sor o f all t h e jo in t s o f t h e litt le fi n g e r ,

an d it a id s in e x t e n sio n o f t h e wr ist an d e lbow .

1 82 THE SU PER I OR EXTRE M I TY
ex t e n so r in dic is . Th e do rsal in te ro v
sse o u s n e r e ap p e ars t h ro u gh
t
t h e su bs an ce o f t h e su p in o , cro sses t h e su rf ace o f th e at r
t
abdu c o r p o llicis lo n g u s , an d dip s de e p t o t h e ex t e n so r p o llicis
lo n gu s Th e do rsal in e ro sse o u s ar e ry ap p e ars be
. een th e t t tw
adj ace n t
bo rde rs o f t h e su p in a o r an d t h e abdu c o r p o llicis t t
lo n gu s an d desce n ds alo n g t h e radial bo rde r o f th e e xt e n so r
carp i u ln aris su p e rfi cial t o t h e ex t e n so r p o llicis lo n gu s an d t h e
e xt e nso r in dicis F irs cle an th e do rsal jn te ro sse o u s p e rv e an d
'

. t
se cu re its bran c h e s Af e r it p ie rc e s t h e su p in a o r it g i es . t t v
bran ch e s o f su p p ly t o all t h e de e p m u scles ex ce p t h e su p in a o r, t t
an d t o t
h re e o f t h e su p e rfi cial m u scle s, v iz , th e ex t e n so r .

t
dig i o ru m co mm u n is, th e ext e ns o r dig i i u in i, an d t h e ex t e nso t q t r
carp i u ln aris Th e bran c h es to t h e su p e rfi cial m u scle s
. e re w
f o u n d as t h e ext e n so r dig i o ru m c o m mu n is an d t h e e xt e n so r t
t q
dig i i u in i e re re fl e c e d t w Th e bran c h t o t h e e x e n so r in dicis t . t
v
is g i e n o ff be f o re t h e n e r e dip s de e p t o th e e x e n so r p o llicis v t
lo n gu s, an d it c ro sse s t h e su p e rfi cial su rface o f t he lo n g
e xt e n so r o f t h e t
h u m b W h e n it h as be e n f o u n d p u ll th e .

e x t e n so r p o llicis lo n gu s an d t h e e xt e n so r in dicis o w ards t h e t

m e dial side , an d f o llo t he do rsal in e ro sse o u s n e r e , w h ic h w t v
p asse s de e p t o bo h o f h e m , t o t he ba ck o f t h e radiu s t t
h e re it w
t
e n e rs t h e o s e o f ascial co m p art m e n t h ro u gh h ic h th e ext e n so r
-
tt w
t
dig i o ru m co mm u n is an d t h e ex t e n so r in dicis p ass t o t h e do rsu m
o f th e h an d W h e re it lies u n de r co e r o f t h e ext e n so r p o llic is
. v
lo n gu s it is j o in e d by t h e p e rf o ra in g bran c h o f t h e o lar in e r t v t
o sse o u s art e ry , w
h ic h p ie rce s th e in e ro sse o u s m e m bran e abo u t t
5 0 mm a b o e t h e
. w r i s ,
a n d h e n v
a cc o m p an ie s t h e d o rs a l t t
t
in e ro sse o u s n e r e P u ll aside t h e v
e n do n s o f t h e ext e n so r
. t
co mm u n is an d t h e ex t e n so r in dicis be y o n d t h e do rsal carp al
t
lig am e n an d fi n d t he e rmin al p art o f t h e n e r e an d t h e co n t v
tin u atio n o f t h e art e ry , de e p t o t h e e n do n s o n t h e back o f th e t
w rist j o in t Th e n e rv e d in a gan glifo rm n large m n t fro m
. e n s e e
w h i h twigs ar distribu t d t th lig am n t o f th w ri t j o int
c e e o e e s e s ,
an d t h e v o lar i t ro ss o u s art e ry t e rmin at es by j o inin g t hn e e e
do r al arp al art rial arc h
s c e .

No w l an t h e d p m s le c e n o te t h e o st f ascial o m p art ee u c s, eo -
c
m e n t s o n t h e ba k o f t h radi s t h ro u gh w h i h t h y p ass t o t h e
c e u c e
h an d an d t race t h e ir t e n do n s t o t h e ir in se rt io n s
, .

D ep
e M us c l e s — Th e se are t he su p in at o r ; ( 2 ) the
.

a bduct o r p o llic is lo n gu s 3 ) the e xt e n sor p o llic is br e vis ( 4 )

t h e e x t e n sor p o llic is lo n gu s ; an d ( 5 ) the e x t e n sor in d ic is
ro
p p r iu s
( g
F i .

Th e su p in ator w ill be r e cog n ise d fro m th e c lo se m a n n e r

in wh ich it is a pp lie d to the p ro x im a l p art o f t h e body o f
the rad iu s The oth e r m u sc le s tak e O rig in p ro xim o d ista lly
.
-

in th e ord e r in wh ich th e y hav e be e n n a me d The attach .

m e n t s o f the su p in ator ca n n ot be sat isfact o rily stud ie d at

p r e se n t Th
. e y w ill b e d e scr ibe d at a l at e r stag e o f th e

d isse ct io n .

M Abduc t o r P o llicis L o ngus ( O T Ex t e nso r O ssis

. . .

M et acarp i P o llicis) Th e lo n g a bductor o f t h e thu mb ar ise s.

-
 F OR E AR M A N D H AN D 1 83

fr o m both bo n e s o f th e for e ar m, an d fro m the in t e ro sse ou s

me mbra n e , wh ich str e tch e s be tw e e n th e m I ts o rigin fro m .

t/ze radiu s corr e sp o n d s to the m idd le th ird o f t h e dor sa l

sur fac e o f that bo n e its o rigin fro m t/ze u lna is mor e p ro x im a l ,

fro m t he lat e ra l p art o f the d o r sa l sur fac e o f th e body im ,

m e d iat e ly d ista l to th e o bliqu e lin e wh ich m ark s th e d ista l

limit o f th e in se rt io n o f th e an c o n ae u s Th e mu sc le p roc e e d s .

d ista lly an d lat e ra lly an d co me s to th e sur fac e in the in t e rva l

,

be tw e e n t h e e x t e n sor d ig itoru m co m mu n is an d th e e x t e n sor

carp i rad ia lis bre vis Th e n it cro sse s the two rad ia l ex t e n sor s
.
,

clo se ly acco mp a n ie d by the e x t e n sor p o llic is br e v is The .

t e n do n wh ich issu e s fro m it as it be c o m e s su p e rfic ia l is , ,

co n t in u e d d ista lly ov e r th e lat e ra l sid e o f the e x p a n d e d

,

d istal e n d Of the rad iu s an d u n d e r cove r o f the dorsa l carp a l

,

liga me n t an d is in se rt e d in to th e lat e ra l sid e o f t h e ba se o f

,

t h e me tacar p a l bo n e o f t he thu mb Th e m u sc le is su pp lie d .

by t he do rsal intero sseo u s n erve I n add it io n to be in g an .

a bductor o f t he thu mb it a ssist s in p roduc in g su p in at io n an d

a bduct io n o f the ha n d ( F ig s 7 4 7 5 7 6 .
, , ,

M Ext e n so r P o llic is Brevis ( O T Ext e n so r Primi I n t er

. . .

n o dii P o llic is) — Th e short e x t e n sor o f th e thu mb is lac d

'

.
p e

a lo n g the d ista l bord e r o f the p r e c e d in g mu sc le I t arise s .

fro m a sm a ll p ort io n o f th e dor sa l sur fac e o f the rad iu s an d ,

a lso fro m the in te ro sse ou s me m bra n e I ts t e n do n is c lo se ly .

a pp lie d to that o f the a bductor p o llic is lo n gu s an d acco m ,

p a n ie s it d e e p to t h e dor sa l car p a l liga m e n t I t m u s t b e .

trac e d o n the dor sa l a sp e ct o f the m e tacarp a l bo n e o f the

,

thu mb to the ba se o f the p rox ima l p hala n x in to wh ich it is

, ,

in se rt e d The m u sc le is su pp lie d by th e do rsal intero sseo u s

.

n erve . I t is an e x t e n sor o f t h e fir st in t e r p ha la n g e a l j o in t
an d o f t he me tacar o ha la n g e a l j o in t o f t h e thu mb an d it
p p
-
,

tak e s a su bsid iary p art in th e p roduct io n o f abduct io n o f

t h e ha n d .

M Ext en so r P o llic is Lo ngus ( O T Ex t en so r Se cundi I nt er

. . .

n o dii P o lli cis) — Th e lo n g e x t e n sor o f t h e thu m b tak e s or ig in

.

fro m t h e lat e ra l p art o f th e dor sa l sur fac e o f the body o f th e

uln a in its m idd le th ird an d also fro m the in t e ro sse ou s
, ,

me mbra n e I t ov e r la p s to so m e e x t e n t th e p r e c e d in g
.
, ,

mu sc le an d it e n d s in a t e n do n wh ich p a sse s u n d e r cov e r

,

o f t h e dor sa l car a l liga me n t wh e r e it o ccu ie s a d e e n arrow

p p p ,

groov e o n the dor su m o f th e d ista l e n d o f the rad iu s .

O n the car p u s it tak e s an o bliqu e cour se an d a ft e r cro ssin g

'

, ,

1— 12 6
 TH E SUPER I O R EXT R E M I TY
t he t e n do n s two rad ia l e x e ns t or s an d th e rad ia l art e ry ,

it r e ach e s the

M i
t r ce p s brach ii thu mb I t is .

in se rt e d in to
.

the ba se o f the
d ista l p ha la n x
O f th e thu mb
an d is su p p lie d

by a bra n ch o f
th e do rsal in ter
b i ce p s brach n
o s s e o u s n e rv e .

M . i
su p n at o r I t is an e x t e n sor
o f j o in t s
all t h e

o f t h e thu mb ,

an d it tak e s
p art in t h e in

it iat io n Of su p

in at io n o f the
for e ar m ( F ig s .

M p ro nato
. r
t e re s 79 )

W hen th e

thu mb is po w e r
fu lly e x te n de d in ,

the liv in g p e rso n ,

th e t e n do ns o f its
h
t re e last me n
t io n e d m u scle s be
co me p ro min e n t
o n thela t e ral .

asp e c t o f the w rist .

The o bliq u e c o u rse

o f the t e n do n o f
x
th e e t e n so r po l ~

li c i s lo n g u s i s
re n de re d e v ide nt ,
an d a distin ct de

p re ssio n be tw e e n
it an d the o th e r
t w o t e n do n s i s
se e n .

Ex t p o
. ll l g
. o n .

M Ex t enso r
.

FI G .
78 .
— D o rsa l asp e c t o f th e B o ne s o f th e F o re ar m,
I n dI C I S P ro
w i th Att ach me n ts o f M u sc l es m ap p e d o ut
The
.

p ri u s .

sp e c ia l t
e x e ns or o f the in d e x fi ng e r arise s distal to ,
th e p re
 THE SUPER I OR EXTRE M I TY

M . i
t r ce p s brach i i

i
M b ce p s brach n
.

M brach
. i lia s

An nu l li g
ar a me n t o f t he
radi u s

D o rsa li n te ro sse o u s n e rv e

M . a n co n a
e us

I n t e ro sse o u s re cu rre n t

art e r y
M .
p ro nat o r t e re s

N er v e to e x t po lli i
c s
l g
.

o n u s and e x t . in dlC lS
p ro p ri u s

D o rsa li n t e ro sse o u s n e r e v ‘

abduc to r po lli i l g
c s o n us

M . e x t e n so r nd c s i ii p ro p r u s i
e x te nso r p o lli i c s bre vi s

x
E t e n so r d igi i q i i p p i
t u nt ro r us
Ex t e nso r di g i m mm i
to ru co un s

D l pl o rsa y c ar a art e r

R di l a a art e r

FIG .
79 .
— Di sse ctio n o f t he D o rsu m o f t he Fo re arm an d H an d .
 F ORE AR M AN D H AN D 1 87

dista lly be tw e e n th e su pe rfic ia l an d d e e p m u scle s o n th e

back o f the for e ar m .At th e p ro x im a l bord e r o f the e x t e n sor
p o llic i s lo n gu,
s it le av e s t h e dor sa l in t e ro sse ou s art e ry d ip s ,

a n t e rior to the e x t e nsor p o llic is lo n gu s an d j o in s the p e r

,

fo ratin g bra n ch o f th e
v o la r i n t e r o s s e o u s
B hi l y
rac a art e r
art e ry o n t he dorsa l
a sp e ct o f th e in te ro sse
o u s m e mbra n e Ac P f d roy f un a arte r o
h m
.
t e ar

c o m p a n i e d by t h a t
art e ry it d e sc e n d s ,

through th e mo st m e d ia l
groov e o n the back o f
t h e rad iu s w ith t h e t e n
do n s o f the e x t e n sor S p i l u e r o r u nar

d ig itoru m co mm u n is ll l co y at e ra art e r

an d t h e e x t e n sor in d ic is

ro
p p r iu,
s t o t h e back o f

t h e wr ist wh e r e it e n d s
in a ga n g lifor m e n larg e
m e n t wh ich lie s be tw e e n I f i l n e r o r u n ar

the e x t e n sor t e n do n s ll l co y a t e ra art e r

an d t h e p o st e r ior liga

m e n t o f t he wrist .

The h andle: wh ich

sp rin g fro m th e dor sa l

in t e ro sse ou s n e rv e in A mi l nt . ter na
b h fp f d ra n c o ro un a
the fo r e ar m are g iv e n y art e r

e n t i r e ly t o m u s c le s .

B e for e t h e d e e p bra n ch
o f th e rad ia l n e rv e
p ie rc e s th e su p in ator y art e r
an d be co m e s th e dor sa l y 5 art e r

in t e r o sse ou s n e rv e it ,
y art e r

g ive s bra n ch e s both t o FI G 8 Di g m f A t m i

. 0 .
— a ra o n as o d o s s aro u n

t h e su p in ator an d to t h El b w J i t
e o o n .

t h e e x t e n so r c a r p i
rad ialis bre vis Aft e r it a pp e ar s o n the dor su m o f the
.

fo r e arm as t h e d or sa l in t e ro sse ou s n e rv e it su p plie s t h e

, ,

e x t e n sor d igitoru m co mm u n is t h e e x t e n sor d ig it i qu in t i p ro

,

p r iu s
, t h e e x t e n sor ca r i uln ar is t h e a bductor
p , p o l lic i s lo n gu s ,

two e x t e n sor s o f the thu mb an d the e x t e n sor in d ic is p ro p r iu s

, .
1 88 TH E S UP E R I OR EXTRE M I TY
It s u pplie s th e r e for e all the mu sc le s o n t he lat e ra l an d
, ,

dor sal a sp e ct s o f th e for e ar m w ith t he e x c e p t io n o f th e ,

brach io rad ia lis an d th e e x t e n sor car p i rad ia lis lo n gu s wh ich

-

d e r iv e th e ir n e rv e —su p p ly d ir e ct ly fro m th e radial n erve ( O T . .

nz u scu lo sp iral T eu s d e r iv e s it s m a in n e rv e o f su p ly
-

) h e an co n a
.
p
fro m th e rad ia l n e rv e bu t n o t in fr e qu e n t ly it a lso o bta in s a
,

se co n d tw ig fro m t h e dor sa l in t e r o sse o u s n e rv e .

D is s e c t i o n — D t h t h e a co a e ac fr m it rig in a d t h r w
n n us o s o n o
it t w ards it in rt i n i
o o rd r t
s se disp lay t h
o n rse f th ee o e co u o
do r l i t ro
sa n er u rr t art ry Tra t h at art ry t o th e
sse o u s ec en e . ce e
ba k f t h lat ral p ico dy l
c o e e a d th n e am in th
n art rial
e, n e ex e e e
an ast m o i aro o n d th
s s lb w j i t
u e e o -
o n .

Ana st o mo sis a ro un d t h e Elbo w J o in t — Th e se r ie s o f .

in o scu lat io n s arou n d t he e lbow sh o u ld n o w be r e v ie w e d as a

who le A d ist in ct in o scu lat io n w ill be fou n d to tak e p lac e
.

u p o n both th e a n t e r ior an d p o st e r io r a sp e ct o f e ach e p i

co n dy le o f the hu me ru s B e h in d the lat e ra l e p ico n dy le the
.

intero sseo u s recu rrent artery j o in s t h e p o sterio r o ranc/z o f the

profu nda orac/zii artery : a n t e r ior to the sa me e pico n dy le th e
an terio r o rancli o f t h e p rofu n da orac/zii arter y co mm u n icat es

w ith the radial recu rrent On the me d ia l sid e o f the j o in t the

.

anter i o r an d p o sterio r u lnar recu rrent arteries a sc e n d r e sp e ct iv e ly

in fro n t o f an d be h in d th e m e d ia l e p ico n dy le t h e fo r me r
a n a sto m o se s w ith the anterio r oranclz o f t he inferio r u lnar
co llateral arter y an d t he l
,
att e r w ith t h e p o sterio r b ra n ch o f
t h e sa m e art e ry an d w ith t h e superio r u ln ar co llateral artery .

I n th is accou n t o f t h e a n a sto m o sis arou n d t h e e lbow j o in t

o n ly t he le ad in g in o scu lat io n s are me n t io n e d R ich n e t .

work s o f fin e v e sse ls are for m e d o v e r the o le cra n o n an d th e

two e p ico n dyle s o f th e hu me ru s On e v e ry d ist in ct an d fa irly .

co n sta n t arch r e qu ire s sp e c ia l me n t io n I t is for m e d by a .

bra n ch wh ich cro sse s the p o st e r ior a sp e ct o f th e hu me ru s ,

imm e d iat e ly p ro x im a l t o th e o le cra n o n fo ssa an d co n n e ct s ,

th e p o st e r ior bra n ch o f t h e p ro fu n da brachn art e ry w ith

th e p o st e r ior bra n ch o f th e in fe r io r u ln ar co llat e ra l art e ry .

Termin al B ranch o f t h e Art eria I nt ero ssea V o laris .

The so ca lle d p e r forat in g bra n ch o f t h e vo lar in t e ro sse ou s

-

art e ry is a v e sse l o f so me siz e an d is r e a lly th e m a in c o n , , ,

t in u at io n o f t he art e ry I t p e r forat e s t h e in t e ro sse ou s m e m

.

bra n e a bout 5 0 m m p r o x im a l to t he d istal e n d o f th e rad iu s

.
,

an d is at o n c e jo in e d by t h e d o r sa l in t e ro sse o u s n e rv e It .

d e sc e n d s w ith th e n e rv e in the mo st m e d ial groov e o n the

, ,
 TH E SU PER I O R EXT R E M I TY
I t is broad ha llow an d it ho ld s th e t e n do n s o f the
an d s ,

e x t e n sor car p i rad ia lis lo n gu s an d e x t e n so r car p i rad ia lis br e vis

Fl x di g i m bli m i e o r t o ru su s

Fl x di g i m p f d e o r t o ru ro un us

C vi y f y v i l h h a t o s no a s e at

Fl x p lli i
e o r o c s lo n

R di l a a
er e v
Pr o na t o r q u adra t u s

E x te n

E x t e n so r

x
E te n so r po lli i
c s

FI G . 8 r — Tran s
. ve rse se ctio n thro ugh Fo re arm p ro xi mal to the L ig ame n tu m
C arp i Tran sve rsu m Sh o w i n g the re l at i o n o f t h e m u c o u s sh e aths t o t he
.

t e n do n s .

an d th e ir mucou s
h e ath s The tlzira co mpartment is fo r me d
s .
'

ov e r th e n arrow d e e p o bliqu e in t e r me d iat e groov e o n the

, ,

dor su m o f the d istal e n d o f the rad iu s I t co n ta in s th e t e n do n .

FI G . 82 .
—
( Fro m L u sc hka ) .

1 . i l
M dd e me tacarp a bo ne l 4 Se c o n d u m br ca mu sc e
. . l i l l .

2 Te n do n o f fl e x o r d t o ru m su b m s
. igi li i
5 Se c o n d do rsa n t e ro sse o u s mu sc
. . li l e .

3 Te n do n o f fl e x o r d
. ig i
t o ru m p ro fu n du s 6 C o mm o n e t e n so r t e ndo n . . x .

I , I I , an d I I I The t h re e p ha an e s
. . . l g .

o f th e ex e n st or p o llic is lo n gu s an d its m ucou s sh e ath Th e .

f o u rtlz p co m artment is p lac e d ove r th e w id e sha llow gr o ov e

wh ich m ark s the me d ia l p art o f th e dorsa l a sp e ct o f th e d ista l
 F O R E AR M AN D H AN D 1 9 1

en d o f th e rad iu s I t is trav e r se d by t e n do n s o f the e x t e n sor

.

d ig itoru m co mmu n is an d the t e n d o n o f th e e x t e n sor in d ic is

ro
p p r iu s an d th e ir m uc o u s s h e ath ,
and b
y t h e t e r m in al

p art s o f t h e d o r sa l in t e ro sse o u s n e rv e a n d t h e p e r fo rat ing

bra n ch o f t h e v o lar in t e ro sse o u s art e ry The fif tlz co mp art .

ment is situat e d o v e r th e in t e rva l be tw e e n th e d ista l e n d s o f

th e rad iu s an d u ln a I t co n ta in s t h e sle n d e r t e n do n o f t h e
.

e x t e n sor d igit i qu in t i p ro p r iu s an d it s m ucou s sh e ath The

’

six t/z an d mo st media l co mpartmen t wh ich corr e sp o n d s w ith t h e ,

gr o ov e o n the dor su m o f the d ista l e n d o f the u ln a e n clo se s ,

t h e t e n do n o f t h e e x t e n sor car p i u ln ar is an d it s mucou s

sh e ath
( se e F ig .

Dis s e c ti o n — Aft e r th e c mp art m e n ts o f t h e d r al carp al

. o o s
lig am n t an d t h e ir o n t n t s h ave b
e am i cd di p la th e een ex ne s ce e
vari u s t n d a far a m ay b ce sary an d l an th do r al
o e o ns s s e ne s ,
c e e s

p art o f t h e radial a rt ry an d its bra h s Th art e ry e n t r

e nc e . e e s

t h do r al p art o f t h e w ri t r g i n by
e s rlin g ro d t h lat ral s e o cu un e e

bo rd r o f t h w ri t de p t t h t d
e e f t h abdu ct o r p llici
s e o e en o ns o e o s
ol n gu s an d t h e s h rt an d l n g t rs o f t h
o t h m b an d it o ex e n so e u ,

di app e ar i t o t h p alm at t h p r im al
s s n e d f th fi r t i t r , e ox en o e s n e
o s se o u s pa be tw e n t h tw o h e ads o f t h fi r t do r l i t r
s ce , e e e s sa n e
o s eo
s s m scle
u A it lie s at t h
u . id o f t h e w ri t tw o do r al
s e s e s s
art ri e o f th
es t h m b a d th d rsal radial arp al bran c h sp ri g
e u n e o c n
f ro m it an d j ,
t b fo re it di pp ar it g iv s ff th d rsal art ry
us e sa e s e o e o e
t o th i d e fi g r a d th fi r t d rs l m t a arp al art ry n l s
n ex n e ,
n e s o a e c e , u es
t h at bran h rises in co m m o n w it h th do r al radial arp al art ry
c e s c e .

R a di a l Art ery O n ly a sma ll p o rt io n o f the rad ia l

.

art e ry is se e n in th is d isse ct io n At the d ista l e n d o f .

th e rad iu s th e v e sse l tur n s dor sa lly d ista l to the sty lo id ,

p roc es s a n d u p o n t h e rad ia l co llat e ra l liga m e n t o f t h e

radio carp a l jo in t Havin g ga in e d th e d o r sa l a sp e ct o f th e

-
.

car p u s it ru n s d ista lly u p o n th e n av icu lar an d o s m u lt

,

an gu lu m m aju s an d fi n a lly d isa p p e ar s fro m V ie w by turn in g

,

v o larwards through th e p r o x im a l p art o f th e fir st in t e ro sse ou s

,

Sp ac e an d be tw e e n t h e h e ad s o f or ig in o f t h e fir st d o r sa l

in t e ro sse ou s m u sc le ( F ig s 7 5 I n t h e p a lm it tak e s th e.
,

ch ie f Shar e in th e for mat io n o f th e d e e p vo lar arch .

Wh ile th e rad ial art e ry r e st s o n th e rad ial co llat e ra l

car p a l liga me n t it is d e e p ly p lac e d an d is cro sse d by the
, ,

t e n do n s o f the abductor p o llic is lo n gu s an d th e e x t e n so r

p o llic is b r e v is O n t h e. car p u s it l ie s n e ar e r t h e sur f ac e ,

an d is cro sse d o bliqu e ly by t h e e x t e n sor p o llic is lo n gu s I t is .

acco mp a n ie d by two ven a co mites an d so me fin e fi la m e n t s fro m

t h e lat e ra l cuta n e ou s n e rv e o f th e for e ar m wh ich tw in e arou n d it .
1
9 2 TH E SU PE R I OR EXTRE M I TY
The oranc/zes wh ich sp r in g fro m rad ial art e ry
th e in th is
p art o f its c o ur se are o f sm a ll siz e . Th e y are
I . R am u s do rsalis
c arp e u s .

2 . A a m e t ac arp e ae do rsale s
. .

3 . A a dig it ale s Two do rsal arte rie s o f the th u mb

. .

do rsa e s l
O n e do rsal arte ry o f the inde digit
. x .

The do rsal radial carpal artery tak e s o r ig in o n the lat e ra l

a sp e ct o f th e wrist , an d ru n s m e d ially, u p o n th e carp u s, to jo in
th e corr e sp o n d in g car p a l bra n ch o f t he u ln ar art e ry Th e arch .

thu s forme d is p lac e d u n d e r cove r o f th e e x t e n sor t e n do n s, an d

g iv e s o ff two bra n ch e s wh ich run d ista lly in th e th ird an d
fourth in t e r me tacar p a l in t e rva ls
-
Th e y are t e rm e d the seco nd .

an d t/zird do rsal metacarp a l a rteries .

The first do rsal metacarpal artery ar ise s, as a ru le , fro m th e

rad ia l tru n k, a lthough n o t in fr e qu e n t ly it m ay be se e n to
Sp r in g fr o m t h e dor sa l car a l arch I t e x t e n d s d ista lly in
p .

t h e se co n d in t e ro sse ou s sp ac e .

Th e thr e e dor sa l m e tacar p a l art e r ie s are brought in to

co nn e ct io n w ith the art e r ie s in the p a lm by co mm u n icat in g
bra n ch e s Th e y are j o in e d by the thr e e p e rforat in g tw igs o f
.

t h e d e e p vo lar arch , wh ich m ak e th e ir a p p e ara n c e o n t h e

dor su m o f th e ha n d be tw e e n the h e ad s o f the m e d ia l thr e e
dorsal in t e ro sse ou s mu sc le s F urth e r, at the d ista l e n d s o f the
.

in t e ro sse ou s sp ac e s th e dor sa l me tacar p a l art e rie s u sua lly se n d

distal p erfo rat ing oran clzes to j o in t h e corr e sp o n d in g co mm o n
vo lar d ig ita l art e r ie s in t h e p a lm .

Th e two do rsal arteries of Me t/z u mo ru n d ista lly o n e

u p o n e ach sid e o f that d ig it .

Th e do rsal artery of tire index is d istr ibut e d o n the lat e ra l

sid e o f the in d e x fi n g e r .

D is s e c t io n — Th e lim b s h o u ld n o w be tu rn e d ro u n d so t h at ,

t h e t ran s v e rse m e t ac arp al lig am e n t w h ic h st re t c h e s acro ss th e

v o lar asp e c s t o f the h e ads f t h e m e acarp al bo n e s m ay be
o t
e x am in e d p re io v us t o the t
disse c io n o f t h e in e ro sse o u s m u scle st .

n
Ligame t u m Cap it ulo rum T ran sv e rsu m — The tra n sv e r se .

liga m e n t o f t he h e ad s o f t he m e tacar p a l bo n e s is a stro n g

ba n d co m p o se d o f tra n sv e r se fi br e s wh ich cro sse s t h e vo lar
, ,

a sp e ct s o f th e h e ad s o f the fo ur me taca rp a l bo n e s o f th e fi n g e r s .

C o mme n c in g o n th e lat e ra l Sid e u p o n t h e d ista l e x tr e m ity o f ,

t h e in d e x m e tacar p a l it e n d s at t h e me d ia l marg in o f th e
,

ha n d u p o n th e h e ad o f th e m e tacarp a l bo n e o f th e little fi n ge r
,
.
1
94 TH E SU PER I OR EXTRE M I TY
first mo st lateral do rsal intero sseo u s muscle, t he t e n d o n is
o r

in se rt e d in to t h e lat e ra l sid e Of t h e ba se O f t h e fir st p ha la n x ,
an d a lso in to t he lat e ra l m arg in O f th e d o r sa l e x a n sio n O f t h e
p
e x t e n sor t e n d o n O f t h e in d e x Th e seco nd an d tnird do rsal .

intero sseo u s mu scles are in se rt e d in a sim ilar m a n n e r, o n e o n

e ach sid e O f t h e ba se O f th e fir st p hala n x O f t h e m idd le fi n g e r ;

whilst the f o u rt/z has a c o rr e sp o n d in g in se rt io n u p o n th e m e d ia l

a sp e ct O f the ba se O f th e first p ha la n x Of th e r in g fi n ge r .

Th e fir st dor sa l in t e r o sse ou s m u sc le is fr e qu e n t ly t e r m e d
th e aodu cto r in dicis an d be tw e e n it s two h e ad s O f or ig in t h e

rad ia l art e ry e n t e rs the p a lm B e tw e e n the h e ad s Of th e oth e r .

thr e e mu sc le s th e sm a ll p e r fo rat in g art e rie s p a ss .

I n add it io n t o act in g as adductor s o r a bductor s O f the

fi ng e r s th e in t e ro sse i fl e x the m e tacar p o p ha la ng e al j o in t s an d -

h e lp to e x t e n d the in t e r p ha la n ge al j o in t s ( se e p Th e .

in t e r o sse ou s m u sc le s are su pp lie d by th e deep bran cfi o f th e

u ln ar n erve .

Te n do n o f t he Flex o r Carp i R a dia lis — The t e n do n Of th e

r ad ia l fl e xo r O f th e carp u s shou ld n o w be trac e d through th e
groov e o n the vo lar a sp e ct O f th e O S mu lta n gu lu m m aju s to its
in se rt io n in to th e ba se O f th e m e tacarp a l bo n e O f th e in d e x
fi n g e r I t p r e se n t s a lso a min or attach m e n t to the ba se Of the
.

m idd le m e tacarp a l bo n e O n its way t o it s in se rt io n it p a sse s

.

be h in d the t e n do n O f t he fl e x o r p o llic is lo n gu s .

D is s e c t i o n — All t he m u scle s aro u n d t h e e lbo w j o in sh o u ld t

be re m o e d v As t h e brac h ialis an d t h e rice p s are raise d fro m
. t
t t
t h e an e rio r an d p o s e rio r asp e cts o f t h e ar icu la io n , so m e c are t t
r v
is e q u ire d t o a o id in j u ry t o t he an e rio r an d p o s e rio r p ar s O f t t t
t h e cap su le v r
I t is ad isable to e m o e t h e su p in a o r las , be cau se
. v t t
t t
it is o n ly w h e n h a m u scle is co m p le e ly iso la e d h a a p ro p e r t t t t
t t
ide a O f its a t ac h m e n s an d m o de o f ac io n c an be O b ain e d t t .

v t
B e fo re it is re m o e d its a t ac h m e n s an d ac io n s m s be s u die d t t ut t .

M Sup in at o r ( O T Su p ina t o r Bre v is) — Th e su p in ator

. . . .

mu sc le e n v e lo p s th e p ro x im a l p art O f th e bo dy an d th e n e ck
O f t h e rad iu s, cov e r in g it co mp le t e ly , e x c e p t o n it s m e d ia ]

S id e g ar r m d d r io
( F i s 6 4,. I t ise s f o t h e e e p e p e ss n

d ista l to th e rad ia l n otch O f th e u ln a an d a lso fro m th e ,

rad ial co llat e ra l liga m e n t Of th e e lbow an d the a n n u lar

liga m e n t O f t h e rad iu s F ro m th e ir or ig in th e fi br e s sw e e p
.

rou n d th e d o rsa l lat e ra l an d vo lar sur fac es Of th e rad iu s an d

, , ,

c lo th e its body as far d ista lly as th e in se rt io n O f th e p ro n ator

t e re s The dorsa l in t e ro sse ou s n e rv e su pp lie s the m u sc le
.
,

trav e r se s its su bsta n c e an d se p arat e s it in to two lay e rs

,
.
 E L B OW J O I N T 1
95

A RT I C U L AT I O N S .

AR TI C U L ATI O C U B I TI
( E L B OW J O I N T
) .

Th is j o in t in c lud es ( 1 ) the art icu lat io hu m e ro u ln ar is ( 2 ) -

t h e art icu lat io hu m e ro rad ia lis an d ( 3 ) t h e art icu lat io rad io

-

u ln ar is p ro x im a lis I n the hu m e ro u ln ar art icu lat io n the

.
-

troch le a O f th e hu me ru s is gra sp e d by t he semilu nar

n o te/z O f th e u ln a I n the rad io hu m e ra l art icu lat io n the
.
-

cap itu lu m of tn e nu meru s r e st s in t he Sha llow f o o ea cap ita li O f

t h e rad iu s an d in t he p ro xim a l rad io u ln ar art icu lat io n t h e

,
-

a rticu lar circ m ference O f the h e ad O f the rad iu s is h e ld in

u

a pp o sit io n w ith t he radial no tc/z o f the u ln a by the an n u lar

liga men t ( F ig s 8 5 .
,

The jo in t is surrou n d e d by a ca p su le wh ich is r e in forc e d at

t he sid e s by c o llat e ra l liga m e n t s ; in add it io n t he in t e ro sse ou s ,

me m bra n e wh ich p a sses be tw e e n th e in t e ro sse ou s cr e st s Of t h e

,

rad iu s an d u ln a an d the O bliqu e cord wh ich co n n e ct s th e

, ,

tu be ro sity O f the u ln a w ith t he p ro x im a l p art O f the in t e r

o sse o u s cr e st O f the rad iu s h e lp to ke e p the rad iu s an d u ln a in
,

a p po sit io n an d are th e r e for e in c lud e d in the ligame n t s O f the

,

e lbow j o in t Th e liga me n t s O f the e lbow j o in t are th e r e for e

.

I . C apsu la art icularis .

4 . L ig ann u lare radn
. .

2 . . l
L ig co late rale u ln are .
5 . M e m bran a in te ro sse a an tibrac hi i .

3 . L ig co llat e rale radiale

. . 6 . C h o rda o b iq u a l .

Th e articu lar capsu le is attach e d p r o x im a lly to th e a n t e r o

me d ia l an d a n t e ro lat e ra l sur fac e s O f t he hu m e ru s, p r o x ima l to
-

t h e coro n o id an d rad ia l fo ssae , r e sp e ct iv e ly At t he sid e s, .

it is attach e d to th e e p ico n dy les ; an d, p o st e r io r ly , t o t h e

p o st e r ior sur fac e, O n wh ich t he lin e O f attach me n t p a sse s through
th e p r o xima l p art O f th e O le cra n o n fo ssa D ista lly , t he ca p su le .

is attach e d to t h e a n t e r ior m arg in O f t h e p ro x im a l, me d ia l,

an d lat e ra l sur fac e s O f t h e O le cra n o n to the m e d ia l an d v o lar
m argin s O f t h e cor o n o id p roc e ss O f th e u ln a , an d to th e ah
n u lar liga me n t O f t h e rad iu s Th e a n t e rio r p art O f t h e c ap su le
.

co n sist s O f fi br e s w hich tak e an irr e gu lar cour se ov e r t he

a n t e rio r a sp e ct O f t he j o in t Th e p o st e r ior p art O f th e .

ca p sule is w e ak e r tha n th e a n t e r io r an d it s attac h me n t t o

th e p o st e r ior sur fac e O f t h e hu m e ru s is c o m p arat iv e ly lo o se .

The cav ity O f t he j o in t is c lo se d d ista lly o n t h e rad ia l

sid e by lax fi br e s wh ich p ass fro m t h e d ista l bo rd e r O f t h e

a n n u lar liga me n t to t h e n e ck O f th e rad iu s an d by a t h in ,

sh e e t O f fi br e s, ca lle d t h e li amen t u m u adratu m, wh ich e x t e n d s

g o
I— 13 a,
 TH E SU PER I OR EXTRE M I TY
fr o m t h e m e d ia l sid e O f t h e n e ck O f t h e rad iu s to th e d ista l
bord e r O f t h e rad ial n otch O f th e u ln a .

Liga me nt u m C o llat e ra le R adiale ( O T E x t e rna l L at e ra l . .

L iga me n t ) The rad ia l co llat e ra l liga me n t is a str o n g bu t

.
-

short ba n d wh ich is attach e d p r o x im a lly t o t he d ista l a sp e ct

O f t h e lat e ra l e p ico n dy le O f th e hu me ru s D ista lly , it is .

fi x e d t o t h e a n n u lar liga me n t O f t he rad iu s, an d a lso , m o r e

p o st e r io r ly ,
t o t h e lat e ra l sid e O f t h e O le cra n o n O f t h e u ln a .

Th e a n n u lar liga m e n t is a str o n g liga m e n t o u s co llar wh ich

surr o u n d s t h e h e ad O f t h e rad iu s, an d r e ta in s it in t h e rad ia l

no tch Of th e u ln a .

H u me r
i
Tr c e p s m u se l
Te n do n

a c h a lis
i
i
Tr c e
An t e r o i li g
r am e n t

Te n do n o f b ice p s
O le cra
'
1 ro ch le a o f
brac h n m u sc l e

h u m e ru s
,

Ba si l ic v e m

n da v e n i
mo i d p ro ce ss o f

I a dia lis

Fl x
e o rd igi t o ru m

p ro fu n du s

it o ru m
p ro fu n du s

FI G . 8 3 — Sag t ta
. i l i
s e c t o n O f t he R i gh t El b w R gi o e o n .

Ligame n t um Co llat e rale U 1na re (O T . . I n t e rn al L a t e r al

Ligame nt ) u ln ar co llat e ra l liga m e n t tak e n as a who le
.
— Th e , ,

is fan sha p e d
-
B y its p ro x im a l p o in t e d p art it is attach e d t o
.

t h e m e d ia l e p ic o n dy le O f t he hu m e ru s D ista lly it sp r e ad s .

o ut an d is in se rt e d in t o t h e c o ro n o id p roc e ss an d t h e
O le cra n o n I t co n sist s O f thr e e v e ry d ist in ct p ort io n s v iz an
.
, .
,

a n t e r ior a p o st e r ior an d a tra n sv e r se ( F ig

, , .

Th e anterio r part sp r in g s fro m th e d ista l an d a n t e r ior p art O f

t h e m e d ia l e p ic o n dy le an d is attach e d to t h e m e d ia l m arg in
,

O f t h e coro n o id p roc e ss Of t h e u ln a Th e p o sterio r part is .

attach e d p ro xim a lly to th e d ista l an d d o r sa l p art O f t he m e d ia l

, ,

e p ic o n dy le wh ilst d ista lly , it is fi x e d to t h e m e d ia l bord e r O f

,
-
1
98 TH E SU PE R I O R EXTRE M I TY
Th e rv e su pp ly O f t he j o in t
ne is d e r iv e d fr o m th e m e d ia n ,
u ln ar an d rad ia l n e rv e s
, .

Mo v e t h e Elbo w J o in t — The m o v e m e n ts at the e lbo w j o in t

me n t s at
must n o t be co n fo u n de d w ith th o se th at t ak e p lace at the p ro im a radio x l
l
u n ar j o in t l
At th e e bo w j o in t t wo m o v e m e n ts, v iz , f lex io n , o r fo rw ard
. .

m o v e m e n t O f th e fo re arm , an d ex ten sio n , o r backw ard m o v e m e n t O f t he

fo re arm , are p e rm itte d .

The m u scles wh ich a re ch ie fl y c o n ce rn e d in fl e in g th e fo re arm u po n t he x

,
H u m e ru s

An t e r o i r
i yl
p art O f c a p su e l Ep c o n d
me d a i s il
us

L ig co ll a t e ra el
ll l l
.

LI g co a t e ra e u n a re

di l
.

ra a e

Li g an n u are l en do n Of
0

bic e p s bra c hn

C ho rda o bli q ua

R di a us

FIG . 8 5 — A n t e rio
. r as p e c t O f t he E bo l wj i o nt .

ar m at the e lbo w j o in t are th e bice p s, the brac ia is , th e h l

m u sc le s attach e d
to t he m e dial e pico n dy le ,
an d th e brach io radialis -
The m u sc le s wh ich
.

x
e te n d th e fo re arm a re th e t rice p s an d an co n ae u s an d t he m u sc le s wh ich
sp rin g fro m th e late ra e p ico l nd yl e .

i
D s ec o
s t i n — . v
I t is ad isable t o s u dy th e radio —c arp al o r ris t w t
t t
j o in , be fo re t h e ar icu la io n s be w e e n th e tw o bo n e s O f th e t t
f o re arm are e x am in e d Th e ran s e rse , o lar, an d do rsal c arp al
. t v v
t t t wt
lig am e n s, o g e h e r i h t h e e x t e n so r an d fl e x o r e n do n s, s h o u ld t
t
be co m p le e ly re m o e d f ro m t h e ris v
N O a e m p , h o e e r, w t . tt t wv
t
s h o u ld be m ade t o de ac h t h e e xt e n so r e n do n s f ro m t h e do rsal t
t
asp e c s O f t h e fi n g e rs an d t h u m b Th e S h o r m uscle s o f t h e . t
t t
h e n ar an d hyp o h e n ar e m in e n ce s m u s also be ak e n aw ay t t .
 P L ATE XI

H u me ru s

M ed a i l pi e co n d yl e

Ol e c ra n o n
“ t

I v
n te r a lb w et een

t ro c hl e a an d Late ral e p i c o n d yl e
c o ro no id p ro ce ss
p
f

H e ad o f i
rad u s

FIG . 86 .
— An te ro p o ste r o r R adio-
i grap h Of e xt e n de d E bol wJi o nt .

(M r A . . D R id )
. e .

Shado w c au se d by
o v l
e r a p O f O e cra no n l
a n d t ro ch e a o l f
h u m e ru s
o v l
e r ap O f c o ro n o i d

p ro c e ss o n t ro c h l ea

Shado w ca u se d by O f h u m e ru s

o v l
e r ap o f i
rad u s o n
co ro n o id p ro c e ss

FIG . 87 .
-
L at e ral R dia o grap h O f e x te n de d El bo w Jo i n t .

( Dr . R . K no x ) .
 P L ATE XII

O ve r a
p ol f c o ro n o id p ro c e s s
11 l
t ro c h e a O f hu me ru s

H u me rus

i
rad u s o n c o ro n o id
p ro ce ss 0 f l
u na
O ve r al f O le
p o
c ran o n o n t ro c h e a l
Of h u me rus

Ol e c ra no n

FIG . 8 8 — L ate ra
. l R di a o grap h Of l
p art y be n t E bo w l .

O l
ve r ap o f he ad o f ra d i us O l
v e r ap O f c o ro no id p ro c e ss
o n c o ro n o i d p ro c e ss o n t ro c h l ea

Ol e cran o n

FIG . 89 .
— L ate ral R di a o grap h Of h al f be nt
-
l
E bo w .

( M r M art . i n .
)
 P L ATE XIV

H u me ru s

i l pi
Med a e co n d yl e

Ep p h i yi s s o f
l
O e c ran o n

FI G .
9 1 .
—
l R di g p h
L ate ra a o ra Of a l
p art y be n t E bo l wJi
o ho w i n g
nt , s
Ep i p hy i s s o l
f O e cran o n .

M
( r A. . D R id )
. e .
 P L ATE XV

Ep ip hy sis Of
l
O e c ra n o n

il i l
M e d a d st a
i yi
Ep p h s s o f e p i p hy i
s s o r,
he ad i
O f rad u s

FIG .
92 .
— -
i
An te ro p o ste r o r R di
a gra p h o f
o yo u n g l wJi
E bo o ho w i ng
nt , s

i
all Ep phy se s.
 P L ATE xv t

Ep p h i yi s s Of
ol e c ra n o n

i yi
Ep p h s s
me di a l p i dy l
e co n e

Ol e cran o n Ep p h i yi s s o f he ad
O f radi u s

FIG .
93 .
—A n te ro p o i R di g ph f y
-
st e r o r a o ra O o ung l
E bo w Ji o nt . Th e ep i p hy i
s s

l
O f th e at e ra l p i dy l f th h m e co n e O e u e ru s h as no t
ye t ap p e are d .

N o te th t t h l t
a l di t l p i phy i f m
e a e ra s a e s s o r s no t o n l y th e c ap it l
u u m Of th e

h u me ru s b t l u
p t f th t
a so ahl ar O e ro c ea .

M e dial d stal i
ep i p hy i
s s Of
Ep i p h y 0

si s O f he a d O f radi u s hu me ru s L at e ra dl i l p i p hy
st a e si s o f hu me ru s

i yi
Ep p h l
s s O f O e cran o n

FIG .
94
— L a te ra
. l R dia o grap h 01 a hal f be n t yo u n g El bo w Jo i n t
-
.
2 0 0 T HE SU P ER I O R EXTRE M I TY
a rt icu lar fac e t o n the e x tr e m e lat e ra l p art Of the p r o x im a l
sur fac e O f t h e tr iqu e tra l bo n e Two in t e r o sse o u s liga me n t s .

str e tch acro ss th e n arr o w in t e rva ls be tw e e n t h e thr e e bo n e s

— O n e O n e ach sid e O f t he lu n at e bo n e an d c o m p le t e t h e —

car p a l surfac e Th e car p a l surfac e thu s for m e d is c o n v e x

.

in all d ir e ct io n s F urth e r it sh o u ld be O bse rv e d that th e

.
,

art icu lar sur fac e e x t e n d s d ista lly to a gre at e r e x t e n t o n th e

d o r sa l tha n On the vo lar a sp e ct .

The p ro x imal su rface o r so cket ( F ig 9 7 ) is e lo n gat e d fro m .

sid e to sid e an d co n cav e in all d ir e ct io n s

,
Th e gr e at e r .

p art O f it is fo r me d by t h e d ista l e n d O f t h e rad iu s bu t , ,

o n th e m e d ia l sid e t he art icu lar d isc O f the d ista l rad io

,

H d f l ea O u na

St yl i d p
o ro ce s s
Of u na l

S u rface fo r
vi l bo
na c u ar ne
Ap e x O f a rt i c u arl
dlSC
G ro o ve fo r t e n do n O f e x t
i l
lli i l g Art
.

cu ar
po c s o n us
S u rfa c e fo r
0

( llS C
l u n at e bo ne

FIG .
95 .
-
C arp a Art l i l c u ar Su rfac e s O f t h e R di a u s an d O f t h e Art i l
cu ar

Di sc O f th e r st Wi .

u ln ar j o in t a lso e n t e r s in to it s c o n struct io n Th e d ista l .

art icu lar sur fac e O f the rad iu s e x t e n d s furth e r d ista lly o n its
d o r sa l an d lat e ra l sid e s tha n o n its v o lar an d m e d ia l sid e s ,

an d it is d iv id e d by a lo w r idg e in t o a lat e ra l tr ia n gu lar an d

a m e d ia l quadrilat e ra l fac e t Th e lat e ra l fac e t in t h e .

,

O rd in ary p o sit io n O f th e ha n d is in co n tact w ith th e gr e at e r ,

e x t e n t O f t h e p ro x im a l art icu lar sur fac e O f th e n av icu lar bo n e .

The m e d ia l fac e t O f th e rad iu s t o g e th e r w ith th e art icu lar ,

d isc fo r m s a m uch larg e r sur fac e tria n gu lar in out lin e

, , ,

wh ich is O p p o se d to t he p r o x ima l art icu lar sur fac e O f t he

lu n at e bo n e Wh e n the ha n d is p lac e d in lin e w ith the
.

fo r e ar m n o p art O f th e p ro xima l art icu lar sur fac e is a llo tt e d

to the tr iqu e tra l bo n e : its small art icu lar fac e t r e st s aga in st
th e m e d ia l p art O f th e ca p su le O f t h e j o in t Wh e n th e ha n d .

is m ov e d m e d ia lly ( i e adduct e d ) h o w e v e r t he tr iqu e tral

. .
, ,

bo n e trav e ls lat e ra lly an d its art icu lar sur fac e co m e s in t o

,
 WR I ST JO I N T 20 1

c o n tact w ith the d ista l sur fac e Of th e art icu lar d isc The .

lu n at e bo n e at t h e sa m e t im e cr o sse s t h e bo u n d in g r idg e o n
t h e d ista l sur fac e O f t h e rad iu s an d e n croac h e s o n t h e ,

t e rr it o ry O f the n av icu lar bo n e wh ilst a co n sid e ra ble p art O f ,

t h e sur fac e O f th e n av icu lar bo n e le av e s t h e rad iu s an d co me s

in t o c o n tact w ith t h e lat e ra l p art O f th e ca p su le .

St ra t um Sy n o v ia le — Th e sy n o v ia l stratu m O f th e rad io .

carp a l j o in t lin e s th e fi br o u s ca p su le an d it c o v e r s the p ro x ima l

sur fac e s O f t h e t wo in t e ro sse o u s liga m e n t s wh ich co mp le t e th e

carp a l surfac e So me t ime s the art icu lar d isc is imp e rfe ct
.
,

an d in th o se ca se s th e sy n o v ia l str atu m O f th e rad io car p a l -

j o in t be c o me s co n t in u o u s w ith th e sy n ov ia l stratu m O f th e
d ista l rad io u ln ar j o in t -
.

The n e rv e su pp ly is d e r iv e d fro m th e v o lar an d dor sa l

in t e r o sse o u s n e rv e s .

M o v me n t at t h Radi o carp al J int

e s Th h d
e b m v d i -
o .
—
e an c an e o e n

f
o ur di ti re c t th di
o ns p l j i t
a Th e w h v
ra ( ) v l o -
c ar a o n . us e a e— a o ar

m v m t
o e en fi i , ; ( 6
o r ) d l m v m t
ex o n t i ( ) l o rsa o e en , o r ex en s o n c u n ar

m v m t
o e en dd t i
, o r
; ( d) di l m v m t
a uc onbd t i I ra a o e en , o r a uc on . n
es tim ti g th
a n x t t f th m v m t i th liv i g p
e e en O th
e se t d t o e en s n e n e rso n e s u en

is ap t m isle d by the in cre ase O f ran ge wh ich is co n tribu t e d by th e

t o be
c arpal j o in ts Th u s, fl e x io n is in re a ity m o re imit e d th an e te n sio n ,
. l l x
l
a th o u gh b
y th e c o m bin e d act io n o f bo t h c arp a an d radi o c arp a j o in t s l -
l
t he h an d c an be c arrie d m u ch m o re fre e y v o larw ards th an do rsa w ards l l .

Addu ctio n , o r u ln ar fl e x io n , can be p ro du ce d to a g re ate r e t e n t th an x

abdu c tio n o r radial fl e x io n
, I n bo th c ase s the e te n t O f m o v e m e n t at
. x
the radio c arp al -
j o int
pro p e r is v e ry s igh t , bu t th e ran g e is e te n de d by l x
m o v e m e n t s O f th e c arpal bo n e s The stylo id p ro c e ss o f the radiu s .

in te rfe re s w ith abdu ctio n .

The m u scles wh ich are ch ie fly co n ce rn e d in p ro du cin g the diffe re n t

m o v e m e n ts O f the h an d at th is j o in t are th e fo l o w in g — ( a ) fi ex o rs— th e l
l
fl e x o r c arp i radia is, the p alm aris o n g u s, an d the fl e x o r c arpi u n aris ; l l
e
( ) e x t e n so rs
px
— e t e n so r c ar i radialis o n g u s , th e e t e n so r c ar i radia is
p l x l
x
bre v is, an d the e te n so r c arpi u naris ; ( c) a fia u cto rs, o r radial flex o rs
’
l
— fl e xo r car i radialis e te n so r c ar i radia is lo n g us abdu c to r
p , p x , p o llicis l
x ll
lo n gu s, an d th e e te n so r p o icis bre v is ; ( d ) addu cto rs, o r u ln ar fi ex o rs
x l
e te n so r carpi u n aris an d fl e x o r c arp i u ln aris .

I n additio n , all th e m u sc le s wh o se t e n do n s cro ss the v o ar asp e c t O f th e l

j o in t c an , u n de r ce rtain c o n ditio n s, assist in t he p ro ductio n O f fl e x io n ,
an d the m u scle s wh o se t e n do n s c ro ss th e do rsal su rface c an assist in th e

p ro d u c t io n O f e te n sio n x .

AR T I C U L AT I O N ES R ADI O U L N AR ES ( R ADI O U L N A R J O I N TS )
- ~
.

At th e rad io u ln ar j o in t s p r o x ima l an d d ista l the

t wo -

, ,

mov e m e n t s Of p r o n at io n an d su p in at io n tak e p lac e At .

th e p ro x imal j o in t th e me d ia l p art O f t h e h e ad O f th e rad iu s

fits in to th e rad ia l n otch O f t h e u ln a ; at th e distal j o in t t h e
2 0 2 TH E SU P ER I OR EXTR E M I TY
sm a ll ca p itu lu m O f t he u ln a is r e c e iv e d in t o th e u ln ar n o tch
o n th e m e d ia l sid e O f th e d ista l e n d O f the rad iu s In .

c o n n e ct io n w ith th e se jo in t s th e r e are Sp e c ia l liga m e n t s

wh ich re ta in t he bo n e s in a pp o sit io n Th e y are fo r .

t he p ro x im a l rad io u ln ar jo in t tlie ann u lar ligamen t ; an d

-

o r th e d ista l rad io u ln ar jo in t a cap su le an d

( )
2 f ( )
a —
( )
e t h e , ,

discu s articu la ris .

In add it io n th e r e are o th e r liga me n t s wh ich p a ss be tw e e n

th e bod ie s O f th e t wo bo n e s O f t h e fo r e ar m an d are th e r e fo r e , , ,

c o m m o n to the two art icu lat io n s v iz th e o bliqu e co rd an d ,

.
,

t h e intero sseo u s memoran e .

D is s e c t io n — TO e x p o se th e O bli u e q c o rd an d th e in e r t
o sse o u s m e m bran e , re m o v e, co m p le t e ly , th e v o la r an d do rsal
m u scle s Of t h e fo re arm .

Li g ame nt u m A nn ulare R a dii ( O T . . O rbicular Liga me nt ) .

Th e a n n u lar liga m e n t is a str o n g fi brou s c o llar wh ich

Ol e c ran o n

R di l
a a n o tch o f u nal
Tra n s v e rse po rt o n i
O f u n ar c ol ll a t e ra l
lg
i ame n t

Se m il u n ar n o tch

An n u l li g
ar am e n t Co ro n o id p ro c e ss

FIG .
96 .
— An n u l ar L ig am e n t O f the R di
a us .

c rc
e n i le s t h e h e ad O f t h e rad iu s an d r e ta in s it i n t h e rad ia l
no tch O f th e u ln a I t f.o r m s fo ur fi ft h s O f a c irc le a n d is -
,

attach e d by its e x tr e m it ie s to t he vo lar an d dor sa l m arg in s O f

th e rad ia l n o tch O f t h e u ln a I t is so m e what n.arr o w e r d is ta ll y
tha n p ro x im a lly SO that u n d e r o rd in ary c ircu m sta n c e s the
, , ,

h e ad O f the rad iu s ca n n ot be w ithdraw n fr o m it in a d ista l

d ir e ct io n an d it is brac e d t ight ly toward s the e lbo w an d
,
,

gr e at ly str e n gth e n e d by the a n t e r ior an d p o st e rio r p o rt io n s

20 4 THE SUPER I O R EXT R E M I T Y
is situat e d (a bout d ista l to
2 t5hmm
e tu b e r o sity
. O f o ne in ch )
th e rad iu s D ista lly it ble n d s w ith th e ca p su le O f th e d ista l
.
,

rad io u ln ar jo in t The fi br e s wh ich co m p o se it ru n fo r th e mo st

-
.

p art o bliqu e ly d ista lly an d me d ia lly fro m th e rad iu s to t h e u ln a ,

a lthough se v e ra l stra n d s may be n ot ic e d tak in g an o pp o sit e

d ire ct io n The d o r sa l in t e r o sse ou s v e sse ls pa ss backward s
.
,

a bove its p ro xima l marg in be tw e e n the two bo n e s o f the ,

for e ar m wh ilst th e t e r min a l bra n ch o f t he vo lar in t e ro sse o u s

art e ry p ie rc e s it a bout two in ch e s fro m its d ista l e n d The .

m e mbra n e brac e s t h e two bo n e s tog e th e r in such a m a n n e r

that forc e s p a ssin g p ro x ima lly thr o ugh the rad iu s are tra n s
, ,

mitte d fr o m th e rad iu s to the u ln a ; an d it e x t e n d s the surfac e

O f o r ig in fo r the mu sc le s o f the for e ar m B y it s vo lar .

sur fac e it g i v e s or ig in to th e fl e x o r d ig it o ru m r o fu n du s an d
p
t he fl e x o r p o llic is lo n gu s m u sc le s wh ilst fr o m its dor sa l ,

sur fac e sp r in g fi br e s O f the two e x t e n sor m u sc le s O f the

thu mb the a bduct o r p o llic is lo n gu s an d the e xt e n so r in d ic is
, ,

p pro r iu s .

Ch o rda O bliq ua ( O T O bliq u e Liga me n t ) Th e O bliqu e

. . .
—

c o rd is a w e ak ba n d O f fi br e s wh ich sp rin g s fr o m the tu be ro sity

O f t h e u ln a I t e x t e n d s o bliqu e ly d ista lly an d lat e ra lly to
.
, ,

fin d its attach me n t to th e rad iu s im m e d iat e ly d ista l to the ,

tu be ro sity O f that bo n e I t cro sse s the O p e n Sp ac e be tw e e n .

th e bo n e s O f t he for e ar m p ro x im a l to th e p r o x im a l bord e r
o f th e in t e ro sse ou s m e m bra n e The O bliqu e cord is O ft e n .

a bse n t an d u n le ss t he ut m o st car e is tak e n in r e m o v in g the

adjac e n t mu sc le s it is ap t to be injur e d .

Mo v e m en t R adio u ln ar J
s at the v -
o in t s —. The m o e m e n ts O f pro n a
~

t io n an d su p in atio n t ak e p lac e at t he radio u ln ar j o in t s W h e n the lim b -

.

is in a co n ditio n o f c o m p le te su pinatio n the th u m b is dire c te d late ra y , the ll

t w o bo n e s o f the fo re arm are p aral e , th e radiu s ly in g a o n g the lat e ral side l l l
O f t he u n a l I n the m o v e m e n t o f p ro n atio n th e radiu s is th ro w n ac ro ss th e
.

u lna , so th at it s distal e n d c o m e s to lie acro ss th e v o lar su rfac e an d o n th e

m e dial side o f the u ln a F u rth e r, the h an d m o v e s w it h the radiu s, an d

.

l
wh e n the mo v e m e n t is co m p e te d the do rsa aspe cts o f the h an d an d the l
fo re arm are dire c te d fo rw ards, an d the th u m b is tu rn e d m e dially .

The disse c to r sh o u ld an aly se , as far as p o ssible in th e p art u p o n wh ich

he is e n g ag e d, the m o v e m e n t s at the t wo radio u ln ar j o in ts wh ic h p ro duc e -

th e se e ff e cts A t the sam e tim e it is to be re m e m be re d th at re su ts

. l
O bt ain e d fro m a lim b in wh ic h th e disse c t io n h as p ro ce e de d SO far are ap t

to be de c e p tiv e Th e re fo re the disse c to r sh o u ld u se h im se lf an d his frie n ds

.

as su bj e c t s o n wh ic h to stu dy th e m o v e m e n ts .

I n the case O f the pro x ima l radio u ln a r j o in t the m o v e m e n t is Si m p le -

e n o u gh .The h e ad o f the radiu s m e re ly ro tate s w ith in the an n u la r

lig am e n t, an d acc u racy O f m o tio n is O btain e d by the fo v e a c api tu li radi i

.

re stin g an d m o v in g u po n th e distal e n d o f t he h u m e ru s I t sh o u ld .
 RA DI O -
U LN AR J O I NTS 2 0 5

be n o tice d th at the h e ad o f the radiu s do e s n o t fit accu rate ly u p o n

t h e c apitu lu m in all p o sit io n s o f the e lbo w j o in t I n e tre m e e t e n sio n . x x
x
an d e tre m e fl e x io n o f th e e lbo w it is o n y p art ia y in c o n tac t w ith it l ll .

Th e re fo re t he se m i fl e x e d c o n ditio n O f th e e bo w j o in t p lace s t h e radiu s

-
l
l
in the m o st fav o u rab e p o sitio n fo r fre e an d p re c ise m o v e m e n t at t h e
x l l
p ro im a radio u n ar j o in t ( F ig s 8 6 , 8 7 , 8 8 , 9 1 , 9 2 ,
-
.

At the distal radio u ln a r jo in t the dista e n d O f th e radiu s re v o v e s

-
l l
aro u n d th e dist al e n d o f th e u ln a I t c arrie s the h an d with it , an d de sc ribe s
.

t he arc o f a c ircle th e c e n tre O f wh ic h co rre spo n ds t o th e att ac h m e n t O f t h e

,

l
articu ar disc t o t h e dist al e n d o f t h e u ln a A s the m o v e m e n t o cc u rs the .

l
articu ar disc m o v e s w ith th e radiu s, an d t rav e ls do rsa y o n th e dist al ll
l
e n d o f th e u n a in su p in atio n , an d to w a rds th e v o ar su rface in p ro n atio n l .

B u t th e q u e stio n m ay be ask e d, D o e s the u n a m o v e du rin g p ro n atio n l

an d su p in atio n l
W h e n the e bo w j o in t is e te nde d to its fu e st e te n t the x ll x
l
u n a re m ains alm o st imm o v ab e l
W h e n , h o w e v e r, p ro n atio n an d su pin atio n
.

are c o n duc te d in th e se m i fl e x e d limb , th e u n a do e s m o v e

-
A sm a l l . l
de g re e o f lat e ral m o v e m e n t at the e lbo w j o in t is a o w e d, an d the dista ll l
l
e n d o f the u n a du rin g p ro n atio n is c arrie d s igh t y do rsa y an d at e ra y , l l ll l ll
an d in th e re v e rse dire c t io n du rin g su in at io n
p .

The m u scles which are ch ie fly co n ce rn e d in p ro du cin g sup i n at io n o f th e

fo re arm are — the bice p s brach ii, the brach io radia is an d the su p in ato r -
l .

l
Th ey are aide d by th e o n g abdu c to r an d t he o n g e te n so r O f t he th u m b l x .

The bice p s brach ii, fro m it s in se rtio n in to th e do rsal p art O f the tu be ro sity
O f the radiu s, is
p lac e d in a v e ry fav o u rab e
p o sit io n ,
in so far as it s su pin at l
in g ac tio n is c o n ce rn e d Th e m u sc e s wh ic h act as p ro n ato rs o f the im b are
. l l
—
t he p ro n ato r t e re s, the p ro n at o r q u adratu s, an d, t o a c e rt ain e te n t , the x
fl e x o r carp i radia is l
Th e p ro nato r t e re s, fro m its in se rt io n in to th e
.

x l
p o in t o f m a imu m at e ral c u rv atu re o f radiu s, c an e e rcise its p ro n atin g x
ac tio n to gre at adv ant ag e The balan ce O f po w e r is in fav o u r O f the
.

su in ato rs, o n ac co u n t O f th e
p re o n de ratin g in fl u e n ce o f the bice p s
p p .

D is s e c t i o n — Th e an n u lar lig am e n s h o u ld be cu t h ro u gh ,
. t t
an d t h e O bliq u e co rd a n d t h e in e ro sse o u s m e m bran e s h o u ld be t
v
di ide d p ro x im o dis ally t
B y dra in g t h e radiu s la e rally an d
-
. w t
o p e n in g t h e c ap su le O f t h e dis al radio u ln ar j o in , t h e p ro x im al t -
t
su rf ace o f t h e dis cu s art icu laris o f t h e w ris w ill be disp lay e d t
t
an d its a t ac h m e n s m o re f u lly app re cia e dt t .

A R TI C U L ATI O N ES C AR P E/E ( C A R PAL JOINT ) S .

I n th e car p u s two jo in t s are r e c o gn ise d

I A t i l ti i p i if m i
. r cu a o o ss s s o r s
.

A ti l ti i t 2 p . r cu a o n e rcar e a .

P isif o rm J o int The p isifor m bo n e art icu lat e s w ith the

.
—

v o lar surfac e o f the triqu e tra l bo n e t o wh ich it is attach e d by ,

an art icu lar ca su le T h e cav ty O f t h e isifor m j o in t is

p i
p .

qu it e d ist in ct fro m th o se O f the adjac e n t jo in t s .

The d isse ctor has p r e v iou sly n o t e d that th e t e n do n o f th e

fl e x o r car p i u ln ar is is in se rt e d in t o t he p isifor m bo n e an d ,

as t h e ca p su le w o u ld be qu it e in ca p a ble by it se lf O f w ith
 THE S U PER I OR EXTRE M I TY
s ta n d in g the stra in to wh ich th is mu scle su bj e ct s the
art icu lat io n c e rta in acc e sso ry ba n d s are p rov id e d wh ich
,

a n ch o r th e p isifor m fir mly in p lac e th e y are the p iso ha mat e — -

an d t h e p iso m e tacar p a l ba n d s Th e for m e r p a sse s fr o m th e

-
.

d istal e n d o f t h e p isifo r m to th e bo o k o f th e ha mat e bo n e ;

an d t he latt e r attach e s t he p isifo r m to th e p ro x ima l e n d s o f

t h e fourth an d fi fth m e tacar p a l bo n e s .

A R TI C U L ATI O I N TER C AR P EA ( I N TE R C A R P A L J O I N T) .

Th e in t e rcar p al jo in t h as o ne j o in t cav ity bu t it in c lud e s ,

no t o nl y t he art icu lat io n s be tw e e n the p ro x im a l an d d ista l

OS na vi cu a re l Os l u n at u m
m an u s

0 5 c a ita t
p um
0 5 t ri q u e t ru m

Os m u l t

O s h a ma t u m

FIG .
97 .
— F ro n t a l i
se c t o n t hro u gh R di a o -
carp a l , C arp a l , an d C arp o
me tac arpa l an d I n t e r m e t ac a r
-
p l J i t
a o n s to h o w Jo i n t
S C av i ti es an d

I n t e ro sse o u s i
L gam e n t s ( di agra mm ti )
a c .

r o w s o f car p a l bo n e s wh ich fo r m t he transverse p art o f the

,

j o in t bu t a lso the art icu lat io n s be tw e e n t he bo n e s o f the

,

p ro x im a l ro w an d th o se be tw e e n t h e bo n e s o f t h e d ista l

ro w Th e m a in p art O f t h e cav ity o f th e jo in t lie s be tw e e n

.
~

t he p ro x im a l an d d ista l r o w s ; bu t t wo p r o lo n g at io n s p a ss

p ro x ima lly o ne b e tw een ,

t h e lu n at e an d n av icu lar bo ne s ,

an d t h e oth e r be tw e e n t he lu n at e an d tr iq u e tr al bo n e s an d ,

thre e d iv e rt icu la are p ro lo n ge d be tw e e n t h e bo n e s O f t h e

2 0 8 TH E SU PER I OR EXTR E M I TY
co n cav ity fo r me d by the d ista l surfac e s o f t he tr iqu e tra l an d
lu n at e bo n e s an d t h e d ista l p art o f t h e m e d ia l sur fac e
o f t h e n av icu lar bo n e ; an d th e c o n v e x d ista l sur fac e o f t h e

n av icu lar bo n e is r e c e iv e d in to a co n cav ity fo r m e d b t h e

y
p ro x im a l sur fac e s O f t he gr e at e r and le sse
. r m u lta n gu l ar
bo n e s Th e two O p p o se d sur fac es o f th e tra n sv e r se p art O f
.

t h e j o in t are th e r e for e co n cavo co n v e x fr o m sid e t o sid e

, ,
-

an d ada p t e d o n e to th e oth e r F ig s 9 7
( .
,

M o v me n t at t h Carp al J o in t
e s Th m v m t e t th p l j i t s —
. e o e en s a e c ar a o n s

su p p l m t th
e t th
en di p lj i t
o se a dt d g tly t i
e ra o -
th
c ar a o n , an en re a o n c re ase e

ran g e O f m o v e me n t at the w rist B e t w e e n the in div idu al bo n e s o f e ach ro w

.

th e m o v e m e n t is O f a g lidin g ch aract e r an d v e ry l im it e d A t the t ran s , .

v e rse in te rcarpal j o in t v o lar an d do rsal m o v e m e n ts ( fl e x io n an d e x te n sio n )

alo n e are all o w e d .

B y the m u l tip l ic ity o f j o in ts in th is p art o f the l im b stre n g th an d ,

e lastic ity are c o n t ribu t e d to th e w rist .

The n e rv e su pply O f the radio c arpal an d in t e rc arpal j o in ts is de riv e d

-

fro m th e m e dian u l n ar radial an d m u scu lo c u tan e o u s n e rv e s

, ,
-
.

D is s e c t i o n — Th e in t e ro sse o u s m u scle s sh o u ld n o w be re
mo v
f ro m t h e m e acarp al bo n e s
ed t
At t h e sam e im e th e fl ex o r . t
t e n do n s an d lu m bric al m u scle s m ay be de ac h e d f ro m t h e fi n g e rs t .

t wv
Th e e xt e n so r e n do n s, h o e e r, s h o u ld be le f in p o si io n o n t h e t t
t
do rsal su rf ace s O f t h e m e acarp o p h alan g e al an d in e rp h alan g e al -
t
t t w
j o in s Th e ligam e n s h ic h co n n e c th e carp u s an d m e a
. t t
c arp u s, an d h o se t w
h ic h p ass be e e n th e base s o f th e m e dial tw
r t
f o u m e acarp al bo n e s , s h o u ld be cle an e d an d de fi n e d .

A R TI C U L ATI O N ES I N TE R M ETAC AR P EzE ( I N TER M ETAC A R P A L

J O I N TS) .

Th e fo ur m e tacar p a l bo n e s O f t h e fi n g e r s art icu lat e w ith

o n e a n oth e r by th e ir ba sa l o r p r o x im a l e x tr e m it ie s, an d are

u n it e d t o g e th e r by str o n g liga me n t s The me tacar p a l bo n e .

o f t h e thu mb sta n d s a lo o f fr o m its n e igh bour s, an d e n j o y s

a m uch gre at e r fr ee do m O f m o v e me n t .

Th e liga me n t s wh ich bin d th e m e d ia l fo ur me tacar p a l bo n e s

to each oth e r are
1 A se r ie s O f vo lar an d do rsal ba n d s wh ich p a ss tra n s
.
,

ve rse ly an d co n n e ct th e ir ba sa l e x tr e mit ie s .

2 T/zree stout in tero sseo u s ligaments wh ich occu p y th e

.
,

in t e rva ls be tw e e n th e ba sa l e n d s o f th e bo n e s .

T h e tran s verse lig a m ents of tae beads wh ich co n n e ct t h e

3 .
,

h e ad s o r d ista l e x tr e m it ie s O f the bo n e s ( p Th is liga .

m e n t has be e n r e m ov e d in t he d isse ct io n o f th e in t e ro sse ou s

m u sc le s .
 P L ATE XV I I

R di
a us

Ul na

Di l st a e p ip hy

s is O f ra d u s i
L u nat u m

P i si fo rm
St yl id p o ro

c e ss O f ra d u i
Na vi l
c u ar

Triq u e t ru m
M u lt an gu lu
ma j us

H a m at u m

Mu l t an g u lu rr
m i nu s

C ap i t at u m

FI G .
98 .
— A n te ro p o st e r o
-
i r R di
a o grap h o f t he Wri st o f a P e rso n
Of 1 9 ye ars .

N o te ( )
1 Th e e p p hyse a i l li
n e s o f t h e ra d i u s an d u n a l .

(2 ) i
The d ffe re n ce in e ve O f t he l l styl o i d p ro c e ss o f t he l
u n a as co n
t ra ste d w i th t h e st yl o i d p ro ce ss O f t h e radi u s .

3 ) Th e o ve rl ap o f th e Sh ado ws o f adj a c e n t bo n e s .
 2 1 0 TH E SU P ER I OR EXTRE M I TY
ex c lud e d by th e m fro m the rad io car p a l j o in t I t p a sse s -
.

a lso be tw e e n th e four bo n e s o f th e d ista l ro w o f the carp u s

an d cov e r s th e in n e r sur fac e s o f th e liga m e n t s O f t h e
carp o me tacarp a l jo in t s an d th e liga m e n t s Of th e m e d ial four
-

in t e r me tacar p a l art icu lat io n s .

I n so m e ca se s t h e in t e r o sse ou s liga me n t wh ich co n n e ct s

t h e ba se O f th e th ird m e tacarp al to th e ca p itat e an d ha m at e
bo n e s shut s Off t h e art icu lat io n O f t h e ha m at e bo n e w ith the
m e d ia l two m e tacarp a l bo n e s an d co n v e rt s th e art icu lat io n ,

o f t h e ha m at e bo n e w ith th e m e d ia l two m e tacar a l bo n e s

p
in to a se p arat e se g me n t O f t he car p o m e tacar p a l jo in t -
.

D is s e c ti o n — T di p lay t h e art ic lar u rfa

. O s o f th c arp o u s ce s e
m t a arp al articu lat i n
e c t h e m t a carp s sh o ld b
o s, d t h d e u u e e ac e
f r m t h carp u
o e Th e i t rs. e s lig am e n ts b tw
n e o ss o un th e arp al e ee c
bo n o f the s
es n d ro w a d al o b tw
e co n th e ba ,
s f th e n s e ee se o
m e dial f r m t a arp al b
o u e c an lik w i e b
c d m trate d
o n e s, e s e e o ns
by c arry in g th e k n ife be tw e e n t h e bo an d div idi g t h e n e s, n
lig am e n ts .

Art icula r Surface s — Th e ba se o f th e m e tacar p a l bo n e O f

th e in d e x w ill be see n to be ho llow e d out fo r t h e r e c e p t io n
O f t h e le sse r m u lta n gu lar bo n e O n th e lat e ra l sid e it a lso .

a rt icu lat e s w ith the gr e at e r m u lta n gu lar bo n e , an d o n the

m e d ia l sid e w ith th e ca p itat e bo n e Th e ba se o f th e th ird .

m e tacarp al r e st s aga in st th e ca p itat e bo n e alo n e The ba se .

o f t h e m e tacar a l bo n e o f th e r in g fi n g e r r e st s u o n th e ha m at e
p p
bo n e , bu t art icu lat e s Slight ly w ith t h e ca p itat e bo n e a lso The .

fi fth m e tacarp al bo n e art icu lat e s w ith th e ha mat e bo n e ( F ig s .

Mo ve m f t h e M e t acarp al B o n e s — The O p po se d saddle sh ap e d

e nt s o -

su rface s o f the g re at e r m u ltan gu lar bo n e an d t he m e tacar al bo n e O f th e

p
l
th u mb a lo w fre e m o v e m e n t at th at j o in t Th u s t he m e tac arp a bo n e O f the . l
t h u m b c an be m o v e d— ( I ) do rso lat e rally ( e t e n sio n ) ; ( 2 ) v o larw ards an d
-
x
ll
m e dia y ( fl e x io n ) l
3 ) m e dia ly t o w ards the in de ( addu ct io n ) ( 4 ) lat e ra y x ll
l
( abdu c tio n ) ; 5) m e dia ly acro ss the p alm t o w ards the lit t e fin g e r( o ppo sitio n ) ; l
( 6 ) a c o m bin atio n O f the abo v e m e n tio n e d m o v e m e n t s, o ccu rrin g o n e afte r
-

t he o t h e r, co n st itu t e s c ircu m du c tio n The mu scle s wh ic h O p e rat e o n the

.

th u m b are I x
) th e two Sp e c ial e te n so rs, bre v is an d lo n gu s, an d the
abdu c to r o llicis lo n g u s,
p p ro du cin g e t e n sio n
( 2 ) t h e fl e x
xo r
p o licis bre v is, l
l
t he O pp o n e n s p o lic is, an d th e addu c t o r p o llicis, p ro du cin g fl e x io n an d
o pp o sitio n , t wo m o v e m e n t s wh ich are sim ilar in c h aract e r ; ( 3 ) the
abdu c to r ll
p o icis lo n g u s an d t h e abdu c to r po llicis bre v is , p ro du cin g
abdu c t io n ; l
( 4 ) the addu ct o r p o l icis an d the fi rst do rsal in t e ro sse o u s
m u sc le , wh ich giv e rise to addu ct io n .

Th e m e tac arp al bo n e s o f the in de an d middle fin g e rs p o sse ss v e ry x

little p o w e r o f in de pe n de n t m o v e m e n t The m e tac arp a bo n e o f the rin g
. l
fi n ge r, an d m o re e sp e cially the m e tacarpal bo n e O f the it tle fin g e r, are l
n o t so tigh t ly bo u n d t o the car u s
p W h e n t h e h an d
. is c le n ch e d th e y bo th
 M ET AC A RPO P H AL AN G E AL JO I N T S -
2 1 1

mo ve vo larwardsThe m e tac arp al bo n e o f the little fi n g e r is p ro vide d

.

with an O ppo n e n s mu scle , an d has a fe e ble po w e r O f m o vin g v o larwards

ll
an d late ra y to w ards th e th u m b .

The c arpo m e tac arp al an d in te rm e tac arpal j o in t s are su p p ie d by th e

-
l
l
radial, u n ar an d m e dian n e rv e s .

A R TI C U L ATI O N ES M ETAC AR P O P H AL AN GEzE ET D I G I TO R U M

M R H AL A N G EAL I N TER P H AL AN G EAL J O I N TS)
( ETAC A P O P -
AN D .

Th e liga m e n t s wh ich co n n e ct the m e tacarp a l bo n e s w ith

the p ha la n g e s an d th o se wh i ch co n n e ct t o g e th e r th e
p ha la n g e s O f adjac e n t row s ar e p ract ica lly s im i lar in charact e r
a lthough the jo in t s be lo n g to d iff e r e n t gr o u p s The liga m e n t s .

O f e ach j o in t are :

1 C a p su la art icu lar is

. .

2 L ig acc e sso r iu m vo lar e

. . .

3 L igg co l lat
. e ra lia . .

Cap sula Art iculari s The fi br o u s stratu m o f th e art icu lar

.
-

ca p su le is ble n d e d , o n th e vo lar a sp e ct, w ith the acc e sso ry

vo lar liga me n t an d at th e sid e s w ith the c o llat e ra l liga m e n t s .

D or sa lly it is a bse n t , an d th e r e t he sy n o v ia l stratu m o f th e

ca p su le lie s in d ir e ct r e lat io n w ith th e e x t e n so r t e n do n o r
t e n do n s wh ich cro ss th e jo in t .

Ligame nt um A cc esso ri um V o lare Th e v o lar acc e sso ry .

—

liga me n t is a str o n g fi br o u s p lat e wh ich is fir mly attach e d t o

t he vo lar a sp e ct o f t h e ba se O f t h e d ista l bo n e o f t h e j o in t .

I t e x t e n d s p ro x ima lly ov e r t h e vo lar a sp e ct O f th e h e ad O f

t h e p r o x ima l bo n e O f th e j o in t an d is lo o se ly attach e d to it s
n e ck . I ts m arg in s are co n n e ct e d w ith t h e co llat e ra l liga m e n t s
an d w ith t h e fi br o u s fl e x o r sh e ath O f th e fi n g e r Th e vo lar .

s u rf ac e s O f t h e vo lar acc e sso ry liga m e n t s o f t he m e tacar o

p
p ha la n g e a l j o in t s are gr o ov e d by t h e fl e x o r t e n d o n s an d th e y
are c o n n e ct e d w ith o n e a n o th e r b t h e tra n sv e r se liga m e n t
y
o f t he h e ad s o f t he m e tacar a l bo n e s T w o s e sa m o id bo n e s
p .

are u sua lly d e v e lo e d in t h e v o lar acc e ss o ry liga m e n t s o f t he

p
m e tacar p o p ha la n g e a l j o in t O f th e thu mb an d n o t u n co m m o n ly
-

s e sa m o id bo n e s are fo u n d in th e corr e s o n d in g liga m e n t s O f

p
o th e r m e tacar o ha a g a jo t g
p p l n e-
l in s
( Fi s
9 8 .
,

D is s e c t i o n — Th e e xt e n so r te n do n s sh o u ld n o w be raise d
fro m t he do rsal su rf ace s O f t h e m e acarp o p h alan g e al j o in s t -
t .

t
I f his is do n e care fu lly t h e do rsal p art o f t h e c ap su le o f e ach
w t t v
j o in t ill be le f in act I t is e ry t h in , an d co n sis s, p rac ically ,
. t t
I— 14 a
2 1 2 TH E SU P ER I OR EXTRE M I TY
o f t he s no y vial st ratu m o nl y ,
th e p ro te ct i o n affo rde d by t he
e x t e n so r t e n do n re n de rin g t h e p re se n ce o f th e fi bro u s t t
s ra u m
u n n e ce ssar y .

vement o f t he M et acarp o p h alange al J Oint I

Mo s -
s —
. n e ac h m e t acarpo
p h l g
a anl j i t th ea i og l vity t th p x im l
n e s n e co n ca a e ro a end f the first
o

p h l x
a an t i l t w it h t h d
ar c u a e s d di t l x t m ity e ro u n e s a e re o r h e ad O f t h e

m e tacarp al bo n e The j o in ts are c o n dy lo id j o in ts,

. th e re fo re th e m o v e
m e n ts wh ich o c c u r at th e m are : ( ) fl e x io n , ( 2 ) e I x t e nsio n , ( 3 ) abdu c
t io n , ( 4 ) addu c tio n , ( 5 ) circu m du c tio n .

D u rin g fl e x io n o f t he fi n g e rs t he fi rst ph alan t rav e ls v o larwards w ith x

l
th e th ick acce sso ry v o lar ig am e n t u p o n t he h e ad o f t he m e t ac arp a l
bo n e The in t e ro sseo u s an d lu m brical m u scle s are ch ie fly in stru m e n t al
.

in p ro du cin g th is m o v e m e n t, bu t t h e y are aide d by th e lo n g an d sh o rt

fl e x o rs o f th e dig it s .

l
The first ph a an g e s O f the fi n g e rs, in the m o v e m e n t o f e te n sio n , c an x
l l
be c arrie d do rsal y o n y to a v e ry Sligh t de g re e be yo n d th e lin e O f th e
m e t acarp al bo n e s The ex ten so r co mm u n is an d the sp ecial ex ten so rs o f th e
.

i n dex an d little fi nger are th e m u sc le s wh ich O p e rat e in th is c ase .

Abdu c tio n an d addu c tio n are m o v e m e n t s o f th e first ph alan aw ay fro m x

an d to w ards a lin e p ro lo n g e d dista ly th ro u gh th e m idd e fi n g e r, an d l l
are se e n wh e n th e fin g e rs are Sp re ad o u t an d ag ain draw n t o g e th e r .

The abdu cto r digi t i q u in t i an d the do rsa l i n tero sseo u s m u scles ac t as

l
abdu c to rs O f th e fi n g e rs , wh i st th e v o la r i n t ero sseo u s m u scles o p e rate

as addu c to rs o f the litt le , rin g , an d in de fin g e rs I n the case o f x .

t h e m iddle digit , t he seco n d an d t bi rd do rsal in tero sseo u s m u scles ac t

'

alte rn ate ly as abdu cto rs an d as addu c to rs I n co nn e ct io n w ith th e .

m o v e m e n t s o f abdu c tio n an d addu c tio n , it Sh o u d be n o tice d th at in the l

x
e te n de d
p o sitio n o f th e fi n g e rs t h e y a re v e ry fre e ; b u t if fl e x io n is

in du ce d, the p o w e r o f se p aratin g the fi n g e rs be co m e s m o re an d m o re

l
re stric t e d, u n t i it be co m e s lo st wh e n th e h an d is c lo se d An e am in a . x
l
t io n O f the c o llat e ra lig am e n t s w ill affo rd th e e p lan atio n o f th is fac t x .

Th e y are attach e d so far do rsa y o n t he m e tac ar a bo n e s , as t o be m u c h

p ll l
n e are r t o t h e ir distal e n ds t h an t o th e ir v o lar as e c ts
p
!
( C e an d) C o n l l .

se q u e n tly , wh ile th e y are co m arat iv e ly lax in t h e e te n de d p o sitio n o f

p x
the fi n g e rs , the fu rth e r fl e x io n adv an ce s the t igh t e r th e y bec o m e , an d in
t h is way th e y in te rfe re w ith the late ra m o v e m e n t s o f th e fi rst ph alan g e s l .

x
The fi rst ph alan o f the th u mb has o n ly a lim ite d ran g e O f m o v e m e n t
at th e m e t acar o p h alan g e al j o in t
p
-
.

v
M o e me n t s o f t h e I n t e rp h alan ge al J o int s — The in te rph alang e a . l
j o in ts are h in ge j o in ts, th e re fo re the o n y m o v e m e n ts p o ssible are fl e x io n l
an d e te n sio n x F le x io n O f the se co n d ph a an g e s o f the fin g e rs is bro u gh t
. l
abo u t by t he fl e x o r su blim is , an d o f the u n g u al ph a an g e s by the fl e x o r l
p ro fu n du s E t
. e n sio n x o f t h e p h a a n g e s at t he in t e r h alan g e a
p l j o in t s is l
p ro d uc e d n o t o n y b y t h e l
e te n s o rs o f t h e d ig it s x
b u t al so by t h e in t e ro sse o u s

l
an d lu m bric al m u sc e s ac tin g th ro u gh t he e t e n so r e
p an sio n s, in to wh ic h x x
th e y are in se rte d The in te ro sse i an d lu m bricals, th e re fo re , fl e x th e first
.

l
p h a an g e s at the m e t acarp o ph alan g e a j o in t s an d e te n d th e se c o n d an d
-
l x
u n gu a l
p h alan g e s at th e in te rph alan g e al j o in t s .

I n the c ase O f th e th u m b, the fl e x o r p o icis lo n g u s an d th e e te n so r ll x

ll
p o icis lo n gu s o p e rate at the in t e rph alan g e al j o in t .

So m e o f th e m e t ac arpo ph alan g e al j o in ts an d in te rph alan g e al j o in ts are

-

su p p lie d b
y t h e m e d ian an d so m e b
y th e u nar n e rv e l .
 I N TRO D U C T I O N 2 I
3

I N F ER I OR EX T R E M I TY .

I nt ro du ct oi n — B e for e c o mme n c in g th e d isse ct io n th e stud e n t

.

sh o u ld be fa miliar w ith t h e bo n e s O f t h e r e g io n to be
d isse ct e d an d w ith th e surfac e m ark ings wh ich in d icat e the
p o si t io n s o f the structur e s wh ich are to be d isp lay e d H e .

sh o u ld a lso p o sse ss a g e n e ra l k n ow le dg e o f th e co n st itut io n

'

an d d istr ibut io n o f a sp i n a l n e rv e .

The bo n e s o f t h e in fe r ior e x tr e mity are : The o s co x a or

h ip bo n e ; t he f emu r o r th igh bo n e t h e p atella o r k n e e cap ; -

t he tibia an d fibu la wh ich are t he bo n e s O f t he le g ; se v e n

,

tarsal an d fiv e meta ta rsal bo n es wh ich are t h e bo n e s o f t he ,

foot ; an d fo urt e e n p /z a la nges wh ich are th e bo n e s o f t he

,

to e s thre e fo r e ach e x c e p t t he gr e at t o e wh ich has o nly two

, ,

p ha la n g e s ( F ig s 1 0 1
. 1 0 2 , ,

The o s co x ce or hip bo n e lie s in th e low e r p art o f the tru n k .

I t is j o in t e d p o st e r io r ly to t h e v e rt e bra l c o lu mn wh ilst in ,

fr o n t it m e e t s it s fe llo w o f t h e O p p o sit e sid e in t h e me d ia n

p l a n e ,
at t h e sy mpy/z sis p u bis T h e u pp . e r p art o f t h e o s co x ae

is c alle d th e iliu m I t s h igh est p art for m s a curv e d r idg e

.
,

t h e crest o f tbc iliu m wh ich is e a sily fe lt at th e sid e o f t h e

,

bo dy an d is a litt le be lo w t h e le v e l o f th e e lbo w wh e n th e
arm ha n g s by t h e sid e Th e p o st e r io r e n d o f t he cr e st o f th e
.

iliu m is t h e po sterio r superio r spin e of tire iliu m Th e a n t e r ior .

e n d O f t he cr e st is t h e an terio r sup erio r spin e of tbc iliu m .

The lo we r an d p o st e r io r p art o f t h e O S c o x ze u p o n wh ich ,

t h e body r e st s in t he sitt in g p o stur e is th e isc/ziu m ,it is a

la n d mark O f imp orta n c e wh e n t he p o st e r ior p art o f t he
in fe r io r e xtr e mity is be in g d isse ct e d .

The low e r an d fr o n t p art O f t h e o s co x ae is th e p u bis It .

me e t s its fe llo w Of th e o pp o sit e sid e in t he m e d ia n p la n e at the

, ,

sy m p hy sis p u bis wh e r e it is e a sily fe lt

,
F r o m th e u p p e r e n d
.

o f th e sy m p hy sis p u bis a r idg e calle d t he crest of tbc pu bis

, ,

ru n s lat e ra lly an d t e r min at e s in a p roj e ct io n t e r me d the

pu bic tu bercle .

A fa in t groov e ca lle d the ingu in al su lcus e x t e n d s fro m the

, ,

p u b ic tu b e rc le to t h e a n t e r ior su p e r io r sp in e o f th e iliu m It .

in d icat e s the se p arat io n be tw e e n th e low e r o r in gu in a l r e g io n

o f th e tru n k an d t h e u pp e r or su bin gu in a l r e g io n o f t h e

fro n t O f t he th igh I f p r e ssur e is m ad e a lo n g th e lin e O f t h e

.

in gu in a l su lcu s e la st ic r e sista n c e will be fe lt ; it is du e to

,

1— 14 b
 2 1 4 TH E I N F ER I O R EXTRE M I TY
a fi brou s ba n d ca lle d th e ligamentu m ingu inale ( P o u p arti i ) ,

wh ich is attach e d me d ia lly to t he p u bic tu be rc le an d lat e ra lly

to t he a n t e r io r su p e rio r sp in e o f t he iliu m .

The fi n g e r shou ld n o w be carr ie d d o w n ward s a lo n g th e , ,

sy m p hy sis u b is to it lo w r m arg i wh i ch is at t h a e x Of
p s e n e p ,

t he p u bic arclc F r o m its a p e x th e p u bic arch m u st be trac e d

.

lat e ra lly an d backward s I t is for m e d by t h e ra m i o f t h e

.

p u b is a n d is ch iu m a n d it t e r m in at e s p
,
o st e r ior ly at t h e tu b er

isc/ziadicu m wh ich is t he p rotu be ra n t in fe r ior e n d o f t h e isch ia l

,

p art O f t h e O S c o x ae T h e p u bic arch m ark. s t h e su p e r io r

bo u n dary o f t he me d ial sid e o f th e th igh wh ich is ca lle d ,

t he medial f emo ral regio n .

B e t we e n th e r e g io n O f t h e h ip an d t h e k n ee lie s t h e
r e g io n O f t he ti ng/z, wh ich is the p r o xima l se g m e n t o f t he fre e
p art O f t h e in fe r ior e x tr e mity Th e bo n e o f t h e t h igh is t h e .

f em u r I t art icu lat e s p r o x im a lly w ith th e lat e ra l a sp e ct O f t he

.

OS c o xae at the j u n ct io n o f t he thr e e se g me n t s O f that bo n e ,

an d d ista lly it art icu lat e s w ith t h e tibia wh ich is o n e o f the ,

bo n e s o f t h e le g an d w ith t he p atella or k n e e cap ( F ig

,
-
.

I n t he gr e at e r p art O f it s e x t e n t t he fe mur is d e e p ly
e mbe dd e d a mid st t h e m u sc le s o f t h e h ip an d th igh an d

ca n n o t e a sily be fe lt bu t two p art s o f its p r o xima l e n d can

,

be d ist ingu ish e d v iz t h e h e ad o f t he fe mur an d t h e gr e at e r

,
.
,

tr o cha n t e r I f p re ssur e is mad e be low the midd le o f the

.

in gu in a l su lcu s wh ilst t h e th igh is rotat e d t h e rou n d e d Ii co d ,

of tile femu r c an be d ist in gu ish e d as it m ov e s in t h e cav ity

o f t h e h ip j o in t A m or e r e ad ily fe lt p ort io n o f th e p r o x im a l
.

e n d O f t h e fe mur is t he p r o min e n t p roj e ct io n ca lle d t h e greater

tro clzanter I t lie s a bo ut t e n c e n t im e tre s ( 4 in ch e s) be lo w th e

.

iliac cr e st o n a le v e l w ith th e p u bic cr e st an d it s h igh e st p o in t

, ,

is cr o sse d by a lin e draw n fr o m t h e a n t e r io r su p e r io r sp in e o f

t h e iliu m to t h e in fe r io r e n d O f t he tu be ro sity o f t h e isch iu m .

The p o sit io n O f t h e gr e at e r troch an t e r is in d icat e d o n t h e

“

sur fac e by a p ro min e n c e du e to t h e roj e ct io n O f th e bo n e

, p ,

an d t he r e g io n O f t he r o m i e n c is t h e tro cn a n teric regi o n

p n e .

The ar e a be tw e e n t he trocha n t e r ic r e g io n an d t he cr e st O f
t he iliu m is t he regi o n of tire l n p T h e lat e ra l p art o f t h e .

th igh d ista l to t he trocha n t e r ic r e g io n is th e lateral femo ral

, ,

regi o n .

At the d ista l e n d o f th e a n t e r io r p art o f th e th igh is the

regio gen u a n terio r . In t he m idd le o f th e r e g io n lie s t h e

p at e lla . The o ut lin e Of t h e p at e lla can be se e n as w e ll as

2 1 6 TH E I N F ER I O R EXTRE M I TY
art ic u lat e s at th e a n k le w ith a bo n e o f t h e fo o t ca lle d the
talu s . U n lik e t h e t ibia t h e fi bu la is d e e p ly situat e d in th e
,

gre at e r p art o f its le n gth bu t its p fo x imal e n d the bead Of

, ,

t h e fi bu la is e a sily fe lt im m e d iat e ly be lo w t he p o st e r io r p art

,

o f t h e lat e ra l c o n dy le O f t he t ibia ; it s d ista l e n d wh ich is ,

ca lle d the lateral malleo lus is a lso su p e rfic ia l an d fo r ms a , ,

p r o m in e n t v isible
p roj e ct io n o n t h e lat e ra l S id e o f t he a n k le .

