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adductor magnus. It anastomoses, in front of the distal part of the gluteus maximus, with the inferior gluteal and first perforating arteries and with the transverse branch of the lateral circumflex, and, in the substance of the hamstrings, with the muscular branches of the profunda.
(d) The perforating arteries (Fig. 780), including the terminal branch of the profunda, are four in number. They curve posterolaterally, round the posterior aspect of the femur, lying close to the bone and anterior to the wellmarked tendinous arches which interrupt the continuity of muscular attachments; their terminal branches enter Obturator internus the vastus lateralis
and anastomose, in its substance, with one another, with the descending branch of the lateral circumflex, with the arteria genu suprema, and with the superior lateral genicular branch of the popliteal.
Internal pudendal artery
The first perforating artery pierces the insertions of the adductors brevis and magnus, and some of its branches anastomose, anterior to the gluteus maximus, with the inferior gluteal, with the transverse branch of the medial circumflex, and with the transverse branch of the lateral circumflex, forming what is known as the crucial anastomosis.
The second perforating artery pierces the adductors brevis and magnus, and then passes between the gluteus maximus and the short head of the biceps femoris into the vastus lateralis. It anastomoses with its proximal and distal fellows, and with the medial circumflex and the proximal muscular branches of the popliteal artery.
The third and fourth perforating arteries pass through the adductor magnus and the short head of the biceps femoris into the vastus lateralis. Their anastomoses are similar to those of the second perforating.
A nutrient branch to the femur is given off either from the second or third perforating
FIG. 780.-THE ARTERIES OF THE BUTTOCK AND THE POSTERIOR ASPECT
artery, usually the former; an additional nutrient branch may also be supplied by the first or fourth perforating arteries.
(5) The arteria genu suprema (O.T. anastomotic) arises near the termination of the femoral artery, in the distal part of the adductor canal, and divides, almost immediately, into a superficial, saphenous, and a deep (musculo-articular) branch; indeed, very frequently the two branches arise separately from the femoral trunk.
(a) The saphenous branch passes through the distal end of the adductor canal with the saphenous nerve, and appears superficially, on the medial side of the knee, between the gracilis and the sartorius. It gives twigs to the integument of the proximal and medial part of the leg, and it anastomoses with the inferior medial genicular artery. (b) The musculo-articular branch runs towards the knee, in the substance of the vastus medialis, along the anterior aspect of the tendon of the adductor magnus. It anastomoses with the superior medial genicular artery, and it sends branches laterally, one on the surface of the femur and another along the proximal border of the patella, to anastomose with the descending branch of the lateral circumflex, the fourth perforating artery, the superior lateral genicular, and the anterior tibial recurrent.
The popliteal artery is the direct continuation of the femoral. It commences at the medial and proximal side of the popliteal fossa, under cover of the semimembranosus, and terminates at the distal border of the popliteus muscle, and on a level with the distal part of the tuberosity of the tibia, by dividing into the anterior and the posterior tibial arteries.
From its origin the artery passes' distally, with a lateral inclination, to the interspace between the condyles of the femur, whence it is continued vertically to its termination.
Relations.-Anterior.-It is in contact in front and proximo-distally with the popliteal surface of the femur, the posterior part of the capsule of the knee-joint, and the fascia covering the posterior surface of the popliteus.
·Posterior. The artery is overlapped behind, in the proximal part of its extent, by the lateral border of the semimembranosus; it is crossed, about its middle, by the popliteal vein and the tibial (O.T. internal popliteal) nerve, the vein intervening between the artery and the nerve; whilst, in the distal part of its extent, it is overlapped by the adjacent borders of the two heads of the gastrocnemius, and is crossed by the nerves to the soleus and popliteus and by the plantaris muscle.
Lateral.-On its lateral side it is in relation, proximally, with the tibial nerve and the popliteal vein, then with the lateral condyle of the femur, and, distally, with the lateral head of the gastrocnemius and the plantaris.
Medial. On the medial side it is in relation, proximally, with the semimembranosus, in the middle with the medial condyle of the femur, and, distally, with the tibial nerve, the popliteal vein, and the medial head of the gastrocnemius. Popliteal lymph glands are arranged irregularly around the artery.
Branches. (1) Muscular branches are given off in two sets, proximal and distal. The proximal muscular branches are distributed to the distal parts of the hamstring muscles, in which they anastomose with branches of the profunda artery.
The distal muscular, or sural, arteries enter the proximal parts of the gastrocnemius, the plantaris, the soleus, and the popliteus muscles, and they anastomose with branches of the posterior tibial artery and the lower genicular arteries.
