A L ECTUR E 
ON 
THE CLINICAL ANATOMY OF THE LOWER EX- 
TREMITY AND ESPECIALLY OF THE 
KNEE AND ANKLE JOINTS 
DELIVERED BEFORE THE 
ANATOMICAL AND SURGICAL SOCIETY OF BROOKLYN 
Bv W. W. KEEN, M. U., 
OF PHILADELPHIA, 
SURGEON TO ST. MARY’S HOSPITAL ; PROFESSOR OF ARTISTIC ANATOMY IN 
THE PENNSYLVANIA ACADEMY OF THE FINE ARTS. 
REPRINTED FROM THE ANNALS OF ANATOMY AND SURGERY, JANUARY, 1881. 
BROOKLYN, N.Y. 
28 Ma i) ison St rkk t . 
1881. ON THE CLINICAL ANATOMY OF THE LOWER 
EXTREMITY AND ESPECIALLY OF THE 
KNEE AND ANKLE JOINTS.1 
By W. W. KEEN, M. D., 
OF PHILADELPHIA, 
SURGEON TO ST. MARY’S HOSPITAL ; PROFESSOR OF ARTISTIC ANATOMY IN 
THE PENNSYLVANIA ACADEMY OF THE FINE ARTS. 
I HAVE selected the subject just announced not only be- 
cause of its importance, but also because of its neglect. 
We study anatomy, it is true, on the skeleton and on the 
subject faithfully and frequently; but how seldom on the 
living model! Yet it is just here that we need our anato- 
my, when, in the person of the sick man, the bones are 
clothed with muscles, nerves and vessels, and all are covered 
and hidden with skin and fat. Hence I have ventured to 
call it “ clinical anatomy,” because it is the anatomy of the 
bedside. 
In place of the sick man, I shall use to-night this finely- 
developed specimen of health—a man who has served me as 
a model for several years at the Pennsylvania Academy of 
the Fine Arts—and I trust that we shall be able to observe 
together some points that may be both interesting and. in- 
structive. 
1 A lecture delivered before the Anatomical and Surgical Society, May 
xoth, ISBO. IV. W. KEEN. 
Haydon says that he scarcely knows a knee properly and 
simply defined excepting in the Elgin marbles. Even 
artists, who pay the greatest attention to external form, have 
neglected it or misinterpreted it. And first, the obliquity of 
the joint-surfaces as contrasted with the elbow is a matter 
of importance. The humerus, when we are in the anatomi- 
cal position, is nearly vertical, but the forearms diverge in 
consequence of the general plane of the joint running ob- 
liquely from without inwards and downwards. When there- 
fore the forearms are flexed, the arms being kept immobile, 
the hands fall, not on the shoulders, as they would were the 
elbow exactly transverse, but near to or even across each 
other at the middle line. Now, were the knee so arranged, 
when we stoop, the heels would meet and our base of sup- 
port be of the narrowest; but the general plane of the knee- 
joint being from without inwards and upwards, on stooping 
the tibiae are flexed not toward the middle line nor straight 
backward, but a little outward, and so widen our base of 
support. 
FIG. I.—LOWER END OF FEMUR. ANTERIOR SURFACE, 
The first bony outline to which I call your attention, both 
on this skeleton and on the model, is this fossa on the ex- 
ternal condyle for the origin of the popliteus. It is best CLINICAL ANATOMY. 
3 
felt, as you can readily convince yourselves, in flexion. 
Now, such a point as this, like many others of which I shall 
speak this evening, has but little value of itself, and little, if 
any direct relation to any individual case of injury or dis- 
ease ; but our knowledge or ignorance of them is a fair index 
of our familiarity with the coast along which we are sailing. 
A novice may know the chief points, but only the old sailor 
knows every little headland, every jutting promontory, and 
every hidden rock, and to him, be it foggy or be it clear, blow 
it high or blow it low, what danger to avoid and what harbor 
to seek comes instantly and almost automatically. So to 
the surgeon, diagnosis becomes easy and error infrequent in 
proportion as he has it all at his finger ends. 