Th e fi bu la tak e s n o p art in t h e fo r mat io n Of the k n e e j o in t fo r ,

its p ro x ima l e n d r e ach e s o n ly t o t h e lat e ra l c o n dy le o f th e t ibia

w ith wh ich it art icu lat e s I t s d ista l e n d art icu lat e s w ith the
.

lat e ra l sur fac e o f t he d ista l e n d Of th e t ibia an d w ith t h e

lat e ra l surfac e O f t h e ta lu s ; it e n t e r s th e r e fo r e in to t h e
fo r mat io n o f th e a n k le j o in t ( F ig s 1 0 1 1 0 2 .
, ,

Th e r e g io n be lo w t he a n k le j o in t is t he fo o t I n it are .

se v e n tarsa l bo n es fiv e meta ta rsal bo n es an d fo urt e e n p bala nges

, ,
.

The tar sa l bo n e s fo r m t h e sk e le t o n Of t h e p o st e r ior ha lf O f

the fo o t ; t h e m e tatar sa l bo n e s are Situat e d in t h e a n t e r io r
ha lf O f the fo o t ; th e y are n u mbe re d o n e to fiv e fr o m th e
m e d ia l to t h e lat e ra l sid e The p ha la n g e s are i n t h e to e s ;
.

t wo in t h e gr e at to e an d thr e e in e ach O f the oth e r t o e s

, .

Each O f the tarsa l bo n e s is n a me d The h igh e st O f the .

gr o u p th e talus tak e s p art in the for mat io n o f the a n k le

, ,

j o in t wh e r e it lie s d ir e ctly be low th e t ibia w e dge d be tw e e n

, ,

t h e m a lle o li O f t h e t ibia an d t he fi bu la I t art icu lat e s .

th e r e fo r e w ith bo th the bo n e s O f the le g I ts a n t e r io r p art .

,

tbe bead c an be fe lt be lo w t h e t ibia an d in fro n t o f th e lat e r al

,

ma lle o lu s The in fe r io r sur fac e O f th e ta lu s r e st s u p o n t h e

.

ca lca n eu s wh ich p r o j e ct s backward s be h in d t h e m a lle o li t o

, , ,

fo r m th e p r o min e n c e O f t h e h e e l The str o n g t e n d o n wh ich

.

d e sc e n d s in the back O f the le g t o t he p ro m in e n c e o f th e

h e e l is t h e tendo calcan eu s I n fr o n t O f th e ta lu s in t h e
.
,

m e d ial p art o f t he fo o t is t h e o s n a vicu lare ,

I t s tu be r o sity .
,

wh ich is an imp o rta n t la n d mark can be fe lt a bo ut 2 5 mm ,

.

n e in cb in fr o n t o f t h e t ip O f t h e m e d ia l m a lle o lu s F ig
( o
) ( .

I n fr o n t O f th e n av icu lar lie t h e thr e e cu n eifo rm bo n e s ,

fir st se c o n d an d th ird fr o m th e m e d ia l to t he lat e ra l sid e

, ,
.

Th e fir st can be fe lt in fr o n t o f t he tu be r o sity O f the n av icu lar .

Th e o th e r t wo c an be r e c o g n ise d by p r e ssur e a p p lie d in th e

d o r su m o f th e fo ot bu t th e y are n o t e a sily d ist in gu ish e d in
,

t h e u n d isse ct e d fo ot I n th e lat e ra l bord e r o f t h e fo o t in

.
,

fro n t o f t he ca lc an e u s is t he la st o f t h e se v e n tar sa l bo n e s
, ,

t h e cu bo id I t is d ifficu lt to p a lp at e bu t im me d iat e ly in fro n t

.
,
 I N TRO D U C T I O N 2 1 7

Of it, a bo ut se v e n an d a half c e n t im e tr e s a n t e rio r to th e

lat e ra l m a lle o lu s is th e p ro min e n t p o st e r io r e n d O f t h e fi fth
,

m e tatar sal bo n e an d t h e j o in t be tw e e n th e p o st e r io r sur fac e

,

o f t h e cu bo id an d t he a n t e r io r e n d O f t h e ca lca n e u s is a bo ut

midway be tw e e n th e lat e ra l ma lle o lu s an d th e p o st e r ior e n d

o f th e fi fth m e tatar sa l F ig
( .

All th e m e tatar sa l bo n e s c an be fe lt fr o m the d o r su m o f

t h e fo o t bu t th e larg e fir st an d th e fi fth are t h e m o st e a sily
,

d istin gu isha ble Th e fir st lie s in t h e m e d ia l bo rd e r o f the

.

fo ot be tw e e n t he fir st cu n e ifo r m an d th e fir st p ha la n x o f t h e
gre at t o e Th e se c o n d an d th ird lie r e sp e ct iv e ly be tw e e n the
.

se co n d an d th ird cu n e ifo r m an d th e fir st p ha la n g e s o f t h e

se c o n d an d th ird t o e s Th e fourth an d fi fth e x t e n d fro m

.

t h e cu bo id be h in d t o t h e fir st p ha la n g e s o f th e fo urth an d
fi fth to e s r e sp e ct iv e ly .

All th e a bo v e m e n t io n e d p o in t s c an be v e r ifi e d by the
-

d isse ctor u p o n his o wn p e r so n wh ilst h e is wa it in g to

c o m me n c e the d isse ct io n O f his p art “
.
!

Sin c e m a n y stud e n t s co mm e n c e d isse ct in g be for e th e y

hav e att e n d e d le ctur e s o r d e m o n strat io n s o n a n ato my th e y ,

are u n acq u a in t e d w ith t e r m s wh ich m u st be u se d in t h e

in struct io n s g iv e n r e gard in g t h e d isse ct io n s wh ich are t o be

mad e . F ortu n at e ly m o st O f th e t e r m s u se d r e fe r t o th in g s
wh ich c an be se e n an d fe lt Th e y th e r e fo r e are e a sily .
, ,

u n d e r st o od Th e r e are how e v e r c e rta in t e rms u se d wh e n

.
, ,

bra n ch e s o f sp in a l n e rv e s are u n d e r c o n sid e rat io n wh ich are

n o t se lf e x p la n at o ry
-
an d it is n e c e ssary th e r e for e that t h e
, , ,

stud e n t S hou ld p o sse ss a k n o w le dg e o f t h e t e r m s u se d in

c o n n e ct io n w ith sp in a l n e rv e s be fo r e th e actua l w o rk O f
d isse ct io n is c o m m e n c e d The fo llow in g p o in t s Shou ld be
.

n ot e d : Ev e ry sp in a l n e rv e is attach e d to sp in a l
( )
1 t h e

me du lla ( Sp in a l c o rd ) by two r o ot s an anterio r an d a ,

po sterio r ; ( 2 ) as th e y are le av in g the v e rt e bra l ca n a l through

an in t e rv e rt e bra l fo ra m e n t h e two ro o t s u n it e t o for m
a nerve tru n b ; ( 3 ) imme d iat e ly a ft e r its e x it fro m t h e
in t e rv e rt e bra l fo ra m e n t h e tru n k br e ak s u p in t o a p o sterio r
ramu s an d an a n terio r ra mus o f wh ich e x c e p t in a fe w ca se s
,

th e p o st e r io r is th e sm a lle r ; ( 4 ) e ach p o st e r io r ra m u s d iv id e s
in t o a medial bran cb an d a lateral brancb 5) e ach a n t e r io r
ra mu s d iv id e s in to a lateral brancb an d an anterio r brancb ( F ig .

4, p
Ev e ry a n t e r ior root c o n sist s o f ne rv e fi bre s p a ssin g fro m
 2 1 8 THE I N F ER I OR EXTRE M I TY
ne rv e c e lls in the sp in a l m e du lla t o th e fi br e s o f t h e m u sc le s ;
th e y carry m o t o r imp u lse s to t he m u sc le s Each p o st e rio r .

r o o t c o n sist s o f n e rv e fi br e s p a ssin g to an d fr o m th e n e rv e
c e lls in the ga n glio n o f th e r o o t The fi br e s o f th e p o st e rio r
.

r o o t c o n v e y se n so ry im p u lse s p a in h e at c o ld e tc The
—
, , ,
.

se n so ry im p u lse s p a ss thr o ugh t h e n e rv e c e lls O f t h e ga n g lio n

an d th e n o n ward s t o t he sp in a l m e du lla Th e tru n k o f .

e v e ry sp in a l n e rv e th e r e fo r e c o n ta in s bo th m o tor an d se n so ry
, ,

n e rv e fi br e s an d t h e p o st e r ior an d a n t e r io r ra m i in t o wh ich
,

it d iv id e s a lso c o n ta in bo th m o tor an d se n so ry fi br e s The .

bra n ch e s o f th e ra mi may c o n ta in both m o t o r an d se n so ry ra m i

o r o n e o r t h e o th e r o n ly e v e n tua lly h o we v e r t h e e r i h ra l
, p p e ,

p art s o f t h e fi br e s c o n v e y in g imp u lse s fr o m th e S in a l m e du lla

p
an d th o se c o n v e y in g imp u lse s to th e sp in a l m e du lla se arat e
p
fr o m o n e a n o th e r . Ev e ry n e rv e co n sist s o f o n e o r m or e fi br e s .

Th e fi br e s wh ich co n v e y im p u lse s fr o m th e sp in a l m e du lla

be co me t h e m o tor n e rv e s wh ich e n d in m u sc le fi br e s wh ilst ,

t he fi bre s wh ich co n v e y im p u lse s t o t he Sp in a l m e du lla are

t h e se n so ry n e rv e s an d th o se se n so ry n e rv e s wh ich carry
,

imp u lse s fr o m th e sk in are ca lle d cuta n e o u s n e rv e s .

T H E TH I G H .

O n th e m o r n in g O f th e fourth day a ft e r t h e su bj e ct h as
be e n br o ught in to th e d isse ct in g r o o m, it is p lac e d u p o n the
ta ble ly in g u p o n its back ; th e p e lvis is su p p o rt e d by two
blo ck s, an d th e in fe r io r e x tr e m it ie s are str e tch e d o u t at fu ll
le n gth . I n th is p o sit io n it is a llo w e d to r e ma in fo r fiv e day s,
an d dur in g that p e r io d th e d isse ctor o f the in fe r io r e x tr e m ity

h as a v e ry e x t e n siv e d isse ct io n t o p e r for m H e h as to d isse ct

.

( )I t h e a n t e r io r r e g io n o f t h e th igh , in c lud in g t h e trigo n u m

femo rale an d its co n t e n t s, ( 2 ) the me d ia l r e g io n O f the th igh , in

c lu d in g t he adduct o r ca n a l an d its co n t e n t s W ith so m uch .

work to be co mp le t e d , w ith in a limit e d t ime , he m u st ap p o r

t io n th e five day s to the be st adva n tag e D urin g th e fir st day .

h e sh o u ld d isse ct t h e su p e rfic ia l structur e s o f t he who le O f the

a n t e r io r an d me d ia l a sp e ct s o f the th igh D urin g the se co n d
.

an d th ird day s h e Sh o u ld c o mp le t e t h e d isse ct io n o f t h e

m n d t h e a n t e r ior r e g io n O f t h e th igh , an d t he
f e o r a l tr ia ng le a

re ma in d e r o f the p e riod sh o u ld be d e vot e d to th e disse c

t io n o f th e me d ia l r e g io n .

u
S rf ace A at o yn m .
— B e fo r e m ak in g t h e p re limin ary in c isio n s
 2 2 0 TH E I N F ER I OR EXTRE M I TY
A fa in t su lcu s at th e p ro x im a l e x tr e mity o f the a n terio r
regio n is th e bo u n dary lin e be tw e e n th e ingu in al regi o n O f t h e

a bdo me n an d the su binguinal regio n o f the th igh The .

r e sista n c e fe lt d e e p to th e su lcu s is du e t o the ligamentu m

ingu in ale, wh ich is attach e d , at th e lat e ra l an d su p e r io r e n d
O f t h e su lcu s, to th e a n terio r sup erio r iliac spin e, an d, at its

in fe r ior an d m e d ia l e n d, to th e p u bic tu bercle . F ro m th e

a n t e rior su p e rior iliac sp in e the iliac crest c an be trac e d
backward s t o th e p o st e r io r su p e r io r sp in e ; fr o m th e p u bic
tu be rc le t he fi ng e r Shou ld be carr ie d me d ia lly, a lo n g t he p u bic
crest, t o t h e u p e r e n d O f t h e sy mpb sis p u bis N e x t , th e fi n g e r
p y .

sh o u ld be p a sse d d o w n ward s, a lo n g t h e fr o n t o f th e sy mp by sis

p ubis, to the a p e x o f t h e p ubic arcb an d th e n c e dow n ward s an d

backward s a lo n g t he ra mi o f t h e pu bis an d iscbiu m, wh ich mark
t he su p e r io r bou n dary o f the medialfemo ral regi o n , t o the tu ber
iscbiadicu m . About te n c e n t ime tr e s be low t he h igh e st p art
o f th e iliac cr e st , an d o n t he p la n e o f t h e p u bic cr e st , is

t he tro cba n teric regi o n , in d icat e d by an e min e n c e du e t o t h e

p r o min e n c e O f the trocha n t e r m ajor O f t he fe m ur . A bov e th e

trocha n t e ric r e g io n, an d be tw ee n it an d the iliac cre st is the
regi o n of tbc bi
p( g r e io co x c e
) ,
an d b e l ow t h e trocha n t e r ic r e g io n is

t h e lateral femo ral regi o n . At t he d istal e n d o f t he a n t e r ior

p art o f t h e th igh is t h e r e i
g go en u a n ter io.r I n t h e c e n tr e O f
t h e a n t e r io r p art o f t h e k n e e lie s t he patella or k n e e c ap , t h e -

o ut lin e o f wh ich c an be se e n as w e ll as fe lt . F r o m th e d ista l

e n d o f t he p at e lla t h e liga men t u m p a tellae sh o u ld be fo llow e d

t o t he tu be r o sity o f t h e t ibia .

At th e d ista l e n d o f th e lat e ra l r e g io n O f the th igh th e

out line o f t he lateral co n dy le o f the femu r is e a sily re c o g n ise d .

D ir e ct ly distal t o it is th e la teral co n dy le o f th e tibia, an d at

t h e d ista l an d p o st e r ior p art O f t he latt e r is t h e h e ad O f t he
fi bu la Th e t e n d o n wh ich can be trac e d p ro x ima lly fro m the
.

bead o f t he fibu la, o n th e bord e r lin e be tw e e n t he lat e ra l

an d p o st e r ior fe m ora l r e g io n s, is t h e t e n do n o f th e biceps

f e m o ri s a n d t h e d e n s e ,
l o n g itud in a l b a n d o f fa s c i a imm e di
at e ly a n t e rior to the t e n do n o f the bic e p s is th e ilio tibial -

tract o f th e fa sc ia lata — a fa sc ia l ba n d wh ich i s m or e e a sily

d ist in gu isha ble in the livin g tha n in the d e ad bo dy .

At th e d ista l e n d o f t h e me d ia l p art o f t h e th igh is the

out lin e Of t h e media l co n dy le o f the f emu r, wh ich Sh o u ld be
p p a l at e d ; an d im m e d iat e ly d ista l to it t he m e d i a l co nd y le

o f th e tibia is e a sily r e cog n ise d be n e ath the in t e gu me n t .

 T HE TH I G H 2 2 1

Th e t e n do n s be h in d t h e m e d ia l co n dy le o f the fe mur are

m or e e a sily fe lt in t h e liv in g tha n t he d e ad body ; th e y are

t he t e n do n s o f th e semiten din o su s an d semimembra n o su s

mu sc le s . The le ss e a sily p a lp at e d t e n do n o f t h e addu cto r

magn u s shou ld be d ist in gu ish e d as it de sc e n d s to th e p ro x im a l
bord e r o f th e m e d ia l fe m o ra l c o n dy le .

Th e d isse ctor shou ld v e r ify all th e se p o in t s o f sur fac e

a n at o my n o t o n ly o n th e d e ad bo dy bu t a lso o n t he bod ie s
o f h imse lf an d his fr ie n d s an d h e shou ld e x a m in e th e m , .

r e p e at e d ly u n t il he is qu it e fa m iliar w ith th e m bo th by sight

an d by touch .

TH E AN TE R I O R F EM O R AL AN D M EDI A L F E M O R AL R EG I O N S
A N D TH E AN TE R I O R R EG I O N o r TH E K N E E .

Su p erfi c ia l Disse ct io n Th is d isse ct io n co mp r ise s

—
the
ex a min at io n o f th e fo llow ing p art s :

Su p e rficial fascia .

Th e g re at saph e n o u s v e in an d its tribu tarie s .

The su pe rficial e te rn al pu de n dal arte ry x .

The su p e rficial e pig astric art e ry .

The su p e rficial c ircu m fl e i iac art e ry x l .

L ym p h g lan ds an d v e sse ls .

The fo ssa o v alis .

C u tan e o u s n e rv e s .

The fascia fe m o ris ( de e p fascia o f the th igh ) .

The bu rsae p ate ae ll .

D is s e c t i o n — R e fl e ct io n o f t h e Sk in —I n ci sio ns — ( x) F ro m . .

t
t h e a n e rio r su p e rio r iliac sp in e a lo n g t h e lin e o f t h e in gu in al
t
lig am e n t o t h e sy m p hy sis p u bis ( 2 ) f ro m t h e m e dial e xt re m ity
t
o f t h e fi rs in c isio n do n w w
ards alo n g t h e m arg in o f t h e s cro t u m ,
t t
h e n alo n g t h e j u n c io n o f th e m e dial it h t h e p o s e rio r asp e c w t t
o f the t
h igh an d acro ss th e m e dial asp e c o f t h e k n e e to t h e t
v t t t
le e l o f t h e u be ro s i y o f t h e ibia ; ( 3 ) f ro m t h e dis al e nd o f t h e t
v e rt ic al in c is io n t v
ran s e rse ly a cro ss t h e an e rio r su rf ace o f t h e t
le g t o it s la e ral bo rde r t Th e q u adrila e ral flap o f in e gu m e n ,
. t t t
t h u s m app e d o u t (9 , F ig m u s be raise d care fu lly fro m
. t
t
t h e su bj ace n su p e rfi cial f ascia an d u rn e d lat e rally , p art icu lar t
c are be in g t ak e n in t h e re g io n o f t h e k n e e t o a o id in j u ry t o
'

v
t
t h e p a e llar p lexu s o f cu an e o u s n e r e s t v .

To m ak e a cle an in cisi o n h ro u gh t h e sk in h o ld t he sc alp e l t

at righ t
an g le s t o t h e su rfa ce an d f o rce t h e p o in t h ro u gh t h e t
sk in in o t t
t h e su bj ace n so f su p e rfi c ial f as c ia at t h e p o in t o f t
c o m m e n ce m e n t
o f t h e in c isio n , h e n in clin e t h e blade t o an t
an g le o f f o rt y fi v e de g re e s an d, p re ssin g fi rm ly o n t h e back o f
-

t
t h e blade w i h t h e f o re fi n g e r, dra w it a lo n g t h e lin e o f in c isio n .

t
W h e n t h e o p p o si e e n d o f th e in cisio n is re ac h e d brin g t h e
s calp e l t o a righ t
an g le w it h t h e su rf a ce again an d i h dra it wt w .
2 2 2 TH E I N F ER I O R EXTRE M I TY
To fl ect
re the ski n t ak e h o ld f t h e m o s co n e n ie n an g le
o t v t
o f t h e fl ap— t h e u p p e r o r t h e lo w e r m e dial an g le in t h e p re se n t
t
disse c io n — w i h t h e f o rce p s, t t
an d w i h t h e e dg e o f t h e scalp e l
t
de ac h it f ro m t h e so f f at be n e at h t .

As so o n as t h e an g le se le c e d is su ffi c ie n ly de ach e d discard t t t
z
th e f o rce p s , se i e t h e de ac h e d an g le be t
e e n th e h u m b an d tw t
t
f o re fi n g e r o f t h e le f h an d, an d p u ll it aw ay f ro m t h e f at , k e e p in g
t t
it s re c h e d an d e n se t
t h e n draw t h e e dg e o f t h e scalp e l acro ss
t t
th e sk in , at it s j u n c io n w i h t h e f at , f ro m o n e e dg e o f t h e fl ap
t w
t o t h e o h e r, al ay s k e e p in g t h e e dg e o f t h e k n if e ag a in s t h e t
sk in I f the
. w
o rk is do n e p ro p e rly t h e le a h e ry lo o k in g de e p t -

su rf ace o f t h e sk in w
ill be e n ire ly f re e d f ro m f at , as t h e fl apt
t
is re fl e c e d, a n d t h e su p e rfi cial n e r e s an d e sse ls h ic h lie in v v w
t h e f at w
ill n o t be in j u re d W h e n t h e sk in is re fl e c e d t h e
. t
su p e rfi c ial f as c ia is e x p o se d .

Su p e rfi cial F ascia ( P ann iculu s A dip o sus) — Th e u p e rfic ia l . s

fa sc ia is fo u n d ov e r t he wh o le sur fac e o f t h e bo dy I t var ie s .

in structur e in d iffe r e n t p art s bu t in all p art s w ith t h e , ,

e x c e p t io n o f t h e r e g io n o f t h e scrotu m it co n ta in s a gr e at e r ,

o r a sm a lle r a m o u n t o f y e llo w ish fat t h e a mo u n t v ary in g n o t ,

o n ly w ith t h e art u n d e r co n sid e rat io n bu t a lso w i th t h e

p
g e n e ra l o be sity o r th in ne ss o f the su bj e ct I n so me r e g io n s .
,

such as t h e a n t e r io r p art o f t h e n e ck an d th e adjac e n t p art o f

t h e ch e st r e dd ish m u sc le fi br e s are p r e se n t in t he d e e p e r p art

,

o f t h e fat ; in t h e scr o tu m t h e m u sc le fi br e s e n t ir e ly r e p lac e

t h e fat . The fat is in t e r sp e r se d an d d iv id e d in t o lo bu le s by

la me llae o f d e n se r t issu e ca lle d fibro u s tissu e an d in th e d e e p e r ,

p art o f t h e s u p e rfic i a l fa sc ia t h e fi b r o u s t iss u e b e co m e s m o r e

p r e d o m in a n t f o r m in g ,
a m e m b ra n e wh ich is t h e d e e p e r o r

me mbra n o u s lay e r o f t h e su p e rfic ia l fa sc ia I n t he su p e rfic ia l .

fa sc ia lie th e cuta n e ou s v e sse ls an d n e rv e s an d the d e e p e r

p art s o f t he ha i r f o l lic le s a n d sk in g l a n d s a n d t h e su p e rfic ia l
ly mp h g la n d s U n d e r th e su p e rfic ia l fa sc ia I S a m o r e firm
.

m e mbra n o u s lay e r t he deep fascia surrou n d in g t h e m u sc le s

, ,

an d d e e p e r p art s .

Th e su p e rfic ia l fa sc ia in t e rv e n e s th e r e fo r e be tw e e n t h e
sk in an d t he d e e p fa sc ia an d it is attach e d to bo th by fi brou s
,

stra n d s wh ich a s s through th fa t A s it lie s b e tw e e n t h e

p e .

sk in an d t h e d e e p fa sc ia it r o v id e s a so ft e la st ic cu sh io n u p o n
p
wh ich th e sk in r e st s an d wh ic h by its e la st ic ity a llow s the
, , ,

sk in t o be m ov e d o v e r t he d e e p e r p art s I t r o u n d s o ff th e .

a n gular it ie s o f the d e e p e r p art s an d for ms a be d in wh ich

t h e cuta n e o u s v e sse ls an d n e rv e s ra m ify be fo r e th e y e n t e r
t h e sk in .

I n m o st p art s o f th e bo dy th e la x ity o f t h e sup e rfic ia l

2 2 4 THE I N F ER I OR EXTR E M I TY
tra n sv e rse inc isio n mu st be m ad e thr o ugh th e e n t ir e th ick n e ss
o f t he su e rfic ia l fa sc ia o n t h e fro n t o f th e a bd o m e n fro m
p
t h e a n t e r io r su p e r io r sp in e o f th e iliu m t o t h e m idd le lin e o f t he
bo dy . Wh e n t he lo w e r e dg e o f t he d iv id e d fa sc ia is ra ise d its
t wo lay e r s are e a sily d ist in gu ish e d Th e d e e p e r m e m bra n o u s .

stratu m is k n ow n as Scar a s fa sc ia uat

( g i i
’

p F I n s n e .

t he fi n g e r s be h in d Scar p a s fa sc ia be tw e e n it an d th e p e ar ly
’

lo o k in g t e n do n o f t h e e x t e r n a l o bliqu e m u sc le L itt le .

r e sista n c e w ill be e n c o u n t e r e d fo r the fa sc ia an d t he t e n d o n ,

are o n ly c o n n e ct e d by so m e frag ile ar e o lar t issu e an d t h e ,

fi n g e rs can be p a sse d d o w n ward s as far as th e in gu in al

liga me n t At o r imm e d iat e ly be y o n d th e in gu in a l liga me n t
.

th e p a ssag e o f t h e ha n d in to t h e th igh is barr e d by t h e u n io n

o f Scar p a s fa sc ia w ith t h e d e e a c a th gh wh ch
’

p f s i o f t h e i i is ,

ca lle d t he fascia lata I f t he fi n g e r s are carrie d me d ia lly

.

a lo n g th e lin e o f u n io n o f th e two fa sc iae it w ill be fo u n d ,

that the lin e o f attach me n t d e sc e n d s acro ss th e fr o n t o f the

p u b is to t h e ra m i o f t h e p u b is a n d is ch i u m that is in t o t he , ,

le p erin eu m wh ich is t h e in t e rva l be tw e e n t h e th igh s

regio n o
f ti , .

I n the p e r in e u m t h e d e e p lay e r o f t h e su p e rfic ial fa sc ia is n o

lo n g e r ca lle d Scar p a s fa sc ia ; it be co me s C o lle s fa sc ia an d
’ ’
,

h as d e fi n it e c o n n e ct io n s wh ich w ill be st u d ie d by t h e ,

d isse ctor o f the a bd o me n .

I f ur in e or o th e r flu id is e ffu se d in to th e a n t e r ior p art o f

th e p e r in e u m it ca n n ot ge t in t o t h e m e d ia l fe m ora l r e g io n
,

be cau se o f th e attach m e n t o f t h e d e e p lay e r o f su p e rfic ia l

fa sc ia to t h e ra mi o f th e p u bis an d isch iu m an d t o t h e fro n t
o f th e p u bis bu t it c an a sc e n d in t h e ar e o lar t issu e be tw e e n
, ,

th e d e e p lay e r o f su p e rfic ia l fa sc ia an d th e d e e p fa sc ia t o ,

t h e wa ll o f t he a bdo m e n H av in g r e ach e d the wa ll o f t he

.

a bdo me n it ca n n ot d e sc e n d in to th e a n t e r ior fe mo ra l r e g io n
be cau se o f th e co n n e ct io n be tw e e n t he d e e p lay e r o f t he
su p e rfic ia l fa sc ia an d t h e fa sc ia lata at o r a short d ista n c e

d ista l t o the in gu in a l liga m e n t .

D is s e c ti o n — Th e di ct io n o f t h nt nt sse f th p r e co e s o e su e

fi cial f ascia o f t h bi gu in al an d an t rio r f m ral r g i

e su n e e o e o ns

is ne o f th om st diffi lt di e o ti w h i h fall t t h
cu sse c o ns c o e

l t f t h di se ct r o f t h in f ri r
o o e s o t r m it y Th st r t r
e e o ex e . e uc u es

t o be di p lay d r s ( )
1 eF r v
a e i —
. th gr t p h o u s th e ns e ea sa eno u ,
e

su p e r c ial fi e x t e rn al p u de n dal, the su p e r c ial fi e p i ast ric , g

an d
th e fi
su p e r c ial c ircu m fl e x iliac .
( 2 I Th re e art e rie s— t h e su p e r
fi c ial t
e x e rn al p u de n dal, th e su p e r c ial fi g
e p i as ric , t an d the
fi
su p e r c ial c ircu m fl e x iliac (3 ) Th e p ro x im al an d dist al g ro u p s
.

o f su bin gu in al ly m p h g lan ds an d t h e ly m p h v e sse ls w h ic h e n t e r

 TH E TH I G H 2 2 5

an d le a e h e m v t
Th e p ro x im al g ro u p lie s p aralle l . i h the wt
t
in gu in al lig am e n , t h e dis al g ro u p lie s alo n g t h e side s o f t h e t
p ro x im al p art o f t h e g re a sap h e n o u s e in ( 4 ) Six n e r e s t v . v
t h e ilio in gu in al, t h e lu m bo in gu in al, t h e la e ral cu an e o u s
- -
t t
v
n e r e o f the t
h igh , th e in e rm e dia e cu an e o u s n e r e o f t h e t t t v
t h igh , th e m e dial cu an e o u s n e r e o f th e h igh , t h e sap h e n o u s t v t
ner e v Th e fi rs
. t t
h re e n e r e s m e n io n e d are de ri e d dire ct ly v t v
f ro m a p lexu s o f n e rv e s in side t h e abdo m e n calle d t h e lu m bar
p lexu s an d t h e las t t
h re e are bran ch e s o f t h e fe m o ral n e r e , v
w t
h ic h is i se lf a bran c h o f th e lu m bar p lexu s ( 5 ) T h e f o ssa .

v
o alis ( )
6 T. h e p a e lla r bu rs a ,
a n d ( 7 ) t h e d e e p f t
a sc i a o f t h e
t h igh .

Co mm e n ce by cle an in g the g re a sap h e n o u s e in I t is t v .

e as ily f o u n d abo u t
t h e m id le n gt h o f t h e h igh , n e ar t h e m e dial - t
bo rde r Cu t do wn u p o n it h e re an d h e n , w i h t h e p o in
. t t t t
an d h an dle o f t h e scalp e l, cle an a ay th e f ascia f ro m it s w alls , w
bu t do n o t in j u re its ribu arie s F o llo w t h e e in , dist ally , to t t . v
t
the p o s e rio r bo rde r o f t h e m e dial side o f t h e k n e e an d, p ro x im ally ,
t o w ards a p o in si u a e d abo u 4 cm be lo t t t
an d la e ral t o t h e t . w t
p u bic u be rcle t .

As t h e p ro x im al e n d o f t he e in is ap p ro ac h e d lif it fro m v t
th e be d o f su p e rfi c ial f ascia in h ic h it lie s in se rt t he h an dle w
o f t h e sc alp e l be h in d th e e in an d p u sh it u p ards, u n il it v w t
slip s t
h ro u gh an Op e n in g in th e f ascia la a h ro u gh h ic h t t w
th e v
e in p asse s o n it s w ay t o j o in t o t h e f e m o ral e in Th e v .

o p e n in g in t h e f asc ia lat a is t h e f o ssa o valis Th e lay e r .

o f t h e de e p f asc ia h ic h co e rs t h e f o ssa o alis is calle d w v v

t h e cri brif o rm f asci a Th e c e n e o f t h e o p e n in g is si u a e d . tr t t
abo u t
3 5 4 0 mm dis al an d la e ral t o t h e p u bic
-
. t
u be rcle , t t
t
an d it s dis al m arg in is al ay s e asily de m o n s ra e d in t h e w ay w t t
alre ady in dica e d t
D o n o t a t e m p at p re se n t o disp lay it s
. t t t
t
o h e r bo u n darie s ; h e y ill be disse ct e d la e r W h e n th e t w t .

t
p ro x im al p ar o f t h e e in is be in g cle an e d a n u m be r o f t h e m o re v
t
dis al su bin gu in al ly m p h g lan ds ill be se e n , so m e ly in g la e ral w t
an d so m e m e dial t o t h e e in Th e y are o u n de d o r o o id bo die s v . r v
o f g re y is h o r y e llo ish p ink co lo u r, an d h e y ary g re a ly in w -
t v t
z
si e , so m e be in g as sm all as a p in h e ad, o h e rs as larg e as a - t
larg e be an Co nn e ct e d i h h e m t h e disse c o r ill fi n d a
. wt t t w
larg e n u mbe o f fi n e r
h i e s ran ds h ic h are th e ly m p h esse ls w t t w v
p assin g t o an d f ro m t h e g lan ds Cle an t h e g lan ds an d so m e o f .

v
th e ly m p h e sse ls, bu t do n o t dis u rb h e m f ro m h e ir p o si io n s t t t t
at p re se n t
Th e n p ro ce e d t o cle an t h e o h e su p e rfi cial blo o d
. t r
v e sse ls Th e y are t h e su p e rfi cial e xt e rn al p u de n dal, t h e su p e r
.

t
fi cial e p ig as ric , an d t h e su p e rfi cial circu m fl e x iliac e in s an d v
art e ries B e g in i h the
. e in s w h ic h wt
e rm in a e in t h e g re a v t t t
sap h e n o u s v
e in be fo re it p ass e s h ro u gh t h e f o ssa o alis F o llo t v . w
th e m f ro m t h e ir e rm in a io n s o ards h e ir c o mm e n ce m e n s, t t t w t t
an d at t h e s am e im e cle an t h e ac c o m p an y in g art e rie s , t h ic h w
are bran c h e s O f t h e fe m o ral a rt e ry , bu t a o id in j u ry t o t he v
su p e rfi cial ly m p h g lan ds w h ic h w ill be m e t w i h as t h e disse ct io n t
p r o ce e ds T w o o f t h e art e rie s, t h e su p e rfi c ial e x t e rn al p u de n dal
.

an d t h e su p e rfi cial e p ig as ric , e m e rg e h ro u gh th e f o ssa o alis t t v

t h e su p e rfi c ial c ircu m fl e x ilia c ar e ry w ill be f o u n d a s a ru le , t ,

p ie rcin g t h e de e p f as cia la e ral t o t h e f o ssa Th e ly m p h g lan ds t .

w ill be re co g n ise d by t h e ir fi rm co n sis e n ce an d h e ir g re y is h o r t t

w
y e llo ish p in k co lo u r -
.

V OL . 1— 15
2 2 6 TH E I N F ER I OR EXTRE M I TY
I f th e su b e cj t t d t h at as
is a m ale t h e disse ct o r w ill h ave no e
th e p rfi ial
su t rn al p de d l v
e c e ls p as s t w ard
ex e th e u n a e ss o s
sy m p hy i p u bi t h y r s p rfi i l t a t h i k co rd th
s s s e c o s su e c a o c ,
e

f u nicu lu s Sp erma ticu s w h i h e m rg f ro m th e abd m i al w all . c e es o n

ab v o th p bi t be r le a d d s
e e u d acro th e
c p p r an d
u c ,
n e ce n s ss u e
m dial an g le f t h f r t o f th t h igh in t o t h cro t m
e o e I n th o n e e s u . e
f m ale t h ro n d lig am
e t f th te r s w h i h i l p ro m i t
e u en o e u u , c s e ss nen
an d le ss e asy t d fi li in t h e p o sit i n oo p i d by th sp r
e ne , es o ccu e e e
m at ic rd in t h m ale
co At th e p p r p art f t h lat ral m arg in
e . u e o e e
o f t h e sp rm at ic c rd l k f o r t h e ilio in gu in al n rve w h i h
e o o o -
e c
le av s t h e abdo m e n w it h t h sp e rm at ic o rd an d
e n ds bran ch s e c se e

to t h e u pp e r an d m dial p art o f t h e t h igh ( F ig e .

W h n th ili i g in al n rv h as be e n se cu re d cl an t h e
e e o - n u e e e

su bin gu in al ly m p h g lan ds w h ic h lie alo n g t h e lin e o f th e in

gu in al lig am e n t an d t race so m e o f t h e fi n e w h it e lym p h ve sse ls
,

w h ic h e n t e r an d le ave t h e m Th e su bin gu in al ly mp h glan ds .

f o rm two g ro u p s : a p ro x im al g ro u p w h ic h lie s p aralle l w it h

t h e in gu in al lig am e n t an d a dist al g ro u p alre ady disp lay e d at , ,

t h e side s o f t h e p ro x im al p art o f t h e g re at s ap h e n o u s v e in .

M an y o f t h e m are u su ally o f fairly larg e siz e ; in de e d t h e y are

so larg e t h at as a ru le t h e y c an be f e lt e asily t h ro u g h t h e sk in
, ,

in t h e liv in g su bj e ct Th e y are re co g n ise d in t h e disse ct io n as

.
,

alre ady st at e d by t h e ir fi rm c o n sist e n ce an d t h e ir y e llo w ish

,

p in k c o lo u r ( F igs 1 0 5 .
,

Aft e r t he ly m p h g lan ds h av e be e n lo cat e d an d cle an e d p ro ce e d

t o de fi n e th e lat e ral an d su p e rio r bo rde r s o f t h e fo ssa o v alis
( g
F i . C o mm e n c e at it s in f e rio r b o rde r w h ic h h as a lr e ady ,

be e n disp lay e d N o t e t h at as t h e in fe r io r bo rde r w h ic h is

.
,

c alle d t h e i nf eri o r co rn u p a ss e s m e d ia lly it b le n ds w it h t h e ,

u p p e r p art o f t h e f ascia lat a w h ic h co v e rs t h e m u scle s o f t h e

m e dial p art o f th e f ro n t o f t h e t h igh ; t h at p art o f th e fascia
is k n o w n as t h e p e ct in e al p art o f th e f asc ia lat a t o dist in gu is h it
f ro m t h at p art o f t h e de e p f ascia w h ic h lie s lat e r al t o t h e f o ssa
o vali s an d is c alle d
t h e iliac p art o f t h e f as cia la a t .

t
The la e ral e n d o f t he in fe rio r c o rn u is c o n in u o u s i h th e t wt
f a lcif o rm m ar g i n o f t h e f o s sa o al is h ic h c u r e s u p ar ds a n d v w v w
t
m e dially to e rm in a e in th e sup erio r co rn u t
Th e su p e rio r co rn . u
be n ds m e dially as th e su p e ri o r m arg in o f t h e f o ssa an d is
tt
a ac h e d t o t h e u be rcle o f t h e p u bis an d t o t th e ligame n tum
lacu n are , w
h ich is an e x p an sio n o f th e m e dial e n d o f th e in gu in al
lig am e n t
Th e e dg e o f t h e scalp e l is n e e de d t o de fi n e th e f alci
.

f o rm m arg in an d th e su p e rio r co rn u , f o r bo h are c lo se ly ble n de d t

t
w i h th e cribrif o rm f ascia w h ic h e xt e n ds acro ss t h e fo ssa fro m
t h e f alc if o rm m arg in an d su p e rio r co rn u t o t h e p e c in e al p art o f t
th e f ascia la a t .

w
Cle ar a ay t h e cribrif o rm f asc ia, disse c in g o u t t h e ar e rie s t t
an d ly m p h e sse ls v w
h ic h p ie rce it , an d disp lay be h in d it th e
t
an e rio r w
all o f t h e f emo ral she ath, a lay e r o f f as cia, h ich w
su rro u n ds t h e f e m o ral e sse ls I n sin u a e t h e h an dle o f t h e v . t
sc alp e l be tw
e e n t h e f alc if o rm m arg in an d t h e f e m o ral s h e a h t
t o de m o n s ra e t t t
h e ir in de p e n de n ce , t h e n p ass th e h an dle o f
t h e scalp e l be h in d t h e m e dial bo rde r o f t h e fe m o ral s h e a h t o t
de m o n s ra e t h e f ac t t t t t
h a t h e p e c in e al p ar o f t h e fascia la a t t t
p asse s be h in d t he f e m o ral sh e a h t .

t t
Af e r t h e re la io n s o f t h e m arg in s o f t h e fo ssa o alis h a e v v
be e n de fi n e d se e k t h e re m ain in g su p e rfi cial n e r e s Clo se t o v .
 THE I N F ER I O R EXT R E M I TY
Ly mp h Glan ds d isp o sit io n o f the su p e r
an d V e ssels — Th e
fic ial su bingu in al ly mp h glands in to two grou p s w ill n o w be
ev id e n t — a p ro xima l su bingu in al gro up a lo n g t h e li n e o f th e

in gu in a l liga me n t imme d iat e ly d istal to th e attach m e n t o f

,

C dg f S p f i ut e e o c ar a s
’
asc a

L u mbo

i
Su p e r o r ho rn o f falc ifo
S u bc u ta n e o igi l us n u na

P e ct ne ai lp art off i l as c a a ta

S p e r at m i f i l I
c u n cu us

S up e rfic a il
p u de n d

I i
n fe r o r
m ar g
G re a t sa p he n o u s v e

Tw o d iv i is o ns o f i
a n te r o r
bra n ch o f t he me a di l
c u ta ne o u s n e rv e (O T
i l
. .

n t e rna cu t an e o u s )

FI G . 6 — S u p e rfic ial
10 . Di i
sse c t o n o f th e P ro xi mal P art o f t he F ro n t o f the
T h i gh
Th e fo ssa
. o vali s ( O T saph e no u s o p e n i ng) the su p e rfic i al l y mp h
. .
,

l
g an ds an d ve sse l s o f t h e gro i n are di s p l aye d T he l y m p h v e sse l s may
.

be re co g n i se d by th e i r be ade d ap p e aran ce .

Scarp a fa sc ia
to the fa sc ia lata an d a d ista l grou p wh ich
’
s , ,

e xt e n ds fo r a
short d ista n c e d ista lly a lo n g th e lin e o f th e

gre at sa p h e n ou s v e in B oth grou p s are se p arable in to me d ia l .

an d lat e ra l p art s .

I n a sp ar e su bj e ct or be tt e r st ill in a dro p sica l su bj e ct th e

, , , ,
 THE TH I G H 2 2 9

ge n e ra l arra n g e me nt o f the ly mp h v e sse ls may a lso be mad e

o ut . To the su bin gu in a l grou p o f gla n d s p roc e e d the su p e r
ficial ly m p h v e sse ls O f th e low e r e x tr e mity an d ly mp h v e sse ls ,

fr o m th e e x t e r n a l g e n ita ls t he p e r in e u m an d th e low e r p art , ,

o f t h e a bd o min a l wa ll Th e se are t e r me d the afi erent vessels

. .

I n add it io n to th e m n u me rou s o th e r v e sse ls co n n e ct t h e

,

gla n d s w ith o n e a n oth e r The ly mp h v e sse ls wh ich le ad the .

ly mp h away fro m th e g la n d s are ca lle d the efi erent vessels A .

larg e n u m be r O f th e m p a ss through th e fo ssa ova lis oth e r s ,

p ie rc e t h e fa s c ia lata Th e y j o in t h
. e d e p
e s u bingu in al
g l a n ds

an d t he e x t e r n a l iliac g la n d s wh ich lie in r e lat io n to the ,

fe mo ra l an d e x t e r n a l iliac art e r ie s ( F ig s 1 5 9 .
,

F o ssa 0 v a li s The fo ssa ova lis is an a p e rtur e in th e d e e p

.
—

fa sc ia o f th e th igh thr o u gh wh ich t he gr e at sa p h e n ou s v e in

,

p a s se s b e for e it p ie rc e s t h e fe m o ra l s h e a t h a n d j o in s t h e

fe mo ra l v e in The fo ssa lie s in th e u p p e r an d me d ia l a n g le

.

o f t he fr o n t o f t h e th igh its c e n tr e be in g situat e d a bout

,

37 m m lat
. e ra l an d d i s ta l to t h e p u bi c tu b e rc le
( g
F i .

I t is bo u n d e d lat e ra lly by a th in cur ve d m arg in t h e margo

, , ,

f fa lc i o rm is T .h e m arg o fa lc if o r m is is t h e m e d ia l m arg in o f the

m o r e lat e ra l p ort io n o f th e fa sc ia lata wh ich be cau se it is , ,

attach e d t o t he in gu in a l liga me n t su p e rfic ia l to the iliacu s

m u sc le an d t h e an t e r io r p art o f the iliac cr e st is ca lle d th e
, ,

iliac p art of the fascia lata Th e p r o x im a l e n d O f th e m arg o

.

fa lc ifor mis is th e sup erio r co rn u ( F ig I t tur n s m e d ia lly

.

to ga in att ach me n t to th e p u bic tu be rcle an d t o th e

liga m e n tu m lacu n ar e an d so fo r m s t h e p r o x im a l bou n dary
,

O f t h e fo ssa Th e d ista l e n d o f th e m arg o fa lc ifor m is a lso

.

turn s m e d ia lly for min g th e inferio r co rn u wh ich lie s p o st e r io r

, ,

t o t he u p p e r e n d o f t h e gr e at sa p h e n ou s v e in o n t h e m e d ia l ,

sid e O f wh ich it t e r m in at e s by ble n d in g w ith t h e p ectin ea l pa rt

of the fascia lata so ca lle d be cau se it a sc e n d s su p e rfic ia l t o

,

t h e p e ct in e u s m u sc le to t h e p e ct in e a l lin e O f t h e p u bis

( F ig s . 1 0 6 ,
T h e m a n n e r in wh ich t h e fa sc ia lata
surr o u n d s t he m u sc le s O f t h e p ro x im a l p art O f th e in fe r ior

e x tr e mity so
,
that the iliac p ort io n lie s a n t e r io r t o the
fe mo ra l sh e ath an d t h e p e ct in e a l p ort io n p a sse s p o st e r io r to
t h e sh e ath is sh o w n in t h e se ct io n r e p r e se n t e d in F ig 1 1 3
, . .

The fo ssa o va lis is c lo se d by th e cr ibr ifor m fa sc ia a th in ,

stratu m o f t h e fa sc ia lata wh ich a e s f ro m t h f a lc if r m

p ss e o

marg in an d t h e cor n ua to th e p e ct in e a l fa sc ia Th e cr ibr i .

for m fa sc ia is p ie rc e d by t h e gr e at sa p h e n o u s v e in th e ,

1— 15 a
 TH E I N F ER I OR EXTRE M I TY
s u p e rfic ia l e x t e r n a l p ud e n da l an d su p e rfic ia l e p iga str ic art e r ie s ,

an d by t h e e ffe r e n t ly m p h v e sse ls fr o m t h e su bin gu in a l g la n d s

O n th e ir way t o j o in t h e d e e p e r su bin gu in a l g la n d s wh ich ,

lie in t h e fe m o ra l sh e ath .

Ve na Sa p h e n a M ag na ( O T I n t ern al Sap he n o us Ve in )
. . .

T h e gr e at sa p h e n ou s v e in is the larg e st su p e rfic ia l v e in O f the

in fe r io r e x tr e m ity . I t co m m e n c e s o n th e d o r su m O f t h e fo ot ,

p a sse s a n t e r io r t o t h e m e d ia l m a lle o lu s an d a sc e n d s through

t h e le g acro ss th e m e d ia l sur fac e o f th e d ista l th ird O f th e

t ibia an d th e n alo n g t h e m e d ia l marg in Of the t ibia
, It .

e n t e r s t h e ar e a o f d isse ct io n at p r e se n t u n d e r c o n sid e rat io n

at the le v e l o f th e tube ro sity o f th e t ibia a sc e n d s in the ,

p o s t e r io r p art O f t h e m e d ia l g e n icu lar r e g io n th e n in c lin in g , ,

fo rward s an d lat e ra lly it p a sse s u p ward s t o t h e fo ssa o va lis

, ,

wh e r e it p ie rc e s t he fa sc ia cr ibr o sa an d the fe m ora l sh e ath ,

an d t e r m in at e s in t h e fe m o ra l v e in I n it s cour se through
.

th e th igh it co m mu n icat e s through t h e d e e p fa sc ia w ith

th e d e e p v e in s an d it r e c e iv e s t he fo llow in g tr ibutar ie s : ( 1
, )
The lat eral fe mo ral circu mflex vein f r o m th e a n t e r io r an d ,

lat e ra l p art s O f t h e th igh ( )

2 .T h e medial f emo ral circu m fl ex

v ein ,
wh ich c o mme n c e s at t h e back o f the k n e e wh e r e it
fr e qu e n t ly c o m m u n icat e s w ith t he sm a ll sa p h e n o u s v e in Th e .

m e d ia l fe mo ra l c ircu m fl e x v e in ru n s u p ward s curv e s r o u n d ,

th e m e d ia l sid e o f th e th igh an d j o in s t h e gr e at sa p h e n o u s
v e in m id way be tw e e n th e hip an d the k n e e ( 3 ) The e x t e r n a l
-
.

su p e rfic ia l p ud e n da l v e in su p e rfic ia l e iga str ic

( )
4 T h e.
p
v e in an d 5 ) th e su p e rfic ia l c ircu m fl e x v e in Th e la st thr e e .

tr ibutarie s j o in th e gre at sap h e n o u s v e in imm e d iat e ly be for e

it p a sse s thr o ugh t h e fo ssa ova lis Th e r e are se v e ra l va lv e s
.

in th e in t e r io r o f th e gr e at sap h e n ou s v e in wh ich h e lp to
d ivid e the c o lu mn o f blo o d in t o se ct io n s an d so r e duc e th e ,

p r e s sur e o n t h e wa lls o f t h e d is ta l p art o f t he v e in .

N e r v i Cu t an e i . Th e cuta n e o u s n e rv e s me t w ith in th e
—

are a O f t he p r e se n t d isse ct io n are

I liO in gu in al n e rv e
-
.

F ro m th e lu m bar ple x u s, L u m bo in g u in al n e rv e
-
.

L ate ral c u t an e o us n e rv e o f the th igh .

I n te rm e diat e c u t an e o u s n e rv e o f th e th igh .

F ro m the fe m o ra l ner e, v M e dial cu tan e o u s n e rv e o f the th igh .

Saph e n o u s ner e v .

Th e y hav e a lre ady be e n fo u n d an d c le a n e d N o w th e ir .

p o sit io n s an d d istr ibut io n s shou ld be m o r e fu lly stud ie d .

232 TH E I N F ER I OR E X TRE M I TY
fro m e ach oth e r . The a n terio r divisio n m ak e s it s a p p e ar
a n c e through th e fa sc ia lata
in t h e d ista l th ird o f t h e
L at e ra l c u t an e o u s
th igh a n t e r ior to the gr e at
ner e o v f the t hi gh ,

sa p h e n o u s v e in I t de
Ili i g i l
o -
n u na ne r e v
sc e n d s toward s th e k n e e
.

L mb i g i l u o -
n u na ,

ne r e v an d it s t e r min a l bra n ch e s
B ra nch fro m
me di a l c u t an e o u s turn fo rward s an d lat e ra lly
ne r e o v f t he t h i h g to t he a n t e r io r a sp e ct o f
I n t e rm e d at e c u t a i
ne o u s ne r e v th e p at e lla . Th e po sterio r:
f t he th gh
divisio n r e ach e s t h e sur fac e
o i

Med a il c u ta n e o u s
ner e o v f t he t h I gh o n t h e m e d ia l sid e o f t h e

k n e e be h in d the gr e at
,

G re a t sap he n o u s
sa p h e n ou s v e in an d p ro
v ein
,

c e e ds d ista lly t o su p p ly
t he in t e gu m e n t o n t h e
me d ia l sid e Of t h e p ro x i
m al p art O f th e le g B ut .

t h e m a in st e m o f t h e me dia l
I n frap at e ar bran ch ll
o f sa p he n o u s n e r e v cuta n e ou s n e rv e be for e it ,

d iv id e s a lso se n d s a fe w
,

tw ig s through the fa sc ia
lata to r e ach t h e sk in o n
t he p ro x ima l p art o f t he
G re at sap h e n o u s
m e d ia l a sp e ct o f th e th igh .
ve i n

Th e se mak e th e ir a p p e ar
Sa p h e no us ne r e v an c e a lo n g the lin e o f th e
gr e at sa p h e n ou s v e in
il l
.

Su p e rfic a p e ro n e a
v
n e r e ( O T m u sc u lo . .
N Sa p h enu s ( O T L o n g
. . .

c u t an e o u s ) Sap h e n o u s) — Th e sap h e n
.

o u s n e rv e be co m e s cuta
n e o u s o n t h e m e d ia l sid e o f

t h e k n e e by p e r forat in g t h e
fa sc ia be tw e e n t he t e n d o n s
D ee p p e ro ne a l ne r e v o f th e sartor iu s and grac ilis
(O T . . an t . t i bi l )
a
m u sc le s .Th e gu id e t o I t
is t h e sa p h e n o u s bra n ch
FI G . 1 0 7 .
— C u t an e o u s N e rv e s o n t he F t O f the arteri a en u suprema
ro n

o f t he I n fe r o r E tre m ty i x i g ;
wh ich d e sc e n d s a lo n g sid e
.

I t fo llow s the c o ur se O f t he gr e at sa p h e n ou s v e in in t O
’

o f it .

t he le g B e fo r e it p ie rc e s
. th e fa sc ia it g iv e s O ff an in fra
at a r ra ch
'

p e ll b n .
 TH E TH I G H 2 33

The infrapatellar bra n ch p ie rc e s th e sart o r iu s m u sc le an d

t h e fa sc ia lata o n t h e m e d ia l sid e o f t h e k n e e , an d tur n s
lat e ra lly toward s th e a n t e r io r a sp e ct o f t h e j o in t , d ista l to t he
le v e l o f t he p at e lla ( F ig .

P at e llar P lexus — Tw igs o f four

cuta n e o u s n e rv e s
o f the
o f th e t h igh hav e be e n trac e d to th e sk in o f th e k n e e v iz ,
.
,

t he a n t e r ior d ivisio n o f th e lat e ra l cuta n e ou s n e rv e o f th e th igh ,

th e in t e r me d iat e cut an e ou s t he a n t e r ior d iv isio n o f th e me d ia l

,

cuta n e ou s an d the sa p h e n ou s n e rv e Th e se n e rv e s co mmu n i

,
.

cat e w ith e ach o th e r an d for m an in t e rlac e me n t wh ich is situat e d

ov e r the p at e lla the liga me n tu m p at e llae an d p ro xima l p art o f
, ,

the t ibia . Th e in t e r lac e me n t is t e r m e d t h e p atellar plex u s .

O n the m e dial side o f the thigh t wo m inu te cu tan e o u s n e rv e t w ig s so m e

t ime s m ak e t h e ir app e aran ce whic h do n o t be lo n g t o an y o f t he abo v e
m ain cu t an e o u s t ru nk s O n e appe ars dist al t o the ilio in g u in al n e rv e , an d
.
-

is a t w ig fro m the p e rin e al bran ch o f t he po ste rio r cu tan e o u s n e rv e o f th e

th igh t he o th e r p ie rce s th e de e p fascia at th e m idd e o f the m e dial are a O f l
t he t h igh , an d co m e s fro m the O btu rato r n e rv e .

t t
D is s e c ti o n — Af e r t h e cu an e o u s n e r e s h a e be e n cle an e d
. v v
t h e re m ain s o f t h e su p e rfi cial f as cia m u s be re m o e d in o rde r t v
t t t t
h a th e fas cia la a m ay be s u die d .

F ascia L a t a — Th is is t h e n a m e wh ich is g iv e n to that

.

p ort io n o f t h e g e n e ra l fa sc ia l in v e st m e n t o f t h e in fe r ior
e x tr e mity wh ich c loth e s t h e th igh an d p r e se rv e s it s figur e .

O n ly a p ort io n o f it is d isp lay e d at p r e se n t bu t t he d isse ctor ,

shou ld O bta in a g e n e ra l id e a o f its attach me n t s an d p art s

be for e p roc e e d in g furth e r w ith th e d isse ct io n o f th e a n t e r io r

fe m ora l re g io n .O n e o f its str ik in g fe atur es is t he m ark e d
d iffe r e n c e in str e n gth wh ich it shows in th e lat e ra l an d
me d ia l a sp e ct s o f t he th igh I n t h e lat e ra l sid e o f t he lim b
.

it is g e n e ra lly so d e n se an d stro n g that it a p p e ar s to be mo r e

a p o n e urot ic tha n fa sc ia l in its charact e r whilst in add it io n a , ,
.

sp e c ia l ba n d ca lle d t h e tractu s ilio tibialzs is fo r m e d in it

-
Th e .

tractu s ilio t ibia lis e x t e n d s fro m t h e cr e st o f the iliu m to th e

-

lat e ral co n dy le o f th e t ibia an d th e h e ad o f t he fi bu la an d ,

in to it are in se rt e d th e t e n sor fa sc iae lat ae an d t h e gr e at e r p art

O f th e g lut ae u s m a x imu s m u sc le ; it s d ista l p art th e r e fo r e , ,

se rv e s as an a o n e ur o t ic t e n d o n b m e a n s o f wh ich t h e t wo
p y
m u sc le s ga in in se rt io n in to t he lat e ra l c o n dy le O f th e t ibia “

an d t h e h e ad o f t h e fi bu la Th e ilio t ibia l tract se rv e s as a

.
-

p ow e r fu l brac e o n th e lat e ra l a sp e ct o f th e limb wh ich in

, , ,

t he e r e ct p o stur e h e lp s to st e ady th e p e lv is an d at th e sa m e
,

time ke e p t he k n e e jo in t fir mly e x t e n d e d On th e me d ia l .
2
34 THE I N F E R I OR EXT R E M I TY
si d e O f the th igh the fa sc ia lata is so e x c e e d in gly d e licat e an d
th in that th e su bjac e n t m u scu lar fi br e s sh in e through it an d ,

it is v e ry ap t to be r e m ov e d w ith the su p e rfic ia l fa sc ia u n le ss

car e is e x e rc ise d in the d isse ct io n .

Pro x ima lly arou n d the root o f th e limb th e fa sc ia lata is

,
-

attach e d to the in gu in a l liga me n t an d the bo n e s o f the p e lvis .

Thu s po sterio rly it is co n t in uo u s w ith th e fa scia o f th e butt o ck

, , ,

an d through that it is fi x e d to th e coccy x sacru m an d cr e st o f , ,

t he iliu m O n t h e lateral side it is attach e d to t h e cr e st o f th e

.

iliu m ; an d o n th e medial side to t h e body O f th e p u bis th e , ,

marg in o f the p u bic arch an d to t he tu be ro sity o f th e isch iu m ,

.

A nterio rly its p ro x i ma l attach ,

m e n t is co m p licat e d by t h e
p r e s e n c e o f t h e fo s s a ova lis .

That a p e rtur e se p arat e s t he

fa sc ia lata in to a lat e ra l or iliac
p o r t io n a n d a m e d ia l or p e ct in e a l
p ort io n n o w k n ow n as th e f ascia ,

p ectin ea T h e s u b d i v is io n e x .

t e n d s d ista lly o n ly to the d ista l

bord e r O f th e fo ssa ova lis Th e .

iliac p o rtio n is attach e d a lo n g th e

F ro . 8 Di g m t h w th who le le n gth o f th e in gu in a l liga
1 0 .
-
a ra o s o e

arran g m t f th t h e i t me n t
en O
I t S me d ia l cr e sc e n t ic
e re e n er .

m l
u sc u arpt d th th se a
arg an e
i n bou n d s t h e fo ssa ova li s
re e
.

t
o s eo f i l mp t m t f
-
asc a
m co ar en s o

th th i gh
e
( A f t T .
) l at e raerl ly a n d f or
u rn e r m s
. it s fa lc if or m
a. M di li e m al p m n te r e dg e The cor n u SU P C TI U S 0 l
u scu a r se tu . “

fi: fir st sensi tizes that e dg e ble n d s t

0

.
h
“
t h e tle

lacu n ar e ( O T G imbe r n at s liga

’
. .

me n t ) an e xp a n sio n Of the m e d ia l e n d o f th e in gu in a l
liga me n t I t s in fe r ior cor n u j o in s th e p e ct in e a l p ort io n o f
.

t h e fa sc ia lata The fascia pectin ea c loth e s t h e p ro x ima l

.

p ort io n s O f th e adduct o r lo n gu s a n d p e ct i n e u s m u sc le s I t .

r e c e d e s fro m t he sur fac e as it is trac e d lat e ra lly p a sse s ,

p o st e r ior to t h e sh e ath O f t h e f e m ora l v e sse l s a n d b l e n d s ,

w ith th e ca p su le o f the hip j o in t w ith the d e e p in t e r m u scu lar ,

se p ta an d w ith th e fa sc ia iliaca wh ich cov e r s th e ilio p soa s

, ,
-

mu sc le ( F ig 1 To th e me d ia l sid e o f th e fe mora l v e sse ls

.

th e fa sc ia p e ct in e a is attach e d p ro x im a lly to th e p e ct in e a l
lin e O f th e p u bic bo n e Th e f ascia cribro sa as p r e v iou sly .
,

stat e d is to be r e gard e d as a th in p ie c e o f th e fa sc ia lata

, ,

str e tch e d acro ss th e fo ssa ova lis L at e ra lly it is co n t in uou s .

,
 2 3 6 TH E I N F ER I OR EXTR E M I TY
of t he p at e lla ( )
2 T h e su b fascia l prepatella r bu rsa, situat e d
.

be tw e e n t h e fa sc ia lata su p e rfic ia lly an d t h e p ro x im a l p art o f

the p at e lla a n d t h e adjac e n t p art o f t h e t e n do n o f the
quadr ic e p s d e e ply ; th is bur sa m ay be d isp lay e d by an in c isio n
m ad e through t h e fa sc ia lata in th e ar e a in d icat e d 3) T h e .

su bten din o u s p repa tella r bu rsa ly in g be tw e e n t h e su p e rfic ia l ,

fi bre s o f t h e t e n d o n o f th e quadr ic e p s an d t he p e rio st e u m o f

t h e a n t e r io r sur fac e o f th e p at e lla ( )
4 T h e su ra atellar bu rsa
p p . .

Th is lie s p r o x ima l to th e p at e lla be h in d the t e n d o n o f the ,

quadr ic e p s an d in fro n t o f t he d ista l p art o f the a n t e r io r

sur fac e o f t he fe m ur it u sua lly c o mm u n icat e s w ith th e
cav ity o f th e k n e e j o in t ( 5) T h e s u bc u t a n eo
. u s in f ra

patellar bu rsa p lac e d d ir e ct ly be n e ath th e sk in a n t e r io r t o the

, ,

p r o x im a l
p art O f t h e l iga m e n tu m
p at e llae
( )
6 T h e d eep i nf r a .

p a t ella r b u rsa wh ich is , p la c e d b e tw e e n t h e liga m e n tu m

p at e llae a n d th e a n t e r io r sur fac e o f th e
p ro x im a l
p art o f t h e

t ibia Th e su p ra p at e llar bur sa an d the d e e p in fra p at e llar

.
‘

bur sae are p ract ica lly a lway s p r e se n t bu t o n e or mo r e o f the ,

su bcuta n e o u s an d su bfa sc ia l bur sa e m ay be a bse n t No t un .

co mm o n ly a su bfa sc ia l an d an adjac e n t su bcuta n e ou s bur sa

may co mm u n icat e through an a p e rtur e in the d e e p fa sc ia .

The su bcuta n e o u s bur sae are o ft e n d e str o y e d dur in g th e

r e fl e ct io n o f t he sk in bu t the d e e p e r bu rsze c an u sua lly be
,

fou n d if lo o k e d fo r car e fu lly in th e situat io n s m e n t io n e d

, ,

a bo v e .

D EEP D I SSEC TI O N OF TH E AN TE R I O R AN D M EDI AL

P A R TS OF TH E T H I GH .

I n the cour se o f t h e d e e p d isse ct io n o f th e a n t e r io r an d

m e d ia l fe m o ra l r e g io n s th e fo llow in g structur e s w ill be me t

w ith an d m u st be e x a m in e d
I Th f m l h th
. e e o ra S ea .

2 . N e rv u s lum bo in gu in alis .

3 . N e rv u s cu tan e u s fe m o ris l ate ra li s.

4 . M sarto riu s
. .

5 . N e rv u s fe m o ralis an d its ram i .

6 . A rte ria fe m o ralis an d its ram i .

7 . V e n a fe m o ralis .

8 0 M iliO p so aS
o
'
o

2 re c tu s fe m o ri s.

M q u adrice p s fe m o ris 3 v astu s l

late ra is .

9 . .

3 v astu s in te rm e diu s .

2 v astu s m e dialis .
 TH E TH I G H 2 37

I O . M . articu laris g e nu .

I I . M . t e n so r fasciae lat ae .

12 . l
D e e p p art o f the t ractu s i io tibialis fasciae latae -
.

I 3 . l
The in t e rm u scu ar se pta, late ra an d me dia l l .

Ligame nt I nguina le ( O T P o u p art s Liga me nt ) an d Liga

’
. .

me nt u m L acuna re ( O T Gimbe rnat s Liga me nt ) — Although

’
. . .

both o f th e se liga m e n t s be lo n g m o r e to t he a bdo m in a l wa ll

She a th o f re c t u s Ap o i
n e u ro s s o f e x t e rna l bli q
o ue

I g i l li g
n u na am e n t

FIG . 1 0 9 .
— Di i
sse c t o n t o ho w
s i
t h e co n n e c t o ns o f t h e I n gu i n a l i
L ga m e nt .

tha n to th e th igh it is e sse n t ial that t he d isse ctor o f th e

,

in fe r ior e x tr e mity shou ld o bta in so m e k n ow le dg e o f th e ir

co n n e ct io n s be fore h e p roc e e d s furth e r w ith his d isse ct io n .

The ingu in al ligament is m e r e ly the th ick e n e d low e r bord e r

o f t he a o n e uro sis o f th e e x t e r n a l o bliqu e m u sc le o f t h e
p
a bdo min a l wall fo ld e d backward s u p o n it se lf Th e r e fo r e it .

p r e se n t s a rou n d e d sur fac e toward s t h e th igh an d a gro o v e d ,

sur fac e toward s the cavity o f t he a bd o me n I ts lat e ra l .

e x tr e mity is fi x e d to the a n t e r ior su p e r ior sp in e O f the

iliu m . M e d ia lly it has a dou ble attach m e n t v iz
,
to the ,
.
2
3 8 TH E I N F ER I OR EXTRE M I TY

p u b ic tu b e rc l e
( )
2 through ,
t h e m e d iu m o f t h e lacu n ar liga m e n t
to t he m e d ial p art o f th e p e ct in e a l lin e The in gu in a l .

liga me n t p ur su e s an o bliqu e cour se be tw e e n its iliac an d p u bic

attach me n t s an d at the sa me t ime d e scribe s a g e n tle curv e the
, ,

co nv e xity o f wh ich is tur n e d d ista lly By its d ista l bord e r it .

a fford s attach me n t to the iliac p art o f th e fa sc ia lata an d ,

wh e n that is d iv id e d it lo se s its curvatur e .

Th e ligamentu m lacu n are ( O T Gimbern a t s liga men t) is a . .

’

sm a ll tr ia n gu lar p ie c e o f a p o n e ur o sis wh ich o ccu p ie s th e in t e rva l

be tw e e n th e m e d ia l p art o f the in gu in a lliga me n t an d the me d ia l

in ch o f th e p e ct in e a l lin e — be in g attach e d by it s marg in s to
both . I t s ba se wh ich look s lat e ra lly is shar p cr e sc e n t ic an d
, , , ,

fr e e an d a but s aga in st t h e fe m ora l sh e ath

,
The lacu n ar .

liga m e n t occu p ie s a v e ry o bliqu e p la n e ; it s fe m ora l sur fac e

look s d ista lly an d lat e ra lly wh ilst its a bdo m in a l sur fac e is ,

d ire ct e d u p ward s an d me d ia lly ( F ig .

D sse c t
i i o n — Th po re o f t h
. f e m ral s h e at h i t h n t
e ex su e o s e ex

st e p in t h di s ct io n f t h e t h igh
e s e To disp lay it t h ili ac p o rti n
o . e o

f t h f as cia lat a m t be p art ially re fl e ct d

o e us Divide t h e u p rio r e . s e
h o rn o f th e lat e r al r c n t ic m arg in o f th e fo s a vali a d c es e s o s, n
t h e n carry t h e k ife lat e rally alo n g t he lo w r b rde r o f the
n e o

in gu in al lig am e n t so a t o se v e r t h att ac h m e n t o f t h e f ascia

,
s e

lat a t o t h at t h i k n d ban d Th e in cisi n sh ld

c e e t d to . o o u ex e n
w it h in an in ch f t h e an t ri o r s p e ri r sp in o f t h e ili m Th
o e u o e u . e

p i ce e o f f a sc ia m a r k e d o t b y t h e in i io a bo v aun d b y t h e c s n e,
lat ral f r e m arg in f th e f o ssa o v alis m dially m st be care f lly
e e o e ,
u u
rais d f ro m t h e s bj a e t f m o ral h at h an d t h r wn di t ally
e u c n e s e o s

an d lat e rally On t h e re m o val o f a litt le lo o

. f at t h e f em o ral se ,

sheath w ill be br gh t in t v ie w as it e t rs th t h igh n de r

o u o n e e u

t h e in g in al lig am u t I so lat e it car f lly f r m adj a e n t an d

en . e u o c

s rro u n din g p art s by carry in g t h

u ,
h an dle o f t h e k n if g e n tly e e

ro n d it as f ar as p o s ible
u I n sin at th e h an dl o f th k n if e fi rst
s . u e e e ,

be tw e e n t h S h e at h a d t h e i ngu in al ligam n t n e t be t w n
e n e , x ee

t h e s h at h a d th e lacu n ar ligame n t w h i h lie s m e dial t o it

e n ,
c ,

an d fi n ally be h i d t h s h e at h alo n g t h f ro n t f t h p e ct i al
e n e o e ne

f ascia Lat e rally an d p o st rio rly t h e h e at h is fu d w it h t h

. e s se e
iliac f ascia o n t h e p so as m u scle
1
an d in t h at sit at io n it w ill ,
u

be n e ce s ary t o u s t h e e dg e o f t h e k if e be f o r e th e sh at h can
s e n e

be iso lat e d (F ig .

F emo ral She at h — Th e fu n n e l sha p e d a p p e ara n c e o f th e -

fe m ora l sh e ath w i n o w be a pp ar e t
ll n — th e w id e m outh o f
th e m e mbra n ou s tu be is d ir e ct e d u p ward s t o ward s the
a bdo me n wh ilst th e n arro w d ista l p art gradua lly c lo se s
,

1
D o t nof th ili
c o n u se f i w i t he t h i liac p t f t
asc ah f i l t e ac ar o e asc a a a .

Th ili
e fac i i f
asc a i wh i h d s a d f m th
asc a bd m
c th
e sc e n t i s ro e a o en o n e an e r o r

f
su r ac e s o f th p e d ili so as anm l Th ili ac u sp t f t h f i
usc e s l t i . e ac ar o e asc a a a s

p t
ar f
o t h d pe f i eef t h t h i gh (
asc a o p e se e .
 TH E I N F ER I OR EXTRE M I TY
The arra n g e me n t o f the fa sc ia ] lin in g o f the a bd o min a l
cavity, w ith r e fe r e n c e to th is in t e rva l o f co mm u n icat io n
be tw e e n a bdo me n an d th igh a lso r e qu ir e s att e n t io n Th e ,
.

low e r p art o f t h e p o st e r ior wa ll o f t h e a bdo me n imme di ,

at e ly a bov e the th igh is form e d by the iliacu s an d p soa s ,

mu sc le s Th e se are c o v e r e d by that p art o f the fa sc ia ]

.

lin in g o f th e a bdo me n wh ich r e c e iv e s th e n a me o f th e

Tran s v e rsa li s fasc i a

Tran s v e rsu s abdo min i s

I n t e rna l bli q
O ue

~ E x t e rn a l b o

I g i l
n
r
u na c an a l
C amp e r s
’
fasc i a
o
Tra ns v e rsa i s l
fa sc I a
I n gu rn al 1I game n t
.

Su p e rficra l e p i
ga st rI c v e in

Ap o n e u ro si s o f e x t e rn

p so as

t e rna l ili v i
ac e n

F a sc 1a l a ta
ac fasc i a
F e mo ra lv ein

G re at sa p h e n o u s v e n i

FI G . 1 10 .
— Di g m f th F
a ra o e asc iae an d M u sc l es o f th e I n g u i n al an d

Su bi g i
n l R gi i
u na e o ns n the li ne o f t he F o ssa Ova l is .

iliaca 1 .Th e a n t e r ior wa ll o f th e a bdo m e n is lin e d , in lik e

m a n n e r, by a p ort io n o f th e g e n e ra l lin in g, t e r m e d th e fasci a
transversa/is To t he lat e ra l sid e o f th e fe mo ra l v e sse ls th e se
.

two fa sc ia l lay e r s be c o m e c o n t in u o u s w ith e ach oth e r, and at

the sa m e t im e are attach e d t o th e back o f th e in gu in a l liga
me n t ( F ig I t is be h in d th is u n io n that t h e ilio p soa s,
.
-

h
t e e f m ora rv
l e e, a d t e
n n h lat e ra l cuta n e ou s n e rv e o f t h e

th igh are carrie d d ista lly in to the th igh B u t th e e x t e r n al .

1
T he di s se c t o r m ust be a r in mi nd the i i
d st n ct o n i
be t we e n th e f asc i a i liaca
an d t h e ilia c po rt io n o f th e f asci a lat a . Th e fo rm e r is a p art o f th e ge n e ra l
fasc i l li i g
a n n o f t h e abdo men , an d th e l at t e r is a p art o f the de e p fasc i a o f
the th i gh .
 TH E TH I G H 2 4 1

iliac v e sse ls ( wh ich be co me t h e fe m ora l v e sse ls in t h e th igh ) ,

'

w ith the lu m bo in gu in a l n e rv e , lie a n t e r ior to t he fa sc ia iliaca,

-

or, in oth e r word s, w ith in the fa sc ia l lin in g o f the a bdo me n ,

an d, as th e y p roc e e d d ista lly be h in d t h e in gu in a l liga m e n t ,
th e y carry w ith th e m a fu n n e l—sha p e d p ro lo n gat io n o f t h e
lin in g,
wh ich is the fe m ora l Sh e ath .

Th e d isse ct o r w ill n o w r e ad ily u n d e r sta n d that th e an terio r

w all o f t h e Sh e ath 15 fo r me d o f fascia tra nsversa/is fr o m

N cu tane u s
l l
.

fe mo rI S at e ra i s

M . ili o -
p so as

Fm l he o ra s eat

V f m li e o ra s

l
.

L ig .

Tu be rc u l um pu b i
M pect. i ne us

A IA
F SC I LlAOA

FIG . 1 1 1 .
— Di ssec tio n to s o h w t heF m l Sh th
e o ra ea an d t h e o t he r S tru ct u re s
wh ich p ass be t wee n t he I n u n a g i l L ig m t a en an d th e H ip B o ne .

th e a n t e rio r wa ll o f the a bdo me n wh ile th e po sterio r w all is ,

for me d o f fascia iliaca p ro lo n g e d d ista lly fro m t h e p o st e r ior

, ,

a bdo min a l wa ll ( F ig I .

P o st eri o r W a ll o f t h e F emo ral Sheat h — Th e r e are st ill

so m e add it io n a l fact s r e lat in g to t h e p o st e r ior wa ll o f t h e

fe m ora l sh e ath wh ich r e qu ir e to be m e n t io n e d I t is .

for me d as stat e d a bov e by th e fa sc ia iliaca ; bu t as that

, .

e n t e r s t h e th igh it ble n d s w ith t h e lat e ra l p art o f t he F ig 1 1 3 )

( .

fa sc ia p e ct in e a an d furth e r it is fir m ly fi x e d in p o sit io n by
, ,

c e rta in co n n e ct io n s wh ich it e sta blish e s in t he th igh Thu s .

,

—
V OL . 1 16
 2 4 2 TH E I N F ER I O R EXTRE M I TY
ora l sh e ath it is p ro lo n g e d ov e r the ilio
th e fe m
’

lat e ral to ,

p soa s m u s c le ; wh ils t f ro m it s p o st e r io r a sp e ct a l a m in a is

giv e n o ff wh ich p a sse s p o st e r ior t o that m u scle an d jo in s the

ca p su le o f the hip jo in t ( F ig 1 .

D is s e c ti o n — Th f m ral sh at h m u t be p . d in rde r e e o e s O ene ,

o
t h at th e arra g m t f p art i id m ay b di p lay d M ak e
n e en o s ns e e s e .

t h r v rt i al a d p arall l i isi n s t h r gh th a t ri r w all

ee e c n e nc o o u e n e o
v r t h fe m ral art ry w h i h
o ne o e e p i s th lat e ral p rt f
o e ,
c o ccu e e a o
t h e s h e t h an o t h e r o v e r t h
a ,
f m r l v in in t h lin f th e e e o a e e e o
g r at sap h o u v i an d t h e t h ird ab t h alf a i h m dial
e en s e n, o u n nc e
t th o d Th fi r t tw
e se c o n h ld b g in at t h l v l f th
. e s o s o u e e e e o e
i g i al lig am n t an d s h o u ld
n u n t d di t ally f r an i c h an d a
e ,
ex en s o n
h alf Th e m o st m dial o f t h e t h r i i i
. sh o ld co mm n
e ee nc s o ns u e ce
at t h e m l v l b t h o ld b carr i d di t ally
sa e e e ,
ly f o r h alf an
u s u e e s o n
in c h o r le ss .

I nt e ri o r A litt le d isse ct io n w ill

o f t he F e mo ral Sh e at h —

S h o w that th e S h e ath is su bd iv id e d , by two a n t e ro p o st e r ior -

p art it io n s, in to thr e e co m p art m e n t s Th e fe mo ra l art e ry an d .

lu mbo in gu in a l n e rv e O ccu p y th e mo st lateral co mp artment ; th e

-

fe mo ra l v e in fi lls u p t h e intermediate co mp artmen t ; wh ilst in

th e mo st medial co mp artmen t are lo dg e d a litt le loo se ar e o lar
t issu e , a sma ll ly mp h gla n d , an d so m e ly mp h v e sse ls Th is .

la st c o mp art m e n t , fro m its r e lat io n to fe m ora l h e r n ia , h as th e

sp e c ia l n a me o f femo ra l can al a p p lie d to it .

Can alis F e mo ralis — Th e bou n dar ie s an d e x t e n t o f t h e .

fe m ora l ca n a l m u st be v e ry thorough ly stud ie d Th e be st .

way to c o mm e n c e the study is to in troduc e th e little fi n g e r

in to t he ca n al an d p u sh it g e n t ly u p ward s Th e le n gth o f .

t h e ca n a l is n o t n e ar ly so gr e at as that o f t h e oth e r two

co m p art me n t s I n d e e d , it I S n o t m ore tha n ha lf an in ch
.

lo n g .D ista lly it is c lo se d , an d it ra p id ly d imin ish e s in

w idth p ro x im o d ista lly I t s p ro x ima l ap e rtur e lie s o n the
-
.

lat e ra l sid e o f th e ba se o f th e lacu n ar liga m e n t , an d is ca lle d

th e femo ral ring I t is c lo se d by t h e c lo sely a pp lie d e x tra
.

p e r ito n e a l fatty t is su e o f t h e a bdo m in a l wa ll T h e p art s .

wh ich imm e d iat e ly surrou n d t he o p e n in g can be r e ad ily

d e t e ct e d w ith th e fi n g e r : lat e ra lly the femo ral vein, m e d ia lly
t h e sha r p cr e sc e n t ic b a se o f t h e lacu n ar ligament, a n t e r ior ly

t he ingu in al ligament, an d p o st e r ior ly th e p u bic bo n e cov e r e d

by th e pectineus muscle The p ort io n o f th e e x tra p e r it o n e a l
.
-

fatty t issu e wh ich c lo se s t h e r in g is ca lle d th e sep tu m

femo rale O n th e abdo m in a l surfac e o f the se p tu m fe mora le
.

is th e p e r ito n e a l lin in g o f t h e a bdo m in a l cav ity , an d wh e n

e x a min e d fro m a bov e both are se e n t o be slight ly d e p r e sse d
 T HE I N F ER I OR EXTRE M I TY
o ccu rre n c e in c ase s o f fe m o ral h e rn ia The sh arp te nse base o f the lacu n ar
.

lig ame n t an d t he su p e rio r co rn u o f th e m argin o f th e fo ssa o v alis are

l
e sp e c ial y ap t t o brin g abo u t th at co n ditio n .

A o b rm al O bt ra t r A r t r — T h e acco u n t o f th e su rgical an at o m y
n u o e y
o f fe m o ral h e rn ia c an no t be c o m p le t e w it h o u t m e n tio n o f t h e re lat io n
which the O bt u rato r art e ry freq u e n t ly be ars t o the fe m o ral ring In .

t wo o u t o f e v e ry fiv e su bj e c t s the O btu rato r a rt e ry , o n o n e o r o n bo t h side s ,

t ak e s o rig in fro m t h e in fe rio r e pig ast ric arte ry I n th o se c ase s it p asse s .

p o st e rio r t o t he p u bic bo n e t o g ain th e O btu rato r su cu s in th e u p p e r p art l

L at e ra l c u t an e o u s n e r e v
I g i l li g
n u na am e n t

S u p e rfi c a c rc u m e il iac a rt e r fl x ili y
F
e m o ra ne rv e l
I Su p e rfic a e p ast r c an d i l ig i
P ro fu n da fe mo i
r s art e r y su p e rfic a p u de n da a rt e r e s il l i

L a t e ra l i c rc u m flx e

t y
ar e r

I i
n t e rm e d a t e c u ta
n e o n s ne r e(O T v
l
. .

mi dd e c u t an e o u s)

Addu c t o r bre vi s
F e m o ra lv ein

G re a t sap h e n o u s

v
e in

i
‘

F e mo ra l y
a rt e r

FIG . 1 1 2 — Di sse c t o n o i f th e F e l
m o ra Tr an g i l e o f the ri gh t side

o f th e fo ram e n , an d ac co rdin g t o the p o in t at wh ich it arise s

O btu rato r

fro m the e p ig astric tru nk , it p re se n ts diff e re n t re latio n s to the fe m o ral

rin g .I n the m aj o rity o f c ase s it lie s in c lo se c o n tact w ith the e te rn al i iac x l
l l
v e in an d o n the ate ra side o f the fe m o ral rin g I n th at p o sitio n it is in .

n o dan g e r o f be in g w o u n de d in o
pe ratio n s u n de rtak e n fo r the re lie f o f a
st rictu re d fe m o ral h e rn ia I n abo u t th irty se v e n p e r c e n t , h o w e v e r, o f the
.
-
.

x
case s in wh ich it e ist s t h e art e ry is p lace d le ss fav o u rably
, I n th o se it .

e ith e r
passe s m e dially , acro ss th e se p tu m fe m o ra e wh ich c lo se s the l
o
p e n in g in t l
o t he fe m o ra can al, o r it arch e s o v e r it an d tu rn s
po ste ri o r y, l
o n th e m e dial side o f t he rin g , u o n th e de e a s e c t o f th e base o f the
p p p
lacu n ar ig am e n t l I n the latt e r situ atio n it is in a p o sitio n o f g re at dan g e r,
.
 TH E TH I G H 2 45

g th at it is the base o f the lacu n ar l ig am e n t ag ain st wh ich the su rg e o n s

se e in
’

k nife is g e n e rally dire cte d fo r the re lie f o f strictu re d fe m o ral h e rn ia .

D is s ec t i o n —Th e bo u n darie s an d co n e n s o f t h e fe m o ral

. t t
t rian g le , w h ic h o ccu p ie s t h e p ro x im al h ird o f t h e an e rio r p art t t
O f t he t t
h igh , m u s n o w be disse c e d Co m m e n ce by cle an in g t .

t h e m e dial an d la e ral bo u n darie s t Th e la e ral bo u n dary is . t

t
f o rm e d by t h e p ro x im al h ird o f t h e s art o riu s m u scle , an d t h e
m e dial bo u n dary by t h e m e dial bo rde r o f t h e addu c o r lo n g u s t
m u scle To cle an a m u scle p ro p e rly t h e f o llo w in g ru le s m u s
.
!

t
be o bse r e d v ( 1 ) K e e p t h e m u scle e n se by be n din g o r s raigh e n t t t
in g t h e lim b o r by ro a in g it ( 2 ) M ak e t t
a ll cu s i h t h e sc alp e l
. t wt
w
p aralle l it h m u scle fi bre s
‘

(3 ) R e m o e th e f ascia in o n e c o n
. v
tin u o u s lay e r f ro m o n e bo rde r o f t h e m u s cle t o a n o h e r (4 ) t .

v
D e fi n e e ry care f u lly t h e bo rde rs o f t h e m u scle .

As t h e de e p f ascia is re m o e d t h e s calp e l m u s cu t n o t o n ly v t
p aralle l wt
i h t h e m u scle fi bre s bu t also a g ain s h e m , in o rde r tt
t t
h a n o n e o f th e de e p f ascia m ay be le f o n t h e m u scle t .

t
Cle an t h e s art o riu s fi rs f ro m it s o rig in o n t h e an e rio r bo rde r t
t
o f t h e iliu m , be lo w t h e an e rio r su p e rio r sp in e , t o t h e p o in h e re tw
t
it c ro sse s t h e addu c o r lo n g u s at t h e j u n c io n o f t h e p ro x im al t
an d m iddle t
h irds o f t h e h igh B e g in at its m e dial o r its t .

t
la e ral bo rde r, w v
h ich e e r is m o re co n e n ie n , an d ak e care n o t v t t
t
t o in j u re t h e la e ral cu an e o u s n e r e o f t h e h igh , t h ic h cro sse s v t w
su p e rfi cial t o t h e m u scle n e ar its o rig in , an d t h e in e rm e dia e t t
cu t an e o u s n e r e , v w t
h ic h e i h e r p ie rce s o r cro sse s th e m u scle n e ar
t h e m iddle lin e o f t h e h igh t .

t
N e xt cle an t h e p e c in e al f asc ia f ro m t h e an e rio r su rf a ce o f t
t
t h e addu c o r lo n gu s f ro m t h e p o in wh e re th e m u scle a rise s t
t
f ro m t h e f ro n o f t h e p u bis t o t h e p o in h e re it disapp e ars t w
be h in d t h e s art o riu s at t h e ap e x o f t h e f e m o ral rig o n e t .

W h e n t he m e dial an d la e ral bo u n darie s o f th e rig o n e h a e t t v

be e n disp lay e d p ro c e e d t o t h e disse c io n o f t h e f e m o ral n e r e t v
an d its bran c h e s P
lace a blo ck u n de r t h e k n e e in o rde r t o
.

fl e x t h e hip j o in t an d re lax t h e bo u n darie s an d co n e n s o f t h e

-
t t
t rian g le , t h e n f o llo w t
t h e in e rm e dia e cu an e o u s n e r e u p w ards t t v
t o t h e p o in tw
h e re it sp rin g s f ro m t h e f ro n o f th e ru n k o f t he t t
v t
f e m o ral n e r e , n ex cle an t h e la e ral bo rde r o f t h e ru n k , an d t t
in se rt in g t h e h an dle o f a sp are sc alp e l be h in d t h e n e r e raise it v
v t
f ro m t h e g ro o e be w e e n t h e iliacu s an d p so as in h ic h it lie s w .

v
Le a e t h e sp are scalp e l be h in d t h e n e r e t ru n k an d cle an it s v
v ario u s bran c h e s so f ar as i t h e y lie in t h e fe m o ral rig o n e t .

t
M e dial t o t h e in e rm e dia e cu an e o u s n e r e lie s t h e m e dial t t v
t
c u an e o u s n e r e o f t h e v t
h igh I t sp rin g s f ro m t h e f ro n o f t h e . t
t ru n k o f t h e f e m o ral n e r e , ru n s a lo n g t h e la e ral bo rde r o f v t
t
t h e f e m o ral s h e a h a n d cro sse s t h e fro n o f t h e f e m o ral art e ry t
at t h e ap e x o f t h e rig o n e t
On a p lan e p o s e rio r t o t h e in e r
. t t
t t
m e dia e an d m e dial cu an e o u s n e r e s lie t h e de e p e r bran c h e s o f v
t h e f e m o ral n e r e v
Th e y radia e f ro m th e e x t re m it y o f t h e
. t
t v
ru n k o f t h e n e r e an d are a rran g e d in t h e f o llo in g o rde r f ro m w
abo v e an d la e rally do t w
n w ards an d m e dia lly : t h e n e r e t o v
t
t h e re c u s f e m o ris , t h e n e r e t o t h e v
as u s la e ralis , t h e n e r e v t t v
v t t
t o th e as u s in e rm e diu s , t h e n e r e t o t h e as u s m e dialis , an d v v t
t h e sa p h e n o u s n e r e v
Th e n e r e t o t h e sar o riu s is u su ally a
. v t
t
bran c h o f t h e in e rm e dia e cu t an e o u s n e rv e t
As t h e m u scu lar
’

bran ch e s are be in g cle an e d ak e c are t o a o id in j u ry t o t h e t v

2 46 TH E I N F E R I O R EXTRE M I TY
t
la e ral f e m o ral circu m fl ex ar e ry , w h ic h p as se s la e rally e i h e r t t t
be h in d o r be tw
e e n th e n e r e s Af e r t h e n e r e s m e n io n e d v . t v t
h av e be e n cle an e d p u ll t h e t ru n k o f t h e fe m o ral n e r e la e rally v t
v
an d se cu re t h e n e r e t o t h e p e c in e u s , w h ic h sp rin g s f ro m t h e t
m e dial bo rde r o f th e fe m o ral n e r e an d p asse s m e dially be h in d v
t h e fe m o ral S h e a h t
F o llo w it as f ar as p o ssible be h in d th e
.

t
s h e a h a n d k e e p it in m in d du rin g t h e n e x s ag e o f t h e dis t t
t
se c io n , w h ic h in c lu de s t h e re m o al o i t h e f e m o ral s h e a h an d v t
t h e cle an in g o f t h e f e m o ral art e ry an d its bran ch e s an d t h e
v
f e m o ral e in an d it s ribu arie s t
AS m an y o f th e bran ch e s t .

t
o f t h e a r e ry as p o ssible s h o u ld be re ain e d, bu t sm all bran c h e s t
t o th e m u scle s m ay be re m o e d if h e y o bs ru c t h e cle an in g v t t t
o f t h e larg e r e sse ls v
Th e m ain ru n k s o f t h e e in s m u s also
. t v t
t
be k e p an d cle an e d, bu t t h e e n ae c o m i es o f t h e sm alle r ar e rie s v t t
s h o u ld be re m o ed v .

Co m m e n ce w i h t h e f e m o ral ar e ry t Trace t h e su p e rfi c ial t .

bran c h e s alre ady disp lay e d bac k t o h e ir o rig in f ro m t h e ru n k t t

as it lie s in t h e f e m o ral s h e a h , h e n raise t h e t ru n k o f t h e art e ry t t
t
f ro m t h e sh e a h , an d co m p le t e ly re m o e t h a p o t io n o f t h e v t r
sh e a h t w
h ic h su rro u n de d th e art e ry , bu t do n o t f o rg e t h e n e r e t v
t
t o t h e p e c in e u s w h ic h lie s imm e dia e ly be h in d t h e s h e a h As t t .

t h e art e rial p art o f t h e f e m o ral sh e a h is re m o e d, fi n d t h e de e p t v

e xt e rn al p u de n dal art e ry , w
h ic h sp rin g s f ro m th e p ro x im al p art
o f th e ru n k t
t h e n c le an t h e dis al p ar o f t h e f e m o ral ar e ry as t t t
f ar as t h e ap ex o f t h e rig o n e t
F irs cle an th e m e dial S ide , f ro m . t
w t t
h ic h n o imp o r an bran ch e s arise Th e n cle an alo n g t h e la e ral . t
side , f ro m abo e do v w
n w a rds , an d abo u 5 0 m m dis al t o t h e t . t
t
in gu in al lig am e n fi n d t h e larg e p rof u n da f em o ris bran c h , h ic h w
sp rin g s f ro m t h e p o s e ro t
la e ral asp e c o f t h e p are n ru n k
-
t t t t .

F o llo w
t h e p ro fu n da arte ry dis ally an d m e dially be h in d t h e t
f e m o ral an d p ro fu n da e in s an d se cu re its fi rs tw o bran c h e s , v t
th e me dial an d t h e late ral f em o ral circu mfl ex arteries Th e .

m e dial fe m o ral c ircu m fl e x art e ry p as ses back ards in o t h e w t

t
de e p p art o f t h e rig o n e ; t h e la e ral f e m o ral c ircu m fl e x art e ry t
t
ru n s la e rally , be h in d o r be w e e n t h e m u scu lar bran c h e s o f t h e t
v t
fe m o ral n e r e , t o t h e la e ral bo rde r o f t h e f e m o ral rig o n e , wh e re t
t
it bre ak s u p in o as ce n din g , ran s e rse an d desce n din g bran c h e s t v .

No t u n co m m o n ly o n e o r bo h t h e f e m o ral c ircu m fl ex art e rie s t

sp rin g f ro m t h e t
ru n k o f t h e fe m o ral art e ry , an d t h e disse c o r t
t
m u s be p re p are d t o m e e i h su c h aria io n s twt v t .

t
Af e r t h e art e rie s are disp lay e d, cle an t h e f e m o ral an d p ro
v
fu n da e in s, bo h o f t w
h ic h lie p o s e rio r t o the f e m o ral arte ry t
t
in t h e dis al p art o f t h e rig o n e t
As t h e p o s e rio r asp e c o f t h e . t t
t
p ro x im al p ar o f th e fe m o ral e in is cle an e d t h e n e r e t o t h e v v
t t
p e c in e u s m u s be f o llo w e d t o its e rm in a io n in t h e p e ct in e u s t t
t
m u scle ; h e n t h e re m ain in g p art s o f t h e p e c in e al fascia m u s t t
v
be re m o e d f ro m th e p e ct in e u s an d addu c o r lo n gu s As h a t . t t
is do n e , an in e r al w ill co m e in o t v ie be we e n t h e lo e r t v w t w
t
bo rde r o f t h e p e c in e u s an d t h e u p p e r bo rde r o f t h e a ddu c o r t
lo n gu s, in w
h ic h th e su p e rfi cial di isio n o f th e O b u ra o r n e rv e v t t
s h o u ld be f o u n d t
L as ly , t h e iliac f asc ia m u s be cle an e d f ro m
. t
th e su rf ace s o f t h e iliacu s an d p so as , an d t h e f at in t h e an g le
be tw e e n t h e p so as an d p e c in e u s m u s be re m o e d t v t .

Trigo n um F e mo rale — Th e fe m o ra l tr ia n gle is t he n a me

.

g iv e n to the tr ia n gu lar h o llow wh ich lie s in the p r o xima l

2 48 TH E I N F E R I OR EXTRE M I TY
t h e p so a s m ajor an d th e iliacu s Through it p a ss the fe mora l .

art e ry an d v e in th e d e e p fe m ora l ly m p h v e sse ls the fe mo ra l

, ,

an d lu mbo in gu in a l n e rv e s an d t h e lat e ra l cuta n e ou s n e rv e O f

-

th e th igh .

Art eria Pu de n da Ex t erna P ro fun da Th e d e e p e x .

t e rn a l p ud e n da l art e ry is a sm a ll tw ig wh ich ar ise s fro m t he

me d ia l sid e o f th e fe m o ra l art e ry d ista l to the in gu in a l liga ,

me n t I t ru n s m e d ially u p o n t h e p e ct in e u s an d adduct o r
.
,

lo n gu s mu sc le s an d a ft e r p ie rc in g th e fa sc ia lata e n d s
, , , ,

accord in g to th e se x in th e in t e gu m e n t o f the scrotu m or o f ,

t h e la biu m maju s p ud e n d i .