(2) The genicular branches are five in number-viz., superior and inferior lateral, superior and inferior medial, and a median branch.
(a) The superior lateral genicular artery passes laterally, proximal to the lateral condyle, behind the femur and in front of the biceps tendon, into the vastus lateralis, where it anastomoses with the arteria genu suprema, the descending branch of the lateral circumflex, and the fourth perforating artery; it also sends branches distally to anastomose with the inferior lateral genicular and with the anterior tibial recurrent.
(b) The superior medial genicular artery passes medially, proximal to the medial condyle, behind the femur, and anterior to the tendon of the adductor magnus, into the vastus medialis. It anastomoses with branches of the arteria genu suprema and of the superior lateral genicular artery.
(c) The inferior lateral genicular artery runs laterally, across the popliteus muscle and anterior to the plantaris and the lateral head of the gastrocnemius; then, turning forwards, it is joined by the inferior lateral genicular nerve, and passes to the medial side of the fibular collateral ligament. It terminates by anastomosing with its fellow of the opposite side and with the superior lateral genicular and anterior tibial recurrent arteries.
A. tibialis posterior
M. flexor digitorum
A. tibialis posterior
M. tibialis posterior
M. flexor digitorum
Tendon of M. tibialis
N. plantaris medialis.-
A. plantaris medialis.
A. plantaris lateralis
N. plantaris lateralis-
A. genu inferior
M. flexor hallucis
M. peronæus brevis popliteal fossa. One of these, the superficial sural artery, runs
M. flexor hallucis along the middle of the back of the calf with the vena saphena parva.
(d) The inferior medial genicular artery passes medially, distal to the medial condyle of the tibia, along the proximal border of the popliteus and in front of the medial head of the gastrocnemius, to the medial side of the knee, where it turns forwards, between the bone and the tibial collateral ligament, and terminates anteriorly by anastomosing with its fellow of the opposite side, with the recurrent branch of the anterior tibial artery, and with the superior medial genicular artery.
(e) The arteria genu media passes directly forwards from the front of the popliteal artery, pierces the central part of the posterior surface of the capsule of the knee-joint, and enters the intercondylar fossa. It supplies branches to the crucial ligaments and to the synovial membrane, and is accompanied by the medial genicular branch of the tibial nerve, and sometimes by the genicular branch of the obturator
(3) Cutaneous branches are distributed to the skin over the
ARTERIA TIBIALIS POSTERIOR.
The posterior tibial artery, the larger of the two terminal branches of the popliteal, commences at the distal border of the popliteus and
terminates midway between the tip of the medial malleolus and the most prominent part of the heel, at the distal border of the laciniate ligament (O.T. internal annular). It ends by dividing into the medial and the lateral plantar arteries, which pass onwards to the sole of the foot.
The posterior tibial artery runs distally and medially, in the posterior part of the leg, between the superficial and deep layers of muscles and covered, posteriorly, by the deep intermuscular fascia which intervenes between them.
Relations. Anterior.-It is in contact anteriorly, and proximo-distally, with the tibialis posterior, the flexor digitorum longus, the posterior surface of the tibia, and the posterior ligament of the ankle-joint.
Posterior. The artery is crossed about 37 mm. (an inch and a half) distal to its origin by the tibial nerve. Elsewhere it is in contact with the intermuscular fascia which binds down the deep layer of muscles. More superficially the proximal half of the artery is covered by the fleshy parts of the soleus and gastrocnemius muscles, between which is the plantaris; the distal half of the artery is much nearer the surface, and is covered only by skin and fasciæ, except at its termination, where it lies deep to the laciniate ligament.
Lateral and Medial.—The artery is accompanied by two venæ comites, one on each side. The tibial nerve lies at first on the medial side of the vessel, then crosses posterior to it, and is continued distally on its lateral side. In the most distal part of its course the artery is separated from the medial malleolus by the tendons of the tibialis posterior and the flexor digitorum longus, whilst the tendon of the flexor hallucis longus lies postero-lateral to it.
Branches. The posterior tibial gives off numerous branches, the largest of which, the peroneal, forms one of the chief arteries of the leg. The branches include
(1) Large muscular branches which are distributed to the soleus, the tibialis posterior, the flexor digitorum longus, and the flexor hallucis longus. They anastomose with the deep sural branches of the popliteal artery and the lower medial genicular artery.
(2) A fibular branch passes laterally, to the neck of the fibula, where it anastomoses with the inferior lateral genicular and the deep sural arteries, and supplies the adjacent muscles.