FIG- 2.—SAWN FEMUR SHOWING LINK OF EPXPHYSAL CARTILAGE 
Passing next to the external condyle, note this tubercle 
for the attachment of the tendon of the adductor magnus. 
The importance of this can scarcely be exaggerated. Its 
hypertrophy as an obstacle to cavalry service is rare and of 
little moment, and its value as a point of measurement is only 
occasional. Yet these, I think, are the commonest remarks 
made in regard to it. But look not only at this solid bone 4 
tV. tv. AfEEAT. 
but on this sawn one, and you will see that the tubercle 
marks two other points of importance; first, it is on a level 
with the upper margin of the trochlear surface for the patella ; 
and, secondly, and most important, it marks the line of the 
epiphysal cartilage. 
Both in the diagnosis of fractures and other injuries, and 
especially in resections and other operations at or near the 
knee, these two points are all-important. Resections of 
the knee are much rarer here than in England, but I 
think that not even there is the importance of this point 
appreciated as it deserves. The long bones grow in length 
at the epiphysal cartilages, but by no means with equal 
rapidity at the two ends; and in the femur it is precisely 
this lower cartilage that does the bulk of the work. 
Any interference with it, therefore, before growth is com- 
pleted (and it is chiefly in childhood and adolescence that re- 
sections of the knee are done) must dwarf the corresponding- 
leg and necessitate either lameness or the use of a crutch or 
high shoe. But in order to appreciate its importance justly, 
let us look at it a little more closely. From birth to adult 
life the body grows 3.37 times its original size. But were 
you to take a baby and model the statue of a man after its 
proportions, so that head, trunk, arms and legs were each 
enlarged three and a third times, you would, have a mon- 
strosity. Different parts of the body grow at very different 
rates. Roughly speaking, the head and neck grow two and 
one-half times, the trunk three times, the arms three and 
three-quarter times, and the legs four and one-half times in 
length. If we measure from the trochanter to the foot 
we find the whole leg grows 4.49 times in the male and 4.15 
in the female. Restricting next our measures to the femur, 
from the trochanter to the patella it increases respectively in 
the two sexes 4.94 and 4.57 times. This includes both 
epiphyses of the femur, and shows that the growth of the CLINICAL ANATOMY. 
lower extremity is not uniform, but is greater in the thigh 
than in the leg. But if we measure from the perineum to 
the patella, we exclude the upper epiphysis and measure only 
the growth due to the lower one; and here we find the most 
rapid growth in the entire body. It increases in the male 
7.30 times, and in the female 6.75 times—more than double 
the rate of growth of the body as a whole. This shows that 
the chief growth of the femur is at the lower epiphysis, and 
is due, doubtless, chiefly to its later ossification as compared 
with the upper. Who, then, would be so rash as needlessly 
to injure it in any operation? Unless it must be sacrificed, 
the facts I have stated cry, Hands off! 1 
But this tubercle is also a guide to the upper margin of 
the trochlear surface of the femur in case it cannot be felt 
or seen. We are very apt to think of this groove in connec- 
tion only with the bone, but a moment’s inspection of the 
knee of the model in flexion shows it to you clearly through 
all the soft parts, and its outlines can be followed down to 
their contact with the tibia. Indeed, it can be seen even 
through the clothing. I need not point out the value of an 
examination of such outlines in cases of gunshot wound, 
suspected fracture, or inflammation of the cartilage or bones. 
Especially, however, is it important to note, as on this liga- 
mentous preparation, how movable is the patella and to 
what a very large extent this trochlear surface, covered by 
the patella in extension of the leg, is exposed to manipula- 
tion when the leg is flexed. 