D is s e c t i o n — B e f o re t h e o h e r c o n e n s o f t h e f e m o ral rian g le
. t t t t
t
are stu die d, co m p le e t h e disse c io n o f t h e re m ain s o f t h e an e rio r t t
an d m e dial re g io n s o f t h e h igh an d k n e e t .

t
F irs cle an th e re m ain de r o f th e sart o riu s as far as its in se r
t t t
io n in o t h e ibia, bu t a o id in j u ry t o t h e n e r e s h ic h lie in v v w
t
re la io n w i h it t
Th e la e ral cu an e o u s n e r e o f t h e t h igh ,
. t t v
w t
h ic h cro sse s an e rio r t o t h e m u scle n e ar t h e an e rio r su p e rio r t
sp in e o f t h e iliu m , an d t h e in e rm e dia e cu an e o u s n e r e , w h ic h t t t v
t
e i he r c ro sse s o r p ie rc e s it , h a e alre ady be e n se cu re d B e lo th e v . w
ap e x o f t h e f e m o ral rian g le t h e an e rio r bran c h o f t h e m e dial t t
t
cu an e o u s n e r e c ro sse s su p e rfi c ial t o v th e sart o riu s , an d t h e
t
p o s e rio r bran c h o f t h e s am e n e r e ru n s alo n g it s p o s e rio r bo rde r v t .

t t
A s h o r dis an c e p ro x im al t o t h e k n e e t h e in f rap a e llar bran c h o f t
v
t h e sap h e n o u s n e r e p ie rce s it , a n d t h e ru n k o f t h e sap h e n o u s t
v t
n e r e e m e rg e s be w e e n it s p o s e rio r bo rde r an d t h e e n do n o f t h e t t
g racilis at th e m e dial S ide o f t h e k n e e acco m p an ie d by t h e
sap h e n o u s bran c h o f t h e ar e ria g e n u su p re m a, w h ic h se r e s as a t v
t
g u ide t o its p o si io n Af e r t h e sart o riu s is disp lay e d, u rn t o t h e. t t
t
e n so r f asc ia la a , t w
h ic h lie s imm e diate ly lat e ral t o t h e p ro x im al
p art o f t h e sar o riu s t
At t h e la e ral bo rde r o f t h e p ro x im al p art
. t
t
o f t h e sar o riu s t h e iliac p ar o f t h e f asc ia la a sp li s in o tw o t t t t
lay e rs On e lay e r p asse s su p e rfi c ial t o t h e sart o riu s , an d h as
.

r
be e n e m o e d t o e x p o se t h e m u scle v t h e o h e r p asse s de e p t o t h e t
t e n so r f asc ia t o ble n d w it h t h e e n do n o f t h e re c u s f e m o ris t t .

t
Trace t h e e n so r f as cia t o it s a t ac h m e n t o t h e ilio ibial t a c t t -
t r t
O f t h e f asc ia la a , in o t t w
h ic h it is in se rt e d h e n cu t h ro u gh t h e t t
t v t
f asc ia la a e r ically , alo n g t h e an e rio r bo rde r o f t h e ilio ibial t -
t
t rac do t w t
n t o t h e la e ral co n dy le o f t h e ibia u ll t h e dis al p ar t . P t t
o f t h e ilio t t t t
ibial rac la e rally , an d de m o n s ra e t h e la e ral in e r
-
t t t t
m u scu lar se p u m t w
h ic h p asse s f ro m its de e p su rface t o th e
t
la e ral su p rac o n dy lar ridg e o f t h e f e m u r N o w cle an a ay t h e . w
w h o le o f t h e f ascia lat a be e e n th e e n so r fasc ia la a an d t h e tw t t
t t t
ilio ibial rac o n t h e lat e ral side , an d t h e s art o riu s o n t h e
-

m e dial side Th e m u scle s h ic h ill h e n be bro u gh in o

. w w t t t
v wie t
are t h e re c u s f e m o ris alo n g t h e m iddle o f t h e f ro n o f t h e t
t w
h igh I t ill be re co g n ise d by t h e bip e n n a e arran g e m e n o f
. t t
its fi bre s Be e e n it an d t h e ilio
. tw
ibial rac are p ar s o f t h e -
t t t t
v tas u s la e ralis a n d t
as u s in e rm e diu s , t h e la e r be lo w t h e v t t tt
f o rm e r ; an d be t we e n it an d t h e sar o riu s in t h e dis al h ird o f t t t
t
t h e h igh t h e dis al p art o f t h e as u s m e dialis t
ill be se e n v t w .
 TH E TH I G H
A tan e p r im al t th k th r ct fe m ri n d
s h o rt dis c ox o e nee e e us o s e s
in a t d n wh i h i i
en rt d in t
o t h p r im al bo rd r f t h
c s n se e o e o x e o e

p at lla an d t h va t i n d in ap o n
e , ro t i e p a io n w h i h ar
s e eu c ex ns s c e
att h d t t h e b r d r o f th e p t lla
ac e o o e s a e .

P h th e p ro im al p art f t h art o ri s m dially p ll t h

us x o e s u e ,
u e
t n o r fas ia lat rally an d fi d it
e s c rv f pp ly f r m t h
e ,
n s ne e o su o e

V i m fl ili m p fi i li F i i b
. c rc u exa u su er c a s asc a c r ro se

V f m li e o ra s
S bi g i l l y m p h g l M g f l if m i
.

u n u na a ar o a c o r

p ig i p fi i li li
s

e A f m
as t r c a su er c a s e o ra s
P i lp i l
.

e c t ne a ff art o as c a at a
N o b i m
t u ra t o r us ra u s a n t e ri o r
i m p i
.

o bt u rat o r u s ra us o st e r o r

p f f i l 0 a rt o asc a ata
M f m i . re c t u s e o r s

n . i
b c e p s fe mo i
r s e t se m i ha n t e r m a j o r

Co ll m f m i
u e o rs

A c irc u mfl e x a fe mo i
rs me d a i li
l s o n M C a p su i l i
a art c u ar s
x i p i
. .

bd o N f m
u rat o r e t e rn u s l c u t an e u s e o rs o st e r o r

l d ibi l p )
.

N i hi di (p . sc a a cu s e ro n e a an t a art s

FI G . 1 1 3 .
—Di t i f sse c bli q t
o n ov S ti th gh
an o ue ra n s e rse ec o n ro u u pp e r p art o r

Th i gh h wi g t h s l t i f t h F i t th M l
o n e re a o n o e asc a o e u sc e s .

su p e rio r g lu t e al n e rve
I t e n e rs t h e de e p su rface o f t h e m u scle
. t
t v
a li t le abo e t h e m iddle o f it s le n gt h W h e n th e n e r e is se cu re d, . v
f o llo w it backw ards ill it disap p e ars be een t
t h e adj ace n tw t
t
an e rio r bo rde rs o f t h e glu t a u s m e diu s an d m in im u s at t h e
t
an e rio r m arg in o f t h e g re a e r ro c h an e r ; h e n cle ar a ay t h e t t t t w
t
se p u m o f de e p f as c ia w h ic h p as se s de e p t o t h e e n so r f as c ia t
t
t o ble n d m e dially w i h t h e e n do n o f t h e re c u s f e m o ris an d t t
t
la e rally wt
i h t h e f ro n o f t h e c ap su le o f t h e h ip j o in tAs t h e t .

t
de e p p art o f th e se p u m is re m o v e d, fi n d an d cle an t h e as ce n din g
t
bran c h o f t h e la e ral f e m o ral c ircu m fl ex art e ry , an d lo o k f o r
2 50 TH E I N F ER I O R EXTRE M I TY
t
t h e w ig w h ic h sp rin gs f ro m it an d p ie rce s t h e fi bro u s cap su le
'

o f t h e j o in ; t t
h e n cle an t h e s raig h h e ad o f t h e re c u s fe m o ris t t t
t
t o its o rig in f ro m t h e a n e rio r in f e rio r sp in e o f t h e iliu m , an d
f o llo w t t
t h e re fl e c e d e n do n ba c kw ards t o t h e u p p e r bo rde r o f
t h e a ce abu lu m t w
h e re it is e m be dde d in th e fi bro u s s ra u m o f t t
t h e c ap su le o f t h e h ip j o in N o e t h a t h e in e r al be t e e nt . t t t v w
t
t h e e n so r f ascia an d t h e sa rt o riu s is a p a h by h ic h t h e su rg e o n t w
t t
g e s e asy acce ss t o t h e f ro n o f t h e h ip j o in t i h o u e n dan g e rin g wt t
t
an y s ru ctu re s o f im p o rt an ce Cle an an d de fi n e t h e an t e rio r .

bo rde rs o f t h e glu t a u s m e diu s an d m in im u s Th e n e r e t o t h e . v

t e n so r f as c ia e m e rg e s be tw
e e n t h e clo se ly ap p o se d bo rde rs o f
t h e tw o m u scle s a n d in dic a e s t h e lin e o f se p ara io n No tt t .

u n c o mm o n ly t h e
a t
n e rio r bo rde r o f t h e m e diu s is ble n de d w i h t
th e de e p su rf a ce o f t h e e n so r f as c ia t
if h a is t h e c ase , se p ara e t t t
th e tw o m u s cle s w i h t h e s c alp e l t .

Tu rn n o w t o t h e m e dial side o f t h e m iddle h ird o f t h e h igh , t t

an d p u ll t h e s art o riu s lat e rally o s e rio r t o it h e re is an . P t t
t v
an g u lar in e r al bo u n de d la e rally by t h e as u s m e dialis an d t v t
t
m e dially by t h e addu c o r lo n gu s abo e an d t h e addu c o r m agn u s v t
be lo w t v
Th e in e r al is c ro sse d by a s ro n g lay e r o f f ascia w h ic h
. t
f o rm s t h e ro o f o f t h e adducto r cana l ( u n t e r s ; (F ig s 1 1 4 , H
’
.

On t h e f as cia lie s so m e lo o s e are o lar issu e in h ic h is e m be dde d !

w
t h e su bsart o rial p lexu s o f n e r e s v
Th e plexu s is n o t al ay s e as ily . w
t
de m o n s rable , bu t if t h e disse c o r is su cce ssfu l h e t
ill fi n d h a w t t
t
it is f o rm e d by in e rlacin g w ig s f o m t h e m e dial cu an e o u s, t r t
t h e sap h e n o u s, a n d t h e O b u ra o r n e r e s t t
Cle an t h e p lex u s an d v .

t
are o lar issu e a w ay an d cle an t h e f as cial ro o f o f t h e c an al It .

tt t
is a a c h e d la e rally t o t h e as u s m e dialis, an d m e dially t o t h e v t
t
addu c o rs m ag n u s an d lo n gu s I ts p ro x im al ex t re m i y f ade s . t
t
a w ay in de fi n i e ly at t h e ap ex o f t h e f e m o ral rian g le , bu t at it s t
t t t
dis al e n d it e rm in a e s in a s h arp c re sce n ic bo rde r w h ic h ex t e n ds t
v t
f ro m t h e as u s m e dialis t o t h e addu c o r m ag n u s, at t h e j u n c io n t t
o f t h e middle an d dis al t t
h irds o f t h e h igh Th e sap h e n o u s t .

v
n e r e a cco m p an ie d by t h e sap h e n o u s bran c h o f t h e art e ria g e n u
l
su p re m a w il be se e n e m e rg in g f ro m t h e c an al be h in d t h e dis al t
t
c re s ce n ic bo rde r o f t h e f asc ial ro o f To disp lay t h e co n e n s . t t
v
o f t h e c an al, di ide t h e f as c ial ro o f by a e rt ic al in c isio n ex t e n din g v
t
f ro m it s p ro x im al t o its dis al e n d, an d h e n cle an t h e c o n e n s, t t t
w t
h ich are t h e fe m o ral ar e ry , t h e f e m o ral e in , t h e sap h e n o u s v
v
n e r e , an d t h e n e r e t o t h e as v
s m e dialis v tu .

M . Sart o rius art o r iu s is a lo n g sle n d e r mu sc le

.
— Th e s ,

wh ich arise s fro m the a n t e rior su p e rio r sp in e o f the iliu m an d

t h e u p p e r p art o f th e n otch o n t h e a n t e rio r bord e r o f t h e bo n e
imm e d iat e ly be low t he Sp in e I t cr o sse s t h e fr o n t o f th e .

p r o x im a l th ird o f t h e th igh o bliqu e ly an d ga in in g t h e m e d ia l , ,

sid e o f t h e lim b it tak e s a n e ar ly stra ight c o ur se d ista lly to a

,

p o in t be yo n d t h e m e d ia l
p ro m in e n c e o f th e kn e e Th e r e it .

tur n s fo r ward s an d e n d s in a th in e x p a n d e d a p o n e uro t ic

, ,

t e n d o n wh ich is in se rt e d in to the me d ia l surfac e o f t he body

,

o f the t ibia p o st e r ior t o

,
t h e tu b e r o sity
( g
F i 1 3
9 p .
,
.

B y it s d ista l bo rd e r t h e t e n do n is co n n e ct e d w ith t h e fa sc ia
 THE I N F ER I OR EXTRE M I TY
in se rt io n Ofgrac ilis an d se mit e n din o su s bu t is se p arat e d
th e ,

fro m th e m by a bur sa Th e sartor iu s is su pp lie d by th e .

f e m o ra l n erve I t is a fl e x o r o f .t h e k n e e a n d a m e d ia l
r o tat o r o f t he le g a fl e x o r o f th e hip jo in t an d a lat e ral
,

rotator o f th e th igh .

C ana lis A dduct o ri u s H unt e ri ( O T H un t er s Cana l)

’
. . .

Wh e n t he fe m oral art e ry le av e s th e fe moral tr ia n gle it is c o n

t in u e d d ista lly in th e me d ia l r e g io n o f th e th igh in a d e e p
, ,

furrow wh ich is bou n d e d a n t e r ior ly by the va stu s m e d ialis

,

mu sc le an d p o st e r iorly by th e fa sc ia o n th e a n t e r io r sur fac e s o f

,

t he adductor lo n gu s an d m ag n u s m u sc le s wh ich is t h e m e d ia l ,

in t e r m u scu lar se p tu m o f th e th igh At it s p r o x ima l e n d th is .

furr o w is co n t in u o u s w ith t he d e e p e r w id e r an d m or e a pp ar e n t , ,

M v m di li M v . i m di a st u s e a s . ast us nte r e us

M . sa rt o r u s i
F e mo ra lv l
e sse s a n d

sap he n o u s n e rv e in
addu c t o r c an a l
( H u n t e r s)
'

M . a ddu c t o r o n l g us

Fm e ur

M . va t
s us l a t e ra li s

FIG . 1 1 5 .
— Tra n sve rse S e c t i o n t hro u gh the Addu c to r C an a l .

h o llo w wh ich has be e n d e scr ibe d as the fe mora l tria n gle

, .

F urth e r t h e furr o w is c o n v e rt e d in t o a ca n a l tr ia n gu lar o n

‘

, ,

tra n sv e r se se ct io n by a stro n g fi br o u s m e mbra n e wh ich stre tch e s

,

acr o ss it an d u p o n th e surfac e o f wh ich the sart o riu s m u sc le is

,

p lac e d ( g
F i T h e tu nn e
. l thu s f o r m e d is ca lle d t h e

addu cto r ca n a l The fi br o u s e x p a n sio n wh ich roo fs

in th e ca n a l str e tch e s fro m th e adductor lo n gu s an d th e
adductor mag n u s p o st e r io rly to the va stu s me d ia lis a n t e riorly .

Wh e n it is trac e d p ro x ima lly it is se e n to be co m e th in an d ,

ill de fin e d as it a p p roach e s t h e fe m ora l tr ia n g le ; wh e n trac e d

-

in t h e o p p o sit e d ir e ct io n h o w e v e r it be co m e s d e n se an d , ,

stro n g an d be lo w t h e o p e n in g in th e adductor m ag n u s
, ,
 TH E TH I GH 2
53

at t h e d ista l e n d o f th e ca n a l it p r e se n t s a th ick shar p ly

, ,

d e fi n e d m arg in I n it s d ista l p art t he p o st e rio r wa ll o f

.

t h e ca n a l wh e r e it is fo r m e d by t h e adduct o r m ag n u s
, ,

p r e s e n t s a d e fic ie n cy or a p e rtur e wh i ch le ad s backward s

in t o t he p o p lit e a l fo ssa Th e a p p e ara n c e an d c o n st ru c

.

t io n o f th is a p e rtur e w ill be stud ie d at a lat e r stage I t .

is ca lle d the hiatu s ten din eus or open ing in the addu cto r
magn u s .

The fe m ora l v e sse ls a p h e n ou s n e rv e trav e r se th e

an d the s

adduct o r ca n al Wh ilst the fe m ora l art e ry is in th e ca n a l it

.

g iv e s o ff so me m u scu lar tw igs an d t he art e r ia g e n u su p r e ma .

The f e mo ral v e sse ls le av e th e ca n a l at it s dista l e n d by in clin

ing p o st e rior ly through t h e O p e n in g in t h e adductor m ag n u s
an d e n t e r in g t h e p o p lit e a l fo ssa Th e sa p h e n ou s n e rv e
.
,

acco mp a n ie d by th e sa p h e n o u s bra n ch o f th e art e r ia g e n u

su p r e m a e sca p e fro m t h e ca n a l by p a ssin g u n d e r cov e r o f
,

th e d ista l th ick e n e d m argin o f th e fi brou s e x p a n sio n wh ich

for m s th e r o o f Th e y can be se e n in the p r e se n t stag e o f
.

t h e d isse ct io n in th at situat io n .

Art eria F emo ra li s ( O T F e mo ra l Art e ry Co mmo n an d

. .
,

Su p erfi cial) — B y th e d isse ct io n s wh ich hav e be e n m a d e th e

.

wh o le o f th e fe mo ra l art e ry has be e n e x p o se d an d it s c o urse ,

an d r e lat io n s m ay n o w be stud ie d I t is t h e d ir e ct c o n
.

t in u at io n o f t h e e x t e r n a l iliac art e ry an d is t h e gr e at art e r ia l

tru n k o f the infe r ior e x tre mity I t be g in s at the in gu in al.

liga m e n t be h in d wh ich it e n t e r s th e th igh an d it e x t e n d s

, , ,

d ista lly thr o ugh the p ro x ima l t wo th ird s o f th e th igh to th e

,
-

o p e n in g in t h e adduct o r m ag n u s through wh ich it p a sse s in to

,

t h e p o p lit e a l fo ssa an d be c o m e s th e p o p lit e a l art e ry The .

cour se o f th e fe mo ra l art e ry m ay be m arke d o n the surfac e ,

wh e n th e th igh is slight ly fl e x e d a bduct e d an d rotat e d lat e r

,

ally by a lin e draw n fr o m a p o in t situat e d midway be tw e en

,

th e a n t e r io r su p e r io r sp in e o f th e iliu m an d t he sy mp hy sis

p u bi s t o t h e adduct o r tu be rc le o n th e m e d ial c o n dy le o f t h e

fe mur .

Th e r e lat io n s wh ich the art e ry be ar s t o t h e fe m ur are im

p o rta n t .A S it e n t e r s t h e fe m ora l tria n gle it le av e s t h e brim o f

th e p e lv is an d lie s in fro n t o f t h e m e d ia l p art o f t h e h e ad o f

t h e fe m ur fro m wh ich it is se p arat e d by t h e p so a s m ajor
,

m u sc le . Alth o ugh it s r e lat io n to t h e h e ad o f th e fe m ur is fa ir ly

in t imat e that situat io n shou ld n o t be cho se n fo r a pp ly in g co m
,

p r e ss io n fo r o n accou n t o f t h e m o bility o f t h e h e ad o f t h e
, ,
2 54 THE I N F E RI O R EXTRE M I TY
bo ne, v e sse l is apt to slip fro m u n d e r th e fi n g e r s I t is much
th e .

sa fe r t o co mp r e ss it aga in st t he h ip bo n e D ista l to t he h e ad .

O f t he fe mur dur in g t he r e ma in d e r o f it s cour se through t h e

,

fe mora l tr ia n g le t h e art e ry is n o t in d ir e ct r e lat io n to t h e

,

bo n e . I t cr o sse s a n t e r ior to the a n gu lar in t e rva l be tw e e n

t h e n e ck an d body o f th e fe m ur Toward s t h e a p e x o f th e .

tria n g le how e v e r it co m e s in to r e lat io n w ith th e m e d ia l sid e

, ,

o f t h e body o f t he fe mur an d that p o sit io n it ho ld s to it s ,

t e r min at io n .

I n t he tr ia n g le t he p ro x im a l p art o f t he fe m ora l art e ry is

e n v e lo p e d by t h e fe m o ra l sh e ath an d is se p arat e d fro m t h e ,

sur fac e by t h e sk in su p e rfic ia l fa sc ia an d d e e p fa sc ia ; wh ilst

, ,

m or e d ista lly it is cr o sse d by th e me d ia l cuta n e o u s bra n ch

n t e r n a l cuta n e o u s o f t he fe m o ra l n e rv e wh ich ru n s
( O .T . i ) ,

a lo n g t he m e d ia l bord e r o f t he sart o r iu s m u sc le The e x t e n t .

o f t h e art e ry wh ich lie s in t h e fe m o ra l tr ia n g le var ie s w ith

t h e d e v e lo p m e n t o f t he sart o r iu s m u sc le bu t as a ru le it ,

me a sur e s fr o m to 1 0 c m At t he a p e x o f the tria n g le the .

arte ry e n t e r s t he adductor ca n a l .

I n th e adduct o r ca n a l th e art e ry lie s m o r e d e e p ly an d is ,

se p arat e d f r o m t h e sur fac e n o t o n ly by t h e Sk in su p e rfic ia l ,

f a sc ia an d d e e p fa sc ia bu t a lso by th e sartor iu s m u sc le t h e
, ,

su b— sartor ia l p le x u s o f n e rv e s an d t h e fa sc ia l ro o f o f th e ,

ca n a l and at the mid le n gth o f the ca n a l the sa p h e n ou s

, ,
-
,

n e rv e cr o sse s th e fro n t o f t h e art e ry fro m th e lat e ra l t o th e

m e d ia l sid e .

L at e ra l t o the art e ry in t he p ro x ima l p art o f t h e fe m ora l

,

tr ig o n e is th e fe m ora l n e rv e The two are n o t how e v e r in

,
.
, ,

c lo se c o n tact fo r the lat e ra l p art o f th e fe mora l sh e ath an d

,

th e p r o j e ct in g lat e ra l bo rd e r o f the p soa s m aj o r m u sc le

in t e rv e n e be tw e e n th e m I n the d ista l p art o f the tr ia n g le
.

t he m e d ia l cuta n e o u s n e rv e lie s lat e ra l t o t h e art e ry bu t it is ,

r e p lac e d in the p r o x ima l ha lf o f t he adductor ca n a l by the

, ,

sa p h e n o u s n e rv e an d be yo n d t he m idd le o f t h e addu ctor

’

'

ca n a l wh e re th e sa p h e n ou s n e rv e p a sse s to the fro n t o f t he

,

art e ry th e art e ry it se lf is in r e lat io n o n it s lat e ra l sid e w ith

, , ,

t h e va stu s m e d ia lis m u sc le .

I n t h e p ro x im a l p art o f th e fe m ora l tr ia n g le t he fe m ora l

v e in lie s m e d ia l to th e art e ry se p arat e d fro m it by t he lat e ra l ,

se p tu m o f t h e fe m o r al Sh e ath B e y o n d t he fe m o ra l sh e ath .

t h e v e in p a sse s be h in d t h e art e ry an d n o o th e r structur e

fo r ms a d ir e ct m e d ia l r e lat io n t ill th e d ista l p art o f t h e
2
5 6 THE I N F ER I OR EXTRE M I TY
V en a m
Fe o a
r li s — Th e fe m o ra l v e in is th e
. d ir e ct p ro x im a l
co n t in uat io n o f the p o p lit e a l v e in I t be gin s at th e o p e n in g
.

in th e adductor mag n u s thr o ugh wh ich it e n t e r s th e adduct o r

,

ca n al ; its p ro x im a l e n d p a sse s be h in d the in gu in a l liga m e n t

an d be co m e s co n t in uou s w ith the e x t e r n a l iliac v e in I t ac .

co mp a n ie s th e fe m ora l art e ry but th e r elat io n s o f th e two

,

v e sse ls to e ach o th e r d iffe r at d iffe r e n t stag e s o f th e ir c o ur se .

I n th e d ista l p art o f th e adduct o r ca n a l t h e v e in lie s p o st e r ior

to the art e ry an d o n its lat e ra l sid e bu t it in c lin e s m e d ia lly ,

as it a sc e n d s an d in th e p ro x im a l p art o f t h e th igh it lie s o n

,

th e m e d ia l sid e o f t h e art e ry an d o n t h e sa m e p la n e Th e .

cr o ssin g fro m o n e sid e to th e oth e r tak e s p lac e p o st e rio r t o the

art e ry an d is v e ry gradua l so that fo r a co n sid e ra ble d ista n c e
,

th e fe m ora l v e in lie s d ir e ct ly p o st e r io r to t h e fe m ora l art e ry .

Fo r a d ista n c e o f two in ch e s d ista l t o t h e in gu in a l liga m e n t

it is e n c lo se d w ith in th e fe m ora l Sh e ath o f wh ich it o ccu p ie s ,

th e in t e r m e d iat e co m p art m e n t .

As it a sc e n d s in the th igh th e fe m ora l v e in r e c e iv e s

tr ibutarie s wh ich fo r th e m o st p art corr e sp o n d w ith the
, ,

bra n ch e s o f the fe m ora l art e ry At t h e fo ssa ova lis it

.

is jo in e d by th e gr e at sa p h e n ou s v e in Th e d isse ct o r .

S hou ld Slit t h e fe m ora l v e in o e n w ith the sc issor s S v ra l

p e e .

va lv e s will th e n be se e n O n e is a lm o st in var ia bly fo u n d

.

imm e d iat e ly p r o x im a l to the e n tra n c e o f the v e in wh ich

corr e sp o n d s to the p ro fu n da art e ry .

N e rvu s F e mo ra lis ( O T An t e rio r Crural) — The fe m o ra l

. . .

n e rv e is a larg e n e rv e wh ich a r ise s w ith in th e a bdo m e n , ,

fr o m th e lu mbar p le x u s I t e n t e r s t h e th igh by p a ssin g

.

d ista lly in the in t e rval be tw e e n t he p soa s an d iliacu s mu sc le s ,

p o st e r ior to t h e in gu in a l liga m e n t an d th e fa sc ia iliaca I n .

t h e p ro x im a l p art o f th e th igh it lie s to th e lat e ra l sid e o f th e

fe mora l art e ry an d is se p arat e d fro m it by a sm a ll p ort io n o f
,

th e p soa s m aj o r m u sc le an d t he fe m ora l sh e ath ( F ig .

A sh o rt d ista n c e be low t h e in gu in a l liga me n t it d iv id e s in to

an a n t e r io r an d a p o st e r ior p o rt io n ; th e y at o n c e r e so lv e

th e mselv e s in to a larg e n u mbe r o f cuta n e ou s an d mu scu lar

bra n ch e s wh ich are n a m e d in th e fo llow in g list :
R ami m uscu lare s, To t he p e ctin e u s .

sarto riu s .

I n t e rm e diat e cu tan e o u s
An te rio r div isio n ,
n e rv e o f the th igh
R ami cu tan e i an te ri o re s,
.

l
M e dia c u tan e o u s n e rv e
o f th e th igh .
 TH E TH I G H 2
57

To the re c tu s fe m o ris .

v astu s m e dialis .

v ast u s lat e ra is l .

R ami mu scu l are s , v astu s i n t e r

P o ste rio r div isio n , m e diu s .

m a rt i c u la ri s
.

ge n u .

R am u s cu tan e u s , Saph e n o u s n e rv e .

R am i art icu lare s .

With the e x c e p t io n o f the sa p h e n ou s n e rv e wh ich is d istribut e d ,

u p o n t he m e d ia l Sid e o f the le g an d foot the d istr ibut io n o f the ,

cuta n e ou s bra n ch e s o f the fe m ora l n e rv e has be e n alr e ady

e x a min e d ( p .

Th e n erve to the p ectine u s arise s a Sh o rt d ista n c e d ista l to

t he in gu in a l liga m e n t an d tur n s m e d ia lly p o st e r ior to the ,

fe m ora l v e sse ls to r e ach it s d e st in at io n

,
Th e branches to the .

sarto riu s are t wo or thr ee in n u mbe r As a ru le th e y tak e .

,

o r ig in in co m m o n w ith t h e in t e r m e d iat e cuta n e o u s n e rv e .

Th e in termediate cu taneo u s ne rve ( O T middle cu tan eo u s) . .

so me t im e s p ie rc e s t h e p ro x im a l bo rd e r o f t h e sartor iu s .

I t d iv id e s in to two bra n ch e s wh ich p e r forat e the fa sc ia lata

a bo ut thr e e or four in ch e s d ista l t o t he in gu in a l liga me n t .

The medial cu tan eo us n erve ( O T in tern al cutan eo u s) in c lin e s

. .

d ista lly an d m e d ia lly cro sse s a n t e r ior to th e fe m ora l art e ry

,

at the ap e x o f the fe mora l tr ia n g le an d d iv id e s in to an ,

a n t e r io r an d a p o st e r ior p ort io n wh ich be c o me su p e rfic ia l at

, ,

d iffe re n t le v e ls o n the m e d ia l sid e o f the limb F ro m the

,
.

tru n k o f t h e n e rv e a fe w cuta n e ou s tw ig s are g iv e n to t h e

S k in ov e r t h e p r o x im a l an d m e d ia l p art s o f t h e th igh Th e .

a n ter i o r branch cro sse s t h e sar t o r iu s mu sc le an d m ak e s it s

a p p e ara n c e through th e fa sc ia lata in t he d istal p art o f the
th igh a sh o rt d ista n c e a n t e r ior to t he gr e at sa p h e n ou s v e in
, .

Th e po sterio r branch ru n s d ista lly a lo n g th e p o st e r ior bord e r ,

o f t h e sart o r iu s an d p ie rc es th e d e e p fa sc ia o n t he m e d ia l
,

Sid e o f t h e k n e e be h in d t h e sartor iu s an d t h e sa p h e n ou s
,

n e rv e .

A sh o rt distan ce distal t o t he m iddle o f the thi gh the po ste rio r bran c h o f

th e m e dial c u t an e o u s n e rv e fo rm s, w it h fi lam e n t s fro m the O bt u rat o r n e rv e
x
an d t h e saph e n o u s n e rv e , a p le ifo rm in t e rlac e m e n t , t h e s u b sa rt o ri alp lex u s, -

l
which is p ace d de e p to the sart o riu s m u sc e as it lie s o v e r t he addu cto r l
c an al The t wig fro m t he O btu rat o r n e rv e ap p e ars at t h e m e dia l
bo rde r o f th e addu c t o r lo n gu s .

The pheno us nerve ( O T intern al saphen o u s nerve) is

sa . . th e
lo n g e st bra n ch o f t h e fe m ora l n e rv e I t sp r in g s fro m . the
V OL . 1— 1 7
 2 58 TH E I N F E R I O R EXTRE M I TY

p o s t rior d iv isio n o f that n e rv e an d ru n s d ista lly at fir st o n the

e

lat e ra l sid e o f t h e fe m ora l art e ry I n t h e adductor ca n a l it

.

cro sse s in fro n t o f the fe m ora l art e ry I t e m e rg e s fr o m th e

.

d ista l e n d o f the ca n a l by p a ssin g u n d e r cov e r o f t h e th ick e n e d

bord e r o f t h e fi brou s e x p a n sio n wh ich str e tch e s be tw e e n th e
va stu s me d ia lis an d th e adduct o r m u sc le s an d acco mp a n ie d , ,

by t h e sa p h e n ou s bra n ch o f th e art e r ia g e n u su p r e m a it ,

e sca p e s fr o m u n d e r cov e r o f th e sartor iu s p a ssin g be tw e e n ,

it an d th e t e n do n o f t he gra c ilis Th e n it p ie rc e s the

.

d e e p fa sc 1a at t he me d ia l sid e o f th e k n e e Aft e r it qu it s .

th e adductor ca n a l it giv e s o ff t h e infrap atellar bran ch wh ich ,

p ie rc e s t he sart o r iu s an d a p p e ar s o n t he sur fac e o f th e fa sc ia

lata o n the m e d ia l Sid e o f t h e k n e e ( F ig .

Se v e ral larg e bra n ch e s o f th e p o st e r ior p art o f th e

fe m ora l n e rv e e n t e r th e four se g m e n t s wh ich co mp o se the
gr e at quadric e p s e x t e n so r m u sc le o f the th igh F ro m so me .

o f th e bra n ch e s art icu lar fi la m e n t s are g iv e n e ith e r t o the h i

, p
or to t he k n e e jo in t .

The branch to the rectu s f emo ris sin k s in to t h e d e e p sur fac e

o f that m u sc le I t su pp lie s an art icu lar tw ig to t h e h ip j o in t
. .

Th e larg e bran ch to the vastu s medialis acco m p a n ie s th e

sa p h e n ou s n e rv e an d e n t e r s t h e p ro x ima l p art o f th e adductor

ca n a l I t c an r e ad ily be d ist in gu ish e d be cau se it sin k s

.
,

in t o th e m e d ia l a sp e ct o f the va stu s m e d ia lis a bout th e ,

m idd le o f th e th igh I n th e su bsta n c e o f the m u sc le it

.

e x t e n d s d ista lly an d n e ar the k n e e jo in s the art icu lar bra n ch

,

o f t h e art e r ia g e n u su p r e m a I t g iv e s an art icu lar n e rv e

.

to the sy n ov ia l lay e r o f th e k n e e jo in t Th e n erve to the .

vastu s lateralis is a ssoc iat e d w ith t h e d e sc e n d in g bra n ch o f t h e

lat e ra l c ircu m fl e x art e ry V e ry fr e qu e n t ly it g iv e s an art icu lar

.

tw ig to the k n e e j o in t The nerv es to the vastu s intermedius

.

are two o r thr e e in n u m be r an d th e y sin k in to its a n t e r ior

,

sur fac e . Th e m o st m e d ia l o f th e m is a lo n g sle n d e r n e rv e ,

wh ich c an be trac e d d ista lly u n d e r th e a n t e r ior bord e r o f th e

,

va stu s me d ia lis to t he art icu lar m u sc le o f the k n e e I ts

,
.

t e r min a l tw igs are g iv e n t o th e sy n ov ia l stratu m o f th e

k n e e jo in t .

Thu s o n e fi la m e n t fro m the fe m ora l n e rv e g o e s to the

,

h ip jo in t ; two an d fr e qu e n t ly thr e e fi la m e n t s go to t h e
, ,

k n e e jo in t .

Tract u s I lio t ibialis o f t he F a sc ia L a t a ( O T I lio t ibia l

-
. .
-

B an d) —Th e th ick ba n d o f fa sc ia lata o n th e lat e ra l a sp e ct

.
 TH E I N F ER I OR EXTRE M I TY
cov e r in g t h e gluta u s m e d iu s . It t d s d ista lly w ith a
ex e n ,

slight in c lin at io n p o st e r io r ly ,
an d is in se rt e d in to t h e ilio .

tibial tract of the fascia lata .

Art eria Circu mfl ex a F e mo ris L a t e ralis ( O T Ext e rna l .

. .

Circumfl ex A rt e ry ) .
—The lat e ra l fe m o ra l c ircu m fl e x art e ry is
th e l arge st bra n ch wh ich S p r in g s f ro m t h e p ro fu n da fe mo r is

art e ry I t arise s n e ar the o r ig in o f th e latt e r

.
,
an d ru n s
lat e ra lly be tw e e n t h e d iv isio n s o f t h e fe mo ra l n e rv e
,
an d th e n

M . re c t u s fe mo rs i ( igh h
s t ra t e ad o f o r i gi )
n

M . re c t u s fe mo r s re i ( fl dh e cte e ad o f o r igi ) n
A t t ac h m e n t o t e f h
li g m
a ent M . adduc t o r o n l g us ( o ri g i n)
lis a bdo ii m n s i
(o r g
tus a bd m i i
o n s ( o ri

M . se n i i m M . g rac ili s ii
( o r g n)
bra n o su s (o
M . addu c t o r bre vi ( i g i
s o r

FIG . 1 1 x l
6 — E te rn a S u rface o f t h e P u b s an d I sc
. i hiu m , w t ih the At tach m e n ts
O f M u sc e s m ap p e d o u t l .

u n d e r c o v e r o f t h e sartoriu s to th e d e e p sur fac e o f th e r e ctu s

,

fe m or is m u sc le wh e r e it e n d s by d iv id in g in t o a sc e n d ing
, ,

tra n sv e r se an d d e sc e n d in g bra n ch e s
,
.

Th e ascending bran ch r e ach e s t h e e x t e r n a l sur fac e o f the

u pp e r p art o f the iliu m by a sc e n d in g a lo n g the in t e r
trocha n t e r ic lin e o f th e fe mur u n d e r cov e r o f t h e d ee p sur fac e
o f t he t e n sor fa sc ia lat a As it a sc e n d s it g iv e s a bra n ch to
.

th e hip jo in t tw ig s to t he adjac e n t m u sc le s an d its t e r min a l

, ,

tw ig s an a sto mo se w ith bra n ch e s o f t he su p e r ior g lut e a l art e ry

‘

.
 T H E TH I G H 2 6 1

Th e tran sverse bra n ch is o f sm a ll siz e I t p a sse s t o t h e d e e p .

sur fac e o f t h e va stu s lat e r alis, r e ach e s t h e o st e r io r art o f

p p
t he th igh , an d in o scu lat e s w ith t h e m e d ia l fe mo ra l c ircu m fl e x
art e ry an d t he fir st p e rforat in g art e ry Th e descending branch .

g iv e s t wig s t o the va stu s in t e r m e d iu s an d r e ctu s fe m o ris,

and o n e lo n g br an ch , wh ich m a
y be trac e d d ista lly, a m id
t h e fi br e s o f t h e va stu s lat e r alis, to t h e k n e e , wh e r e it
a na sto mo se s w ith at e ral su p e r io r g e n icu lar art e ry
the l
'

D is s e c ti o n — D iv id t h ili t ibial t ra t f t h f a ia lat a e e o -

c o e sc ,

di t al t t h t
s or fa ia lat a i
e e n so rd r t o bt ai a b tt r d m o n
sc ,
n o e o n e e e
st rat i n f t h lim its f t h lat ral i t rm
o o e c lar s p tu m a d a
o e e n e us u e n
b tt r v i w
e e f t h va t
e lat rali m s l
o e Tak e h ld f t h e
s us e s u c e . o o
di t al p art o f t h ili t ibial t ra t a d p ll it lat e rally at t h e
s e o -
c n u ,

am
s t im p h t h va t s lat rali m e dially t h n t h st r g
e e us e s u e s ,
e e o n
fi br lat ral i t rm
o us ec lar p tu m w ill b
n e n pa in g t o w ard
us u se e se e ss s
th e lin e a asp e ra o n t h e bac k o f t h e fe m u r .

I n t e rmuscular Th e r e are thr e e in t e r mu scu lar

Se p t a .
—

se p ta o f t h e th igh : lat e ra l m e d ia l an d p o st e r ior ( p , ,

.

Th e lat e ra l is stro n g t h e oth e r two are both w e ak , O n ly .

t he lat e ra l an d m e d ia l are to be e x a m in e d at p r e se n t .

The lateral in termu scu lar sep tu m is a fi brou s p art it io n

in t e r p o se d be tw e e n t he va stu s lat e ra lis an d in t e r me d iu s
a n t e r io r ly an d t h e p o plit e a l fo ssa an d the short h e ad o f th e
,

bic e p s fe m or is p o st e r io r ly I t sp r in g s fr o m t h e d e e p sur fac e

.

o f t he ilio t ibia l t ract an d it s d e e p bord e r is attach e d t o t h e

-

lat e ra l su p raco n dy lar r idg e an d to t h e lat e ra l lip o f t h e lin e a

a sp e ra o f t he fe mur P art s o f t he va stu s in t e rme d iu s an d
.

va stu s lat e ra lis ar ise fro m its a n t e r ior sur fac e an d so me o f the ,

fi br e s o f t h e Sh ort h e ad o f t he bic e p s fe m o ris sp rin g fro m its

p o s t e r io r s ur fac e I m m e d iat e ly p.r o x im a l to t h e lat e ra l
c o n dy le Of t he fe m ur it is p ie rc e d by the lateral sup erio r
n icu lar arter an d n erve The medial intermu scu lar tu m,
ge y se p
th in in co mp ar iso n w ith th e lat e ra l se p tu m sh o u ld
.

wh ich is ,

n o w be e x a min e d I t is in t e r p o se d be tw e e n t h e adductor s
.

an d t h e va stu s m e d ia lis I t s d ista l p art wh ich is m o st .

,

d ist in ct p a sse s lat e ra lly fr o m th e fa sc ia lata o n t he me d ia l

, ,

sid e o f t h e th igh be h in d t h e p o st e r io r bo rd e r o f t h e sartoriu s

,

an d be h in d t he sa p h e n ou s n e rv e to t h e m e d ial su p rac o n dy lar ,

r idg e an d it lie s in fro n t o f the d ista l p art o f th e adduct o r

,

m ag n u s I t s p r o x im a l p art is t h e th in lay e r o f fa sc ia o n t h e
.

a n t e rio r sur fac e s o f the adduct o r s m ag n u s an d lo n gu s wh ich ,

is co n t in u o u s a bo v e w ith t he p e ct in e a l fa sc ia .

M Q u a dric ep s F e mo ris — Th e quadr ic e p s fe m o r is mu sc le

.
2 62 TH E I N F ER I OR EXTRE M I TY
is co mp o se d o f four p ort io n s : the r e ctu s fe mor is, wh ich is
p lac e d in t h e
,
a n t e r ior p art o f t h e th igh ,
an d is qu it e

d ist in ct fro m th e oth e r s, e x c e p t at its in se rt io n ; t h e va stu s

lat e ra lis, the va stu s in t e r me d iu s, an d t h e va stu s m e d ia lis,
wh ich c loth e th e body o f the fe m ur o n its lat e ra l, a n t e rio r,
an d m e d ia l a sp e ct s, an d are m or e o r le ss ble n d e d with
e ach o th e r .

M Rect u s F emo ris — Th e

. re ctu s fe m oris m u sc le arise s by
t wo t e n d in o u s h e ad s o f or ig in wh ich w e r e e x p o se d wh e n ,

t h e d isse ct io n was
carrie d d e e p ly in
h in t e rva l b
Ob i t u ra t o r n t e rn u s
t e e '

P i if m r or is tw e e n the iliacu s
an d t e n sor o f t h e

fa sc ia lata ( p .

Th e a n t e r i o r or
straight head sp r in g s

fr o m t h e a n t e r io r
in fe rior sp in e o f t h e
iliu m ( F ig .

the po sterio r or
Ui p reflected head ar ise s g so as ,

u n d e r cov e r o f the
lu t a us m i n im u s fro m a
g ,

mark e d imp r e ssio n o n the

lat e ra l sur fac e o f th e iliu m ,

im m e d iat e ly a bov e t he u p p e r
p art o f t h e rim o f t h e
FIG 7 A t i A p t f P x im l ac e ta bu lu m ( F ig
. 1 1 .
-
n er o r s ec o
It ro a
f F m
.

P t o r io n W th Att hm t
o e ur i ac en s
1 8 co n n e ct e d bo th w th t h e
f M
o l m pp d t
u sc e s a e o u i
.

0
ca p sule o f the hi p jo i n t an d
th e d e e p la min a o f t he ilio t ibia l tract o f th e fa sc ia lata -
.

At th p t t g
e f di ti l y th t i p t f th fl t d
re se n s a e o sse c o n o n e an e r o r ar o e re ec e

h d i v i ibl ; th p t i p t w ill b
ea s s e wh th g l t l g i i
e o s er o r ar e se e n en e u ea re o n s
disse c te d .

two h e ad s o f or ig in o f the r e ctu s fe moris j o in at a

Th e
r ight a n gle imme d iat e ly be yo n d the marg in o f th e ac e ta bu lu m
, ,

an d for m a stro n g flatt e n e d t e n do n wh ic h g ive s p lac e to

, ,

a fu sifor m fl e shy be lly Th e t e n do n o f orig in sp r e ad s out o n

, .

t h e a n t e r io r sur fac e o f th e p ro x im a l p art o f th e m u sc le in t h e

for m o f an a p o n e uro sis Abo ut thr e e in ch e s p ro x im a l to th e .

k n e e j o in t the r e ctu s fe m oris e n d s in a str o n g t e n do n o f

2 64 T H E I N F ER I OR EXTRE M I TY
it s p ro x im a l p art t h e a n t e r ior bord e r , wh ich is fl e shy, is e ith e r
co n t iguou s t o or ble n d e d w ith the in t e r m e d iu s d ista lly, the
At t ach me n t o f u p p e r ban d o f ili fe mo ra
o -
l li g a me n t
bt u ra t o r n t e rn u s i an d e m e g lli
H e ad o f fe m u r

N e ck o f fe m u r
" G lu t a u s m i imn us

I n t e rt ro c ha n t e r c i
V as t u s l li
at e ra s

L e sse r t ro ch an t “
V a st u s me di li a s

At t ach me n t o f l o w e r ba n d o f/
/

ili o - fe m o ra l li g a me n t

"A i n t e r o r su rfa c e o f fe m u r

il
M e d a bo rde r o f fe m u r

‘
V as t u s i n t e rm e d u s i
V as t u s i nte r me d u s i

M . i l i g
a rt c u ar s e nu

Addu c t o r t u be rc l e

M ed ai l p i dyl d
La t e ra h e ad o f l g ast ro c n e m u s i
e co n
i bi l ll l li g m
e an
‘ L a t e ra l i
e p co n dy l e an d fibu la r
t a co a t e ra a e nt
co ll a t e ra llg i a me n t
P ll f
a te ar su r ac e P o p l i te us

FIG . 1 1 8 — . Di agra m o f th e F e m u r se e n fro m in fro nt .

a n t e rio r t e n d in ou s an d ov e rlap s the in t e r me d iu s

bord e r is ,

bu t it is n o t as a ru le fu se d w ith it
, ,
.

The va stu s me d ia lis ar ise s— ( I ) fro m th e lo we r p art o f t he

 TH E THI GH 2 65

in t e rtrocha n t e r ic lin e ; ( 2 ) fro m the lin e t d in g fro m the ex en

in t e rtr o cha n t e r ic lin e t o t h e lin e a a sp e ra ; 3) fro m t h e m e d ia l

lip o f t he lin e a a sp e ra ; ( 4 ) fro m t h e p ro x im a l p art o f t h e
'

m e d ia l su p rac o n dy lar lin e as far d ista lly as t he o p e n in g in t h e

adduc t or m ag n u s ( F ig s 1 1 8 5) fr o .m t h e rou n d
, e d
t e n do n o f the adduct o r m ag n u s Th e fl e shy fi br e s are .

d ir e ct e d d ista lly an d a n t e r iorly an d e n d in the c o mm o n ,

t e n d o n o f the quadric e p s m u sc le wh ich is in se rt e d in to th e ,

p at e lla an d b e co m e s c o n n e ct e d w ith t h e ca p su le o f the k n e e

j o in t Th e m u sc le is su pp lie d by th e femo ral n erve
. .

M V a st us I n t e rme dius ( O T C rureus) — Th e va stu s in t e r

. . . .

me diu s c o v e r s t h e a n t e r ior an d lat e ra l a sp e ct s o f t h e body .

o f t h e fe mur fro m both o f wh ich as w e ll as fro m th e d ista l

, ,

p art o f t h e l at e ra l in t e r m u s cu lar se p tu m it tak e s o r ig in It , .

is in se rt e d in to t he pat e lla through t h e m e d iu m O f t h e

c o mmo n t e n d o n I t is su pp lie d by t he femo ral nerve
. .

Co mm o n Te n do n o f t h e Q u a drice p s — I t shou ld n o w be .

n ot ic e d that t h e co m m o n t e n do n o f th e quadr ic e p s m u sc le

clo se s t he kn e e j o in t p r o x ima l to the p at e lla I t is in se rt e d in to .

th e p r o x ima l bo rd e r o f that bo n e an d is in t im at e ly c o n n e ct e d ,

w ith th e ca p su le o f th e k n e e jo in t So m e fi br e s are carrie d .

d ista lly acro ss th e sur fac e o f the p at e lla in t o the liga m e n tu m

, ,

p at e lla A
.
p ouch o f th e s y n ov ia l stratu m is p ro l o n g e d
p ro x im a lly be yo n d t h e le v e l o f t h e p at e ll a b e tw e e n t h e ,

quadr ic e p s an d the bo n e I n t o th e wa ll o f that p ouch the .

art icu lar mu sc le o f t h e k n e e is in se rt e d .

D is s e c ti o n — Th v a t i t rm di h ld b divid d i a
e s us n e e us s o u e e n
v rt i al dir t io n
e c a
ec t bri g t h litt l art i lar m
, so s o l i t n e e cu u sc e n o
vi w an d t t h
e ,
m t im t h l g
a e sa l d r e rv filam n t e e o n ,
S en e ne e- e
whi h r c al g th m dial b rd r f t h v a t i t rm di
u ns o n e e o e o e s us n e e us

m ay b t r d t th m
e a ce l a d tho y v ial t ratu m f th
e u sc e n e s no s o e
k n e j i t Th
e o n rt i
. l r m e l a i t f a f w lip
cu a f u sc e co n s s s o e s s o

m l fi br
u sc e w h i h p ri g fr m th l w r p art f th f r n t f
es c s n o e o e o e o o
th f m re e Th y r i
u . rt d i t
e tha e p p r p art f t h
n se y v ial
e n o e u e o e s no

s t rat m f th ap l f th k n j i t
u o e c su e o e ee o n .

Th e ligamen tu m patell e wh ich c o n n e ct s th e p at e lla w ith c ,

t h e tu be ro sity o f t he t ibia an d through wh ich t h e quadr i ,

c e p s is attach e d to that bo n e w ill be stud ie d in c o n n e ctio n ,

w ith the k n e e j o in t I t m ay be n ot e d n o w that it is a .

broad th ick t e n d o n wh ich e x t e n d s fro m t h e p at e lla to th e

, ,

tu be ro sity o f the t ibia .

The quadr ic e p s fe m o ris act in g as a wh o le is an e x t e n sor , ,

o f t h e k n e e bu t t h e r e ctu s fe m or is c an a lso fl e x th e h ip jo in t
,
.
2 66 T HE I N F E RI OR EXTRE M I TY

Th e art icu lar is g e n u m e r e ly lift s the u pp e r p art o f th e sy n ovial

stratu m o f t he ca p su le o f t h e k n e e to p r e v e n t it s be in g caught

be tw e e n t h e bo n e s as t he k n e e j o in t is e x t e n d e d .

M E D I AL SI D E O F TH E TH I G H .

The gro u p o f adductor m u sc le s o n the m e d ia l a sp e ct o f th e

th igh t o ge th e r w ith th e blo o d v e sse ls an d n e rv e s a ssoc iat e d
,
-

w ith th e m m u st n e x t be d isse ct e d
,
As th e d isse ct io n .

p r o c e e d s t he fo llo w in g structur e s w ill be d isp lay e d :

P ti ec neu s .

Addu c t o r lo n g u s .

Addu cto r bre v is

M u sc le s,
.

Addu cto r mag n u s .

G racilis .

O btu rato r e t e rn us x .

Art e ri e s,
P ro fu n da fe m o ris ( an d it s bran ch e s) .

O btu rato r .

The t w o div isio n s o f the o btu rato r n e rv e

N e rv e s ,
.

The acce sso ry o btu rato r n e rv e wh e n p re se n t , .

The adductor m u sc le s are d isp o se d in thr e e strata Th e .

a n terio r stratu m is for m e d by th e p e ct in e u s an d th e adductor

lo n gu s, wh ich lie in t he sa m e p la n e Th e ir adjac e n t bo rd e r s .

t o uch o n e a n oth e r p ro x ima lly , bu t d ista lly th e y are se p arat e d

by a sm a ll in t e rva l Th e seco n d stratu m is for m e d by th e
.

adductor bre v is an d th e third, o r po sterio r lay er, by t h e

adductor m ag n u s The graciliS mu scle , a lso an adduct o r,
.
\

e x t e n d s a lo n g th e m e d ia l a sp e ct o f th e th igh I t is a lo n g , .

stra p lik e
-
mu sc le , a pp lie d aga in st th e adductor br e vis an d
adductor magn u s I n t e rp o se d be tw e e n the thr e e mu scu lar
.

lay e r s are t h e t wo d iv isio n s o f th e o btu rato r n erve Th e .

a nterio r divisio n is p lac e d be tw e e n t h e a n t e r ior an d m idd le

lay e r s ; t h e p o sterio r divisio n lie s be tw e e n th e middle an d

p o st e r ior lay e r s I n.oth e r word s , t h e adduct o r b r e v is in t e r
v e n e s be tw e e n th e m At the d ista l bord e r o f the adductor
.

lo n gu s, a fi n e bra n ch fro m t h e a n t e r ior d ivisio n o f th e

n e rv e m ak e s its a pp e ara n c e ; it tak e s p art in t h e for m at io n

o f th e su b sartor ia l n e rv e
-

p le x u s a lr e ady d is se ct e d T h e .

p ro f u n da art e ry a n d it s b ra n ch e s a lso a re to b e f o llow e d .

Fo r a p art o f its course th is v e sse l is p lac e d be tw e e n the

a n t e rior an d midd le m u scu lar strata .

M A ddu ct o r L o ngus — Th e add uctor lo n gu s m u sc le is

.
 TH E I N F ER I OR EXT RE M I TY

( 4 ) Th et e r m in a l tw ig ca lle d t h e fourth p e r
,
forat in g art e ry ,

p i e rc e s t h e adductor m ag n u s in t h e m idd le th i rd o f t h e th igh .

The branches wh ich Sp rin g fro m th e p r o fu n da fe m o r is

are — th e two fe m ora l c ircu m fl e x art e r ie s th e fo ur p e r forat in g ,

art e rie s an d so me mu scu lar bra n ch e s

, .

The lateralfemo ral circu mflex a rt ery arise s fro m th e lat e ra l

a sp e ct o f th e p r o fu n da c lo se t o its or ig in I t has alr e ady
,
.

be e n fo llow e d to it s d istr ibut io n ( p Th e medial .

M . re c t u s fe mo r s i ( st ra i gh t h e ad o f o r ig i ) n

M . fe mo r s ( re
re c t u s i fl e ct e d h e ad o f i gi )
o r n

At ta c h me n t o f t h e li g
l l g ( igi )
.

iliO fe mo ra e - M . addu c t o r o n us o r n

p y m i d li
ra bd mi i
a s a o n s (o r g i i n

M . bd mi i
re c t u s a o n s (o r g ii n

M . se mi me m M . g rac ili s i i
( o r g n)
bra n o su s ( o ri g i n )
M . addu c t o r bre vi s (o r ig i n )

FI G 1 1 9
- x l
E te rna S u rfac e o f th e O s P u b s an d I sch i i um,

i l
. .

w th A tt ach m e n ts o f M u sc e s m ap pe d o u t .

femo ra l circu m flex wh ich tak e s orig in at the sa me

a rtery

v
le e l b u
,
t fro m t h e m e d ia l a n d p o s t e r ior a sp e ct o f t h e p ro

u
f n da w ill ,
b e s tud ie d wh e n t h e p e ct in e u s m u sc le is r e fl e ct e d .

Th e m e d ia l fe m o ra l c ircu m fl e x art e ry f r e qu e n t ly ar ise s fr o m

t h e fe m ora l tru n k Th e mu scu lar bran ches are irr e gu lar both
.

in o r ig in an d Siz e Th e y su pply the adductor m u sc le s an d giv e

. ,

tw igs which p ie rc e the adductor m ag n u s to r e ach the ham

str in g m u sc le s .

Art e ri a P e rf o ran t e s — T h e p e r forat in. g art e r ie s ar i se in

 M E D I A L SI D E O F T H E TH I G H 2 69

se r ie s fro m th e p r o fu n da fe mo ris an d p a ss backward s through ,

t h e adduct o r m u sc le s t o t h e p o st e r io r r e g io n o f t h e th igh .

Th e y may be r e cog n ise d fro m the c lo se r e latio n wh ich th e y

be ar to th e lin e a a sp e ra o f t he fe mur Th e first p erfo rating .

arter y c o m e s o ff at t h e le v e l o f t h e d ista l or m e d ia l bo rd e r o f
t h e p e ct in e u s I t p roc e e d s backward s thr o ugh t h e adductor
.

br e v is an d adduct o r M b x . o t u ra t o r e t e rn u s

mag n u s The seco nd

.

er o ra ting
p f a r t e ry

tak e s or ig in a short
d ista n c e d ista l to M “i P e o '
S O aS ‘

t h e fir st p e rf orat in g ,

o r p e rha p s by a
co m mo n tru n k with M
bre v
a ddu c t o r
is
it. I t p i e rc e s t h e
sa m e m u sc le s

"
v iz ,
.
,

the adduct o r br e v is d d I st , 2 n an
m
,

d m
an d a d d u c t o r 3g b h
! r

in ra n c es

m ag n u s Th e third
.

perfo rating a rt e ry
sp r in g s fro m t h e M
gfi g
dm “

p ro fu n da d ista
,
l to
th e adductor br e v is ,
4 t h p e rfo rat ig
n

an d p a sse s back F m l y e o ra art e r

bra

ward s through th e Op en n i gi n

adduct o r mag n u s .
addu c t o r m a g nu s

Th e f o u rth p erf o rat

ing artery , as be for e
n o t e d, is th e
t e rmin a l bra n ch o f
t h e p r
da o f u n

fe m o r is ; it p ie rc e s
th e adductor F e mo ra l art e r y
m ag n u s a lo n e FIG ,
. 12 0 .
— The P ro fu n da F e m o ris Art e ry an d it s
B ram he s
T h e s up e ri o r
'

n u trien t arter
y o f th e fe m ur m ay sp r in g fro m e ith e r th e se co n d
or t h e th ird p e r forat in g bra n ch An inferio r n u trien t artery .

is fr e qu e n t ly p r e se n t ; it is o ft e n d e r iv e d fro m th e fourth
pe rfo rat in g art e ry .

Wh e n the adductor m ag n u s is m ore fu lly e x p o se d it

w ill be se e n that the p e rforat in g art e rie s as th e y p ie rc e it s ,

t e n do n are p rot e ct e d by a se r ie s o f fi brou s arch e s Th e

, .
 TH E I N F ER I OR EXTRE M I TY
furth e r c o ur se o f t h e p e r forat in g art e rie s is d e a lt w ith o n

P 323 °

H e ad o f fe mu r

O bt u ra t o r e x t e rn u s
i ga me n t u m t e re s

G lu t a u s m e d i us

N e ck Of fe mu r

I i
n t e rt ro c ha n t e r c c re s t wL i n e
o f a t t ac h me n t o f l
a rt i cu ar c ap su e l
Q u adra tu s fe m o ri s
“
L e sse r t ro c h an t e r a n d ili o -
p so as

V l li
"
a st u s at e ra s

P i e c t ne u s
Glu ta u s m a xm '

i us

Addu c t o r ma g nus

V as t u s i n te r me d i us
Addu c t o r bre v i s

l
L a t e ra lip o f li n e a asp e ra " u c to r l g o n us

V a st u s m di li e a s

Sho rt h e ad o f b c e p s fe m o i i
rs

Addu c t o r m a g nu s

il
M e d a lip o f lin e a as p e ra
V as t u s l a te ra li s

V as t u s i n t e rm e d u s i

P o p li l te a su rfa ce "
Addu c t o r t u be rc l e
'

Pl an t a r s i '

il
M e d a h e ad o f g as t ro

l
L a t e ra he a d o f g as t ro c n e m u s i o lla t e ra l li g am e n t
L a t e ra l i
e p co n dy lr

Fi b l
u ar c o ll a te ra l li g m a e nt
ial c o nd yl e

L a t e ra l dyl
co n e a te li g am e n t

A n te r o i i
r c ru c a t e li g a me n t

FI G . 1 2 1 .
-
Di g a ra m o f th e F e mur se e n fro m be h i nd .

M P n u
. Th e p e ct in e u s m u sc le is p lac e d be tw e e n
e ct i e s — .

t h e adduc t o r lo n gu s an d th e ilio p soa s I t is flat an d so me -

.

what broad e r at it s o r igin fro m th e brim o f the pe lvis tha n

2 7 2 TH E I N F ER I OR EXTRE M I TY
o f the p ro fu n da fe m or is art e ry , at th e sa m e le v e l as th e lat e ra l
fe m o ra l c ircu m fl e x bra n ch I t p a sse s p o st e r ior ly be tw e e n t h e .

adj ac e n t marg in s o f the p soa s an d th e p e ct in e u s an d th e n ,

be tw e e n t h e adduct o r br e v is an d t h e o bturator e x t e r n u s, to
the p o st e r io r r e g io n o f t h e th igh wh e r e c lo se t o t h e le sse r , ,

trocha n t e r it d iv id e s in t o an a sc e n d in g an d a tra n sv e rse

,

t e r m in a l bra n ch B e for e the ma in tru n k d ivid e s it g ive s o ff

.

( )
1 a su p e r fi c ia l bra n ch wh ich p a sse s m e d ia lly acr o ss th e , ,

fr o n t o f t h e p e ct in e u s an d th e n be tw e e n th e adduct o r s lo n gu s
an d br e v is an d
( )
2 an art icu lar bra n ch wh ich e n t e r s t h e
,

h ip jo in t thr o ugh t h e ac e ta bu lar n otch Th e t e r m in a l .

bra n ch e s w ill be e x a m in e d in t he d isse ct io n o f th e g lut e a l

r e gio n .

Bran ch e sf t h e F e mo ral Art e ry — I n e v e ry re gio n o f the th igh the

o
disse c t o r has m e t w ith bran c h e s o f the fe m o ra art e ry I t is w e no w l . ll
l
t h at h e Sh o u d re v e rt t o t h is v e sse an d st u dy its bran ch e s in th e o rde r in l
wh ich th e y arise The fo llo w in g Tab e m ay aid him in do in g th is
. l
A a p u de n da e t e rn a
. x .

A e pig ast ric a su p e rficialis

. .

A c ircu m fl e x a i iu m su p e rficialis
. l .

c irc u m fl e x a fe m o ris lat e ra is l .

circ u m fl e x a fe m o ris m e dia is; l

A fe m o rali s p e r fo ran s
p rim a
A p ro fu n da
. . .

p e rfo ran s se cu n da Aa N u trit ia

. .

. . .

pe rfo ran s t e rtia .

p e rf o ran s q u art a ( t e rm in al) .

R am i M u sc u lare s .

A . g e nu su
p re m a .

M . A dduct o r B rev is hort adductor m u sc le lie s — Th e s

p o s t e r io r to t h e adductor lo n gu s an d t h e p e ct ine us I t .

ar ise s be lo w the o r ig in o f t he adduct o r lo n gu s fro m the

, ,

a n t e rio r a sp e ct o f t h e bo dy an d t he in fe r ior ra mu s o f t he
O S p u bis ( F ig As it d e sc e n d s it in c lin e s p o st e r io r ly
.

an d lat e ra lly ; an d it is in se rt e d p o st e r io r to t h e p e ct in e u s , ,

in to t h e gr e at e r p art o f t h e lin e wh ich e x t e n d s fr o m t h e

le sse r tr o cha n t e r t o t he lin e a a sp e ra ( F ig an d in to .

t h e p ro xim a l p art o f t h e lin e a a sp e ra lat e ra l t o t he adduc t or ,

lo n gu s I t is su p p lie d by th e o btu rato r nerve

. I t is an .

adduct o r an d a lat e ra l rotator o f th e th igh an d a fl e x o r o f -

t h e h ip jo in t .

D is s e c t i o n — D iv ide t h add t r br v i p arall l w it h a d e uc o e s, e n

lo
c t o it se rig i a d t r s o it t w a d it i n, rt i n b t do
n tu n o r s s n se o ,
u no

i j r t h a t ri r div i i
n u e e f th bt rat r
n e o rv w h i h lis o n o e o u o ne e c es

i n fr t f it o n Wh oth m s l i r fl t d t h p t e ri r
. en e u c e s e ec e e o s o

di i i f th
v s o n bt rat r n rv
o w ill b e o p d u Tra th o e e e ex o se . ce e

n e rv e p r i m ,all y t t
o xh p in t w h r it p ie r
,
t h o b t rat r e o e e ce s e O u o
 M E D I AL SI D E O F TH E TH I G H
ext e rn u s at th e o btu rato r fo ram e n ,
an d, dis t ally ,
t o its disapp e ar
an ce in th e addu c t o r m agn u s .

N e rv us O bt ura t o riu s — The o bturat o r n e rv e is a bra n ch

o f th e lu mbar p le x u s . It e sca p e s fro m t h e p e lv is by p a ssin g ,

M p so as
.

E x t e rn al ili v ac e sse s l
F e m o ra l v
ne r e (O T . . i
an t e r o r c ru ra )

M re c
.

C ap su l e o f hi p j o m t , g ro o ved

M pe c t. i ne u s

M o bt u rat o r
x
.

e t e rn u s

M ili o -
p so a M adduc t o r
vi
. .

bre s

M pe ct . i ne us

P ro fu n da fe mo r i
M grac
. ili s

M vast us la t
Fm l l
.

e o ra v e sse s an d
sa p he n o u s n e r e v
M v ast us i nte r

i
.

me d u s

M
M . sart o r u s i
. re c tu s fe mo ri s

FI G . 1 2 3 .
-
Di i
sse c t o n o f the F ro n t o f th e T h i gh . Th e h ip j i
o nt h as be e n
e xp o se d by re m o v i ng i
p o rt o n s o f t he m u sc l wh i h li
es c e a n te r o i r to it .

with its co mp a n io n v e sse ls through the u pp e r p art o f the ,

o bturator fora me n o f th e hip bo n e ( F ig Wh ile st ill .

w ith in th e fora me n it d ivid e s in to an a n t e rior an d a

p o st e r ior d iv isio n .

V OL . 1— 18
 TH E I N F E R I OR EXTRE M I TY
Th e anterio r rv e e n t e r s the th igh
divisio n o f th e o bturator ne

ov e r the u p p e r bord e r o f the o bturator e x t e r n u s mu sc le an d ,

p r o c e e d s d is ta lly u p o n t he a n t e rior sur fac e o f th e adduct o r

, ,

br e v is An t e r ior to it are th e p e ct in e u s an d adductor lo n gu s

.

m u sc le s I t g iv e s bra n ch e s to thr e e m u sc le s viz th e adductor

.
,
.
,

lo n gu s th e adductor br e v is an d th e grac ilis

,
V e ry rar e ly ,
.

A B . . Addu c to r bre v s i . O bt u rat o r in

Acc . y
Acc e sso r o bt u rat o r P tiec n e u s.

ne r e v .

A L . . Addu c to r l g o n us .

A M . . Addu c t o r ma g nu s .

G G a ili . r c s .

G Ma Gl t
. . u aeu s ma xi m u s.

I C . . M ed a il i c rcu m fl x e

art e r y o f t he th i gh .

O bt . O bt u rat o r n e rv e .

O E . . O bt u rat o r e x t e rn u s .

FI G . 1 2 4 .
— Di g m t ill t
a ra o us rat e t h e i i
d str bu t i o n o f the Obtu rat o r N e rve an d
th e ge n e ra l di p it i f ths o s o n o e Addu cto r M usc l es i
o f t he Th gh ( P ate rso n
) .

it u pp lie s a tw ig to the p e ct in e u s I n add itio n to th e se

s .

bra n ch e s it a lso su pplie s an articu lar brane}; to t he h ip

jo in t ( F ig 1 2 4 ( )
2 a fi n e tw ig
. w h ich a pp e ar s
. at t h e ,

d ista l bord e r o f the adductor lo n gu s to j o in th e su b sartoria l ,

-

p le x u s ; an d 3
( ) a termin al twig wh ich go e s to th e fe m ora l ,

art e ry — ( F ig 1 2 4 ) — an d bre ak s u p in to fin e fi la me n t s u p o n
.

its wa lls .
2 7 6 TH E I N F ER I OR EXTRE M I TY
t e n do n wh ich in clin e s fo rward s d ista l to the k n e e an d th e n , ,

e x p a n d s an d is in se rt e d in t o t h e p ro x im a l art o f t h e m e d ia l
p
sur fac e o f t h e t ibia u n d e r cov e r o f t h e t e n do n o f t h e sartor iu s
, ,

an d at a h igh e r le v e l tha n the in se rt io n o f th e se mi

t e n din o su s ( F ig 1 3 9 p .
, A muc o u s bur sa se p arat e s the
.

e x p a n d e d t e n do n o f t h e grac ilis fro m t h e t ibia l co llat e ra l liga

me n t o f the k n e e jo in t an d is p ro lo n g e d p ro xim a lly so as to

, ,

in t e rv e n e be tw e e n it an d th e t e n do n o f t h e sartor iu s The .

grac ilis is su pp lie d by th eanterio r divisio n o f the o otn rato r n erve .

I t adduct s t h e th igh fl e x e s th e k n e e j o in t an d rotat e s th e

,

le g m e d ia lly .

M A ddu ct o r M a gn us — Th e adductor m ag n u s is o n e o f
. .

t he m o st p ow e r fu l m u sc le s o f th e th igh I t for m s a flat fl e shy

.
,

m a ss wh ich sp r in g s fro m the a n t e r ior surfac e o f th e e n t ir e le n gth

,

o f t he p u bic arch o f t he corr e sp o n d in g sid e an d fro m t h e lo w e r ,

p art o f t h e is ch i a l tu b e ro si ty ( F i g s 1 2 8 . T h e ,
fi b r e s

wh ich ar ise fro m the p u bic arch sp re ad out as th e y a pp r o ach the

p o st e r ior a sp e ct o f t h e fe m ur ; t h e m or e m e d ia l in or ig in a re

t he m or e hor iz o n ta l in d ir e ct io n ; th e m or e lat e ra l in or ig in
are t h e m or e o bliqu e in d ir e ct io n Th e y are in se rt e d into the
.

p o s t e r i or p art o f t h e fe m ur j u s t m e d i a l to t h
,
e g lut e a l tu b e ro si ty ,

in to th e lin e a a sp e ra an d in to a sm a ll p ort io n o f th e p ro xim a l

,

p art o f t h e m e d i a l s u p raco n dy lar r idg e

( F i g s 1 2 1 T h e
.
,

fi br e s wh ich tak e o rigin fro m th e isch ia l tu be ro sity d e sc e n d

.

a lmo st v e rt ica lly an d for m the th ick m e d ia l bord e r o f the

m u sc le . I n t he d ista l th ird o f th e th igh th e y e n d in a stro n g ,

rou n d e d t e n do n wh ich is in se r te d in to the adductor tu be rc le

,

o n t h e m e d ia l co n dy le o f t h e fe m ur ( F ig s 1 2 0 Th is
.
,

t e n do n is furth e r attach e d to the fe mur by the me d ia l in t e r

m u scu lar se p tu m wh ich str e tch e s be tw e e n it an d th e m e d ia l
su p raco n dy lar lin e C lo se to th e lin e a a sp e ra are t h e
.

fi brou s arch e s for m e d in co n n e ct io n w ith the in se rt io n o f the

,

adductor mag n u s fo r the p a ssag e o f the p e r forat in g art e rie s

, ,

an d in se r ie s w ith th e m is th e o p e n in g through wh ich

t he fe mora l art e ry e n t e rs th e p o p lit e a l fo ssa The O p e n in g .

is a gap be tw e e n two p ort io n s o f t h e mu sc le an d is situat e d ,

at the ju n ct io n o f th e p ro x ima l two th ird s w ith th e d ista l -

th ird o f the th igh ( F ig .

Th e adductor m ag n u s h as a dou ble n e rv e supp ly The .

fi br e s wh ich sp rin g fro m the p u bic arch are su p plie d by th e

p o s t e r i or b ra n ch o f t h e o otn rato r n erv e Tho se wh ich ar ise
.

fro m th e isch ia l tu be ro sity are su p plie d by the so iatie n erve

'

.
 M E D I A L SI D E O F T H E THI GH 2 77

Th e fi br e s wh ich sp r in g fro m t he ra m i o f t h e p u bis an d

isch iu m act lik e t he fi br e s o f t h e o th e r adduct o r m u sc le s that ,

is th e y adduct th e th igh r o tat e it lat e ra lly an d h e lp t o fl e x

, , ,

t he h ip j o in t bu t t he fi br e s wh ich ar ise fr o m t he tu be ro sity o f

,

t he isch iu m an d are in se rt e d by t e n d o n in t o t h e adduct o r , ,

tu be rc le o f the fe mur e x t e n d t he h ip j o in t .

D is s e c t i o n — D t a h t h add t r m ag
. ef r m it
c ig i e uc o nus o s o r n
f r m t h p bi a d is h ial ram i i
o e u c rd r t h t t h
n bt rat r
c ,
n o e a e o u o

t r
ex e nu s m l a d t h o bt rat o r art ry m ay b m r f lly
u sc e n e u e e o e u

e x am in e d .

M . O bt ura t o r Ext ern us .

-
Th e o bturator t r u s is ex e n

a flat fan Shap e d m u sc le wh ich is

,
-

, p lac e d ov e r t h e a n t e r ior

a sp e ct o f the o bturator fo ra me n o f t h e hip bo n e I t .

Sp r in g s fro m t h e m e d ia l ha lf o f t h e m e m bra n e wh ich c lo se s

t h e fora m e n an d a lso fr o m t h e m e d ia l an d low e r p art o f it s

,

bo n y m arg in ( F ig s 1 1 9 I t p a sse s back ward s an d

.
,

lat e ra lly be lo w an d be h in d t h e n e ck o f t he fe m ur an d t h e
,

ca p su le o f t he h ip jo in t an d e n d s in a st o ut t e n d o n wh ich
,

o bta in s in se rt io n in to t he tr o cha n t e r ic fo ssa g

( F i s 1 2 1 .
,

Th is t e n d o n w ill be e x a min e d in th e d isse ct io n o f the g lut e a l

r e g io n The o bturator e x t e r n u s is su pp li e d by t h e po sterio r
.

divisio n o f the o btu rato r nerv e I t is a fl e x o r o f t h e h ip j o in t .

an d a n adduct o r an d lat e ra l rotator o f t h e th igh .

Art O bt ura t o ri a — Th e o bturat o r art e ry a pp e ar s in t h e

. .

th igh thr o ugh t he u pp e r p art o f t h e o bturat o r fora m e n o f

t h e h ip bo n e I t at o n c e d iv id e s in to t wo t e r min a l bra n ch e s
.
,

wh ich d ive rge fro m e ach o th e r an d fo r m an art e r ia l c irc le

up o n t he o bturator m e m bra n e u n d e r cov e r o f th e o bturat o r ,

e x te rn us Th e m u sc le m u st th e r e fo r e be d e tach e d in o rd e r
.

that t he v e sse ls may be fo llow e d B oth bra n ch e s g iv e tw ig s .

to t he n e igh bo ur in g m u sc le s wh ilst th e po sterio r brane/z ,

se n d s an articu lar tw through h ac ta b u lar n otch in t o

ig t e e

t h e h ip j o in t Wh e n the j o in t is o p e n e d th is tw ig may be
.

fo llo w e d in a w e ll—inj e ct e d su bj e ct a lo n g t h e liga m e n tu m

, ,

t e r e s in to t he h e ad o f t he fe mur .

M m P so as M aj o r an d I li acu s
. B o th t h e p so a s m ajor an d .
—

t h e iliacu s m u sc le s ar ise w ith in t h e a bdo m e n an d th e y e n t e r ,

t h e th igh p o st e rior to t h e in gu in a l liga m e n t A te n do n .

a pp e ar s o n t he lat e ra l sid e o f th e p soa s m aj o r an d in to th is ,

th e fi br e s o f t h e iliacu s are fo r t h e m o st p art in se rt e d Th e .

c o nj o in e d t e n do n o f th e ilio p soa s is imp la n t e d in to t he le sse r -

trocha n t e r o f t he fe m ur bu t a c e r t a in p r o p o rt io n o f t he fl e shy
,

1— 18 a
2 7 8 TH E I N F ER I O R EXTRE M I TY
fi br e s o f t he iliacu s
o bta in d ir e ct in se rt io n in to th e bo dy o f
t h e fe m ur d ista l t o that p r o min e n c e ( F ig s 1 2 1
, .
,

Th e act io n o f t he p soa s m aj o r an d t he iliacu s d e p e n d

up o n t h e p o sit io n o f th e hip j o in t wh e n the m u sc le s are in
act io n I f the h ip j o in t is e xte n d e d th e y fl e x it an d rotat e
.
,

it m e d ia lly u n t il it is fl e x e d th e n th e y rotat e it lat e ra lly .

D is s e c t io n — D iv id t h f m ral v l an d t h f m o ral
. e e e o e sse s e e
n rv e ab
e t an i c h di t al t t h i g in al ligam t a d h avin g
, o u n s o e n u en ,
n
t i d t h m t g t h r w it h tw i t h ro w t h m di t ally N w t
e e o e e ne e s . o cu
t h r gh t h art ri an d t h re tu s f m ri abo t tw o in h
o u e s o us e c e o s, u c es
f r m t h e ir o rig i
o a d t rn t h m a id Th t n d o f th
n s, n u e s e . e e o n e
ili p o a m st
o -
xt b
s d t a h d f ro m it i s rt i n an d w it h
s u ne e e c e s n e o ,

the m l t r d u p w ards Th is w ill p

u sc e , u t h e a t ri r
ne . ex o se n e o
rf ac
su o f th ap l f t h h ip j in t
e An i t rv e i g m c s
e c su e o e o . n e n n u o u
b r a alu s w ill b di p lay d Op t h i a d as rt ain its t t
so e s e . en s n ce ex en
by i t r d ci g t h n fi g r I t f a ilit at t h p lay o f t h ili
o u n e n e . c es e e o

p oa s p th fr t f th h ip j i t a d i m a it cavit y
s u o n e o n o e o n ,
n n so e c se s s
w ill b f d t b dire ct ly e ti
o un w it h t h avity f t h
o e co n nu o u s e c o e
j in t t h r gh an ap rt r i t h ap l
o , o u Th i t im at n e u e n e c su e . e n e co
t io
nec w h i h i t be tw n t h ap l o f th h ip j i t an d
n c ex s s ee e c su e e o n
th t d n
e f t h e g lu t a
en m i im s t h r fl t d h ad f t h
o o eu s n u ,
e e ec e e o e
r t f m o ri a d th d p lay r f th ili t ibial t ra t h u ld
ec us e s, n e ee e o e o -
c ,
s o
b n ti de L t ly t r
o a id
ce th t n r f ia lat a an d
. as ,
u n s e e e so as c e ,

c ar f lly l a t h a t ri r a p t f t h cap s l
e u c e n f t h h ip j i t
e n e o s ec o e u e o e o n .

At th e e n d o f t he fi fth day t he d isse ct o r m u st p a in t t h e

var io u s p art s o f th e a n t e r ior an d me d ia l r e gio n s o f t h e th igh
w ith p re se rvat ive so lut io n , re p lac e th e m in p o sitio n an d fix
t he Sk in fla p s o v e r th e m w ith a fe w p o in t s o f sutur e .

O n th e morn in g o f the Six th day, a ft e r th e d isse ct io n o f

'

t he lo w e r limb h as be e n be gu n , the su bj e ct is plac e d u p o n

t he ta ble w ith it s fac e dow n ward s an d it s th o ra x an d p e lv is
su p p ort e d by block s I n th at p o sit io n it is a llow e d t o .

re ma in fo r fi ve day s, an d dur in g that t im e th e d isse ctor

o f t he lo w e r e x tr e m ity has a v e ry e x t e n siv e d isse ct io n to
p e r fo r m H e h a s. t o d isse ct t h e g lut e a l r e g io n
( 2 ) the

p po lit e a l fo ssa an d (3) t he p o st e r ior r e g io n o f t h e th igh .

W ith So m uch work be fo r e him, an d be in g lim it e d as to th e

t ime in wh ich it m u st be d o n e , it is n e c e ssary that h e shou ld
a p p ort io n the fi v e day s at his d isp o sa l so as to c o mp le t e th e
d isse ct io n be fo re the bo dy is tur n e d aga in The first two .

day s h e Shou ld d e v o t e t o t h e study o f t h e g lut e a l r e g io n t h e

t/zira an d f o u rt/z day s m ay be g iv e n to t h e p o p lit e a l fo ssa
'

an d o n t h e fif tlz day h e Sh o u ld u n d e rtak e t h e d isse ct io n o f

t h e back o f t h e th igh , an d r e v ise t h e work o f t h e p r e c e d in g

four day s .
2 80 TH E I N F ER I OR EXTR E M I TY
s acru m an d it corr e sp o n d s w ith the middle o f th e sacr o
,

iliac art icu lat io n Th e p ro min e n c e o f th e n at e s is fo r m e d

.

ch ie fly by th e g lut ae u s m a ximu s mu sc le cov e r e d by a th ick ,

lay e r o f fat A d e e p tra n sv e r se gr o ov e p roduc e d by a fo ld o f

.
,

S k in an d fa sc ia lim it s t h e g lut e a l e le vat io n be lo w

, The groov e .

is ca lle d t h e glu tea l su lcu s an d is so m e t im e s sa id t o c o rr e sp o n d

,

w ith t he d ista l bord e r o f the glut ae u s m a x imu s m u sc le I t c an .

e a sily be sh o w n that th is is n o t t h e ca se I t s m e d ia l e n d lie s .

d ista l to th e in fe r ior m arg in o f th e m u sc le bu t as t h e su lcu s ,

p r o c e e d s tra n sv e r se ly it cro sse s t h e bord e r o f t h e m u sc le an d ,

fi n a lly co m e s to lie o n the sur fac e o f the mu sc le I n d ise a se .

o f th e h ip j o in t t h e buttock lo se s it s p r o m in e n c e wh ilst
, ,

t h e g lut e a l su lcu s be co m e s fa in t The tu be ro sity o f th e .

isch iu m may be fe lt d e e p to t h e lo w e r bo rd e r o f t h e g lut ae u s

,

m a x imu s if th e fi n g e r s are p lac e d in th e me d ia l p art o f t h e

,

g lut e a l su lcu s an d p r e sse d u p ward s A lin e draw n fro m t h e .

m o st p ro m in e n t p art o f th is tu be ro sity to the a n t e r ior su p e r ior

Sp in e o f t h e iliu m is ca lle d N elato n s lin e ; it p a sse s ov e r
’

t h e t o p o f th e gr e at e r trocha n t e r an d cro sse s th e c e n tr e o f

th e ac e ta bu lu m ; an d it is u se d by th e surg e o n in th e d iag n o sis
o f d islocat io n s an d oth e r in jur ie s o f th e h ip jo in t The gr e at e r .

trocha n t e r o f the fe mur m ay be fe lt at a p o in t about six in ch e s

be low the h igh e st p art o f t h e cr e st o f th e iliu m I t c an be .

se e n in th in s u bj e ct s bu t it do e s n o t for m so p roj e ct in g a
,

fe atur e o f th is r e g io n as m ight be e x p e ct e d fro m an in

Sp e c t io n o f t h e sk e le t o n be cau se th e th ick t e n do n o f t he
,

g lut ae u s me d iu s is in se rt e d in to its lat e ra l surfac e an d it is ,

cov e r e d a lso by t he a p o n e uro t ic in se rt io n o f the glut ae u s

m a x imu s .

i
D s s e c t io n — R e fl e ct i o n o f S k in — I ncisi o ns F ro m t h e
. .

t
p o s e rio r su p e rio r sp in e o f t h e iliu m in a cu r e d dire c io n alo n g v t
t
t h e c re s o f t h e iliu m , as f ar f o r ards as t h e p o si io n o f t h e bo dy w t
w t
ill p e rm i ; ( 2 ) f ro m t h e p o s e rio r e xt re m i y o f h is cu r e d t t t v
in cisio n o bliq u e ly do w n w ards an d m e dially t o t h e m iddle lin e
t
o f t h e s acral re g io n , an d h e n p e rp e n dicu larly t o t h e t ip o f t h e
co ccyx ; (3 ) f ro m t h e t ip o f t h e co c c yx o bl iq u e ly dis a lly a n d t
t v t
la e rally o e r t h e back o f t h e h igh , t o t h e j u n c io n o f t h e p ro x im al t
t v
a n d dis al h al e s o f t h e p o s e rio r bo rde r o f t h e la e ral are a o f t t
t h e h igh t .

A larg e fl ap o f sk in is h u s m ark e d o u t , an d t h is m u s be t t
raise d f ro m t h e su bj ace n su p e rfi c ial f as cia an d h ro t n la e rally t w t .

t
On t h e righ S ide o f t h e bo dy t h e disse c o r be g in s at t h e c re s o f t t
th e iliu m an d o rk s do wn w ards an d fo rw ards w w h ils o n t h e le f t t
v
side h e c o mm e n c e s o e r t h e c o c c yx an d w o rk s u p w ards an d
f o rwards .
 G L UTEA L RE G I O N
Sup e rfi cial F ascia ( Panniculus Adip o sus) .
—Af e t r th e s k in

Supe r o i r n uc ha l li ne

M ast o i d p ro c e ss
x t e rn al o cc ipi l p ta ro t u be ra n c e

Sp i ne o f l
sc a p u a
in e o f se v
e n th C e rv ic al v e rt e bra

Acro m i o n

I i
n fe r o r a n gl e o f s ca p u a l

Med a il i
e p c o n d le
y
Ol e c ra n o n

ea d o f rad u s i
P i
o s t e r o r su p e r o r i
Sp i n e o f l
i iu m

Tip f yx yl
h
o c o cc St o id p ro c e ss O f u na

G re a t e r t ro c han t e r Sty 10 1d p ro ce ss 0 f ra 1u s

Tu be ro s i y f i hi
t o sc u m

Med a il c o nd yl
f fe mu r e o
l
L a t e ra co n dy l
e o f fe m u r

l
L at e ra co n dy le o f t b a '
i i
H e ad o f fibu a l

e dial ma e o ll l us
ra l m a ll l
eo us

FIG . 1 2 6 .
— Su rface v i ew sho w i n g
, i ii
n c s o n s an d bo n y po i nts .

18 re fl e ct e d the s u p e rfic ia l fa sc ia wh ich is e xp o se d ,

is se e n to
2 82 T H E I N F ER I OR EXTRE M I TY

p artak e o f th e s a me charact e rs
corr e sp o n d in g lay e r o f as t h e

fa sc ia in oth e r p art s o f
L mb u ar n e rve
th e bo dy I t p r e se n t s .
,

C b
u t an e o u s h ran c how e v e r c e rta in Sp e c ia l
es ,
f h
o t eh h 12 i
t t o rac c
cu l iar i t i I i m uch
d ili h y p g i
an o -
o a st r c p e e s t s .

v ne r e s
m or e h e av ily lad e n w ith
S l v ac ra ner es
fat m or e p art icu larly so —

P f i g e r o ra t n in th e fe ma le ; it th ick e n s
B h f m
ra n c
c u t an e o u s
es ro
ov e r the u pp e r an d low e r
p i
o ste r o r c u t a ne o u s
marg in s o f th e g lut ae u s
v f h h i gh
ne r e o t e t
L l
at e ra c u t an e o u s m a x imu s an d it be co me s
v f h hi g h
ne r e o t e t
,

tough an d str in gy ov e r
L gp i l
t h e is c h i a l t u be r o s i t y
o n er n ea
,

P i
o s t e r o r c u t an e o u s wh e re it fo r m s a m o st
n e rv e of h h igh t e t

M di l e a c u t an e o u s e ffi c ie n t cu sh io n u p o n
f h hi g h
n e rv e o t e t
wh ich th is bo n y p ro min
L l a t e ra
e n c e r e st s wh ile t h e body
c u t an e o u s

f h
n e rv e o h gh t e t l

is in th e sitt in g p o stur e .

N erv i Cut an e i ( F ig
M di l
.

v f h hi g h
ne r e o
e a c u tan e o u s
t e t
—Th e c u t a n e o u s

n e rv e s of th e glut e al
A m i p
n ast o lo t c
r e g
e ro n e a
i o n a r e n umerous .

v So me o f th e m are d ifficu lt
ne r e

P i v
o st e r o r c u t an e o u s n e r e
to fi n d an d if t h e su b
h gh
,
f h o t e t i

j e c t is o b e se m a ny o f ,

th e m are so e mbe dd e d
in t h e fat at d iff e r e n t ,

M di l e a v f
c u t an e o u s n e r e o le v e ls that a sat isfactory ,
h
t lf
e ca m m ra
d isp lay o f th e who le se r ie s
u s co
m m b l )u c an s t 1 1a ts

is n o t e a sily o bta in e d .

N v e r u s su ra li ( O T h s Th
.
e r e for e
. s the
o rt d isse ct o r ,
ph ) sa e no us
work ing u p o n th e buttock
fo r th e fir st t ime mu st ,

n o t be d isa pp o in t e d if t h e
M di l e l a c a can e a n n e rv e
fi n a l r e su lt o f h is work
d o e s n o t qu it e re alise his
ho p e s an d e x p e ctat io n s .

Th e n e rv e tw ig s dis
F G I 7 C t
1 2 N v
— th u an e o u s er es o n e
tr ut ed to th e sk in o f
. .

p t i
o s e r o r as p t f t h I f i Ex
ect m i ty o ib e n er o r re .

th e glut e al r e gio n are

d e r iv e d fro m th e a n t e rior ra mu s o f the la st thorac ic an d
fro m t h e a n t e r ior an d p o st e r ior ra mi o f t h e lu mbar an d
2 84 TH E I N F ER I OR EXTRE M I TY
th e tw ig fr s o m j
a d ac e n t v
n e r e s c ro ss o n e an o th e r an d s o m e t im e s
un it w it h
e o ne an o th
h t w ig s t o t h e ir so u rce s o f
er . Trace su c
o rig in ; wh e n t h e t ru n k f ro m w h ic h t h e y a rise is f o u n d f o llo w ,

it an d it s bran c h e s t o t h e ir p e rip h e ral dist ribu t io n I f t h e p lan .

o u t lin e d is f o llo w e d t h e disse ct o r w ill de m o n st rat e t h e bran c h e s

o f t h e lu m ba r n e rv e s w it h o u t an y g re at diffi cu lt y H e s h o u ld .

t h e n att e m p t t o fi n d th e late ral bran c h e s o f t h e il io hyp o g ast ric -

an d las t t h o ra c ic n e rv e s f o llo w in g t h e s am e p lan o f se arc h , .

Th e t ru n k s o f t h e t w o bran c h e s c ro ss t h e iliac c re st an t e rio r t o

t h e lu m bar n e rve s t h e lat e ral bran c h o f t h e last t h o rac ic abo u t
,

5 c m p o st e rio
. r to f t h e iliu m an d
t h e an t e rio r su p e rio r sp in e o
t
t h e la e ral bran c h o f t h e ilio hyp o g as ric a ce n im e re o r m o re -
t t t
t
f u r h e r back I f t h e bran c h e s o f t h e p o s e rio r di isio n o f t h e
. t v
t t
la e ral cu an e o u s n e r e o f t h e h igh w e re f o u n d an d le f in v t t
t t
p o si io n w h e n t h e an e rio r p ar o f t h e h igh w as disse c e d, h e y t t t t
v
m ay be re ise d n o w , o h e r ise t h e disse c o r n e e d as e n o im e t w t w t t
in lo o k in g f o r h e m , f o r h e y t
ill h a e be e n alre ady re m o e d t w v v .

No t t
im e n e e d be lo s in lo o k in g f o r t h e p e rf o ra in g cu an e o u s t t
n er e v I t p ie rc e s t h e de e p f asc ia an d e n e rs t h e su p e rfi c ial f asc ia
. t
t
n e ar t h e m e dia l p a r o f t h e lo w e r bo rde r o f t h e g lu a e u s m ax im u s t
a bo u t
2 o r 3 c m f ro m t h e t ip o f t h e co cc yx a n d m e dial t o t h e
.

t t
isc h ial u be ro si y , an d it h as e i h e r be e n disp lay e d an d le f i n t t
t
si tu by t h e disse c o r o f t h e p e rin e u m , o r it h as be e n re m o e d v .

t
To disp lay t h e g lu e al bran c h e s o f t h e p o s e rio r cu an e o u s n e r e t t v
o f t he t t
h i gh , c u t h ro u gh t h e su p e rfi cial fascia alo n g t h e lo e r w
t
bo rde r o f t h e g lu ae u s m ax im u s ill t h e de e p f asc ia is e x p o se d, t
t t
h e n re fl e c t h e su p e rfi cial fascia u p w ards an d se cu re t h e bran c h e s
so u gh t t
f o r as h e y p ie rc e t h e de e p f asc ia abo u m id ay be w e e n t w t
t t
t h e ro c h an e r m aj o r a n d t h e u be r is c h ii t .

t
I n w e ll in j e c e d su bj e c s m an y o f t h e n e r e s m e n io n e d a re
-
t v t
a cco m p an ie d by sm all in j e c e d a r e rie s w h ic h se r e as g u ide s t t v
v
t o t h e n e r e s , bu t su c h a r e rie s c an n o be de p e n de d u p o n , an d t t
t
t h e disse c o r s h o u ld re ly u p o n h is s e n se s o f s igh an d o u c h t o t t
t
e n able h im t o dis in g u is h t h e fi rm e r n e r e fi bre s f ro m t h e s ra n ds v t
o f co n n e c i e issu e tv t
h ic h p e rm e a e t h e fat w t .

t t
A f e r t h e c u an e o u s n e r e s h a e be e n de m o n s ra e d t h e v v t t
re m a in s o f t h e su p e rfi c ial m u s be re m o e d bo h f ro m t h e t v t
re g io n o f t h e glu t a u s m ax im u s a n d t h e re g io n an e rio r t o it in t
t t
o rde r h a t h e de e p f asc ia m ay be e x am in e d .

Dee p F a scia —
d e e p fa sc ia n o w e x p o se d d iffe r s in
Th e
charact e r in t h e a n t e rio r an d p o st e r ior p ar t s o f its e x t e n t .

I n fr o n t o f t h e g lut ae u s m a x im u s wh e r e t h e fa sc ia lie s o v e r t h e ,

a n t e rio r p art o f t he g lut ae u s me d iu s it is de n se in t e x tur e ,

an d o p a qu e an d p e ar ly wh it e in co lo ur That p art Sta n d s .

in m ark e d c o n tra st w ith t h e d e e p fa sc ia o v e r t h e g lut ae u s

m a x im u s it se lf wh ich is th in an d tra n sp ar e n t
,
Su bse qu e n t dis .

se c t io n w ill S h o w t hat t h e d e n se fa sc ia o v e r t h e a n t e r io r p art

o f t h e g lut ae u s m e d iu s wh e n it r e ach e s t h e a n t e r io r bord e r,

o f t h e g lut a e us m a x im u s sp lit s in to t wo la me llae wh ic h ,

e n c lo se t h e g lu t a e u s m a x imu s be tw e e n th e m .