(3) The peroneal artery (Fig. 781) is the largest branch of the posterior tibial. It arises about 25 mm. (an inch) below the distal border of the popliteus, curves laterally across the proximal part of the tibialis posterior to the medial crest of the fibula, along which it passes to the distal part of the interosseous space. About 25 mm. (an inch) proximal to the ankle-joint it gives off a perforating branch and then passes, posterior to the tibio-fibular syndesmosis and lateral malleolus, to the lateral side of the heel and the foot. It supplies the ankle, the tibio-fibular syndesmosis, and the talo-calcanean joint, and anastomoses with the medial calcanean branch of the lateral plantar artery, and with the tarsal and arcuate branches of the dorsalis pedis.
As the peroneal artery passes laterally from its origin it lies posterior to the tibialis posterior, and is covered posteriorly by the deep intermuscular fascia and by the soleus. As it descends along the medial crest of the fibula it lies in a fibrous canal between the tibialis posterior in front and the flexor hallucis longus behind. The peroneal artery is accompanied by two venæ comites, and is crossed anteriorly and posteriorly by communicating branches between them.
Branches. (a) Muscular branches are distributed to the soleus, tibialis posterior, flexor hallucis longus, and the peroneal muscles. Some pass through the interosseous membrane and supply the anterior muscles of the leg.
(b) A nutrient branch enters the nutrient foramen of the fibula.
(c) A communicating branch passes across the back of the distal end of the shaft of the tibia, about 25 mm. (an inch) above the tibio-fibular syndesmosis, to anastomose with the posterior tibial artery.
(d) The perforating branch passes forwards at the junction of the distal border of the interosseous membrane and the interosseous tibio-fibular ligament, and runs, in front of the ankle, to the dorsum of the foot, where it anastomoses with the lateral malleolar branch of the anterior tibial artery and with the tarsal branch of the dorsalis pedis; it also supplies branches to the tibio-fibular syndesmosis, to the ankle-joint, and to the peronæus tertius.
(4) The nutrient branch, the largest of the nutrient group of arteries to long bones, springs from the proximal part of the posterior tibial, pierces the tibialis posterior, and enters the nutrient foramen on the posterior surface of the tibia. In the interior of the bone it divides into proximal and distal branches, the former passing towards the proximal extremity of the bone, and the latter towards the distal extremity. Before entering the tibia the nutrient artery gives small muscular branches.
(5) A communicating branch unites the posterior tibial to the peroneal artery about 25 mm. (an inch) above the tibio-fibular syndesmosis. It passes posterior to the shaft of the tibia and anterior to the flexor hallucis longus.
(6) Cutaneous branches are distributed to the skin of the medial and posterior part of the leg.
(7) A posterior medial malleolar branch is distributed to the medial surface of the medial malleolus, anastomosing with a corresponding branch of the anterior tibial artery.
(8) The medial and lateral plantar arteries are the terminal branches of the posterior tibial artery. They arise, under cover of the origin of the ligamentum laciniatum, midway between the tip of the medial malleolus and the most prominent part of the medial side of the os calcis (Figs. 781, 782).
Arteria Plantaris Medialis.-The medial plantar artery is the smaller of the two terminal branches of the posterior tibial artery. It passes forwards, along the medial side of the foot, in the interval between the abductor hallucis and the flexor digitorum brevis, to the head of the first metatarsal bone, where it terminates by uniting with the plantar digital branch of the dorsalis pedis, which is distributed to the medial side of the great toe. In its course forwards it
Oblique head of
Quadratus plantæ gives off a superficial
FIG. 782.-THE PLANTAR ARTERIES AND THEIR BRANCHES.
Arteria Plantaris Lateralis.-The lateral plantar artery is the larger of the two terminal branches of the posterior tibial artery. It runs forwards and laterally, first between the flexor digitorum brevis superficially and the quadratus plantæ deeply, and then, in the interval between the flexor digitorum brevis and the abductor digiti quinti, to the medial side of the base of the fifth metatarsal bone, where it turns abruptly medially and, gaining a deeper plane, passes across the bases of the metatarsal bones and the origins of the interossei, and above the oblique head of the adductor of the great toe, to the lateral side of the base of the first metatarsal bone, where it terminates by anastomosing with the dorsalis pedis artery. The last part of the artery is convex forwards and forms the plantar arch, which is completed by the profunda branch of the dorsalis pedis.
Branches. Between its origin and the base of the fifth metatarsal the lateral