In connection with this movable patella in varying posi- 
tions of the leg, observe one very important fact as to the 
1 In a paper in St. Thomas’s Hosp. Repts., Vol. X., 1880, p. 277, Mr. Wag- 
staffe gives a striking commentary on these facts In the 25 cases of knee- 
joint diseases (not operations) reported, 76 per cent, showed an appreciable 
alteration in length ; in 56 per cent, there was elongation, the result of hyper- 
nutrition ; in 16 per cent, shortening, and in one case though the whole leg 
was as long as the other, the tibia was shortened and the femur lengthened 
each 2 cm. The greatest alteration in any case was 6.6 cm., and this 
after only one year of disease, the boy being 14 years old. 6 
W. W. KEEK. 
synovial membrane of the knee. We are apt to think of it 
as terminating at the margin of the trochlear surface. But 
this is far from true. It extends, usually, as you see in this 
ligamentous preparation, about 5 cm. (2 inches) above the 
upper margin of the patella when the leg is extended, and 
is gradually pulled down by the patella as flexion proceeds 
until, in extreme flexion, its upper limit is about at the 
upper border of the trochlear surface.1 Hence, in all opera- 
tions near the knee joint at its upper margin, the incisions 
ought to be made while the knee is in flexion. 
When the leg is completely extended and the quadriceps 
is relaxed, the posterior ligament of the knee is tense, and 
the knee, as in storks, is “ locked.” Usually, along with this 
FIG. 3.—PATELLA AND CONDYLES OF LEFT FEMUR VIEWED FROM THE 
KNEE-JOINT.2 
the corresponding hip is locked and all the tension here 
comes on the inverted Y ligament. The opposite leg is 
flexed and the pelvis sinks on that side so that the height of 
1 The following day I was so fortunate as to hear Prof. C. L. Ford’s 
anatomy lecture, when he illustrated on the subject very admirably this 
widely-extended synovial membrane, by a blowpipe driven through the 
patella into the cavity of the partly-dissected but still unopened joint. 
Every inflation of the joint showed not only the great extent of the synovial 
membrane, but also several other later points—e.g., dropsy of the joint, etc. 
2 This vast. int. is only diagrammatic, and is intended to call attention to 
its great thickness over the int. condyle and not to show its mode of inser- 
tion into the patella. CLINICAL ANA TOMY. 
7 
the person is diminished about one and one-half inches. It 
is surprising, however, to see how little variation takes place 
in this in persons of different heights. Thus, in a person 
five feet four and one-half inches in height the loss of height 
was one and four-eighths inches, and in a person just six feet 
high the loss was one and five-eighths inches. In this same 
locked knee, or when in sitting the weight of the extended 
leg comes on the heel, you will note the mobility of the 
patella; and in moving it sideways you will appreciate anew 
the far sharper hill formed by the external condyle, and 
therefore its greater resistance to dislocation in this direc- 
tion, though the knee looks largest on the inside on account 
of the lower belly of the internal vastus (see Fig. 4). And it 
is just here that such resistance is most needed ; for, be it 
noted, the thigh and leg are not in a straight line, but, since 
the thighs converge and the legs are vertical, they form an 
obtuse angle on the outside of the knee. When the quadri- 
ceps then acts on the leg and tends to assume a straight line 
—e.g., from the anterior superior spine to the tubercle of the 
tibia—the tendency is to throw the patella outward. But be- 
sides the resistance encountered in the bones we have a 
more powerful safeguard in the arrangement of the muscular 
fibres. I have not the dissected subject here, but this cast, 
taken directly from a good subject at the Academy of the 
Fine Arts in Philadelphia, will reproduce it to you. The 
fibres of the external vastus terminate near the upper bor- 
der of the patella and terminate obliquely ; the fibres of the 
internal vastus extend nearly as far down as the lower bor- 
der of the patella, and, moreover, they run transversely, and 
so guard the patella from external dislocation—an aid, too, 
that is exerted most powerfully at the moment when most 
needed, i, e., when the quadriceps is tending to produce such 
a dislocation. But turn from the cast of the dissection to 
the living model. Let him call the muscles of the knee into 8 
IV. IV. KEEN. 
vigorous action, and then note here the high external vastus, 
there the lower and stouter internal, here the patella and 
there the “ supra-patellar flat,” as artists call it i. e., the ten- 
don chiefly of the rectus, and here the ligamentum patellae 
and then, if never before, you will appreciate not only the 
facts to which I have asked your attention but the value of 
this method of studying anatomy. It adds a living interest 
to it that the cadaver cannot give ; muscles can be relaxed 
FIG. 4.—THE FIBRES OF INSERTION INTO THE PATELLA. OF THE VASTI 
MUSCLES. 