D is s e c ti o n — F o llo w t h e br ch f t h p st ri r t an an es o e o e o cu eo us
 G L U TE AL RE G I O N 2 85

ner e ov t t
f t h e h igh to t h e ru n k o f h a n e r e at t h e lo w er bo rde r t t v
t
o f t h e g lu ae u s m ax im u s , an d a f e r t h e ru n k o f t h e n e r e is t t v
se cu re d, p ro ce e d t o c le an t h e g lu a e u s m ax im u s Th e disse c o r t . t
o f t h e righ t t
in fe rio r e xt re m i y s h o u ld be g in at t h e u p p e r bo rde r
o f t h e m u s cle an d w o rk do w n w ards, t h e disse c o r o f t h e le f t t
lim b s h o u ld w
o rk u p w ards f ro m t h e in f e rio r bo rde r On t h e .

righ t
s ide t h e disse c o r s h o u ld cu t t
h ro u gh th e dee p f as cia a t
t
li t le be lo w t h e u pp e r bo rde r o f t h e m u scle , h e n h e sh o u ld t
v
raise t h e u p p e r p o rt io n o f t h e di ide d f as cia u n il t h e u p p e r bo rde r t
o f t h e m u s cle is : e x p o se d, an d t h e f as cia su p e rfi cial t o it is
’

t
f o u n d t o ble n d w i h t h e s ro n g f as cia co e rin g t h e g lu ae u s t v t
m e diu s Th e u pp e r bo rde r o f t h e m u scle s h o u ld n o w be raise d
.

an d dra n do wn w w
ards t o disp lay t h e lay e r o f de e p f as c ia su b
t t
j ace n t o it W h e n h is h as be e n do n e t h e disse c o r ill re adily
.
’

t w
re alise t t t
h a th e s ro n g f as cia o n t h e m o re an e rio r p art o f th e t
t t
g lu e u s m e diu s sp li s at th e u pp e r bo rde r o f t h e m ax im u s in o t
a su p e rfi cial lay e r w v
h ic h co e rs t he m ax im u s an d a dee p lay e r
w w
h ic h p asse s do wn ards o e r t h e lo e r p art o f t he g lu ae u s v w t
w
m e diu s an d t h e m u scle s h ic h lie m o re dis ally at t h e back o f t
th e h ip j o in t
Th e disse c o r o n t h e le f s ide
. t ill de m o n s ra e t w t t
t h e s am e f ac s t w
h e n h e re ac h e s t he u p p e r bo rde r o f t he m u scle ,
fo r he w
ill fi n d t h e de e p f ascia w h ic h h e h as raise d f ro m t h e
su rf ace o f t h e g lu ae u s m ax im u s ble n ds t i h t h e s ro n g wt t
t
f as cia o n t h e g lu ae u s m e diu s, an d by lif in g t h e u p p e r bo rde r o f t
t h e m ax i m u s h e w
ill disp lay t h e de e p e r lay e r o f f as cia .

t
Th e g lu ae u s m ax im u s is a diffi cu l m u s cle t o cle an , as t h e t
f as cicu li are ex ce e din g ly co arse I t is n e ce ssary h e re f o re n o t
. t
o n ly t o re m o e t h e f as cia v w
h ic h co e rs t he m u scle , bu t at t h e v
sam e t
im e t o f o llo w , f o r a s h o rt dis an ce , th e se p a h ic h t t w
t t
p e n e ra e be tw
e e n t h e f as c icu li an d t o re m o e h e m also D o v t .

n o t re m o e t h e v t
h ick Op aq u e f as cia h ic h co e rs t h e in se rt io n w v
o f t h e m u scle .

I f t h e w o rk is t o be do n e w
e ll t h e disse c o r m u s k e e p cle arly t t
be f o re him t h e ru le s w v
h ic h h a e alre ady be e n laid do w n re g ard
in g t h e cle an in g o f a m u scle ( )
1 R e n de r t h e fi b re s a s e n se as t
t t
p o ssible by ro a in g t h e lim b m e dially ; ( 2 ) re m o e t h e f as cia v
t
in o n e co n in u o u s lay e r ; ( 3 ) alw ays cu t in t h e dire c io n o f t h e t
m u scu lar fi bre s ; ( 4 ) de fi n e e ry c are fu lly t h e bo rde rs o f t h e v
m u scle .

M . Glu t aeu s M a ximus

glut ae u s max imu s is a
.
— Th e
p ow e r fu l m u s c le wh i ch ar is e s f r o m a n arr o w r o ugh ,

ar e a o n t he dor su m i111 wh ich is in clud e d be tw e e n t h e p o st e rior

,

curv e d lin e an d t h e out e r lip o f t he cr e st ( 2 ) fro m the sid e s

o f th e lo w e r t wo p ie c e s o f t h e sacru m an d th e u p p e r thr e e

p ie c e s o f t h e c o ccy x
( 3) f r o m t h e e n t i r e p o st e r ior sur fac e O f

t h e sacro tu be r o u s liga m e n t ( O T
-
gr e at sc iat ic ) ; an d . .

Slight ly fro m t he p o st e r io r lay e r o f t h e lu m bo d o r sa l fa sc ia

-

, ,

at t he attach m e n t o f that fa sc ia to the cr e st o f th e iliu m .

F r o m th is e x t e n siv e o rig in t h e c o ar se fa sc icu li O f t h e

m u sc le p roc e e d o bliqu e ly dow n ward s an d forward s toward s
th e p ro x im a l p ort io n o f t he fe mur ; bu t o n ly a co mp arat iv e ly
 2 86 TH E I N F ER I OR EXTRE M I TY
ma ll p ro p ort io n o f th e m r e c e ive d ir e ct in se rt io n in to that
s

bo n e Th e gr e at e r p art o f t he m u sc le is in se rt e d in to th e
.

fa sc ia lata To be mor e p r e c ise , it may be sa id that th e d e e p e r

.

fi br e s o f the lo w e r half o f the mu sc le are d ir e ct ly attach e d

M .b uu s
o li q e x t e rn u s
L at 15 5 1m u s do rs I a bdo m i n i s

sarto r u s i
M . t e n so r fasc a i l at ae

M . g m ll
e e u s su p e r o rx i -

M
M . g m ll
e e us i n fe r o r i p e c t ln e u s

M . se i
m me mbrano su s

M m b ce p s i and
i i
.

se m t e n d n o su s re c t u s abdo m i i
n s

p y ram 1dal1s
M . addu c t o r o n l g us

M . q u adrat u s fe mo ri s
M g rac ili s

vi
.

M . addu c t o r bre s

F IG . 1 2 8 .
-
x
E te rn a l asp e c t o f th e H ip B o n e , wi h
t t he At tach me n ts
o f th e l
M u sc e s m ap p e d o u t .

to th e glut e al tu be ro sity o n the back o f the fe m ur ( i e th e .

r idg e wh ich e x t e n d s fro m the gr e at e r trocha n t e r to the lin e a

a sp e ra ) ( F ig 1 2 2 p All t h e r e ma in in g fi br e s o f th e
. .
, .

m u sc le are in se rt e d in to th e fa sc ia lata a lo n g th e p o st e r ior

bord e r o f th e p ro x im a l p art o f th e ilio t ibia l tract Th e -
.
2 88 T HE I N F ER I O R EXTRE M I TY
a tt a hc ed by fi bre t
s ran ds to the glu t ae u s m ax im u s an d to th e
tu be ro si ty t
I mm e dia e ly m e dial an d su p e rio r t o t h e isc h ial
.

tu be ro s it y
t h e de e p fi bre s o f t h e m u scle sprin g f ro m t h e su p e r
fi c ial su rf ace o f t h e sac ro u be ro u s lig am e n ; de ac h t h e m -
t t t
c are fu lly f ro m t h e lig am e n an d se cu re t h e p e rfo ra in g cu an e o u s t t t
v
n e r e an d t h e c o ccyg e al bran c h e s o f t h e in f e rio r g lu e al art e ry t
w h ic h p ie rce th e lig am e n t
Th e art e rie s m u s be di ide d in o rde r. t v
t t t
h a th e re fl e c io n o f th e m u scle can be co n in u e d, bu t th e n e r e t v
s h o u ld if p o ssible be p re se r e d Co n in u e t h e de ach m e n o f v . t t t
t h e m u sc le f ro m t h e sa cro t u be ro u s lig am e n u n il t h e m arg in s -
t t
o f t h e sac ru m an d c o c c yx are re ac h e d, an d as h e y are app ro ac h e d t
t
lo o k f o r t h e p o s e rio r bran c h e s o f t h e sac ral n e r e s h ic h fo rm v w
a p lexu s o n t h e su p e rfi c ial su rfac e o f t h e lig am e n de e p to t h e t
mu scle .

t
Th e m e h o d o f disse c io n su gg e s e d abo e is o n e be s adap e d t t v t t
v
t o a o id in j u ry t o t h e bran c h e s o f t h e in fe rio r g lu e al n e r e t v
w h ic h su p p lie s t h e m u scle ; an d it g i e s a ie w o f t h e s ru c u re s v v t t
su bj ace n t
t o t h e m u scle sim ilar t o h a o b ain e d by th e su rg e o n t t t
t
O p e ra in g o n t h e p ro x im al p ar o f t h e s cia ic n e r e t t v .

t
Th e m e h o d o f disse c io n p re io u sly ado p e d in h is M an u al t v t t
t
w as t o de ac h t h e m u scle f ro m its o rig in f o m t h e iliu m , t h e r
sa cru m , t h e co c c yx , an d t h e sac o be ro s lig am e n , an d t o r tu u -
t
t h ro w it t o ards it s in se rt io nw Th at m e h o d also g i e s an . t v
e x ce lle n t
disp lay o f t h e su bj ace n s ru c u re s , f ro m a p u re ly t t t
t
an a o m ical p o in o f t v
ie w, an d t h e s u de n w h o is disse ct in g t he t t
t
bu t o c k f o r t h e se co n d im e m igh e m p lo y it wi h ad an ag e , t t t v t
bu t it is n o t a p lan w
h ic h co u ld be ado p e d by th e su rg e o n Th e t .

t
disse c o r w h o e m p lo y s h a m e h o d m u s co mm e n ce by cle arin g t t t t
t h e u pp e r an d lo e r bo rde rs o f t h e m u scle w W h e n h a h as . t t
be e n do n e t h e le f h an d m u s be in sin u a e d be t e e n t h e m u scle t t tw
an d t h e de e p e r s ru c t tu
re s, o n t h e m e dial side o f t h e g re a e r t
t t t
ro c h an e r, e i h e r f ro m abo e o r f ro m be lo w a cco rdin g t o t h e v
side o n w h ic h t h e lim b is be in g disse c e d Th e n , h e n the t . w
t
m u scle h as be e n g e n ly raise d f ro m t h e de e p e r s ru c u res t h e t t
t
re fl e c io n s h o u ld be co mm e n ce d, bu t t h e p lan t o be ado p e d t
is diffe re n o n t h e t wo side s t On t h e le f side th e m u scle m u s . t t
t
be de ac h e d f ro m it s o rig in s fro m abo e do wn w ards , c o mm e n cin g v
t
at t h e p o s e rio r p art o f t h e iliu m W h e n th e su rface o f th e
do rsu m ilii f ro m w
h ic h it sp rin g s 13 cle are d t h e u pp e r m arg in
t
o f t h e g re a e r sc ia ic n o c h is re ac h e d t t
Th e re t h e disse ct o r m u s . t
p ro ce e d wt
i h c au io n , be cau se t
h ro u gh th e n o c h p ass t h e t t
t v t
glu e al e sse ls, an d h e ir bran c h e s e n e r t he de e p su rf ace o f th e t
glu t a u s m ax im u s m u scle W h e n h e se are se cu re d th e m u scle . t
t t
m u s be de ac h e d f ro m th e side o f t h e sacru m ; h e n t h e p iri t
f o rm is m u scle , e m e rg in g f ro m u n de r co e r o f t h e s ac ru m , co m e s v
t
in o sigh t
Th e m u scu lar fi bre s m ay n o w be raise d f ro m t h e
.

su rf ac e o f t h e sacro u be ro u s lig am e n t
a n d s e p ara e d f ro m t h e
-
t t
side o f t h e c o ccyx t
As h is is be in g do n e , c are s h o u ld be ak e n
. t
v t
t o p re se r e th e h re e sac ral cu an e o u s n e r e s in ac , in o rde t v t t r
t t
h a t h e y m ay be su bse q u e n ly race d to h e ir o rig ins AS th e t t t .

su rf ace o f t h e sacro tu be ro u s lig am e n is g radu ally laid bare ,

-
t
t
a n u m be r o f sm all ar e rie s (t h e co ccyg e al bran c h e s o f t h e in f e rio r
t
g lu e al art e ry ) w ill be se e n p ie rcin g it an d imm e dia e ly sin k in g t
t t
in o t h e su bs an ce o f th e g lu e u s m ax im u s Th e se can n o be t . t
t
re ain e d I t is n e ce ssary t o se e r h e m in o rde r h a t h e m u scle
. v t t t
m ay be fre e d The p e fo a in g c an e o s n e r e ,
. r r t ut
hich w in ds u v w
 2 90 T H E I N F ER I OR EX TR EM lTY

bo rde r f t h e p irif o rm is ; ( 2 ) bran c h e s o f t h e i nf e ri o r glu te al

o
artery a n d th e i nf eri o r glu te al n erve be lo w t h e le e l o f t h e p iri v
f o rm is v t
Th e e n ae co m i e s o f t h e a r e rie s m ay at o n ce be re m o e d,
. t v
t v
bu t t h e ar e rie s an d n e r e s m u s be c le an e d as h e y co m e in o t t t
v t
ie w an d f o llo w e d in o t h e su bs an ce o f t h e glu t a u s m ax im u s t .

F in ally , in o rde r t o allo w t h e co mp le e re fl e c io n o f t h e m u scle , t t

t v t
t h e ar e rie s a n d n e r e s m u s be cu t , bu t a sm all p o r io n o f t h e t
m u scle s h o u ld be le f in c o n n e c io n t i h h e ir cu t e n ds s o h a t wt t t t
t h e y m ay be re adily re co g n isable du rin g t h e fu r h e r s age s o f t t
th e disse c io n t
Th e w h o le m u scle c an n o w be h ro w n dis ally
. t t
t t
a n d la e rally , an d, af e r a li le disse c io n , a n e x ce lle n ie tto f t tv w
t
it s in se r io n c an be o b ain e d t .

Wh e n t he r e fl e c tio n o f the m u sc le is c o mp le t e d n ot e
car e fu lly the p o sit io n s o f th e fo llo w in g p art s : ( 1 ) the
p o s t e r io r b o rd e r o f t h e tr o cha n t e r m aj o r ; ( 2 ) th e g lut e a l
tu be r o sity wh ich lie s imm e d iat e ly d ista l t o ( )
3 t h e

tu be ro sity o f th e isch iu m ( 4 ) the sa cro tu be r o u s liga me n t -

.

Th e trocha n t e r m aj o r is Situat e d in th e lo w e r an d lat e ra l

p art o f t h e ar e a e x p o se d by t h e r e fl e ct io n o f the g lut a e u s

m a x im u s . I m m e d iat e ly d ista l t o it is th e g lut e a l tu be r o sity

in to wh ich t h e low e r d e e p fi br e s o f t he glu t mu s m a x imu s are
in se rt e d . The isch ia l tu be r o sity lie s a bo ut 7 o r 8 c m m e d ia l .

t o t h e d ista l p art o f t he trocha n t e r m aj o r I f t h e th igh is .

rotat e d lat e ra lly t he trocha n t e r is a p p r o x imat e d t o th e

tu be r o sity an d it r e c e d e s fr o m th e tu be ro sity wh e n th e th igh
,

is rotat e d m e d ia lly 1
The sacro tu be r o u s liga m e n t e x t e n d s
.
-

u p ward s an d m e d ia lly fr o m th e tu be r o sity o f th e isch iu m

,

to th e m arg in s o f the sacru m an d c o ccy x an d to the p o st e rior ,

in fe r ior an d su p e r io r sp in e s o f t he iliu m Th e in fe r io r \
.

bo rd e r o f t h e liga me n t is r e lat iv e ly stra ight I t fo r m s t h e .

p o st e r i or b o u n dary o f t h e isch io r e cta l fo ssa o f th e

p e r in eu m -

wh ich has a lr e ady be e n e xp lo r e d by th e d isse ct o r o f the

a bdo me n I ts u p p e r m arg in is curv e d w ith th e co n cav ity
.
,

d ir e ct e d fo rward s an d u p ward s an d imm e d iat e ly in fro n t o f ,

it are t h e gr e at e r an d le sse r sc iat ic fo ra m in a wh ich are ,

se p arat e d fr o m o n e a n o th e r by t he sacro Sp in o u s liga m e n t -

.

Th e sacro Sp in o u s liga m e n t c an be f e lt wh e r e it is attach e d

-

to the Sp in e o f the isch iu m cm a bov e the u pp e r bord e r

,
.

o f t h e tu be r o sity o f t h e isch iu m N ot e a lso a gr o u p o f .

m u sc le s wh ich are attach e d to th e tu be r o sity an d d e sc e n d

fr o m it in t o t h e p o st e r ior r e g io n o f t h e th igh Th e y are the .

ha m strin g m u sc le s do n o t c le a n th e m at p r e se n t .

1
Th th i gh i
e i d t b t t d m di lly wh it
s sa o e ro a et i f i e a en s an e r o r su r ace s

tu rn e d t w d t h m di
o ar s e pl e d l t
an lly wh th t i
a ne , an f i a e ra en e an e r o r su r ac e s

tu rn e d w y f m th m di
a a ro e pl e an an e .
2 9 2 TH E I N F ER I OR EXTRE M I TY
v e sse ls t he p ud e n da l n e rv e t he n e rv e to th e o bturat o r
, ,

in t e r n u s an d su p e r ior g e me llu s an d th e n e rv e to t he ,

q uadratu s fe mo r is a n d in fe r ior g e m e llu s Through t h e le sse r .

sc iat ic fo ra me n p a ss t h e o bturator in t e r n u s m u sc le th e ,

p ud e n da l n e rv e t h e n e rv e to
,
t h e o bturator in t e r n u s an d

t h e in t e r n a l p ud e n da l v e sse ls ( F ig All t h e structur e s .

me n t io n e d as w e ll as oth e r m u sc le s v e sse ls an d n e rve s h av e

, , , ,

to be c le a n e d an d e x a m in e d Th e r e for e th e se c o n d day s .
’

d isse ct io n is e xt e n siv e an d c o mp licat e d an d u nle ss it is ,

p roc e e d e d w ith in a r e gu lar an d d e fi n it e m a n n e r it w ill n o t

be succ e ssfu lly c o mp le t e d .

D is s e c ti o n — C o m m e n ce wt
i h t h e su p e rfi c ial bran c h e s o f t h e
t t
su p e rio r g lu e al a r e ry , w h ic h e n e r t h e u p p e r p ar o f t h e de e p t t
t
s u rfa c e o f t h e g lu ae u s m ax im u s, an d f o llo w h e m to t h e p o in t t
w t t
h e re h e y e m e rg e h ro u gh t h e cle f be e e n t h e bo rde r o f t h e t tw
t
g lu e u s m e diu s an d t h e u p p e r bo rde r o f t h e adj ace n p irifo rm is t
m u scle Th e n cle an t h e p irifo rm is , f ro m t h e g re a s cia ic
. t t
t
f o ram e n , h ro u gh w h ic h it e m e rg e s , t o t h e g re a e r ro c h an e r, t t t
t
wh e re it s e n do n disap p e ars u n de r co e r o f t h e glu t a u s m e diu s v .

t
Af e r t h e p irifo rm is is de fi n e d, cle an th e p o s e rio r c u an e o u s t t
v
n e r e o f t h e t h igh , f o llo w in g it u p ard to its e x i f ro m t h e w t
t
g reate r s cia ic f o ram e n at t h e lo w e r bo rde r o f t h e p irifo rm is .

Se cu re its p e rin e al bran c h , h ic h sp rin g s fro m its m e dial w

bo rde r an d p asse s f o rw ards an d m e dially o w ards t h e p e rin e u m , t
t
a n e rio r t o t h e t
u be r isc h ii, a n d n o e t h e cu an e o u s bran c h e s t t
w h ic h w e re se e n o n th e lo w e r p ar o f t h e g lu ae u s m ax im u s t t .

t t
Th e p o s e rio r c u an e o u s n e r e is so m e im e s ac co m p an ie d by a v t
bran c h o f t h e in fe rio r g lu e al art e ry t
I f t h e in fe rio r g lu e al . t
v e sse ls an d n e r e , w h ic h lie m e dial t ov t h e p o s e rio r cu an e o u s t t
v
n e r e , w e re n o t disp lay e d a s t h e g lu aeu s m ax im u s w as re fl e c e d, t t
cle an t
h e m n o w , an d f o llo w h e m t o th e lo w e r bo rde r o f th e t
p irif o rm is W h e n th e in fe rio r g lu e al ar e ry an d its bran c h e s
. t t
v
h a e be e n cle an e d, p lace t h e le g o n a larg e blo ck to fl e x t h e
t t t t
k n e e , so h a th e s ru c u re s in t h e bu t o ck an d t h e back o f t he t
t h igh m ay be re lax e d, h e n p ro ce e d t o se cu re an d cle an t h et
s c iat ic n e r e v
I t is t h e larg e w h i e fi rm co rd w h ic h lie s im m e di
. t
t
a e ly de e p t o t h e p o s e rio r cu an e o u s n e r e t t
Th e re fo re p u ll t h e v .

tt
la e r n e r e m e dially v wt
i h h o o k s, h e n at t h e le e l o f t h e t o p o f t v
t t
t h e ro c h an e r m aj o r cu t lo n g i u din ally h ro u gh t h e f ascia o n t t
t v t
t h e scia ic n e r e ill t h e n e r e is e x p o se d v
I n se r t h e h an dle . t
t
o f t h e s c alp e l in o t h e in c isio n in t h e f asc ia a n d ru n it u p w ards ,
alo n g t h e late ra l bo rde r o f t h e n e r e , t o t h e g re a e r sc ia ic f o ram e n v t t
a n d do w
n w ards t o t h e p o in tw
h e re t h e n e r e p asse s an e rio r to v t
v
t h e bice p s f e m o ris a n d le a e s t h e a re a o f t h e p re se n disse c io n t t .

Cle an t h e f ascia f ro m t h e bac k o f t h e n e r e f ro m t h e la e ral t o v t

t h e m e dial bo rde r, a n d se cu re t h e bran c h e s t o t h e h am s rin g t
m u scle s , w h ic h sp rin g f ro m t h e m e dial bo rde r, at o r a li t le t
t
dis al t o t h e le e l o f t h e u be r isc h ii v t
F o llo t h e bran c h e s t o . w
v
t h e m u scle s an d p re se r e t h e bran c h e s o f t h e m e dial f e m o ral
c ircu m fl ex a r e ry t w
hic h j o in t he n e es as h e y ap p ro ac h h e i rv t t r
t re m in a io n s t .
 G L U TE AL R E G I O N 2 93

Af t er t h e bran c h e s
f t h e scia ic n e r e t o t h e h am s rin g s
o t v t
v
h a e be e n cle an e d, p u ll t h e p ro xim al p ar o f t h e scia ic n e r e t t v
t
la e rally, t o e xp o se t h e n e rv e t o t h e q u adra u s f e m o ris , w h ic h t
lie s be tw t v
e e n t h e s c ia ic n e r e a n d t h e p o s e rio r su rf a ce o f t h e t
isc h iu m v
Th e n e r e t o t h e q u adra u s fe m o ris is f re q u e n ly
. t t
a c c o m p an ie d by a s m all bran c h o f t h e in f e rio r g lu e al art e ry t .

On t h e m e dial side o f t h e n e r e t o t h e q u adratu s f e m o ris, ly in g v

o n t h e sp in e o f t h e is c h iu m , fi n d t h e n e r e t o t h e o b u ra o r v t t
t t
in e rn u s, th e in e rn al p u de n dal e sse ls , an d t h e p u de n dal n e r e v v
in t t
h a o rde r fro m t h e la e ral t o t h e m e dial side Cle an a ay t . w
v t
t h e e n a c o m i e s o f t h e art e ry , bu t care fu lly p re s e r e t h e art e ry v
t
i se lf an d t h e n e r e s v .

t v v
Af e r t h e n e r e s an d e sse ls m e n io n e d h a e bee n ide n ifi e d t v t
an d cle a n e d, p ro c e e d t o t h e e x ami n a io n o f t h e m u s cle s wh ic h t
t
lie de e p ( an e rio r) t o t h e scia ic n e r e Th e y are , f ro m abo e t v . v
do w n w ards, t h e su p e rio r g e m e llu s , t h e o b u ra o r in e rn u s , t h e t t t
in fe rio r g e m e llu s, t h e q u adra u s f e m o ris , a n d t h e p ro x im al t
p art o f t h e addu c o r m ag n u s t
Em e rg i n g be e e n t h e adj ac e n . tw t
t
bo rde rs o f t h e q u adra u s f e m o ris an d t h e addu c o r m ag n u s t h e t
t v
ran s e rse t
e rm in al bran c h o f t h e m e dial f e m o ral c ircu m fl e x
t
ar e ry w
ill be f o u n d, an d, p ie rcin g t h e addu c o r m ag n u s at t h e t
t
m e dial bo rde r o f t h e g lu e al u be ro si y o f t h e f e m u r, in a e ll t t w
t t t
in j e c e d su bj e c , t h e fi rs p e rfo ra in g bran c h o f t h e p ro fu n da t
t
ar e ry m ay be se e n Cle an t h e art e rie s, an d h e n c le an t h e
. t
m u scle s f ro m abo e do wn w ards v
No e h a t h e o b u ra o r . t t t t t
t
in e rn u s e m e rg e s fro m t h e sm all s cia ic f o ram e n an d h a as it t t t
v
e m e rg es it o e rlap s bo h t h e g e m e lli, t
h ils n e ar t h e ro c h an e r w t t t
t w w
m aj o r, o ard h ic h all h re e m u scle s co n e rg e , t h e g e m e lli t v
v
o e rlap t h et e n do n o f t h e o b u ra o r in e rn u s t t t .

t
Af e r t h e m u scle s are cle an e d, di ide t h e e n do n o f t h e v t
t t
o b u rat o r in e rn u s abo u 15 t
mm f ro m t h e le sse r scia ic . t
f o ram e n W h e n t h e m e dial p art o f th e e n do n is raise d an d
. t
t u rn e d backw ards t h e disse c o r w ill n o e h a its de e p su rf ace t t t t
t t
is cle f in o f o u r o r fi v e s ran ds, an d h a t h e m arg in o f t h e t t t
t
le sse r scia ic f o ram e n , o n w
h ic h t h e t e n do n glide s , is co v e re d
wt i h sm o o h c art ilag e t w
h ic h is raise d in o ridg e s co rre sp o n din g t
wt v
i h t h e g ro o e s o n t h e de e p su rf ace o f t h e e n do n A larg e t .

bu rsa in e r e n e s be t ve e n th e tw
e n do n an d t h e bo n e t .

t
Tu rn n e xt t o t h e h am s rin g m u sc le s , wh ic h sp rin g f ro m t h e
t t
u be ro si y o f t h e isc h iu m , an d s e p ara e t h e co m m o n e n do n o f t t
t h e bice p s f e m o ris an d t h e se m i e n din o su s f ro m t h e fl a t e n e d t t
t e n do n o f t h e se m im e m bran o su s , w h ic h lie s im m e dia e ly su b t
j ace n t Th e n p u ll t h e h am s rin g s la e rally an d disp lay t h e
. t t
t
o rig in o f t h e addu c o r m agn u s f ro m t h e in fe rio r p art o f t h e
t u be r is c h ii .

P art s un de r Co v e o r f t h e G lu t a us M ax im us — F o ur .

grou p s o f structur e s lie u n d e r c o v e r o f t h e glut a u s m a x imu s ,

v iz
.
,bur sa m u sc le s v e sse ls an d n e rv e s
, ,
.

Th e bur sa wh ich hav e a lr e ady be e n e x a m in e d ( se e p 2 9

,
.

are th re e in n u m be r ; a ur sa be tw e e n t h e m idd le o f t h e
( )
1 b
in fe r io r bo rd e r o f t he glu t a u s m a x im u s an d t he tu be r isch ii ,

e bur sa be tw e e n t h e t e n d in ou s in se rt io n o f t h e glu t a u s
( )
2 t h
m a x im u s an d t h e trocha n t e r m ajor an d imm ed iat e ly ,

1— 19 b
 TH E I N F ER I OR EXTRE M I TY
d ist a l t o th e l s at ,bur sa be tw e e n t h e t e n d in ou s in se rt io
th e n
Of th e glu ta u s m a x imu s an d t h e va stu s lat e ra lis .

Th e m u sc le s m e t
.
with be tw e e n t h e dor su m ilii a bo v e
and th e tu be r isch ii an d t h e
p o s t e r ior ar e a o f th e th igh
N er v e to q
u adrat u s fe m o n s
J f ez “
! 2 I i gl
n fe r o r u te a l v
ne r e P u de n da n e r l v e

P o st erio r c u t ane o u s n e r e o v f th igh I n fe r o ri gl lu te a arte r y

Sup e rfic ia Lp art bf su p e r o r u t e a i gl l art e r y I n t e rn a lp u de n da l arte r y
Su p e h o r u t e a n e rv e gl l Ner v e to o bt u rat o r i n t e rn u s

M . g e me ll u s su p e r o r i
D ee p p art o f su p .
M . o bt u rat o i
r n t e rn u s

gl u te a l a rte r y M . g e me ll u s 1 n fe r1o r

Sacro -
t u be ro u s li g a me nt

M .
glu t a us me d u s i
N e r e tov t e n so r fasc a i l at a
l
a n d at e ra l c1rc u m fl e x art e r y

G re at e r t ro c han t e r

M . q u adrat u si fe m o rs ( c u t)
Me di l i
a mfl x c rc u e arte r y
M addu c t o rmagn
mag n u s
.

M . addu c t o r
M . se m i m e mbran o su s

M . i
se m t e n d n o su s i
M b ce p s
. i fe mo r i s

FI G . 1 3o .
— Di sse c t o n i o f th e G l u te a l R gie o n . The G lu ta u s M a m u s an d xi
t he G lu ta us M e diu s have be e n re m o ve d , an d t h e Q u adrat u s e mo r s F i
h as be e n re fl e cte d .

be lo w Th e p o st e r io r p art o f t h e glu t a u s m e d iu s ;
are

( 2
) t h e p ir ifo r m is,
issu i n g f ro m t h e p e lv is thr o ugh t h e gr e a t e r
sc iat ic fora m e n t d turat r t r u
(3) t h e e n o n o f t h e o b o in e n s ,

p a ssin g through t h e le sse r sc iat ic fo ra m e n

; ( 4 ) th e g e m e llu s
su p e r io r, attach e d to the u p p e r bo rd e r o f t he o bturator
 2 9 6 TH E I N F ER I O R EXTRE M I TY
bra n ch o f the p ro fu n da art e ry p ie rc e s t he adduct o r m ag n u s
c lo se to t h e d ista l p art o f t h e glut e a l tu be ro sity o f th e fe m ur .

N e rv u s Glut a u s I nf e ri o r — Th e in fe r ior g lut e a l n e rv e is

.

the n e rv e o f su pp ly to t h e gluta u s m a xim u s I t Sp r in g s .

fro m t he sacra l p le x u s, an d e n t e r s t h e g lut e al r e g io n through

th e low e r p art o f t h e gr e at sc iat ic fora m e n Wh e n the .

lu t a u s m a x im u s was r e fl e ct e d t h e n e rv e was se e n br e ak in g
g
u p in to n u m e rou s tw ig s wh ich e n t e r e d t h e d e e s ur fac e f
p o

th e mu sc le .

Art e ria Glut a a I nf e ri o r ( O T . . in fe r ior

Sciat ic) — Th e .

glut e a l art e ry, a bra n ch o f the hy p oga stric art e ry ( O T in . .

t e r n al iliac ), issu e s fro m th e p e lv is, through th e gre at sc iat ic

fora m e n , be low t h e p ir ifo r m is m u sc le , an d p roc e e d s dista lly ,
w ith the sc iat ic n e rv e , u n d e r cove r o f the glu ta u s ma ximu s,
in t h e ho llow be tw e e n th e gr e at e r trocha n t e r an d th e isch ia l
tu be r o sity At the low e r bord e r o f the glu ta us max im u s it
.

is co n t in u e d , as a fin e cuta n e ou s tw ig, to t h e p o st e r ior a sp e ct

o f th e th igh , in co mp a n y w ith th e p o st e rior cuta n e ou s n e rv e .

I t g iv e s o ff n u m e rou s bra n ch e s in th e glut e a l r e g io n Of .

th e se the larg e mu scu lar o ffse t s to the glu ta u s ma ximu s, an d

th e cuta n e ou s tw ig s that acco mp a n y th e bra n ch e s o f t h e

p o s t e r ior cuta n e ou s n e rv e o f th e th igh wh ich tur n rou n d t he

d ista l bord e r o f that m u sc le , hav e be e n a lr e ady stud ie d The .

fo llow in g thr e e bra n ch e s r e m a in to be e x a min e d the

co cc yg ea l bran c/z , wh ich p a sse s m e d ia lly be tw e e n t h e sacro
tu be rou s an d sacro sp in o u s liga m e n t s to re ach the in t e gu m e n t
-

an d fa sc ia in t h e r e g io n o f t h e c occy x ; a n u mbe r O f twig s

d e riv e d fro m th is bra n ch have be e n p r e viou sly n ot ic e d p ie rc in g

t h e sacro tu be rou s liga m e n t an d e n d in g in th e glu ta u s
-

ma x imu s ( 2 ) arteri a co mitans n ervi isclziadia , a min ut e art e ry,

'

wh ich ru n s d istally o n the sc iat ic n e rv e an d fi n ally p e n e trat e s

in to it s su bsta n c e ; ( 3 ) the arter y to tlze q adratu s femo ris,
u

wh ich acco mp a n ie s the n e rv e to that m u sc le ; it w ill be fou n d

ly in g o n t he hip bo n e u n d e r cov e r o f th e sc iat ic n e rv e .

I n a w e ll in j e ct e d body the a n a sto m o sis be tw e e n the

-

in fe r ior g lut e a l art e ry, th e two t e r m in a l bra n ch e s o f th e

m e d ia l c ircu m fl e x art e ry, an d th e fir st p e r forat in g art e ry m ay
be m ad e o u t .

N e rvu s Cut an eu s F e mo ri s P o st e rio r ( O T Sma ll Sciat ic . .

N e rv e) —.Th e p o st e r ior cuta n e o u s n e rv e o f t h e th igh ar ise s,

w ithin the p e lv is, fro m th e sacra l p le xu s Aft e r e sca p in g .

through the gre at e r sc iat ic fora me n it e x t e n d s d ista lly, w ith the

 G L UTE AL RE G I O N 2 97

in fe r ior glut e a l art e ry, u n d e r cov e r o f the glu ta u s ma x im u s .

F ro m th e in fe r io r bo rd e r o f th e glu ta u s ma x im u s it p roc e e d s
d ista lly, o n the back o f the th igh, im me d iat e ly su bjac e n t to
th e d e e p fa sc ia I t w ill a ft e rward s be trac e d t o th e p o st e r ior
.

a sp e ct o f the ca lf o f the le g .

I n t h e g lut e a l r e g io n it giv e s o ff se v e ra l cuta n e ou s bra n ch e s,

u m bo -
sa c ra l t ru n k

i gl
Su p e r o r u tea l ne r e v
fe rio r gl u te a l v
ne r e

Ner v e to q u adra t u s fe mo rs i
N er v e to o btu rat o r i n te rn u s

To p i if
r o rm s i

i
To p ir fo rm i s

Vi sc e ra
Sci at i c ne r e v
m mo n
ro n e al n e rve
V i sce ra l
ic ne r e v

O T sm a ll i i
sc at c )
i P l
. .

o f pen s u de n da

ner e v

v Ner v es to lv
e at o r an i

Co cc yg l b
ea ran ch e s

FI G . 1 31 .
— Di agram o f Sacra l Pl x e us .

v iz.
r
in fe io r ne rv e s o f t h e b uttock wh i ch w in d rou n d ,

th e in fe i r or bo rd e r o f t h e g lu t a u s m a x im u s t o su p p ly a
limit e d ar e a o f th e sk in o f t h e buttock ; ( 2 ) a fe w tw ig s to
k
t h e s in t o t h e m e i l d a r e g io n o f t h e th i gh ; a n d ( 3) t h e

p e r in e a l bra n ch e s o f wh ,
i ch o n e is k n ow n a s t h e l o n g p er i n ea l
n erve O T lo n en dal) Th is bra n ch tur n s m e d ia lly r o u n d
( .
gp . u d . ,

th e orig in o f t h e ha mstr in g m u sc le s to r e ach the p e r in e u m ,

.
2
9 8 TH E I N F ER I O R EXTRE M I TY
N e rvu s I schia dicu s ( O T Gre at Sciat ic N e rv e) — Th e sc iat ic . . .

n e rv e , th e larg e st n e rv e in the bo dy , co me s fro m th e sacra l

p le x u s,
an d e n t e r s t h e g lut e a l r e g io n through t h e lo w e r p art
o f th e gre at sc iat ic fo ra me n At fir st it has th e fo r m o f a .

flatt e n e d ba n d bu t soo n it be co me s ova l or rou n d as se e n in

, ,

se ct io n C ov e r e d by th e glu t a u s m a x im u s th e sc iat ic n e rv e
.
,

trav e r se s the glut e al r e gio n in th e in t e rva l be tw e e n th e gre at e r

trocha n t e r o f the fe m ur an d the tu be r o sity o f the isch iu m .

F ro m a bov e dow n ward s it lie s o n t he body o f the isch iu m

an d th e n e rv e to th e quad ratu s fe mor is th e t e n d o n o f th e ,

o bturator in t e rn u s w ith t he two g e me lli mu sc le s the quadratu s ,

fe mor is an d th e adductor m ag n u s
,
Th e n e rve s to o n e or .

m or e o f t he ha mstr in g m u sc le s issu e fro m th e m a in tru n k

n e ar th e lo w e r bord e r o f th e glu t a u s m a x imu s .

Th ei ti
sc a v fr q t l y p f m th p lv i i th f m f t w
c ne r e e u en e sca es ro e e s n e o r o o

t ru n k s ( th e t wo di isio n s v in to wh ic h it n o rm all y div ide s in the th igh , v iz , .

the tibial an d the co mm o n p e ro n e al) wh ich e n c lo se be t w e e n th e m a

p o rt io n

o f the p irifo rm is m u sc le .

Art eria Pu den da I nt erna

Pude ndu s ( O T I nt ernal , N e rvu s . .

Pu dic) and t he N erv e t o t h e O bt urat o r I nt ernu s — The

, .

in t e r n a l p ud e n da l art e ry th e p ud e n da l n e rv e an d th e n e rv e
,

to the o bturat o r in t e r n u s m u scle are e xp o se d in the p r e se n t ,

d isse ct io n o n ly in a v e ry short p art o f th e ir e x t e n t Th e y all

, .

e m e rg e fro m th e gr e at e r sc iat ic f ora m en an d cro ss th e sp in e

o f t h e isch iu m or t h e adjac e n t p art o f the sacrO Sp in ou s -

liga m e n t th e n th e y e n t e r t h e le sse r sc iat ic fo ra m e n an d p a ss

o u t o f v ie w Th e nerve to tile o étu rato r internu s is p lac e d
.

m o st lat e ra lly I t lie s o n th e ba se o f th e isch ial Sp in e an d

.
,

fur n ish e s a tw ig to the g e me llu s su p e r ior Th e in tern al .

pudendal artery w ith a co mp an io n v e in o u e ach sid e cro sse s

,
-

th e t ip O f t h e sp in e The p uden dal n erve is p lac e d mo st

.

m e d ia lly an d lie s o n th e sacro Sp in ou s liga m e n t c lo se to its

,
-

attach me n t to th e sp in e I n so m e ca se s how e v e r th e .
, ,

p ud e n da l n e rv e u n it e s
'

in a p le x ifor m m a n n e r w ith t h e

n e rv e t o t h e o bturator in t e r n u s so that t he who le o r a p art , , ,

o f it may lie lat e ra l to th e p ud e n da l v e sse ls .

Small Lat eral R o t at o r M uscle s o f t h e Thigh — U n d e r th is

h e ad in g are in clud e d the p irifor mis th e o bt u rator in t e rn u s , ,

an d t h e two g e m e lli th e quadratu s f e m or is an d the o bturator

, ,

e xt e r n u s Th e y all lie d ir e ct ly u n d e r cov e r o f the glu ta u s

.

m a x imu s in th e gr e at e r p art o f th e ir e x t e n t e x c e p t th e ,

o bturator e x t e r n u s wh ich lie s d e e p ( a n t e rior ) to the quadratu s

 TH E I N F ER I O R EXTRE M I TY
d ivid e d an d th e p e cu liarit ie s o f its d e e p sur fac e hav e be e n
e x a m in e d ( se e p .

M Qu adrat us F emo ri s — Th e quadratu s fe m o ris lie s

. .

be tw e e n t he g e me llu s in fe r io r an d th e adduct o r m ag n u s It .

arise s fro m t he lat e ra l bord e r o f th e isch ia l tu be ro sity an d ,

p r o c e e d s h o r iz o n ta lly to ga in i n se rt io n in t o t h e quadrat e
tu be rc le an d in t o a lin e wh ich e x t e n d s d ista lly fro m it o n
, ,

t h e back o f t h e fe m ur fo r a bo ut t wo in ch e s ( F ig s 1 2 1 , .
,

D is s e c t i o n — Th n rv t o t h e q adr t f m ri h u ld n w
e e e u a us e o s s o o
b tr
e d t it s t rm i at i
a ce o I t li d p t t h tw e g m lli n o n . es ee o e o e e ,
t h o bt rat r i t rn s a d t h q ad at
e u o n e f m ri Th u h tu ,
n e u r us e o s . e o
ra t o r in t rn h as alr ady b n div id d
e us N w div id t h tw o e ee e . o e e
g m lli m l s l t ral t t h
e e u sc e rv R ais t h m dial p art
,
a e o e ne e . e e e s
a d f ll w t h
n o orv b h in d t h m eA t h i f ri r g m ll
ne e e e . s e n e o e e us
si ap p ro a h d se r thc tw ig w h i h th n rv
e cu pp li e t o it e c e e e su es .

L a t ly div id t h
s ,
fl at q adrat e f m ri m idw ay b tw n th
e u us e o s, e ee e
t b r it y f th i h i m d th f m r a d t h r w th tw p art
u e o s o e sc u an e e u n o e o s
a id
s e Wh . t h di t i n is mp l t d o t ly i t h w h le
en e sse c o co e e n o n s e o
l n gt h o f t h
e rv t t h q adrat e ne f m ri p e d b t al
o a e u us e o s ex o se ,
u so
co n s id rabl p rt io n f t h p t ri r
e e op t f th p lo f the e o s e o as ec o e ca su e o
h ip j i t i laid bar ; f rt h r p art
o n s f th bt rat o r et rn u e ,
o e o u ex e us
m s l t h t rm i at i n o f t h m di l ir u m fl
u c e, e e n a rt ry nd
o e e a c c ex e ,
a
t h e in s rt i n f the ili p o a ar br gh t i t o v i w
o o e Th o -
s s e o u n e . e
ex p s d p st ri r p art
o e o f th ap
e l f t h h ip j o in t co n i t s
o o e c su e o e s s
larg e ly o f c ircu larl y arran g e d fi bre s .

N e rv e t o Q ua drat us F emo ris Th e sm a ll n e rv e t o

t he —

t h e quadratu s fe m o r is ru n s d ista lly o n t h e hip bo n e an d

p a ss e s succ e ssiv e ly a n t e r io r t o t h e fo llow i n g structur e s : t h e

sc iat ic n e rv e t h e g e m e llu s su p e r ior th e t e n do n o f the o bturat o r

, ,

in t e r n u s t h e g e me llu s in fe r ior
, I t g iv e s t h e n e rv e o f su p p ly .

to th e g e me llu s in fe rior an d a tw ig to the hip jo in t an d e n d s ,

by sin kin g in t o t h e d e e p surfac e o f t h e quadratu s fe m or is .

M O bt urat o r Ext e rnus

. Th e t e r m in a l p art o f t he o bturator .
—

e x t e r n u s m u sc le c an n o w be se e n w in d in g r o u n d t h e n e ck o f

t he fe mur I t e n d s in a r o u n d e d t e n do n wh ich is im p la n t e d
.

in to th e fo ssa trocha n t e r ica o f the fe mur ( F ig 1 2 2 p .

,
.

I t s o r ig in has a lr e ady be e n e x a m in e d ( p .

Art e ria Circumfl ex a F e mo ri s M e di a lis Th e me d ia l c ir —

c u m fl e x art e ry co m e s t o an e n d at t h e p ro x im a l bo rd e r o f

t he adduct o r m ag n u s by d iv id in g in t o it s a sc e n d in g an d tra n s
v e r se t e r min al bra n ch e s The ascending branc/c ru n s o bliqu e ly .

u p ward s an d lat e ra lly a n t e r ior to the quadratu s fe m oris ,

an d u p o n th e p o st e r io r sur fac e o f t h e o bturator e x t e r n u s .

I t s t e r min a l tw ig s ra m ify in t he n e igh bo urh o o d o f th e

tr o chan t e r ic fo ssa wh e r e th e y a n a st o m o se w ith tw ig s fro m
,
 G L UTE AL RE G I O N 3 0 1

the in fe r ior u p e r io r g lut e a l art e rie s The tran sverse

an d s .

branc/z p a sse s p o st e r io rly be tw e e n t h e quadratu s fe m oris an d

,

th e adduct o r m ag n u s an d e n t e r s th e ha m str in g m u sc le s
, It .

a n a sto mo se s w ith the t e rm in a l tw ig o f the midd le d ivisio n o f

t h e lat e ra l c ircu m fl e x art e ry wh ich in a w e ll in j e ct e d su bj e ct , ,
-

w ill be n ot ic e d a pp e ar in g fro m a mid st the fi bre s o f the p ro x ima l

p art o f t h e va stu s lat e ra lis A n art e r ia l c irc le is thu s c o m
.

p le t e d arou nd ,
t h e p ro x im al
p art o f
'

t h e fe m ur ; it c o m
mu n icates p ro x im a lly w ith th e in fe r ior g lut e a l art e ry an d
d ista lly w ith th e fir st p e rforat in g art e ry Th is se rie s o f in .

o scu lat io n s is so me t im e s sp ok e n o f as the cru ci al an asto mo sis

O f th e th igh .

The d isse ctor h as n o w e x a m in e d all th e structur e s in the

glut e a l r e g io n wh ich lie be low th e le v e l o f the p irifo r mis .

H e shou ld in the n e x t p lac e tur n his att e n t io n to that

, ,

p ort i o n o f t h e d isse ct io n wh ich lie s a bo v e t h e le v e l o f

that mu sc le Th e r e h e w ill find se v e ra l structur e s wh ich lie
.

in c lo se r e lat io n to the dor su m ilii Th e se are th e gluta u s .

m e d iu s th e glu ta u s min imu s an d th e t e n so r fa sc ia lat a

, , ,

tog e th e r w ith the blood ve sse ls an d n e rv e wh ich su p ply th e m

-

v iz . th e su p e r ior g lut e a l art e ry an d v e in an d t h e su p e r ior

, ,

glut e a l n e rv e .

The p o st e r ior p art o f t h e glu ta u s m e d iu s m u sc le was

cov e re d by the glu ta u s ma xim u s I ts a n t e rior bord e r is .

ov e r la p p e d by the t e n sor fa sc ia lat a an d the in t e r me d iat e ,

ar e a is in v e st e d by the d e n se fa sc ia l lay e r a lr e ady r e fe rr e d to .

i
D is s e c t o n — v
R e m o e t h e f as cia f ro m t he su p e rfi cial su rf ace
o f t h e glu t a u s m e diu s an d p u ll t h e e n so r f ascia la a f o r ard t t w .

M Glut a us M
. e dina — Th e glu t a u s me d iu s ar ise s fr o m
that p art o f t h e do r su m ilii wh ich is bou n d e d abov e by th e
p o s t e r ior curv e d lin e an d t h e a n t e ri or four fift h s o f t h e cr e st o f -

t he iliu m an d be low by t h e a n t e r ior g lut e a l lin e ( F ig 1 2 8

,
.
,

p . 2 86
) it d e riv e s fi br e s a lso fro m t h e stro n g fa sc ia wh ich

c o v e r s it The fi br e s co n v e rge to fo r m a flatt e n e d ba n d

.
,

p art l y fl e shy an d p art ly t e n d in ou s wh ich is in se rt e d in t o an ,

o bliqu e lin e o n the lat e ral a sp e ct o f the gre at e r trocha n t e r

o f th e fe mur an d in to t h e sur fac e imm e d iat e ly a bov e it
,
.

The glu ta u s m e d iu s mu sc le is su p p lie d by th e sup erio r glu teal

n erve AS a who le th e mu sc le is an a bductor o f th e th igh
.
,

bu t its a n t e r ior fi br e s can rotat e the th igh me d ia lly and th e ,

o st e r i o r fi bres can rotat e it lat e ra lly

p .
 3 0 2 T HE I N F ER I OR EXTRE M I TY
D is s e c t io n — Th e glu t a u s m e diu s m u s n o w be re fl e c e d
. t t .

t
K e e p t h e e n so r f asc ia p u lle d w e ll f o r ard I n se r t h e fi n g e rs w . t
w t
be t e e n t h e p o s e rio r bo rde rs o f t h e glu t a u s m e diu s a n d m in im u s ,
t
a n d s e p ara e t h e m u scle s , f ro m be h in d f o rw ards , t o h e ir an e rio r t t
w
m arg in s , h ic h w e re e x p o se d an d de fi n e d in t h e disse c io n o f t h e t
t
an e rio r p ar o f t h e t h igh (se e p t Th e n di ide t h e m e diu s . v
v
tw o in c h e s abo e t h e ro c h an e r m aj o r t
Tu rn t h e lo w e r p ar t . t
t o w ards t h e t t t
ro c h an e r, in o wh ic h it is in se rt e d, an d t h e u p p e r

p ar t t
o w ards it s o rig in f ro m t h e iliu m As t h e lo e r p ar o f . w t
t
t h e m u scle is re fl e c e d t o it s in se r io n in o t h e o bliq u e lin e o n t t
t t
t h e la e ral su rf a c e o f t h e ro c h an e r m aj o r, a sm all bu rsa ill t w
be disp lay e d be tw
e e n t h e m u sc le an d t h e u p p e r a n d an e rio r t
t t
p a r o f t h e la e ral su rf ace o f t h e ro c h an e r W h e n t he u p p e r t t .

t t w
p ar o f t h e m u scle is raise d, o a rds it s o rig in , t h e bran c h e s o f
t v
t h e su p e rio r g lu e al e sse ls an d th e su p e rio r g lu e al n e r e , h ic h t v w
t
lie be w e e n t h e glu t a u s m e diu s a n d m in im u s , ill be e x p o se d ; w
t t
h e y m u s be care fu lly cle an e d an d p re se r e d, e x ce p th e sm alle r v t
tw ig s w t
h ic h e n e r th e de e p su rfa ce o f t h e glu t a u s m e diu s h ic h w
m ay be o u t if h e y in e rf e re t t wt
i h t h e re fl e c io n o f t h e m u sc le t .

t
As t he bran c h e s o f t h e ar e ry an d n e r e are f o llo w e d t h e su p e r v
fi cial su rf ace o f t h e glu t a u s m in im u s m u s be c le an e d t .

N e rv us Su
Glut a u s t r e me rg in g fro m the
p e ri o r .
— Af e

p e lv is thr,
o ugh t h e gr e at e r s c iat ic fo ra me n the su pe r io r ,

glut e a l n e rv e tur n s forward be tw e e n the glu ta u s me d iu s an d ,

m in imu s an d imm e d iat e ly d iv id e s in to an u pp e r an d a low e r

,

bra n ch Th e u p p e r bra n ch fo llo w s th e u pp e r bord e r o f th e

.

lu t a u s m in imu s an d it g iv e s bra n ch e s to t h e glu ta u s m e d iu s

g .

The lo w e r bra n ch o f t h e n e rv e cro sse s t he m idd le O f th e

g lu t a u s m i n im u s w ith t h e lo w e r bra n ch o f t h e s u p e r ior
g lut e a l art e ry I t su pp lie s bra n ch e s to bo th the glu ta u s
.

me d iu s an d m in im u s th e n p a sse s be tw e e n the a n t e r ior

,

bord e r s o f tho se two m u sc le s an d e n ds in th e t e n sor fa sc ia t

lat a .

Art eria Glu t a a Su p e r io r The su p e r io r g lut e a l art e ry is

.
—

a larg e v e sse l wh ich sp r in g s fro m the hyp oga stric art e ry an d

e sca p e s fro m th e p e lv is through th e u p p e r p art o f t he gr e at
,

sc iat ic fo ra m e n a bov e t h e le v e l o f t h e p ir ifo r m is

,
.

I m me d iat e ly a ft e r its e x it it d iv id e s in to a su p e rfic ia l an d ,

a d e e p d iv isio n The superficial divisio n h as be e n a lr e ady

.

se e n du rin g th e re fl e ct io n o f the glu ta u s m a x imu s I ts .

bra n ch e s are d istr ibut e d t o the d e e p sur fac e o f that mu sc le .

Th e deep divisio n bifurcat e s c lo se to its or ig in in to a , ,

su p e r ior an d an in fe r ior bra n ch wh ich ru n fo rward s be tw e e n ,

the glu t a u s m e d iu s an d m in im u s Th e superio r éran c/z .

fo llow s accurat e ly t he a n t e r ior g lut e a l lin e o n t h e dor su m ilii ,

an d at th e a n t e r ior su p e r ior Sp in e t e r m in at e s by a n a sto m o s

, ,

in g w ith t he su p e rfic ia l an d d e e p c ircu m fl e x iliac art e r ie s ,

 THE I N F ER I OR EXTRE M I TY
attach e d to th e ac e tabu lar rim M a n y o f th e fi br e s o f t he .

p o st e r ior p art o f t h e ca p su le ru n c ircu lar ly r o u n d t h e n e ck

o f t h e fe mur Oth e r s ru n p ara lle l w ith the n e ck at r ight
.
,

a n gle s to the c ircu lar fi br e s an d in th e low e r p art o f th e ,

ca p su le wh ich is cov e r e d by th e o bturat o r e x t e r n u s is a

, ,

ba n d o f fi br e s th e isclzio cap su lar fiand wh ich ru n s u p ward s

,
—
,

an d lat e ra lly p ara lle l w ith th e course o f t he O bturator

e x t e rn u s .

Th e r e fl e ct e d t e n d o n o f th e r e ctu s fe m o r is is attach e d to
th e floor o f a groov e situat e d imm e d iat e ly a bov e th e u p p e r

p art o f t h e m arg i n o f t h e ac e ta bu lu m an d is th e r e e mbe dd e d ,

in th e su p e rfic ia l fi br e s o f t he ca p su le wh ich m u st be r e m ov e d ,

t o e x p o se it by cutt in g thr o ugh th e m p ara lle l w ith t h e

,

d ir e ct io n o f the t e n do n .

F O SSA POP LI TE A ( POP L I TE AL SP AC E ) .

Th e p o p lit e a l fo ssa h o u ld be d isse ct e d if p o ssible be fo re

S , ,

th e p o st e r io r r e g io n o f t h e th igh is d istur be d in o rd e r that ,

it s co n t e n t s m ay be e x a m in e d be fo r e th e m e d ia l an d lat e ra l
bou n dar ie s o f its p ro x im a l p ort io n are d isp lac e d fro m th e ir
p o sit io ns D.ur ing t h e d isse ct io n t h e fo llo wing structur e s

w ill be m e t w ith
H Su p e rfi cial fascia .

N The sm all saph e n o u s v e in .

m Th e p o st e rio r cu tan e o u s n e rv e f the t h igh

‘

o .

é P l
o p it e al fascia .

fe m o ris .

M uscle s wh ich bo un d
Se m im e m bran o su s
the
fo ssa
.

G astro cn e m iu s .

lan t aris P .

Th e tibial an d co m m o n p e ro n e al n e rv e s an d th e ir bran ch e s .

l
The p o p lite a arte ry an d v e in an d th e ir bran ch e s an d tribu tarie s .

A fe w ly m p h g lan ds .

A Sle n de r bran ch fro m th e o btu rato r n e rv e .

The p o plite u s m u sc e l .

Surf ac e An at o my Th e ar e a o f the p o p lit e al fo ssa is

.
—

p po u lar ly ca lle d t/ze lza m I t is situat e d in t h e p o s t e r i

.or
r e g io n o f the k n e e an d it lie s be h in d the d ista l th ird o f th e
,

fe mur t h e k n e e jo in t an d t he p r o x im a l fi fth o f t h e t ibia

, , .

I t a p p e ar s as a ho llow wh e n t h e k n e e j o in t is fl e x e d bu t ,

fo r ms a Slight p ro min e n c e wh e n th e j o in t is fu lly e x t e n d e d .

 POP L I TE AL F O SSA 30 5

I n t he si d es o are a a bout the m idd le o f it s le n gth

f the , ,

t h e co n dy le s o f t h e fe m ur are e a sily dist in gu ish e d ; d ista l t o

th e m lie th e co n dyle s o f the t ibia The h e ad o f th e fi bu la is
.

p o st e ri or a n d a litt le d ista l to t h e m o st p roj e ct in g p art o f t h e

lat e ra l co n dy le o f t h e t ibia .

Th e t e n do n s wh ich for m t h e me d ia l an d lat e ra l bou n dar ie s

o f t h e p ro x ima l p art o f th e p o p lit e a l fo ssa are t h e t e n do n s o f

t h e ha m str in g m u sc le s t h e bic e p s fe m or is o n th e lat e ra l sid e

an d t h e se mit e n d in o su s an d se m ime m bra n o su s o n t h e me d ia l

sid e . Th e y can be se e n in both th e e x t e n d e d an d fl e xe d

p o s i t io n s o f t h e k n e e b u t
,
th e y a re m o s t o b v i ou s wh e n t h e

k n e e is fl e x e d Wh e n the k n e e is fl e x e d an d d e e p p re ssure
.

is mad e in the midd le o f the ho llow be tw e e n th e ha m strin g

t e n do n s the ( in j e ct e d ) p op lit e a l art e ry can be d ist in gu ish e d
, ,

an d in t h e liv in g su bj e ct t h e p u lsat io n s o f t h e art e ry c an be

fe lt. Th e bic e p s t e n do n S hou ld be fo llow e d to its in se rt io n

in to the h e ad o f t h e fi bu la wh ilst t h e k n e e is fl e x e d th e n t he ,

k n e e shou ld be e x t e n d e d Wh e n that has be e n do n e an d

.

p r e ssur e is m ad e imme d iat e ly a bov e th e h e ad o f t h e fi bu la ,

at the a n t e rior bord e r o f the bic e p s t e n do n the p ro xima l ,

p art o f t h e cord l ik-

e fi b u la r co ll at e ra l l iga m e n t o f t h e k n e e

jo in t may be d ist in gu ish e d wh ilst o n th e m e d ia l Sid e o f th e

, ,

p o s t e r ior b ord e r O f t h e b ic e p s t e n do n t h e co ,
m m o n p e ro n e a l
n e rv e can be fe lt Wh e n a little care is e x e rc ise d th e n e rv e
.

c an be rotat e d aga in st t h e p o st e r ior p art o f t h e lat e ra l

co n dyle o f the fe mur bu t p alp at io n o f t h e n e rv e is m or e
,

e a sily do n e in th e liv in g tha n th e d e ad body Th e n e rv e

.

shou ld be fo llo w e d to th e back o f th e h e ad o f the fi bu la

wh e r e it c an be p r e sse d aga in st th e p ro xima l p art o f th e

so le u s m u sc le . Wh e n th e kn e e j o in t is e x t e n d e d the
rou n d e d t e n do n o f th e adductor m ag n u s can be fe lt as ,

it p a sse s to its in se rt io n in t o th e adductor tu be rc le wh ich lie s ,

o n th e u pp e r bo rd e r o f th e m e d ia l co n dy le at t h e d ista l e n d

o f t h e me d ia l su p raco n dy lar r idg e The adduct o r tube rc le

.

is an imp orta n t p ract ica l la n d m ark fo r it in d icat e s t h e p la n e

,

o f j u n ct io n o f th e bo dy o f t h e fe m ur w ith t h e d ista l e p ip hy sis .

I n m u scu lar su bj e ct s th e two h e ad s o f th e ga stroc n e m iu s

mu sc le for m p ro m in e n t r o u n d e d cu sh io n s wh ich e x t e n d fro m
th e d ista l p art o f th e p o plit e a l ar e a in to th e p ro xim a l p art o f
t h e p o st e r ior r e g io n o f t h e le g .

Pro x ima l to the p o plit e al re g io n th e p o st e rior r e g io n o f the

th igh p r e se n t s a smooth rou n d e d sur fac e o n wh ich in th in , ,

V OL . 1— 20
30 6 TH E I N F E R I O R EXTRE M I TY
su bj e ct s in d icat io n s o f th e out lin e s
, o f t h e be llie s o f the
ha m str in g mu sc le s may be se e n .

D is s e c t i o n — R e fl e ct io n o f t h e Sk im— lace a blo ck u n de r P

t h e k n e e t o su p p o rt t h e lim b a n d t o re n de r e n se th e m u scle s t
w h ich f o rm the bo u n darie s o f t h e p o p li e al f o ssa I n ci sio ns t .

v t
( 1 ) A e r ical in c isio n alo n g t h e m e dian lin e o f t h e lim b f o m r
t
t h e j u n c io n o f t h e m iddle an d dis al t h irds o f t h e h igh t o th e t t
t
j u n c io n o f th e p ro x im al f o u r h i h t h e dis al h re e fo u rt h s t wt t t -

o f t h e le g t
(2 ) A ran s e rse in cisio n at t h e p ro x im al e n d o f
. v
the v
e rt ic al in c isio n (3 ) A ran s e rse in c isio n at th e dis al
. t v t
end o f th e v
e rt ic al in cisio n Eac h o f t h e tw o ran s e rse . t v
t
in cisio n s s h o u ld e x e n d h alf w ay ro u n d th e limb .

Th e tw o fl ap s o f sk in de fi ne d by th e in cisio n s (2 1 an d 2 2 ,
t t
F ig 1 2 6 ) m u s be se p ara e d f ro m t h e su p e rfi c ial f asc ia an d u rn e d
. t
t tv
t o h e ir re sp e c i e side s .

Sup e rfi cial F a scia — V e n a Sap h e n a P arv a ( O T Ext e rna l . .

Sap h e n o u s V e in) — B ranch es o f t h e P o st e rio r C u t an e o u s

N e rv e o f t he Thi gh ( O T Small Sc ia t ic) — Wh e n th e Sk in . . .

is r e fl e ct e d t h e fatty lay e r o f t h e su p e rfic ia l fa sc ia o f t h e

p o p lit e a l r e g io n is brought in to v ie w I t p r e se n t s n o p e cu liar .

fe atur e s an d as a ru le it co n ta in s o n ly a m od e rat e a mou n t

, , ,

o f fat a m id st wh ich t h e fo llow in g structur e s m u st be so ught

,

( 1
) T h e p r o x im a l
p art o f t h e s m a ll sa lz en o u s vein ;
p ( )
2 t h e

t e r min a l p art o f th e p o st e r ior cuta n e ou s n e rv e o f the th igh ;

( )
3 b ra n ch e s o f t h e p o st e r ior cuta n e o u s n e rv e o f t h e th igh ;
( )
4 t h e p o s t e r ior b ra n ch o f t h e m e d ia l cuta n e ou s n e rv e o f
t h e th igh 5) t h e a n a sto m ot ic p e ro n e a l n e rv e .

D is s e c ti o n — Lo k fi rst f r t h e sm all sap h e

o v in I t
o no us e .

asce n ds alo n g the f t h e back o f t h e c alf an d p ie rce s

m iddle lin e o
v
th e de e p f as c ia o e r t h e dis al p art o f t h e p o p li e al f o ssa t As t .

t v
t h e p ro x im al p ar o f t h e e in is be in g c le an e d se c u re t h e e rm in a l t
t r
p a rt o f t h e p o s e io r cu an e o u s n e r e o f t h e h igh t h ic h ru n s v t w
alo n g side o f t h e e in v
At a h igh e r le e l, in t h e f at in t h e m iddle
. v
lin e o f t h e p ro x im al p art o f t h e p o p li e al are a o n e o r m o re w ig s t t
t t
f ro m t h e p o s e rio r cu an e o u s n e r e o f t h e h igh m ay be f o u n d, v t
p ie r c in g t h e d e e p f as c ia o n h e ir w a y t o t h e sk in t .

W h e n th e m e dial side o f th e h igh w as disse c e d th e p o s e rio r t t t

t
bran c h o f t h e m e dial cu an e o u s n e r e o f t h e h igh w as f o u n d v t
de sce n din g alo n g t h e p o s e rio r bo rde r o f t h e s ar o riu s m u sclet t
( g
F i I t s h o u ld b e f o llo w e d n o w a s it d e sce n ds be h in d t h e

m e dial bo u n dary o f t h e p o p li e al fo ssa t o t h e bac k o f t h e calf t .

t t
Th e p e ro n e al an as o m o ic n e r e m ay be f o u n d at t h e lo w e r an d v
t t t
la e ral p ar o f t h e p o p li e al are a as it p ie rce s t h e de e p f asc ia
co v t
e rin g t h e la e ral h e ad o f t h e g as ro cn e m iu s m u scle (F ig t .

v
I n so m e c ase s , h o w e e r, t he n e r e p ie rce s t h e de e p f ascia at a v
t v
m u c h m o re dis al le e l I n su c h c ase s it ill n o t be f o u n d u n il
. w t
t h e back o f t h e le g is disse c e d t
Af e r t h e sm all sap h e n o u s . t
v e in an d t h e n e rv e S m e n t io n e d h a e be e n se c u re d an d cle an e d,
t v
v
re m o e t h e re m ain s o f t h e su p e rfi cial f ascia , bu t be c are fu l t o
v
a o id in j u ry t o t h e de e p f ascia h ic h is so m e h a h in w w tt .
 TH E I N F ER I OR EXTRE M I TY
ne rve p r e v iou sly d isse ct e d ( p 2 7 I t d e sc e n d s in c lo s e .

a p p o sit io n to th e p o p lit e a l art e ry Oth e r imp orta n t c o n t e n t s .

o f t h e fo ssa are ly mp h g la n d s s o m e o f wh ich lie r e lat iv e ly -

su p e rfic ia l n e ar th e p o in t wh e r e t h e sm a ll sa p h e n ou s v e in
,

M b . i ce p s fe m o r s i M . se m i i
t e n d no su s

M m ime m bran o su s
’

. z se

Te n do n o f addu c t o r ma g n us

C o mmo n p e ro n e a n e r e l v
( O T e x t p o p te a )
. . . li l P li l y
o p te a art e r

Ti bi l v ( i p p li l )
a ne r e n t. o te a
A . g e n u su p e r o r i l at e ra li s
A g p i m di li
C o mmo n t ru n k o f l at e ra l .

d f m ll
e n u su er o r e a s

c u t a ne o u s n e r e o v f t he C ut en o s a

ca lf a n d an ast o mo t c i saph vi e no us e n

p e ro n e a l n e rve M di l edy l a f f m co n e o e ur

Pl a n t ar s i T d en f mi di
o n o s se te n n o su
M g . mi m di l h
as t ro c n e u s, e a e ad
T d en f g ili
o n o rac s
M g ast ro c n e m u s i P p li t l i
l lh ea
.
o ve n
at e ra e ad

M ed a il c u t an e o u s n e r e v N er v e to po p li t e us mu sc l e

f t he ca f o l
( O T ram u s co m
i i li
. .

m u n ica n s t b a s )
Te n do n o fp l an tar s i m u sc l e

N e rve t o so l e us

So l e us

FI G . 1 32 .
— Di sse c t o n o i f th e L e f t P o p li te al Fo ssa . Th e p ro xi m l b a o u n dar e s i
have bee n p ull e d ap art an d t he ap o n e uro si s i n to wh i c h th e two h e ads o f
th e gastro cn e m i u s is at tach e d has be e n Sp li t an d t h e h e ads h ave be e n
di sp l ac e d t o th e i r re sp e c t i ve side s .

p ie rc e s t h e o
p p lit e a l f a sc ia b u t t h e m ajor ity are d e e p y
l ,

p lac e d adjac e n t to t h e p o p lit e a l v e in a n d art e ry .

D iss e c ti o n — D o n t att mp t t o o p n u p t h e po p lit e al f o ssa o e e

an d disp lay it o n t e n t s u n t il it p ro im al bo u n dar e h av be n
s c s x i s e e
l an e d an d t h e ir re lat io n sh ip s to t h e f o ssa h av be e n d fi n e d
c e e e .
 POP L I TE AL F O SSA 3 0
9

Th e dis t al bo n darie s w ill be cle an d an d disp laye d as s m e o f

u e o
t h e co t ts f th f o sa are se cu r d an d fo llo w e d t o w ard t h ir
n en o e s e s e
t e rm i at i n s n o .

Cl an fi r t t h p ro im al lat ral bo u n dary

e s e M ak e an in isio n
x e . c
t h ro u gh th e d p fascia al n g its m dial m arg in tu rn th fas ia
ee o e , e c
lat r lly an d
e a p o s t h bic p f m o ris ex Cl an t h m u cl an d its
e e e s e . e e s e
t n d n f o llo w t h t d n t it i s rt io n in t o th e h ad f th
e o , e en o o s n e e o e
fi b la an d n t e t h at at th l v l f t he k n e e t h e bi p f m o ri
u , o e e e o ce s e s
cr s t h lat ral h e ad f t h e g as t ro
o sse e e mi Af t e rt h di t al p art
o cn e u s. e s
o f t h e bi p f mo ris h as b e n cl an d t rn t o t h e p ro im al m e dial
ce s e e e e , u x

bo r de r o f t h e p ac ; m ak e an in isi n t h ro gh t h d p f as cia
s e c o u e ee
alo n g it lat ral m arg in an d r e fl e ct t h e f ascia co v rin g it t o w ard
s e ,
e s
t h e m dial id t o ex p o e th s se m it e n din o u s an d se m im m
e se e s e
bran s m s l ; f o llo w t h te n do n o f the m o r s p e rfi ci l
’

o su u c e e e u a
s m it n di o
e e m uscle t o t he l v l f t h e m e dial
n su s n dy l e e o co e
o f t h t ibia e Th n p ll t h se m it e n din o u s as ide an d l an t h e
. e u e s c e
di t al p art
s f th se m im e mbran o o an d f o llo w it
e te n do n su s , s
t o its in e rt i n in t o t h e m e dial
s o dy l o f t h e t ibia Pr co n e . e
s rve if p o ssible t h m u scu lar br an h
e o f t h e p o p lit e al art e ry
e c es
w h i h n t r t h lat e ral p art o f t h m u scle an d n o t e t h at t h e
c e e e e ,

t n do n f in rt io n sp rin g s m ain ly fro m th lat ral bo rd r a d

e o se e e e n
a n t e rio r ( d p ) su rf ac o f t h e m u scle
ee P u ll t h e p art f th
e . o e
m scl w h ic h lie at t h le v e l o f t h e m dial co n dy l o f t h e fe m r
u e s e e e u
t w ards th e m dial sid f t h k n e an d di p lay t he s m i
o e e o e e s e
m e m bran o s s b rsa w h i h lie s b tw e e n t h se m im e mbran o su s
u u ,
c e e
an d t h e m dial h e ad o f t h e g ast ro cn e m iu s as t h e y c ro ss o n e
e
an o t h e r Th e se m im m bran o su s bu rsa o ft e n co mm u n icat s
. e e ,

ro u n d t h m e dial bo rde r o f t h e g ast ro n e m iu s w it h a bu rsa

e c ,

w h ic h lie s b tw e e n t h e m dial h e ad o f t he g ast ro cn e m iu s a d

e e n
t h e back f t h e k n e e j o in t an d t h at in tu rn
o o mm u n ica t e w it h , , ,
c s
t h e av it y c f t h e k n e e j o in t o Op e n t h e bu rsa an d if p o ssible .
, ,

di p lay t h e co mmu n icat io n s w h ich h av e be e n m e n t io n d w it h

s e
t h e a id o f a p ro b N o w p u ll t h se m it n din o su s a d se m i
e . e e n
m mbra s s lat rally an d l an t h e g racilis w h i h lies m e dial
e no u e c e , c
an d an t rio r t o t h e m e At t h e an t e rio r bo rde r o f t h e g racilis .

th esap h e n o s n e rv e e m e rg es b tw e e n t h e
u g racili an d t h e s e

p st e rio r bo rd r o f t h e sart ri s acco m p an ie d by t h e sap h e n o

o e o u us
bran c h o f t h e art ria g e n u su p re m a ; s cu re th e art ry an d e e e
n rv e an d f o llo w t h m do wn w ards t o t h e m e dial bo r d r o f t h e
e e e
t ibia an d n o te t h at t h e y acco mp an y th e great sap h e n o s v in u e ,

w h i h was e p o s d w h e n t h e m dial side o f t h e t h igh wa

c x e e s
disse ct e d Th e n p ll t h e g racilis m e dially an d cl an t h e dist al
. u e

p a r t f t h oe a dd u c t o r m a g n w h ic h lie s l a t e r al t o it us .

W h n th p ro im al bo u n daries o f th e f o ssa h ave b n cle an e d

e e x ee
an d ex am in e d se iz e t h p o t e rio r t a n
,
e o u s n e rv e o f t h e t h igh
e s cu
a t t h p o in t w h e r it p i rce s t h e p o p lit e al f ascia ( se e p
e e an d
e .

f ll w it t t he p ro im al an gle o f t he f o ss a dividin g t h e p o p lit e al

o o o x ,

f ascia w h i h lie s s p e rfi cial t it ; t h e n r m o v e t he re m ain o f

c u o e s
t h e p o p lit e al f ascia f ro m t h e p ro im al p art o f t h e p o p lit e al are a x .

N o w p u ll t h p o st e rio r c t an o s n e rv a ide w it h a h o o k an d
e u e u e s , ,

cu t t h ro u gh t h f at in t h p ro im al ap e e o f t h e f ssa t ill t h e e x x o

larg t ibial n e rv e is e p o s d
e F o ll w t h e t ibial n e rv e distally x e . o ,

c le an in g it p art ly w it h t h aid o f t h e h an dle o f t h e scalp e l an d

,
e

p art ly by o c casio n al t o c h s w it h t h p o in t o f th e scalp e l an d u e e ,

s cu r
e it s cu tan e o s m sc lar an d art icu lar bran c h e s
e u ,
I ts u u , .

cutan e o u s bran c h the medial cu taneo us nerve o f the calf arises

, ,
3 1 0 TH E I N F ER I OR EXTRE M I TY
t
f ro m its p o s e rio r asp e ct an d de sce n ds be w e e n t h e tw o h e ads t
t
o f t h e g as ro cn e m iu s F o llo w h a bran c h to th e dis al an gle. t t t
v
o f t h e f o ssa, di idin g t h e p o p li e al f asc ia su e rfi c ial t o it
p Th e t .

art icu la r bran c h e s are h re e 1 n n u m be r, sup eri r me dial ge nicu lar,

o t
i nf erio r medi al e n icu lar, an d mi ddle ge nicu lar A ll h re e t
g
.

bran c h e s sp rin g o m t h e m e dial side o f t h e ibial n e r e , t h e t v

su p e rio r bran c h at o r abo e t h e p ro x im al an g le o f t h e f o ssa, an d v
t
t h e o h e r tw o at m o re dis al le e ls Eac h j o in s a co rre sp o n din g t v .

bran c h o f t h e p o p li e al a r e ry , an d is dis ribu e d t i h it t

Th e t t wt .

su p e rio r bran c h le a e s t h e f o ssa abo v

e t h e m e dial c o n dy le o f v
th e f e m u r, t h e in fe rio r bran c h u rn s m e dially be lo t h e m e dial t w
c o n dy le o f t h e t
ibia , an d t h e m iddle bran c h p ie rce s t h e p o s e rio r t
t
lig am e n o f t h e k n e e j o in Th e muscu lar bran ches arise abo u t . t
t h e m iddle o f t h e f o ssa an d p ass t o t h e tw o h e ads o f t h e g as ro t
t
c n e m iu s , t h e p lan aris , t h e so le us , an d t h e p o p li e u s t h e h e ads t
t
o f t h e g as ro c n e m iu s m u s be se p ara e d t o o b ain a p ro p e r ie t t t v w
o f t
h e se bran c h e s Th e bran c h t o t h e so leu s ill be re co gn ise d
. w
w
be c au se it p asse s be t e e n t h e p lan aris an d t he la e ral h e ad o f t t
t
t h e g as ro cn e m iu s Th e n e r e t o t h e p o p li e u s lie s de e p ly in
. v t
t
t h e an g le be w e e n t h e h e ads o f t h e g as ro cn e m iu s su p e rfi c ial t
t o t h e p o p li e al ar e ry t It t
ill be f o llo e d t o its e rm in a io n . w w t t
in a su bse q u e n disse c io n (se e p t t .

t
W h e n t h e ibial n e r e an d its bran c h e s h a e be e n cle an e d v v
re t u rn t o t h e p ro x im al an g le o f t h e f o ssa , disse c in t h e f at la e ral t t
t v
t o t h e ibial n e r e at t h e m e dial bo rde r o f t h e bice p s, a n d se cu re
t h e co m m o n p e ro n e al n e r e I t de sce n ds alo n g t h e m e dial v .

bo rde r o f t h e bice p s, an d le a e s t he f o ssa at t h e la e ral an g le , v t

c ro ssin g su p e rfi cial t o t h e p lan aris a n d t h e la e ral h e ad o f t h e t t
t
g as ro cn e m iu s (F ig F o llo w t h e n e r e care fu lly f ro m
. v
abo e dov n w ards w W h ils it is in t h e f o ssa it g i e s o ff two
. t v
art icu lar bran c h e s, sup eri o r lateral gen icu lar, an d inf eri or
lateral gen icu lar, an d a cu an e o u s bran c h , t h e an asto m o ti c t
p ero n e al n e rve , w
h ic h cro sse s t h e la e ral h e ad o f t h e g as ro t t
cn e m i u s AS t h e co mm o n p e ro n e al n e r e lie s su p e rfi cial t o
. v
t
t h e la e ral h e ad o f t h e g as ro cn e m iu s it g i e s o ff t h e latera l t v
cu tan eo us n erve o f the ca l f ,
h e n it p a sse s p o s e rio r t o t h e h e ad o f t t
t h e fi bu la, f ro m w
h ic h it is se p ara e d by t h e h igh e s fi bre s o f t t
t h e s o le u s, an d disapp e ars be w e e n t h e p e ro n e u s lo n gu s an d t h e t
n e c k o f t h e fi bu la Th e su p e rio r la e ral art icu lar bran c h le a e s
. t v
t h e f o ssa p ro x im al t o t h e la e ral co n dy le o f t h e f e m u r i h th e t wt
co rre sp o n din g bran c h o f t h e p o p li e al art e ry Th e in fe rio r t .

t t
la e ral ar icu lar bran c h j o in s t h e in f e rio r la e ral g e n icu lar t
t
bran c h o f t h e p o p li e al ar e ry at t h e la e ral side o f t h e k n e e t t
be tw e e n t h e h e ad o f t h e fi bu la an d t h e la e ral c o n dy le o f t h e t
fe mu r t
Th e la e ral cu an e o u s n e r e o f t h e c alf an d t h e an asto
. t v
t t
m o ie p e ro n e al cu an e o u s b an c h so m e im e s arise f ro m t h e r t
c o mm o n p e ro n e al n e r e by a co m m o n s e m (se e F ig v t .

v
W h e n th e n e r e s m e n io n e d h a e be e n f o u n d an d cle an e d, cle an t v
t h e tw o h e ads o f t h e g as ro cn e m iu s an d se p ara e t h e p lan aris t t t
f ro m t h e m e dial bo rde r o f t h e la e ral h e ad, ak in g c are n o t t o t t
v
in j u re t h e n e r e t o t h e so le u s h ic h p asse s be e e n t h e p lan aris w tw t
t
an d t h e la e ral h e ad o f t h e g as ro cn e m iu s As t h e m u scles are t .

t
cle an e d, n o e t h e bran c h es o f t h e p o p li e al a rt e ry h ich p ass t o t w
t v t
h e m , bu t di ide h o se bran c h es if h e y in e rfe re i h th e se p ara t t wt
t io n o f t h e m u scle s .

t v
Th e p o p li e al e in an d its ribu arie s an d t he p o p li e al art e ry t t t
 3 1 2 TH E I N F ER I OR EXTRE M I TY
in to v ie w
by dissectio n diff e rs wide ly fro m the c o n ditio n wh ich is o bse rv e d
wh e n t ran sv e rse se ctio n s are m ade th ro u gh th is p art o f the fro e n lim b z
( F ig . B e fo re the in te gu m e n ts an d fascia are re m o v e d all th e p art s
l
are t igh t y brace d t o g e th e r, an d th e fo ssa
p o p it e a is re p re se n t e d m e re y by l l
l
a sm a l in te rm u scu lar in te rv al be t w e e n th e distal
p art s o f th e h am st rin g

m u scle s The fo ssa in th is co n ditio n is rath e r u n de r an in ch w ide at its

.

bro ade st p art . l

Th e po p ite al arte ry , th e re fo re , as it trav e rse s th e sp ace ,
is c o v e re d by m u scle s th ro u gh o u t its wh o le co u rse , w ith the e ce p io n o f a x t
l
v e ry sm a l p art imm e diate ly p ro imal to the kn e e j o in t x .

N e rv us C u t an eus F e mo ris P o st erio r ( O T Small Sc ia t ic) . . .

Th e p o st e r ior cuta n e ou s n e rv e o f th e th igh e n t e r s the p o p lit e a l

fo ssa at its p ro x im a l a n gle an d p a sse s d ista lly imme d iat e ly
, ,

su bjac e n t to th e d e e p fa sc ia I t g iv e s o n e or two tw ig s .

through the fa sc ia to the sk in an d fi n ally p ie rc e s the fa scia in ,

th e d ista l p art o f the f o ssa I t s t e r m in a l tw ig s are d istr ibut e d

.

to the sk in o v e r the p ro x ima l p art o f the ca lf o f the le g .

N e rv as Tibialis ( O T I nt e rna l P o p lit eal N e rv e ) — Th e t ibia l

. . .

n e rv e e n t e r s t h e fo ssa at it s p ro x im a l a n g le e m e rg in g f ro m ,

u n d e r cov e r o f the bic e p s fe m oris I t ru n s v e rt ica lly dow n .

ward s to t he d ista l a n g le an d thu s bise ct s the fo ssa

lo n g itud in a lly I t co m me n c e s a bout t he midd le o f th e th igh
.

as t he larg e r o f th e two t e r min a l bra n ch e s o f t he sc iat ic

n e rv e an d it le av e s th e fo ssa at th e low e r bord e r o f t h e

,

p o p lit e u s m u sc le an d e n t e r s the p o st e rior r e g i o n o f the le g

, .

I t s su p e rfic ia l p o sit io n in the fo ssa h as a lr e ady be e n r e fe rr e d

to . Wh e n it e n t e r s th e fo ssa it lie s o n the lat e ra l Sid e o f the
p po lit e a l v e sse ls at t h e m id l,
e n gth o f t h e sp ac e -
i t cro sse s
su p e rfic ia l to th e m an d in th e d ista l p art o f t h e Sp ac e it is
,

m e d ia l t o th e m co n se qu e n t ly the mu scu lar bra n ch e s g iv e n o ff ,

in t h e low e r p art o f th e fo ssa to the lat e ra l h e ad o f t he ,

ga stroc n e miu s the p la n tar is the so le u s an d the p o plit e u s

, , ,

p a ss p o s t e r ior to t h e v e sse ls o n th e i r way to t h e m u s c le s th e y

su p p ly .

Th e bra n ch e s o f the n e rv e in t h e p o p lit e a l fo ssa are

c la ssifi e d as cuta n e ou s mu scu lar an d art icu lar , , .

Th e medial cu tan eo u s n erve of the calf is the cuta n e ou s

bra n ch I t ar ise s a bout th e m idd le o f t h e fo ssa an d p ro
.
,

c e e ds d ista lly in th e furrow be tw e e n t h e two h e ad s o f t h e

ga stroc n e miu s I t w ill a ft e rward s be see n to u n it e w ith th e

.

p e ro n e a l a n a sto mo t ic n e rv e a litt le d ista l to t h e m idd le o f t h e

,

ca lf o f th e le g to form th e n e rvu s sura lis ( F ig

,
.

Th e mu scu lar branches su p p ly both h e ad s o f the ga stro

c n e miu s t h e p la n tar is th e so le u s an d th e p o p lit e u s : th e y
, , ,

co me o ff in the d istal p art o f the fo ssa The bran ch to the .

 POP L I TE AL F O SSA 3 3 1

o
p p lit e u s r e qu ir e s sp e c ia l n ot ic e I t ar ise s m or e d ista lly tha n .

t h e oth e r s an d cro sse s t h e su p e rfic ia l sur fac e o f the p o p lit e a l

,

art e ry to r e ach the lat e ral Sid e Of that v e sse l I t th e n ru n s .

d ista lly o n the p o st e rio r sur fac e o f th e p o plit e u s m u sc le an d ,

ga in s th e a n t e rior surfac e by w in d in g rou n d the d ista l bord e r .

Th is w ill be be tt e r se e n wh e n the p o p lit e u s m u scle is d isse ct e d .

Th e articu lar br anches are thr e e in n u m be r Th e y are .

g iv e n o ff by the t ibia l n e rv e in t he p ro x im a l p art o f th e fo ssa ,

so me t im e s e v e n p ro x im a l to t h e fo ssa an d th e y acco mp a n y ,

th e m idd le g e n icu lar art e ry an d th e two m e d ia l g e n icu lar

P p ll b re a te ar ursa

B . B i ce p s

f e mo r s i
G E
. . L at e ra h e ad l
o f g ast ro

c n e m iu s .

G I . . il
M e d a he a d
o r g st a ro
P o p li l
te a art e r y
cn e m iu s

P li l v i
o p te a e n

bran o su s .

V V Tb l v (O T
0 0

i ia ne r e

p pl l)
.
ast u s
.

me d a il is
int . o i te a

se m i i
t e n d no su s

FI G . 1 33 .
— Tran sv e rse i
se ct o n t hro u gh P o p li teal Fo ssa o f th e
t he R i ght
I n fe ri o r Ex tre m i ty .

art e rie s That wh ich acco mp a n ie s t he in fe rior m e d ia l art e ry

.

is larg e r tha n t h e oth e r two an d can as a ru le be e a sily , , ,

d iscov e r e d as it ru n s a lo n g the p ro xima l bord e r o f th e p op lit e u s

m u scle .

N e rvus P e ro naeu s Co mmuni s ( O T Ex t e rn al P o p lit e al) . . .

Th e co mm o n p e ro n e a l n e rv e is th e sma lle r o f th e two t e r min a l

bra n ch e s o f th e sc iat ic n e rv e I t ar ise s fro m t h e sc iat ic .
,

n e rv e a bo ut t he m idd le o f t he le n gth o f the th igh an d it

, ,

t e r min at e s at the lat e ra l sid e o f th e n e ck o f t h e fi bu la u n d e r ,

c o v e r o f th e p e ro n e u s lo n gu s by d ivid in g in to a su p e rfic ia l ,

an d a d e e p p e ro n e al t e r min a l bra n ch I t do e s n o t trav e r se .

the e n t ir e le n gth o f th e p o p lit e a l fo ssa fo r as it ru n s d ista lly , ,

 T HE I N F ER I O R EXT R E M I TY
an d lat e ra lly
a lo n g the me dia l bo rd e r o f the bic e p s fe moris ,

it le av e s the fo ssa at its lat e ra l a n g le wh e r e it cro sse s t h e ,

p la n tar is a n d t h e l at e ra l h e ad o f t h e ga stroc n e miu s th e n it

p a ss e s be h in d t h e h e ad o f t h e fi bu la fr o m wh ich it is ,

Su p e rfi c i lf i
a asc a

M . se m i i
t e n d n o su s
D eep fa sc i a

M . se m im e mbran o su s

M . g rac ili s

i
M b ce p s fe mo r s i
i
.

M . sarto r u s

iil
Tba ne r e v (O T Su pe r o i r me d a il
in t p o p
. li l)
te a
. .

g e ni cu ar art e r l y
O igi
r n o f t he p e ro l
nea
P o li l v
p te a l
e ss e s
an as t o mo t i c ne r e v

M se m im e mbran o su s

M .
p l an t ar s i

( t e ndo n o f)

So l e us

Sm a ll sap he n o us
v e n i

FIG . 1 34 .
— P o p li te al F
The t wo h e ads o f the gastro c n e m u s an d p o
o ssa . i rtio n s

o i i i
se m m e m bran o su s an d se m te n d n o su s h ave be e n re m o v e d so
f t he as to

i l ll
d sp ay mo re fu y t he co n te n t s o f th e fo ssa .

se p arat e d by th e u p p e r p art o f th e so le u s fi n a lly it turn s

forward s t o it s t e r min at io n be tw e e n th e lat e ra l Sid e o f th e
, ,

n e ck o f t h e fi bu la an d t he ro x im a l p art o f t h e o r ig in o f
p
th e p e ro n e u s lo n gu s I t g iv e s o ff t wo cuta n e ou s an d thr e e .

art icu lar bra n ch e s .

The cutaneo u s branches are two in n u mbe r viz the an asto ,

.
,
 P L ATE XX I I

F e mu r

il l
L a te ra c o n
M ed a co n yl
d e o f fe m u r
yl
d e o f fe m u r

FI G . 1 36 .
— R di
a o grap h o f th e R gi
K nee e o n o f an ij
n e c te d i i
n fe r o r e xt iy
re m t
j T R ki
.

(Ma o r . an ne .
)
 POP L I TE AL F O SSA 3 5
1

mo tic p e ro n e a l n e rv e , an d th e cuta n e ou s n e rv e o f th elat e ra l

calf wh ich su p plie s th e Sk in o n the a n t e rio r an d lat e ra l a sp e ct o f
,

th e p r o x im a l p art o f t he le g Th e y fr e qu e n t ly tak e orig in by a

.

co mm o n st e m Th e anasto mo tic pero neal n erve arise s fro m th e

.

co mmo n p e ro n e a l tru n k in the p o p lit e a l fo ssa an d is co n t in u e d ,

d ista lly ov e r th e lat e ral h e ad Of the ga stroc n e miu s I t u lt i .

m at e ly u n it e s w ith th e m e d ia l cuta n e ou s n e rv e o f t h e ca lf to
fo r m th e n e rvu s sura lis .

Th e articu lar branches are thr e e in n u m be r Th e y are

'

th e su p e r io r an d infe r io r lat e ra l art icu lar bra n ch e s an d t h e

r e curr e n t art icu lar n e rv e The fir st two acco mp a n y the .

su p e r ior an d in fe rior lat e ra l g e n icu lar bra n ch e s o f the p o p lit e a l

art e ry r e sp e ct iv e ly Th e y are o f sma ll siz e an d are d iffi cu lt

.

to fi n d The recu rrent articu lar nerv e wh ich sp rin gs fr o m

.

t h e t e r min at io n o f th e co m m o n p e ro n e a l n e rv e will be dis

se c t e d at a lat e r stag e ( p .

Art eri a P o p lit e a — Th e p o p lit e a l art e ry is t h e c o n t in uat io n

o f t h e fe m ora l art e ry an d is th e r e for e p art o f t h e gr e at art e ria l
,

tru n k O f the low e r lim b I t be g in s at the O p e n in g in the

.

adductor m ag n u s wh e r e the fe m ora l art e ry e n d s ; an d it

,

t e rmin at e s at the d ista l bord e r o f t he p o p lit e u s m u sc le by

d ivid in g in to the an t e r ior an d p o st e r ior t ibia l art e r ie s Th e .

d iv isio n is hidd e n fro m vie w at the p r e se n t stag e o f the ,

d isse ct i o n by the p ro x ima l bord e r o f th e so le u s m u sc le bu t

, ,

it w ill be e x p o se d wh e n t h e le g is d isse ct e d
.

Th e c o ur se wh ich th e p o p lit e a l art e ry tak e s through the

p po li t e a l fo s sa is n o t stra ight A t fir st it d e s c
. e n d s v e rt ica lly

an d so r e ach e s the m idd le o f t h e fo ssa be tw e e n the

co n dyle s o f the fe mur F ro m that p o in t to its t e r min a
.

t io n it in c lin e s o bliqu e ly d istally an d lat e ra lly Throughout

,
.

t h e gr e at e r p art o f it s le n gth it is p lac e d d ee p ly I n the .

p r o x ima l
p art o f t h e fo ssa it i s cov e r e d b y t h e se m im e m
bran o su s bu t wh e r e it lie s in t he in t e rva l be tw e e n th e two
,

co n dyle s a lthough it is p lac e d d e e p ly in the fat o f the

,

fo ssa it is cov e r e d m e r e ly by t h e in t e gu m e n t s an d fa sc ia
,

o f t h e t ibia l n e rv e an d t h e p o p lit e a l v e in
, That p art o f .

t h e v e sse l is v e ry Short how e v e r — n o t m or e tha n a bout

, ,

2
5 mm .
; th e n it p a ss e s be tw e e n an d a n t e r ior to th e t w o

h e ad s o f th e ga stroc n e m iu s is cro sse d by t he p la n taris , ,

an d fi n a lly at its t e r min at io n it sin k s u n d e r cov e r o f t he

, ,

p ro x im a l bord e r o f t h e so le u s Throughout i t s who. le c o ur se

t h e p o p lit e a l art e ry r e st s aga in st t h e floor o f th e p o p lit e a l

 TH E I N F ER I OR EXTRE M I TY
fo ssa . I n it s p ro x im a l p art it is arat e d fro m th e fe mur se p

by so m e fatty t issu e ; at
t h e le v e l o f t h e in t e rva l
Add m g be tw e e n t h e co n dy le s o f
u c to r a nus

p p li i oi the fe m ur it cro sse s t h e

te a ve n

o bliqu e liga me n t o f the

P p li l o y k n e e j o in t ; an d in the
t e a art e r
,

d ista l p art o f the fo ssa it ,

is in co n tact w ith t h e
S p i m di l fa sc ia C OV C I I llg t h e p Op ‘ ’

u er o r e a

g m l
lit e u s m u sc le
ar a r‘ e r
f
e
y C‘
.

s I
fiiiiii Z iig f;
u l
s Th e p op liteal vein lie s in
r
-

a m or e sup e rficial p la n e ,

I f i l l an d cro sse s the art e ry I n

n e r o r at e ra .

i m
t h e p ro x im a l p art o f th e
g yen c ar ar‘e r

fo ssa it is p lac e d u p o n t h e
H d f fib l lat e ra l sid e o f t h e art e ry
ea o u a
,

I f i m di l wh i
n er o r
lst in t h e
e
d ista
a
l p art
g i l y it is situat e d u p o n it s
e n cu ar a rt e r

m e d ia l sid e T h two
P p li o te u s
e .

v e sse ls how e v e r are in , ,

c lo se a ssoc iat io n through

S l o
out an d are bou n d tog e th e r
e us

by a d e n se fi brou s sh e ath .

Th e tibial nerv e is su p e r
ficial to both v e sse ls an d ,

— R igh t P
cro sse s both fro m t he lat e ra l
F G
I 371 p l it l A t y
o ea d r er an
. .

it B s h ran c es .
to th e m e d ia l sid e ; in

t h e p ro x im a l p art o f t he
fo ssa it lie s lat e ra l to the v e in bu t in th e d ista l p art it lie s ,

o n t h e m e d ia l sid e F ig s 1 3 2 1 3 3 1 3 4
. .
, , .

Th e branches of the p op liteal artery are

Th e muscu lar branches co n sist o f a p ro x im a l an d a d ista l

se t
. Th e p ro x imal branches are d istr ibut e d to the ha mstr in g
mu scle s n e ar t he ir in se rt io n s Th e distal branches, t e r m e d .

t h e su ral arteries, e n d ch ie fly in t h e two h e ad s o f th e

ga stroc n e miu s bu t twig s go a lso to th e so le u s an d p la n tar is .

The cutaneo u s branch, ca lle d the superficial su ral, fr e qu e n t ly

 TH E I N F ER I OR EXTRE M I TY
midd le g e n icu lar art e ry Sp r in g s fro m the p o plit e al as it lie s
u p o n the o bliqu e p o p lit e a l liga me n t o f t he kn e e jo in t I t .

p ie rc e s that liga m e n t to r e ach t h e cruc iat e liga me n t s an d the

sy n ov ia l lay e r.

Ve n a P o p lit ea — Th e p o p lit e al v e in is for me d n e ar th e ,

d ista l bord e r o f t h e p o p lit e u s m u sc le by the u n io n o f the ,

v e n a co mit e s o f th e a n t e r io r an d p o st e r ior t ibia l art e rie s .

I t ru n s p ro x ima lly through t h e p o p lit e a l fo ssa an d e n t e r in g , ,

th e adduct o r ca n a l through t he O p e n in g in t he adductor

,

m ag n u s it be co me s th e fe mora l v e in
, The r e lat io n s wh ich .

it p r e se n t s to the p o p lit e a l art e ry hav e a lr e ady be e n d e ta ile d .

I n add it io n to tr ibutar ie s corr e sp o n d in g t o bra n ch e s o f th e

art e ry it r e c e iv e s the sma ll sa p h e n ou s v e in wh ich has be e n
, ,

se e n p ie rc in g t h e p o p lit e a l fa sc ia to j o in it B y slitt in g it .

o p e n w ith t h e sc issor s t h e d isse ctor w ill se e that it p o sse sse s

thre e ( so me t im e s fo ur ) va lv e s in its in t e r io r .

Th e Gen icu lar B ran ch of the 0 btu rato r N erve Th is Sle n d e r .

-

co n t in uat io n o f t he p o st e r ior d iv isio n o f the o bturator n e rv e

u sua lly lie s u p o n th e p o st e r ior a sp e ct o f the p o plit e a l art e ry .

I t e n t e r s t h e p o p lit e a l fo ssa by p ie rc in g t he d ista l fi br e s o f

t h e adductor m ag n u s ; an d it e n t e r s the k n e e j o in t a ft e r

p a ssin g through th e o bliqu e p o p lit e a l liga m e n t .

B AC K OF T H E TH I G H .

Th e d isse ct io n o f the back o f th e th igh mu st be co m

p le te d o n t h e fi fth day Th e fellow in g are t h e structur e s
.

wh ich are to be d isp lay e d :

I . Su pe rficial fascia .

2 . C u tan e o u s n e rv e s .

3 . D e e p fascia .

Bic e p s fe m o ris .

Se m i t e n di n o su s
M u scle s,
.

4 .

Se m i m e m bran o su s .

Addu cto r m ag n u s ,

N e rv e s,
P o st e ri o r cu tan e o u s o f th i gh .

5 .

Sciatic .

6 . Arte rie s, F o u r p e rfo ratin g .

D is s e c t i o n — R e fl e ctio n o f Sk in — A e r ical in cisio n m u s be. v t t

l
m ade , in t h e m e dian in e o f t h e h igh , h ro u gh t h e be l o f skint t t
t l
w h ic h s il e n circ le s th e limb p o s e rio rly Th e tw o fl ap s c an t .

t t t
h e n be re fl e c e d, t h e o n e la e rally , an d th e o h e r m e dially t .

Su p erfi cial F a scia — C u t an eo us N e rv e s — The s u p e rfic ia l

 B AC K O F TH E T H I GH 3 9 2

fa sc ia o f th e back o f t h e th igh p r e se n t s n o fe atur e s o f sp e c ia l

in t e r e st , bu t in it th e r e ra mify cuta n e ou s n e rv e s d e r iv e d fro m
fo ur sourc e s, ( 1 ) fro m th e po sterio r cu tan eo u s ne rve of the thigh,
( )
2 fro m t h e lateral cu ta n eo u s n erve o
f the thig (3)
h,
f r o m t h e

p o sterio r branch of the medial cu tan eo us nerve, an d ( 4 ) fro m the

o btu rato r nerv e .

D is s e c tio n — Th e bran c h e s o f t h e p o s e rio r cu an e o u s n e r e t t v

o f t he t
h igh mu st be so u gh in th e su p e rfi cial fascia alo n g t he
'

t
m iddle o f t h e back o f h igh ; h e y ary in n u m be r, an d h e y p ie rc e t t v t
th e de e p f as c ia at ary in g le e ls (F ig v Th e se arc h f o r h e m v . t
w t t
ill be f ac ili a e d if th e disse c o r p u lls g e n ly o n t h e ru n k o f t t t
th e n e r e v w
h e re it is alre ady e xp o se d in t h e lo e r p ar o f th e w t
t
g lu e al re g io n Th e bran c h e s o f t h e la e ral an d m e dial cu an e o u s
. t t
v
n e r e s s h o u ld be f o llo e d f ro m t h e p o rt io n s o f h o se n e r e s w t v
w w
h ich e re disp lay e d h e n t h e fro n an d m e dial side s o f th e w t
t h igh w e re dissec e d (p p 2 2 7 , No t
im e n e e d be lo s in . t t
s e e k in g f o r t h e cu an e o u s bran c h o f t h e o b t
ra o r n e r e , f o r it tu t v
v v
is n o t o n ly e ry ariable in si e an d p o si io n , bu t also it is n o t z t
u n co mm o n ly abse n t
W h e n p re se n it lie s u su ally in th e dis al
. t t
a n d m e dial p art o f t h e p o s e rio r are a o f t h e h igh t t .

t
W h e n t h e cu an e o u s n e r es o f t h e back o f t h e h igh h a e v t v
t
be e n s u die d t h e re m ain s o f t h e su p e rfi cial fascia m u s be t e t
v
m o e d to disp lay t h e de e p fascia .

De e p F ascia Th e d e e p fa sma o f the back o f th e th igh

‘

is th in bu t fa irly S tro n g I t co n sist s o f lo n g itud in a l fi br e s .

ble n d e d w ith tra n sv e r se fi br e s wh ich se rv e t o bin d t h e h am

str in g m u sc le s tog e th e r .

v
D is s e c ti o n — D i ide t h e de e p f ascia by a lo n g i u din al in cisio n
. t
ru n n in g a lo n g t h e m iddle o f t h e back o f t h e t h igh , an d be care fu l
n o t t o in j u re t h e p o s e rio r cu an e o u s n e r e o f t h e t
h igh , h ic h t v t w
t
lie s im m e dia e ly u n de r co e r o f t h e f ascia Tu rn t h e tw o fl ap s v .

o f de e p fas cia aside , an d h e n f o llo w an d cle an t h e p o s e rio r t t

t
cu an e o u s n e r e v w
h ic h is n o w e x p o se d in t h e wh o le o f its le n gt h .

t t
Af e r th e ru n k o f t h e p o s e rio r cu an e o u s n e r e o f t h e t h igh t t v
h as be e n se cu re d c le an t he p o s e rio r su rface s o f t h e h am s rin g t t
m u scle s . t
Th e y are h re e in n u m be r, t h e bice p s fe m o ris, t h e
t
se m i e n din o su s, an d t h e se m im e m bran o su s Th e lo n g h e ad o f t h e .

bic e p s sp rin gs f ro m t h e p o s e rio r p art o f t h e u be ro si y o f t h e t t t

is c h iu m , by m e an s o f a e n do n c o mm o n t o it an d t h e se m i t
t e n din o su s I t is re co gn ise d by t h e f ac h a it ru n s dis ally an d
. tt t t
t
la e rally , w t
h ils t h e se m i e n din o su s an d se m im e m bran o su s ru n t
t
dis ally an d m e dially Th e sh o rt h e ad arise s fro m t h e bo dy .

o f t he fe m u r . P
u ll t h e lo n g h e ad o f t h e bice p s m e dially t o
e x p o se t h e scia ic n e r e , t
h ic h lie s de e p (an e rio r) to it ; h e n v w t t
f o llo w t
t h e la e ral bo rde r o f t h e s cia ic n e r e t o se cu re t h e bran c h t v
w h ich g o e s fro m it t o t h e s h o r h e ad o f t h e bice p s N e xt p u ll t .

t v
t h e sc ia ic n e r e la e rally an d cle an t h e bran ch e s t h ic h p ass w
f ro m it t o t h e lo n g h e ad o f t h e bic e p s , t h e se m i e n din o su s, t h e t
se m im e m bran o su s , a n d t h e addu c o r m ag n u s As a ru le t h e re t .

is o n e bran ch t o t h e lo n g h e ad o f th e bice p s, a bran c h h ic h w

 TH E I N F E R I O R EXT R E M I TY
v
di ide s to s up p ly t he se mime mbran o sus an d the addu cto r magnu s
,

in . C L U T A EU

il
M e d a fe mo ra l
c 1 rc u mfl e x a rt e r y
Sc i i
at c n e rv e

i
M b ce p s fe mo r s (
. i l gh o n e ad )
i
Th rd p e rfo rat ig
n arte r y
Tba i il v
ne r e ( c u t)

G i l
e n cu ar bran ch o f o bt u rat o r n e r v e

P o p li l te a art e r y
C o mmo n p e ro n e a l
v
ne r e

P li l
o y
p te a art e r
Anast o m i b
o t c h f ranc o

p l v
e ro n e a ne r e

S
p i ul l e r o r at e ra

g l y
e n i c u ar arte r

i
Su p e r o r m e d al i g i l e n cu a r art e r y

M . g ast ro cn e m u s i

FIG . 1 38
—
Di i
sse ct o n o i R gi
f th e P o ste r o r e o n o f th e T h i gh .

an d t h e re ar tw o bran c h e s t o the se m ite n din o sus an pp e r an d

e
,
u
a lo w e r The lo w e r bran ch t o t h e se m t e n d n o su s W ll b f n d
. i i i e o u
 T H E I N F ER I OR EXT R E M I TY
cro sse s th e t ibial co llat e ra l liga m e n t o f th e k n e e jo in t an d , ,

be co min g flatt e n e d is in se rt e d in t o the p ro x ima l p art o f t h e

,

m e d ia l sur fac e o f th e body o f th e t ibia n e ar th e a n t e r ior ,

cr e st o f that bo n e an d imme d iat e ly d ista l to the t e n do n o f

,

th e grac ilis F ro m its d ista l bord e r a p o n e urot ic fi br e s p a ss

.

in to the d e e p fa sc ia o f th e le g it s p ro x im a l bord e r is adh e r e n t

to the grac ilis fo r a bout ha lf an in ch fro m its in se rt io n an d ,

both t e n do n s are co n c e a le d by th e e x p a n d e d in se rt io n o f t he
sartor iu s A mucou s bur sa lie s be tw e e n th e thr e e t e n do n s
.

an d th e t ibia l co llat e ra l liga m e n t o f t h e k n e e jo in t .

B i ce p s fe mo ri s

Fi b l
u ar c o ll a t e ra l
li g a me n t

i
S art o r u s

G ili
rac s

Se m i i
t e n d n o su s

E x t e nso r d i gi m
t o ru
l g
o n us

FI G . 1 39 .
— xi l i
An te rio r aspe ct o f P ro m a P o rt o n s O f B o nes o f L eg w i th
l
Attach m e n ts o f M u sc e s m ap p e d o u t .

Th e m u scu lar be lly o f th e se mit e n d in o su s is d iv id e d in to

p ro x ima l an d d ista l p art s by a v e ry o bliqu e t e n d in ou s in t e r

se ct io n , an d e ach p art r e c e iv e s a bra n ch fro m th e sc iat ic

n e rv e Th e m u sc le is a fl e x o r o f t h e k n e e , a m e d ia l rotator
.

o f th e le g, an d an e x t e n sor o f the hip j o in t .

M Semimembran o su s — Th e se mim e mbra n o su s m u sc le

. .

ar ise s fro m the lat e ral imp r e ssio n o n the U pp e r p art o f the
tu be ro sity o f the isch iu m ( F ig 1 2 8, p Th e t e n do n o f
. .

or ig in is broad at it s attach me n t to the bo n e , an d n arrow s as

it p a sse s me d ia lly a n t e r ior to the or ig in o f th e bic e p s fe mor is ;
it th e n e x p a n d s aga in , an d, p a ssin g d ista lly an d me d ia lly ,
a n t e rior to the se mit e n d in o su s, is fo ld e d in such a m a n n e r
 B AC K OF TH E TH I G H 3 3 2

as to fo r m a groov e in wh ich the se mit e n d in o su s lie s The

, .

t e n do n o f in se rt io n is attac he d ch ie fly t o th e fl o o r o f the
gr o o ve o n the back o f the m e d ia l co n dy le o f the t ibia u n d e r ,

cov e r o f the t ibia l co llat e ra l liga m e n t o f the k n e e jo in t Thr e e .

add it io n a l attach me n t s how e v e r mu st be n ot e d Th e se are , , .

e ff e ct e d by a p o n e urot ic e x t e n sio n s fro m t he t e n d o n o f in

se rt io n to the back o f the ca p su le o f the k n e e jo in t ,

fo r m ing a co n sid e ra ble p art o f t h e o bliqu e p o p lit e a l liga me n t ;

( )
2 to th e s u r fac e o f t h e o
p p lit e u s m u sc le wh ich is cov e r e d ,

by t h e e xp a n s o n an d 3 ) to th e t ibia l co llat e ra l liga m e n t o f

i
t he k n e e jo in t The se m ime m bra n o su s is su pp lie d by th e
.

sc iat ic n e rv e I ts act io n s are th e sa me as th o se o f t h e

.

se m it e n d in o su s se e p
( .

N erv u s I schi a dicu s ( O T Gre a t Sc ia t ic N e rv e ) — Th e . . .

sc iat ic n e rv e c o mm e n c e s at th e low e r bord e r o f t h e gr e at e r

sc iat ic fora m e n an d u sua lly t e r m in at e s a bout t he m idd le o f th e

,

th igh bu t o cca sio n a lly at a h igh e r le v e l by d iv id in g in to the

, ,

t ibia l n e rv e an d co mm o n p e ro n e a l n e rv e I ts re lat io n s in .

t he g lut e a l r e g io n hav e a lr e ady be e n stud ie d I n t h e th igh .

it lie s o n th e p o st e r io r sur fac e o f t he adductor m ag n u s m u sc le ,

an d is cov e r e d by t h e lo n g h e ad o f t h e bic e p s fe m o ris It .

g iv e s bra n ch e s t o both h e ad s o f th e bic e p s to th e se m i ,

t e n din o su s to th e se m im e mbra n o su s an d t o t h e adductor

, ,

m ag n u s ; th e bra n ch e s to th e two la st n am e d m u sc le s ar ise -

by a co mm o n tru n k I n a fe w ca se s it g iv e s o ff a lo n g
.

art icu lar tw ig wh ich e n t e r s t he p o p lit e a l fo ssa an d tak e s th e

,

p lac e o f t h e l at e ra l s u p e r io r art icu lar n e rv e wh ich as a ru l e , , ,

is a bra n ch o f th e c o m mo n p e r o n e a l n e rv e .

D i s e c ti o n — T bri g t h e add t r m ag
s o m r f lly i t
n uc o nu s o e u n o
vi w a d t o f a ilitat th l a i g f it p t ri r rfac a d
e ,
n c e e c e n n o s o s e o su e, n
at t h am e s t im to f ll w th t rm i al p art o f t h p rf rat in g
e e o o e e n s e e o
a rt e ri t h e h am t ri g m u l
e s, s h ld b d t a h d fr m t h ir
n sc e s s o u e e c e o e
o rig i a d t h ro w
ns n di t ally F ir t de t a h t h
n s mm t dn
. s c e co o n en o
o f t h bi e p s f m ris an d e m it n di s s f r m t h i h ial t ub r
e c e o s e no u o e sc e

o s ity W h e n t h at h
. b d th a t att a c h m
as een t o f th o ne e ex c en e

s m im e m bra o
e is di p lay d a d aft r t h at m
n su s s l ha b n e ,
n e u sc e s ee

ag ain e am in d x d r t h p re e t m re adva t ag
e ,
un e ec ir m s n o n eo us cu

s ta it al o m
n ce s , t b d t a h d fro m its rig i an d t rn e d
s us e e c e o n u

dist ally Th p o t ri r
. e rf a s e f th add o t r ma gn w ill
su ce o e uc o us
t h e b f lly p d a d it att a h m t t th f m r a d it
n e u ex o se ,
n s c en o e e u n s

re lat i s t o nt h e p e rfo rat i g art ri s c an b

o tu di d n e e e s e .

Art eria P e rf o rant e s F o ur p e r fo rat in g art e r ie s w ill be

.
—

fou n d in th e p o st e r ior p art o f th e th igh be tw e e n th e adductor

m ag n u s m u sc le an d th e fe m ur c lo se to th e lin e a a sp e ra ,
.

I— 21 a
 TH E I N FE R I O R EXTRE M I TY
Th e y are bra n ch e s
f t h e p r o fu n da fe m o r is an d are ca lle d
o

first, seco nd, third, an d fo u rth, acc o rd in g to t he le v e l at wh ich

th e y a p p e ar, p ro x imo d ista lly Th e fo u rth is th e t e r min a l
-
.

bra n ch o f th e p r o fu n da , it m ak e s its a p p e ara n c e a bout 2 5 m m .

o n e in ch ) p r o x im a l t o t h e o p e n in g in t h e adduct o r mag n u s
(
m u sc le through wh ich th e p o plit e a l art e ry e n t e r s th e p o p lit e a l
fo ssa . Th e p e r fo rat in g art e r ie s an d th e ir bra n ch e s m u st
be thorough ly c le a n e d , tog e th e r w ith th e a p e rtur e s in th e
adduct o r mag n u s thr o ugh wh ich th e y p a ss I t w ill th e n be .

se e n that th e y do n o t p ie rc e the fl e shy su bsta n c e o f the

m u sc le , fo r be h in d e ach is a t e n d in o u s arch , an d t h e art e r ie s
r e ach the p o st e r io r r e g io n o f t he th igh by p a ssi n g be tw e e n
t h e arch e s an d t he lin e a a sp e ra , t o wh ich t h e p ie r s o f t h e
arch e s are attach e d .

Th e o p e n in g s are in th e sa m e lin e w ith an d are in all

r e sp e ct s a n a logou s to th e larg e O p e n in g in the adductor
m ag n u s m u sc le fo r th e p o p lit e a l art e ry Th e r e su lt O bta in e d
.

is t h e sa m e in e ach ca se ; wh e n the m u sc le co n tract s th e ,

v e sse ls are p rot e ct e d fro m p re ssur e .

Aft e r p a ssin g t he t e n d in ou s arch e s t h e p e r forat in g art e rie s

w in d rou n d th e p o st e r ior bo rd e r o f th e fe mur O n th e ir way
to the va stu s lat e ra lis mu sc le in wh ich th e y e n d an d in
, ,

wh ich th e y a n a sto mo se w ith bra n ch e s o f the lat e ra l fe m o ra l

c ircu mfl e x art e ry The h igh e st p e rforat in g art e ry p ie rc e s t he
.

in se rt io n o f t h e glu t a u s ma x imu s be fo r e it r e ach e s t h e va stu s

lat e ra lis an d th e lo we r thr e e p ie rc e t h e fe m o ra l h e ad o f th e
,

bic e p s fe mor is an d t h e lat e ra l in t e r mu scu lar se p tu m .

Ana st o mo ses o n t h e P o st e ri o r Asp e ct o f t h e Thi gh — I n a

w e ll inj e ct e d su bj e ct a cha in o f art e ria l a n a st o mo se s can be
-

trac e d fro m the glut e a l r e g io n to t he p o p lit e a l fo ssa an d ,

th e p r e sen t is t h e be st t ime t o e x a min e it C o mme n c in g

.

p r o x im a lly in t h e g lut e a l r e g io n
,
t h e su p e r io r g lut e a l art e ry
,

is fou n d a n a sto m o sin g w ith th e in fe r io r g lut e a l an d t h e ,

in fe r io r g lut e a l w ith t h e t e r m in a l bra n ch e s o f t he m e d ia l

fe m o ra l c ircu mfl e x art e ry I n t he p o st e r ior p art o f th e th igh
.

the cha in o f a n a sto m o se s is carr ie d d ista lly by t he m e d ia l an d

lat e ra l fe m ora l c ircu m fl e x art e rie s a n a st o m o sin g w ith t h e fir st
p e r fo rat in g art e ry an d by a n a st o mo se s be tw e e n th e p e r forat in g
,

art e r ie s The cha in is c o mp le t e d d ista lly by a n a st o mo se s

.

be tw e e n th e m o st d ista l p e r fo rat in g art e r ie s an d t h e m u scu lar

bra n ch e s g iv e n fr o m t h e p o p lit e a l art e ry to t he h a m str in g
m u sc le s .
 THE I N F E R I OR EXTRE M I TY
cre st by a bo ut ha lf an in ch an d it s attach me n t to the d ista l ,

p art o f t h e p o st e r ior sur fac e o f t h e n e ck o f t he fe m ur is w e a k .

Wh e n t he ca p su le o f th e hip j o in t has be e n car e fu lly c le a n e d

it w ill be se e n that t h e fi br e s wh ich co m p o se it ru n in two
d iffe r e n t d ir e ct io n s The maj o rity p a ss lo n g itud in a lly fr o m
.

t h e hip bo n e t o t h e fe m ur Th e r e are how e v e r o th e r fi br e s

.
, ,

wh ich lie m o r e o r le ss at r ight a n g le s to th e lo n gitud in a l

fi br e s Th e y c o n st itut e the z o n a o rbicu laris an d are se e n to
.

An t e r o i i
r n fe r o r i
sp i n e o f i iul m

L abru m gl e no id la e

H e ad O f fe mu r

P u ho -
l li g
c ap su a r am e n t

FEMUR

P u bo -
l li g
c a p su a r a me n t

FIG . 1 40 .
— Di sse c t io n o f H ip J i t f
o n ro m th e fro n t .

adva n tage o n ly o n the p o st e rior a sp e ct o f the ca p su le wh e r e ,

th e y w e re n o t e d du rin g t he d isse ct io n o f the g lut e a l r e g io n

(p . T h e lo n g itud in a l fi br e s are m o st m a sse d o n t h e

fro n t o f th e jo in t .

C e rta in th ick e n e d p ort io n s o f th e ca p su le w ith mo r e o r ,

le ss d ist in ct attach m e n t s are d e scr ibe d u n d e r Sp e c ia l n a m e s

,
.

Th e y are
I I li f m
. O l l ig m t
-
e o ra 3 I hia p l l ig m t
en . . sc o -
ca su ar a en .

2 P b
. u
p ol l i
-
g mca t su ar 4 T h z a b i l
en i . . e o na o r cu ar s .
 HIP JOI NT
Th e ilio fe m o ra l liga m e n t is
L igamen tu m [ ho f emo rale - — -

p lac e d o v e r t h e fro n t o f t h e art icu lat io n ,

an d co n st itut e s t h e

th ick e st an d mo st p ow e r fu l p art o f the ca p su le Pro x ima lly .

it is attach e d to th e a n t e r io r in fe r io r Sp in e o f t h e ilium an d
t o th e d e p r e sse d sur fac e imme d iat e ly lat e ra l t o that sp in e .

V
ili m p fi i li F i i b
. c irc u m fl e x a u su er c a s asc a c r ro se

V ph m g V f m li sa e na a u e o ra s

S b g i l l ymp h g l M g f l i f mi
. .

u in u na an ar o a c o r s
V p i g i p fi i li e A f m li
as t r c a s u er c a s e o ra s

P i lp i l
. .

f f
e c t ne a art o a sc a ata
N . O bt u ra t o ri u s ra m u s a n t e ri o r
O bt u ra t o ri u s ra m u s p o s t e ri o r
art o f f a sc i l
a a ta
M . re c t u s fe m o ri s

i
r . i
m b c e p s fe mo i
r s e t se m i te
h an t e r m a j o r
M . se mi me mbra n o su s
Co ll m f
u e mo r s i
A c irc u m fl e x a fe m o i
rs me d a i li s o n M C ap s u l i l
a art c u ari s
x
. .
.

o bdu ra to r e t e rn u s l N c u ta n e u s fe m o ri s p o st e ri o r

l l
.

N i sch i adi a cu s ( p e ro
. ne a an d t i bi a p art s)

FIG . 1 41 .
— Di t i sse c o n o f an o li v
b q u e t ran s e rse S e c o n t ro u g ti h h u p pe r p art Of

Th i gh h w i s o n g th e l i
re at o n o f t h e F
asc a t o th e M u sc i l es .

D ista lly it is attach e d to the in t e rtr o cha n t e r ic lin e o f the

fe m ur At its u p p e r o r iliac e n d it is a sin g le m a ss o f
.

fi br e s bu t as it p a sse s d ista lly it d iv id e s in to a lateral an d

, ,

a medial ba n d ( F ig .

Th e lat e ra l an d short e r ba n d is imp la n t e d in to t he u p p e r

p art o f t h e in t e rtrocha n t e r ic lin e an d t o t h e adjac e n t p art o f

th e gr e at e r trocha n t e r I t is so m e t im e s ca lle d th e ilio .

1— 2l b
 TH E I N F ER I OR EXTRE M I TY
tro chan teric ba n d . r e m e d ia l an d lo n g e r ba n d is
The m o
a lmo st v e rt ica l an d it s d ista l e n d is attach e d t o the lo w e r
,

p art o f t h e in t e rtr o cha n t e r ic lin e T h e in t e rva l be tw e e n th e .

t wo d iv e rg in g ba n d s is o ccu p ie d by a th in n e r p ort io n o f th e
ca p su le wh ich is p e r forat e d by an art icu lar tw ig fro m th e
a sc e n d in g bra n ch o f th e lat e ra l fe mo ra l c ircu m fl e x art e ry .

Th e ilio fe m ora l liga me n t is so m e t im e s ca lle d th e Y shaped

- -

liga men t bu t in m ak in g u se o f th is t e r m r e me mbe r that

, , ,

t h e S ha p e it p r e se n t s is that o f an in v e rt e d Y .

L iga men tu m P u bo cap su lare ( O T P u bo femo ral L igamen t) . . .

The p uho ca p su lar liga m e n t is th e n a me a p p lie d t o fa sc icu li

-

wh ich sp r in g fr o m th e p u bic bo n e an d the O bturator me m

bra n e an d j o in t h e lo we r an d a n t e r ior a sp e ct o f t h e ca p su le
, .

I n ca se s wh e r e t he bur sa u n d e r t h e ilio p so a s is co n t in uou s -

w ith the cavity o f th e jo in t the a p e rtur e o f co m m u n icat io n ,

is p lac e d be tw e e n th is ba n d an d t h e ilio fe m ora l liga m e n t -

.

L igamen tu m [ p ( O T
schio ca su lare
[ sc h io fi m o ra l L iga m en t ) . .
- ’
.

— Th e isch io ca su lar liga me n t is a co m arat iv e ly w e ak ba n d

p p
-

wh ich Sp r in g s fro m th e isch iu m, be low the ac e ta bu lu m, an d

p a sse s u p ward s an d lat e ra lly , a n t e r io r to t h e t e n do n o f t h e

o bturat o r e x t e r n u s I t t e r m in at e s in th e ca p su le
. .

Z o n a Orbicu laris ( O T Orbicu la r L iga ment) —The z o n a o r bi

. . .

c u laris is co mp o se d o f c ircu lar fi br e s, wh ich are m o st d ist in ct

o n t h e p o st e r io r a sp e ct o f t h e ca p su le I t e n c irc le s t h e n e ck o f .

t h e fe mur p o st e r io r ly an d be low , bu t is lo st as it is trac e d an

t e rio rly toward s t h e u p p e r an d a n t e r io r p art s o f t h e ca p su le .

The d isse ctor has a lr e ady n ot e d th e c lo se c o n n e ct io n

wh ich is e x h ibit e d be tw e e n the ca p su le o f the h ip j o in t an d
t h e t e n do n s o f t h e glu t a u s min imu s, an d t he r e fl e ct e d h e ad o f
t h e r e ctu s fe m or is R e in forc in g fi br e s are co n tr ibut e d to the
.

ca p su le by both o f tho se t e n do n s .

M o ve men t s p e rmitt e d Jo in t — Be fo re the capsu le o f the

at t h e Hi p .

j o in t is o pe n e d the ran g e o f m o v e m e n t wh ich is pe rm itte d at t he hip j o in t

sh o u ld be t e st e d F lex io n o r fo rw ard m o v e m e n t is v e ry fre e an d is
.
, , ,

c h e ck e d by the an t e rio r su rfac e o f t he t h igh c o m in g in t o c o n tac t w ith th e

abdo min al w al l E x ten sio n o r backw ard m o v e m e n t is l im ite d by the
.
, ,

ilio fe m o rallig am e n t
-
Th at po w e rfu l l ig am e n t has a m o st im po rtan t p art to
.

p l ay in
p re se r v in g t h e u righ t attitu de w ith th e le ast
p po ssib l e e x p e n ditu re

o f m u scu lar e x e rtio n I n t he e re ct p o stu re the l in e o f g rav ity fa ll s Sl igh tly

.

be h in d the lin e j o in in g t he ce n t ral p o in ts o f th e t w o hip j o in ts I n th e .

u p righ t att itu de t he ilio fe m o ral lig am e n ts are t e n se an d p re v e n t t he p e lv is

-
,

fro m ro ll in g backw ards o n the h e ads o f the fe m o ra A bdu ct io n o r late ra l .

,

m o v e m e n t o f th e limb is ch e ck e d by the pu bo c ap su lar l ig am e n t A ddu ct io n

,
-
.
,

o r m e dial m o v e m e n t ( e g as in cro ssin g o n e t h igh o v e r t he o th e r) is lim it e d

. .
,
 T HE I N F ER I O R EXTRE M I TY
Liga me nt um Tran sv e rsum Ac e t a buli — Th e tra n sv e r se .

liga me n t co n 5 1st s o f tra n sv e r se fi br e s wh ich br idg e acro ss

t h e ac e ta bu lar n o tch an d are attach e d t o its m arg in s
, It .

lie s be tw e e n t he la bru m g le n o ida le lat e ra lly an d th e bo tt o m

o f t h e n o tch m e d ia lly bu t a s ac e is le ft be tw e e n t h d a
, p e m e i l

I hi l p i
sc a s ne

L a bru m gl e no id l
a e

L ig a me n t u m
t e re s

Trans v e rse li g am e n t

R i l
e t n ac u a

FI G . 1 42 .
— Di t i sse c o n o f H ip J io nt fro m be h ind. Th e bo t t o m o f t h e
ac e t a u u b l m h as be e n re m o ve d t o Sh o w the li game n tu m te re s .

marg in o f t he liga me n t an d th e botto m o f t he in c isura

thr o ugh wh ich v e sse ls an d n e rv e s e n t e r the j o in t Th e
.

lat e ra l m arg in o f t h e liga m e n t is attach e d to t he la bru m

gle n o ida le .

Liga me n t um Te res F e mo ris — Th e liga me n tu m t e r e s is

no t r o u n d as it s n a me might le ad o n e to e x p e ct bu t
, ,

is so me what flatt e n e d an d fan lik e in sha p e I ts n arrow -

.
 P L AT E XX I V

H e ad o f

Tu be ro s iy t o f
i sc h i u m

L e sse r t ro chan t e r

FI G . 1 44 .
— R di g
a o rap h o f the H ip Jo i nt o f an adu tl .

( Dr . R K x
. no .
)
 P L ATE XXV I

Ili u m

H e ad o f

L e sse r; t ro c han t e r
Tu be ro s i y f i hi
t o sc um

FIG 4 6
. 1 .
—
R di g
a o rap h o f t h e H ip R gi
e o n o f
’
a c h ild u ye ars o ld .

The ep i p hy i s s o f th le e sse r h
tro c an te r h as n o t
ye t ap p e are d, i
The infe r o r
ram i o f th e p u b i s an d i hi
sc um h ave fu se d .
 P L ATE XXV I I

Ili u m

I hi
sc u m

FI G . I R di g p h f th H ip R gi f h il d
47 .
— a o ra o e e o n o a c .

Th e . e p ip hy i f th l
s s o t h t h
e e sse r
t y t pp d bro c an e r as n o e a e are ut th e
i f i m i f th p bi d i hi m h v f
,

n e r o r ra o e
d u s an sc u a e use .
 P L ATE XX V I I I

Ili um

P i
ub s

FIG . 1 48 R di g ph f th H ip R gi
.
—~ a o ra o e e o n o f h il d
a c .

The ep i p hy i s s o f th l t eh t h
e sse r t y t ro c an e r as n o e ap p e are d, an d th e
i f i
n e r o r ra m i f t h p bi
o d i hi m h v
e u s an sc u a e no t
ye t un it ed .
 P L ATE XXX

Ili u m

I sch i u m

H e ad o f fe mu r

Fme ur

I i
n fe r o r ra mus
o f I sc h i u m

FIG . 1 50 .
—
R di g
a o rap h o f t he ~H ip R gi
e o n o f a c h il d
.

Th e gap s be twe e n t hevari o u s segm e n ts o f the bo n e s indi cate t he

z
si e s o f th e i n t e rve n i n g cartil a e se g me n t s
g .
 HIP JO I N T 33 1

fe mora l tr e mity is imp la n t e d in t o the fov e a ca p it is fe m or is

ex ,

wh ilst its flatt e n e d ac e ta bu lar e n d is bifid an d is fi x e d to th e ,

marg in s o f the ac e ta bu lar n o tch an d a lso to th e tra n sv e r se ,

liga me n t Th is attach me n t c an be d e fi n e d by the r e m ova l

.

o f t h e sy n ov ia l lay e r an d so me ar e o lar t issu e Th e liga .

me n tu m t e r e s is surr o u n d e d by a p ro lo n gat io n o f t h e sy n ov ia l
lay e r an d a sm a ll art e ry ru n s a lo n g it to th e h e ad o f t h e
,

fe m ur .

I t is d ifficu lt to u n d e r sta n d th e p art wh ich t he liga m e n tu m

t e re s p lay s in the me cha n ism o f th e hip j o in t I t p r e se n t s .

v e ry d iffe r e n t d e gr e e s o f str e n gth in d iffe r e n t su bj e ct s I t .

be co me s v e ry t e n se wh e n th e th igh is slight ly fl e x e d an d
th e n adduct e d .

The I nt erio r o f t he J o in t an d t he Sy n o v ial St ra t um A —

ma ss o f so ft fat occu p ie s the n o n art icu lar botto m o f t he -

ac e ta bu lu m U p o n th is t he liga me n tu m t e re s is plac e d an d
.
,

blood v e sse ls an d n e rv e s e n t e r it by p a ssin g through t h e

-

n otch u n d e r c o v e r o f th e tra n sv e r se liga m e n t The v e sse ls .

are d e r iv e d fro m the m e d ial fe mo ra l c ircu mfl e x an d the

o bturat o r art e r ie s an d th e n e rv e s are tw ig s fro m the a n t e r ior
,

bra n ch o f t he o bturator n e rv e fro m t h e acc e ssory o bturator , ,

wh e n it is p r e se n t an d fro m the n e rv e to t he r e ctu s fe mor is

,

m u sc le .A n e rv e tw ig is a lso su p p lie d to th e p o st e r io r
-

p art o f t h e jo in t b y t h e n e rv e to t h e quadratu s fe m or is .

Th e sy no vial stratu m lin e s th e in n e r sur fac e o f t h e fi br o u s

stratu m o f t h e ca p su le F ro m t h e fi brou s stratu m it is r e fl e ct e d
.

o n to th e n e ck o f t he fe mur an d it c lo th e s t h e bo n e as far ,

as t he m arg in o f t h e art icu lar cart ilag e wh ich cov e r s t h e h e ad .

Alo n g t he lin e o f r e fl e ct io n so me fi br e s o f the fi brou s stratu m

p roc e e d p ro x im a lly o n t h e n e ck o f t h e fe m ur a n d ra ise t h e

sy n ov ia l lay e r in t h e for m o f r idg e s Th e se fi br e s are t e rm e d

.

t he retin acu la o r cervical ligamen ts .

The ret i n ac u la m e su rgical impo rtan ce

are o f so I n in trac ap su lar .

fract u re o f th e n e ck o f th e fe m u r t h e y m ay e scap e ru p tu re , an d th e y
x l
m ay th e n , to so m e e te n t , h e p t o re tain t he frag me n t s in a pp o sitio n .

x
H e n ce e am in atio ns o f th is c lass o f fractu re m u st be co n duct e d g e n t ly ,
le st by ru tu rin g t h is
p l
ig am e n t o u s c o n n e ctio n th e frag me n ts be p e rm a
l
u e n t y disp lace d .

At ac e ta bu lar attach me n t o f t he ca p su le th e sy n ov ia l
t he

m e mbra n e is r e fl e ct e d o n to th e la bru m g le n o ida le an d

in v e st s both it s sur fac e s I t a lso cov e r s t h e art icu lar sur fac e
.

o f t he tra n sv e r se liga m e n t an d th e cu sh io n o f fat wh ich

 THE I N F E R I O R EXTRE M I TY
o ccu p ie s the bott o m o f the cav ity . L a st ly , it g iv e s a tu bu lar
in v e st me n t t o t h e liga m e n tu m t e r e s .

v
R e mo al o f th e Limb — The lim b m u st n o w be re m o v e d fro m th e t ru n k
by div idin g t he lig am e n tu m t e re s I t sh o u d th e n be t ak e n to o n e o f th e
. l
l
t ab e s se t aside fo r t he disse c t io n o f se p arate p arts B e fo re p ro ce e din g to .

t he disse c t io n o f t he le g the att ach m e n t s o f t he v ario u s m u sc e s t o the l

l
fe mu r Sh o u d be re v ise d l
The bu k o f th e m u sc le s m ay be re m o v e d, bu t
.

p l
a sm all o rtio n o f e ac h sh o u d be le ft , so th at t he att ac h m e n ts m a
y a g ain

l
be re v ise d, sh o u d it be fo u n d n e ce ssary to do so , at a lat e r p e rio d .

TH E L EG .

Surf ac e A na t o my .
— B e fo re
d isse ct io n o f the le g is the
c o mme n c e d the r e lat io n s o f th e t ibia an d fi bu la to th e
,

s ur fac e S hou ld be car e fu lly in v e st igat e d Th e sh ar p anteri o r .

crest o r shin o f t h e t ibia d o e s n o t f o r m a r o j e ct io n v isib le

p
t o t h e n ak e d e y e bu t n e v e rth e le ss it is su bc u ta n e ou s an d
, , ,

c an be fe lt v e ry d ist in ct ly wh e n t h e fi n g e r is a s se d a lo n g it
p .

I t e x t e n d s fr o m t h e tu be ro sity O f t h e t ibia t o t h e a n t e r io r
bord e r o f th e m e d ia l m a lle o lu s p ur su in g a slight ly sin u o u s ,

course an d in it s d ista l p art it is rou n d e d o ff an d in d istin ct

, .

Th e br o ad flat me d ia l sur fac e o f t he bo dy o f th e t ibia is

a lso su bcuta n e ou s d ista l to the le v e l o f th e in se rt io n o f t h e
,

sartor iu s an d t h e m e d ia l bor de r o f t h e bo n e wh ich fo r m s it s

,

p o s t e r i o r b o u n dary c a n be f o llow e d b y t h e fi n g e r thr o ughout

it s e n t ir e le n gth fro m t h e m e d ia l c o n dy le t o th e p o st e r io r ,

bo rd e r o f t he m e d ial ma lle o lu s I t in d icat e s t h e p o sit io n o f

.

t h e gr e at sa p h e n o u s v e in an d th e sa p h e n ou s n e r v e .

The fi bu la o n t h e wh o le is m or e d e e p ly p lac e d
, ,
Th e h e ad .

is e a sily d ist in gu ish e d be lo w an d p o st e r io r t o t he lat e ra l

co n dy le o f the t ibia ; th e tru n k o f t he p e ro n e a l n e rv e lie s
be h in d it . Th e p r o x ima l ha lf o f t h e bo dy o f th e bo n e
is c o n c e a le d by t h e surr o u n d in g m u sc le s an d ca n n ot be
p pa l at e d s at is factor ily T h e d ista l e.n d o f t h e b o n e wh ich ,

fo r m s t h e lat e ra l m a lle o lu s an d t he d ista l p art o f t h e body

, ,

p ro x im a l t o t h e m a lle o lu s are s u bcuta n e o u s in a tr ia n gu lar ar e a

,

wh ich w ill be fou n d to be bo u n d e d a n t e riorly by the p e ro n a u s

t e rt iu s an d by th e p e ro n a u s lo n gu s an d br e v is mu sc le s
,

p o s t e r io r ly .

Th e t wo m a lle o li for m m ark e d p r o j e ct io n s in t h e r e g io n o f

t he a n k le . Th e m e d ia l m a lle o lu s is t h e br o ad e r an d m o r e
 TH E L EG 333

p r o m inent o f t h e t wo ; i t d o e s n o t p a ss so f ar d ista lly ,

bu t it s a n t e r io r bo rd e r is S ituat e d m o r e a n t e r io rly tha n th e

lat e ra l ma lle o lu s . Th is is du e t o its gr e at e r bre adth be cau se ,

wh e n e x a min e d fr o m be h in d t h e p o st e rio r bo rd e r s o f the t wo

,

p r o j e ct io n s a re se e n to o ccu p y v e ry n e ar ly t h e sa m e tra n sv e r se

p l a ne .

O n t he p o st e r ior a sp e ct O f t he le g t he p r o m in e n c e k n ow n
as t h e ca lf o f th e leg is v isible Th is is larg e ly du e to th e
“ !
.

fl e shy bellie s O f th e ga str o c n e miu s mu sc le D ista l t o the ca lf .

,

an d imm e d iat e ly p r o x ima l t o t h e h e e l t h e p ow e r fu l t e n d o ,

ca lca n e u s c an be fe lt An t e r io r t o that t e n do n a Slight h o llow

.

is a pp are n t o n e ach sid e o f th e lim b .

Th e Sk in w ill be r e fl e ct e d fro m t h e dor su m o f t h e fo o t

durin g th e d isse ct io n o f the le g ; th e re for e t he p r e se n t O p p o r
t u n ity sh o u ld be se iz e d fo r study in g th e sur fac e a n ato m y o f t h e
fo o t Th e in d iv idua l tar sa l bo n e s ca n n o t be r e cog n ise d through
.

t h e in t e gu m e n t wh ich cov e r s t h e dor su m o f t h e foot ; bu t if

t h e fo o t is p ow e r fu lly e x t e n d e d t h e h e ad o f th e ta lu s w ill
,

be br o ught in to v ie w in t h e sha p e o f a slight p r o m in e n c e

, ,

wh ich lie s be low an d a n t e r io r t o t h e a n k le j o in t Th e .

m arg in s o f th e fo ot r e qu ir e car e fu l study be cau se it is by ,

t h e r e c o g n it io n o f c e rta in bo n y p roj e ct io n s in th e m that

-

the surg e o n is e n a ble d to d e t e r min e t h e p o in t at wh ich t o

e n t e r t h e k n ife wh e n h e is ca lle d u p o n t o p e r for m p art ia l
a m p utat io n o f the fo o t E x a min e the medial margi n fir st
.
.

B e g in p o st e r io rly at t h e p r o j e ct io n fo r m e d by t h e m e d ia l p roc e ss
,

o f t he ca lca n e u s an d p roc e e d fo rward s

,
About o n e in ch .

be low th e m e d ia l m a lle o lu s th e m e d ia l e dg e o f th e su st e n ta
c u lu m ta li m ay be r e c o g n ise d an d a bout o n e in ch o r a litt le
, ,

mo r e a n t e r ior to that is th e tu be rc le o f t he n av icu lar

, , Th e n .

c o me s th e first cu n e ifo r m bo n e wh ich is succ e e d e d by ,

the fir st m e tatar sa l bo n e N o n e o f th e se bo n y p o in t s c an
.

be sa id to for m v isible p ro m in e n c e s o n t h e sur fac e In .

ord e r t o d ist in gu ish th e m th e m e d ia l m argin o f the foot m u st

be car e fu lly p alp at e d O n th e lateral margin o f t h e fo ot th e
'

tu be ro sity o n t he ba se o f the fi fth m e tatar sa l bo n e sta n d s o u t

as a d ist in ct la n d m ark P o st e r ior to it is th e cu bo id an d
.
,

st ill m or e p o st e r ior t h e lat e ra l surfac e o f th e ca lca n e u s wh ich ,

is a lmo st c o mp le t e ly su bcuta n e o u s Wh e n p r e se n t in a w e ll
.

d e v e lo p e d for m the tr o ch le ar p roc e ss ( O T p e ro n e a l tu be rc le )

,
. .

o n th is sur fac e m ay be d ist in gu ish e d a bout o n e in ch d ista l ,

an d a litt le a n t e rio r to the lat e ra l ma lle o lu s I f th e foot is .

 THE I N F ER I O R EXTRE M I TY
s tr o ngly in v e rt e d th e a n t e r ior e n d o f the ca lca n e u s w ill be
se e n to p roj e ct o n t h e sur fac e .

Su bdiv isio n o f t he Le g in t o R e gi o n s I n the d isse ct io n o f —

t h e le g four d ist in ct r e g io n s may be r e c o g n ise d v iz ,

.

I A t i
. l gi
n a n er o r cru ra i wh i h pl d th e t
re t
on, wh i h
n c are ac e o s s ru c u re s c

lie an t e rio r to the in te ro sse o u s m e m bran e , an d be t w e e n th e t wo

bo n e s o f th e le g .

2 . A m ea ial cru ral regio n , co rre sp o n din g t o the su bcu tan e o u s o r m e dia]
’

su rfac e o f the bo dy o f th e t ibia .

A lat e ral cru ral regi o n , wh ich in clu de s th e p arts in re latio n to the
late ral su rface o f the fibu la .

A po sterio r cru ral regi o n , in wh ich are p lace d the parts, o n the back
o f th e le g, wh ic h lie p o st e rio r t o the in t e ro sse o u s m e m bran e an d th e

t wo bo n e s o f th e le g .

AN TE R I O R C R U R A L R EG I O N AN D D O R SU M OF F O OT .

Th e a n t e r io r crura l r e g io n shou ld be d isse ct e d fir st ,

an d it is u sua l to c o n j o in w ith th is t h e d isse ct io n o f t he

d o rsu m o f th e fo ot The fo llow in g p art s are e x p o se d

.

Su p e rficial v e in s . x
E te n so r h allu cis lo n gu s .

C u tan e o u s n e r e s v . An te rio r tibial v e sse ls .

D e e p fascia, w ith its in e r t Pe rfo ratin g bran ch o f th e

p e ro
mu scu lar se p ta , the tran sv e rse n e al art e r y .

lig am e n t O f th e le g, th e lig . D e e p p e ro n e al n e r e v .

lacin iatu m , an d th e c ru ciat e R e cu rre n t articu lar bran ch

ligam e n t O f the le g . fro m the co mm o n p e ro n e al
l
Tibia is an e rio rt . ner e v .

x
E te n so r digito ru m lo n g u s . x
E te n so r digito ru m bre v is .

P e ro n aeu s te rtiu s . D o rsalis p e dis v e sse ls .

— lim b in a — To
D is s e c t io n R e fl e ct io n of k
S in p lace t he
v
co n e n ie n t t
p o si io n f o r t h e disse c io n o f h is re g io n , a blo ck t t
t
s h o u ld be in ro du ce d be n e a h t h e k n e e , a n d t h e f o o t s h o u ld be t
e xt e n de d a n d f as e n e d fi rm ly t o t h e t able by m e an s o f h o o k s t .

t
Th e sk in sh o u ld be re fl e c e d f ro m t h e tibi al an d p e ro n e al (medi al
a n d la te ral) cru ral re g io n s at t h e sam e im e I n ci si o ns — ( x) t .

a v e rt ical cu t alo n g t h e m e dian lin e o f t h e le g an d do rsu m o f t h e

t
f o o t o t h e base o f t h e m iddle t o e ( )
2 a ra n s e rse in c is io n a c ro ss t v
t t
t h e an k le j o in ; ( 3 ) a ran s e rse in cisio n ac ro ss t h e do rsu m v
o f the f o o t
at t h e ro o s o f t h e o e s t t .

Th e f o u r fl ap s o f sk in , t h u s m ap p e d o u t ( 1 0 , n , 1 2 , I 3 , F ig .

t
m u s n o w be raise d fro m t he su bj ace n f a y issu e , an d t h e t tt t
su p e rfi c ial v
e in s an d n e r e s disse c e d o u t v t .

Su p e rficial F ascia — Th e su p e rfic ia l fa sc ia o f th e fro n t an d

t he m e d ia l an d lat e ra l
d e s o f the le g an d the d o r su m o f
si

th e foot p r e se n t s n o p e cu liar fe atur e s ; an d it co n ta in s as

a ru le o n ly a m od e rat e a mou n t o f fat in wh ich lie the ,

cuta n e o u s v e in s an d n e rv e s .
 THE I N F ER I O R EXTRE M I TY
m e dial t
m in al bran c h o f t h e su p e rfi cial p e ro n e al n e rv e w as
er
f o u n d, o r t he co mm u n icat in g bran c h f ro m t h e su ral n e rv e t o
t h e lat e ral t e rm in al br an c h o f t h e su p e rfi cial p e ro n e al n e rve
w as f o u n d, f o llo w
o n e o r th e o h e r o f h o se bran ch e s u p w ards t t
to t h e ru n k t t
O h e r ise cu t do w n
. w
h ro u gh th e fat , at th e t
j u n ct io n o f t h e m iddle an d dis al h irds o f th e le g, abo u 2 5 mm t t t .

t o t h e m e dial side o f t h e fi bu la , an d se cu re t h e ru n k o f t h e t
v
su p e rfi c ial p e ro n e al n e r e as it p ie rce s t he dee p f as cia F o llo . w
t v
it dis ally t o its di isio n in o m e dial an d la e ral bran c h e s, t t
an d h e n t t
race e ac h o f t h e bran c h e s an d h e ir su bdi isio n s t o t v
t t t
h e ir e rm in a io ns o n th e o e s On e o f th e su bdi isio n s p assest . v
t o t h e m e dial side o f th e g re a t o e t
A se co n d p asse s t o t h e cle f . t
t t
be w e e n t h e fi rs an d se co n d t o e ; f o llo it i h care , an d fi n d, w wt
sp rin g in g f ro m its m e dial side , a t ig o f c o m mu n ica io n to t h e w t
v
m e dial di isio n o f t h e dee p p e ro n e al n e r e F o llo t h e ig v . w tw
o f c o mm u n ic a io n , t
se cu re t h e m e dial di isio n o f th e de e p v
v
p e ro n e al n e r e , an d f o llo w its tw o e rm in al bran c h e s t o t he t
t
adj ace n side s o f t h e fi rs an d se co n d o e s t t .

V e n ae Sup e rfi ciale s ( t h e Cut an e o u s Ve in s o f t he D o rsum

o f t he F o o t an d t h e F ro nt o f t h e L eg) cuta n e ou s v e in s .
—Th e

o f th e dor su m o f the foot an d t he a n t e r ior r e g io n o f th e le g

are t h e d ig ita l v e in s t h e dor sa l v e n ou s arch an d the p art s

, ,

o f th e gr e at an d sm a ll sa p h e n ou s v e in s .

Th e r e are two do rsal digi tal veins in e ach to e o n e o n e ach ,

sid e o f t h e dor su m o f t he t o e The m e d ia l dor sa l d ig ita l v e in.

o f t h e gr e at t o e j o in s w ith t he m e d ia l e n d o f t he dor sa l v e n ou s

arch to for m the co m me n c e me n t o f th e gr e at sa p h e n ou s

v e in an d the lat e ra l dor sa l d ig ita l v e in o f the little to e u n it e s
,

w ith th e lat e ral e n d o f th e d o r sa l v e n ou s arch to for m the

sma ll sa p h en ou s v e in Th e two dor sa l d ig ita l v e in s wh ich
.

ru n a lo n g th e adjac e n t sid e s o f e ach o f t h e f our in t e rd ig ita l

c le ft s u n it e at the a pic e s Of t he cle ft s to for m a co mm o n

st e m an d th e f our st e ms thu s for me d wh ich are so me t im e s
, ,

ca lle d the co mm o n d igita l v e in s e n d in the dor sal v e n ou s ,

arch .

Th e do rsal veno us arelz lie s in t he su p e rfic ia l fa sc ia o n

t h e a n t e r ior p art s o f t h e bod ie s o f t h e m e tatar sa l bo n e s ,

su p e rfic ia l to t h e t e r min a l bra n ch e s o f th e su p e rfic ia l p e ro n e a l

n e rv e I ts me d ia l e n d j o in in g w ith t h e me d ia l dor sa l d ig ita l

.
,

v e in o f the gr e at t o e fo r ms the co mm e n c e m e n t o f t he gr e at
,

sa p h e n ou s v e in an d it s lat e ra l e n d u n it e s w ith th e lat e ra l

,

d o r sa l d ig ita l v e in o f th e little t o e in the for m at io n o f the

sm a ll sa p h e n ou s v e in .

Th e maj or ity o f th e su p e rfic ia l v e in s o f th e fro n t o f th e

le g p a ss me d ia lly an d u p ward s an d th e y t e r min at e in th e ,

gr e at sa p h e n ou s v e in an d as th e gr e at sa p h e n ou s v e in lie s
,
 TH E L EG 337

in fr o n t o f th e m e d ia l m a lle o lu s it r e c e iv e s tr ibutar ie s fro m

t h e m e d ia l sid e o f th e fo o t .

The Su p erfi cia l Ly mp h V e sse ls o f t h e Dor sum o f t h e F o o t

an d t h e F r o n t of t h e L eg — Th e m a in su p e rfic ia l lym p h
v e sse ls acco mp a n y the v e in s The gr e at e r p art o f t he ly mp h .

fr o m t h e d o r su m o f th e fo o t p asse s a lo n g v e sse ls wh ich

acc o mp a n y th e gr e at sa p h e n o u s v e in t o th e d ista l se t o f
su p e rfic ia l su bin gu in a l ly m h g la n d s m
p (p b u t so e o f .

th e ly mp h v e sse ls fr o m t h e lat e ra l bord e r o f t h e fo o t an d th e ,

lat e ra l p art o f t h e d o r su m acc o mp a n y t h e sm a ll sa p h e n o u s ,

ve in an d t e r min at e in the ly mp h gla n d s in the p o p lit e a l

fo ssa . Th e ly mp h v e sse ls fr o m t he fro n t o f th e le g p ass to
t h e larg e r ly mp h v e sse ls wh ich acco mp a n y t h e gr e at sa p h e n o u s
v e in ( Fig .

N e rvi Cu t an e i ( t h e cu t an e o u s n e rv e s o f t he do r su m o f
t he f o o t an d t h e f r o n t o f t h e le g) — Th e d isse ct o r shou ld .

n ot e that bra n ch e s o f t hr e e n e rv e s su ly t h e s k in o f th e
pp
fr o n t o f t he le g bra n ch e s o f thr e e n e rv e s su p p ly t h e dor su m
,

o f t h e fo o t an d that t h e dor sa l a s e ct s o f t h e t o e s are fo r

, p ,

th e m a in p art su pp lie d by bra n ch e s o f thr e e n e rv e s bu t

, ,

that o n ly o n e n e rv e th e su p e rfic ia l p e ro n e al is c o mm o n to all

, ,

thr e e r e g io n s .

The p r o xima l p art o f th e fro n t o f the le g be lo w t he ,

p at e ll a i s,
s u pp lie d b y t h e in
f p
r a ate ll a r éra ne /z of t/z e sap /z eno u s

n erv e
( Fi g s 1 0 7 .
,

Th e lateral entaneo n s n erv e of t/ze leg a bra n ch O f t h e ,

eo mmo n p ero n eal n erv e is d istr ibut e d t o the sk in o f t h e

,

a n t e rior sur fac e fr o m t he in fra p at e llar r e g io n to th e ju n ct io n

o f t he m idd le an d d ista l t h ird s o f th e le g an d th e re ,

m ain de r o f th e fro n t o f the le g is su pp lie d by t h e snp er fi ei a l

p ero n eal nerve .

Th e m e d ia l sid e o f t h e d o r su m o f th e foot is su p p lie d by

t h e sap lt en o n s n erve t h e lat e ra l sid e by t he su ra l n erve an d
, ,

t h e in t e r me d iat e ar e a by t h e su p e rfic ia l p e ro n e a l n e rv e .

Th e adjac e n t sid e s o f th e fir st an d se c o n d to e s are su p p lie d

by the medial divisio n o f t h e deep pero n eal n erve th e lat e ra l ,

sid e s o f t h e litt le t o e by t h e su ral n erve an d all t h e r e m a in in g ,

p art s b y bra n ch e s o f t h e s p fi
n er eia l ero n eal n erve
p .

Th ek i v t h t m i l ph l g
s n o er f th fi t
e er d th i d
na d a an es o e rs ,
se co n ,
r an

th m di l p t
e e a f th f ar th t oi p p l i d by be h o ur f th m di l
o es s su e ran c es O e e a

p la n tar n e rv e .

N e rv us P e ro n aeu s Sup e rfi cialis .

— Th e su p e rfic ia l p e ro n e a l
V OL . 1— 22
 TH E I N F ER I O R EXTRE M I TY
ne rv e p ie rc e s the dee p fasc ia
ju n ct io n o f th e midd le at the
an d d ista l th ird s O f t h e le g an d e ith e r at o n c e o r ,

sh o rt ly a ft e rw a rd s it d iv id e s in t o a m e d ia l an d a lat e ral
d iv isio n wh ich are qu it e u n n e c e ssarily ca lle d th e me d ia l an d
,

in t e r me d iat e d o r sal cuta n e o u s n e rv e s o f t h e fo o t t h e sura l ,

n e rv e ,
wh e n it r e ach e s the d o r su m o f t he fo o t be in g ca lle d ,

t h e lat e ra l dor sa l cuta n e o u s n e rv e o f th e foot t o mak e th e

se r ie s co mp le t e Th e m e d ia l d iv isio n su pp lie s t he m e d ia l
.

p art O f t h e dor su m o f t h e fo o t a n d d iv id e s in to t wo bra n ch e s ,

o n e o f wh ich is d istr ibut e d t o t h e m e d ial sid e o f t h e gr e at

t o e an d t h e o th e r t o t h e adjac e n t sid e s o f t h e se co n d an d
,

th ird t o e s ; it a lso g ive s a c o mm u n icat in g tw ig to the d e e p

p e ro n e a l n e rv e
( g
F i T h e la t e
. ra l d iv isio n su pp lie s t h e

in t e r m e d iat e p art o f t h e d o r su m o f t he fo ot an d a lso d iv id e s ,

in t o t wo bra n ch e s o n e o f wh ich su p p lie s t h e adj ac e n t sid e s

,

o f t h e th ird an d fo urth t o e s an d t h e oth e r a ft e r r e c e iv in g a , ,

tw ig fro m th e sura l n e rv e su p p lie s the adj ac e n t sid e s o f the ,

fo urth an d fi fth t o e s ( F ig Th e bra n ch e s o f bo th.

d iv isio n s lie d e e p to th e d o rsa l v e n o u s arch .

N e r v u s Sura lis Th e su ra l n e rv e is fo r m e d at t he back o f

.
-

t h e le g by t h e u n io n o f t h e a n a st o mot ic bra n ch o f t he c o m m o n

p e r o n e a l n e rv e w ith t h e m e d ial cuta n e ou s n e rv e o f t he ca lf

fr o m th e t ibia l n e rv e ( F ig I t acco m p a n ie s t h e sm a ll
.

sap h e n ou s v e in p a sse s be h in d an d be lo w t h e lat e r al m a lle o lu s

, ,

an d th e n ru n s a lo n g t he lat e ra l bord e r O f t h e fo o t wh e r e it ,

g iv e s o ff a tw ig t o t h e m o st lat e ra l bra n ch o f t he su pe rfic ia l

p e r o n e a l n e rv e
( g
F i a n d t h e n ru
. n s o n t o su pp ly t h e

lat e ra l p art o f t h e d o r su m o f t h e litt le t o e .

The ac c o u n t giv e n abo vef the do rsu m O f th e

o f t he v
c u tan e o u s n e r e s o
fo o t an d to e s in dic ate s the g e n e ral arran g e me n t fre q u e n t y m e t w ith , bu t l
t he disse c to r m u st be p re p are d t o m e e t w ith m any v ariatio n s , e sp e c ial y o n l
l
t h e lat e ra side , wh e re t he su ral n e rv e an d t h e lat e ral div isio n o f the
su p e rfic ial p e ro n e a n e rv e l
n o t u n co mm o n ly re
p ac e o n e a n o th e r t o a l
g re ate r o r a l e ss e xt ent .

D is s e c ti o n — Af e r t h e cu an e o u s t
e in s an d n e r e s o f t h e t v v
t
do rsu m o f t h e f o o an d t h e f ro n o f t h e le g h a e be e n e x am in e d, t v
tt
t h e re m ain s o f t h e f a y su p e rfi cial f ascia m u s be re m o e d t o t v
disp lay t h e de e p f asc ia .

D e e p F a scia — Th e d e e p fa sc ia d o e s n o t form a co mp le t e
in v e st me n t fo r t h e le g I t is a bse n t o v e r the m e d ia l ar e a O f
.

t h e t ibia an d is attach e d to t he a n t e r ior an d m e d ia l bo rd e r s

,

o f that bo n e I t is a lso a bse n t ov e r t h e tr ia n gu lar su bcuta n e o u s

.

s ur fac e o n t he d ista l
p art o f t h e fi bu la be in g attach e d t o t h e ,
 TH E I N F ER I OR EXTRE M I TY

pe ro n e a l r e t in acu la bin d th e t e n d o n s o f th e p e ro n aeu s lo n gu s

an d br e v is t o t h e lat e ra l sur fac e o f t h e ca lca n e u s ( F ig .

I nt e rmuscular Se p t a As t h e d e e p fa sc ia o f th e le g p a sse s
.
—

backward s ov e r t h e fibular r e g io n two stro n g in t e r m u scu lar ,

se p ta are g iv e n o ff fro m it s d e e p surfac e Th e se are dis .

tin gu ish e d as th e a n t e r ior an d p o st e r ior fibu lar se p ta The .

an terio rfi o u lar septu m in t e rv e n e s be tw e e n th e p e ro n e a l m u sc le s

an d th e e x t e n sor m u sc le s o f t h e to e s an d is attach e d to th e ,

a n t e rior cr e st o f the fi bu la Th e po sterio r fibu lar septu m is .

in t e r p o se d be tw e e n t h e
p e ro n e a l mu sc le s an d the
m u sc le s o n t he back o f
th e le g an d is attach e d ,

t o t h e lat e ra l cr e st o f th e
fi bu la .

Th e le g is thu s su b
d iv id e d in to thr e e o st e o
fa sc ia l co mp art me n t s cor ,

r e sp o n d in g to th e a n t e rior ,

la t e r a l a n d p o s t e r i o r ,

crura l r e g io n s The an .

te ri o r co mp a rt m e n t is
bou n d e d by th e in v e st in g
d e e p fa sc ia the a n t e r ior ,

fibu larse p t u mn
e art Of th e
b
m e al s
e

t i bi li
dl u rfac
a p t i s i m
o s er o r m
s l o re a u scu ar p
a p i th
o n e u ro s s t f
an a i l pt m ;
rue O f the
asc a fi bu la ( that p art
se u

b t it i
u v i t f d i p ti v p
s co n en en o r
which lie s a n t e r io r to t h e
e scr e ur

p t
o se s g do itre ar f t h p ti
as o n e O e ar
i n t e r o sse ou s cr e st ) t h
ti
e ,
o ns .

in t e ro sse ou s m e mbra n e ,

an d th e lat e ra l sur fac e o f th e t ibia Th e lateral co mpartmen t .

is bou n d e d by th e lat e ra l sur fac e o f th e fi bu la th e in v e st in g ,

fa sc ia an d th e two fibu lar se p ta

,
Th e po sterio r eo mp artmen t .
,

wh ich w ill be stud ie d lat e r is much t he larg e st its walls are ,

for me d by the p o st e r ior sur fac e o f t h e t ibia th e p o st e r io r ,

p art o f t h e m e d ia l sur fac e an d t h e who le o f t h e p o st e r ior

sur fac e o f t h e fi bu la t h e in t e ro sse ou s m e m bra n e t he p o st e r io r
, ,

fi bu lar se p tu m an d t h e in v e st in g d e e p fa sc ia
,
.

i
D is s e c t o n — . t
Th e an e rio r co m p art m e n o f t h e le g s h o u ld t
n o w be o p e n e d by th e re m o al o f t h e de e p f ascia v
Th e ran s e rse . t v
t
an d c ru c ia e lig am e n s , h o w e e r, m u s t be re ain e d, an d h e irv t t t
t
bo rde rs s h o u ld be se p ara e d art ifi c ially by t h e k n ife , f ro m t h e ,
 TH E L EG 34 1

dee p f ascia w it h w h i h t h y ar n t in o Gr at are m t c e e co u u s. e c us

b t ak ne t t i j r th m
e no u osh t h f th t ibiali a t ri r
n u e e u co s ea s o e s n e o
a n d th t so r t n d
e ex e n f th e t wh t h m arg i e f th o ns o o e s, en e ns o e
tran v r a d r iat ligam t ar b in g de fi n e d a d w h il t
s e se n c uc e en s e e ,
n s
t h d e p f a ia i b in g r fl
e e sc t e d Th y li l t th d p rf a e
s e e ec . e e c o se o e ee su c
o f t h d p f a ia e I n t h p r im l p art o f t h l g it w ill b
ee sc . e o x a e e e
f n d im p o
o u ible t rai t h e de p f as ia f r m t h
ss o bj c n t se e c o e su a e
m l w it h t la rat i g t h ir rf a
u sc e s o u I t h u ld t h r f r
ce n e su ce s . s o ,
e e o e,
be le f t i p sit i n n At a m o r di t al l v l it an re adily b
o o . e s e e c e
se p ar t d D ivide it in a l g it din al dire ct i n m idw ay be tw n
a e . o n u o ee
t h t ibia an d fi b l
e T rn t h m dial p i u a t o t h m dial ide
. u e e e ce e e s ,

u n t il it att a ch m e n t t o t h
s an t rio r b rde r o f t h t ibia i d m n e e o e s e o
s trat d ; t h e t rn t h lat ral p i ce t t h e lat ral sid u n t il it
en u e e e o e e, s
co n t in it y w it h t h
u an t e rio r fi b lar p t m is di p lay d
e u se u s e .

Aft r t h e m dial a d l t ral att a h m n t

e e f t h d p f ascia n a e c e s o e ee
h av b n tu di d att m p t to di t d t h sy n o vial sh at h s f
e ee s e e s en e e o
th e t d en it h e r by in fl at io n w it h a blo w p ip
o n s, e o r by t h -
e, e
i j ti n
n ec f om o fl id by m a
o s f a m all y rin g e
e Th r e
u e ns o s s . e
s h e at h ar t b s am i e d ; f r m t h m dial t t h lat ral id
o e ex ne o e e o e e s e
t h y ar th h at h f th e t ibialis n t rio r t h sh at h o f t h
e e, e s e o a e , e e e
e x t e n so r h allu cis lo n gu s an d th e sh e at h co mm o n t o t he e xt e n so r ,

dig it o ru m lo n gu s an d t h e p e ro n a u s t e rt iu s (se e F ig 1 5 3 p .
, .

I f t h e blo w p ip e is u se d m ak e a sm all in c isio n t h r o u gh t h e

-

de e p f ascia o f t h e f o o t in t o e ac h sh e at h in tu rn e it h e r be t we e n ,

t h e tw o ban ds o f t h e cru c iat e lig am e n t o r be y o n d t h e lo w e r

bo rde r o f t h e cru ciat e lig am e n t an d if a sy rin g e is u se d in se rt ,

th e n e e dle in t o t h e s h e at h s in t h e sam e re g io n s I f in fl at io n .

o r in j e ct io n f ails t h e p o sit io n s an d e x t e n ts o f t h e s h e at h s c an be
,

f airly sat isf act o rily de m o n st rat e d by th e u se o f a blu n t p ro be ,

in t ro du ce d in t o t h e cav it ies o f t h e sh e at h s t h ro u gh t h e o p e n in g s
m ade t h ro u gh t h e ir bo u n darie s .

Th e M uc o us Sh eat hs on t h e D o rsum o f t he F o o t — . Thr e e

m ucou s s h e ath s fou n d in th e
r e g io n o f t he fr o n t o f the
are

a n kle an d o n the dor su m o f the foot o n e rou n d t he t e n do n —

o f t h e t ibia lis a n t e rio r th e se co n d r o u n d the t e n d o n o f t h e ,

e x t e n sor ha lluc is lo n gu s an d t h e th ird e n c lo se s t he t e n do n s ,

o f t h e e x t e n so r d ig itor u m lo n gu s an d t h e p e ro n a e u s t e rt iu s .

The fir st e x t e n d s fro m th e p ro x im a l bord e r o f the tra n sv e r se “

liga m e n t t o w ith in a short d ista n c e o f t h e in se rt io n o f t h e

t ibialis a n t e r io r in to th e m e d ia l sid e o f the first cu n e ifor m
bo n e . Th e se c o n d e x t e n d s fro m be h in d t he low e r p art o f
th e tra n sv e r se liga m e n t to th e fir st p ha la n x o f th e gr e at t o e ;
an d t h e lim it s o f t h e th ird are t h e low e r bord e r o f t h e

tra n sv e r se liga me n t p r o x im ally an d t h e m idd le o f th e , ,

dor su m o f t he fo ot d ista lly The sh e ath s fac ilitat e t he .

mo v e m e n t s o f th e t e n do n s be h in d th e liga m e n t s wh e n th e
mu scle s are in act io n an d th e y are o f surg ica l im p orta n c e ,

be cau se th e y are lia ble to be c o m e in fla m e d .

1— 22 b
 TH E INFE R I OR EXTRE M I TY
Aft e r t he muc o u s sh e ath s hav e be e n e x a m in e d , th e c o n t e n t s
o f t h e a n t e r ior crura l co m art m e n t m a b i v t igat d
p y e n e s e .

C o nt e nt s o f t h e A n t erio r Crural Co mp art me nt — F o u r

m u sc le s are brought in t o v ie w wh e n th e d e e fa sc ia o f th e p

M . e x t e n so r d ig i t o ru m l g o n us Tba i i
M p e ro . e u s t e rt i u s
na
M . e x l g
t e n so r o n us h aHU C N

M . t i bi li
a i
s an t e r o r

M p e ro . n aau s bre v 1 s

M p e ro n ae u s
. l g o n us

L ig am e n t u m t ra n s v e rs u m

S he a t h o f p e ro n e i t e n do n s
L ig m a e o . ll li l a t e ra li s Lig . c ru c ia t u m
a n t e ri u s
L ig . l
t a c - fi bu laris a n t e r o r i She a t h o f t 1 b1a li s an t e r1 o r

R i e t n ac u u m l m m p e ro . She a t h o f t i bi li
a s i
p o st e r o r
na
eo ru m su p e n u s
Li g a me n t u m c ru c 1a t u m
R e tm

Sh e a t h o f e x t e n so r d igi t o ru m
l g
o n us

M e x t e n s o r digit o ru m br She a t h o f e x t e n so r ha ll iuc s

l g
.

o n us

Te n do n
r o f p e ro ne u s t e rt iu

M . e x t e n so r ha ll iuc s bre vi s

FG I .
‘

1 53 .
— M u co u s sh e at h o f th e D o rsu m O f t he Fo o t .

f ro n t f the le g h as be e n r e m ov e d , v iz , th e t ibia lis a n t e r io r,

o .

t he e x t e n sor d ig it o ru m lo n gu s, t h e e x t e n sor ha lluc is lo n gu s,

an d t he p e ro n ae u s t e rt iu s Th e tibialis anterio r lie s in r e lat io n .

t o th e t ibia ; th e ex tenso r digito ru m lo ngus is p lac e d a lo n g the

fi bu la ; an d wh e n tho se m u sc le s are se p arat e d fro m o n e a n oth e r
t h e ex tenso r nallu eis lo ngu s w ill be se e n in t he in t e rva l be tw e e n
 T H E I N F ER I OR EXTR E M I TY
the fi bu la
,
in m o st ca se s is co n t in uou s w ith t h e e x t e n sor
an d

d ig itoru m lo n gu s The an terio r tibial vessels an d t/z e deep .

p ero n eal n erve

( O T a n terio r tibial
) p roc e e d d ista lly in
. th is .

co mp art m e n t At first th e y are d e e p ly p lac e d, bu t as th e y

.

a pp roach t he a n k le th e y c o me n e are r to th e sur fac e .

D i s s e c t i o n — To e x p o se t h e an e rio r ibial esse ls an d t h e t t v

v
de e p p e ro n e al n e r e in t h e ir e n ire co u rse o n t h e f ro n o f th e t t
t t
le g, th e ibialis an e rio r an d t h e ex t e n so r dig i o ru m lo n gu s m u s t t
r t
be se p a a e d f ro m e ac h o h e r, alo n g t h e lin e o f a s ro n g in e r t t t
t
m u s cu lar se p u m w h ic h dip s back ards be t ee n h e m , an d w w t
aff o rds a su rfa ce o f o rig in t o e ac h The k n ife sh o u ld be carrie d .

p ro x im ally alo n g t h e p lan e o f t h is se p u m I f t h e p e ro n a u s t .

t e rt iu s m u scle is dra n as ide , t he p er w

fo rati ng branc h of the
ero n eal artery w ill be se e n p ie rcin g t h e in e ro sse o u s m e m bran e t .

t is a sm all art e ry w h ic h desce n ds u p o n t h e dis al e n d o f t h e t

t
fi bu la As th e s ru c u e s in t he an e rio r cru ral co m p art m e n
. t r t t
are be in g ex p o se d a n d cle an e d, th e disse ct o r s h o u ld, at t h e sam e
t im e , carry o n t h e disse c io n o f t h e do rsu m o f t h e f o o t
Th e re t .

t h e t e n do n s o f t h e m u s : les o n t h e f ro n o f t h e le g m u s be fo llo w e d t t
to t h e ir inse rt io n s, t h e n t h e t e n do ns o f th e ex e n so r dig i o ru m t t
t
lo n gu s m u s be p u lle d aside in o rde r h a t h e ext e n so r h allu c is t t
bre vis an d t he ex t e n so r dig i o ru m bre is, h ic h lie de e p t o t h e t v w
t e n do n s o f t h e lo n g ex t e n so r o f th e t o e s, m ay be c le an e d a n d
t h e ir t e n do n s f o llo e d t o w
h e ir t e rm in a io ns Th e do rsalis t t .

p e di s a rt e r y ,
h i w
c h is t h e co n in u a io n o f t h e an e rio r ibial t t t t
arte ry , an d t h e de e p p e ro n e al n e r e , an d h e ir bran c h e s, m u s v t t
w
also be cle an e d an d f o llo t e d to t t
h e ir e rm in a io n s .

M Tibialis A nt e ri o r ( O T Tibialis A nt ic us) — Th e t ibia lis

. . . .

a n t e r ior is a p ow e rfu l m u scle wh ich tak e s or ig in fro m the ,

d ista l p art O f the lat e ra l co n dy le o f th e t ibia an d fro m the ,

p ro x i m a l ha l f o f t h e lat e ra l s ur fac e o f it s b ody ( g 54 p

F i 1 .
, .

I t d e r iv e s m a n y fi br e s a lso fro m the d e e p fa sc ia wh ich cov e r s

it fro m th e fa sc ia l se p tu m be tw e e n it an d th e e x t e n so r d ig i
,

toru m lo n gu s an d fro m the p ort io n o f the in t e ro sse ou s

,

me mbra n e o n wh ich it r e st s I n oth e r word s it sp r in g s fro m .

,

t h e structur e s wh ich for m t he wa lls o f t he m e d ia l p ort io n o f

th e o st e o fa sc ia l co m p art m e n t in wh ich it lie s A stro n g
-
1
.

t e n do n issu e s fro m its fl e shy be lly in the d ista l th ird o f the

le g an d th is r e ach e s th e dor su m o f th e foot by p a ssin g
,

T1 d
- to d th
un tt h m t f th m l
e rs an f th l g it i
e a ac en s o y e u sc e s o e e , s n e ce ssar

to b i m i d th t t h i t
e ar n n m mb a wh i h t t he th
n e ro sse o u s e ran e , c s re c e s acro ss e

i t v l b tw t h t w b
n er a e eenf th l g e d th x t d th
o o ne sf O f e e , an us e en s e su r ace o

o ri gi f th m l i tt h d t th i t
n o r e se u sc e s , t f t h t i bi ( i
s a ac e o e n ero sseo u s c re s o e a . e .

b tw
e it l t
een l dp t i s a e ra f ) and t th i t t f th
o s e r o r su r a ce s an o e n e ro sse o u s c re s o e

fib l u a Th i t . e t f t h fib l t v
n e ro sse o u s th m di l c re s f o f e u a ra e rse s e e a su r ac e o

th t b
a d di v id
o ne , it i t
an t i d p t i
es p t Th
n o t i
an an e r o r an a o s er o r ar . e an e r o r

par t g i v i g i t t h
es o r x t m n l o d t h p t
e e i p t t t h
e n so rt i b i li u sc e s an e o s er o r ar o e a s

p o ste r1o r.
 TH E L EG 34 5

through both th e tra n sv e r se an d cruc iat e liga m e n t s O n .

th e foot it in c lin e s me di a lly an d tur n in g rou n d t he me d ia l , ,

m arg in ga in s in se rt io n by two slip s in to th e me d ia l an d

, , ,

d ista l p art o f the fir st cu n e iform bo n e an d in to the adj o in ,

in g p art o f th e ba se o f th e fir st me tatar sa l bo n e Th e t ibia lis .

a n t e rior is sup plie d by the deep p ero neal n erve I t is a d o r si .

fl e x o r an d an in v e rtor o f t he foot .

M Ext e nso r Digit o rum L o ngus — Th e e x t e n sor lo n gu s

.

d ig itoru m mu sc le ar ise s fo r th e m o st p art fro m th e , ,

structur e s wh ich for m th e lat e ra l p ort io n o f the wa ll o f t h e

M :fl e x dig
. . .l g’

o n .

P i
o st e r o r t i bi l a
a rt e r y
i i l v (O T
Tba ne r e
i i bi l)
. .

p o ste r o r t a

M p . l a n t ar s i

Su ral n e rve an d s ma ll sap h e n o u s v ein

FIG . 1
55 .
—Trans ve rse i
se c t o n h
t ro u g h t he i l
M dd e o f th e L e g .

a n t e rior crural r e g io n Thu s it sp rin g s fro m the d istal p art

.
,

o f th e lat e ra l co n dy le o f th e t ibia fro m th e h e ad o f t h e ,

fi bu la an d fro m the p ro x ima l thr e e fourth s o f the a n t e rior

,
-

p art o f t he m e d ia l surfac e o f t h e body o f the fi bu la

( g 5 p
F i .1 4 , I t.tak e s or ig in a lso fro m a s m a ll p ort i o n

o f the p ro x im a l
p art o f t h e in t e ro sse ou s m e m b ra n e t h e ,

d e e p in v e st in g fa sc ia o f the le g the a n t e rior fibu lar se p tu m , ,

an d t h e in t e r m u scu lar se p tu m wh ich lie s be tw e e n it an d

-

t he t ibia lis a n t e r ior Th e t e n do n o f t he e x t e n sor d ig itoru m

.

lo n gu s d e sc e n d s a n t e r io r to the a n k le jo in t an d p a ssin g , ,

through th e tra nsve r se an d cruc iat e liga me n t s ( p .

d iv id e s in to fo ur slip s wh ich d iv e rg e fro m e ach o th e r o n

,
 TH E I N F ER I OR EXTRE M I TY
th e dorsu m o f the foot to r e ach the lat e ral four to e s .

O n the dor su m o f t h e fir st p ha la n x o f e ach o f th e me d ia l

thre e o f the lat e ra l fo ur to e s e ach slip is jo in e d o n its lat e ra l ,

sid e by a t e n do n fro m t he e x t e n sor d ig itoru m br e v is

, .

The m a n n e r in wh ich th e four t e n do n s o f th e lo n g

e x t e n sor are in se rt e d is similar in all e ssen t ia l r e sp e ct s to
, ,

that in wh ich the c o rr e sp o n d in g t e n do n s o f th e fi n g e rs are

attach e d bu t th e re are slight d iff e r e n ce s an d as the d isse ctor
, ,

o f t h e foot may n o t hav e d isse ct e d t he ha n d a d e scr ip t io n

o f t he co n d it io n s m e t w ith is n e c e ssary The t e n do n s o f

.

t h e e x t e n sor d ig itoru m lo n gu s go to th e se co n d th ird fourth , , ,

an d fi fth to e s an d tho se o f th e e x t e n so r d igitoru m br e v is to

,

t h e fir st se co n d th ird an d fourth to e s
, , ,
I n the ca se s o f t h e
.

se co n d th ird an d fourth to e s th e t e n do n s o f t he lo n g an d
'

, ,

short e x t e n sor s u n it e an d t he co n j o in e d t e n do n s for m an

,

e x p a nsio n o n t h e dor sa l a sp e ct o f t h e fir st p ha la n x Th e .

e x p a n sio n is j o in e d by t h e sle n d e r t e n do n s o f o n e lu mbr ica l

an d two in t e ro sse i an d th e n it d iv id e s in to a c e n tra l an d

,

two co llat e ra l p art s The sle n d e r c e n tra l p art is in se rt e d

.

in t o th e ba se o f the se co n d p ha la n x ; th e stro n g e r

co llat e ral p art s are p ro lo n ge d forward s an d a ft e r th e y hav e , ,

u n it e d tog e th e r th e y are in se rt e d in to the ba se o f th e t e rmin a l

,

p ha la n x ; thu s fiv e t e n do n s ga in in se rt io n in to th e d o r sa l

a sp e ct s o f the ba se s o f e ach o f the se co n d an d t e rmin a l

p ha la n g e s o f t h e se co n d th ird ,
a n d fourth to e s
, a n d m ov e ,

me n t s be co m e p o ssible wh ich cou ld n o t be r e ad ily O bta in e d

in an y oth e r way fo r wh ilst the fl e x o r t e n d o n s fl e x th e
,

m e tacar p o p ha la n g e a l j o in t s th e lu mbrica ls an d in t e ro sse i c an

-

e x t e n d th e in t e r p ha la n g e a l jo in t s by v irtu e o f th e ir co n n e ct io n

w ith t he e x t e n sor e x p a n sio n I n the ca se o f t h e foot th is is

.

n o t a v e ry imp orta n t m att e r bu t in th e ca se o f the ha n d it

,

is o f e x tr e me imp orta n c e fo r it is o n ly by the me a n s in d icat e d

,

that it is p o ssible to p lac e the fi n g e r s in the writ in g p o sit io n ,

an d u se th e m in t h e u sua l m a n n e r ad o p t e d fo r wr it in g
T e e x t e n sor d ig itoru m lo n gu s is su p p lie d by
( se e p . h
t h e deep pero n eal n erve I t is an e x t e n sor o f the in t e r p ha la n g e a l
.

an d m e tatar so p ha la n g e a l j o in t s o f t h e lat e ra l four to e s an d

-

it dor si fl e x e s t h e foot
-
.

M E te
. x n so r H a ll uc is L o ng u s — Th e lo n g e x t e n sor o f th e
gr e at t o e is p lac e d in th e in t e rva l be tw e e n th e t ibia lis a n t e r ior
an d the e x t e n sor d ig itoru m lo n gu s I n its p ro x im a l p art it
.

is h idd e n fro m v ie w by tho se mu sc le s bu t n e ar th e a n k le it ,

 T H E I N F ER I O R EXTRE M I TY
t or ha lluc is lo n gu s o n the lat e ra l sid e I n th e d ista l
ex ens .

th ird o f th e le g wh e r e the m u sc le s g iv e p lac e t o th e ir t e n d o n s

, ,

th e art e ry c o m e s n e ar e r to t h e sur fac e I n that p art o f it s .

c o ur se it r e st s u p o n th e t ibia an d is o v e rla pp e d o n the lat e ra l

sid e by th e e x t e n so r ha lluc is lo n gu s I m m e d iat e ly p ro x im a l .

t o t h e a n k le j o in t t h e t e n do n o f th e e x t e n sor ha lluc is lo n gu s
cro sse s su p e rfic ial to the art e ry an d so co me s to lie o n it s
m e d ia l sid e .

Two venee co mites c lo se ly acco m p a n y the a n t e rior t ibia l

art e ry an d se n d short c o mm u n icat in g bra n ch e s both a n t e r io r
,

an d p o st e r ior to it Th e deep p ero n eal n erv e is a lso in t im at e ly

.

r e lat e d to it I t jo in s th e art e ry a short d ista n c e d ista l to

.

t h e k n e e an d soo n tak e s u p a p o sit io n a n t e r io r to th e v e sse l

, .

N e ar t he a n k le j o in t the n e rv e as a ru le aga in lie s o n t he , ,

lat e ra l sid e o f th e art e ry Wh ilst the art e ry is st ill in th e

.

back p art o f th e le g it g iv e s o ff a fibu lar an d a p o st e r ior

t ibial re curr e n t bra n ch wh ich w ill be se e n in a su bse qu e n t
d isse ct io n ( se e p .

O n the fro n t o f t h e le g the a n t e r ior t ibia l art e ry g iv e s o ff

t h e fo llow in g brane/res

I . M u scu lar .
3 . A m alle o laris
. an t e rio r m e dialis .

2 . A . re cu rre n s tibialis an t e rio r.

4 . A m alle o aris
. l an t e rio r lat e ralis
.

Th e mu scu lar bra ne/z es are n u m e rou s ,

an d co me O ff at
irr e gu lar p o in t s a lo n g th e wh o le the le n gth o f art e ry Th e y
.

su p p ly th e m u sc le s O f t h e an terio r cru ral regi o n .

Th e an t e rio r t ibia l re curren t a rt ery is a sma ll v e sse l

wh ich sp r in gs fro m th e a n t e r ior t ibia l imm e d iat e ly a ft e r it
r e ach e s th e fro n t o f the le g I t tur n s p ro x im ally, o n the .

lat e ra l c o n dy le o f th e t ibia , in th e fi br e s o f th e t ibia lis a n t e r ior

m u sc le I t s t e r m in a l tw ig s r e ach the fr o n t o f t h e k n e e j o in t ,
.

an d a n a sto m o se w ith t h e in fe r ior g e n icu lar bra n ch e s o f th e

o
p p li t e a l art e ry .

a
M alle o l r Art eries — Th e se art e rie s tak e orig in im m e d iat e ly
p r o x im a l to t h e a n k le j o in t Th e lateral a n terio r malleo la r
.

a rter
y is th e larg e r o f th e t wo I t p a sse s lat e ra lly u n d e r
.

cove r o f the t e n do n s o f th e e x t e n sor d igit o ru m lo n gu s an d

e ro na e u s t e rt iu s, t o r e ach t h e lat e ra l sur fac e o f t h e lat e ra l
p
m a lle o lu s, an d it a n a sto m o se s w ith th e p e r forat in g bra n ch o f t h e
p e ro n e a l art e ry an d w ith t h e lat e ra l tar sa l art e ry T h e medial .

a nterio r malleo la r artery ru n s me d ia lly , u n d e r cove r o f th e

 TH E L EG 349

t e n do n s O f the e xt e n sor ha lluc is lo n gu s an d t ibia lis a n t e r io r .

I t in o scu lat e s w ith bra n ch e s fr o m t h e p o st e r ior t ibia l art e ry .

Art eria D o rsa lis P e dis Th e d o r sa l art e ry o f t he foot is

.
—

t h e c o n t in uat io n o f t h e a n t e r io r t ibia l I t be g in s a n t e r ior t o .

,

t h e a n k le jo in t at a ,

po in t m i dway b e .
'
M i bi li i . t a s an t e r o r

twe e n t he t W O m al M x digi ml g . e t e n so r t o ru o n us

le o li an d it e x t e n d s
,

forward s u p o n th e
, M p b vi . e ro n a
e us re s

dor sa l p art Of t he M p l g . e ro na
e us o n us

ta lu s an d acr o ss th e
,
M x h ll i l g e t e n so r a uc s o n us

n av i cu lar
.

an d ,
t he
s e c o n d c u n e if o r m T i bi a

bo n e tO th e P o St e riO T
, M p i . e ro n a
eus t e rt u s

p art o f t h e fir s t in

t e ro s s e o u s s p a c e .

T v li g m rans e rse a e nt

Th e r e I t le av e s the Ex h ll i l g t e n so r a uc s o n us

d o r su m O f the fOOt ,
D li p di y o rsa s e s art e r

by d ip p in g p la n tar C i li g m ru c at e a ent

ward s be tw e e n th e D pp l v ee e ro n e a ne r e

tW O h e ad s O f th e i li i a s an t e r o r

fir st d o r sa l in te ro sse
o u s m u sc le to r e ach ,

th e p la n tar r e g io n ,

W h e re I t u n lt e s W lt h
M x di g i m e t e n so r t o ru
lat e ra l p la n tar i
.

th e b re v s

art e ry in the fo rm a A y rc u a t e art e r

t io n o f th e p la n tar
arch . I t s r e lat io n s T d f x en o ns o e t e n so r
dg m m 1 8
' ‘

‘r “
o n th e dor su m O f t h e
‘ 1 5

foot are v e ry sim p le .

( )
1 I t lie s in t h e ih
t e rval be tw e e n th e
t e n do n o f the e xt e n
so r ha lluc is lo n gu s o n

t h e m e d ia l sid e an d FIG . 1 56 .
— Di i
sse c t o n o f th e D o rsu m o f t he Fo o t .

t he m o st m e d ia l te n
do n o t
f the r d igitoru m lo n gu s o n the lat e ra l sid e
e x e n so .

s cro sse d fir st by t h e p r o x im a l ba n d o f th e cruc iat e

( )
2 I t i
liga m e n t th e n by t h e d ista l ba n d an d n e ar it s t e r min at io n it
, ,

is cr o sse d by t he t e n d o n o f t h e e x t e n sor ha lluc is br e v is w ith

tho se e x c e p t io n s the v e sse l is cov e r e d m e r e ly by the in te gu
'
 TH E I N F ER I O R EXTRE M I TY
me n t an d fa sc iae
( 3) T h.e m e d ia l t e r m in a l bra n ch o f t h e

d e e p p e r o n e a l n e rv e lie s a lo n g its lat e ra l sid e , an d two ven d

1

co mites acc o m p a n y it .

As the d o r sa lis p e d is art e ry trav e r se s th e dor su m o f th e

fo o t it g iv e s o ff se v e ra l tw ig s t o the m e d ia l m arg in o f the fo o t ,
an d thr e e n a m e d bra n ch e s wh ich p a ss lat e ra lly
°

I . A a t arse ae m e diale s
. .

2 . A tarse a late ralis

. .

3 . A arcu ata
. .

4 . A m e tatarse a do rsalis p rim a

. .

Art e r iae Tarseae M e diales — Th e m e d ia l tar sa l bra n ch e s

.

two o r m or e in n u mbe r, sp rin g fro m the me d ial sid e o f the

dor salis p e d is an d d e sc e n d acr o ss the me d ia l bo rd e r o f the
foot to a n a sto m o se w ith bra n ch e s o f t he me d ia l p la n tar
art e ry .

A .Tarse a L a t era lis et A Arcu at a ( O T Tar sa l an d . . .

M et at a rsal) Th e lateral tarsal artery ar ise s o p p o sit e th e

.
-

n av icu lar bo n e , an d th e arcu ate arter y arise s n e ar t he ba se s o f

t h e m e tatar sa l bo n e s Th e y bo th ru n lat e ra lly, u n d e r cov e r o f
.

th e e x t e n sor ha lluc is br e v is an d t he e x t e n sor d igitoru m

br e v is, to r e ach t he lat e ra l marg in o f th e fo ot Th e r e th e y .

a n a sto m o se with bra n ch e s o f the lat e ra l pla n tar art e ry The .

lat e ra l tar sa l art e ry a n a sto m o se s a lso w ith t h e lat e ra l ma lle o lar

an d p e r o n e a l art e r ie s .

F ro m the arch wh ich is fo r me d by t h e arcuat e art e ry

t/z ree do rsal metatarsal arteries p roc e e d , o n e to e ach o f the
lat e ra l thr e e in t e ro sse ou s sp ac e s, an d at t he c le ft s be tw e e n
th e t o e s th e y d iv id e an d su pp ly do rsal digital t w igs to th e
adjac e n t sid e s o f the se co n d , th ird, fo urth , an d fi fth t o e s .

F ro m th e m o st lat e ra l do r sa l m e tatar sa l art e ry a tw ig is g iv e n

to the lat e ra l sid e o f the litt le to e .

A M e t at arse a Do rsa lis P rima ( O T F irst D o rsal I u t e ro s

. . .

se o u s) — Th e fir st d o r sal m e tatar sa l art e ry is a sm a ll v e sse l

.

wh ich tak e s or ig in fro m the d o r sa lis p e d is, at the p o in t wh e re

that v e sse l tur n s p lan tarwards to r e ach t he p la n tar r e g io n o f
t h e foot F r o m it s o r ig in it co n t in u e s forward s, u p o n t h e
.

fir st dor sa l in t e r o sse ou s m u sc le , an d d ivid e s in to do rsal digital

ora ncnes fo r t he m e d ia l sid e o f th e gr e at t o e an d t he adjac e n t
sid e s o f t he gr e at t o e an d se c o n d t o e
2
.

P erf o rat ing B ranch o f P ero n eal Art ery ( O T An t erio r . .

1
The v
n e r e so l
m e tim e s de sc e n ds a o n g its m e dial side .

2
Fo r th e bran ch e s li i l
fro m t h e do rsa s p e d s in th e p an t ar re g o n se e p 3 9 8 i . .
 T H E I N F ER I OR EXTRE M I TY
in sta n c e ly in g lat e ral to th e m , th e n a n t e r ior ; bu t n e ar the
a n k le jo in t it again , as a rule , lie s o n th e ir lat e ra l sid e It .

p a sse s p o st e r ior t o t h e tra n sv e r se an d cruc iat e liga m e nts ,

a n d e n d s by d iv id in g in t o a m e d ia l an d a lat e ra l bra n ch .