or contracted and their reliefs studied in relation to vessels, 
nerves or other neighboring organs of importance ; the lungs 
can be perceived in expansion and contraction ; the position 
of the stomach, the liver, the intestines, the bladder, etc., can 
be shown ; the course of the arteries exhibited ; movable bones 
shown in various positions ; the relations of parts in different 
postures shown clearly and in their relations to medicine, 
surgery, obstetrics, etc., and all shown at the most important CLINICAL ANATOMY. 
9 
time—i. e., the very moment when they are being studied. 
I began this method of studying anatomy with my classes 
some twelve years ago, and I have been more and more con- 
stantly and increasingly impressed with its value from year 
to year. So true is this that I venture to affirm that the 
living model should form as indispensable a part of the means 
of illustration in the anatomical lecture room as the cadaver. 
In not a few respects, indeed, it is even more important. 
If its inconvenience and expense be urged, I may remind 
you that one model we always have—ourselves—and it is 
surprising how much anatomy we may learn from studying 
our own bodies. 
But besides the fibres of the vasti which reach the tibia 
through the patella and its ligaments, others, whose tension 
can be felt on each side, go directly to the tibia, and these, 
together with the tensor vaginae femoris and glutaeus maxi- 
mus which reach the tibia through the fascia lata, explain 
why it is that in cases of ankylosis or fracture of the patella 
or rupture of its ligament, we not uncommonly see a moder- 
ate amount of extension still retained. The tendon of the 
tensor vaginae femoris is best seen by standing on one leg 
and crossing the free leg to the outside of the other, where 
it should bear just enough weight to steady the body. You 
see it shows in the model, but shows feebly. Had we a 
female model it would show far more sharply. 
The ligamentum patellae is best seen in about two-thirds 
extension of the lifted leg, the foot being unsupported. Ten- 
sion then brings it into relief. Its condition, moreover, may 
be of use, even in so distant an injury as fracture of the neck 
of the femur. My friend Dr. Cleeman, I believe, first called 
attention to this fact: that the ligament may be relaxed and 
wrinkled in consequence of the approximation of the two 
points of attachment of the muscles. It will not always be 
the case, but it may sometimes help us, and in such obscure W. W. KEEN. 
cases as these often are, not even slight helps are to be 
despised, as you know. In dropsy of this joint, as this liga- 
ment resists the pressure of the fluid so much more firmly 
than the looser capsular ligament on each side of it, it forms 
a furrow flanked by the dropsical swelling. But this must not 
be confounded with the slighter normal bulge on each side of 
the ligament, due to the fat beneath it. This fat in flexion 
recedes within the articular cavity, but in extension is quite 
evident. Another effect of any considerable effusion into 
the joint is the lifting up of the patella so that it is no longer 
in contact with the femur. In the model you note that a 
blow on the patella is received at once by the femur, but in 
dropsy of the knee joint the patella has an elastic cushion 
of fluid behind it, whose resilience is perceived, and on sud- 
den pressure the patella is felt to strike against the femur. 
Both of these signs are wanting in peri-articular effusion ; 
from the difference in the physical conditions the swelling 
is uniform, and impact is absent. In well-nourished young 
children, however, it is to be remembered that the fat about 
the knee is so great that it causes great transverse creases, 
and may obscure the differential diagnosis just referred to. 
It acts as an important protective cushion until the ossifica- 
tion of the patella, which does not begin till about two and 
one-half years of age. 