I n it s cour se thr o ugh t h e le g t h e d e e p p e r o n e a l n e rv e

g iv e s muscu lar brane/res to th e e x t e n so r d ig it o ru m lo n gu s t he ,

t ibia lis a n t e r io r the e x t e n sor ha lluc is lo n gu s an d the p e ro n ae u s

, ,

t e rt iu s ; an d a fin e articu lar t g to t h e a n k le j o in t .

e rse li g ame n t

a li s an t e r o r i

Tb ii a
P e ro n mu s t e rt 1

Ta l us

Fi b lu a

i i li p i
Tba s o s te r o r

D l i d li g m
e to a ent

Ca l c ane u s
Fl x di g i m
e o r t o ru

P e ro n ae u s bre w s
lo n g us

il l
Med a p y a n t ar a rt e r
P e ro n e a l M d l pl v
i
re t n ac u u m l e ia an t ar n e r e

P e ro n ze n s l go n
Fl x h ll i l g
e o r a uc s o n us

M bd
. ah ll i u c to r a uc s

pl v an t ar n e r e

Pl a n t a r a p o n e u ro s is
a n t ar art e r y
M fl e x o r dI g I t o
. ru m bre w s

dra t u s p l a n t ae

FIG . 1 57 .
— F ro n t a l se c t io n t h ro u gh the L e ft A n k l e Jo i n t ; Tal us ,

an d Ca l c an e u s
( P ate rso n
) .

Th e medial terminal orancli a l n e rv e is o f th e deep p e o ner

c o n t in u e d fo rward s u p o n the dorsu m o f the fo o t a lo n g the
lat e ra l sid e o f th e dor sa lis p e d is art e ry 1
At t h e p o st e r ior e n d .

o f th e fir st in t e ro sse ou s sp ac e it p ie rc e s the d e e p fa sc ia an d , ,

d iv id e s t o su pp ly the c o n t iguou s margin s o f th e gr e at to e an d

t h e se co n d t o e ( p B e fo r e it r e ach e s t h e sur fac e it
.
,

fur n ish e s articu lar tw igs t o t h e tar so me tatar sa l an d m e tatar so -

1
N o t u n co mm o n ly it c ro sse s fi
su p e r cial to the arte r y an d de sce n ds
alo ng its m e dial side .
 TH E L EG 353

p ha la n g e a l j o ints f t h e gr e at t o e , an d fr e qu e n t ly , a lso , a
o

fi n e muscu lar tw ig to t h e d o r sa l sur fac e o f t h e fir st d o r sa l

in t e ro sse o u s m u sc le .

Th e lateral termin al ora n clt o f t h e d e e p p e ro n e a l n e rv e

tur n s a bru p t ly lat e ra lly u n d e r cov e r o f th e ex t e n sor d ig itoru m
,

br e v is an d e n d s o n t h e d o r su m o f t h e tar su s in a ga n g lifor m
,

e n larg e m e n t B ra n ch e s p roc e e d fro m th e e n larg e m e n t to

.

su p ly t h e e t e n so r d i g it o ru m b r e v is an d t h e n u m rou
p x e s

art icu lat io n s in t he n e igh bourhood O n e fi n e fi la me n t c an .

,

in so me ca se s be trac e d to t he se co n d dor sa l in t e r o sse ou s

,

m u sc le Th e t e r min a l sw e llin g r e se m ble s c lo se ly t h e corr e

.

sp o n din g e n larg e m e n t in wh ich t h e dor sa l in t e ro sse o u s n e rv e

o f t h e su p e r ior e x tr e mity e n d s se e p
( .

Ligame nt um Tran sv ersum Cruris e t Liga me n t um Cru ciat um

(O . T A
. n t e ri o r A nn ul a r Li g am e n t ) — Th e d isse ctor shou ld
.

n o w re e x a m in e t h e tra n sv e r se an d cruc iat e liga m e n t s

-
an d ,

t h e arra n g e me n t o f t h e structur e s wh ich p a ss d e e p to th e m .

Th e transverse ligamen t is attach e d to t h e fi bu la by its lat e ra l

end ,
an d to th e t ibia by its m e d ia l e x tr e mity I f th e .

fibu lar attach m e n t is d ivid e d an d t h e liga me n t is throw n

,

me d ia lly it w ill be se e n to co n ta in a d ist in ct co m p art me n t fo r

,

th e t ibia lis a n t e rior an d it s m uco u s sh e at h .

Th e cru ciate ligamen t is t h e m or e im p orta n t o f th e two .

I t s attach me n t s hav e a lr e ady be e n n ot e d ( p E x a min e .

t h e m a n n e r in wh ich it ho ld s t h e t e n do n s in p o sit io n It .

co n sist s o f two laye r s an d th e se by se p arat in g at c e rta in

, ,

p o in t s a n d b e co m in g r e u n i t e d at o th e r s for m thr e e d ist in ct

,

co mp art me n t s The t e n d o n o f th e t ibia lis a n t e rior p a sse s

.

through the medial co m p art me n t t he t e n do n o f th e e x ,

t e n sor ha lluc is lo n gu s trav e r se s t he in termediate o n e an d th e ,

t e n do n s o f the e x t e nsor d ig itoru m lo n gu s an d p e ro n ae u s

t e rt iu s are tra n smitt e d thro ugh the lateral co mp art m e n t .

As the t e n do n s p a ss through the co mp art me n t s o f t h e

liga me n t s an d fo r so me d ista n c e p r o x im a l to th e tra n sv e r se
‘

liga me n t an d d ista l to th e cruc iat e liga m e n t th e y are ,

surr o u n d e d by m ucou s sh e ath s a st ly no t e

( se e p L .
,

t h e p o sit io n o f th e a n t e r ior t ibia l v e sse ls an d th e d e e p

p e ro n e a l n e rv e a s th e y p a s s u n d e r cov e r o f t h e liga m e nts .

Th e y lie be tw e e n th e e x t e n so r ha lluc is lo n gu s an d the

e x t e n so r d ig itoru m lo n gu s F ig 1 5 6 p
( .
,
.

V OL . 1— 23
 TH E I N F ER I OR EXTRE M I TY

P ER O N EAL O R L ATE R AL C R U R AL R EG I O N .

B e fo re the p e ro n e a l r e g io n is o p e n e d u p , t he disse ctor

s hou ld e x a min e t h e m ucou s sh e ath s o f t h e t e n do n s o f the

p e ro na
e us gu s an d br e v is lo n . B e h in d an d be low th e lat e ra l
m a lle o lu s th e two t e n do n s are en clo se d in a c o mm o n sh e ath ,

bu t im me d iat e ly p o st e r io r t o t h e tr o ch le ar p roc e ss o f th e
ca lca n e u s th e co m m o n sh e ath is se p arat e d in to two p ort io n s ,

M . e x t e n so r d igi t o ru m lo n g us

M t ibi a li s an t e r o r i

L ig m a e nt u m t ran sv e rsu m

M p e ro n aeu s
.

lo ng us
h o f e x t e n so r dig 1t o ru m lo n g us

M p e ro n ae u s
o f ti bi i
al s an t e r o r i
b re w s

n t e rio r

o f e x t e nso r h allu c i s lo g
n us

S h h
e at o f
l g
O

p e ro n ae u s o n us

Re t i n ac u lu m
n az o ru m
p e ro
A bd 0

u ct o r d1g 1 t 1 q u 1n t 1
p e ro na
e us b i
re v s ti b i
re v s

M . e x t e nso r d1g1t o ru m b i re v s
i
M p e ro nze u s t e rt
. us

FIG . 1 58 .
— Di i
sse c t o n o f Le g an d F o o t sh o wi n g M u co u s Sh e ath o f Te n do ns .

o ne ach t e n d o n ( F ig
fo r e Th e U p p e r p o rt io n wh ich .
,

surr o u n d s t h e c o n t in uat io n o f t h e p e ro n a
e u s br e v is t e n do n ,

e x t e n d s fo rward s a lmo st t o th e in se rt io n o f th e t e n d o n in to
t h e ba se o f t h e fi fth m e tatar sa l bo n e Th e lo w e r p ort io n .
,

wh ich surr o u n d s the c o n t in uat io n o f th e p e ro n aeu s lo n gu s

t e n do n may acco mpa n y that t e n d o n t o its in se rt io n in to t he
,

lat e ra l sid e o f th e ba se o f t h e fir st m e tatar sa l bo n e o r it m ay ,

e n d at t h e lat e ra l bo rd e r o f t h e cu bo id bo n e as t h e t e n do n
, ,

tur n s m e d ia lly in t o the so le o f the foot I n th e latt e r ca se .

t h e p art o f t h e t e n do n wh ich lie s in th e so le has a se p arat e

m uc o u s sh e ath Th e sh e ath s shou ld e ith e r be in flat e d o r
.
,
 TH E I N F ER I OR EXTRE M I TY
fac ilitat e d by th e p r e se n c e a co mm o n mucou s sh e ath O n
o f .

th e lat e ra l sur fac e o f t h e ca lca n e u s t h e t e n d o n s are r e ta in e d

in p o sit io n by th e inferio r p ero n eal retin acu lu m bu t e ach t e n d o n ,

lie s in a se p arat e co mp art me n t surr o u n d e d by its o wn sp e c ia l

p r o l o n gat io n o f t h e m ucou s sh e ath At the back o f t h e
.

lat e ra l m a lle o lu s th e t e n d o n o f t h e p e ro n ae u s br e v is is
,

a n t e rior to the t e n d o n o f the p e ro n ae u s lo n gu s an d th e r e for e

be tw e e n it an d t he fi bu la c o n se qu e n t ly as t h e t wo t e n d o n s
,

tur n fo rward s a lo n g t he lat e ra l sid e o f the ca lca n e u s th e

t e n d o n o f t he p e ro n ze u s br e v is o ccu p ie s a h igh e r p o sit io n
tha n t h e t e n d o n o f th e p e ro n ae u s lo n gu s an d p a sse s a bo v e
t h e tr o ch le ar p r o c e ss o f t h e ca lca n e u s wh ich in t e rv e n e s ,

be tw e e n th e m uc o u s sh e ath s o f t h e two t e n d o n s Th e .

p e r o na e u s b r e v is is s u pp lie d b y t h e su p erfi ci a l p ero n eal n erve .

I t is a p la n tar fl e x o r an d an e v e rt o r o f t h e fo o t .

N P e ro n aeus Co mmuni s ( O T Ex t e rna l P o p lit e a l N e rv e )

. . . .

Th e c o m m o n p e ro n e a l n e rv e has p r e v iou sly be e n trac e d as

far as t h e n e ck o f th e fi bu la At that p o in t it d isa p p e ar s
.

fro m v ie w by p a ssin g fo rward s be tw e e n t h e p e ro n ae u s lo n gu s

m u sc le an d th e bo n e Th e m u sc le m u st th e r e for e be car e
.

fu lly tur n e d a sid e fr o m its or ig in in o rd e r that t h e n e rv e may

be fo llo w e d to its t e r m in at io n As it lie s be tw e e n th e p e ro n ae u s
.

lo n gu s an d t h e n e ck o f t h e fi bu la it g iv e s o ff a sm a ll
recu rrent articu la r bra ncic t o t h e k n e e j o in t an d th e n d iv id e s ,

in t o t h e deep an d sup erficial p ero n eal n erves .

Th e recu rren t brane/z p ie rc e s t h e e x t e n so r d ig itoru m lo n gu s ,

an d th e n acco mp a n ie s th e a n t e r ior t ibia l r e curr e n t art e ry thr o ugh

,

th e u p p e r fi br e s O f t h e t ibia lis a n t e r ior I t g iv e s tw ig s t o

.

t h e t ibia lis a n t e r ior bu t its t e r m in a l fi la m e n t s are d istr ibut e d

,

to t h e sy n o v ia l stratu m o f t h e ca p su le o f t h e k n e e j o in t .

Th e deep pero neal n erve p ie rc e s t h e p ro x im a l p art o f th e

e x t e n sor d ig it o ru m lo n gu s t o r e ach th e a n t e r io r r e g io n o f t h e

le g wh e r e it has a lr e ady be e n d isse ct e d

,
.

N P e ro n aeu s Su p e rfi cialis ( O T M u scu lo C u t an e o u s N e rv e )

. . .
-
.

-
Th e su p e rfic ia l p e ro n e a l n e rv e p a sse s d ista lly in the su b
sta n c e o f t h e p e ro n a e u s lo n gu s re ach e s the in t e rva l be tw e e n
t he two p e ro n ae i m u sc le s ; g iv e s bra n ch e s to bo th ; an d
th e n lie s be tw e e n th e p e ro n ae u s bre v is an d the e x t e n sor
d ig itoru m lo n gu s I n t he d ista l th ird Of th e le g it p ie rc e s t he
.

d e e p fa sc ia be c o m e s cuta n e o u s an d d iv id e s in to a me d ia l
, ,

an d a lat e ra l bra n ch wh ich hav e be e n ca lle d t h e me d ia l an d

,

in t e r me d iat e d o r sa l cuta n e o u s n e rv e s o f t h e fo o t ( p .
 TH E L EG 35 7

M ED lA L C R U R AL R EG I O N .

Th is re g io n c o rre sp o n d s to the su bcuta n e o u s o r m e d ia l

sur fac e o f t h e t ibia Th e d e e p fa sc ia ble n d s w ith t he p e r i
.

o s t e u m o f t h e bo n e an d t h e structur e s wh ich hav e t o

,
be
e x a min e d are .

Th g e t ph
re a vi sa e no u s e n .

N The sap h e no u s n e rv e .

M The e xp a nde d t e n do n s o f in se rtio n o f t he sa rt o riu s , s e m it e n din o su s , a n d

g rac il is
(

P- l l
Th e tibia co llate ra liga m e nt o f the k n e e j o in t .

m The in fe rio r m e dia g e nic u lar arte ry l .

h
C The in fe rio r m e dial articu lar n e rv e .

D is s e c t i o n — Th e g re at h e n o u s v e in an d t h e sap h e no u s
s ap
ner e v h av be e n
e alre ad y c le an e d w h e re t h e y lie u p o n t h e di st al

th ird o f t h e m e dial su rfa ce o f t h e ibia No w re m o e t h e re m am s t . v

o f t h e su p e rfi cial f asc ia f ro m t h e re g io n o f t h e m e dial su r a c e
f
o f the t t
ibia , h e n ag ain e x am in e t h e in se r io n s o f t h e s art o ri u s, t
g rac ilis, an d se m it e n din o su s .

T he a n d e d t e r m in a l p art s o f t h e t e n d o n s o f t he
e xp

sart o r iu s grac ilis an d se m it e n d in o su s are all in se rt e d in t o

, ,

t he p ro x ima l th ird o f th e m e d ia l sur fac e o f th e t ibia N ot e .

h o w t h e sart o r iu s o v e r la p s t h e t e n do n s o f t h e oth e r t wo an d ,

h o w t he t e n do n o f the grac ilis ov e r la p s the p r o x ima l p art o f

t he t e n d o n o f t he se m it e n d in o su s M uc o u s bur sae se p arat e .

t he t e n do n s fr o m e ach oth e r .

U n d e r cov e r o f t h e sart o r iu s grac ilis an d se mit e n d in o su s , , ,

an d se p arat e d fro m th e m b a bur sa t h e tio ia l co llatera l

y ,

l ga men t o f th e k n e e j o in t e x t e n d s d ista lly fo r a short d ista n c e

i
, ,

u p o n t he m e d ia l a sp e ct o f t h e bo dy o f t he t ibia Pa ssin g .

fo rward s u n d e r cov e r o f t h e liga me n t so as t o ga in th e ,

a n t e rio r a sp e ct o f t he k n e e are the in erio r medial gen icu lar ,

vessels an d th e inferio r medial a rticu lar n erve .

As t h e gr e at sa p h e n o u s v e in an d th e sa p h e n ou s n e rv e
cr o ss th e d istal th ird o f t he m e d ia l sur fac e o f t he t ibia t h e y ,

are v e ry lia ble t o inj ury be cau se th e y lie qu it e su p e rfic ia lly

be t we e n th e sk in an d th e bo n e .

P O STER I O R C R U R AL R EG I O N .

The fo llowin g is a list o f the tructur e s wh ich

s are m et
w ith in th is d isse ct io n
 TH E I N F ER I O R EXTRE M I TY

H Su p e rfic ial v e in s,
G re at saph e n o u s v e in .

Sm a ll sa h e n o u s v e in
p .

2 . C u tan e o u s n e rv e s .

3 . D e e p fascia .

G astro c n e m iu s .

4 . S u p e rfi cial m u sc le s o f th e calf, Pl an taris .

So le u s .

5 . Te n do c alc an e u s l
( Ach i lis) an d its bu rsa .

6 . P o st e rio r t ibial v e sse l s .

7 . Tibia l ne r e v .

8 . D e e p m u scle s,

9 . L ig am e n tu m lacin iatu m .

D is s e c t i o n — R e fl e ct io n o f S k in — Th e lim b m u s n o w be . t
t
p la ce d o n its an e rio r asp e c , an d t h e m u scle s o f th e c alf re n de re d t
t
e n se by do rsi fl e x in g t h e f o o
-
at t h e a n k le j o in Th a p o si io n t t . t t
t
s h o u ld be m ain a in e d by t h e a id o f h o o k s , f as e n e d t o t h e t o e s t
a n d t o t h e u n de r su rf ac e o f t h e able Th e sk in h as alre ady be e n t .

t
re fl e c e d t o t h e m e dial an d la e ral bo rde rs o f t h e le g an d f o o t t .

t v
No w m ak e a ran s e rse in c isio n ac ro ss t h e dis al p ar o f t h e t t
h e e l an d carry t h e e x re m i ie s o f t h e in cisio n fo r ards, alo n g t t w
t h e m e dial a n d la e ral bo rde rs o f t h e f o o t re sp e c i e ly , hen t tv t
v
re m o e t h e sk in f ro m t h e h o le o f t h e back o f t h e le g, co m w
t
m e n c in g t h e re fl e c io n e i h e r f ro m t h e m e dial o r la e ral bo rde r t t
a s m ay be m o s co n e n ie n t v
As t h e e fl e c io n p o ce e ds k e e p t . r t r
t h e e dg e o f t h e k n ife al ays ag ain s t h e sk in to a o id in j u ry t o w t v
v
t h e su p e rfi c ial e in s an d n e r e s v .

Su p e rfi c ia l F a sc ia u p e rfic ia l fa sc ia o f the p o st e r ior

.
— Th e s

crura l re g io n p r e se n t s n o sp e c ia l o r p e cu liar fe ature s bu t it ,

co n ta in s the fo llo w in g structur e s wh ich mu st be d isp lay e d by

t h e d isse ctor :

S p fi i l P t f th g
u er c a art op h v i
e re a sa eno u s e n .

v i
e ns , P t f th m ll phar o v i
e s a sa eno u s e n .

S p fi i l ly m ph v
u er c a l e sse s .

P art f th e sap h e n o u s n e rv e
o .

l
The t e rm ina part O f th e p o ste rio r bran ch o f th e m e dial
c u t an e o u s n e rv e o f th e th igh .

C u tan e o us Th e te rm in al p art o f the p o ste rio r c u tan e o u s n e rv e o f the th igh .

v
n e r e s, The m e dial c u tan e o u s n e rv e o f the c alf .

Th e an asto m o t 1c pe ro n e al n e rv e .

The su ra n e rv e l .

l
Th e m e dia c alc an e an n e rv e s .

D is s e c ti o n — Th e su p e rfi c ial e in s an d t h e cu an e o u s n e r e s v t v
t
m u s n o w be f o llo w e d an d cle an e d Th e ly mp h e sse ls c ann o . v t
t t
be de m o n s ra e d in an o rdin ary disse c io n ; th e m aj o ri y o f t t
t h e m a cco m p an y t h e e in s an d h e ir ribu arie s Th e g re a v t t t . t
s ap h e n o u s e in v
an d t h e s ap h e n o u s n e r e h a e alre ady be e n v v
t t
ra ce d a cro ss t h e dis al h ird o f t h e m e dial su rf ac e o f t h e ibia t t
 TH E I N F ER I OR EXTRE M I TY
me n e e s at the m e d ia l bord e r o f th e fo o t wh e r e it is fo r me d ,

by th e u n io n o f th e m e d ia l e n d o f th e d o r sa l v e n ou s arch o f
t h e fo ot w ith t h e m e d ia l d ig it al v e in O f t h e gr e at t o e It .

a sc e n d s a n t e r io r to th e m e d ia l m a lle o lu s p a sse s o bliqu e ly ,

u p ward s an d backward s acr o ss th e me d ia l sur fac e o f the d ista l

th ird o f th e t ibia an d th e n v e rt ica lly u p ward s a lo n g the
, ,

me d ia l bo rd e r o f th e t ibia t o th e p o st e r io r p art o f th e m e d ial

,

sid e O f the kn ee Th e n c e it p a sse s o bliqu e ly u p ward s

.
,

fo rward s an d lat e ra lly thr o ugh t h e su p e rfic ia l fa sc ia o f t h e

, ,

m e d ia l an d a n t e r io r ar e a s o f the th igh t o th e fo ssa o va lis , ,

wh e re it p ie rc e s the cr ibr ifo r m fa sc ia an d th e fe mo ra l sh e ath

an d t e r m in at e s in th e fe m o ra l v e in g
( F i s 1 63 1 0 7 .
, ,

I ts n a me d tr ibutar ie s are th e dor sa l v e n o u s arch the ,

m e d ia l d ig ita l v e in o f th e gr e at to e th e lat e ra l an d m e d ia l ,

fe m ora l c ircu m fl e x v e in s ( p th e su p e rfic ia l p ud e n da l

.
,

e p iga str ic an d c ircu m fl e x iliac v e in s p u t it r e c e iv e s

, ( b .

in add it io n n u m e r o u s o th e r tr ibutar ie s fro m th e d o r su m o f

t h e fo o t an d fro m t he fro n t m e d ia l sid e an d back o f t h e
, , ,

le g. F urth e r it fo r ms n u me r o u s co mm u n icat io n s w ith t h e

,

d e e p v e in s o f t he limb by a n a sto m o sin g cha n n e ls wh ich

p ie rc e t h e d e e p fa sc ia A fa ir l y . larg e c o m m u n icat in g
v e in p ie rc e s the liga m e n tu m lac in iatu m an d curv e s be lo w th e
m e d ia l m a lle o lu s to j o in t he gr e at sa p h e n ou s v e in at t he
a n t e r io r bord e r o f that p r o c e ss ; o th e rs p ie rc e t h e d e e p fa sc ia
a lo n g t he m e d ia l bord e rs o f th e t ibia an d in t he d istal th ird
O f t h e th igh .

Th e gr e at sa p h e n ou s v e in is acco mp a n ie d by n u me r o u s
su p e rfic ia l ly mp h v e sse ls Th e y dra in th e r e g io n s fro m
.

wh ich the tr ibutar ie s o f th e v e in issu e an d t h e y t e r min at e ,

in th e m e d ia l an d lat e ra l grou p s o f su bin gu in a l ly mp h g la n d s ,

wh ich lie at the sid e s o f the p ro x ima l p art o f th e v e in in t h e

r e g io n o f th e fe m ora l tria n gle I t is a lso acc o mp a n ie d by .

se v e ra l cuta n e o u s n e r ve s fr o m th e fo ssa o va lis t o t h e m idd le

—

o f th e th igh by bra n ch e s o f th e m e d ia l cuta n e o u s n e rv e o f

t h e th igh fr o m th e midd le o f t h e th igh t o t he k n e e by t h e

,

a n t e rior t e r min a l bra n ch o f th e m e d ial cuta n e o u s n e rv e o f th e

th igh and fr o m t he k n e e t o th e m e d ia l bord e r o f t h e fo o t
,

by t h e sa p h e n ou s n e rv e .

I t c o n ta in s a n u mbe r o f va lv e s wh ich h e lp t o d iv id e t h e
lo n g c o lu m n o f blo o d in t o a se r ie s o f se g m e n t s an d so ,

d imin ish th e p r e ssur e o n th e wa lls o f th e m o re d ista l p art s

o f t he v e in .
 T H E L EG 3 6 1

V e na Sap h e n a Pa rv a Th e sm a ll sa p h e n ou s v e in is
.
—

fo r m e d i n t h e lat e ra l bo rd e r o f th e f o o t by t h e u n io n o f t h e
, ,

lat e ra l d ig ita l v e in o f t h e litt le t o e with t h e lat e ra l e n d o f t h e

dor sa l v e n o u s ar ch o f th e fo o t F r o m its p o in t o f c o mm e n c e .

me n t it ru n s backward s be lo w th e lat e ra l ma lle o lu s an d ,

th e n u p ward s be h in d th e lat e ra l m a lle o lu s in c o m p a n y w ith ,

t he sura l n e rv e an d su p e rfic ia l t o t h e p e ro n e a l r e t in acu la

, .

Aft e r ward s it a sc e n d s p ara lle l w ith t h e lat e ra l bo rd e r o f t h e

,

t e n do ca lca n e u s wh e re it is st ill a sso c iat e d w ith th e su ra l

,

n e rv e . Abo v e th e le v e l o f th e t e n d o ca lca n e u s it a sc e n d s
alo n g the m e d ia n lin e o f the ca lf t o the lo w e r p art o f th e
p p o lit e a l r e g io n wh e r e,
it p ie rc e s t h e p po lit e a l f a sc ia a n d
t e r min at es in the p o plit e a l v e in I n t h e lo w e r p art o f it s .

a sc e n t a lo n g th e m e d ia n lin e o f th e ca lf it is a ssoc iat e d w ith

th e me d ia l cuta n e o u s n e rv e o f th e ca lf an d in th e u pp e r ,

p art b y t h e d is ta l p ort io n o f th e
p o s t e r ior cuta n e o u s n e rv e

o f t h e th igh .Th e sma ll sa p h e n ou s v e in r e c e iv e s tr ibutar ie s

fro m t he lat e ra l bo rd e r o f t h e fo o t t h e h e e l an d t h e back , ,

o f t h e ca lf . I t is acc o mp a n ie d by su p e rfic ia l ly mp h v e sse ls

wh ich co mme n c e in th e ar e a s in wh ich the tributar ie s o f
t h e v e in ar ise an d wh ich t e r min at e in t h e p o p lit e a l ly mp h
,

g lan d s ( Fig s 1 6 3.
,

Th e t wo sa p h e n ou s v e in s are c o n n e ct e d t o g e th e r by t h e
m e d ia l fe mo ra l c ircu m fl e x v e in wh ich co m me n c e s fro m t h e ,

s m a ll sa h e n o u s v e in im m e d iat e ly be fo r e it ie rc e s t h e d e e
p , p p
fasc ia an d t e r min at e s in t h e gr e at sa p h e n ou s v e in a bov e th e
,

m idd le o f th e th igh I n so m e ca se s t h e m e d ial fe m o ra l

.

c ircu mfl e x v e in fo r ms t he d ir e ct c o n t in uat io n o f th e sm a ll
sa p h e n o u s v e in an d in th o se ca se s t h e s ma ll sa p h e n o u s v e in
,

h as e ith e r o n ly a v e ry sm a ll co n n e ct io n o r n o co n n e ct io n at ,

all w ith t he p o p lit e a l v e in

, .

Th e Lymp h Ve sse ls an d Lymp h Glan ds o f t h e I n f e rio r Ex t re mit y .

l
The y m p h v e sse ls o f th e in fe rio r e tre m ity can n o t be disp lay e d in an x
o rdin ary
“
p ar t ,
!
b u t so m e at l e as t o f the ly m h g an ds are a w ay s fo u n d,
p l l
an d as bo t h l l
y m ph v e sse s an d lym ph g an ds are o f g re at practica l l
i m p o rtan ce , it is e sse n tial th at th e disse cto r sh o u ld h av e a g e n e ra k n o w l
le dg e o f th e ir p o sitio n s an d fu n c t io n s The ly m p h v e sse ls c o n t ain a
.

co lo u rle ss fl u id c alle d l y mp /z , wh ich drain s in to th e ir fin e r t ribu t arie s fro m

the su rro u n din g tissu e s M icro o rg an ism s wh ich h av e g ain e d ac ce ss to
.
-

ll
th e tissu e s, an d t h e c e s o f m alig n an t t u m o u rs g ro w in g in the t issu e s, m ay
e n te r th e ly mp h v e sse s an d so l he c arrie d o n w ards in the ly m p h stre am .

The ly m ph c arrie d by th e ly m ph v e sse s e v e n tu al y p asse s in to t wo l l

t e rm in al t ru n k s the t /z o racic du ct an d th e righ t y m ph du c t, e ach o f wh ich
, l
t e rmin ate s in a larg e v e in th e re fo re th e ly m ph , an d m ic ro o rg an ism s o r -

o i n s fo rm d b m i r o rg an ism s wh ich h av e e n te re d th e ly m h , a re
p so e y c o p
-
 TH E I N F ER I O R EXTRE M I TY
e v e n tu all y po u re d in to the blo o d an d by it are disp e rse d to all parts o f the
,

bo dy . B o t h t e rmin al l y m ph v e sse l s e n d at th e ro o t o f th e n e ck be h in d
t he ste rn al e n d o f the c lav ic le the t h o rac ic duc t in the le ft inn o m in at e
,

v e in an d the righ t l y m ph du ct in the righ t inn o m in at e v e in ( F ig .

C i s t e rn a c h y li

L u mba r l y mp h g l an d

I g i l li g m
n u na a e n t.

P xi m l bi g i l
ro a su n u na
C o mm o gl d
] y mp h g l
' n 1 l1a c an
d an s
E x t e rn a l i li gl d
ac an s

Fo s sa o v a h s ,
P u b i c su bi g i
n l
u na

! M e d a d sta il i l b su
mg u i l l y mp h g l
na a n ds

y
L mp h v l whi
e s se s ch
- ac c o mp a n y h gt e re at
,

sa p h e n o u s v e n i

FIG . 1 59
— Di g a ra m o f t he L m p y e sse hV l s o f t h e fro nt o f th e
i
I n fe r o r E t re m t x iy .

All t he ly m ph , h o we v e r be fo re it re ach e s the te rm in al ly m ph v e sse ls

, ,

p asse s t h ro ugh o ne o r se v e ra l ly m p h g l an ds u su all y se v e ral fo r t he g l an ds

, ,

a re in te r o se d lik e sm al l filt e rI n g in t h e c o u rse s o f t h e l y m h

p , g ps o n e s p
,

v e sse l s ; t h e re fo re the l y mph co ll e ct e d fro m the tissu e s is carrie d in t he

first in st an ce to a ly m ph g l an d an d th e n as a ru le it passe s th ro u gh se v e ral
, , ,

o th e r g l a nds be fo re it re ac h e s t e rm in al ly m h v e sse l s T h e ly m p h v e sse l s

p .
 TH E I N F ER I OR EXTRE M I TY
su fi
p e r c ia l di
f th e an te rio r p art o f the th igh ( se e p
sse ct io n o Th e y .

fo rm t w o g ro u p s, a p ro im al an d a distal x Th e p ro im al g ro u p w as fo u n d . x
l ll l
yin g para e w ith an d c lo se to the in gu in al lig am e n t, an d the distal
g ro u p at the side s o f t he p ro im a p art o f the g re at saph e n o u s v e in x l
( F ig s 1 0 6 ,
.

l
A ll the y m ph fro m th e sk in an d the su bcu tan e o u s st ru c tu re s o f th e
x x
in fe rio r e t re m ity , e ce p t th at de riv e d fro m the lat e ral side o f th e fo o t ,
l
the back o f th e h e e , an d th e back o f the le g, p asse s th ro u gh o n e o r o th e r o f
t he t w o g ro u p s o f su p e rfic ia su bin g u in a l
g lan ds, an d fro m th e m it is l
c arrie d t o t he de e p su bin gu in a g an ds by e fl e re n t v e sse ls wh ich l l
p ie rce th e
c ribrifo rm fascia an d t h e an te rio r w all o f the fe m o ral sh e ath The ly m ph .

l
fro m the do rsu m an d m e dia side o f the fo o t , the fro n t an d m e dial side o f
l
t h e le g, the m e dia side an d the g re ate r p art o f th e fro n t o f the th igh , is
c o n v e y e d to larg e r ly m ph v e sse ls wh ic h ac co m p an y th e g re at saph e n o u s
v e in an d e n d in the distal su bin gu in al g an ds The ym ph fro m the l . l
bu tto ck a n d back o f th e th igh fl o w s t o th e p ro im a su bin gu in al g an ds x l l .

l l
The y m ph fro m th e lat e ra side o f the fo o t , th e back o f the h e e l an d
t he le g, p asse s in to l
y mp h v e sse ls wh ich acco m pany the sm all saph e n o u s
v e in an d t e rminate in the p o plite a ly m ph g an ds l l .

ll l
I t fo o w s , fro m wh at has a re ady be e n st ate d, th at all the ly m p h o f th e
x x
i n fe rio r e tre m ity , e c e p t th at fro m the de e p p arts o f the bu tto c k an d back
o f t he th igh ,
p asse s th ro ugh the de e p su bin g u in al g lan ds F ro m th e de e p .

su bing u in al g lan ds t h e ly m p h p asse s in to t h e e te rn al iliac g lan ds, wh ich lie x

in th e lo w e r an d an t e rio r p art o f th e abdo m e n clo se to the in fe rio r e n d o f
x l
the e te rn al i iac arte ry an d i mm e diate ly abo v e the in g u in a igam e n t , an d ll
fro m th e m it is co n v e y e d th ro u gh the c o mm o n i iac g an ds, wh ic h lie at a l l
l l l
h igh e r e v e , to the lu m bar g an ds The lu m bar g an ds are situ ate d sti . l ll
h igh e r in th e abdo m e n o p po site th e lu mbar v e rte brae at the side s o f the
l
ao rta, an d th e y are th e last g an ds th ro u gh wh ich t he y m ph o f the in fe rio r l
x
e tre m itie s passe s be fo re it e n t e rs t he th o rac ic du c t ( F ig s 59 , . I
N e rv i C u t an e i — B e fo re p roc e e d in g to d isp lay t he d e e p
fa sc ia o f t h e back o f th e le g t he d isse ctor shou ld r e v ise t h e
n u me rou s cuta n e ou s n e rv e s .

a
N S p h e us
. n — The sa p h e n o u s n e rv e is th e m o st m e d ia l
o f the d e e p e r gro u p o f bra n ch e s o f the fe mo ra l n e rv e .

I t c o mm e n c e s th e r e fo r e in t h e fe m o ra l tr ia n g le wh e r e it ,

d e sc e n d s a lo n g t h e lat e ra l bo rd e r o f t he fe mo ra l art e ry ; it
acc o mp a n ie s t h e art e ry thro ugh th e adduct o r ca n al ly in g ,

first o n its lat e ra l sid e th e n in fro n t o f it an d fi n a lly in t he

, ,

d ista l p art o f t h e ca n a l o n it s me d ia l sid e I t d o e s n o t .

acco mp a n y th e art e ry thr o ugh th e O p e n in g in the adduct o r

m ag n u s bu t at t h e d ista l e n d o f t h e adduct o r ca n a l it
, ,

p a sse s b e tw e e n t h e s artor iu s an d grac ilis m u sc le s acc o m p a n ie d

by t he sa p h e n o u s bra n ch o f t h e art e r ia g e n u su p r e m a At .

t h e m e d ia l sid e o f t h e k n e e it p ie rc e s t h e d e e p fa sc ia e n t e r s ,

t h e su p e rfic ia l fa sc ia an d th e n it acc o m p a n ie s t h e gr e at
,

sa p h e n o u s v e in t o t h e m e d ial bo r de r o f t h e fo o t I n th e .

a dd u ct o r ca n a l it g iv e s tw ig s t o the su bsart o ria l p le x u s .

Aft e r it le av e s t h e ca n al an d be fo r e it e me rg e s be twe e n t h e
,
 T H E L EG 6
3 5

s art o r iu s an d grac ilis it g ive s o ff an in frap at e llar

, bra n ch ,
wh ich p ie rc e s t h e sart o r iu s
o n it s way t o t h e p at e llar L mb w u ar n e es

le xus B e y n d t h k
p . o e n ee

its bra n c he s are d istr ibut e d

t o t h e sk in o f t h e m e d ial
sid e o f t h e le in c l ud i g S l ac ra n e rv e s

g n
,

t h e m e d ia l crura l r e g io n ,

t h e m e d ia l p art o f t he
B h f m ra n c es ro

p O S t C lIO I
‘

crura’

l r e g i o n p i ,
o st e r o r c u tan e o u s

n h gh
m e d ial p art o f
“ e rv e o '
a n d t he
L l a t e ra c u tane o u s

t he d o r su m O f t he fo o t P i l mi f .
e r ne a ra o

s t e rlo r c u t a n

fig}?
po o u
N o C u t an e u s S u ra v
ne r e o f t he t 1

M e dialis — The m e d ia l Po s t e n o r c u ta n e o u s

n e rv e o f t he t h I gh

cuta n e o u s n e rv e o f the Med a il c u ta n e o u s

m
’

f t h 6 i h 1g h
ca lf sp rmgs fr o m the t 1b1a l “ o

n e rv e m th e o
p p lI t e al L a te ra l c u t an e o u s
n e rv e o h he t h ig h
fo ssa ,
d e sc e nd s be tw e e n
t h e t wo h e ad s o f t h e gas

t ro c n e miu s p ie rc e,
s t h e
fsgg
fig fgggg
figg
t
a f

d e e p fa sc ia o f th e le g ,

a bo ut m idway be tw e e n th e P e ro naea l a n a s t o mo t 1c
k n e e an d t he a n k le an d ,
ne r e v
u n it e s w ith the a n a st o mo t ic P
i égf lf zfigg
ste r o

e rv
cu af
t e
o u

bra n ch o f t he p e ro n e a l
n e rv e to fo r m t h e sura l
n e rv e at th e lat e ra l bo rd e r

o f t h e p r o x ima l p art o f t h e M e d a] i c u t an e o u s n e r e v
t e n d o c alca n e u s I t Sli p .
o f t h e c a lf ( O T ra m u s
i
c o m m u n c a n s t b a s)
. .

i i li
f t h e m 1 ddle
.

p lI e s t h e sk 1 n o

p art Of t he c alf O f t he le g. N er v u s s u ra li s
sh o rt s a h e n o u s
)
ast o mo
p
N Q t icu s P e r
o men s — a n a st o m ot ic
The
bra n ch o f th e co m m o n
M di l l v e a c a c a n e an n e r e

p e r o n e a l n e r v e S p r i ngs

fr o m t he c o mm o n p e r o n e a l
n e rv e in t he p o p lit e a l fo ssa ,

cr o sse s su p e r fic ia l t o th e
F 6 C t N v th IG 1 — u an e o u s
lat e ra l h e ad o f t he ga str o
. 1 . er es o n e

p t i p t f th I f i Ex t m i ty o s e r o r as ec O e n er o r re
c n e miu s wh e r e as a ru le
.

, , ,

it p ie rc e s t he d e e p fa sc ia ; th e n it p a sse s d o w n ward s an d
me d ia lly to th e p r o x ima l e n d o f th e lat e ra l bo rd e r o f th e
 THE I N F ER I OR EXTRE M I TY
t e n d o ca lca n e u s wh e r e it j o in s w ith the m e d ia l cuta n e o u s
,

n e rv e o f t h e ca lf in t h e fo r m at io n o f t h e sura l n e rv e It .

su p p lie s t h e sk in o f t he p r o x im a l t wo th ird s o f t h e o st e r io r
p
-

sur fac e o f t h e ca lf .

N Suralis . Th e sura l n e rv e is fo r m e d by th e u n io n o f
.
—
,

t he a n a st o m ot ic bra n ch o f t h e p e r o n e a l n e rv e an d t h e m e d ia l
cuta n e ou s n e rv e o f t he ca lf in th e su p e rfic ia l fa sc ia at the ,

le v e l o f t h e p ro x im a l e n d o f t h e lat e ra l bo rd e r o f t h e t e n d o
ca lca n e u s I t d e sc e n d s a lo n g sid e o f t h e sma ll sa p h e n o u s
.
,

v e in be h in d th e lat e ra l m a lle o lu s th e n it tur n s fo rward s be lo w

, ,

t h e lat e ra l m a lle o lu s to t h e lat e ra l bord e r o f t h e d o r su m o f

,

t he fo o t ; th e r e it g iv e s a c o mm u n icat in g tw ig t o th e bra n ch o f
th e su p e rfic ia l p e ro n e a l n e rv e wh ich is d istr ibut e d in th e
adj ac e n t sid e s o f the fo urth an d fi fth to e s an d th e n c o n t in u e s ,

fo r ward s to t he lat e ra l p art o f t he d o r su m o f t h e litt le t o e .

I n t he r e g io n o f t h e d o r su m o f t he fo o t it is k n ow n as t he
lat e ra l d o r sa l cuta n e ou s n e rv e o f th e fo o t a su p e rflu o u s an d ,

u n n e c e ssary t e r m .

Th e m e d ia l cuta n e o u s n e rv e o f t he th igh t he p o st e r io r ,

cuta n e o u s n e rv e o f t he th igh an d t he lat e ra l cuta n e o u s ,

n e rv e o f t h e le g hav e a lre ady be e n su ffic ie n t ly d e scribe d

( se e pp . 2
57 , 306 ,

t
D is s e c tio n — Af e r t h e cu an e o u s e in s an d n e r e s o f th e t v v
t v
p o s e rio r re g io n o f t h e le g h a e be e n s u die d, re m o e t he re m ain s t v
t
o f t h e f a t y su p e rfi c ial f asc ia , an d cle an t h e de e p f asc ia h ic h w
lie s su bj ace n t o it t .

D e ep F a scia — I n t h e p ro x i a l p art o f th e ca lf th e d e e p m
fa sc ia is th in an d tra n sp ar e n t ; it th ick e n s c o n sid e ra bly as
th e r e g io n o f t h e h e e l is a p p r o ach e d I n n o p art o f its .

ex e n tt is it v e ry d e n se bu t as it p a sse s fro m th e back o f the

,

le g to t h e me d ia l sid e o f t h e a n k le an d c o v e r s t he in t e rva l ,

be tw e e n t h e m e d ia l m a lle o lu s an d t h e ca lca n e u s it is gr e at ly ,

str e n gth e n e d to fo r m t h e liga m e n tu m lac in iatu m ( O T . .

in t e r n a l a n n u lar liga me n t ) wh ilst at t h e lat e ra l sid e o f t he

,

a n kle it is a lso th icke n e d to fo r m t he p e ro n e a l r e t in acu la

(p .

c o n t in u o u s p r o x ima lly w ith t he p o p lit e a l fa sc ia an d a

I t is , ,

sh o rt d ista n c e d ista l t o t h e k n e e 0 11 t h e m e d ia l sid e it r e c e iv e s ,

r e in fo rc e me n t s o f fi br e s fr o m t he t e n d o n s o f the sart o r iu s ,

grac ilis an d se mit e n d in o su s D ista lly o n t he m e d ia l sid e it

,
.
, ,

is co n t in u o u s w ith t h e liga me n tu m lac in iatu m ( O T in t e r n a l . .

 TH E I N F ER I OR EXTR E M I TY
D is s e c ti o t r m st n o w p ro e e d to th di t i n
n — Th e disse c o u c e sse c o
o f th t t o f th t h r e t i n s o f th p o t rio r o t f a ial
e co n e n s e e se c o e s e s eo -
sc
co m p art m t co mm n cin g w it h t hen , p rfi ial s t i e e su e c ec o n .

F irst l a ar f lly th la in iat e lig am t a d

c e n c e u re t h e e c en ,
n se cu
m dial al an an br n h
e c c f t h p t rio r t ibial art ry a d f t h e
e a c es o e o s e e n o
t ibial n e rv w h i h p i rc it N o te t h at it is t in o s p r im ally
e c e e . co n u u ox
w it h th d p fas ia f t h p t e rio r p art f th e l g an d t h at di t ally
e ee c o e o s o e ,
s
it g iv att ac h m
es t t th e abdu ct r h all i ; t h e n m k a l g i
en o o uc s a e o n
t di al in i i n t h r
u n gh t h e d p fascia do w n th e m iddle f
c s o o u ee ,
o
t h ba k f t h l g f r m t h e p p lit al r g io
e c o e e p r im ally t o th e
,
o o e e n ox
ca c l an di t ally
eu s T r t h tw fl ap s s d fi n d t t h m dial
s . u n e o o e e o e e
a d lat ral
n id s r p t iv ly
e s D ta h the di t al d o f th e
es ec e . e c e s en
m dial fl ap f ro m t h lig am n tu m laci iat m b t d
e o t i jur
e e n u ,
u o n n e
t h at ligam t an d d t ach th e di t al n d f th lat e ral fl ap fr m
en ,
e s e o e o
th e su p ri r p r n al r t in ac l m b t if p o
e o e o ibl av id in j ry
e e u u ,
u ,
ss e, o u
t o t h e r t in acu l m e N t th a tt a ch m u t f th m e dial fl ap
. o e e en o e
t o th m e dial bo rd r o f t h t ibi
e a d th o ct i n o f t h e
e e a, n e c nne o
lat ral fl ap w it h t h p st ri r fi b lar p t m by m a
e e f whi h o e o u se u ,
e ns o c
att a h m c t to th e lat ral cr t o f th fi bu la is att ain d (F ig
en e es e e s .

1 52 I 55 )
,

W h n th e n n c t io n s o f t h e d
e co p f a cia h v b n di p lay e d
e ee s a e ee s ,

m ak an p i g i t o t h m c s sh at h o f t h t n do
e o en n n l an e e u o u e e e ca c u s,
at o n o r t h r bo rde r f t h e t e n do n a d by in fl at io n in j ct i n
e o e o ,
n , ,
e o
o r p lo rat i
ex w it h a bl n t p ro b att mp t t d m t rat th
o n u e, e o e o ns e e
ex t e n t o f t h sh at h w h i h is so m w h at v ariabl
e e N e t cl an ,
c e e. x e
th e g a t ro m i s an d t h e t n d calcan s a d r m ve t h e
s cn e u e o eu ,
n e o
t h i k p ad o f fat w h i h lie s in fr n t f th e t n d cal a s an d
c c o o e o c neu ,

se p arat it f ro m t h fi rst f a ial s p t u m o f t h e p st ri r

es e m p art sc e o e o co
m nt e N w . am in t h dist al p o rt io n o f t h fi r t f as ial se p t m
o ex e e e s c u
a d n o t e t h im p rt an t p art it p lay s in bi din g do w
n e o the m cl s n n us e
o f t h e m iddl s ct i n f t h co m p artm n t an d in t h e fo rm at i n
e e o o e e ,
o
o f th lig am n t m la i iat m
e e u c n u .

I f th m dial h ad o f t h g ast r n m i s w as n t divid d

e e e e o c e u o e
w h n t h e p o p lit al f sa w a di e ct d div ide it
e e ow at t h o s s ss e ,
n ,
e
l v l o f th kn
e e j in t a d tu rn it lat rally ; t h n cl an t h s ral
e ee o ,
n e e e e u
art rie s f r m t h
e p p lit al t r n k a n d th e bran c h e o f t h e t ibial
o e o e u ,
s
n rv
e w h i h u pp ly th g a tro n m i s Rais th e p ro im al
e c s e s c e u . e x

p art f t h div id d m u cl a d n o t e t h b r a w h i h in t e rv e n s
o e e s e, n e u s c e
b tw n it an d th
e ee s m im m bran s Th b rsa u ally e e e o us . e u su
co mm icat w it h a b rsa n de r co ve r f th e s m im m bra
un es u u o e e n o su s
w h i h in it t r co m m n icat s w it h t h av it y f t h k
c ,
s u n, u e e c o e nee
j i t Op t h b r a a d p lo r it
o n . en e t n t w it h a bl
u t p ro b
s n ex e s ex e un e,
if t h at h as t alr ady be n d n ( no p N e t f ll w t h e
e e o e se e . x o o
n rv
e to t h e
e l w h ich w a f n d w h n th e p o p lit al fo a
so e u s, s o u e e ss
w a di s ct d ( sse p eI t sp ri g s f ro m t h t ibial n rv in
se e . n e e e
th ep p lit al f o a o th
e m dial side o f t h p o p lit al art e ry
o ss ,
n e e e e ,

r
c o sse s th p t ri r s rf a e f t h e di t al p art
o s e f t h art ry
o u ce o s o e e ,

pa sses b tw n th ep lan t aris an d t h lat e ral h e ad o f t h ga t r

ee e e e s o
cn e mi a d u s, t r th p t rio r rfa o f th s l s W h n
n en e s e o s e su ce e o eu . e

th e rve t o t h e
ne l h a be e n le a d a d f llo w e d t o it
so eu s s c ne n o s
t rm i at i cl an th p la tari an d f o ll w it sl de r t n d n
e n o n, e e n s, o s en e o

t its i s rt i
o i t t h p t ri r s rf ac o f t h
n e o n n o alca e s n th e e o s e o u e e c n u o

m e dial ide o f t h e t n do ca l an e
s e c us .

Sup e rfi cial M uscle s — Th e su p e rfic ia l m u sc le s o f t h e ca lf

o f t h e le g are thr e e in n u m be r v iz t h e ga stroc n e miu s t h e , .
, ,
 TH E L EG 6
3 9

p la n tar is, an d t he so le us
ga str o c n e miu s is the m o st
. Th e
su p e rfic ia l ; t h e so le u s is p lac e d u n d e r cov e r o f t h e ga stro

c h e mins ; wh ilst t h e sle n d e r p la n tar is e x t e n d s d ista lly an d

me d ia lly be tw e e n th e m The t e n do n s o f in se rt io n o f th e
.

ga stroc n e miu s an d so le u s u n it e to form th e t e n do ca lca n e u s

( t e n do A ch illis
) .

M Gast ro cn emiu s — Th e ga str o c n e m iu s is a stro n g m u sc le

. . .

I t ar ise s by two h e a d fro m t h e p o st e r ior p art o f th e d ista l e n d

,
s
,

o f t h e fe m ur B o th h e ad s hav e be e n a lr e ady stud ie d in

.

c o n n e ct io n w ith th e p o p lit e a l fo ssa wh ich th e y bou n d in it s ,

d ista l p art Th e lateral lzead sp rin g s fro m an imp r e ssio n o n

.

t h e lat e ra l sur fac e o f t h e lat e ra l c o n dy le o f t h e fe m ur an d ,

a lso fro m a sma ll p ort io n

o f th e p o p lit e a l ar e a o f t h e

bo n e im me d iat e ly p ro x im a l
,

to t he lat e ra l co n dy le .

Th e medial lzead tak e s M di l h d e a ea

or ig in fro m the p r o x im a l f g P l i o as t ro an t ar s

m c ne ius

p art o f t h e m e d 1 a l c o n

dy le an d a lso fro m a rough

,

r idg e o n t h e adjac e n t p art

o f t he p o p lit e a l sur fac e o f

t he fe m ur Th e two fl e shy
.

be llie s sw e ll o u t as th e y
p a ss d is ta lly an d e n d n e ar
, ,

t h e m idd le O f t h e le g in a
P i i A i i o st e r o r c ru c at e n t e r o r c ru c at e
rg m lg m
o

, 1 a e nt I a e nt

th i n ap o n e u ro tlc t e n d ? “ FIG 6 P t i
p t f di t l p 1 2 — o s e r o r as ec o s a o r
Th e y do 11 0 1 ble n d W lt h
.

ti f F m w i t h At t h m t f o n o e u r, ac en s o

e ach oth e r an d are u sua lly ,

M l m pp d t u sc e s a e o u .

se p arat e d by a f urrow at ,

t h e botto m o f wh ich t he flatt e n e d t e n do n to wh ich t h e fa sc icu li ,

o f both h e ad s are attach e d may be se e n Th e me d ia l h e ad is

,
.

t h e m or e bu lky o f t h e two an d it e x t e n d s furth e r d ista lly tha n ,

t h e lat e ra l h e ad Th e flatt e n e d t e n d o n in wh ich th e y

.

t e r m in at e n arr o w s slight ly as it d e sc e n d s an d a sh o rt d ista n c e , ,

d ista l to the midd le o f th e le g it ble n d s w ith t h e stout e r ,

t e n do n o f t h e so le u s to for m th e t e n do ca lca n e u s ( t e n d o
Ach illis) .

Th e ga stroc n e m iu s is su p p lie d by the tibia l n erve I t is .

a p la n tar fl e x o r o f th e fo ot an d a fl e x o r o f the k ne e bu t it ,

ca n n ot act e ffic ie n t ly both o n t he k n e e and th e a n k le j o in t at

t h e sa me t ime Th e r e fo re if the fo ot is in the p o sit io n o f
.
,
-

—
V OL . 1 24
 TH E I N F ER I O R EXTRE M I TY

p la n tar fl e x io n it ca n n o t fl e x th e k n e e an d if the k n e e is ,

fl e x e d it ca n n ot act u p o n the a nk le I t is imp o rta n t to .

r e me mbe r th e se fact s in a sso c iat io n w ith fractur e s o f the

d ista l p art o f th e fe m ur .

M P lant aris — Th e sm all fl e shy be lly o f th e p la n tar is is n o t

. .

mo r e tha n thr e e or four in ch e s lo n g I t lie s a lo n g t he me d ia l .

sid e an d p art ly u n d e r cov e r o f t h e lat e ra l h e ad o f t h e ga stro

, ,

c n e miu s I t ar ise s fro m t h e p o p lit e a l sur fac e o f t h e fe m ur

.
,

imm e d iat e ly p ro x ima l to th e lat e ra l co n dy le I t e n d s in a .

sle n d e r t e n do n wh ich is r e m arka ble fo r it s gr e at le n gth

,
Th e .

t e n do n p roc e e d s d ista lly an d me d ia lly be tw e e n the ga stro ,

c n e miu s an d so le u s an d th e n ru n s a lo n g the m e d ia l sid e o f t h e

,

t e n d o ca lca n e u s ( Ach illis) to ga in in se rt io n in to the p o st e rior

a sp e ct o f the ca lca n e u s I t is fre qu e n t ly c lo se ly co n n e ct e d
.

w ith the t e n d o calca n e u s an d so m e t ime s be co me s ble n d e d w ith

,

it o r w ith t h e fa sc ia o f th e le g a bov e t h e le v e l o f ca lca n e u s

, .

Th e p la n tar is is su pp lie d by a bra n ch fro m the tibial n erve .

act io n s are similar to t h o se o f the ga stroc n e mius .

v
D is s e c t i o n — D i ide t h e la e ral h e ad o f t h e g as ro cn e m iu s , t t
v
at t h e le e l o f t h e k n e e j o in Tu rn t h e p ro x im al p ar u p ards, t . t w
an d e x am in e it t o se e if it co n ain s a se sam o id bo n e h ic h is t w
s o m e im e s p re se nt (F ig th e n lo o k f o r a bu rsa h ich is
. t w
o ccas io n ally p re se n be t tw
e e n it an d t h e p o s e rio r p art o f t h e t
c ap su le o f t h e k n e e j o in t
Tu rn t h e dis al p ar do w n ards an d
. t t w
t
n o e t h e m an n e r in w
h ic h t he tw o h e ads j o in h e ir h in ap o n e u ro t t
t
t ic e n do n , an d t h e u n io n o f th e e n do n w i h t h e e n do n o f t h e t t t
so le u s t o f o rm t h e e n do c alcan eu s t No w cle an t h e p o s e rio r . t
t
su rf ace o f t h e s o le u s, n o e it s o rig in f ro m ( 1 ) t h e bac k o f t h e
h e ad, an d th e p ro x im al p ar o f t he p o s e rio r su rf ace o f t he bo dy t t
o f t h e fi bu la, ( 2 ) t h e fi b o u s arc h o r
e r t h e dis al e n d o f t h e p o p li e al v t t
a rt e ry , ( 3 ) t h e o bliq u e lin e o f t h e ibia, an d (4 ) t h e m iddle t
t r
h ird o f t h e m e dial bo de r o f t h e ibia N o e also t h e m an n e r t . t
in w t
h ic h t h e m aj o ri y o f its fi bre s e n d in th e s ro n g e n do n h ic h t t w
ble n ds wt t
i h t h e e n do n o f t h e g as ro cn e m iu s to f o rm t he e n do t t
c alcan e u s , w t
h ils so m e o f h e m p ass dire c ly t o t h e de e p su facet t r
o f th e t
e n do c alcan e u s .

M . Th e so le u s is a flat , th ick , an d p ow e r fu l
So leus —

m u sc le wh ich ar ise s fro m both bo n e s o f t h e le g, as w e ll as

f ro m a stro n g fi brou s arch wh ich is throw n acro ss th e p o p lit e a l
v e sse ls I t s fibu lar o rigi n is fro m th e p o st e rior surfac e o f
.

t h e h e ad an d t h e p ro x ima l th ird o f t h e p o st e r ior sur fac e

o f t h e body o f t h e bo n e ; by it s tibial o rig i n it is attach e d to
t h e lin e a p o p lit e a o f t h e t ibia , d ista l to t h e p o p lit e a l sur fac e ,

an d, m or e d ista lly , to t h e m e d ia l bord e r o f t h e bo n e as far

as t h e m idd le o f t h e le g F ig 1 6 6 , p T e so le u s e n d s
( h . .
 TH E I N F ER I OR EXTRE M I TY
t
p o s e rio r o s e o t - f ascial co mp art m e n t ,
f ro m t h e dis al p art o f an d t
t
t h e in e ro sse o u s m e m bran e , t o bo h o f h ic h it is a ac h e d t w tt .

As t h e fi bu la is app ro ac h e d t h e p e ro n e al bran c h o f t h e p o s e rio r t

t ibial art e ry w
ill be f o u n d de sce n din g be w e e n t h e fl e x o r h allu cis t
lo n gu s an d t h e p o st e rio r su rf ace o f t h e se co n d f ascial se p u m , '

t
w t
h ich se p ara e s it f ro m t h e ibialis p o s e rio r Trace th e art e ry t t .

dis ally t v
B e lo w t h e le e l o f t h e o rig in o f t h e ibialis p o s e rio r
. t t
t
it lie s o n t h e p o s e rio r su rf ace o f t h e in e ro sse o u s m e m bran e , t
t
an d im m e dia e ly abo e t h e dis al ibio fibu lar j o in v
it g i e s o ff t t -
t v
t h e p e rf o ra in g bran c h , t w
h ich w as se e n in t h e disse ct io n o f t h e
do rsu m o f t h e f o o (p t
No w p u ll t h e dis al p ar o f t h e
. t t
fl ex o r h allu cis lo n gu s m e dially an d f o llo w t h e dis al p ar o f th e t t
t
p e ro n e al ar e ry be h in d t h e an kle j o in an d alo n g t he m e dial t
side o f t h e p e ro n a t
e i e n do n s t o t h e la e ral side o f t h e c alc an e u s t .

I n o rde r t o e x p o se it s t e rm in al bran c h e s t he p e o n e al re in acu la r t

v
m u st be di ide d, an d it m ay be n e ce ssary t o disp lace t h e p e ro n e al
t e n do n s .

Te rmina t io n P o p lit eal Art ery — The t e r min at io n o f

o f t he .

t h e p o p lit e a l art e ry wh ich was c o n c e a le d by t he p r o x im a l

,

bord e r o f th e so le u s is n o w fu lly e x p o se d ,
I t e n d s at t h e .

d ista l bord e r o f th e p o p lit e u s wh e r e it d iv id e s in t o its two ,

t e r min a l bra n ch e s t he a n t e rior an d p o st e r io r t ibial art e rie s

,
.

At t he sa m e p o in t the v e n ae co mit e s o f th e a n t e r ior an d

p o st e r io r t ibia l art e r ie s j o in to f or m t he co mm e n c e m e n t o f
th e p o p lit e a l v e in .

Art eria Tibialis An t e rio r — The a n t e r ior t ibia l art e ry p a sse s .

forward s be tw e e n t he two h e ad s o f t he t ibia lis p o st e rior

,

m u sc le to t h e a n t e r ior r e g io n o f th e le g wh e r e it h as a lr e ady
, ,

be e n d isse ct e d Wh ilst st ill in t he back o f t he le g the

.

a n t e rior t ibia l art e ry g iv e s o ff a p o st e r ior r e curre n t t ibia l

an d a fibu lar bra n ch Th e po sterio r tibial recu rrent is a
.

sma ll tw ig wh ich is n o t a lway s r e se nt I t ru n s p r o x im a lly

p .
,

u n d e r cov e r o f the p o p lit e u s m u sc le to th e back o f th e k n e e ,

j o in t The fi bu lar brancb ru n s lat e ra lly 0 11 t he n e ck o f t he

.
,

fi bu la an d is d istr ibut e d to the m u sc le s an d in t e gu me n t in

,

that n e igh bourho o d .

Art eria Tibialis P o st erio r — Th e p o st e rior t ibia l art e ry is .

t h e larg e r o f th e two t e r min a l bra n ch e s o f t he p o p lit e a l tru n k .

I t tak e s or ig in a t t he d ista l bord e r o f t he p o p lit e u s m u sc le an d

e n d s by d iv id in g in to t h e lat e ra l an d m e d ia l p la n tar art e r ie s
,

in the h o llow o n t h e m e d ia l sid e o f th e ca lca n e u s u n d e r ,

cov e r o f the liga me n tu m lac in iatu m I n th e fir st in sta n c e .

the art e ry is p lac e d be tw e e n th e two bo n e s o f t h e le g u p o n

, ,

t he fa sc ia cov e r in g th e p o st e r ior sur fac e o f th e t ibia lis p o st e r io r

mu sc le bu t as it p a sse s d ista lly it in c lin e s gradua lly m e d ia lly
, ,
 ‘

P L ATE XXX I I
Se m i i
t e n d n o su s P o s te r o r if bra n c h o f me d a il c u tan e o u s
v
ner e o the th h ig
V as t u s me d a i li s
i
Se m me m bra n o su s
G rac ili s

il
M e d a fe m o ra l i
c rcu m flx i e ve n
P a te ll a r bra nc h o f v
s a p he n o u s n e r e

Sa rt o r usi

M ed a il cu tan e o u s n e r e o v f t he ca lf; Sa p h e n o u s n e rv e

L at e ra h e adl o f g as t ro c n e m u s i
Sma ll sa p h e n o u s v i
e n
G re a t sa he n o u s
p v i
e n

An as t o mo i
t c p e ro n e a l ne r e v
il
M e d a h e ad o f g as t ro c n e m u s i

So l e us

P i
o st e r o r t i bi l
a art e r y
T ba iil ne r e v
T ba i i li s p o st e r oi r ( t e n do n )
Te ndo l
c a c an e u s

S u ra l n e rv e Fl x e o r d igi t o ru m l g
o n us ( te n do n )
i ig
C o m mu n y cat n a rt e r

Fl h ll i l g
ex o r a uc s o n us
L ac ii
n at e li gam e n t

L l pl a t e ra a n t ar n e rv e
Med a p il l a n t ar n e r e v
M di l e l a c a ca n e an n e rv e Abdu c t o r ha ll i
uc s

Ca l c an e a n b h f l
ran c l pl o a t e ra a n t ar
art e r y

FIG . 1 63 — .
Di sse c t o n o
i f th e P o ste ri o r Asp e c t o f t he L e g vi e we d fro m be hi n d
an d m e di a ll y .

N o t e the n u m e ro u s an ast o mo se s b e t we e n t h e g re at an d t he sm a ll
sa p he n o u s v e i n s .
 P L ATE X XX I I I

il
M e d a fe mo ra l i c rc u m fl xv i
e e n
G re at sap h e n o u s v e m

B i ce ps fe m o i
r s

C o mm o l i
Sart o r u s
n p e ro ne a n e rv e

G ilirac s
TI bI al ne r
0

v e
Se m 1t e n d1n o su s

An ast o m o t i c p e ro n e a l n e rve
i
Se m m e m bran o su s

l
L ate ra h e ad o f g as t ro c n e m u s i M e dialg
h e ad o f g i
ast ro c n e m u s

Med a il c u t an e o u s n e rv e o f t he ca lf
~
S ma ll sa p h e n o u s v i
e n

l
L ate ra cu t a n e o u s n e r e o v f t he ca lf

Ga st ro cne q s -
G ast ro c n e m u s i
C o mmu n i i
c at o n to g re a t sap he n o u s v e i

P e ro n e u s l g
o n us

So l e us
So l e us

C o mm u n i i
c at o n fro m g re a t sap h e n o u s ve ni
P e ro n e u s bre vi s!

Su ra l n e rve

Fl x
e o r ha ll i l g
uc s o n us

Sm a ll sap he n o u s ve n i
l
L at e ra p o s t e rio r~ malle o lar art e r y
C o m mu n i cat I n
'

g ve n i
e n do l
c a c an e u s

P e ro n e a l re t n ac u u i l m Ca l c an e u s

FIG . 1 64 — .
Di sse c t o n o i P o ste ri o r Asp e c t o f t he L e g v i e we d fro m
f th e
be h i n d an d late rall y .

I n t he sp e c im en t h e re we re n u m e ro u s l arge a n ast o m o s i n g chan n e l s be twe e n

t h e sm a ll an d t h e g re at sap he n o u s v e m .
 TH E I N F ER I OR EXTRE M I TY

p 3 0 5)
.

(4) a co mm u n icat in g bra n ch wh ich sp r in g s f r o m the ,

Ti bi l v (O T i l p p li l v ) a ne r e . . n t e rn a o te a ne r e
C mm p l v (O T x l o o n e ro n e a ner e . . e t e rn a
P p li l y [ p p li l) o t e a art e r o te a
M m i m mb . se e ra n o su s

M g mi (l l h d) . as t ro c n e us a t e ra ea

pl i an t a r s
M g mi ( m di l h d) . as t ro c ne us e a ea

o f se i
m me mbran o su s
i n fe r o r i g i l e n cu a r a rt e i
y
g i l
e n c u ar a rt e r y
P o li l v
p te a e sse l s
M . li
p o p te u s
N er v e to p o p li te u s

C o mmo n p e ro ne a l ne r e v
Te rm i i
n at o n o f po p li l te a a rt e r y
So l e us ( cu t )
ii
Tba
Fi b l u a

P o st e r o r i i bi l v
t a e sse l an d t i bi l
a ne r e v
P e ro n e a lv l e sse s

N u tr e n t i a rt e r yt o fi bu l a

M p e ro n ae us
. l g o n us

M . fl h ll
exo r i l g a uc s o n us

M . ti bi li p i a s o ste r o r

M . fl di g i
ex o r ml g t o ru o n us

T b ane r e iil v
i i bi l)
( O T p o st e r o . . rt a

P i i bi l v l
o st e r o r t a e sse s

Fl x h ll i l g e o r a uc s o n us

Fl x di g i m l g e o r t o ru o n us

Ti bi li p i a s o s te r o r

T b l b k f l u e rc e o n ac o ta us (o s tr ig o nu m)
B u rsa
L ig am e n t u m l i i
ac n at u m (O T . . i n t e rn a l l
an n u ar
li g .
)
Te n do l
c a can e u s

FI G . 1 65 .
— D eep Di i
sse c t o n o f th e B ack o f th e L e g .

me d ia l sid e f th e p e ro n e a l art e ry a bout o n e in ch p ro x ima l

o

to th e d istal e n d o f th e t ibia , an d p a sse s m e d ia lly , a n t e r ior

 TH E L EG 375

o r
p o st rior to fl e xo r ha lluc is lo n gu s to jo in the p o st e r ior
e ,

t ibia l art e ry 5 ) th e t e r min a l lat e ra l ca lca n e a n bra n ch e s .

Th e p e ro n e a l art e ry is so m e t ime s as larg e as t h e c o n

t in u at io n o f t h e p o st e r io r t ibia l art e ry be yo n d the o int o f
p
o r ig in o f t h e p e ro n e a l I n such ca se s t h e p e r fo rat in g bra n ch
.

m ay be larg e an d m ay p art ia lly o r e n t ir e ly r e p lac e th e d o r sa lis

,

p e d is art e ry o r t h e c o m m u n icat in g bra n ch to t h e

, p o s t e r ior
t ibia l art e ry may be larg e .

Th e p e r o n e a l art e ry is acc o m p a n ie d by v e n ae co mit e s ,

an d in t h e p ro x ima l p art o f its e x t e n t it is a lso acco m a n ie d

, p ,

by t he n e rv e to th e fl e x o r ha lluc is lo n gu s .

The n u trien t artery Sp rin g s fro m t h e p o st e r ior t ibia l c lo se

to its or igin an d a ft e r g iv in g so me tw ig s to mu sc le s e n t e r s
, , ,

t h e n utr ie n t fora me n o f th e t ibia I t is r e m arka ble o n

.

accou n t o f its larg e Siz e .

Th e mu scu lar branc/zes su p p ly t h e d e e p m u sc le s o n th e

back o f th e le g an d o n e or two o f larg e siz e e n t e r th e so le u s
, .

Th e cu taneo u s brane/zes are g iv e n t o th e Sk in o n the me d ia l

a sp e ct o f the le g .

Th e co mmu n icating brane/z is g iv e n o ff a bout an in ch

p r o x ima l to t he d ista l e n d o f th e t ibia I t p a sse s tra n sv e r se ly
.

lat e ra lly u n d e r cov e r o f t h e fl e x o r ha lluc is lo n gu s or su p e rfic ia l

,

to it an d j o in s th e p e ro n e al art e ry ( F ig s 1 6 3 1 6 4
, .
, ,

Th e medial calcanean bran clzes p ie rc e t h e liga me n tu m

lac in iatu m an d acco mp a n y th e n e rv e s o f t h e sa m e n a m e
,

t o t h e sk in o f th e h e e l an d t h e so le .

Cru ral P art o f N e rv us Tibialis ( O T P o st e ri o r Tibial . .

N erv e ) — Th e t ibia l n e rv e is co n t in u e d fr o m th e p o p lit e a l fo ssa

.

through th e p o st e rior r e g io n o f the le g to th e hollow be tw e e n

t h e h e e l an d t h e me d ia l m a lle o lu s wh e r e it d iv id e s in to th e
,

lat e ra l an d m e d ia l p la n tar n e rv e s Th e d iv isio n tak e s p lac e

.

p ro x ima l t o t h e d iv isio n o f t h e p o st e r ior t ibia l art e ry T h e .

n e rv e acco m a n ie s th e o st ri or t ib ia l v se l s a n d r e se n t s t h e
p p e e s p ,

sa me r e lat io n s F o r a short d ista n c e in t he p ro x ima l p art o f

.
,

t h e le g it lie s o n th e m e d ia l sid e o f t h e p o st e r ior t ibia l art e ry

, ,

bu t it soo n cro sse s su p e rfic ia l t o th e art e ry an d is th e n c o n ,

t in ne d d ista lly an d fo r the r e m a in d e r o f it s cour se lie s o n

, , ,

t he lat e ra l sid e o f t h e v e sse l .

I t su p p lie s— ( a ) mu scu lar brane/zes t o t h e t ibia lis p o st e rior ,

fl e x o r ha lluc is lo n gu s fl e x o r d ig itoru m lo n gu s an d so le u s ;
, ,

— th e medial ca lca n ean bran cbes— wh ich S r in g

( )
b cu tan eo u s t g s p
fr o m it c lo se to it s t e r min at io n an d p ie rc e t h e liga me n tu m
,
 T H E I N F ER I OR EXTRE M I TY

M . se m im e mbra n o su s lac in iatu m to r e ach t he in

t e gu me n t o f the h e e l an d so le
o f t h e foot ; an d ( c) articu lar

filaments t o th e a n k le jo in t .

De e p M uscle s The pop .

—

liteu s mu scle w ill be se e n ly in g

u p o n th e p o st e rior a sp e ct o f
t h e k n e e j o in t an d u p o n t h e

p o st e r ior s ur fac e o f t h e t ib ia
p ro x i m a l to t h e lin e a p po lit e a .

I t s t e n do n o f orig in lie s w ith in

t h e ca p su le o f t h e k n e e jo in t ,

so l e us
an d ca n n ot be p ro p e rly
stud ie d u n t il that art icu la
t io n is d isse ct e d .

N o te th e stro n g
fascia wh ich
co v e rs th e po st e rio r su rface o f th e

p o plit e u s, an d t rac e it p ro im ally x

an d m e dially to the m e dial side o f
th e k n e e . Th e re it beco me s co n
t inu o u s wit h the te n do n o f th e
‘

se m im e mbran o su s, an d th ro u gh it ,

th e re fo re , the se m im e m bran o su s

m ay be re g arde d as h av in g an in
se rtio n in to the line a p o
p lite a o f the
tibia .

Th e fl ex o r fiallu cis lo ngu s

is p lac e d u p o n th e p o st e rior
fi bu la an d its a sp e ct o f the ,

n ot ic e d
g t e n do n will be
ro o v

in g th e p o st e rior bord e r o f
th e ta lu s as it p a sse s d ista lly
an d forward s to ga in t h e so le

o f t h e foot Th e jlex o r digi .

to ru m lo ngus lie s u p o n t h e t ibia .

Th e tioialis po sterio r r e st s u p o n
the in t e ro sse ou s me m bra n e
G v ro o e

an d be tw e e n t h e fl e shy be llie s

o f t h e two fl e x o rs bu t u p o n a
FIG 6 6 — P t i
. 1
p t . f dee er
p p la
o s er o r
n e
as ec o

w i th A t t h
.

B f L g
o ne s o e ac
m t f M l m pp d t
en s o
M
u sc e s
P o pa
li te
eus — Th e
o u .
o
p p .

lit e u s m u sc le ar ise s by a stout

n arrow t e n do n w ith in t h e ca su le o f th e k n e e jo in t fro m th e
p , ,
 T HE I N F ER I OR EXTRE M I TY
fl exo r d ig itoru m lo n gu s wh ich cov e rs it
,
an d fr o m t h e fa sc ia .

I n F ig 1 5 2 .
p 3 4 0 t h e ,
co mp
. art m e n t wh ich it occu ie s
, p
is show n in a d iagra m mat ic m a n n e r an d t h e sur fac e s fro m ,

wh ich it tak e s origin are in d icat e d Toward s the d ista l .

p art o f t h e le g t h e t ib ia lis p o st e r ior in c lin e s m e d ia lly ,

u n d e r cove r o f the fl e x o r d ig itoru m lo n gu s an d its stro n g ,

flatt e n e d t e n do n groov e s th e back o f th e m e d ia l ma lle olu s

to the me d ia l sid e o f the t e n do n o f that mu scle Pro c e e d .

in g u n d e r cov e r o f t he liga me n tu m lac in iatu m its t e n do n is ,

i i li
Tba s p o st e r o r i
Fl xe o r

L a t e ra p l l an t a r
and

N er v e t 0 t he il l Med a c a c an e an
q u adra t u s p lt
an t ae l v l d v e sse s an ne r e
Ad C tOI
'

di g o

i i q u m tl
. .

Qua d pl
rat u s an t a
e

FI G . 1 67 .
— Di i
sse c t o n o f t he m e d a s de i l i o f th e Ank l e, s h w i g th l t i
o n e re a o ns
o f t he li g l
. i
acin at u m ( O T . . i n te rn a l a n n u ar l

in se rt e d in to t h e tu be rc le o f th e n av icu lar bo n e , an d a lso , by

a n u mbe r o f slip s, in to c e rta in o f the tar sa l an d me tatarsa l
bo n e s Tho se slip s w ill be d isse ct e d lat e r The t ibia lis
. .

p o st e r ior u pp lie d by the tibial nerve I t is a p la n tar fl e x o r

is s .

an d an in v e rtor o f t h e foot .

L game nt um
i Laciniat um — Th e co n n e ct io n s o f th is .

th icke n e d ba n d o f the d e e p fa scia shou ld n o w be care fully

re e x a min e d
-
I t br idg e s acro ss t h e ho llow be tw e e n th e
.

me d ia l ma lle o lu s an d t he me d ia l p ro min e n c e o f th e ca lca n e u s ,

an d is attach e d to both I t h as a lr e ady be e n show n that it s

.

p ro x im a l bord e r is co n t in uou s n o t o n ly with t h e d e e p fa sc ia

 TH E L EG 3 79

cov e r in g t he su p e rfic ia l m u scle s o f th e ca lf bu t a lso w ith the

se p tu m wh ich se p arat e s tho se m u sc le s fro m the d ee p e r
m u sc le s o f th e le g ( se e p . an d it h as be e n p o in t e d out

that th e se p tu m tak e s a m o r e im p o rta n t p art in th e for m at io n

o f t h e liga m e n t tha n t h e mo r e su p e rfic ia l lay e r o f d e e p fa sc ia .

I ts d ista l o r a n t e r io r m arg in is c o n t in uou s w ith t h e m e d ia l

p art o f t h e p la n tar a p o n e uro sis an d it g iv e s attach m e n t t o
,

t he a bductor ha llu cis mu sc le wh ich is su bjac e n t to that

a p o n e uro sis I t is p ie rc e d by t he m e d ia l ca lca n e a n bra n ch e s
.

o f t h e p o st e r io r t ibia l art e ry an d th e t ibia l n e rv e an d by a ,

co mmu n icat in g v e in wh ich c o n n e ct s the gr e at sa p h e n ou s

v e in w ith the v e n ae co mit e s o f th e p o st e r io r t ibia l art e ry .

The d isse ctor sh o u ld n o t e that u n d e r cov e r o f t h e liga m e n t

lie ( I ) the t e r m in at io n o f t h e p o st e r ior t ibia l art e ry an d t h e
co m me n c e me n t o f its t wo t e r min a l bra n ch e s the me d ia l an d ,

lat e ra l p la n tar art e r ie s w ith th e ir acco mp a n y in g v e in s ( 2 )

,

t he d ista l p art o f th e p o st e r ior t ibia l n e rv e an d its me d ia l

an d lat e ra l p lan tar t e r m in a l br an ch e s ; 3 ) t h e t e n do n o f th e
t ibia lis p o st e r ior ; ( 4 ) the t e n do n o f th e fl e x o r d ig itoru m lo n gu s
5) t h e t e n d o n o f t h e fl e x o r ha lluc is lo n gu s F r o m t h
. e m e d ia l
t o t he lat e ra l sid e th e structur e s lie in th e fo llow in g ord e r

H Te n do n of tibialis po ste rio r .

N Te n do n o f fl e x o r digito ru m lo n gu s .

J
Q P
o ste rio r tibial v e sse ls .

Q- Tibial n e rv e .

U Te n do n o f fl e x o r h allu cis lo n gu s .

Th e t e n do n s are iso lat e d fro m o n e a n oth e r an d fro m the ,

v e sse ls an d n e rve by se p ta wh ich p a ss fro m t he d e e p sur fac e

,

o f th e liga m e n t to r idg e s o n t h e adjac e n t bo n e s Th e se p ta .

c an be d e m o n strat e d b sl itt in g O e n t he liga me n t fo r a short

y p
d ista n ce a lo n g the lin e o f e ach t e n do n Each o f the thr e e .

co mp art me n t s w ill th e n be se e n to be lin e d w ith a glist e n in g

m ucou s sh e ath an d th e d isse ctor shou ld in v e st igat e th e
,

e x t e n t o f e ach sh e ath as far as p o ssible w ith th e aid o f a ,

blu n t p ro be fo r as t he sh e ath s hav e be e n fr e e ly o p e n e d it

,

w ill n o t be p o ssible to in flat e o r inj e ct th e m The sh e ath s .

e n d p ro x im a lly a bout 2 mm a b ov t h m d ia l ma ll o lu
5 e
. e e e s .

D ista lly t h e sh e ath o f t h e t ibia lis p o st e r ior r e ach e s t o t h e

in se rt io n o f th e t e n do n in to th e tu be rc le o f th e n av icu lar
bo n e . Th e sh e ath o f th e fl e x o r d ig itoru m lo n gu s e x t e n d s t o
a bout the midd le o f the le n gth o f th e fo ot an d that o f the ,

fl e x o r ha lluc is lo n gu s c an be trac e d u n d e r favoura ble c ircu m

,
 T H E I N F ER I OR EXTRE M I TY

ta n c e s as far as the m idd le o f the m e tatar sa l bo n e o f the

s

gre at to e ( F ig .

An ast o mo sis aro u n d t h e Ankle J o in t Th e d isse ct o r —

sh o u ld n e x t sat isfy h im se lf w ith r e gard t o the a n a sto m o sis o f

art e r ie s wh ich take s p lac e arou n d the a n k le j o in t O n the .

lateral aspect o f th e j o in t h e w ill o bse rv e in o scu lat io n s tak in g

ii
Tba

Fl x e o r d igi m l gt o ru o n us

Ti bi li i a s an t e r o r

L ig a me n t u m v
t ra n s e rsu m c

She a th o f t i bi li a s p o ste r o i r\

L ig a me n t u m c ru c ia t u

She a t h o f t i bi li
a s a n te

She at h o f e x t e n so r ha ll i l
uc s

l i uc s

rt e ry an d n e r e v
Fl x e o r h
ll i l
A bdu c t oFl x dg r m b v
ha u c s e o r i i t o ru re is

Fl x ll i l g N i l b
e o r ha u c s o n us av c u ar o ne

FIG 6 8 Di t i f L g d F t h wi g M
. r .
— sse c o n o Sh th f T d
e an o o s o n u co u s ea s o en o ns .

1 A i i bi li p i
rt e r a t a s o s t e r o r.N i bi li 2 e rv u s t a s.

3 Fl x h ll i l g l
. .

e o r a uc s o n usT d 4 en o c a ca n e u s

5 Fi i m l p m fp i 6 C l
. . .

rs t nte r u s c u a r se tu o o s te r o r a c a ne u s
l gi k i g p i h f m i 7 L ig m m l i i
. . .

c ru ra re o n ta n a rt n t m e o r at o n a e nt u ac n a t u
f h li g m m l i i
. .

o t e am e ntu ac n a t u .

p lac e b e tw e e n b ra n ch e s o f t h e fo llow i n g art e r ie s —

( )
a lat e ra l
m a lle o lar ; ( b) p e r forat in g bra n ch o f p e ro n e a l ( c) t e r min a l
p art o f p e ro n e a l an d ( )
a lat e ra l tar s a l
’
.

O n t he medial asp ect o f t he j o in t t he m e d ial m a lle o lar

bra n ch o f th e a n t e r ior t ibia l a n a st o m o se s w ith sma ll tw ig s
fro m t he m e d ia l ca lca n e a n bra n ch e s o f t he p o st e r ior t ibia l .
 T HE I N FE RI O R EXTRE M I TY
s o me r e sp e ct s r e se mble s the su p e rfic ia l fa sc ia wh ich cov e r s
t he isch ia l tu be ro sity Trav e rsin g it are tough fi br o u s
.

Ca l c an e u s

Med a il l c a c an e an
v
n e r e an d art e r y

L at e ra p a rt l o fp l a n t ar
ap o n e u ro si s

C u ta ne o us bran c he s
fro m l a t e ra l pl an t a r
M e d a p a rtil o f
art e r y an d n e r e v p l a n t a r a p o n e u ro s s i

i
Th rd and fo u rth
l
u mbr c a s i l
Di g i l
ta ne r e s v fro m
l a t e ra l pl a n t ar

Di g i l v ta ner e s fro m
m di l p l
e a an t a r

FI G . 1 69 .
-
Su p e rfic ial Di i
sse c t o n o f th e S o l e o f th e Fo o t th e Sk i n an d

Su p e rfic i lF
a i l
asc a a o n e re m o ve d .

ba n d s, wh ich su bd ivid e the fatty tissu e in to sma ll lo bu le s ,

an d co n n e ct t h e th ick skin o f the so le w ith the p la n tar

a p o ne uro sis .
 SO L E o r TH E F OOT 8
3 3

D is s e c t i o n — Th e medial calcane an n erves, h ich h a e alre ady w v

be e n f o u n d p ie rcin g t h e lig am e n u m lacin iatu m , sh o u ld be race d t t
to t t t
h e ir dis ribu io n Th e y su p p ly t h e sk in o f th e so le in t h e
.

n e igh bo u rh o o d o f t h e h e e l, an d a re acco m p an ie d by ram ifi ca io n s t

o f t h e m e dial calc an e an bran c h e s o f t h e p o s e rio r ibial an d t t
t t
la e ral p lan ar a r e rie s t .

Th e su p e rfi cial f ascia m ay n o w be re m o e d D iv ide it alo n g v .

t h e m iddle lin e o f t h e so le , an d u rn it la e rally an d m e dially , t t

cle an in g at t h e sam e t
im e t h e p lan ar ap o n e u ro sis As t h e t .

t t
disse c o r ap p ro ac h e s t h e la e ral an d m e dial m arg in s o f t h e f o o t
tv
re sp e c i e ly , h e will n o e , o n e a c h s ide , a f u rro t ; t h e fu rro s w w
w
e xt e n d f o r ards at t h e s ide s o f t h e in e rm e dia e p art o f t h e p lan ar t t t
ap o n e u ro sis Alo n g t h e f u rro s a n u m be r o f blo o d e sse ls an d
. w -
v
so m e n e r e s v w
ill be se e n p ie rc in g t h e de e p fascia in o rde r t o
re a c h t h e sk in To w ards t h e in e r als be e e n th e h e ads o f t h e
. t v tw
t t t t
m e a arsal bo n es t h e m e a arsal ar e rie s an d t h e p lan ar dig i al t t t
v t t
n e r e s are u n p ro e c e d by t h e ap o n e u ro sis , a n d t h e disse c o r m u s t t
p ro c e e d ca u io u s lt
y T h e n e r e
. s a n d e s se ls h ic h g o t o tvh e v w
t
m e dial side o f t h e g re a t o e an d t o t h e fi bu lar side o f t h e li le tt
t o e are e sp e cially liable t o in j u ry , as h e y p e rfo ra e t h e ap o n e u t t
ro sis f art h e r back h an t h e o h e rs t t
A ban d o f ran s e rse fi bre s , . t v
w t
h ic h cro sse s t he ro o s o f th e o e s an d lie s o e r t h e dig i al e sse ls t v t v
v
an d n e r e s , s h o u ld be n o ice d t
I t is t h e sup erfici al tran sve rse .

t
ligame n t o f t h e o e s, an d is clo se ly c o n n e c e d i h t h e sk in w h e re t wt
t t t
h a fo rm s th e cu an e o u s e bs be twe e n t h e o e s B y fo rcibly w t .

t
s e p ara in g th e t
o e s its c o n n e c io n s w ill be c o m e e ide n t W he n v t .

t t v
t h e re la io n s o f th e lig am e n h a e be e n s u die d it m ay be re m o e d t v .

Ap o n euro sis Plan t aris ( O T Plan t ar F a sc ia) — The p la n tar . . .

a p o n e uro sis, wh ich is n o w brought in to vie w, co n sist s o f thre e

p ort io n s—
( )
a a m e d ia l, ( )
b a n in t e r m e d iat e , a n d c a lat e ra l
()
p art. T h e s u bd iv isi o n is in d icat e d b y a d iff e r e n c e in t h e

d e n sity o f the thr e e p art s an d by two sha llow furr o w s wh ich

trav e r se the foot in a lo n gitud in a l d ir e ct io n, o n e u p o n e ach sid e
o f t h e stro n g in t e r m e d iat e p ort io n o f t h e a p o n e uro sis Each .

o f t h e thr e e p ort io n s is in r e lat io n to a su bjac e n t m u sc le .

The intermediate po rtio n cov e r s th e fl e x o r d ig it o ru m br e v is ;

t h e lateral part c loth e s th e a bductor d ig it i qu in t i an d t h e

medial part cov e r s the a bductor ha lluc is .

Th e intermediate po rtio n o f th e p la n tar a p o n e uro sis sta n d s

o u t in m ark e d co n tra st t o th e lat e ra l an d me d ia l p ort io n s
in p o in t o f str e n gth an d d e n sity Po st e r iorly, wh e re it .

is attach e d to th e me d ia l p roc e ss o f t h e ca lca n e u s, it is

n arr o w, bu t it e x p a n d s as it p a sse s f orward s, an d, n e ar t h e

h e ad s o f the me tatar sa l bo n e s, Sp lit s in to fiv e p roc e sse s,

wh ich are bou n d tog e th e r by tra n sv e r se fi br e s I n the .

in t e rva ls be tw e e n t h e d ig ita l slip s t h e m e tatar sa l v e sse ls, t he

d ig ita l n e rv e s, an d th e lu mbrica l mu sc le s app e ar Trac e .

t h e p roc e sse s forward s O n e go e s to t h e root o f e ach t o e ;

.
 T H E I N F ER I O R EXTRE M I TY
th e r e d ivid e s in to two Slip s The two slip s e mbrac e the
it .

fl e x o r t e n do n s o f th e t o e an d be c o m e fi x e d to th e fl e x o r ,

sh e ath s an d to t h e
, tra n sv e r se liga m e n t o f the h e ad s o f
t h e m e tatar sa l bo n e s Th e g e n e ra l charact e r s th e r e for e
.
, ,

o f th e in t e r m e d iat e art o f t h e la n tar a o n e uro s is c lo e ly

p p p s

r e se mble tho se o f th e in t e r me d iat e p art o f t h e p a lmar

a p o n e uro si s .

The lateral and medial parts o f th e p la n tar a p o n e ur o sis are

w e ak in c o mp ariso n w ith th e in t e r m e d iat e p ort io n Th e y
, .

m e r e ly co n st itut e fa sc ia l cov e r in g s fo r th e m u sc le s wh ich

lie su bj ac e n t A stro n g ba n d is to be n ot e d in co n n e ct io n
.

w ith t he lateral part I t stre tch e s be tw e e n th e p ro min e n c e

.

for me d by t h e ba se o f t he fi fth m e tatar sa l bo n e an d t he

lat e ra l p roc e ss o f th e tu be rc le o f th e ca lca n e u s .

I n co n n e ct io n w ith th e p la n tar a p o n e uro sis t wo in ter

mu scu lar sep ta a lso hav e to be stud ie d Th e se p a ss dor sa lly .

in to the so le a lo n g th e lin e s o f th e lo n g itud in a l furrow s

,

wh ich m ark o ff the in t e r me d iat e fro m t he me d ia l an d lat e ra l

p art s o f t h e a p o n e uro sis Th e y co n se qu e n t ly lie o n
. e u p o n

e ach sid e o f th e fl e x o r d ig itoru m br e v is an d fo r m p art it io n s ,

wh ich se p arat e it fro m the a bductor ha lluc is o n t he o n e sid e ,

an d t h e a bd uctor d ig it i qu in t i o n t h e oth e r .

D is s e c t i o n — To d m n st rat e t h e ab ve m e n t io n d se p t a e o o - e ,

m ak a t ran sv rs i ci i n t h ro gh t h e i t e rm diat p o rt i n f
e e e n s o u n e e o o

t h e p l t ar ap n an r si abo t an i ch in fro t o f th m dial

o eu o s, u n n e e

p ro s f t h t b rcl
ce s o f t h e cal an
e u e a d als e o a lo n g itu di al c e u s, n o n
c t t h ro
u gh th sam p i u f ap o n
e r i e t n di g f ro m t h
e e ce o eu o s s, x e n e
fi r t in isi al g t h m iddl li
s c o n o n f th fo o t eN w rais th e ne o e . o e e
div id d ap e r si a d t h r w it lat r lly an d m dially
o neu o s n So m o e a e . e

diffi c lt y w ill bu p rie d o w i ge t ext h d e p rf a c o f t

n ce h n o e ee su e e

ap n oro i a ff rdi g
eu s s rig in in it p o t ri r p art t o th s bj a n t
n o ,
s o s e o ,
e u ce
fl o r dig it o r m br v i
ex A th u m rg i e f thi m s . le ar s e a ns o s u sc e

app ro a h e d t h c s p t a ar br gh t i t v i w
e e A th a t e ri r e o u n o e . S e n o

p art f t h div ide d ap n

o e ro si i r fl t d ar om t b t ak n eu s s e ec e ,
c e us e e

t o av o id in j ry to th e p lan t ar dig it al art ri

u an d n e rv w h ich e es es

li clo s t o t h de e p su r f a e o f th ap n
e e e r is c e o eu o s .

M uscle s an d Te n do n s o f t h e So le I t is cu sto mary to —

look u p o n t h e m u scle s an d t e n do n s fou n d in t h e d isse ct io n

o f t h e so le as be in g d isp o se d in fo ur strata in o r be tw e e n ,

wh ich lie th e p la n tar v e sse ls an d n e rv e s an d th e ir bra n ch e s ,

wh ilst th e lay e r s th e mse lv e s are se p arat e d fro m o n e a n o th e r

by fi brou s p art it io n s v iz ,
.

F irst lay e r .
 TH E I N F ER I OR EXTRE M I TY
Th e tr k a un bran c h e s o f t he re la i e ly sm all m e dial p lan ar
nd tv t
art e ry ac co m p an y t h e t
ru n k an d bran c h e s o f t h e m e dial p lan ar t
v
n e r e , an d m u s t
be cle an e d as t h e n e r e an d its bran c h e s are v
t
disse c e d o u t o f t h e su rro u n din g f as cia .

W h e n t h e m e dial p lan ar e sse ls an d n e r e s h a e be e n dis t v v v

t
p lay e d, c u t do wn in o th e in e r al be w e e n th e fl ex o r dig i o ru m t v t t
v t
bre is an d t h e abdu c o r dig i i q u in i, be h in d th e p ro j e c in g base t t t
t t
o f t h e m e a arsal bo n e o f t h e fi f h t o e , an d se cu re t h e t
ru n k o f t
t t v
t h e la e ral p lan ar n e r e , be f o re it di ide s in o it s su p e rfi cial an d v t
v
de e p di isio n s, an d t h e acc o m p an y in g la e ral p lan ar art e ry t t
w t
h ic h lie s la e ral t o t h e n e e As t h e n e r e p asse s fo r ards rv . v w
v t
it di ide s in o a su p e rfi c ial an d a de e p bran c h , at t h e le e l o f t h e v
t t t
bas e o f t h e fi f h m e a arsal bo n e an d, at th e sam e le e l, t h e la e ral v t
t
p lan ar a rt e ry , a cco m p an ie d by t h e de e p bran c h o f t h e n e r e , v
t u rn s m e dially an d de e p ly t o be co m e t h e
p lan tar arteri al arch .

w v
F o llo th e su p e rfi cial di isio n o f t h e n e r e fo r ards, an d se cu re v w
( 1 ) th e m u scu lar bran c h e s h ic h it g i e s t o t h e fl e x o r dig i i w v t
t v t
q u in i bre is, an d th e in e ro sse i o f th e f o u rt h in e ro sse o u s sp ace t
t
(2 ) its tw o dig i al bran c h e s, o n e to t h e la e ral Side o f th e li le t o e , t tt
v
an d o n e w h ic h di ide s t o su p p ly th e a dj ac e n side s o f t h e f o u r h t t
t t
an d fi f h o e s ! th e la e tt r
is c o n n e c e d, by a co m m u n ica in g w ig , t t t
wt t t
i h t h e f o u r h dig i al bran c h o f t h e m e dial p lan ar n e r e Cle an t v .

also t h e ar e rie s t w
h ic h acco mp an y t he n e r e s N o w di ide v . v
th e m u scu lar be lly o f t h e fl e x o r dig i o ru m bre is, ran s e rse ly , t v t v
at t h e m iddle o f it s le n g h t
u rn t h e p o s e rio r p ar backw ards , t t t
tt t
an d de fi n e it s a ac h m e n s t o t h e m e dial an d la e ral p ro ce ss e s t
o f t h e c alcan e u s t w
h ro t h e an e rio r p ar f o r ards o w ards th e t t w t
t o es w t t
h e re it s e n do n s e n e r t h e fl e x o r s h e a h s, w h ich w ill be t
e x am in e d la e r t t
N e xt de a c h t h e abdu ct o r h allu cis f ro m t h e
.

m e dial p ro ce ss o f t h e calcan e u s, bu t n o t f ro m th e lacin ia e t

t
lig am e n , an d u rn it m e dially t Th e s ru c u re s n o w ex p o se d . t t
are t
( 1 ) th e fi rs p art s o f t h e la e ral p lan ar e sse ls an d t t v
v
n e r e , an d t
h e ir bran c h e s ; (2 ) de e p t o th e e sse ls an d n e r e , v v
t t
t h e q u adra u s p lan ae ; (3 ) p o s e rio rly , be w e e n t h e tw o h e ads t t
o f t h e q u adra u s p lan a t t
e , t h e p o s e rio r p ar o f t h e lo n g p lan a r t t t
t
lig am e n ; ( 4 ) m e dial t o t h e q u adra u s p lan ae th e e n do n o f t t t
t
t h e fl e x o r dig i o ru m lo n gu s di idin g , an e rio rly , in o fo u r v t t
slip s f ro m w
h ic h t h e lu m brical m u scle s arise ; ( 5 ) m e dial t o
t
t h e fl ex o r lo n gu s dig i o ru m a f u r h e r p o r io n o f t h e t e n do n t t
o f t h e fl ex o r h allu c is lo n gu s ly in g be w e e n t h e tw o h e ads o f t
th e fl e x o r h allu cis bre is (F igs 1 7 0 , v .

t t
Cle an , fi rs , th e la e ral p lan ar n e r e an d its m u scu lar bran c h e s t v .

t
Th e fi rs bran c h is t h e bran c h t o t h e abdu c o r dig i i q u in i It t t t .

lie s f ar ba ck , clo se t o t h e p ro ce sse s o f t h e c alcan eu s Th e .

t
bran c h t o t h e q u adra u s p lan ae is a li le fu rt h e r f o r ard t In tt w .

t t
addi io n h e re are a n u m be r o f cu an e o u s bran c h e s h ic h be co m e t w
t v
su p e rfi c ial alo n g t h e in e r al be t e e n t h e abdu c o r dig i i q u in i w t t t
an d t h e fl e x o r dig i o ru m bre is t v
N ex c le an t h e la e ral p lan ar . t t t
art e ry an d f o llo w
it s m e dial c alc an e an bran c h t o th e p o s e rio r t
t v t
p art o f t h e in e r al be w e e n th e fl e x o r dig i o ru m bre is an d t h e t v
t
abdu c o r h allu cis W h e re it be c o m e s su p e rfi c ial I t is dis ribu e d . t t
t o t h e f at an d sk in o f t h e h e e l Af e r t h e e sse ls an d n e r e s are . t v v
c le an e d cle an t h e m u scle s an d e n do n s t .

M Flex o r Digit o rum B re v is — Th e short fl e x o r o f t h e

.

to e s arise s fr o m the me d ial p roc e ss o f the ca lca n e u s, fro m

 P L ATE XXX I V

Pl a n t ar a o n e u ro s s
p i (i n t e rm e d a t e i
p art )
Pl i
an t a r ap o n e u ro s s o n abdu c t o r
dlgm q u inti
Fl x
e o r dig i t o ru m bre v is

Abdu c t o r dlgl t l q u i n ti
- L a t e ra l pl an t ar a rt e ry

L a t e ra l pl an ta rn e rv e

Q u adra t u s p lan tm Q u adra t u s p lan t az

Med a p il l an t a r n e r e v
Te n do n o f p e ro naau s l g
o n us Me di l p l
a an ta r art e r y

L a t e ra p l l a n t ar art e r y
L a t e ra p l l an tar n e r e v
Di g i l ta a rt e r y an d n e r e v
Fl x di g i i q i i b vi
e o r t u nt re s
an d3 d plr a n ta r i n t e ro sse o u s

Di g i l v d s h
'
ta n e r e an t
Fl x e o r ha ll i
uc s bre vi s

pl m
a n t ar l y
e ta t a rsa a rt e r

4 h d
t li o rsa n t e ro sse o u s
Fl x ll i l g
m l u sc e
e o r ha uc s o n us

h l mb i l 4t B h f pl
u r ca ra n c o I st a n tar

T d en f fl o n o b vi exo r re s
m e l y
t a t arsa a rt e r

di g i m t o ru l mb l
rs t u ric a

grd lu m br d l mb i l
2n u r ca

B h f pl
ra n c o I st a n ta r

l
4 t h p an t ar m e ta tarsa l ar
‘

m l y
e t a t arsa a rt e r

3 rd p l an t a r me t at arsal art e r y

Te n do n o f fle xo r , bre v is d igi t o ru m

FI G . 1 7o .
-
Su p e rfi c ial d i i
sse c t o n o l
f t h e S o e o f th e F
o o t Th e
.
pl an t ar

ap o n e u ro s s i h as be e n re m o v ed . i i
T h e a bdu c to r d g t i q u i n t i an d th e
abdu c to r hall u c i s h ave be e n ll i
p u e d as de .
 THE I N F ER I O R EXTRE M I TY
Art P lant a ris M e dialis ( O T I nt e rnal P lan t ar Art e ry )
. . . .

— Th e m e d ia l la n tar art e ry is t h
p e sm a lle r o f t h e two t e r m in a l

bra n ch e s o f th e p o st e r io r t ibia l art e ry I t ar ise s in t h e ho llo w

.

be tw e e n th e me d ia l m a lle o lu s an d t he p ro m in e n c e o f t h e
ca lca n e u s, u n d e r c o v e r o f the liga me n tu m lac in iatu m At .

t h e d ista l bo rd e r o f t h e liga m e n tu m lac in iatu m it p a sse s

u n d e r cov e r o f the a bduct o r ha lluc is ; bu t as it p roc e e d s ,

for ward s it a p p e ar s in the in t e rva l be tw e e n that m u sc le an d

,

t h e fl e x o r d ig itoru m br e vis F in a lly at t h e r o o t o f th e gr e at

.
,

t o e it e n d s by jo in in g t h e p la n tar m e tatar sa l art e ry t o th e

,

m e d ia l sid e o f t h e ha llu x .

Th e brancbes wh ich p roc e e d fro m the me d ia l p la n tar art e ry

are sma ll bu t v e ry n u m e rou s Th e y are
. thr e e tw ig s
wh ich acco mp a n y t he d ig ita l bra n ch e s o f th e m e d ia l p la n tar
n e rv e to t h e c le ft s be tw e e n th e me d ia l four to e s — th e y
e nd by jo in in g th e m e tatar sa l bra n ch e s o f the p la n tar
arch ; ( 2 ) a se r ie s o f cuta n e ou s bra n ch e s t o th e sk in o f the
so le wh ich p ie rc e t h e a p o n e uro sis in t h e furrow be tw e e n its
,

me d ia l an d in t e r m e d iat e p art s ; ( 3 ) a n u mbe r o f bra n ch e s t o

t he m u sc le s in t he v ic in ity ; ( )
4 so m e o ffse t s wh ich p a ss

me d ia lly u n d e r cov e r o f the a bductor ha lluc is to r e ach t h e

m e d ia l bord e r o f the foot .

Art P lant aris L at eralis ( O T Ex t ernal P lan t a r Art e ry )

. . . .

— Th e lat e ra l la n tar art e ry i s m uch larg e r tha t h e m e d ia l

p n

p la n tar I
. t is ac c o m p a n ie d b y t h e lat e ra l p la n tar n e rv e an d
two vena co mites F ro m it s or ig in in th e ho llow o f th e calca n e u s
.
,

u n d e r cove r o f t he lac in iat e liga me n t it p a sse s lat e ra lly , ,

acro ss th e so le to r e ach the in t e rva l be tw e e n t h e fl e x o r

,

d igitoru m br e vis an d th e a bductor d ig it i qu in t i I n that .

in t e rva l it is co n t in u e d forward s fo r a short d ista n c e an d ,

th e n at t he le v e l o f the ba se o f the fi fth m e tatar sa l bo n e it

, ,

tur n s sudd e nly to th e me d ia l sid e an d cro sse s th e so le a ,

se co n d t im e ,
u n d e r cov e r o f the fl e x o r t e n d o n s an d t h e
adductor ha lluc is for min g t h e p la n tar arch I n the p r e se n t
,
.

stag e o f th e d isse ct io n it is d is lay e d o n ly as far as t he ba se

p
o f t h e fi fth m e tatar sa l bo n e B e tw e e n it s or ig in an d that
.

p o in t i t s r e lat io n s are as fo llo w s z

( )
r it i s u nd e r c o ve r o f
—

t h e lac in iat e liga me n t ( )

2 it i s p lac e d be t we e n t h e a bductor

ha lluc is an d th e ho llow o f th e ca lca n e u s ; ( 3 ) it lie s be tw e e n

th e fl e x o r d ig itoru m br e v is an d th e quadratu s p la n t ae ; ( 4 ) it
o ccu p ie s t h e in t e rva l be tw e e n th e fl e x o r d ig itoru m br e v is an d

t h e a bductor d ig it i qu in t i I n th e latt e r situat io n it is n e ar

.
 SO L E O F TH E F OOT 389

th e surfac e ,
an d is cov e r e d m e r e ly by th e in t e gu m e n t an d

fa sc iae .

Th e brancbes wh ich p r o c e e d fr o m th is p art o f t h e v e sse l are

twig s to t h e n e igh bo urin g m u sc le s ( 2 ) medial calcanean
bra ncbes, wh ich ar ise n e ar its o r igin an d ga in th e h e e l by ,

p a ssi n g through t h e c le ft be tw e e n t h e fl e x o r d ig it o ru m br e v is

an d t h e a bductor ha lluc is o r by p ie rc in g th e or ig in o f t h e

a bductor (3) cuta n e o u s bra n ch e s wh ich a pp e ar ,

through the p la n tar a p o n e uro sis a lo n g the lin e o f t h e lat e ra l

in t e r m u scu lar se p tu m ( 4 ) tw ig s to t h e lat e ra l m arg in o f t h e
fo ot wh ich an a sto mo se w ith t h e lat e ra l tar sa l an d arcuat e
,

bra n ch e s o f t h e dor sa lis p e d is .

N ervus P lan t a ris M e dialis ( O T I n t e rn al P lan t ar N e rv e)

. . .

— Th e m e d ia l p la n tar n e rv e ar ise s as t h e larg e r o f t h e two

t e r min a l bra n ch e s o f the t ibia l n e rve in th e ho llow o f t h e
ca lca n e u s u n d e r cov e r o f t he liga m e n tu m lac in iatu m I t
,
.

a cco mp a n ie s the m e d ia l p la n tar art e ry an d h as Similar ,

r e lat io n s Aft e r it e me rg e s fro m u n d e r cove r o f th e a bductor

.

ha lluc is it giv e s o ff a d igita l bra n ch to t h e m e d ia l sid e o f the

ha llu x an d th e n e n d s in t he in t e rva l be tw e e n t he a bductor
, ,

ha lluc is an d th e fl e x o r d igit o ru m br e v is by d iv id in g in t o thr e e ,

t e r min a l d ig ita l bra n ch e s .

Th e bran cbes o f th e me d ia l p la n tar n e rv e are :

1 . C u tan eo u s t w ig s t o the s kin o f th e so le .

2 . M u scu lar bran ch e s .

3 . F o u r digital bran ch e s .

The cu taneo us trvzgs to th e in t e gu m e n t o f t h e SO le sp r in g

fr o m t h e tru n k o f t h e n e rv e , an d p ie rc e the a p o n e uro sis in
t h e lin e o f t h e m e d ia l in t e r m u scu lar se p tu m .

The d ig ita l bra n ch e s o f t h e m e d ia l p la n tar n e rv e Su p p ly

t h e sk in o f t h e p la n tar sur fac e s o f thr e e an d a ha lf to e s, th e
fir st, se c o n d , third , an d ha lf the fo urth Th e y also su p ply .

th e sk in o v e r th e d o r sa l a sp e ct s o f t h e t e r m in a l p ha la n g e s
o f tho se t o e s an d t h e j o in t s an d liga m e n t s o f t h e t o e s t o

wh ich th e y are d istr ibut e d .

Th e digital n erve to tbe great to e su p p lie s t he m e d ia l sid e

o f that to e .

Th e tbree termin al digi tal bran c/z es p a ss to t he p r o x ima l

e n d s o f th e m e d ia l thr e e in t e rd ig ita l c le ft s, wh e r e e ach
d iv id e s to su p p ly t he adjac e n t sid e s o f th e to e s wh ich bou n d
t h e c le ft s
,
F ro m th e th ird t e r m in a l d ig ita l bra n ch o f the
.

1— 25 b
 THE I N F ER I OR EXTRE M I TY
me d ial p la n tar ne rv e a c o mmu n icat io n is g iv e n t o t he su p e r
fi c ial p art o f th e lat e ra l p la n ta r n e rv e Th e d ig ita l d istr ibut io n
.

M . abduc t o r d igi i q i i
t u nt

M fl exo r d
. igi t o ru m bre vi s

L at e ra p l l an t ar
arte r y an d n e r e v
M . q u adrat u s p lan taa

l g M ed a i l pl an t ar
P e ro n aau s on us v
n e r e an d art e r y

M . abdu ct o r ha ll iuc s

Te n do n o f flexo r

Te n do n o f flexo r
hall i l g uc s o n us

M fl di g i i q i i
exo r t u nt
b vi
.

re s

Mm . l u mbr c a e s i l

M fl e x o r ha
. ll i
uc s bre vi

FI G . 1 7 1 .
— Di i
sse c t o n o l
f t h e So e o f t he F
o o t th e Fl x Di gi t
e o r o ru m B re v is
h as be e n re fl e c te d .

o f t h e m e d ia l p la n tar n e rv e in t h e fo o t c lo se ly r e se m ble s that

o f t h e m e d ia n n e rv e in t h e ha n d .
 TH E I N F ER I OR EXT RE M I TY
wh e r e it d iv id e s in t o fo ur t e n d o n s fo r t h e lat e ra l fo ur to e s .

Wh e r e the t e n do n s cro ss t he t e n d o n o f t he fl e x o r ha lluc is ,

lo n gu s g iv e s a slip to th e d e e p sur fac e o f t h e t e n d o n o f t h e

fl e x o r d ig itoru m lo n gu s .

Si W ill i m T
r a ll d tt ti t th f t th t th lip wh i h
u rn e r c a e a en o n o e ac a e s , c

passe s f m th t d
ro e f th fl
en o n h ll i l g t th t d
o e f th exo r a uc s o n us o e en o n o e

fl e x o r lo n g u s dig ito ru m v arie s g re atly in m ag n itu de an d in th e m ann e r in

,

wh ich it is co nn e ct e d w ith the fl e x o r t e n do n s o f th e to e s I n the m aj o rity .

o f c ase s it g o e s t o t he t e n do n s o f th e se co n d an d th ird t o e s o r to th e t e n do n s

o f th e se co n d, th ird, an d fo u rth to e s ; in so m e c ase s , h o w e v e r, o n y to l

t h e t e n do n o f th e se co n d t o e V e ry rare y do e s it div ide so as to brin g
. l
all the t e n do n s o f th e fl e x o r dig ito ru m o n g u s in to co n n e c t io n w ith th e l
l
t e n do n o f th e fl e x o r h a lu cis o n g u s l .

Th e mu scu lu s q u adratu s plan tw, wh ich is in se rt e d in t o t h e

t e n d o n o f t h e lo n g fl e x o r o f t h e t o e s, an d a lso th e fo u r
lu mbrical mu scles, wh ich ar ise fr o m t h e fl e x o r t e n do n s, c an
n o w be d ist in gu ish e d N o t e t h e p o sit io n o f t h e lo n g
.

p la n tar liga m e n t be tw e e n t h e t wo h e ad s o f o r ig in o f the

quadratu s p la n t a .

D is s e c t io n —
B e f o re t h e fl e x o r e n do n s are rac e d f o rw ards t t
t
t o t h e o e s , t h e fi bro u s fl e x o r s h e a h s o f t h e o e s m u s be dis t t t
p l a y e d a n d e x a m in e d T h e S k in o n t h e p.lan a r a s p e c s o f t h e t t
t o e s h as alre ady be e n re fl e c e d an d t h e dig i al e sse ls an d n e r e s t t v v
v
h a e be e n cle an e d No w re m o e th e re m ain s o f th e su p e rfi cial
. v
f asc ia an d e xp o se t h e fl e x o r s h e a h s t .

t t
Eac h s h e a h co n sis s o f tw o s ro n g p o r io n s, c alle d t h e dig i al t t t
v ag in al lig am e n s , t w
h ic h lie o p p o si e t h e bo die s o f t h e fi rs an d t t
se co n d p h alan g e s an d are a t ac h e d t o t
h e ir m arg in s, an d w e ak e r t
t t
p o r io n s , O p p o si e t h e in e rp h alan g e al j o in s , t
h ic h are a ac h e d t w tt
t o t h e e n ds o f th e adj a ce n p h alan g e s a n d t h e m arg in s o f t h e t
t
p lan ar a cce sso ry lig am e n s o f t h e j o in s t
Th e s ro n g e r p ar s t . t t
a re t o p re e n v t t
t h e e n do n s s p rin g in g a ay f ro m t h e bo n e s wh e n w
t
t h e j o in s a re fl e x e d, w h ils t h e e ak e r p ar s allo the m o e t w t w v
t
m e n s o f t h e j o in s t o ak e p lace t t .

Cle an t h e su rf ace s o f at le as tw o s h e a h s , h e n O p e n o n e o f t t t
t t
h e m by a lo n g i u din al in cisio n , t o display t h e m u co u s lin in g
an d t h e tw o t
e n do n s wh ic h are e n clo se d by t h e sh e a h t .

Th e F lex o r She a t hs o f t he Digit s an d t h e I n se rt io n s o f

t h e F le x o r Te n do n s — I n e ach d ig it an o st e o fibro u s ca n a l is
.
-

for m e d . I t is bo u n d e d , dor sa lly , by th e p la n tar sur fac e s o f

t h e p ha la n g e s an d t h e p la n tar liga m e n t s o f t h e in t e r p ha la n g e a l
jo in t s, an d, p lan tarwards an d at t he Sid e s, by the fi brou s
fle xo r h e ath s Two t do n s e nt e r e ach ca
s . a t e n do n
en n a l—

o f th e short fl e x o r o f t h e t o e an d a t e n do n o f t h e lo n g fl e x o r .

O p p o sit e th e p o st e r io r p art o f t h e fir st p ha la n x t h e sh o rt
fl e x o r is su p e rfic ia l an d t h e t e n d o n o f t he lo n g fl e x o r lie s
 SO L E O F TH E F OOT 39 3

be t we e n it an d th e bo n e , bu t at t h e m idd le o f t h e p ha la n x
the t e n d o n o f t h e sh o rt fl e x o r is p e r fo rat e d by t h e t e n do n o f
t h e lo n g fl e x o r, wh ich p a sse s fo rward s t o be in se rt e d in to t he
ba se o f th e t e r m in a l p ha la n x , wh ilst t h e t e n do n o f th e sh o rt
fl e x o r, be yo n d t he p e r fo rat io n , sp lit s in to t wo p art s wh ich are
attach e d t o t he m arg in s o f t he se c o n d p ha la n x .

Th e o st e o -
fibro u s ca n a l is lin e d w ith a m ucou s s h e at h ,

wh ich n o t o n ly fa cilitat e s
the p lay o f t he ten do n s
,

wh e n t he mu scle s are in C l a c an e u s m

act io n bu t a lso fo r m s fo ld s
,

ca lle d vincula wh ich aid

in attach in g t h e t e n d o n s t o
t h e bo n e s .

Th e r e are t wo se t s o f
v in cu la short an d lo n g
,
.

Two short v in cu la are

p re se n t in e ach sh e ath .

Th e y are sh o rt tr ia n gu lar Q dm m p h mm ua s

f o ld s c o n t a i n i n g s o m e
y e llo w e la st ic t issu e O n e .

o f th e m c o n n e ct s t h e t e n

do n o f t he lo n g fl e x o r to
t he p la n tar liga me n t o f t h e
L mb i l
" '
u r ca s

t e r m ina l in t e r pha la n g e a l
j o in t and the adjac e n t p art
o f t h e se co n d p ha la n x an d ,

th e oth e r co n n e ct s th e
t e n d o n o f th e short fl e x o r
I n a S lm l] ar m a n n e r t o t he
FIG 7 S d l y f M l 1 2 d — e co n a er o u sc e s a n
a n tar ll am e n t O f t h e fi rS t
. . .

P l g T d i th S l f th F
en t o ns n e o e o e o o .

in t e r p ha la ng e a l jo in t an d
t o th e adjac e n t p art o f t h e fir st p ha la n x Th e co n d it io n is .

e x act ly similar t o that fo u n d in t h e fi n g e r s T

( F ig h e .

v in cu la lo n ga are m o r e Sle n d e r th e y are irre gu lar in n u mbe r

,

an d p o sit io n .

Te n do n o f t h e Flex o r H alluc is L o ngu s — Aft e r g iv in g its

slip to t h e t e n do n o f th e fl e x o r d ig itoru m lo n gu s t he t e n d o n ,

o f th e fl e x o r ha lluc is lo n gu s is p ro lo n g e d forward s t o the

gr e at t o e On the p la n tar a sp e ct o f t he ha llu x it is r e ta in e d
.

in p lac e by a fi br o u s fl e x o r S h e ath an d fi n a lly it is in se rt e d

, , ,

in t o th e ba se o f th e t e rmin a l p ha la n x .
 TH E I N F ER I OR EXTRE M I T Y
M .Qu r u s P lant ae ( O T Flex o r Acc e sso riu ) Th is
ad at . . s — .

m u sc le tak e s a cour se stra ight fo rward s fro m th e h e e l an d ,

act s as a d ir e ct fl e x o r o f the to e s I t a lso t e n d s to br in g th e .

t e n do n s o f th e lo n g fl e x o r mu sc le in to a li n e w ith t h e to e s u p o n
wh ich th e y O pe rat e I t ar ise s by two h e ad s wh ich e mbrac e .

th e ca lca n e u s an d th e lo n g p la n tar liga m e n t Th e medial .

bead w id e an d fl e shy sp r in g s fro m t h e m e d ia l c o n cav e

, ,

sur fac e o f t h e ca lca n e u s ; t h e lateral be ad n arrow p o in t e d , , ,

an d t e n d in ou s tak e s or ig in fro m th e lat e ra l surf ac e o f t h e

,

ca lca n e u s an d a lso fro m the lo n g p la n tar liga me n t The

,
.

quadratu s p la n t ae is in se rt e d in t o th e t e n do n o f th e fl e x o r
d ig itoru m lo n gu s in t h e midd le o f the so le I t is su pp lie d .

by a bra n ch fro m th e lateral p lan tar n erv e .

M m Lumbrica le s —Th e lu mbrica l m u scle s o f th e fo o t are

. .

n o t SO stro n g as t he c o rr e sp o n d in g m u sc le s in t h e p a lm o f th e

ha n d Th e y are four in n u mbe r an d arise fro m th e t e n do n s

.
,

o f t h e fl e x o r d ig itoru m lo n gu s Th e lat e ra l thr e e lu mbr ica ls .

sp r in g fro m t he adjac e n t sid e s o f t h e t e n do n s be tw e e n wh ich

th e y lie th e fir st or m o st me d ial m u sc le tak e s orig in fro m the

me d ia l Sid e o f t h e t e n do n o f t h e lo n g fl e x o r wh ich go e s to th e
se co n d t o e Th e sle n d e r t e n do n s o f th e lu mbr ica l mu sc le s
.

p roc e e d t o t h e m e d ia l sid e s o f t h e l at e ra l fo ur to e s a n d a re ,

in se rt e d in to th e e x p a n sio n s o f t h e e x t e n sor t e n do n s o n t h e
dor sa l a sp e ct s o f the p ro x ima l p ha la n ge s ( se e p Th e .

first o r mo st medial lu mbrical is su p p lie d by th e medial plan tar

n erv e : th e o tbers are su p lie d b t h e la t r l p lan tar n erv e
p y e a .

D is s e c t i o n — To bri g t h e t h ir d lay r o f m u s l in t v i wn e c es o e

t h f o llo w in g di e ct io n m st b m ad — D iv id t h tw
e ss h ads u e e e e o e
f th q u adrat
o e p la t a a n d dr a w t h m
us s l f rw a rd sn f ro me e u c e o
n de r t h
u lat ral p lan t ar v e l a d n rv
e S v r l th e sse s n e e . e e a so e
t d n s f th fl e r dig it o r m lo g a d t h fl e o r h all cis
en o o e xo u n us n e x u
lo g s at t he p o in t w h r t h y m e rg e f r m u n d r c v r o f t h
n u e e e e o e o e e

lig am e n t m la in iat m an d t r t h m t w ard t h t o e

u c u af t r
,
u n e o s e s, e

tt in g th e bra ch fr m th late ral p la tar rve to t h q u adrat

cu n o e n ne e us

p la t ae nA th t e n d s f the l g fl
. s r f th
e t ar tu rn d
o n o o n ex o o e o es e e

f rw ard t h e l m brical m u cl s w ill b rai d an d t h e tw ig s w h ic h

o s u s e e se ,

ar f u r ish d t o t h e s co n d third an d f
e n e rth by t h d p divi io ne , ,
ou e ee s
f t h lat ral p la t ar n rv m t b lo k d f r
o e e n Th at f o r th e e us e o e o . e

es co n d l m bric al m u l w ill be s n t t ak e a r
u rr n t
sc e rse ee o e cu e co u
r u n d th
o t ran v r h e ad o f t h addu t r h allu cis m s le
e s e se e c o u c .

Last ly t t h m dial p la t ar
,
cu rv el t it o rig in a d t rn
e n ne e c o se o s n u

it aside .

Third L a y e r o f M u scle s — The fl ex o r ballu cis brevis lie s

a lo n g th e l ate ra l sid e o f th e a bductor ha lluc is .

Th e o bliq u e bead f
o tbc addu cto r ballu cis h as a v e ry o bliqu e
 TH E I N F ER I OR EXTR E M I TY

p ro x im a l p ha la n x o f t h e gr e at t o e in co m m o n w ith , the
o bliqu e h e ad I ts n e rv e o f su pp ly co me s fro m the
. deep

O ri g i f M abd
n o . u cto r dig i i q i i
t u nt

O igi f M fl
r n o . e xo r di g i m b vi
t o ru re s

Lo n g pl a n ta r li g am e n t

L at e ra p l l an t ar art e r y an d n e r e v
p l an t ar art e r y an d n e r e v
M ll i
. abdu c to r ha uc s

M q d pl
. ua rat u s an t ae

Fl x di g i m l g
e o r t o ru o n us

F le x o r ha ll i l g
uc s o n us

P e ro n aau s l g o n us

a rt e r y

M fl e x o r di
. g i t i q i t i b vi
u n re s

M . addu c t o r ha ll i
u c s, o b li q ue
h e ad

M fl e x o r ha
. ll i b vi
uc s re s

M . addu c t o r h ll i
a u c s, t ran s
v e rse h e ad

Mm . l u mbr c a i l es

FIG . 1 73 .
— D eep Di i
sse c t o n o f th e F o o t th e Su p e rfic al M u sc i l e s an d a so l
t he Fl
e xo r Te n do n s , e tc . , h ave be e n re m o e d v .

divisio n o f t h e lateral pla ntar n erve . I t is an adduct o r o f t he

gre at to e .
 P L ATE X X XV

Se c o nd do rs a l
me t a t arsa l art e r y
i
Th rd p a n tar l
m e t a t arsa l art e r y
Se c o nd p l a n ta r
me ta t arsa l ia rt e r
y
i
Th rd do rsa l
m e t a ta rsa l a rt e r y

Pl an t a r arc h

S e co nd c u n e if o rm
o o ne

F .
Fi f h m t e t a ta rsa lb o ne

fl
m
Th i d
i rs t c u n e i o r

o ne
r c u n e i fo r m bo ne

C b id
u o

N av i l
c u ar bo ne

L a t e ra p l l a n t ar

M ed a p il l an t a r
a rt e r y
a rt e r y

Ta l us

L a t e ra p l l an t a r
a rt e r y

Ca l c a ne u s

FI G . 1 74 .
—
R di
a o grap h o f an In j e c te d F o o h
t s o w i l i
n g th e re at o n s o f so me
o f th e arte i
re s to the bo ne s .
 TH E I N F E R I O R EXTRE M I TY
ru n forward s o pp o sit e the se co n d th ird an d fo urth in t e r
, ,

m e tatar sa l Sp ac e s p a ss dor sa l to th e tra n sv e r se h e ad o f the

,

adduct o r ha lluc is an d at t he p ro x ima l e n d o f the corr e

, ,

sp o n din g in t e rd ig ita l c le ft e ach p la n tar m e tatar sa l art e ry e n d s

,

by d iv id in g in t o two bra n ch e s wh ich su p p ly t he adjac e n t

s id e s o f t h e d ig it s bou n d in g t h e c le ft The bra n ch e s o f
.

t h e se c o n d p la n tar m e tatar sa l art e ry su p p ly t h e adjac e n t

sid e s o f t he se co n d an d th ird to e s ; tho se o f t he th ird
s u p p ly t h e adjac e n t sid e s o f t h e th ird an d fourth to e s ;
an d tho se o f t h e fourth t h e adjac e n t Sid e s o f the f ourth an d

fi fth t o e s
.

I m me d iat e ly be for e it d iv id e s e ach p la n tar m e tatar sa l

,

art e ry se n d s dor sa lly an a n t e rior p e r forat in g art e ry wh ich

j o in s th e corre sp o n d in g dor sa l me tatar sa l art e ry .

U p o n th e sid e s o f t he to e s the pla n tar d ig ita l bra n ch e s o f

th e m e tatar sa l art e r ie s are d istr ibut e d in e x act ly the sa m e
ma n n e r as th e d ig ital art e rie s o f t he fi n g e r s ( see p .

Th e p la n tar me tatar sa l bra n ch to the lat e ra l bord e r o f th e

litt le t o e Sp r in g s fro m t h e lat e ra l e x tr e m ity o f t he p la n tar arc h ,

cr o sse s t h e p la n tar surfac e o f the fl e x o r d ig it i qu in t i bre v is ,

an d ru n s fo rward s to t h e d ista l e n d o f th e t o e .

Th e F irst P lan t ar M et at arsal Art e ry ( O T Art e ria . .

M agn a H allu c is) corr e sp o n d s w ith th e art e r ia v o laris in d ic is

rad ia lis an d t he art e r ia p rin c e p s p o llic is o f the ha n d I t arise s .

fro m t h e p la n tar e x tr e m ity o f t h e dor salis p e d is at t h e p o in t ,

wh e re th e latt e r jo in s the p la n tar arch an d ru n s forward s to

,

t h e c le ft be tw e e n t he gr e at to e an d th e se co n d t o e wh e r e ,

it d iv id e s in to two bra n ch e s fo r t h e su p ply o f the adjac e n t

‘

sid e s o f t h e fir st an d se co n d to e s . B e for e it d iv id e s it g iv e s ,

o ff a bra n ch to th e m e d ia l sid e o f t h e gr e at t o e wh ich is

j o in e d by t h e t e r m in a l p art o f the me d ia l pla n tar art e ry .

D e ep Div isio n o f t h e L t eral P lan t a N e rve

a r — Th e d e e p
d iv isio n o f th e lat e ra l p la n tar n e rve acco m p a n ie s the pla n tar
arch in its c o urse me dialwards acro ss t h e sole I t lie s .

p o st e r io r t o t h e arch an d e n d s in t h e d e e p surfac e o f t he
,

o bliqu e h e ad o f th e adductor ha lluc is I n add it io n to that.

mu sc le it su p plie s all th e in t e ro sse ou s m u scle s ( w ith th e

e x c e p t io n o f tho se in the fo urth sp ac e ) t h e tra n sv e r se h e ad o f
,

t h e adductor ha lluc is an d t h e lat e ra l tbree lu mbr ica l mu sc le s

, .

Th e tw ig to th e se co n d lu mbr ica l tak e s a r e cu rr e n t cour se

rou n d the a n t e rior bord e r o f the tra n sv e r se h e ad o f the
adductor ha lluc is .
 SO L E O F TH E F OOT

D is s e c ti o n — D e a c h th e t tr n v r e h d f th add to r
a s e s ea o e uc
h allu c is fro m its o rig in an d t h r w it m dially t w ard th e
o e ,
o s
h allux , disp lay th e
to tran s v r ligam t o f th h ad f th
e se en e e s o e
m e t at arsal bo n es .

Tran sv e rse Lig amen t o f t h e H e a ds o f t he M et at arsal

B o n e s — Th e tra n sv e r se liga m e n t o f t h e h e ad s o f t h e m e ta

N er v e to abdu c t o r dlgm q u m “
P i ibi l
o ste r o r t a art e r y
Me di l p l
a an t a r n e r e v
L a t e ra l pl a n t a r n e rve

N er v e to M . q u adrat u s lp a n ta:

N e rve to M . abdu c to r h llai uc s

L a t e ra p l l a n t ar art e r y N e rv e t o M . fl exo r di gt i o ru m bre v is

L at e ra l pl an t a r n e r e v M ed a p il l an t a r n e r e v
l l
L a t e ra p an t ar n e ry e , Me di l p la an tar a rt e r y
iv
de e p d i s i o n
L a t e ral pl a n ta r ne ry e

p fi i l l
,
.

su er c a lS lo n

v
er e to Mm . i i ff h p
n t e ro sse o o u rt s ac e

v di g i i q i i b v i
a
er e to M flexo r
. t u nt re

Pl an t a r e n d o f do rsa li s ped i s art e r y

Pl a n t ar arc h N e rv e t o M . ll i
fl e x o r ha uc s bre v i s

N er v e to M . l mb i li
u r ca s 1

FI G . 1 75 .
— Art e r e s i an d N er ve s o f t h e So l e o f th e F o o t .
( Di agram ) .

The p l v
an t a r n e r e s a n d t h e r i bra n ch e s are u n co l o u re d.

tarsa l bo n e s is a stro n g fi brou s ba n d wh ich str e tch e s acro ss

an d is attach e d to th e p la n tar acc e ssory liga me n t s o f t h e

fiv e m e tatar so p ha la n g e a l j o in t s -
I t d iff e r s fro m t h e c o rr e .

sp o n din g liga m e n t o f t h e ha n d in a sm uch as it in c lud e s w ith in ,

its gra sp th e p la n tar acc e sso ry liga m e n t o f t h e m e tatar so

p ha la n g e al j o in t o f t h e fir s t d ig it .

D s s e c ti o n
i — A at i fact o ry di p lay f t h e i n tero s eo us muscle s
s s s o s

an o t be o bt ain d
c n l s t h e t ra sv e rse l gam e n t
e l
u n es de d n i is l
 TH E I N F ER I O R EXTR E M I TY
be tw ee n the h e ads o f the vari o usm e t at arsal bo n es Th e t o e s .

c an th en be se p ara t e d mo re f re e ly f ro m e ac h o t h e r, an d t h e
in te ro sse o u s m u scle s t rac ed to th in se rt io n s
e ir I t is . w e ll, at
t h i t ag
s s e, to re fl e ct th e fl e x o r t t
dig i i q u in i bre is also v .

I n t e ro sse o us M u scle s
Th e r e are se v e n in t e ro sse ou s
.
—

m u sc le s thr e e p la n tar an d fo ur d o r sa l
, Th e plan tar inter .

o sseo u s mu scles are so p lac e d that th e y adduct th e lat e ra l thr e e

t o e s toward s t h e m idd le lin e o f th e se co n d t o e Th e y ar ise .

fro m the p la n tar a sp e ct s an d p art s o f t he m e d ia l sur fac e s o f

t h e lat e ra l thr e e m e tatar sa l bo n e s an d e ach is in se rt e d u p o n ,

t h e m e d ia l sid e o f t h e fir st p ha la n x o f t h e c o rr e sp o n d in g t o e .

Th e do rsal intero sseo u s m u scles occu p y th e fo ur in t e r m e tatar sa l

sp ac e s an d co n se qu e n t ly th e y m u st be d isse ct e d u p o n both
,

p la n tar a n d dor sa l a s e ct s O f t h e fo ot
p Th e y a r e arra n g e d so .

as to a bduct t h e se c o n d th ird an d fo urth to e s fro m t he

, ,

midd le lin e o f the se co n d to e Each ar ise s by two h e ad s .

fro m t h e dor sa l p art s o f t h e adjac e n t sid e s o f th e m e tatar sa l

bo n e s wh ich bo u n d t h e c le ft in wh ich it lie s Th e y are .

in se rt e d as fo llo w s : th e first u p o n th e m e d ia l sid e o f the fir st

,

p ha la n x o f t h e se c o n d t o e ; t h e seco nd u o n th e lat e ra l Sid e

p ,

o f t h e sa m e p ha la n x ; t h e tbird u p o n t h e lat e ra l sid e o f t h e,

fir st p ha la n x o f the th ird to e an d the f o u rtb u p o n the lat e ra l ,

sid e o f th e fir st p ha la n x o f t h e fo urth t o e Th e Sle n d e r .

t e n d o ns o f the in t e ro sse ou s m u scle s are o n ly v e ry slightly

attach e d to th e ba se s o f th e p r o xim a l p ha la n g e s Th e y are .

in se rt e d fo r th e m o st p art in to t he e x p a n sio n s o f t he e x t e n sor

t e n do n s o n the d o r sa l a sp e ct o f th e to e s ( p .

Te n do n s o f t h e Tibialis P o st erio r an d P e ro n aeus L o ngu s . .

B e fo r e le av in g t h e so le o f th e fo Ot t he d isse ctor m u st d e t e r
min e t h e p r e c ise in se rt io n s o f th e t e n do n s o f the t ibia lis
p o st e r ior a n d o f t h e p e ro n ae u s lo n gu s T h e t e n do n o f t h e .

tibialis po sterio r is in se rt e d n o t m e r e ly in t o th e tu be ro sity

o f th e n av icu lar bo n e F ibrou s Slip s are se e n to Sp r e ad out
.

fro m it an d th e se m ay be trac e d t o e v e ry bo n e o f th e tar su s

, ,

w ith the e x c e ptio n o f the talu s an d a lso to the ba se s o f th e ,

se co n d th ird an d fourth m e tatar sa l bo n e s

, ,
As it lie s u n d e r .

an d g iv e s su p p o rt t o t h e h e ad O f th e ta lu s t he t e n d o n o f t h e ,

t ibialis p o st e r ior has d e v e lo p e d w ith in it a se sa m o id n odu le

o f fibro cart ilag e an d in so m e ca se s a se sa m o id bo n e
-

( g
F i .

Th e t e n d o n o f the pero na u s lo ngus tur n s rou n d th e

lat e ra l m arg in o f t h e fo o t an d ru n s m e d ia lly acro ss , ,
the
40 2 T HE I N F ER I OR EXTRE M I TY

A R T I C U L ATI O G EN U
( K N EE j o i n T
) .

I n t h e k n e e j o in t thr e e bo n e s are in a p p o sit io n v iz

-
,
.
,

t h e d ista l e n d o f t h e fe m ur th e p ro x im a l e n d o f t he ,

t ibia an d the p at e lla I t is the larg e st an d m o st co m

,
.

p licat e d art icu lat io n in t h e body ; an d wh e n t h e bo n e s are ,

e x a m in e d in t h e dr ie d sk e le to n t h e j o in t p r e se n t s an a ar e n t
pp ,

in se cur ity be cau se t h e bo n y sur fac e s Sh o w litt le ada p tat io n

,

t h e o n e t o t h e o th e r I n r e a lity h o w e v e r t h e k n e e jo in t is
.
, ,

v e ry stro n g an d o n acc o u n t o f th e stre n gth o f th e liga me n t s

, ,

wh ich re ta in t he bo n e s in p lac e it v e ry rar e ly su ffe r s d islo cat io n ,

.

The liga m e n t s o n t h e e x t e r ior o f th e j o in t are

I . The cap su lar lig am e n t .

2 . Two co llate ral ig am e n ts— fibu lar an d t ibial l .

3 . l
The ig am e n tu m p ate lae ( o r an te rio r igam e n t ) l l .

4 . The o bliq u e p o plite al ig am e n t l .

D is s e c t i o n — B e fo re t h e disse c io n o f t h e k n e e j o in i se lf is
. t t t
co m m e n ce d, t h e n e r e s v w
h ic h su pp ly it , an d t h e art e rie s h ich w
t
an as o m o se a ro u n d it an d p ro ide it s blo o d su p p ly S h o u ld be v
disp lay e d an d s u die d t
To a ce r ain e x e n h e y c an be disse ct e d
. t t tt
t
S im u l an e o u sly Th e su p e rio r, in fe rio r, an d m iddle art icu lar
.

t
bran c h e s o f t h e ibial n e rv e , t h e su p e rio r an d in f e rio r art icu lar
bran c h e s o f t h e co m m o n p e ro n e al n e r e , an d t h e art icu lar v
bran c h o f t h e o b u ra o r n e r e t t
e re f o u n d du rin g t h e disse c io n v w t
t
o f t h e p o p li e al f o ssa , e ac h be in g a cco m p an ie d by a g e n icu lar
bran c h o f t h e p o p li e al a r e ry t t .

t t t
N o e h a t h e m iddle g e n icu lar bran c h o f t h e ibial n e r e , t v
t h e a cco m p an y in g a rt e ry , an d t h e ar icu lar bran c h o f t h e O h t
v
tu rat o r n e r e p ie rce th e p o s e rio r lig am e n o f t h e k n e e j o in t t t .

t t
Th e y su p p ly s ru c u re s in side t h e c ap su le , bu t t h e de m o n s ra t
t t t t
io n o f h e ir dis ribu io n is e ry diffi cu l , an d n o a e m p m u s v . t tt t t
be m ade t o f o llo h e m f u rt h e r at p re se n wt t .

Th e bran c h e s o f t h e f e m o ral n e r e t o t h e ast u s m e dialis , t h e v v

v t t
a s u s in e rm e diu s, a n d t h e as u s la e ralis se n d ig s t o t h e v t t tw
t
k n e e , an d w igs o f th e de sce n din g bran c h o f th e la e ral fe m o ral t
c ircu m fl e x a rt e ry de sce n d i h t h e n e r e to as u s la e ralis t o wt v v t t
t t
ak e p ar in t h e an as o m o sis ro u n d t h e j o in t
Th e n e r e s an d t . v
t
th e arte ry m e n io n e d w e re f o u n d du rin g t h e disse c io n o f t h e t
t tt t t
h igh A e m p t o race h e m n o w t o t he k n e e , an d de m o n s ra e ,
. t t t
t
if p o ssible , t h e an as o m o sis o f th e de sce n din g bran c h o f th e la e ral t
f e m o ral circu m fl e x ar e ry i h t h e su p e rio r la e ral g e n icu lart wt t
t
bran c h o f t h e p o p li e al ar e ry , an d w i h t h e m u scu lar bran c h e s t t
o f t h e a rt e ria g e n u su p re m a N e xt race t h e su p e rio r g e n icu lar . t
bran c h e s o f t h e p o p li e al art e ry an d t h e acco m p an y in g n e r e st v .

Th e m e dial su p e rio r g e n icu lar art e ry , as it le a e s t h e p o p li e al v t

t
f o ssa, p ie rce s t h e p o s e rio r in e rm u scu lar se p u m o f t h e h igh , t t t
an d t h e n p asse s be t e e n t h e e n do n o f th e addu c o r m ag n u sw t t
an d t h e f e m u r be f o re it e n e rs t h e as u s m e dialis, wh e re it t v t
t
an as o m o se s w i h t h e adj ace n art e rie st Th e la e ral su p e rio r t . t
g e n icu lar art e ry , an d t he acco m p an y in g n e r e m u s be fo llo w e d v , t
 K N EE j O I N T 40 3

t h r gh o u the la t t
in e rm u s cu lar se p u m , an d be w e e n t h e
e ral t t
bice p s fe m o ris an d t h e bo n e , in o t h e su bs an ce o f t h e as u st t v t
t
in e rm e diu s .

As t h e in f e rio r g e n icu lar e sse ls an d n e r e s are f o llo w e d c are v v

t t v
m u s be ak e n t o a o id in j u ry t o t h e co lla e ral lig am e n s o f t h e t t
kn e e j o in t t
Cu t h ro u gh t h e bice p s f e m o ris at t h e le e l o f t h e
. v
t t
p ro x im al p ar o f t h e la e ral c o n dy le o f t h e f e m u r, p u ll th e dis al t
p art do w n w a rds , an d cle an t h e fi bu lar co lla e ra l lig am e n , w h ic h t t
t
des ce n ds f ro m t h e la e ral e p ico n dy le o f t h e f e m u r h ro u gh t h e t
t e n do n o f t h e bic e p s t o t h e h e ad o f t h e fi bu la (F ig Th e n .

f o llo w t
t h e in f e rio r la e ral g e n icu lar a rt e ry an d n e r e f o rw ard, v
be t we e n th e fi bu lar co lla e ral lig am e n an d t h e fi bro u s cap su le t t
t o t h e f ro n o f t h e k n e e t Ne x h ro th e e n do n s o f t h e sart o riu s,
. tt w t
t
g racilis, an d se mi e n din o su s fo r ards ; cle an t h e bro ad ibial w t
t
c o lla e ral lig am e n , t w
h ic h de sce n ds f ro m t h e m e dial e p ico n dyle
o f t h e f e m u r t o t h e m e dial co n dy le an d t h e m e dial su rf ace o f t h e
tibia ; h e n f o llo t w
t h e in f e rio r g e n icu lar art e ry an d t h e ae co m
p an y in g n e r e a lo n g t h v
e p ro x im al bo rde r o f t h e p o p li e u s t o t h e t
p o in tw t
h e re h e y disap p e ar u n de r co e r o f t h e ibial co lla e ral v t t
t
lig am e n be lo w t h e m e dial co n dy le o f t h e ibia Tu rn n o w t o t .

t
t h e an e rio r bo rde r o f t h e ibial c o lla e ral lig am e n , an d se cu re t t t
t h e in f e rio r m e dial g e n icu lar art e ry as it issu e s f ro m u n de r co e r v
o f the t t
ibial co lla e ral lig am e n , an d, if p o ssible , disp lay its t
a n as o m o se st wt
i h t h e adj ac e n art e rie s t .

t
N o w u rn t o t h e re cu rre n bran c h e s o f t h e an e rio r ibial t t t
a rt e ry t
Th e p o s e rio r ibial re cu rre n ar e ry sp rin g s fro m t h e
. t t t
t t
an e rio r ibial art e ry at t h e ba ck o f t h e le g an d as ce n ds t o t h e
t
k n e e an e rio r t o t h e p o p li e u s ; h e re fo re h a m u scle m u s be t t t t t
re fl e c e d t t
Cu t h ro u gh t h e n arro w p ar o f t h e m u sc le , im m e di
. t
t
a e ly m e dial t o t h e p ro x im al ibio fi bu la r j o in , an d u rn t h e t -
t t
t
m e dial p ar t o t h e m e dial side ; h e n fo llo t h e art e ry t o its t w
t t
e rm in a io n an d at t h e sam e im e n o e t h e t e rm in a io n o f t h e t t t
n e r e to v t
t h e p o p li e u s ; it e n e rs t h e an e rio r su rf ace o f t h e t t
m u scle .

t t
Th e an e rio r ibial re cu rre n art e ry an d t h e acco m p an y in g t
bran c h o f t h e c o m m o n p e ro n e al n e r e e re disp lay e d du rin g v w
t
t h e disse c io n o f t h e an e rio r an d la e ral re g io ns o f t h e le g t t .

F o llo wt t
h e m n o w h ro u gh t h e p ro x im al p art o f t h e o rig in o f t h e
t t
ibialis an e rio r t o h e ir e rm in a io n s t t t .

A n ast o mo sis a ro u n d t h e K n ee J o in t — Th e m o st imp o rta n t .

o f th e a n a sto m o se s arou n d t h e k n e e jo in t are p lac e d o n t h e

a n t e r ior a sp e ct o f th e art icu lat io n , an d tak e the fo r m o f

thr e e tra n sv e r se arch e s The mo st pro x imal o f th e se arterial .

arcades p a sse s thr o ugh t h e su p e rfic ia l fi br e s o f t h e quadr ic e p s

e x t e n so r, c lo se t o t h e p r o x im a l bo rd e r o f t h e p at e lla , an d is

f or m e d by t h e u n io n o f a bra n ch fr o m t h e su p e r ior lat e ra l

g e n icu lar art e ry w ith a tw ig fr o m t h e art icu lar bra n ch o f t h e
art e r ia ge n u su p re in a Th e middle an d t he d ista l tra n sv e r se .

arch e s are bo th p lac e d u n d e r c o v e r o f t h e liga m e n tu m p at e llae .

Th e middle areb ru n s acro ss in th e fatty t issu e c lo se t o th e

d ista l e n d o f the p at e lla I t is fo r me d by t h e in fe rio r lat e ra l .

I— 26 a
 TH E I N F ER I O R E X T R E M I TY
g e n icu lar art e ry an d a bra n ch wh ich r e su lt s fr o m th e u n io n o f
,

a tw ig fro m the art e ria ge n u su p r e m a an d a n o th e r fr o m t he ,

su p e r ior m e d ia l g e n icu lar art e ry Th e mo st distal areb lie s o n .

t h e t ibia im m e d iat e ly a bov e it s tu be ro sity an d r e su lt s fr o m

, ,

th e a n a st o m o sis o f t h e a n t e r io r r e curr e n t t ibia l an d in fe r ior

me d ia l g e n icu lar art e r ie s Th e p r o x im a l an d m idd le o f th e se
.

tra n sv e rse arch e s are co n n e ct e d o n e ach sid e o f th e p at e lla , ,

by a sc e n d in g an d d e sc e n d in g bra n ch e s wh ich a n a sto m o se ,

w ith o n e a n oth e r an d thu s e n c lo se th e p at e lla in an ,

irr e gu larly quadrilat e ra l art e r ia l fra m e work F ro m all sid e s o f .

th is art e ria l e n c lo sure tw ig s are g iv e n o ff wh ich e n t e r sm a ll

,

M . v as t u s l a te ra li s

D eep bran c h o f
art e r a i g e n u su p re ma

M . v a st u s me d a i li s

Su p e r o r m e d a i il
y
art e r o f t he k n e e

L ig am e n t u m p at e ll ae

M e d a me nil i sc u s

L ig a me n t u m p at e ll a: Fi b l u ar co ll at e ra l
lg mi a e nt

H e ad o f fibu l a

i
An t e r o r re cu rre n t
t ib l ia art e r y
An t e r o r t b a i iil art e r y

FIG . 1 77 .
— A n as to m o i
s s o n th e fro nt o f t h e L e ft K nee j i
o nt .

fo ra min a o n t h e a n te r io r surfac e o f t h e p at e lla t o su pp ly the

o sse o u s su bsta n c e Six art e r ie s th e r e fo r e tak e p art in t h e
.
, ,

fo r mat io n o f th is sy st e m o f a n a st o m o se s o n t h e fr o n t an d
lat e ra l a sp e ct s o f t h e j o in t v iz t h e m u sc u lo art icu lar bra n ch ,
.
,
-

O f t h e art e r ia g e n u su p r e m a t h e t wo su p e r ior an d t h e t wo ,

in fe r ior g e n icu lar bra n ch e s o f t he p o p lit e a l an d th e a n t e r ior ,

r e curre n t bra n ch o f the a n t e r ior t ibia l I n add it io n t o t he .

tw ig s wh ich p roc e e d fro m th e se to fo rm th e art e r ia l arch e s ,

n u m e r o u s bra n ch e s are g iv e n wh ich sp r e ad ov e r t h e bo n e s in

t h e for m o f a c lo se m e shwork D ur in g t h e d isse ct io n o f t he .

art icu lat io n th e se v e sse ls w ill be co me a p p ar e n t .

 TH E I N F ER I OR EXTRE M I TY
P o rt io n t
f th e e n do n s o f th e bice p s f e m o ris , se m im e m bran o su s,
s o
t
sart o riu s, se m i e n din o su s, g ra c ilis , an d p o p li e u s , o ge h e r i h t t t wt
sm all p ie c e s o f t h e h e ads o f t h e g as ro cn e m iu s, s h o u ld be le f t t
in p lac e in o rde r h a t t t
h e ir co n n e c io n s w i h t h e ligam e n s o f t t t
t h e j o in t t
m ay be s u die d Th e q u adrice p s e x t e n so r m ay be .

v
di ide d abo u tt
h re e in c h e s p ro x im al to th e p a e lla, an d th e dis al t t
t w
p ar a llo e d t o re m ain in p o si io n t .

P at e ll a r s u rfac e o f fe m u r

Se m il u n ar fa c e t fo r

I mp i
ress o n o f l a t e ra l p at e ll a

me n i sc u s
M e di a l t i bi a l
su rfac e

l iil
L a te ra t b a su rfac e
P 0

o st e ri o r c ru c ia t e

li g am e n t

i
An te r o r cru c i at e
Fi b l
u a r co ll a t e ra l li g
a me n t

li g a me n t
Trans v e rse li g t .

Te ndo n O f
iiiid: il i
z l
ft ri
M e d a me n sc u s

i i l ll
T b a co at e ra l
li g
ame n t

L iga m e n t u m p at e ll a:

Op en ni gi i n n te r

o sse o u s m em b
b l v
f
l
ra n e o r
il
M e d a p e rp e n d c u i l ar
an t e ri o r t i ia e sse s
fac e t o n p at e ll a

FIG . 1 78 .
— Di i
sse c t o n o f th e i i
n te r o r o f the K nee j i
o nt fro m th e fro nt .

C a p su la Art icul a ris — Th e ca p su le o f the k n e e j o in t

.
,

t o g e th e r w ith t he t ibia l co llat e ra l liga me n t an d th e o bliqu e

p p t e a l liga m e n t fo r m a co m p le t e in v e st me n t fo r the j o in t
o li ,
.

I n so m e p lac e s t h e fi br o u s o r p e r ip h e ra l p art o f t h e ca p su le
has d isa p p e ar e d a n d has be e n r e plac e d e ith e r by bo n e an d
cart ilage or by t e n do n an d in o th e r p lac e s it has be e n ,

str e n gth e n e d an d e x t e n d e d b t h e in cor p o rat io n o f adj ac e n t

y
p o rt io n s o f fa sc ia an d t e n d o n s ; thu s a n t e r io r ly t h e p at e lla , ,
 K N EE J O I N T 40 7
'

en t ir e ly re p lac e s a p ort io n o f t h e ca p su le Pro x ima l to t he .

p at e lla t h e ca p s u le is r e p r e se n t e d m e r e ly by t h e sy n ov ia l
stratu m cov e r in g t h e p o st e r io r surf ac e o f t h e t e n d o n o f t h e

quadric e p s m u sc le ; o n th e oth e r ha n d the a n t e ro me d ia l an d -

t he a n t e ro lat e ra l p art s o f t h e ca p su le hav e be e n str e n gth e n e d

-

by fu sio n w ith e x p a n sio n s fro m t h e va st i p ort io n s o f t h e

quadric e p s an d w ith th e su p e rjac e n t p art s o f the fa sc ia lata .

Th e p o sit io n an d attach m e n t s o f th e or ig in a l ca p su le are st ill

in d icat e d in t he adu lt by t h e sy n ov ia l lay e r w h ich fo r m s
, ,

a c o n t in u o u s e n c lo sin g me mbra n e e x c e p t in the r e gio n o f the

p at e lla
.

Ligame nt u m P at e llae — Th e p at e llar liga m e n t is situat e d

.

in r e lat io n to the d ista l p art o f th e fro n t o f t h e ca p su le .

I t co n st itut e s at the sa me t im e t h e t e n do n o f in se rt io n o f
, ,

t h e quadr ic e p s e x t e n sor m u sc le an d a liga me n t co n n e ct in g

t he p at e lla with th e tu be ro sity o f t h e t ibia I t s a n t e r io r .

sur fac e an d marg in s shou ld be car e fu lly d e fi n e d .

Th e liga m e n t is a stro n g ba n d a bo ut two in ch e s lo n g , ,

wh ich is at tach e d p ro xima lly to t h e a p e x o f the p at e lla an d ,

d ista lly to t h e smo oth p ro x ima l p art o f th e tu be ro sity o f

t h e t ibia . I t s su p e rfic ia l fi br e s are d ir e ct ly co n t in u o u s ov e r ,

th e sur fac e o f t h e p at e lla w ith t he c e n tra l p art o f th e co mm o n

,

t en do n o f th e quadric e p s e x t e n so r I ts d e e p surfac e is
.

se p arat e d p ro x im a lly fro m the sy n ov ia l lay e r by t he in fra

p at e llar p a d o f fa t a n d d ,
is ta lly it is se p arat e d fr o m t h e

a n t e r ior surfac e o f th e p r o xima l e n d o f th e t ibia by t h e d e e p

i n fra p at e llar bur sa ( F ig .

Ligame n t um Co lla t e ra le F ibula re ( O T Ext e rna l L at eral . .

Liga me nt ) — Th e fibu lar c o llat e ra l liga me n t is rou n d e d an d

.

c o rd lik e I t sta n d s w e ll away fro m the jo in t cav ity an d

-
.
,

tak e s n o p art in t h e fo r m at io n o f the art icu lar ca p su le I t .

is attach e d p r o x im a lly to a tu be rc le o n t he lat e ra l co n dy le

o f t h e fe m ur ; d ista lly it is fi x e d to th e h e ad o f t h e fi bu la
, ,

a n t e rio r to th e a p e x I t is c lo se ly a sso ciat e d w ith the t e n do n

.

o f t h e bic e p s fe m or is an d th e t e n d o n o f th e p o p lit e u s It .

Sp lit s t h e t e n d o n o f t h e bic e p s in to t wo p ie c e s an d e x t e n d s ,

be tw e e n th e m t o its fi bu lar attach m e n t The t e n d o n o f t h e

.

p po lit e u s tak e s o r ig in f ro m t h e lat e ra l co n dy le o f t h e fe m u r

d ista l t o an d a n t e r ior t o the fe m o ra l attach m e n t o f th e fibu lar

c o llat e ra l liga me n t As t h e t e n d o n ru n s backward s it lie s
.

u n d e r c o v e r o f th e fibu lar c o llat e ral liga m e n t bu t is se p arat e d ,

fr o m it by t h e art icu lar ca p su le .

1— 26 0
 TH E I N FE R I OR EXTRE M I T Y
An is so m e tim e s de sc ribe d a s the po ste rio r p a rt O f th e
additio n al slip
ll
fi bu lar co ate ra lig am e n t l
W h e n p re se n t it e n ds a bo v e in t he capsu e ,
. l
u n de r co v e r o f t he lat e ra l
h e ad o f the g astro cn e m iu s B e o w , it is im . l
pl an t e d into th e a e
p o f t h e h e ad o f x
t h e fi bu la .

L iga me nt u m C o lla t e rale Tibiale ( O T I nt ern al Lat e ral L iga . .

n
me t ) — Th e t ibia l co llat e ra l liga m e n t is a lo n g , flat ba n d ,
.

broad e r in t h e m idd le tha n at e ith e r e x tr e m ity I t sp rin g s .

fro m t h e m e d ia l e p ic o n dy le O f t he fe mur, d ista l t o th e adduct o r

tu be rc le As it d e sc e n d s it in c lin e s slightly fo rward s, an d,
.

fi n a lly, it ga in s attach me n t to
the m arg in o f t h e m e d ia l
co n dy le an d to the p rox im al
fo urth o f t h e body o f th e t ibia
be lo w t h e me d ia l co n dy le .

At t h e le v e l o f t he in t e rva l
be tw e e n th e fe m ur an d t he
L lm i
a t e ra e n sc u s t ibia it s d e e p sur fac e I S fu se d
w ith an d tak e s p art in t he
for m at io n o f th e fi brou s strat u m
o f th e art icu lar ca p su le Th e .

m a in p art o f the t e n do n o f th e
se mim e m bra n o su s e xt end s

FIG 7 9 — Th Fi b l C ll t l forward s u n d e r c o v e r O f it s
. 1 . e u ar o a e ra ;

L ig m a t f th K en
Ji t o st e r ior bord e r t o ga in an in
o
p
e ne e o n .
,

se rt io n in to t h e m e d ia l co n dy le
o f th e t ibia wh ilst m or e d ista lly t h e in fe r ior m e d ia l g e n icu lar
, , ,

v e sse ls are carr ie d forward s be tw e e n it an d th e t ibia Th e .

t e n d o n s o f t he sartoriu s grac ilis an d se mit e n d in o su s lie , ,

u p o n th e lo w e r p art o f it s sup e rfic ia l surfac e bu t are se p arat e d ,

fr o m it by an in t e rv e n in g bur sa .

The P o st erio r P art o f t he C a p sule an d t h e Ligame n t um

P o p lit e um Obliq u um ( O T P o st e rio r Ligame nt ) — Th e p o st e r io r
. . .

p art o f t h e ca p su le e x t e n d s as a co n t in uou s Sh e e t acro ss t h e

p o st e r ior a sp e ct o f t h e j o in t ; lat e ra lly it is co n t in uou s w ith
t h e lat e ra l p art o f th e ca su le wh ich lie s m e d ia l to t h e fibu lar
p ,

c o llat e ra l liga me n t an d me d ia lly it fu se s w ith the d e e p

,

sur fac e o f t he t ibia l co llat e ra l liga m e n t as t h e latt e r cro sse s

t h e lin e o f th e j o in t Th e lat e ra l h e ad o f the ga stroc n e m iu s

.

fu se s w ith t h e p r o x ima l p art o f it s lat e ra l p o rt io n an d t h e ,

t e n d o n o f the p o p lit e u s p a sse s thr o ugh the d ista l p art o f the

sa m e
p o rt io n The m e d ia l p art o f t he p o st e rio r p o rt io n o f th e
.

ca p su le is se p arat e d fro m th e m e d ia l h e ad o f th e ga stroc n e miu s

 TH E I N F ER I OR EXTRE M I TY
u n d e r cov e r o f the m e d ia l h e ad o f the ga stroc n e miu s c o m
mu n ic ate s w ith th e cav ity o f th e j o in t an d that through wh ich ,

t h e t e n d o n o f th e p o p lit e u s e m e rg e s th e r e are se v e ra l sm a ll ,

a p e rtur e s in th e p o st e rior p art o f th e ca p su le fo r th e tra n s

missio n o f v e sse ls an d n e rv e s in to th e in t e r ior Of th e jo in t .

D is s e c t io M ak e a t ran sve rse in c isio n t h ro u gh t h e q u adri

n —
ce p s e xt e n so r, imm e diat e ly p ro x im al t o t h e p at e lla , an d p ro lo n g
e ac h e n d o f t h e in cisio n do w n w ards , abo u t 3 7 mm p o st e rio r t o .

the p a t e lla, to t he yle s

f t h e ibia, h e n u rn t h e p a e lla
co n d o t t t t
w
do n wa rds t
Th e j o in is n o w Op e n e d fro m th e f ro n an d th e
. t
w t
f o llo in g s ru ctu re s can be se e n an d e x am in e d, v iz , t h e sy n o ial . v
t t
lin in g , t h e cru c ia e lig am e n s , w h ic h co n n e c t h e f e m u r i h t h e t wt
t ibia, an d t h e m e n isci, w h ic h lie u p o n an d are a t ac h e d t o t h e t
t ibia t v
I mm e dia e ly abo e t h e j o in , be t we e n t h e dis al p ar o f
. t t t
t
t h e q u adrice p s e x e n so r an d t h e f ro n o f t h e f e m u r h e re is a t t
w
larg e sup rap a te llar bu rsa h ic h is f re q u e n ly c o n in u o u s w i h th e t t t
t vt
j o in ca i y To disp lay the e x t e n o f h a bu rsa, sp li t h e lo w e r
. t t t t
p art o f t h e q u adrice p s by a e r ical in c isio n in t h e m iddle lin e v t
o f th e t t
h igh an d u rn th e tw o p art s aside .

I n t eri o r o f t h e J o int F ir st
gre at p ad o f so ft fat
.
— n ot e th e
wh ich is p lac e d o n the d e e p surfac e o f the liga me n tu m p at e llae .

I n v e rt ica l se ct io n th e fatty m a ss is tr ia n gu lar in for m ( F ig 1 8 i ) . .

I t is t e r m e d t he infra patellar pad an d it fi lls u p t h e in t e rva l

-

be tw e e n t h e p at e lla fe mur an d t ibia an d ada p t s it se lf to

, , ,

t h e var ie d fo r ms wh ich that r e c e ss a ssu m e s in t h e d iff e r e n t

m ov e me n t s o f th e j o in t I t is se p arat e d fro m t h e in t e rio r
.

o f t h e j o in t by a c o v e r in g o f t h e sy n ov ia l lay e r an d fro m ,

it s sur fac e a fo ld o f that lay e r e x t e n d s backward s an d

u p ward s t o the a n t e r io r marg in o f t he in t e rco n dylar fo ssa
o f t h e fe m ur wh e re it is attach e d That ba n d is t e r me d
,
.

t h e p atellar sy n o vial fo ld ( O T ligamentu m mu co su m) AS. . .

it a pp r o ach e s t h e fe mur it be c o m e s n arrow an d sle n d e r ;

bu t wh e r e it cov e r s t h e sur fac e o f th e infra p at e llar p ad it is -

br o ad an d tr ia n gu lar an d p r e se n t s two fr e e marg in s wh ich

,

e x t e n d a lo n g t h e bord e r s o f t h e d ista l p art o f t h e p at e lla ,

an d r e c e iv e t h e n a m e o f plied alares ( O T lig a men ta alaria

) . . .

I t m u st be c le ar ly u n d e r st o od that th e se are n o t liga me n t s

in t h e ord in ary se n se o f t h e word bu t m e r e ly fo ld s o f t h e ,

s n ov ia l lay e r
y .

St rat um Sy n o viale ( O T Sy n o v ial M e mbran e) . As t h e

. .
—

k n e e j o in t is th e larg e st jo in t in the bo dy it s sy n ov ia l stratu m is

m or e e x t e n siv e tha n that o f an y oth e r j o in t I t lin e s th e d e e p .

sur fac e s o f t h e liga m e n tou s structur e s o f t h e lat e ra l m e d ia l ,

an d a n t e r ior p art s o f th e j o in t I t lin e s th e d e e p sur fac e s .

 KN EE JO I N T 4 1 I

o f t h e m e d ia l an d lat e ra l p ort io n s
f th e p o st e r ior p art o f th e o

ca p su le a lso , an d fr o m th e m it is p ro lo n g e d a n t e riorly , a lo n g
t h e sid e s an d rou n d t h e fro n t o f t he cruc iat e liga me n t s I n th e .

a n t e r ior p art o f the j o in t it is p r o lo n g e d u p ward s, be yo n d

t he art icu lar sur fac e o f the d ista l e n d o f t h e fe mur, in th e
for m o f a gr e at cu l de sac, u n d e r cov e r o f t h e t e n do n o f t he - -

quadric e p s ( F ig 1 8 1 Th e p r o xima l e x tre mity o f th is cu l de sac

.
- -

u sua lly co m mu n icat e s by an or ific e o f gre at e r or le ss w idth

w ith t he su p ra p at e llar bur sa The sy n ov ia l lay e r a lso in v e st s .

t he m e n isc i an d a p ouch lik e d iv e rt icu lu m is p ro lo n g e d

,
-

p o st e r ior l y a n d d i sta lly a lo n g t h e t e n do n o f t h e o

p p lit,
e u s ,

wh ich it p art ia lly e n sh e ath s acro ss t he p o st e r ior p art o f th e ,

e x t e r n a l bord e r o f t he lat e ra l m e n iscu s to th e p o st e r ior a sp e ct

o f th e p r o x ima l e n d o f t h e t ibia That p ro lo n gat io n lie s in .

c lo se r e lat io n w ith t h e ca p su le o f the t ibio fibular j o in t an d -

in so m e ca se s a co mm u n icat io n is e sta blish e d be tw e e n the

cav ity o f t h e d iv e rt icu lu m an d the cav ity o f the t ibio fibu lar -

jo in t .

D is s e c t io n — D iv id th e p at e llar sy n v ial fo ld an d r m o v e
. e o e
t h e i frap at e llar p ad f f at
n Th n p an d am in e t h e b r a
o . e o en ex u s
b tw e n t h lig am e n t u m p at e lla an d t h e p r im al p art o f t h e
e e e e o x
t ibia N t disse t aw ay t h e in t rm diat e p art f t h e p o t rio r
. ex c e e o s e

p rt io n f t h e cap s l ( bliq
o o p p lit e al lig am e n t ) a d t ra
u e th o ue o n ce e
m iddl g e n i lar art ry w h ic h p i rc s it f rw ards t t h cru ciat
e cu e , e e ,
o o e e
lig am t s I t w ill n w be e n t h at the p o st ri r s rfa
en . o f s e e o u ce o
t h p o t ri r cru iat
e s e lig am n t is n o t co v r d by t h e sy n o v ial
o c e e e e
lay r an d t h at it i
e , n n e t e d by are lar t i u to t he d p
s co c o ss e ee
su rf a o f th ce p o t e ri r p art f t h e fi br s
e t ratu m o f t h
s o o o u s e
cap le su D fi t h e att c h m
. t o f t h ru iat lig am n ts by
e ne a en s e c c e e
r m o v in g t h
e yn v ial lay r w h i h co ve rs t h m at t h e S id an d
e s o e c e es
in f r t a d t h ar lar t iss e in
o n ,
n nn e t i n w it h t h m Th
eo u co ec o e . e
m i i als sh o ld r
e n sc ive t h att n t io n o f t h e dis ct o r a d t h
o u e ce e e se ,
n e
m an r i w h i h t h ir fi bro
ne n p i t d c t re m it i s ar fi e d t
e u s, o n e ex e e x o
t h t ibia m
e t b st di d At t h i st ag t h h a ge s p ro d ce d in
us e u e . s e e c n u
th d g r e f t e n sio
e f th
ee o r iat e lig am n t a d the n o ha g e c uc e s, n c n e

in t h p it i ef t h e m n i ci bro u gh t abo u t by m v m e n t
o s o n o e s o e s
o f t h e j o i t h o ld b am in d
n , s u e ex e .

M o ve m nt at t h e K n e J o in t
s Th m v m t f th k ee j i t .
— e o e en s o e ne e o n are
th o se o f fl i d xt
e x o n an i Th l g eb b t p t i ly
en s o n til th. e e c an e en o s er o r un e

p ro min e n c e O f th e c alf co m e s in to co n tact w ith the p o ste rio r asp e ct o f th e

x
t h igh ; bu t in e t e n sio n th e m o v e m e n t is bro u gh t t o a c lo se wh e n th e le g
co m e s in to a lin e w it h the t h igh I n th at p o sitio n the j o in t is fi rm y lo ck e d, . l
an d th e an te rio r cru ciate , th e t ibial an d th e fibu lar co l ate ral lig am e n t s, an d l
th e p o st e rio r p art o f th e c ap su le w ith th e o bliq u e po p lit e al ig am e n t l
be in g fu lly stre t ch e d, the le g an d th igh are co n v e rte d in to a rigid co lu m n
o f su pp o rt I n fl e x io n , h o w e v e r, the ig am e n ts m e n t io n e d are re a e d, an d
. l l x
a ce rt ain am o u n t o f ro tatio n o f th e t ibia u o n the fe m u r is allo w e d
p .

lx l
F e t he j o in t acu te y , an d e am in e the c arti ag e co e re d su rface o f x l -
v
th e distal e n d o f the fe mu r I t co n sist s o f an an te rio r t ro ch le ar p o rtio n
.
 THE I N F ER I OR EXTRE M I TY
l
fo r the p ate la , an d t w o co n dy lar su rface s wh ich m o v e o n the m e n isci an d
t ibia l
The t ro ch e a is se p arate d fro m th e su rface o f the late ra co n dy e by a
. l l
l
fain t y m ark e d g ro o v e , wh ich t ak e s a sligh t y cu rv e d co u rse , fro m the ate ral l l
bo rde r o f the dist al e n d o f th e fe m u r, m e dial y an d po ste rio rly to th e fo re l
p art o f th e in t e rco n dy lar fo ssa At e ach e t re m ity th is g ro o v e w ide n s o u t
. x
into a distin c t de pre ssio n I n fu l e te n sio n the late ra de p re ssio n re st s
. l x l
u po n th e an t e rio r p art o f th e lat e ra m e n iscu s, wh i st the m e dial de p re s l l
sio n re sts ag ain st th e an te rio r bo rde r o f the lat e ra tu be rc le o f the in t e r l
l
c o n dy o id e m in e n ce o f th e t ibia ( B ru ce Y o u n g ) The lin e o f de m arc atio n .

l
be t w e e n th e t ro ch e a an d th e dist al su rface o f th e m e dial co n dyle o f the
fe m u r is n o t so distin c t C lo se to the m e dial m arg in o f the bo n e th e re is a
.

P o p li lt e a art e r y

M . i
se m te nd n o su s i
M . se m ime mbr

~
F e mu r

M dd e i l g

ll ar bm sa

\ Su bcu t an e o u s i n fra
ll
p at e ar bu rsa

Pl i
an ta r s t e n do n Tu be ro s iy t o i i
f t b a

M .
po p li te u s
Tba ii
M . g as t ro c n e m i u s

FIG . 1 81 .
— S ag i tt l S t i
a ec o n o f th e K n e e jo in t .

l x
de p re ssio n wh ich , in fu l e t e n sio n , re sts u p o n p art o f the an te rio r h o rn o f
th e m e dial m e n iscu s ( B ru c e Y o u n g ) : bu t lat e ral to th is t he t ro ch le ar
l
su rfac e is p ro o n g e d p o st e rio rly fo r a c e rtain distan c e alo n g the an t e rio r
l
an d m e dia m arg in o f the in te rco n dy lar fo ssa A p o rtio n o f the m e dial .

l
c o n dy le is th u s in c u de d in th e t ro ch e ar su rface , v iz , th e p o rtio n sk irtin g l .

the m e dial bo rde r o f the an t e rio r p art o f the in te rco n dy lar fo ssa, an d th is
is t e rm e d the cre sce n tic face t o f th e m e dia co n dy le l .

The p o ste rio r su rfac e o f the p at e l a m ay n e t be e am in e d ( F ig an d l x x .

its m o v e m e n ts in co nn e c tio n w ith fl e x io n an d e te n sio n o f the k n e e j o in t x

stu die d A h igh v e rt ical ridg e div ide s the p o ste rio r su rface in to a arg e
. l
late ral an d a sm a le r m e dial are a l
Each o f th e se is still furth e r su bdiv ide d
.

by fain t ridg e s o n the c arti ag e wh ich co at s th e su rface l

A fain t lin e u po n .

l
the m e dial are a o f t he p at e la de sce n ds in a v e rtical dire ctio n so as to m ark
o ff a n arro w st rip clo se to the m e dial bo rde r o f t he bo n e Th is stri p i s .
 TH E I N F ER I OR EXTRE M I TY
p o p lite u s, sarto riu s, g racilis, se m it e n din o su s, an d se m im e m bran o su s Of .

l
t h e se , o n ly o n e is in se rte d o n th e late ra side o f th e lim b, v iz , th e bice p s . .

The o th e r fiv e are in se rte d in to the tibia o n the m e dial side o f the le g .

M e dial ro tatio n is p ro du ce d by the p o p lite u s, g rac ilis , sarto riu s, se m i

t e n din o su s, an d se m ime m bran o su s L ate ra ro tatio n by th e bice p s fe m o ris
. l .

D is s e c t io n — I n o rde r t o o b ain a p ro p e
. ie t
o f t h e a t ac h rv w t
t t t
m e n s o f t h e cru cia e lig am e n s t h e f o llo w in g disse c io n m u s t t
be m ade — Th e f e m u r m u s be s aw n a c ro ss abo u tw o in c h e st t
p ro x im al t o its dis al a rt icu lar su rf ace t W h e n h a h as be e n . t t
t t
do n e div ide t h e dis al p ar o f t h e bo n e by a e r ic al, an e ro v t t
t
p o s e rio r s aw cu t , w
h ic h sh o u ld e n d dis ally in t h e in e rco n dy lar
-
t t
f o ssa be tw
e e n t h e co n dy le s an d be e e n t h e p ro x im al a ac h tw tt
t
m e n s o f t h e tw o c ru c ia e lig am e n s t
Af e r h is p ro ce du re t h e t . t t
t t t
c ru c ia e lig a m e n s c an be s u die d sin g ly , o r o g e h e r, an d h e ir t t t
t t
re la io n t o t h e c o lla e ral lig am e n s o f t h e j o in t
c an be e x am in e d t .

It w t t
ill be se e n h a t h e fi bu lar co lla e ral lig am e n an d t h e an e rio r t t t
t
c ru c ia e lig am e n t tt t
co n s i u e a p a ir o f lig am e n s w h ic h are fi x e d t
t
t o O p p o si e side s o f t h e la e ral co n dy le t
Th e ibial c o lla e al . t t r
t t
an d t h e p o s e rio r c ru cia e lig am e n s be lo n g t o t h e m e dial co n dy le t
tt
o f t h e f e m u r, an d are a ac h e d t o it s m e dial an d la e ral su rfa ce s, t
re sp e c i e ly tv t t t
W h e n h a re la io n sh ip h as be e n n o e d, t h e ibial
. t t
t
c o lla e ral lig am e n t v
m ay be di ide d t o f re e t h e m e dial co n dy le ,
v t
an d g i e g re a e r sp ace f o r t h e s u dy o f t h e cru c ia e lig am e n s t t t .

L iga me nt a Cru ciat a Ge n u ( O T Cru cia l Ligame nt s) — Th e . . .

cruc iat e liga me n t s are w e ll n a me d, be cau se th e y cro ss e ach

oth e r like t he limbs o f the le tt e r X in the in t e rva l be twe e n
, ,

t he two co n dy le s o f t he fe m ur Th is cruc iat e arra n g e me n t

.

is se e n wh e th e r th e y are v ie w e d fr o m t he sid e by t he r e m o va l ,

o f t he d ista l p art o f o n e c o n dy le or fro m the fr o n t o r the ,

back o f th e j o in t The a n t e r ior cruc iat e liga m e n t is attach e d

.

to th e t ibia in fro n t o f t h e in t e rco n dy lar e m in e n c e an d to

t h e m e d ia l sur fac e o f t he lat e ra l co n dy le o f t h e fe m ur wh ilst ,

t he p o st e r ior is fi x e d to th e t ibia be h in d t h e in t e rco n dy lar

e min e n c e an d to t h e lat e ra l sur fac e o f t h e m e d ia l co n dy le o f

th e fe m ur .

Th e anteri o r cru ciate liga ment sp r in g s fr o m t h e in t e r m e d iat e

rough ar e a o n the p ro x ima l sur fac e o f t h e t ibia in t he ,

a n t e r ior in t e rco n dy lar fo ssa o f t he t ibia im me d iat e ly a n t e r ior ,

to th e m e d ia l tu be rc le wh ich sur m ou n t s the in t erco n dy lar

e m in e n c e Th e n c e it p roc e e d s u p ward s backward s an d
.
, ,

lat e ra lly to ga in attach m e n t t o t h e p o st e r io r p art o f t h e

,

m e d ia l sur fac e o f t h e lat e ra l co n dy le o f t h e fe m ur ( F ig .

Th e po sterio r cru ciate liga men t sp r in g s fro m t h e p o st e r io r

in t e rco n dy lar fo ssa o f t h e t ibia p o st e r ior to t h e in t e r
co n dy lo id e min e n c e an d p o st e rio r a lso to the attach me n t s
,

o f t h e p o st e r io r hor n s o f both m e n isc i I t p a sse s u p ward s .

,
 P L ATE XXXV I

P at e ll a

Tba i i

Fib l u a

FI G . 1 82 . R
— a dio h o f t he K n e e
grap o f an adu lt .

( M ajo r T R anki ne )
. .
 P L ATE XXXV I I
F e mu r

P a te ll a

Tba ii

Fi b l
u a

FI G . 1 83 —
. R di g
a o rap h o f th e K ne e o f an adu l t in e xt i
e ns o n .

( P ro f . Al e xi s Th o m so n ).

N o te th e l i
re at o n s o f th e fe m u r t o t h e p a te ll a an d t o th e t i bi a .
 P L ATE XXX I X
F e mu r P at e ll a

Med a il co n
yl
d e o f fe mu r

Fib l
u a

T baii

FIG . 1 85 .
-
R ad i g
o h o f a fu lly fl e x e d K n e e
rap .

( M r . H u gh M M art i n )
. .

N o t e t he l i
re at o n s o f t he fe m u r to th e p ate ll a an d t h e t ib a i .
 K N EE J O I N T
fo r ward s, o me what me d ia lly an d cr o ssin g th e a n t e r io r
an d s , ,

cruc iat e liga me n t o bliqu e ly is attach e d to t he a n t e r io r ,

p ort i o n o f t he lat e ra l s urfac e o f t h e m e d ia l c o n dy le I t .

r e c e ive s o n e o r so me t ime s t wo str o n g slip s fro m the p o ste rior

, ,

hor n o f t he lat e ra l m e n iscu s ( F ig .

The a n t e r io r cruc iat e liga m e n t is t ight in ex ten sio n an d ,

Te n d n o f i i
n se rt o n P li l
te a s u rfa c e o f fe m u r
pt
o p
o f ad ne o t ma

‘
An te r o i r c ru c a t e i li g a me n t

Te ndo n o f po p li te u s
m u sc l e ( c u t)

il
M e d a me n i sc u s

L a t e ra me n l i sc u s

P i
o s t e r o r c ru c a t e i G v
li g a me n t
ro o bi a fo r t e n
e o n ti

do n o f p o p t e u s m u sc e li l
l
xi l
C ap su e o f p ro m a
ii i l i
t b o fi bu lar a rt cu a t o n
-

Fi b l ll l
u a r co a t e ra
li g ma ent

P i i bi fib l
o st e r o r t o -
u ar
lg m
i a e nt

H d f fib l
ea o u a

bran o s us l ( )
mu sc e cu t

Ti bi l a ll l co a t e ra
li g m a e nt

P p li l
o te a
f bi o ti a

FIG . 1 86 .
—
' ‘

I he K n e j o i n t O p e n e d fro m
e be h i n d by t h e re m o va l o f t he
P o ste ri o r p art o f the C ap su l e .

th e p o s e t rio r cr u c iat e liga me n t is t ight in fl ex io n o f th e k nee

jo in t .

M enisc i ( OT Semiluna r Cart ilages) — Th e m e n isc i are two

. . .

cre sc e n t ic p lat e s o f fibro cart ilage wh ich are p lac e d o n the -

co n dy lar surfac e s o f the t ibia Th e y d e e p e n the surfac e s u p o n .

wh ich the co n dy le s o f the fe m ur ro ll an d be in g m ova ble th e y , , ,

fill u p t h e g ap s wh ich wou ld oth e rw ise ar ise dur in g th e mo v e

 TH E I N F ER I O R EXTRE M I TY
me n t s o f t he j o in t . Each me n iscu s p r e se n t s t wo fi bro u s
e x tr e m it ie s, o r h o r n s, wh ich are attach e d t o t h e rough in t e r

me d iat e sur fac e o n the p ro x im al e n d o f th e t ibia Th e y are .

th ick toward s the c ircu mfe r e n c e o f the j o int, bu t th in away to a

fin e fr e e c o n cav e e dg e in th e o p p o sit e d ir e ct io n B o th sur fac e s
.

are sm ooth an d cov e r e d w ith th e sy n ov ia l lay e r Th e y do n o t

.

cov e r the e n t ire e x t e n t o f th e c o n dy lar sur fac e s o f th e t ibia .

The c e n tra l p art s o f t he latt e r , as w e ll as the Slo p in g sur fac e s

o f t he tu be rc le s o f t h e in t e rco n dy lo id e m in e n c e , are fr e e .

Wh e n t he cart ilag e s are ra ise d fro m t he sur fac e u p o n wh ich

th e y r e st , d ist in ct imp re ssio n s, similar in Sha p e an d e xt e n t ,
are se e n o n t h e s u bjac e n t e n cru st in g cart ilag e o f t h e t ibia .

D is s e c ti o n — Care f u lly de fi n e t h e tta h m e t

a c n s o f th e fi bro u s
h o rn s o f th e m e n isci.

Th e lat e ra l m e n iscu s is u sua lly so me what th ick e r arou n d

its c ircu m fe r e n c e tha n t he m e d ia l m e n iscu s I t for m s t h e
.

se g me n t o f a sm a lle r c irc le , an d it s hor n s be in g fi x e d to t h e

t ibia clo se tog e th e r, a v e ry n e ar ly co mp le t e c irc le is for m e d .

Th e a n t e r ior fi brou s hor n is attach e d , im me d iat e ly in fro n t o f

th e in t e rco n dy lar e m in e n c e , to t h e lat e ra l Sid e o f an d p art ly
u n d e r cov e r o f t he attach me n t o f the a n t e rior cruc iat e liga m e n t .

Th e p o st e r io r hor n is fi x e d to t he su m mit o f th e in t e r
co n dylar e m in e n c e in the in t e rva l be tw e e n the two tu be rc le s .

I t g iv e s a str o n g Slip a lso to th e p o st e r io r cruc iat e liga me n t .

Th e fibu lar c o llat e ra l liga me n t is se p arat e d fro m the lat e ra l

m e n iscu s by t he lat e ra l p art o f th e art icu lar ca p su le an d a lso
by th e t e n d o n o f th e p o plite u s wh ich lie s in sid e th e fi brou s
\

stratu m o f t h e lat e ra l p art o f t h e ca p su le Th e t e n do n o f

.

t h e p o p lit e u s groov e s th e p o st e r ior p art o f th e lat e ra l bord e r

o f t he lat e ra l m e n iscu s, bu t be h in d an d in fro n t o f t h e groov e

t h e p e r ip h e ra l marg in o f t h e lat e ra l m e n iscu s is ble n d e d w ith

t h e in t e r n a l sur fac e o f t h e fi brou s stratu m o f th e art icu lar
ca p su le .

The m e d ia l m e n iscu s is se mic ircu lar in out lin e , an d for ms

th e se g me n t o f a m uch large r c irc le tha n t h e lat e ra l m e n iscu s .

I ts a n t e r io r fi brou s hor n is fi x e d to t he a n t e r io r p art o f th e

a n t e r ior in t e rco n dy lar fo ssa O f the t ibia , in fro n t o f the attach
me n t o f th e a n t e r ior cruc iat e liga me n t ; it s p o st e r ior h o r n is
attach e d in the p o st e r ior in t e rco n dylar fo ssa o f t he t ibia,
be h in d the in t e rco n dylar e min e n c e an d in fr o n t o f th e
attach me n t o f the p o st e rior cruc iat e liga me n t The gr e at e r .
 P L ATE XLI

F e mu r

P l
at e l a

i i
Tba Fib l u a

FIG . 1 88 .
— R di
a o grap h o f the p art ly fl x
e ed K nee o f a c h il d .

N o t e th e re al ti o ns o f th e fe mu r t o th e p ate ll a an d th e t i bi a .
 P L ATE X L I I
F e m ur Ep p h i y l li
se a ne o i l
f d sta e nd o f fe mu r

Fib l
u a

Tba ii

F IG . 1 89 .
-
R di g p h f th K
a o ra o e ne e o f a c h il d
.

O ssific at io n o f the p a t ll
e d th p xi m l
a an e ro a e nd o f th e fibu l a h as no t

ye t co mm e n ce d .
 P L ATE XL I I I
F e mu r

Fi b l
u a

Tba ii P roxi m l p i phy l li

a e se a ne o f t i bi a

FI G . 1 90 .
— R di
a o gra p h o f the K ne e o f a c hi l d .

O ssifi c at io n o f th e p a t e ll a h as co m me n ce d .
 TH E I N F E RI O R EXTRE M I TY
me n iscu s th e se are p lac e d sid e by sid e bu t t he attach m e n t
° '

o f t he liga me n t wh ich lie s t o the m e d ial sid e o v e rla p s that

, ,

o f t h e lat e ra l m e n iscu s T o st e r ior hor n o f t he lat e ra l

( )
4 h e p .

me n iscu s o n t h e su mmit o f the in t e rco n dy lar e m in e n c e

,

be tw e e n it s two tu be rc le s ( 5 ) T h e p o st e r io r hor n o f.t h e

m e d ia l me n iscu s im m e d iat e ly be h in d t he in t e rco n dy lar

,

e m in e n c e o st e r ior cruc at ga nt at
( )
6 T h e.
p i e li m e t h e ,

p o st e r ior p art o f t h e ar e a .

AR TI C U L ATI O T A L O C R U R AL I S ( AN K L E jo i N T) .

The a n k le j o in t is a d ia rthrod ia l art icu latio n o f th e

g in gly m u s o r h in g e var ie ty The art icu lat io n tak e s plac e
.

An t e r o i r ta o l fib l
-
u ar A i li g m f l l m ll l n te r o r a e nt o a t e ra a eo us
lg m
i a ent (O T A i i f i i bi fib l l g m )
. . nter o r n e r o r t o -
u a r- i a e nt

Fi b l u ar fac e t

D l i d li g
e to a me n t

l ll l
L a t e ra ma eo us

Ca l c an e o -
fib

P o s te r o ri l
'

l a t e ra l m ll l a eo us
M di al mall
e eo l us

P i l fib l
o st e r o r t a o -
u ar
lg m i a e nt
Di l li g m f sta a e nt o S y vi l p
no a ad
h l l m ll l
t e a t e ra a eo us o f fat

FIG . 1 92 .
— A ti l S f
r cu ar f Ti b i
u r ac e s o a an d Fb i u la wh i ch i l
art c u ate

w i th t h T l e a us .

be tw e e n th e bo n e s o f the le g an d the ta lu s, an d the w e ight o f

th e body is tra n sfe rr e d through it t o t h e foot I t is a jo in t .

o f gr e at str e n gth its sta bility be in g e n sur e d n o t o n ly by th e

p ow e r fu l liga m e n t s wh ich surrou n d it, bu t a lso by t h e c lo se

in t e rlo ck in g o f t h e art icu lat in g sur fac e s .

The bo n e s wh ich e n t e r in to the for m at io n o f the a n k le

jo in t are the d ista l e n d s o f the t ibia an d fi bu la an d the
p ro x im a l, m e d ia l, an d lat e ra l sur fac e s o f t h e ta lu s T h e d ista l .

e n d s o f th e le g bo n e s are v e ry fir m ly u n it e d t o g e th e r by in t e r

o sse ou s an d o th e r liga m e n t s wh ich g iv e t he j o in t a c e rta in

a m ou n t o f el sa t ic ity o r sp r in g . Th e y for m a d e e p h o llo w

 AN K L E JO I N T
re se mblin g a m o rt ic e an d th e u pp e r p art o f the t alu s is
re c e ive d in t o the cav ity .

D is s e c t i o n — R e m o e th e re m ains o f t h e la c in ia e an d r an s v t t
v t
e rse lig am e n s an d cu t t h ro u gh an d disp lace t h e e n do n s h ic h t w
t
are in re la io n w i h t h e j o in , bu t do n o t re m o e t
h e m Th e n t v t .

i
I I b o fi bu la r -
i n t e ro s se o u s

m e m bra n e

Di l st a e nd o f S ha ft o f t bi i a Di l sta e nd o f sha f t o f fibu l a

G ro o v e o n me d a il P i li m f l l
o ste r o r e nt o a t e ra
ma ll l
eo us fo r t e n do n o f m ll la ( T P i
a
o st e r o r
l
t i bi a i s p o s t e rio r n er o r t
eo us

i f i i bi fib l li g m ) o
.

-
.

u ar a ent
’

Tro c hl f Di l li g m f h
st a a e nt o t e
e a r su r a ce

o f ta u s l l l m ll l
a t e ra a eo us

F l f di l
ac e t o n t a u s o r s ta

f i i bi fib l t
D l i d li g !
in e r o r o u ar
-

e to am e n t lg m
i a ent

P i l fib l
o st er o r t a o -
u ar

li g m a e nt

Fi bro u s sh

, Ca l c a ne o -
fibu lar li g am e n t

Fl x
e o r ha ll i l g
uc s o n us t e n do n

P o st e r o r t a oi l -
l
c a c a ne a n
lg i a me n t

P i
o s t e r o r s u rfa c e o f l
c a c a ne u s

FIG . 1 93 .
— Ank l e j o i nt i
d sse c te d fro m be h i nd , m t h p a rt o f t he Art i l c u ar

C ap su l e re m o ve d .

e n de a vo ur to t ra ri i
ce o u t th e an as o t m o se s be tw e e n t h e art e es n
t h e n e igh bo u rh o d f t h j in t a d if p o ibl e c re t h e tw ig
o o e o ,
n ss e s u s
f r m t h e t ibial an d de e p p ro n al n e r es w h i h u pp ly th e j in t
o e e v c s o .

Th e Art e ria l A na st o mo sis a ro un d t h e Ank le J o in t — Th e .

art e r ie s wh ich a n a st o m o se aro u n d t he a n kle j o in t are : 1 )

t he m a lle o lar bra n ch e s o f t h e a n t e r io r t ibia l art e ry , ( 2 ) the
e r fo rat in g bra n ch o f t h e p e r o n e a l art e i y, ( 3 ) t h e t e r m in a l
p
p art o f t h e p e r o n e a l art e ry All t h e v e sse ls are v e ry var ia ble .
 TH E I N F ER I OR EXTRE M I TY
in siz e , an d t he m a lle o lar bra n ch e s o a n t e r io r t ibi a l
f th e
art e ry are fr e qu e n t ly no inj e ct e d in
t ord in ary su bj e ct s .

Th e L iga me n t s o f t h e A nk le J o in t are
°

r C ap su la art ic u aris l .

e L ig am e n tu m de lto ide u m .

v Li g a m e n t u m t alo fibu lare an te riu s .

a L ig a m e n t u m t alo fibu lare p o ste riu s .

w L i g am e n t u m c a can e o fi bu lare l .

D is e c t
s i o n — Af t
t h e art e rial an as o m o ses aro u n d t h e an k le
er t
j o in t h ave be e n s tu die d p u ll as ide t h e e m ai n s o f t h e art e rie s an d r
Tba ii
Fi b l u a

P o i li g
s te r o r ame n t o f An t e r o r i li g
ame n t o fl m ll l l a t e ra a eo us

l a t e ra lm alle o l . . i i i i bi fib l li g
( O T A n t e r o r n fe r o rt o -
u ar am e n t )
P o st
A rt i l f f l
c u a r s u r ac e o ta us
A rt i c u l a r su rface
A i l fib l
n t e r o r ta o -
u ar

l li g m u ar a e nt

D l o rsavi l c une o -
na c u ar
b v i l lig
cu o na cu a r am e i
S d if m
e co n c u ne o r

i
Th rd c u n e fo rm i

C u bo d i

o -
c u bo i d li g am e n t
l
C a ca n e o cu bo d o n t - i ji
Te n do n o f p e ro naeu s o n u s l g
Ca l c a ne o -
n av i l
c u a r p a rt o f b f u rc a t e i
ame n t li g
lo -
l
c a c a ne an j i
o nt

La t e ra l l ta o -
l
ca c ane a n li g a me n t

FIG . 1 94 .
— L ig am e n t s o n t h e l
L at e ra Asp e c t o f t he An k l e Jo i n t an d o n
t he D o rsu m o f t h e Tarsu s .

n e r e s, v an d c le an c are f u ll y f t h e an t e rio r an d po t
s e rio r p art s o
t
t h e c ap su le , bo h o f wh ic h are e x re m e ly h in a n d e asily in j u re d t t .

tt
W h e n t h e a ac h m e n t s an d re la io n s o f t h e an e rio r an d p o s e rio r t t t
t v
p ar s o f t h e c ap su le h a e be e n de m o n s ra e d re m o e bo h p art s t t v t
in o rde r t o brin g t h e m e dial an d la e ral a c ce sso ry lig am e n s m o re t t
f u lly in o re lie f t .

Cap sula A r t icula ris — The a n t e r io r an d p o st e r io r p art s o f

. .

t h e fi brou s stratu m o f t h e art icu lar ca p su le are v e ry th in .

M e d ia lly th e fi br o u s stratu m ble n d s w ith th e d e e p sur fac e o f

 TH E I N F E RI O R EXTRE M I TY
Th e major ity fi br e s o f both the an t e r ior an d p o st e r io r
o f t he

p art s o f t h e fi brou s stratu m o f the ca p su le ru n tra n sv e r se ly .

Th e L at era l Ac ce sso ry B an ds ( O T Ex t e rn al L a t era l . .

Liga me nt ) —Th e lat e ra l acc e ss ory ba n d s o f t h e ca su le o f

.
p
t h e a n k le j o in t are thr e e in n u mbe r ( )
i T h e ant e rio r t a lo .

fi bular liga me nt ; ( 2 ) t h e p o st e ri o r t alo fibular ligame nt ; -

3) t h e c a lcan e o fibular liga me n t -

.

The anterio r ta/afi éu lar fil m n t is t h e m o st a n t e rior o f

a e

th e thr e e I t is a flatt e n e d ba n d wh ich p a sse s forward s frbm

.

t h e a n t e r io r bord e r o f th e lat e ra l m a lle o lu s to t h e body o f

t he ta lu s imme d iat e ly adjac e n t to t h e fibu lar fac e t .

Th e p erferz o r lalo jzézzlar 112 2227726 121 is th e stro n g e st an d t he

' ’

m o st p o st e r ior o f t h e thr e e ba n d s I t ru n s a lmo st hor iz o n .

ta lly fr o m the d e e p p it p o st e rior to the d ista l art icu lar sur fac e
,

o f th e fi bu la to a p ro m in e n t tu be rc le o n t h e p o st e r ior sur fac e

o f th e ta lu s .

Th is t u be rc le is te rme d t h e po ste rio r p ro ce ss

f the talus G e n e rally o

in t h e c h l
i d, an d so me tim e s in the adu lt , it is a se arate
p p ie c e o f bo n e ,
att ach e d t o th e t alu s by a lay e r o f c artilag e an d the su rro u n din g
e rio st e u m I n su ch c ase s it fo rm s a su p e rn u m e rary tarsal bo n e wh ic h
p .

go m mz fo u n d in so m e m am m als
re p re se n t s th e o r f rzl I f th is fact is n o t .

t
k e p t in min d a fractu re o f the alu s m ay be diag n o se d wh e n the se parate
bo n e is se e n in a radio g rap h o f an inj u re d ankle ( F ig s 2 0 0 , .

Th e ea/ea zzeo fi éu / ar liga men t is a rou n d , cord lik e ba n d

- -

wh ich p a sse s fro m the d ista l e n d o f the lat e ra l ma lle o lu s to the

lat e ra l sur fac e o f th e ca lca n e u s .

Ligame nt um D elt o ideum ( O T I n t e rn al Lat e ral . .

Th e d e lt o id liga me n t is an acc e ssory ba n d o n th e m e d ia l

side o f th e j o in t tr o n g an d o f tr ia n gu lar for m I ts
. I t is s .

a pe x is attach e d
to a sha llow p it o n the d ista l e n d o f th e
me d ia l m a lle o lu s I ts fi br e s d iv e rg e fr o m th e a p e x an d are
.
,

att ach e d in a co n t in uou s lin e fro m be for e backward s to the , ,

n av icu lar bo n e th e ta lu s su st e n tacu lu m ta li o f t h e ca lca n e u s

, , ,

an d p o st e r ior to that t o th e ta lu s aga in .

St rat um Sy n o v iale — The sy n ov ia l lay e r lin e s the in t e r n a l

.

sur fac e o f th e fi brou s stratu m o f the ca p su le d e scr ibe d abov e ,

an d in so m e ca se s it se n d s a sma ll p roc e ss p ro xima lly

be tw e e n the t ibia an d fi bu la I t is throw n in t o a tra n sv e r se
.

fo ld a n t e r io rly wh e n t h e j o in t is fl e x e d an d in to a sim ilar ,

fo ld p o st e r ior ly wh e n t h e jo in t is e x t e n d e d .

R e lat io n s B e fo r e th e furth e r e x a m in at io n o f th e jo in t
—

is p r o c e e d e d w ith r e p lac e th e t e n do n s v e sse ls an d n e rv e s

, , ,
 AN K L E
'
JO N
’
I I 423

an d ot e th e ir r e lat io n s to the a n t e r ior an d p o st e r ior

n

p art s o f t h e art icu lar ca su le

p A n t e r io r ly fro m th e m e d ial
.
,

t o t h e late ral side lie t h e t ibia lis a n t e r io r th e fle x or ha lluc is

‘

lo n gu s th e
,
a n t e rior
t ibia l art e ry the d e e p ,

p e ro n e a l n e rv e an d t h e ,

e x t e n so r d ig it o r u m
lo n gu s w ith t h e p e ro
na eus t e r t iu s T h e .

a n a st o mo t ic bra n ch o f
the p e r o n e a l a r t e r y
d e sc e n d s a c ro s s t h e
a n t e rior ta lo fibu lar lig a -

m e n t la t e r a l t o t h e
s t e rt iu s
p e ro n a e u
( g
F i .

B e h in d the
j o in t fro m t h e m e d ia l
,

t o the lat e ra l sid e th e ,

stru c tur e s in c lo se r e la
t io n w ith t he ca p su le
are t h e t ibia lis p o st e r io r
, ,

the fl e xo r d ig itoru m
lo n gu s the
, p o s t e r io r
t ibia l art e ry the t ibia l FIG 9 6 F t l S t i th gh th A k l
, . 1 .
— ro n a ec o n ro u e n e

n e r ve t h e fl e x o r ha lluc is
, j i t t h T bi Fi b l o Sy d m i
n , e d i o -
u ar n es o s s, an

lo n gu s an d th e t e r m in a l th T l C l l j ei t Th
a o d lt id
-
a c an e a o n s . e e o
,
li g m t th m di la id en d th o n e e a s e, an e

p art o f t h e r a ,

p e o n e l p t i t l fib l d th
o s er o r l a o -
u ar an e c a c an e o

art e ry M or e p o st e rio rly

. fib l li g m t ,
thu ar l t l id a e n s, o n e a e ra s e, are

h w i th ti Th g i
se p arat e d fro m t h e fl e x o r
s o n t n t e se c o n . e s ro n n er

t l l o sse o u sli g m t i a o -
c a c a n e an a en s se e n
ha lluc is lo n gu s by a f m i g th l t l b d y f th j i t
o r n e a e ra o un ar o e o n

larg e p ad o f fat is t h e b tw,

th h d f th t l
e een d th e ea o e a us an e

t e n d o ca lca n e u s w ith t t l m t li Th p i t i
su s e n acu u f th a . e o s o ns o e

di t l p i phy l li s a f th t i bi
e d se a nes o e a an
the t e n d o n o f the fib l h ld b b v d u a s o u e o se r e .

p la n tar i s o n its m e d ia l L i gh t bl ti l t il g ue ar cu ar c ar a e .

sid e . Th e t e n d o n s o f S t i p d bl li g m t r e ue a en s .

th e t ibia lis p o st e r io r G p i t m re e n er o s e u .

R d y vi l m mb e s no a e ran e
an d th e fl e x o r d ig i
.

toru m lo n gu s lie aga in st th e su p e rfic ia l sur fac e o f th e d e lt o id

liga me n t an d t h e t e n d o n s o f t h e p e ro n ae u s lo n gu s an d br e v is
cr o ss th e lat e ra l sur fac e o f t he ca lca n e o fi bular liga me n t -
.

D is s e c ti o n — C t t h r gh t h an t ri r t alo fi b lar lig am n t

. u o u e e o - u e ,

th cal an e fi b lar lig am e n t an d t h e g re at r p art f t h d lt o id

c eo - u ,
e o e e

1— 27 a
 THE I N F ER I OR E XTRE M I TY

lig am e n , t so t h at t h e art icu lar s urface s c an be t

se p ara e d an d
e x am in e d .

Th e A rt icular Surf ac e s o f t h e Ank le J o int Th e p ro x im a l

— .

art icu lar ar e a is for me d by th e d ista l sur fac e o f th e t ibia, the

lat e ra l sur fac e o f t h e m e d ia l m a lle o lu s, an d th e m e d ia l sur fac e
o f t h e lat e ra l m a lle o lu s Th e thr e e sur fac e s t o g e th e r fo r m.

t h e bo u n dar ie s o f a so ck e t I t is imp orta n t to n ot e that t h e .

so ck e t is w id e r in fr o n t tha n it is be h in d , an d that it is

co n cav e both fro m sid e to sid e an d fr o m be fo r e backward s .

Th e d is ta l art icu lar ar e a is fo r me d by t he d o r sa l sur fac e o f

t he body o f t he ta lu s an d by p art s o f it s m e d ia l an d lat e ra l
sur fac e s I t a lso is broad e r in fr o n t t h a n be h in d
. I t is .

g e n e ra lly c o n v e x bo th fr o m be fore backward s an d fro m sid e

to sid e , an d it fits in t o t he sock e t for me d by the bo n e s o f
t h e le g Wh e n the j o in t is d o r si fl e x e d, that is, wh e n the to e s
.
-

are tur n e d u p ward s, the br o ad p art o f t h e d ista l art icu lar

ar e a r o tat e s backward s in t o t h e n arr o w p art o f th e p ro x im a l

art icu lar ar e a an d the j o in t be c o me s lock e d W h e n th e jo in t .

is p la n tar fl e x e d, that is, wh e n th e t o e s are tur n e d dow n ward s,

-

t h e n arro w p art o f th e d ista l art icu lar ar e a m ov e s forward s

in to t he w id e p art o f t he p ro x ima l art icu lar ar e a an d a sm a ll
a mo u n t o f sid e to sid e mo v e me n t be c o me s p o ssible .

M o ve ment s — The m o v e m e n t s wh ich tk a e p l ac e at th e an k le j o in t are

—
( ) I do rsa( l -
fl e x io n so me tim e s ca ll d
fl e x io n ) ; ( 2 ) plan tar fl e x io n ( so m e e -

l
t im e s ca le d e t e n sio n ) x
an d ( 3 ) a v e ry lim it e d de g re e o f lat e ral m o v e m e n t
wh e n p lan tar fie x io n is co m p le te The t wo prin cipal m o v e m e n ts ( do rsi
-
.

l
fi e x io n an d p an tar fl e x io n ) t ak e place aro u n d a h o ri o n tal a is, wh ic h is
-
z x
n o t t ran sv e rse , bu t wh ic h is dire c te d lat e rally an d o st rio rly s t h at it
p e , o

is in clin e d to the m e dian plan e o f the bo dy at an ang le o f abo u t 60

°

( K rause ) z x
Th is h o ri o n tal a is passe s th ro u gh o r n e ar the inte ro sse o u s
.

can al be t w e e n t he c alcan e u s an d talu s ( H e n e ) As the articu lar c av ity l .

fo rm e d by the tibia an d fibu la, an d a so the p art o f the talu s which l

p lay s in it , are bro ade r in fro n t th an be h in d, it fo llo w s th at the
l
mo re co mp e te ly the an k le j o in t is do rsi fle e d, th e m o re tigh tly w ill the -
x
t alu s be g rasp e d be t w e e n t h e t wo m alle o li I n the e re c t p o sitio n the talus .

is h e ld fi rm ly in the bo n y so ck e t , an d p o rtio n s o f its articu lar su rface pro j e ct

bo th in fro n t o f an d be h in d th e tibia The lin e o f the c e n tre o f g rav ity .

falls an te rio r to the an k le j o in t , an d as a re su lt th e bo n e s are k e p t firm ly

lo ck e d W h e n , o n t he o t h e r h an d, the an k le j o in t is fu y plan tar fl e x e d
. ll o

( as wh e n we rise o n tip to e ) th e n arro w e r p o st e rio r p art o f the t alu s is

-

bro u gh t in to th e so ck e t , an d th u s a limite d am o u n t o f late ral m o v e m e n t is

ll
a o we d I n do rsz fi ex z o n the calcan e o fibu lar an d po ste rio r talo fibu lar
.
' '

- -

ban ds, th e g re ate r p art o f th e de lto id lig am e n t , an d the p o st e rio r p art o f

l
th e c apsu e are p u t o n th e st re tch I n p lan ta rfl ex io n th e an te rio r t a o .
-
l
l
fibu lar ig am e n t, the an te rio r fibre s o f the de lto id li g am e n t , an d the an te rio r
part o f the cap su le are re n de re d t e n se .

The M u scle s p rin cip ally co n ce rn e d in p ro ducin g do rsi fi e x io n o f the -

 TH E I N F E R I O R E X TRE M I TY
o f t hefi bula Th e p o st e rior ba n d is the w e ak e r o f th e two
.

,
an d th e t e n do n o f th e
p o p lit e u s w ith itS sy n o vial in v e st m e n t
'

re st s u p o n its p ro xim al p art The in v e st m e n t is a p ro lo n ga .

t io n fro m t he sy n ovia l lay e r o f th e k n e e jo in t an d in so m e ,

ca se s it w ill be fou n d to be d ir e ct ly co n t in uou s w ith the

sy n ov ia l lay e r o f t h e ca su le o f the t ibio fibu lar j o in t
p -
.

Th e fi bu lar c o llat e ra l liga m e n t o f the k n e e jo in t an d th e

t e n do n o f the bic e p s fe m oris mu scle hav e imp orta n t r e lat io n s

E x t e n so r h allu c s i lo n

A i
n t e r o r li gam e n t o f an k le jo i nt

F i rst cu

B u rsa m uc o sa

F i rst me tatarsal

E x t e nso r h allu c s ib i re v s

FI G . 1 97 .
— Ob que li sa g i ttal se c t i o n thro u gh th e F o o t al o n g a p l ane e x te n di n g ,

fro m t h e ce n tre o f t h e h e e l be h i n d t o t he c e n t re o f th e gre at t o e in

fro n t .

1 . Fl x ll i l g
e o r ha uc s o n u s. 7 . i i li p i
Tba d s o st e r o r te n o n.

2. Pl ym
a n ta r acc e sso r e t at a rso -
p ha l ~
8 . Fl x di g i m l g
e o r d t o ru o n us te n o n .

g l li g m
an ea a e n t. 9 Pl l
an t a r i l li g c a c an e o n av cu ar a
-
.

3 . S m id b
e sa o o ne . me nt .

4 . Fl x h ll i b vi
e o r a uc s re s . 10 . M . q u adra t u s p la n t aa .

5 . Pl an t ar a
p i o n e u ro s s. 1 1 . L at e ra p l l a n ta r v l
e sse s a n d n e r e . v
6 . M fl . di g i m b vi
exo r t o ru re s. 1 2. Ca l can e u s.

to th e jo int B oth are attach e d to the h e ad o f th e fi bu la

.
,

lat e ra l t o th e j o in t an d so me o f t he t e n d in ou s fi bre s o f t h e
,

bic e p s e x t e n d forward s t o th e lat e ral c o n dy le o f th e t ibia .

Add it io n a l su pp o rt is thu s a fford e d to th e p ro x ima l t ibio

fibu lar jo in t .

Sy n desmo sis Tibio fibularis ( O T I n fe ri o r Tibio fibular . .

-

J o in t ) ( F ig s 1 9 3 an d — The d ista l t ibio fi bu lar art icu la

.
-

t io n is co n struct e d u p o n a stro n g e r p la n tha n t h e p ro x im a l ,

be cau se th e str e ngt h o f t h e a n kle j o in t v e ry larg e ly d e p e n d s

u p o n it s se cur ity I n so me cases a v e ry n arrow str ip o f the
.
 TI B lO F I B U L AR -
J OI NTS 4 2 7

d ista l p art o f e ach o f th e O pp o sin g surfac e s o f th e bo n e s is

art icular an d coat e d w ith cart ilag e co n t in u o u s w ith the
cart ilag e o n th e d ista l e n d s o f the t ibia an d fi bu la wh e r e th e y
tak e p art in the fo r m at io n o f the a n kle jo in t ; in o tlzer eases
a r/ieu lar cartilage is en tirel y aé sen z T h e sur fac e s o f t h e
‘
.

p ro x ima l
p art O f t h e sy n d e sm o sis a re a lway s roug h an d are ,

h e ld t o g e th e r by an e x c e e d in gly stro n g in lero sseo ns ligament

I n add it io n to t h e imp orta n t in t e ro sse o u s liga m e n t thr e e
'

o th e r liga m e n t s are p re se n t

1 . . ll l l
L ig m a e o i late ra is an te riu s ( O T An t in f tibio fibu la r lig am e n t )
. . . .
-
.

2 . . l l
L ig m a le o i ate ralis po ste riu s ( O T o st in f tibio fibu lar ig am e n t )
. . P . .
-
l .

3 . D istal lig am e n t o f the ate ral m a le o lu sl l .

The an teriar an d p o slerio r ligamen ts are flat stro n g ba n d s “

wh ich p a ss fro m the t ibia to t he fi bu la , in an O bliqu e dire c

t io n lat e ra lly an d d ista lly
,
.

The d ista l p art O f t h e p o st e r ior liga me n t fo r m s a stro n g

n arr o w ba n d o f y e llow ish fi br e s, wh ich tak e s a tra n sv e r se
c o ur se o n the back o f the jo in t an d is firmly attach e d to
both t ibia an d fi bu la , fi llin g u p t h e in t e rva l be tw e e n th e m .

I t co n st itut e s a p art o f t h e t ibio fibu lar sock e t fo r t he -

talu s at t he a n kle j o in t ( F ig s 1 9 2 an d an d o n t h e .

p r o x ima l a sp e ct O f t h e art icu lar sur fac e o f t h e ta lu s, t h e

ar e a ov e r wh ich it p lay s is u sually e a sily d ist in gu ish e d Th is .

p ort i o n o f t h e p o st e ri or liga m e n t is ca lle d t h e a

’
isla l li ament
g
o f th e lat e ra l m a lle o lu s .

D is s e c ti o n — To se e t h e in e ro sse o u s lig am e n o f t h e ibio t t t

fi bu lar sy n de sm o sis th e bo n e s o f t h e le g m ay be se w n h ro u gh t
abo u t
tw o in c h e s f ro m t h e dis al e n d o f t h e ibia , an d h e n t t t
di ide dv wt
i h t h e saw p ro x im o dis ally in a e r ical ran s e rse , -
t v t -
t v
t
o r f ro n al dire ct io n Th is cu t s h o u ld be p lan n e d so as t o p ass
.

t t
h ro u gh th e ibio fi bu lar sy n de sm o sis Th e sh o r s ro n g fi bre s
-
. t t
t
o f t h e in e ro sse o u s lig am e n t
w ill t h e n be se e n , an d also th e sh o r t
n arro w t v
art icu lar in e r a l be w e e n t h e dis al p o rt io n s o f t h et t
o pp o sin g su rfaces o f th e bo n e s h e n h a in e r al is p re se n If w t t t v t .

vt t t
a ca i y is p re se n in t h e dis al p ar o f t h e j o in t h e syn o ial lay e r t t v
o f t h e c ap su le o f t h e an k le j o in is p ro lo n g e d p ro x im ally o e r t v
t
t h e in n e r su rf ace o f h o se p art s o f t h e lig am e n s o f t h e ibio t t
fibu lar sy n de sm o sis w h ic h h e lp t o f o rm t h e bo u n darie s o f t h e
ca i y vt .

AR TI C U L ATI O N S OF TH E F O OT .

Th e art icu lat io n s Of the fo o t are v e ry n u m e rou s . Th e y

co n sist O f
 THE I N F ER I O R EXTRE M I TY
I . A rticu lat io n e s in te rtarse ae , tarso m e tat arse ae , an d in te rm e tat arse ae .

2 . l
A rt icu atio n e s m e tatarso phalange ae -
.

3 . l
Articu atio n e s digi to ru m p e dis .

Th e bo n e s wh ich e n t e r in to th e se art icu lat io n s are t h e

se v e n tar sa l bo n e s, t h e m e tatar sa l bo n e s, an d t he h a la n g es
p .

The tar sa l an d m e tatar sa l bo n e s are bou n d tog e th e r by in t e r

o sse ou s, p la n tar, an d dor sa l liga me n t s, an d are d isp o se d in th e
for m o f two arch e s, v iz , a lo n g itud in a l an d a tra n sv e r se
. Th e .

in t e gr ity o f th e se arch e s is m a in ta in e d : ( 1 ) p art ly by t h e

fo r ms O f t h e bo n e s ; ( 2 ) p art ly by th e t e n sio n o f t h e liga
me n t s ; ( 3 ) p art ly by su pp ort in g t e n do n s ; an d ( 4 ) p art ly by
t h e t e n sio n o f t h e p la n tar ap o n e ur o sis .

Th e lo n g itud in a l arch p r e se n t s a gr e at e r h e ight an d a

w id e r sp a n a lo n g the m e d ia l tha n a lo n g the lat e ra l sid e o f the
fo o t . The ta lu s lie s at t h e su mmit o f th is arch an d for m s
its k e y sto n e The p o st e rior p illar Of th e lo n g itud in a l p la n tar
.

arch is short an d so lid , be in g for me d by the ca lca n e u s a lo n e

t he a n t e r ior p illar , m uch lo n g e r, is co m p o se d O f se v e ra l bo n e s,
v iz , t h e n av icu lar, t he cu bo id , t h e thr e e cu n e ifo r m s, an d t he
.

m e tatar su s F urth e r, the a n t e r io r p illar m ay be co n sid e r e d

.

as be in g f or m e d O f a m e d ia l co lu m n co m o se d o f th e n av icu lar ,
p
t h e thr e e cu n e ifor m, an d t h e m e d ia l thr e e me tatar sa l bo n e s,
an d a lat e ra l co lu mn co m p o se d o f th e cu bo id an d th e lat e ra l

two me tatar sa l bo n e s The w e ight o f the body is tra n s

.

m itte d to the su mm it O f th e arch thro u gh th e ta lus, an d th e

m o st imp orta n t liga m e n t s co n c e rn e d in the p r e v e n t io n o f
e x c e ssiv e flatt e n in g o f t h e arch lie in t h e p la n tar co n cav ity ;

th e y are the p lan tar plan tar liga

ca lca n eo n avicu la r,
-
the lo ng
men t t h e p lantar ealean eo enéo ia ligament Th e var iou s slip s
’
-
.
,

O f t h e tendo n of tlze tibialis p o sterio r as th e y p a ss to fin d ,

attach m e n t to t he d iffe re n t tar sal an d me tatar sa l bo n e s g iv e ,

add it io n a l su p p o rt The p lantar ap o neu ro sis is a lso an im p o rt

.

an t factor fo r as it e x t e n d s be tw e e n th e t wo p illar s an d is
, ,

"
attach e d t o bo th it O p e rat e s as the lat e Sir Ge org e Hu mp hry
, ,

o n c e p o in t e d o u t in the sa me man n e r as t h e t ie be a m o f
,
“ -

'
a roo f Th e tra n sv e r se arch o f th e foot is se e n to be st
.

adva n tag e acro ss the lin e o f th e tar so m e tatar sa l art icu lat io n s -
.

D is s e c t i o n — Th m l an d t n d es w h i h h av h it h rt
u sc e s e o n c e e o

b en e ly p art ially d t ac h d f ro m t h bo n s f t h f t sh o u ld
o n e e e e o e o o
n w b co m p l t ly r m o v e d an d t h
o e e e lig am t de fi n d
e e en s e .

c
Talo id Art i ulat io s n — The ta lu s art icu lat e s by me a n s
o f t h e larg e p o st e r ior fac e t o n th e p la n tar sur fac e o f it s bo dy
 TH E I N F ER I OR EXTRE M I TY
fo r ward s, fro m t he m e d ia l bord e r o f t h e gr o ov e o n t h e ta lu s
fo r t h e fl e x o r ha lluc is lo n gu s to t he su st e n tacu lu m ta li .

Th e p o sterio r talo ealeanean liga ment p a sse s fro m t h e p o s

-

t e rio r bord e r o f t h e ta lu s t o t h e ca lca n e u s I t c lo se s t he .

‘

p o st e r io r ta lo ca lca n-
e a n art icu lat io n be h in d .

The do rsal ta lo n ao it n lar liga ment e x t e n d s, o n t he dor su m

- '

o f t h e fo o t , fro m t he h e ad o f t h e ta lu s to t h e n av icu lar

bo n e . I t is th in an d m e m bra n o u s .

The m e d ia l an d lat e ra l p art s o f t h e c ap su le o f t h e a n k le

j o in t a lso h e lp to k e e p t he ta lu s in its p lac e .

D is s e c t io n —D i ide t h e ario u s lig am e n s

. v h ic h h o ld t h ev t w
t alu s in p la ce , an d re m o e t h e bo n e v
W h e n h a h as be e n do n e . t t
t t
t h e diffe re n p ar s wh ic h f o rm t h e so ck e f o r t h e h e ad o f t h e t
t alu s c an be e x am in e d, an d it ill be o b io u s h a t h e p o s e rio r w v t t t
t t
alo calcan e an a rt icu la io n is co m p le e ly c u t o ff f ro m t h e an e rio r
-
t t
t t
by t he s ro n g in e ro sse o u s ale c alc an e an lig am e n t
Th e g re a -
t . t
t
s re n gt h o f t t t
h a lig am e n can n o w be ap p re cia e d, an d t h e h re e t t
t
f ace s o n t h e h e ad o f t h e alu s s u die d t
a co n v e x su rface t ’

w w
h ich lo o k s f o r ards an d art icu la e s w i h t h e n a icu lar ; (2 ) t t v
an e lo n g a e d f ace t o n it s p lan ar asp e ct ( so m e im e s d i ide dtin o t t v t
tw o ) , w r t
h ic h e s s u p o n t h e su s e n acu lu m ali an d (3 ) be w e e n t t t t
1 an d 2 , a t rian gu lar f ace tw
h ic h co rre sp o n ds i h t h e do rsal wt
su rfa ce o f the p lan ar c alcan e o n a icu lar lig am e nt I n th e -
v t .

re ce n t t t
s a e ( an d in de e d u su ally also in t h e m ace ra e d co n di io n t t
o f t h e bo n e ) t t
h e se h re e face s are e ry dis in c ly m ap p e d o ff t v t t
t
f ro m e ac h o h e r by in e r e n in g ridg e s t v .

Calcan e o n av ic ula r Ligame n t s

-
Although th e ca lca n e u s —

do e s n o t d ir e ctly art icu lat e with the n av icu lar bo n e it is ,

c o n n e ct e d w ith it by two p ow e rfu l liga me n t s v iz a p la n tar ,

.
,

ca lca n e o n av icu lar liga me n t an d the ca lca n e o n av icu lar p art

- —

o f t he bifurcat e liga me n t .

The u pp e r sur fac e o f t he p lan tar ealeaneo n ao it zz lar ligamen t —

nferio r ealt a n eo seap /z o ia lig a men t s br o ught in to v ie w

( T ) i
’
O. . i -

by t h e r e m o va l o f t he ta lu s I t fi lls u p t h e a n gu lar gap .

be twe e n th e su st e n tacu lu m ta li an d t he n av icu lar bo n e an d ,

e n t e r s in to t h e for m at io n o f t h e so ck e t fo r t he h e ad o f t h e

ta lu s ( F ig . I t s u pp e r sur fac e is sm ooth an d cov e r e d

w ith a sy n ov ia l lay e r ; it s p la n tar sur fac e is su p p ort e d
by t h e t e n do n o f th e t ibia lis p o st e r io r Th is liga m e n t .

h as an imp orta n t p art to p lay in ma in ta in in g t h e in t e gr ity

o f t he lo n g itud in a l arch o f t h e foot Po st e r io rly it is .

attach e d to the a n t e r io r bo rd e r o f the su st e n tacu lu m ta li .

wh ilst a n t e riorly it is fi x e d t o t he p la n tar sur fac e o f the

n av icu lar bo n e .

The catt aneo n ao ieii lar p art of t/ze bif u rcate ligament ( O T
-
. .
 JO I N T S O F T H E F OOT 431

ex tern a l calca n eo sea -

a p art o f the
p /io ia ligamen t )
’
a lso fo r m s
s ock e t fo r t h e h e ad o f the ta lu s
I t is p lac e d d e e p ly in .

t h e a n t e r ior p art o f th e d e p r e ssio n be tw e e n t h e ca lca n e u s

an d t he h e ad o f t he ta lu s an d is t h e me d ia l p art o f t h e
,

V sha p e d ligamentu m bif u rcatn m wh ich sp r in g s fr o m t h e

-

T d f i i f en o n o n se rt o n o

p l g m l e ro na u s o n us usc e

B ase o f m e tat a rsa bo l ne

o f ha u ll x

Te n do n o f i n se rt o ni
Pl i me t a of t i bi a l is a n t e ri o r
a nt ar
ta rsa
n te r

l li g
-

am e n t s
m u sc e l
Fi rs t c u n e ifo rm ho ne

Pl an t ar n a v ic u lo -
c u ne i
fo rm lg i a me n t

R i dg e o n c u bo id b o ne

Pl a n t a r c u bo -
c u ne i
fo rm lg i ame n t

Pl l i do n o i i li f t ba s
an ta r c a c a n e o
c u bo r d li g a me n t p o s te r o r i m l u sc e

G ro o v e fo r t e n do n o f
Te n do n o f p e ro na
e us
ti bi li p
a s o st e ri o r mu sc l e

lo n g us m u sc l e
Pl l
a n t a r c a c a ne o
i l li g
n av cu ar a me n t

Lo n g pl a n ta r li g a me n t

D l i d li g
e to a me n t

of kl
an e

G ro o v e fo r t e n do n o f fle xo r

ha ll i l g
uc s o n us m u sc l e

Ca l ca n e u s

FI G . 1 99
— P l an tar Asp e ct o f Tarsa l an d Ta rso me tat arsal
-
Jo i n ts .

a n t e rior p art o f the u p p e r sur fac e o f t h e ca lca n e u s an d

imme d iat e ly d iv id e s in to a m e d ia l o r n av icu lar p art an d
a lat e ra l o r cu bo id p o rt io n Th e ca lca n e o n av icu lar p art .
-

is co n t in uou s be lo w an d m e d ia lly w ith the p la n tar ca lca n e o

n av icu lar liga m e n t an d dor sa lly w ith t h e ta lo n av icular
,
-

liga m e n t .
 TH E I N F ER I OR EXTRE M I TY
Calcan e o A r t icula t io n — I n t he ca lca n e o cu bo id
cubo id
‘

- -
.

j o in t t he co n cavo co n v e x sur fac e o n th e a n t e r ior a spe ct o f

-

t he ca lca n e u s art icu lat e s w ith t h e corr e sp o n d in g sur fac e o n

t h e p o st e r ior a sp e ct o f t h e o s cu bo id e u m I t is a d ist in ct .

j o in t, that is, its cav ity d o e s n o t co m m u n icat e w ith th e cav it ie s

o f n e igh bour in g j o in t s Th e ligaments wh ich bin d t h e t wo
.

bo n e s tog e th e r are
I C p l . a su a art ic u aris l .

2 . L ig am e n tu m ca can e o l -
c u bo ide u m p l an t are .

3 . l l
L ig am e n tu m p an tare o ng u m .

Th e eap sii le co mp le t e ly surr o u n d s th e jo in t an d i ts d o r sa l

an d m e d ial p art s wh ich are so m e what th ick e n e d are so me
, ,

t ime s ca lle d th e d o r sa l an d me d ia l liga me n t s o f t he jo in t .

The m e d ial lig am e n t is t h e c alca n e o cu bo id p art o f t h e lig -

.

bifu rcatu m m e n t io n e d a bov e .

The lo ng p lan tar ligamen t Sp r in g s fro m t h e p la n tar sur fac e

o f t h e ca lca n e u s imm e d iat e ly a n t e r io r t o t h e tu be r ca lca n e i
, .

I t e x t e n d s forward s t o t h e p la n tar sur fac e o f t h e cu bo id bo n e

wh e re it br o ad e n s o u t an d is fo r t he m o st p art attach e d , ,

t o t h e tu be ro sity o f that bo n e N u m e r o u s str o n g fi br e s .

,

ho we v e r are p ro lo n g e d fo rward s acro ss t h e t e n d o n o f

, ,

t he p e ro n ae u s lo n gu s to ga in attach m e n t t o t h e ba se s o f
,

th e se co n d th ird an d fourth m e tatar sa l bo n e s Th e lo n g

, ,
.

p la n tar liga m e n t th e r e fo r e e x t e n d s o v e r t h e gr e at e r
, , p art o f t h e

p la n tar a sp e ct o f t h e l at e ra l p ort io n o f t h e tar su s a n d is t h e ,

lo n g e st O f t h e tar sa l liga me n t s F urth e r it for m s th e gr e at e r

.
,

p art o f t h e s h e ath o f t h e t e n do n O f t h e p e ro n a
e u s lo n gu s .

The planta r calcan eo t ii oo ia liga men t ( O T s/ o rt plan tar

-
’
. . z

liga men t ) is p lac e d u n d e r cov e r o f t h e lo n g p la n tar liga m e n t .

Slip t he k n ife be tw e e n th e m an d carry t h e cutt in g e dg e back

ward s so as t o d e tach t h e lo n g p la n tar liga m e n t fro m the
p la n tar sur fac e o f t he ca lca n e u s Wh e n t he d e tach e d ba n d is
.

throw n forward s th e p la n tar ca lca n e o cu bo id liga m e n t co m e s -

in to v ie w an d litt le d isse ct io n is r e qu ir e d t o m ak e its co n n e c

,

t io n s a p p are n t I t is c o mp o se d o f short stro n g fi bre s n o t

.
, ,

m o r e tha n an in ch in le n gth Th e y sp rin g fro m t h e sm a ll

.

tu be rc le o n th e a n t e rio r p art o f th e p la n tar ur fac e o f th e s

ca lca n e u s an d are attach e d an t e rior ly t o the p la n tar sur fac e

, , ,

o f th e cu bo id p o s t e
,
r io r to it s tu b e ro si ty T h e l iga m e n t is .

br o ad e r tha n t h e lo n g p lan t ar liga m e n t an d cou ld be se e n

at t he me d ia l bord e r o f th e latt e r be for e it was r e fl e ct e d .

I n t h e ma in t e n a n c e o f t h e lo n g itud in a l arch o f th e foot ,

 TH E I N F ER I O R EXTR E M I TY
by a sm a ll fac e t o n the m e d ia l surfac e o f t h e cu bo id as
w e ll Th e art icu lar surfac e o f t h e n av icu lar is d iv id e d by
.

p ro m in e n t r idg e s in to ar e a s o r f ac e t s c o rr e s o n d in g w ith t h e
p
d iffe re n t p art s o f th e so ck e t in wh ich it lie s Th e sy n o vial .

stratu m wh ich lin e s th is jo in t is ro lo g d f rward i to t h

, p n e o
, s n e
in te rc u n e ifo rm j o in t s .

Cuba n av ic ula r an d Cuba cu n e if o rm Art ic ulat io n s

- -
I t has .
-

be e n n ot e d that t h e a n t e r ior p illar o f t h e lo n g itud in a l arch o f

t h e foot co n sist s o f a lat e ra l an d a m e d ia l co lu mn Th e .

tar sa l p o rt io n s o f th e se are co n n e ct e d tog e th e r by th e cu bo

n av icu lar an d t h e cu bo cu n e ifor m art icu lat io n s
-
.

I t is o n ly occa sio n a lly that t h e n av icu lar touch e s an d

art icu lat e s d ire ct ly w ith the m e d ia l surfac e o f the cu bo id .

Wh e n it do e s so th e fac e t o n t he cu bo id lie s in se r ie s
,

w ith th e art icu lar sur fac e s o n the p o st e r ior e n d s o f th e cu n e i

fo r m bo n e s an d fo r ms w ith th e m th e sock e t fo r t h e a n t e r io r
,

s ur fac e o f the n av icu lar Th e ligaments wh ich bin d t h e

.

n av icu lar to t he cu bo id are d isp o se d tra n sv e r se ly an d ,

c o n sist o f ( r) a se r ie s o f short stro n g in tero sseo u s fi br e s

—

wh ich bin d the O pp o se d surfac e s tog e th e r ; ( 2 ) a dorsa l ba n d

an d 3
( ) p a l a n tar b a n d .

Th e dor sa l ba n d h as p re vio u sly b e e n d iv id e d in e xp o sin g

t h e in t e rior o f the cu n e o n av icu lar jo in t an d in d e fi n in g t h e
-

lat e ra l ca lca n e o n av icu lar liga m e n t bu t t h e in t e r o sse ou s an d

-

p la n tar liga m e n t s m a y b e r e ad ily d isp lay e d .

Th e cu bo id by an ova l fac e t o n its me d ia l sur fac e

, ,

art icu lat e s w ith the th ird cu n e ifo r m bo n e fo r min g th e r e by ,

th e eno o eii n eif o rm j o in t

-
Th e two bo n e s are bou n d tog e th e r
.

by intero sseo u s do rsal an d p lantar ligamen ts

, ,
B y d iv id in g .

t he dor sa l liga m e n t an d in sin uat in g t h e k n ife be tw e e n t h e

two bo n e s th e in t e r o sse ou s liga me n t m ay be d e t e ct e d I t is .

t h e stro n g e st o f t h e thr e e liga m e n t s .

Th e sy n o vial lay er wh ich lin e s the cu n e o n av icu lar art icu la -

t io n is p ro lo n g e d in t o th e cu bo cu n e ifo rm j o in t an d a lso
-

in to th e n avic u lo cu bo id jo in t wh e n that e x ist s

-

,
.

Ta rso met a t a rsal Art icula t io n s

-
Th e ba se s o f t h e fiv e
—

me tatar sa l bo n e s art icu lat e w ith the thr e e cu n e ifor m bo n e s

an d th e cu bo id bo n e an d are v e ry fir mly attach e d t o th e m
,

by d o r sa l p la n tar an d in t e ro sse o u s liga m e n t s

, ,
I t is p art ie n .

larly im p orta n t to n o t e that t h e lin e o f art icu lat io n is irr e gu lar ,

an d that t h e ba se o f t h e se c o n d m e tatar sa l bo n e is w e dg e d

be tw e e n the fir st an d th ird cu n e ifo r m bo n e s .

 J O I NTS O F T H E F OOT 4 35

Th e do rsal ligamen ts are flat , d ist in ct ba n d s wh ich c an

r e ad ily be d e fi n e d by th e care fu l d isse ctor One such liga .

me n t p a sse s t o t h e ba se o f th e fir st me tatar sa l fro m t h e

fir st cu n e iform tli ree, o n e fro m e ach o f the cu n e iform bo n e s,
p roc e e d t o t h e b a se o f t h e se c o n d m e tatar sa l ; o n e e x t e n d s

fr o m th e th ird cu n e ifor m to t h e ba se o f t h e th ird me tatar sa l ;

tw o , o f wh ich o n e p roc e e d s fro m th e th ird cu n e ifor m an d th e
oth e r fro m the cu bo id, go to t he ba se o f the fourth m e ta
tarsa l ; an d o ne p a sse s fro m t he cu bo id to th e ba se o f the
fi fth m e tatarsa l .

Th e p lan tar ligamen ts are n o t so r e gu lar ly d isp o se d . Tho se

in co n n e ct io n w ith the fir st an d se co n d me tatar sa l bo n e s are
v e ry stro n g So me o f the ba n d s hav e an o bliqu e d ir e ct io n ,
.

an d tho se wh ich go to t h e ba se s o f t h e se co n d , th ird , an d

fo urth m e tatar sa l bo n e s are mor e or le ss co n n e ct e d w ith t h e

sh e ath o f t h e t e n do n o f th e e r n a
e u s lo n gu s a n d th e r e for e
p o ,

w ith t h e lo n g p la n tar liga me n t .

To brin g the intero sseo u s ligaments in to V ie w , d iv id e fr e e ly

t h e dor sa l liga me n t s, an d th e n forc ibly be n d the m e tatar su s

p l an t ar w a r ds u p o n t h e tar s u s
. T h e in t e ro s se ou s l iga m e n t s

w ill r e sist th is p r o c e e d in g, an d o n look in g in to th e jo in t s the

disse ctor w ill se e th e m str e tch e d an d t e n se I f the forc e is .

co n t in u e d th e y w ill ru p tur e The in t e ro sse ou s liga me n t s are

.

thr e e in n u mbe r, viz , a m e d ia l, an in t e r me d iat e , an d a lat e ra l

. .

Th e medial intero sseo us ligament is an e x c e e d in gly stro n g

ba n d , wh ich p a sse s lat e ra lly fro m t he a n t e r ior p art o f t h e
lat e ra l surfac e o f t h e fir st cu n eifor m bo n e to t h e adjac e n t
sur fac e o f t h e ba se o f t h e se co n d me tatar sa l bo n e
'

. Th e
in termediate in tero sseo u s ligamen t is sm a ll . I t p a sse s be tw e e n
th e a n t e rior p art o f th e me d ia l surfac e o f t h e th ird
cu n e iform an d the adjac e n t surfac e o f the ba se o f the
se co n d m e tatar sa l . Th e lateral in tero sseo u s ligamen t p a sse s
fro m t h e lat e ra l surfac e o f t he th ird cu n e ifor m bo n e to th e
m e d ia l sid e o f t he ba se o f th e fourth me tatar sa l . O n e in t e r
o sse ou s liga me n t , th e r e fo r e , p a sse s fro m th e fir st cu n e iform
bo n e an d two fro m t h e th ird cu n e ifo r m ; an d o f th e se , two
are attach e d to t he ba se o f the se co n d , an d th e th ird to t h e

ba se o f th e fo urth me tatar sa l bo n e .

Tarso me tat a rsal Art icular Surfaces — Th e m a n n e r in

-

wh ich the me tatarsu s is im p la n t e d u p o n the tar su s shou ld

n o w be e x a min e d . The first metata rsal r e st s aga in st th e
first cu n e ifor m, an d th is jo in t p o sse sse s a se p arat e sy n ov ia l
1— 28 a
 TH E I N F ER I O R EXTRE M I TY
cavity The seco nd metatarsal r e st s aga in st the se c o n d cu n e i
.

fo r m bu t its ba se is gra sp e d by t h e p roj e ct in g a n t e rio r

,

e n d s o f t h e fir st an d th ird cu n e ifor m bo n e s w ith bo th o f ,

wh ich it art icu lat e s an d w ith both o f wh ich it is co n n e ct e d

,

by in t e ro sse ou s liga m e n t s I t is n o t surp r isin g th e r e for e

.
, ,

that th is m e tatar sa l shou ld p o sse ss so litt le p ow e r o f in d e

p e n d e n t mo v e m e n t an d p r e se n t a d ifficu lty to t h e surg e o n
,

wh e n h e is calle d u p o n to a mp utat e t he a n t e rior p art o f the

fo ot through t h e tar so me tatar sa l art icu lat io n
-
The t/i ird .

metatarsal r e st s aga in st th e th ird cu n e ifor m Th e sy no vial .

lay er wh ich lin e s t he j o in t s be tw e e n t h e tar su s an d t h e se co n d

an d th ird m e tatar sa l bo n e s is co n t in uou s w ith that wh ich is

p r e se n t be tw e e n t h e fir st an d se c o n d cu n e ifo r m bo n e s an d ,

through that w ith the sy n ov ia l lay e r o f the cu n e o n av icu lar -

art icu lat io n Th e ba se s o f the f o nrt/i an d fif t/i metatarsal

.

t o n es are su p p ort e d by t h e cu bo id bu t that o f the fourth , ,

by its me d ia l m arg in art icu lat e s a lso w ith th e th ird cu n e i

,

for m . Th e j o in t for me d be tw e e n th e lat e ra l two m e tatar sa l

bo n e s an d th e tar su s h as a ca p su le an d a cav ity se p arat e fro m
that o f th e adjac e n t j o in t s .

I nt e rme t a t arsal J o int s — The ba se s o f adjac e n t m e tatar sa l

.

bo n e s w ith t h e e x c e p t io n o f t h e fir st art icu lat e w ith e ach

, ,

oth e r an d are v e ry fir mly bou n d t o ge th e r

,
.

Th e liga me n t s wh ich co n n e ct t h e ba se s o f t h e four lat e ra l

me tatar sal bo n e s are do rsa l p la ntar an d intero sseo us ,
Th e y
, .

are stro n g ba n d s wh ich p a ss be tw e e n the n o n art icu lar p o r -

t io n s o f t he ba sa l p art s o f t h e bo n e s an d th e y co n st itut e th e ,

ch ie f bo n d s o f u n io n .

D is s e c t io n — To brin g the in e ro sse o u s lig am e n t ts i t o vie w

n
v t
di ide t h e do rsal lig am e n s an d h e n f o rc ibly se p ara t te th e base s
o f t h e bo n e s f ro m o n e an o h e r t .

In dd it io n to t he liga me n t s wh ich co n n e ct the ba sa l e n d s

a

o f th e m e tatar sa l bo n e s th e stro n g transverse metatarsal lig

,
a

men t o f the h e ad s o f th e m e tatar sa l bo n e s u n it e s t h e d ista l

e x tr e mit ie s o f t h e bo n e s t o g e th e r That liga m e n t has be e n
.

p r e v iou sly d e scr ibe d (p .

J o int C a vit ies o f t h e F o o t — Th e r e are six se p arat e

jo in t cav it ie s in co n n e ct io n w ith t h e tar sa l tar so me ta ,
-

tarsa l an d in t e rme tatar sa l art icu lat io n s v iz

,
Th e cav ity ,
.

be tw e e n th e p o st e r ior fac e t s o f th e ta lu s an d ca lca n e u s .

( )
2 T h e ca l ca n e o cu bo id jo in t cav ity
-

( 3) T h e cav ity o f t.h e

 P L ATE X L V I
Di s t ai e p ip h y sis Di l st a e p iphy l se a
o ii
f t b a li ne o f t i bi a Ti bi a

Fi b l u a

vi
Na l
c u ar

Ta l us

C u bo d i Ca l c an e u s

Ep p h i yi s s o f
l
c a ca n e u s

FIG .
—
R di
a o gra p h o f t he F o o t o f a il
Ch d 6 ye ars o ld .

N o te (1 ) That t he i fi t i f th p i p hy i f t h l
o ss ca o n o e e s s o e ca c an e u s
h j t m m d d th t th i
as us co i di i
e n ce an a e re s no n c at o n
f th o t ige o s m ( F ig
r o nu se e .

(2 ) Th t t h di t l
a e
p i p hy l li f th fib l
s a e se a ne o e u a ru n s

p ll l w i th th p p b d f th t l
ara e e u er o r er o e a us .
 P L A TE X L V I I

Ta l us

Fi b l
u a

Na vi l
cu are

C a lc a n e u s

C u bo d i

FIG . 20 3 .
— R di g
a o ra
p h o f th e F o o t o f an l
Adu t sh o w i n g an

l v i ti
o c c asio n a ar a o n .

( M a j A W Pi i
o r . . re .
)
 4 38 TH E I N F ER I OR EXTR E M I TY
or ,
ca se s o f th e me tatar so p ha la n ge a l jo in t o f th e gr e at
in t h e -

t o e an d occa sio n a lly o f so m e o f t h e oth e r t o e s a lso u p o n t h e

, ,

se sa m o id bo n e s d e v e lo e d i n t h e la n tar acc ry liga m t

p p e sso e n

( g
F i . W h e n th e j o in t s are fl e x e d th e
p ro x im a l e nd o f
t h e d ista l bo n e m o v e s t o t h e p la n tar a sp e ct o f t h e d ista l e n d
o f t h e p ro x im a l bo n e an d th e e x tr e m it ie s o f th e d ista l bo n e s
,

are th e n c o v e r e d o n ly by th e e x t e n sor t e n do n s an d the sk in .

W h e n the jo in t s are fl e x e d th e r e fo r e th e y are e a sily o p e n ed

, ,

fro m th e dor sa l a sp e ct s by cutt in g tra n sv e r se ly d ir e ct ly aga in st

th e h e ad s o f t h e p ro x im a l bo n e s The d isse ctor sho u ld o p e n
.

o n e o r m or e j o in t s in that ma n n e r .

Each jo in t p o sse sse s the fo llow in g liga me n t s

C apsu la articularis ,

L igam e n ta c o llate ralia .

L ig am e n tu m ac ce sso riu m p lan tare .

Cap sula Art icularis — The fi brou s stratu m o f the art icu lar
.

ca p su le is d e fic ie n t dor sa lly an d th e r e t he e x t e n sor t e n don s

,

lie in d ir e ct r e lat io n w ith th e sy n ov ia l stratu m wh ich lin e s the

in t e r ior o f the fi brou s stratu m At th e sid e s th e fi brou s
.

stratu m is ble n d e d w ith t h e co llat e ra l liga m e n t s an d o n t h e ,

p la n tar a sp e ct w ith t h e p la n tar acc e ss ory liga m e n t .

Ligame n t a A cc e sso ria P lantaria — Each p la n tar acc e ssory .

liga m e n t is a d e n se fi brou s p lat e wh ich is fir mly attach e d t o

t he p la n tar a sp e ct o f th e ba se o f t h e d ista l bo n e o f t h e j o in t ,

wh ilst it is loo se ly attach e d to t he p la n tar a sp e ct o f th e n e ck

o f t h e p ro x ima l bo n e o f t h e j o in t The co llat e ra l liga m e n t s
.

an d t h e fl e x o r sh e ath are fi x e d to its m arg in s an d t h e tra n s ,

v e r se liga me n t o f the h e ad s o f th e me tatar sa l bo n e s is attach e d

to t he p la n tar acc e ssory liga me n t s o f the me tacarp o p ha la nge a l -

j o in t s The p la n tar acc e ssory liga me n t s a lway s m ov e w ith the

.

d istal bo n e s .

Ligame nt a Co llat e ralia — Th e co llat e ra l liga m e n t s are

.

str o n g th ick tr ia n gu lar ba n d s p lac e d o n e o n e ach sid e o f e ach

,

j o in t The a p e x o f th e ba n d is attach e d to t he tu be rcle an d

.

th e d e p r e ssio n o n t h e corr e sp o n d in g sid e o f t he h e ad o f th e

p ro x ima l bo n e o f t h e j o in t an d t he e x p a n d e d ba se is attach e d
,

to t h e sid e o f the ba se o f the d ista l bo n e an d to the corr e

sp o n din g m arg in o f t he p la n tar acc e ssory liga m e n t .

M o v eme n t s I t has a lr e ady bee n p o in t e d o u t that at th e

—

inteip /z alangeal j o in ts wh ich are lzinge j o in ts o n ly t h e m ov e

, ,

me n t s o f fl e x io n an d e x t e n sio n are p e r mitt e d wh ilst th e ,

 J O I N TS OF THE F OOT 4 39

metatarso p na langeal j o ints, wh ich are co n dy lo id j o in ts, p e r m it

-

a lso a bduct io n , adduct io n , an d c ircu mduct io n At all the .

j o in t s th e move m e n t s o f e x t e n sio n are p roduc e d by the

e x t e n sor s o f t h e to e s, bu t e x t e n sio n o f t h e in t e r p ha la n g e a l

j o in t s o f the lat e ra l four to e s is p roduc e d a lso by the act io n

o f t h e lu mbr ica l an d in t e ro sse i m u sc le s, wh ich act by m e a n s

o f th e ir attach m e n t s to t h e e x t e n so r e x p a n sio n s . Fle x io n o f

t h e t e r min a l in t e rp ha la n g e a l j o in t s o f t h e lat e ra l fo ur is

p roduc e d by t h e fi e x o r d ig itoru m lo n gu s fl e xio n o f the fir st

in t e r p ha la n g e a l jo in t by th e Sh o rt fl e x o r o f th e t o e s, a id e d
by the lo n g fl e x o r o f t h e t o e s . I n fl e x io n o f t he m e tatar so
p ha la n g e a l j o in t s t h e lo n g an d short fl e x o rs p lay a p art, bu t
th e y are a id e d by th e lu m br ica l an d in t e r o sse i m u sc le s, an d
in th e ca se o f t h e litt le t o e by t h e fl e x o r d ig it i qu in t i br e v is .

F le xio n an d e x t e n sio n o f t h e in t e r p ha la n g e a l j o in t o f t h e
gr e at t o e are p roduc e d by th e lo n g fl e x o r an d e x t e n sor re sp e c
t iv e ly, an d fl e x io n an d e x t e n sio n o f t h e m e tatar so p ha la n g e a l
-

j o in t by t h e Short fl e x o r an d e x t e n sor, a id e d by the lo n g fl e x o r

an d e x t e n sor . Th e d isse ct o r shou ld r e me mbe r that the
lu mbr ica l an d in t e ro sse i are fl e x o rs o f th e m e tatar so p ha la n -

g e a l j o in t s an d e x t e n sor s o f th e in t e rp ha la n g e a l jo in t s
.

Abduct io n an d adduct io n o f th e to e s at th e m e tatar so

p ha la n g e a l jo in t s a re p roduc e d b y t h e in t e ro sse i an d t h e

sp e c ia l a bductor s an d adductor s . Th e m o v e m e n t s tak e p lac e

fr o m an d t o ward s a lin e drawn lo n g itud in a lly a lo n g t h e m idd le
o f th e co n d to e The lat e ra l thr e e to e s are adduct e d by
se .

t h e p la n tar in t e ro sse i th e gr e at t o e by the o bliqu e an d tra n s

,

v e r se adductor s Th e gre at t o e an d the litt le hav e e ach a

.

Sp e c ia l a bductor m u scle . Th e se co n d t o e is a lt e r n at e ly
a bduct e d an d adduct e d away fro m o r toward s its o wn midd le
lin e by t h e fir st an d se c o n d d o r sa l in t e r o sse ou s m u sc le s Th e .

th ird t o e is a bduct e d by the th ird an d th e fourth to e by th e

,

fo urth dor sa l in t e r o sse ou s m u sc le .

44 2 I N D EX

Art e ri e s Art e ri e s , recu rren t ( co n td .

in te rco stal, 17 o f v o lar arc h , 1 6

7
i n t ero sseo u s, co m mo n , 142 , 143 sap he no u s , 25 1 , 2 5 5 , 30 9
50 , 2
do rsa l , 1 4 3, 1 8 5 sc apu lar, circu m fle , 2 8 , 36 , 9 1 x
re c u rre n t , 1 8 5 , 1 88 v e rse 1 3
t ran s , , 4 1 , 59 , 9 0
v o lar , 1 4 4 , 1 4 8 , 1 8 2 , 1 88 , 1 9 1 su bc lavian
39 ,

m alle o lar, 3 4 8 , 4 1 9 su bsca

p u lar, 2 8 , 36
m amm ary , e xt e rna l , 1 7, 35 f tran sv e rse scapu lar, 90
o

in te rn al, 1 2 , 1 4 , 1 7 su ra , 3 1 6 l
m e dian , 1 4 4 1 4 7 , tarsal, ate ral, 3 50 l
l
m e tacarpa , do rsal, 1 9 2 m e dia , 3 50 l
l
v o ar, 6 7 tho racalis su pre m a, 35
m e tatarsal, do rsal, 3 50 th o racic , alar, 36
p lantar, 39 7 , 39 8 late ral, 1 7 , 2 8 , 3 5 , 36
m u scu lo articu lar, 2 55
-
th o raco acro m ial, 1 3, 1 9 , 2 3 ,
-
2 5,
n u t rien t , o f fe m u r, 2 69 35
o f fi bu la, 3 7 3 t h o rac o -
do rsal, 2 8 , 36 , 6 1 , 9 1
o f h u m e ru s, 1 0 1 , 1 0 4 t ibial, an te rio r, 34 4 , 3 4 7 , 37 1 ,
o f radiu s , 1 4 4 37 2
o f scapu a , 90 l 37 1 , 3 7 2
p o st e ri o
.

r,
o f tibia, 3 7 5 t ran sv e rse ce rv ic a , 4 1 , 58 l
o f u ln a, 1 4 4 asce n din g bran ch o f, 58 , 8 5
o btu rat o r, 2 7 7 de sce ndin g bran ch o f, 58, 6 0 ,
abn o rm al, 2 4 4 6 1 , 90
p f
e r o rat i n , o f fo o t ,
g 39 7, 39 8 sc a u lar,
p 1 3, 4 1 , 59 , 9 0
o f ban d, 1 6 7 , 1 9 2 u lnar, 7 3, 1 10 ,
1 2 9, 1 4 2 , 1 52
o f in t e rn al m am m ary , 1 3 , 14, de e p bran c h o f, 1 56
u ln ar c o llat e ral, in fe rio r,
7
I 10 1 ,
o f p e ro n e al, 3 4 4 , 3 5 0 , 37 3 , 4 1 9

o f p ro fu nda fe m o ris, 2 6 7 , 2 6 8 , pe rio r, 1 0 1 , 1 0 4 1 88

su ,

vo lar, su p e rfi cial, 1 3 2
p e ro n e al, 3 7 1 , 3 7 3 , 4 1 9 vo laris in dicis radialis, 7 0 , 1 70 ,

plan tar, late ral, 38 5 , 3 8 8 t 1 71

m e dial, 38 5 , 3 88 Articu lat io n s S ee J o in t s .

p o p lit e al, 30 5 , 30 7 , 3 1 1, 31 5 , x
A illa, 1 , 3, 7 , 8 , 1 6 , 2 1

p rin c e p s p o ll i i c s, 70 , 1 70 , 171 B o die s, P

acin ian , 7 1 , 1 5 9

p ro fu n da brach ii , 98, 10 1 , 10 4, B rach iu m , I

B re ast , 1 4
fe m o ris, 2 4 6, 2 4 7 , 26 7 B re ast bo n e , 2 , 8
-

pu de n dal, e x te rnal, de e p , 2 46, B ursae

24 8 bice p s brachn , 1 0 7
fi c o raco c lav icu lar, 9 2
su
p e r cial, 2 2
5 2 27 -
,

in te rn al, 2 9 3 2 9 5 , , 29 8 g astro cn e miu s, 30 9 , 368 , 37 0 ,

to q u adratu s fe m o ris , 2 96 40 9
radial, 1 10 ,
1 3 0 , 1 70 ,
191 g lu te u s m ax im u s , 2 8 7 , 2 9 1 , 2 93

re cu rre n t , 1 3 1 , 1 88 m e diu s, 30 2
radialis in dicis v o laris , 70 , 1 70 ,
min imu s, 30 3
171 gracilis, 2 7 6 , 32 2 , 3 57 , 4 0 8
recu rren t , o f e lbo w , 11 1 ilio p so as 2 7 8, 3 2 8
-
,

in te ro sse o us, 1 8 5 , 1 88 in fra pat e llar, 2 36 , 4 1 1

-

radial, 1 3 1 , 1 88 in fraspin atu s, 89

t ibial, an te rio r, 3 4 8 , 4 0 3 latissim u s do rsi, 8 7
o btu rato r in t e rn u s, 2 9 3
p o ste rio r, 3 7 2 , 4 0 3
u ln ar, do rsal, 1 4 3 , 1 8 8 l
o ec ran o n , 9 5

vo lar, 1 4 3 , 1 88 p at e lar, l 2
35
 I N D EX 443

B ursa ( co n td ) . Disse ct io n s o f u p p erlimb ( co n td .

p e c t o ralis m aj o r, 24 fl e x o r sh e ath s, 1 32 , 1 6 0 , 1 6 2
p re l
p at e lar, 2 3 5, 2 36
-
fo re arm , back , 1 7 3 , 1 7 4 , 1 7 6 ,
sarto riu s, 2 52 , 32 2 ,
3 57 , 4 0 8 1 8 1 , 1 88, 19 1
se m im e mbran o su s, 30 9 , 36 8 , 4 0 9 fro n t , 1 2 9 , 1 30 , 1 38 , 1 4 2 , 1 4 8
se m ite n din o sus, 32 2 , 3 7 , 4 0 8
5 h an d, back , 1 7 7
su bacro m ial, 7 8 , 8 1 , 4 hy p o th e n ar e min e n ce , 1 52
su bsca u lar, 88 , 1 2
p 3 in t e ro sse o u s m e mbran e , 2 0 2
su p ra p at e llar, 2 36 , 4 1 0
-
mu scle s, 1 9 3
t e n do calcan e u s, 37 1 m am m ary glan d, 1 8
z
trap e iu s, 55 , 58 l
m e tacarpo ph a an g e al j o in ts, 2 1 1
-

t rice p s brac hn , 1 1 8 p alm , 1 52 , 1 5 3 , 1 55 , 1 60 , 1 6 5 ,

1 66 , 1 6 9 , 1 7 0 , 1 9 3
C alcan e us, 2 1 6 , 3 3 3, 334 p almar apo n e u ro sis, 1 5 3
Can al, addu cto r, 2 4 7 , 2 50 , 2 5 2 pe c t o ral re gi o n , 9 , 1 2 , 1 9
ce rvico a illary , 2 3 -
x re m o v al o f lim b, 6 1
fe mo ral, 2 4 2 sc a u lar anasto m o sis, 90
p
C arp al bo n e s, 2 , 4 re g io n ) 7 7 , 84 3 8 5 2 8 7 , 8 gi 90 ,
C art ilag e , c o stal, seco n d, 8 92
sev e n th , 8 sh o u lde r j o in t , 1 2 1 , 1 2 5

C h o rda o bliq u a, 2 0 4 v
ste rn o cla icu lar j o in t , 3 7 , 38
-

C ist e rn a chy i, 36 3 l subscapu lar bu rsa, 8 7

v l
C la ic e , 1 , 2 , 7 , 8 su e rfi cial st ru ctu re s, 6 2 , 6 9
p
C le ft, n atal, 2 79 t h e n ar e m in e n ce , 1 6 0
x
C o ccy , 4 9 w rist j o in t , 1 98, 1 9 9
l
C o n dy e s o f fe mu r, 2 1 5 , 30 5 Di sse ct io n s o f lo we r limb
o f t ibia, 2 1 5 , 30 5 ank le j o in t , 4 1 9 , 4 2 0 , 4 2 3
C o rd, sp e rm atic , 2 2 6 arte rie s aro u n d k n e e , 4 0 2
sp in al, 5 , 2 1 7 art icu laris g e n u , 2 6 5
P
C o rp u scle s , acinian , 7 1 , 1 59 e xt e n so r sh e ath s , 34 0
Cre st o f iliu m , 4 9 , 2 1 3, 2 7 9 fascia lat a, 2 33
o f pu bis , 2 1 3 fe mo ral sh e ath , 2 38 , 2 42
o f sca u la, 2
p t riang le , 2 4 5
C u bo id bo n e , 2 1 6 , 3 33 fl e x o r sh e ath s, 37 9
C u n e ifo rm bo n e s, 2 1 6 , 333 fo o t , do rsu m , 3 34 , 335 , 338, 344
5 0 13 : 38 1 , 384 , 38 5 , 38 7 , 3 9 1 ,

D isc , articu lar, o f wrist , 2 0 3 39 2 , 394 , 39 5 , 39 7 , 39 9 , 4 0 1

Disse ct i o n s o f u p p e r limb g lu te al re gio n , 2 80 , 2 83 , 2 84 ,
arm , fro n t , 9 8 , 1 0 0 , 1 0 6 , 1 0 8 , 1 1 1 2 8 7 , 2 92 , 30 0 , 30 1 , 30 2 , 30 3 ,
back , 1 1 2 , 1 1 5, 1 1 7
articu lar disc o f w rist , 2 0 5 h i p jo m t , 32 9
x l
a il a, 2 3 , 2 5 , 2 6 , 4 7 l
i io pso as bu rsa, 2 7 8
-

b ack o f t ru nk , 50 , 5 1 , 5 3, 55 , 5 7 , j o ints o f fo o t, 4 2 8, 4 30 , 4 33, 4 36

58 , 60 , 6 1 kn e e j o in t, 4 0 2 , 4 0 5, 4 1 0 , 4 1 1 ,
brach ial p le u s, 38 x 4 1 4, 4 1 6, 4 1 7
carpo m e tac ar al j o int s , 2 0 8 , 2 0 9 ,
-

p l ate ral in t e rmu scu lar se tu m , 2 6 1

p
2 10 le g, back , 3 58, 366 , 36 7 , 370 , 3 7 1
c o raco m ial arch , 84
-
acro fro nt , 334 , 335, 338, 34 o , 344 °

co rac o clav icu ar lig am e n t , 9 2

-
l o btu rato r art e ry , 2 7
7
co sto c o raco id m e m bran e , 2 5
-
n e rv e , 2 7 2

cubita fo ssa, 1 1 1 l p e ro n e al re gio n , 354

de lto p e cto ral trian g le , 1 9
-
p o p lite al fo ssa, 30 6 , 30 8
do rsal c arp al lig am e n t , 1 7 3 p ro fun da fe m o ris art e ry , 2 6 7
e l b w j i t 94
o o n , 1 q u adratu s fe m o ris, 30 0
e xt h th
e n so r s ea s, 1 74 re m o v al o f lim b ,
3 32
finge rs 1 62 th igh , back , 8 3 9 3 2 : 3 2 5
, 3 1 , 1 , 3
4 44 I N D EX

Dis se ct io n s o f lo we r limb Fascia, su per ficial ( co n td ) .

t h igh , fro n t , 2 2 1 , 2 2 4 , 2 33 , 2 38 , o f le g, bac k , 3 58

2 4 2 , 2 4 5, 2 4 8, 2 6 1 , 2 78 f ro n t , 3 34
m e dial side , 2 6 7 , 2 7 1 , 2 7 2 , 2 7 7 o f lo w e r im b, 2 2 2 l
su e rfi cial stru ctu re s , 2 2 1 , 2 2 4 o f e c t o ral re g io n , 1 1
p p
l
tibia re g io n , 3 57 o f t high , 2 2 3 , 3 1 8

tibio fibu lar jo m t s, 4 2 5 , 4 2 7

-
o f C o lle s, 2 2 4

Du ct , lac tife ro u s, 1 7 , 1 8 o f Sc arp a , 2 2 4

ly m p h atic , righ t , 6 7 , 68 , 36 1 F e mu r 2 1 4 ,

t h o racic , 6 7 , 6 8 , 36 1 , 36 3 F ibu la 2 1 5 2 1 6 30 5 3 32
, , , ,

F l e x o r sh e ath s o f fin g e rs 1 33 , , 1 34 ,
Emin e n c e , hy po th e nar , 1 49 1 60 , 1 62
h e n ar 1 4 9
t , f to e s, 37 9 , 39 2
o

Epico ndyle s o f fe m u r , 2 15 F o ld, alar, 4 1 0

o f h u m e ru s 3 94 , , x ll
o f a i a , 8 , 2 1 , 2 2 , 57

x
E te n so r e pan sio x n o f fing e rs ,
1 78 l
g ut e al S ee Su lcu s .

o f to e s, 34 6 sy n o v ial, p at e llar, 4 1 0

ll
Fo icle s, h air, 1 1 , 2 2 2
F ascia , deep , 1 1 , 2 2 2 Fo ram e n , sciatic , g re ate r, 2 90 ,
291

o f arm , 9 8 le sse r, 2 90 , 2 9 1 , 2 9 2
x
a illary , 1 8 F o ssa , cu bital, 1 0 8
o f bu tto ck , 2 84 in frast e rn al, 8
o f c alf , 36 6 isch io re c t al, 2 9 0
-

c lav i p e ct o ral, 2 4
-
o v alis o f th igh , 2 2 5, 2 2 6, 229 ,
cribrifo rm , 2 2 5, 2 2 6, 2 29, 2 43
2 34 , 2 4 3 po p l it l ea , 30 4
o f fo do rsu m , 339
o t, Fu n icu lu s spe rm aticu s , 226
s o le , 38 3 F u rro w il iac 2 79
, ,

o f fo re arm , 1 2 8 , 1 7 3

o f h an d, do rsu m , 1 7 4 , 1 7 7

alm , 1 54
G an glia spin al 5 2 1 8
, , ,
p
l
i iac a, 2 38 , 2 4 0 , 2 4 1 , 2 4 3
G irdle sh o u lde r 1
, ,

Gl an ds lymp h 1 1
in fras pin atu s, 7 5 , ,

ax illary 2 6 2 8 2 9 67
lata, 23 3 , 3 1 9 , , , ,

brach ial 6 7
l
i iac p art o f, 2 2 9 , 23 4 , 2 3 8 ,
cu bit al, 6 3 , 6 7, 6 8
,

2 48
de lt o p e cto ral, 1 9 , 6 7
-

p e ctin e al part o f, 2 2 9 , 2 34 hypo g astric, 36 3

o f le g, 3 38 , 366
iliac , co m m o n , 36 3
lu m bo do rsa , 5 1 , 5 5-
l in frac av icu lar, 6 8 l
p e ctin e a , 2 2 9 , 2 34 l
o f lo w e r im b, 36 1
o f pe cto ral re g io n , 1 8
lu m bar, 36 3
p o
p li t e al, 30 7
o lit e al, 30 8 , 36 3
o f sh o u lde r, 7 5 p p
su bscapu lar, 8 5
su bin g u in a , 2 2 5, 2 2 6, l
o f thigh , 2 33 , 3 1 9
36 3
t ibial, an te rio r,
.

t ran sv e rsalis, 2 4 0 , 2 4 1 , 2 4 3
o f u p p e r lim b, 66
o f u pp e r lim b, 7 2
Glan ds, m am m ary , 1 1 , 1 4
s upe r fi cial, 1 1 , 2 2 2
se bac e o u s , 1 1, 222
o f arm , 6 2

o f back , 50
w e at
s , 1 1, 222

o f bu tto ck , 2 8 1
G ro o v e ,
in gu in al, 2 13

o f fo o t , do rsu m , 3 34

so l e , 2 2 3, 381 H air fo ll icle s ,

1 1 ,
222

o f f o re arm , 6 2 H am , 30 4
o f h an d, do rsu m , 6 2 H am ate bo n e , 1 5 2
p alm , 6 2 , 7 0 , 2 2 3 H e rnia, fe m o ral, 2 4 3
446 I N D EX

Ligame n t s ( co n td ) . Ligame n t s, t ra n sverse ( co n td .

c u bo n av icu lar, 4 4 o f kne e , 4 1 7

3
-

cu n e o n av icu ar, 4 -

33 l o f m e tacar als, 1 2
p 9
de lto id, 4 2 2 o f m e tatarsals, 39 9
o f e lbo w , 1 9 5 o f scap u la , in fe rio r, 8 9

gle no h u m e ral, 1 2 4 su pe rio r, 59 , 8 9

-

o f hi , 3 2 su e rfi cial, o f fo o t ,
p 5 p 38 3
ilio fe m o ral, 32 7
-
o f h an d, 7 0

in g uinal, 2 1 4 , 2 2 0 , 2 3 7 , 2 4 7 z
t rap e o id, 9 2
in t e rcarp al, 2 0 5 u ln ar c ar al, 1
p
-

99
in te rclav icu lar, 38 v
ag in al, o f fin g e rs, 1 6 2
inte rcu n e ifo rm , 4 33 o f to e s, 39 2
in te rm e tacarp al, 2 0 8 v o lar acce sso ry, 2 1 1
in t e rm e tatarsal, 4 36 Y sh ap e d, 3 2 7
-

in te ro sse o u s, tibio fibu lar, 4 2 7 L in e , N e lato n s, 2 80

’
-

in t e rph alan g e al, o f fo o t, 4 38 Ly mp h glan ds , a illary , 2 6 , 2 8 ,

-
x
o f h an d, 2 1 1 29 , 6 7
in te rtarsal, 4 2 9 brach ial, 6 7
isch io cap su lar, 32 8-
cu bit al, 6 3 , 6 7 , 6 8

o f kn e e , 40 7, 4 1 4 de lto p e cto ral, 1 9 , 6 7

-

lacin iatu m , 36 6 , 3 6 8, 3 7 8 , 38 7 hy po g ast ric , 36 3

lacu n ar, 2 8 8 , 2 4 3, 2 4 7 iliac , co m m o n , 36 3
o f late ral m alle o lu s , 4 2 7 in fraclav icu lar, 6 8
me tacarp al, t ran sv e rse , 1 9 2 o f lo w e r lim b,
“

3 6 1
m e tacarp o ph alan g e al, 2 1 1 -
lu m bar, 36 3
m e tatarsa , t ran sv e rse , 39 9 l p p e al, 30 8, 36 3
o lit
m e tatarso ph alan g e a , 4 38 -
l su bin gu in al, 2 2 , 2 2 6 , 2 2 8 , 360 ,
5
p a t e llae , 2 1 5 6 5, 4 0 7
,
2 36 3
p iso h am at e , 2 0 6
-
t ibial, an te rio r, 36 3
p iso m e tacarp al, 2 0 6 o f u p e r limb, 6 6
p
-

p lan tar acce sso ry , 4 8

3
-
v
Ly mp h e sse ls, affe re n t , 2 2 9, 36 3
lan tar, lo n g 386 , 39 2 , 4 2 8 , 4 32 e ffe re n t , 2 2 9 , 36 3
p ,

p p
o lit l
e a , o bliq u e , 4 0 8 , 4 0 9 x
o f le g, 3 37

u bo cap su lar, 3 2 8 o f mam m ary g lan d, 1 7

p
-

q u adratu m , 1 9 5 o f lo w e r lim b, 36 1

radio c arp al, 1 9 9

-
o f u p p e r lim b, 6 6

ro u n d, o f fe mu r, 330
o f u te ru s, 2 2 6 M alle o li, 2 1 5, 2 1 6 , 33 2 , 333
sacro sp in o u s, 2 9 0 , 2 9 1
-
M amm a, 11 14
sac ro t u be ro u s, 2 88 , 2 90 , 2 9 1
-
lym p h v e sse ls o f ,
17

o f scapu la, t ran sv e rse , in fe rio r, in m a e , 1 7 l

9 M an u briu m , 8
su p e rio r, 59 , 89 M an u s, 1
o h o u l de r
f s , 1 19 M arg o falcifo rmis, 2 2 9
su sp e n so ry , o f a x ill a, 2 4 M e du lla sp in alis, 5
t alo -
calcan e an , 42 9, 4 30 M e mbran e , c o sto co raco id, -
1 8, 22 ,

t alo fibu lar, an te rio r, 4 2 2

-
2 3, 2 4
p o st e rio r, 4 2 2 in te ro sse o u s, o f fo re arm , 2 0 3
t alo n a icu lar, 4 30
-
v o f le g, 4 2 5

t arso m e tatarsal, 4 35
- M e n isci o f k n e e , 4 1 5
o f t arsu s, 4 2 9 M e tac arpal bo n e s , 2 , 4
t e re s fe m o ris , 330 M e tatarsal bo n e s, 2 1 6 , 333
u te ri, 2 2 6 l
M u tan gu lu m m aj u s, 1 4 9
t ran sv e rse , o f ace t abu lu m , 3 30 M u scle s
cru ris, 3 39 , 3 53 a bdu cto r dig1 t1 q u in ti , o f fo o t, 38 5 ,
o f h u me ru s, 1 2 2 387
 I N D EX 447

M u s cle s ( co n td ) . M u scle s ( co n t d ) .

a bdu ct o r d git i i q u in ti ,
o f h an d , f ex o r digito
l ru m l g
o n us, 37 1 , 3 7 6 ,
I S3 3 7 7 , 386 , 39 1
h all ucis
38 5 , 3 8 7 , p ro fu n dus, 1 4 7 , 1 4 8 , 1 6 4
in dicis, 1 9 4 l
su b imis, 1 30 , 1 39 , 1 4 1 , 1 6 4
ll
p o ic is bre v is, 1 60 , 1 6 9 h allu cis bre v is, 385, 394 , 3 9 5
lo n g u s, 1 7 4 , 1 8 2. 1 89 lo n gu s, 3 7 1 , 37 6 , 3 7 7 , 38 5 ,
adducto r bre v is, 2 66 , 2 7 2

l
h a lu cis, 39 5 p ollic is bre v is, 1 60 , 1 6 9
l g
o n u s, 2 4 5, 26 6 de e p h e ad, 1 7 0
mag n u s, 2 66, 27 6, 2 9 3, 2 95, l
o n gu s , 1 4 7 , 1 4 8 , 1 60 , 1 6 6

30 5 , 39 7 gastro cn e miu s, 30 5 , 30 7 , 3 6 9
p e n i n g 1 11 , 2 53
o l
g e m e lu s in fe rio r, 2 93, 2 9 5, 2 9 9
p o l ic il
s,
1 60 , 1 7 0 su e rio r, 2
p 93, 2 9 4 , 2 9 9
an co n ae u s, 1 74 , 1 81 x
g lu taeu s m a imu s, 2 33 , 28 5 , 2 9 5
articu laris ge nu ,
2 6 5, 2 66 m e dius, 2 4 9 , 2 50 , 3 0 1
bic e ps brach ii ,
2 3, 2 6, 9 4 , 99 , m in im u s, 2 4 9 , 2 50 , 3 0 3
106 g racilis, 2 66 , 2 7 5 , 30 7 , 3 57
lo n g h e ad, 1 2 6 h amstrin g , 2 90 , 2 9 3, 2 9 5 , 30 5,
fe m o ris, 2 1 5 , 30 7 , 3 1 9 , 3 21 ,
42 6 iliacu s, 2 7 7
brach ialis, 9 9 , 1 0 8 infrasp in atu s, 8 5 , 88
brach io radia is, 9 9 , 1 30 , 1 74 , 1 7 6
-
l in t e rco stal, 2 3
co cc yg e u s , 2 95 in te ro sse i o f fo o t , 3 8 5 , 4 0 0
c o rac o -
brach ialis, 2 3, 2 6, 9 4 , 99, o f ban d, 1 8 1 9 3
7 ,
106 latissim u s do rsi, 8, 1 4 , 1 8, 22,
de lto id, 2 , 7 , 1 8, 7 7 56
re latio n s o f, 7 8 i n se rtlo n , 87
do rso e p itro chle aris, 8 7
-
le v ato r an i, 2 9 5
ex t en so r c arp i radia is l bre v is, sc ap u lae ,
5 3 , 59 , 6 0
I 74 a 1 8 0 , I 9O lu mbri cale s o f fo o t , 3 8 ,
5 39 2 , 3 9 4
lo n gu s , 10 0 , 1 74 , 1 7 9 , 1 90 o f ban d, 1 6 6 , 1 7 8

u ln aris, 1 74 , 1 81 , 1 9 1 l ,
x
o b iq u e , e te rn al o f abdo m e n , 1 4 ,

co m mo n o rigin , 1 80 , 181 4 7, 5
dig iti q u in ti p ro p riu s , 1 74 , 1 80 , o x
btu rato r e t e rn u s, 2 7 7 , 30 0
191 in t e rnu s, 2 93 , 2 9 4 , 2 9 9
dig ito bre v is, 3 5 1
ru m o m o hy o id, 4 1 , 5 9
mm u n is, 1 7 4 , 1 7 8 , 1 8 0 , o pp o n e n s digiti q u in ti, 1 3
co 191 5
lo n gu s
34 2 , 3 4 5 , p o llicis , 1 60 , 1 6 9 , 1 7 0
x
e p an sio n o f fi ng e rs, 1 7 8 p a lm ari s b re v is, 6 3, 1 5 2
o f t o e s, 3 4 6 lo n gu s, 7 3 , 1 2 9 , 1 30 , 1 38, 1 4 0
l
h al u cis bre v is, 3 5 1 p e c t in e u s, 2 6 6 , 2 7 0

lo n gu s, 34 2 , 3 4 6 p e cto ralis m aj o r, 2 , 7 , 8 , 1 4 , 1 6 ,
in dicis p ro p riu s, 1 8 4 , 1 9 1 1 8, 20 , 2 2 , 24
o ll ic is bre v is, 1 7 4 , 1 8 3 , 1 8 9 in se rtio n , 8 7
p
lo n gu s, 1 74 , 1 8 3 , 1 90 min o r, 8 , 2 2 , 2 4 , 26 , 2 7
e x tern al o bliq u e , o f abdo m e n , 1 4 , p e ro n aeu s bre v is, 3 55
4 7 , 55 dig iti q u in ti, 3 5 5
lo n gu s, 3 5 5
.

radi ali s,
fl ex o r c arp1 1 30 , 140,
in se rtio n , 4 0 0
u ln ari s, 1 30 ,
1 38 , 1 4 0 , 2 0 6 t e rtiu s , 34 3, 3 4 7
mm o n o rigin , 1 39 irif o rm is, 2 2 , 2 9 4 , 2 9 9
co p 9
digiti q u in ti bre v is o f fo o t , 38 5 , p lan t aris, 30 7 , 3 7 0
p la ty sm a, 1 1 , 4 1

f ban d, 1 53
o l
p o p ite u s, 3 7 6 , 4 0 7 , 4 0 8 , 4 1 1
digito ru m bre v is, 38 5, 3 8 6 p o n ato r q u adratu s, 1 4 8
r
 I N D EX

M u scle s ( co n t d ) . Ner ve s ,
a rt icu la r
( co n ta
’
.

pro n ato r te re s, 1 30 , 1 39 t o in te rm e t ac arp al o in t s, 2 1 1 j

p so as m aj o r, 2 77 to in te rp alan e al o in t s oh g j f
q u adratu s fe m o ris ,
2 9 3, 2 9 5 , 30 0 h an d , 2 12

p l 38 6 , 3 9 2 , 3 9 4
an tae, to kne e , 2 58, 2 7 5, 3 1 0 , 3 1 3,
q u adrice p s fe m o ris, 2 6 1 3 1 5, 3 1 8 , 3 57 , 4 0 2 , 4 0 5
in se rtio n , 2 6 5 t o m e taca rp o ph a an g e al j o in t s, -
l
re c t u s fe m o ris , 2 4 8, 2 6 2 2 12
re fle c t e d h e ad, 2 50 , 3 0 4 m e t atarso p h alan g e a j o in t s ,
to -
l
rh o mbo ide u s m aj o r,
5 3 , 59 , 60 3 52
m in o r, 5 3 , 5 9 l
t o sh o u de r, 7 8 , 84 , 9 2
sacro S in a is, 4
p
-

9 l t o t arsal j o in t s, 3 5 3
sarto rius, 2 4 5 , 2 4 8 , 2 5 0 , 30 7 , 3 5 7 t o tarso m e tat arsa j o in t s, 3 52
-
l
scale n u s an te rio r, 4 1 t o w rist , 1 82 , 2 0 1 , 2 0 8
m e diu s, 4 1 , 4 6 x
a illary , 2 8 , 4 3 , 7 7 , 8 3
se m im e m bran o su s , 2 2 1 , 30 7 , 3 1 9 , calc an e an , m e dial, 3 59 , 37 , 8
5 3 3
o f car al j o in t s, 2 0 8
p
se m ite n din o su s, 22 1, 30 7, 31 9, o f c ar o m e tacar al j o in ts, 2 1 1
p p
-

l l l
co l ate ra , u nar, 2 8 , 1 1 7
se rratu s an t e rio r, 3, 14, 1 6, 1 8, cu t an eo u s, 6 , 1 1 , 2 1 8

7, 4 7
2 3, 2 o f arm , late ra , 6 8 , 6 9 , 7 , 84
5 l
p o st e rio r in fe rio r, 6 1 m e dial, 2 6 , 4 3 , 6 8 , 6 9 , 9 7 ,
su p e rio r, 6 0 100
so le u s, 3 70 p o ste rio r, 2 8 , 7 0 , 9 7
ste rn o hyo id, 39 -
o f back , 5 1
t
s e rn o m asto id, 8 -
o f bu tt o ck , 2 8 2
st e rn o thy re o id, 39
-
o l
f c a f, late ral, 3 1 0 , 3 1 5 , 33 5,
su b an c o n aeu s, 1 1 4 , 1 1 8
-
337
su bc lav iu s, 2 4 , 2 5 , 3 7 m e dial 30 9 , 3 1 2 , 3 59 , 3 6 5
,

su bsca u laris , 2 2 , 7 8 , 8 6 , 8 8 o f c h e st , an t e rio r, 1 2 , 1 4

p
su pin ato r, 1 1 0 , 1 9 4 lat e ral, 1 3 , 1 4 2 7 , 30 ,

su p rasp inat u s, 59 , 8 5 , 88 do rsal o f u n ar, 6 8 , 7 1 , 1 2 8 ,

, l
t e n so r fasc iae latae , 2 33 , 2 4 8 , 25 9 1 46
t e re s m aj o r, 8 , 1 8 , 2 2 , 3 2 , 8 6 o f fo o t , in te rm e diat e ,
338
m in o r, 8 5 , 89 late ral, 338 , 36 6
t ibialis an te rio r, 34 2 , 3 44 m e dia , 3 38 l
o st e rio r, 37 1 , 3 7 6 , 3 7 7 , 4 2 8 o f fo re arm , do rsal, 6 8 , 6 9 , 9 7 ,
p
in se rtio n , 4 0 0 1 2 8 , 1 73
z
trap e iu s, 5 1 , 5 3, 5 4 l
late ra , 6 8 , 6 9 , 9 8 , 1 2 7 , 1 2 8 ,
n e rv e s o f, 5 5 , 5 8 1 72
t ric e p s brach ii, 1 1 2 m e dia] , 2 6, 4 3, 66 , 68 , 6 9 ,
v astu s in te rme diu s, 2 4 8 , 2 6 5 97 , 10 0 , 1 2 7, 1 72
late ralis, 2 4 8 , 2 6 3 , 2 9 5 o l
f i io hy po g astric , lat e ral, 2 8 3
m e dialis, 2 4 8 , 26 3 o f in t e rco st als , an te rio r, 1 2 , 1 4
late ral, 1 3 , 1 4 , 2 7 , 30
N av icu lar bo n e o f fo o t , 2 16 o f le
g S ee o f c alf
.

o f han d, 1 4 9 o f lu m bar p o st e rio r ram i, 5 1 ,

v
Ne r e s 2 83
acc e sso r y , 55, 58 p al m a r , o f m e d ian , 6 8 , 7 0 , 7 3,
affe re n t , 2 18 1 2 8, 1 2 9 , 1 4 7
5 ,

o f an kle j o in t
3 52 , 37 6 ,
o f radial, 7 1 , 1 2 8

a rt icu la r, t o an k le , 3 5 2 , 37 6 o f u ln ar, 6 8 , 7 0 , 7 3, 1 2 8,
t o c arp al j o in ts, 2 0 8
t o carp o me tacarp al j o in ts,
-

p e rfo rat in g , 2 83 , 28 4 , 2 8 7 , 2 88
t o e lbo w , 1 1 5 , 1 4 6 , 1 9 8 o f sacral
p o ste rio r rami, 2 83 ,

t o hip , 2 56 , 2 58, 2 7 4 , 30 0 , 2 88
 I N D EX
N e rV e s S e p t a, in term u scu la r co n ta’
l de e p bran ch , 1 6 7
u n ar,
( .

o f le , o f c alf 3 6 7
g , , 37 1
do rsal bran ch , 1 4 6 , 1 7 fibu lar, 34 0
3
u lnar co l ate ral 2 8
, ,
l
1 17 o f fro n t ,
344
o f w rist j o in t , 1 82 , 2 0 1 , 2 0 8 o f
p alm o f h an d, 1 54
N ip p le , 9 , 1 5 o f sca u ar re g io n
p l , 76 , 78
in m ale , 1 7 l
o f so e o f fo o t
, 3 84
N o tch , j u g u ar, 8 l o f th igh , 2
3 5, 2 6 1
S e p t u m, f emo ra l, 2 2
4
O le cran o n , 3, 94 S e samo id bo n e s in
O p e n in g in addu cto r m agn us, 2 5 3, addu c t o r o lic is 1 0
p , 7 , 211 l
2 76 fl e x o r h allu cis bre v is,
39 5 , 4 38
O s co ae , 2 1 3x fl e x o r p o llicis bre v is, 1 0 2 1 1
7 ,
O s h am atu m , 1 52 g astro cne mius, 3 70
O s m u lt an gu lu m m aj u s, 1 4 m e tacarp o p h alan g e al j o in ts 1 0
9
-

, 7 ,
O s trig o n u m , 4 2 2 211
m e tatarso ph alan g e al j o in ts
-

, 39 5 ,

Pa cin ian co r u sc le s 4 38
p 71, 1 59
p e ro ne u s lo n g u s, 4 0 1
,
P ad, in frap ate llar, 4 1 0
t ibialis p o ste rio r
Pann icu lus adi o su s
p , 1 1, 222 .
, 40 0

S h e at h s , f ascial o r bro u s
also F ascia su er cial
p fi fi
Pap illa m ammae 1
,

5, 1 7
x l
a il ary ,
33
Pat e lla, 2 1
4
,
fe m o ra , 2 2 6 , 23 8 l
Ph alan g e s o f fi n g e rs, 2 , 4 fl e x o r, o f fin g e rs, 1 6 2
Pisifo rm bo n e , 1 4
9
o f t o e s,
39 2
P it o f sto m ach , 8 m u co us o r sy n o v ia l
o f bice s brach ii lo n g h e ad
P lex u s, brach ial, 2 , , 39 5 33 p , ,

obtu rato r, 2 50 , 12 4, 126

2 57

p at e l l
ar, 2 2 7 , 2 3 3
o f e xt e n so rs in lo w e r limb , 34 1 ,
su bsarto rial, 2 0
5 , 2 57 353
su btra e ia , z l in u p pe r lim b, 1 7 , 1 6
p 58 5 7
o f fl e x o rs in lo w e r lim b
P li ca S ee also F o ld
. , 3 7 9 , 39 3

alare s, 4 1 0
in u p pe r limb, 1
3 3, 1 3 4 , 1 6 0 ,
P ro ce ss , co raco id, 2 , 7 1 64
o f
sty lo id, o f radiu s
, 4
p e ro n aei, 3 5 4 , 4 0 1
o f
o f u ln a,
3 p o p lite u s, 4 1 1
o f talu s
, p o ste rio r, 4 2 2
o f t e n do c a can e u s
, 368
l
t ro h l e ar 3 33
c ,
o f tibialis an te rio r 3 4 1
, , 3 53
o f tibialis
x iph o id 8 ,
Sh in , 2 1 5 , 3 32
p o ste rio r, 37 9
P u bis, 2 13
Sh o u lde r g irdle , 1
Sin u s, lac tife ro u s, 1 7 , 1 8
R adiu s, 2 , 3 , 4 , 6
9 Sp ac e , q u adrilat e ral,
R e tin acu la o f hi j o in t 77, 8 2
33 1
p e ro n e al, 339: 3 55, 36 7
p ,
t rian gu ar, l
7 7, 8 1
S pin al co rd o r m e du lla
R ib, first, 8 , 5, 2 1 7
Sp in e s o f ilium , su e rio r
sec o n d, 8 p , 49, 2 1 3,
se v e n th , 8
2 79
t w e lfth , 50
o f sca u a, 2
p l , 49
R in g , fe m o ra , 2 4 2 l o f v e rte brae , 48
Ste rnu m , 2 , 8
to m ach,
Sc ap u la, 1 , 2 , 3 , 4 9 p it o f, 8
S ulcu s , g lu te al, 2 80
Scro tu m , 1 1 , 2 2 2 iliac , 2 7 9
Se p t a, in term u scu la r, 7 2 in g u inal, 2 1 3
o f arm , 9 8 , 1 1 8
S urf ace an at o my
o f fo re arm , 1 2 8 1 38
, arm , 94
 I N D EX 45 1

S urf ace an at o my ( a mi d ) V e in s ( co n t d ) .

x
a illa , 8 basilic , m e dian , 6 4
back , 4 8 brac h ia , 37 l
e lbo w , 94 c e p h alic, 1 9 , 2 3 , 2 , 6 , 6 5
5 3 , 94 ,
fO O t , 3 33 96 , 1 2 7 , 1 72
g l u te al re gio n 2 79 , m e dian , 6 4
h an d 1 4 9 1 7 1
, , c e rv ic al, t ran sv e rse , 4 1

le g, 332 x
circ u mfl e , fe mo ral, late ral, 2 0
3
lo w e r limb, 2 1 3 m e dia] , 2 30 , 36 1
p e c to ral re g io n , 7 l
c u bita , m e dian , 6 , 6 , 6 6 , 6
3 5 9
p po l it e a l re gi o n , 30 4 dig ital, do rsal, o f fo o t , 3 35 , 3 3 6
th igh , 2 1 8 o f h an d, 6

r lim b 1 e pig astric , su e rficial, 2 2 , 2 0

u
pp e , p 7 3
Su rg ic al an ato my o f p alm fe m o ral, 2 4 6 , 2 4 7 , 2 5 6
fin ge rs ,
171 iliac , c irc u m fl e , su p e rficial, 2 2 7 ,x
Su ste n tacu u m ta i, 333 l l 2 30
Sy m physis pu bis, 2 1 3 l
in gu in a , su p e rficial, 2 2 7
Sy n de sm o sis tibio fibu laris, in n o m in ate , 6 7 , 36 2
4 26 j u gu lar, an te rio r, 38
x
e t e rn al, 4 1

Talu s, 2 1 6 , 33 3 m e t ac arp al, do rsal, 6 3

Tarsu s, 2 1 6 p po lit e l
a , 30 7 , 3 1 1 , 3 1 8 ,
37 2
Te n do calcan e u s, 2 1 6 , 3 3 3 , 3 7 1 p ro fu n da fe m o ris, 2 4 6 , 2 4 7
Th e n ar, 1 4 9 p u de n dal, e t e rn al, x
su p e rficial,
Tibia, 2 1 5 3 32 ,
2 2 7 , 2 30
l
Trac t , i io tibial, 2 33 , 2 4 8 , 2 5 8
-
sap h e n o u s g re at , , 2 2 5, 2 2 7 , 2 2 9 ,
Tri an gle o f au scu ltatio n , 57 2 3 0 , 2 39 , 3 3 5 , 3 57 , 3 5 9
de lt o p e ct o ra , 2 , 7 , 1 8
-
l sm a l l, 30 6 , 33 5 ) 3 59 , 3 6 1
lu m bar ( e tit ) , 5 7 P sc ap u lar, t ran s v e rse , 41
Trig o n e , fe m o ra , 2 4 6 l V e rte bra p ro m in e n s , 49
Tro c h an t e r m aj o r, 2 1 4 , 2 80 , 2 90 V e sse ls , cu tan e o us, 1 1
Tu be r isch iadicu m , 2 1 4 , 2 80 , 2 90 ly m ph , aff e re n t , 36 3
Tu be rcle , addu cto r, 2 1 5 , 30 5 e ffe re n t ,
36 3
o f h u m e ru s, g re at e r, 3 o f le , 337
g
u b ic 2 13 o f lo w e r limb, 36 1
p ,

Tu be ro sity o f fe m u r, g u te al, 2 90 l o f m am m a, 1 7 , 1 8

o f t ibia , 2 1 5 o f u p p e r limb, 6 6

l
V in cu a t e n dinu m , 1 6 4 , 39 3
mm .
2, 3, 4

V e in s W hitl o w 1 72 ,

an tibrach ial, m e dian , 6 4 W rist an d p alm , 1 48

x ll
a i ary , 2 5 , 2 6 , 3 7 , 6 5 , 66
l
basi ic , 6 3 , 6 5 , 9 4 , 9 6 , 1 0 0 ,
1 2 7, Z o na o rbicu l airs o f hip -
j o in t , 32 6,
1 72 32 8

EN D OF V OL . I

P rin ted i n Gre a t B rit a in oy R

’
. R . C L A R K , L I M I T E D , E din bu rg h .