I need scarcely refer to a third variation in form of the 
knee—viz., that of housemaid’s knee due to the distension 
of the bursa over the patella. Its median position, its pro- 
jection directly over the patella and its limitation to this 
spot, together with its history, proclaim its character at 
once. 
Placing the knee in about one-third flexion—as the model 
does now—you notice the transverse furrow between the tibia 
and the femur, and then you can examine the proximal sur- 
faces of these bones to a considerable extent, and determine CLINICAL ANATOMY. 
11 
their condition. The internal tuberosity of the tibia, the 
external, with the attachment of the tendon of the tensor 
vaginae femoris, are both to be studied till we are familiar 
with their outlines. Nor must the head of the fibula be over- 
looked. Its form is to be studied, and also its position—not 
lateral, but postero-lateral. 
Let us look next at the tendons behind the knee. Besides 
the gracilis and the sartorius, which, by the way, are only ten- 
dinous below the knee, we have three chief tendons, called the 
ham-strings, the semi-tendinosus, and -membranosus inter- 
nally and the biceps externally. The biceps tendon is easily 
felt, and the other two can be differentiated with a little care. 
The slender cord next the popliteal space is the semi-tendin- 
osi^s; and, as you see now, I can slip my finger some distance 
into the interspace between it and the semi-membranosus. 
And now let me direct your attention to one fact very prom- 
inently perceived at the knee, but which has its repetitions 
at not a few points over the body. Try an experiment on 
yourselves to-night. Stand, as the model is, with your back 
against the wall, keep the pelvis fixed, and then flex the 
knee as far as you can on the trunk. You see you can almost 
make the knee touch the belly; but observe that the leg is 
flexed on the thigh as is the thigh on the pelvis. Now vary 
the conditions; flex the thigh as before, but keep the leg ex- 
tended. You see that the heel can only be lifted a short dis- 
tance from the ground ; and on trying the experiment per- 
sonally you will find that any effort to carry the rigid leg 
higher will produce a sharp pain behind the knee. Now flex 
the knee, and, as before, you can carry the bent knee as high 
as you please. Why? Because the raising of the rigidly 
extended leg stretches the ham-string muscles, and when they 
have once reached the limit of their natural extension, what 
Prof. Cleland calls their “ ligamentous action ” comes into 
play. The distance from the tuber ischii to their tibial inser- 12 
IV. tV. KEEN. 
tion is increased by flexion up to a right angle some 6 or 8 
cm. or even more. The experiment can be reversed, and is 
then a reminiscence with nearly all of us. Keeping the knee 
rigid, try to bend over and touch the ground with the fingers. 
Only a few, and those chiefly trained to it by practice, can do 
so. Flexion of the pelvis on the rigid leg is limited by the 
ham-strings, as was flexion of the rigid leg on the pelvis. Try 
a similar experiment with the wrist (and you can do so at the 
instant). The fingers being extended, flex your wrist, and 
you see that in general you can flex it to the right angle. 
Next extend the wrist, and then flex it again, but not now 
with the fingers extended but made into a “ fist.” Instead 
of reaching 90°, you see that flexion in my wrist scarcely 
passes beyond 30° or 350, though in others it may (though 
rarely) pass even to 6o° or 70°. In other words, the exten- 
sor muscles, by making a fist, were stretched nearly to their 
limit, and, on flexing the wrist 30°, their extreme limit was 
reached and flexion was arrested. Now, what lesson shall we 
learn from this ? That in all cases of passive motion (as to 
prevent anchylosis or after fracture of the thigh or at the 
wrist, etc.) we must be careful not to o’erstep the bounds of 
nature. We must not flex the wrist with fingers already 
flexed but extended, nor flex the thigh with the leg extended 
but flexed. And it is because I have so often seen needless, 
nay more, positively harmful torture inflicted by such inju- 
dicious passive motion, that I insist so strenuously on the 
point. To ascertain the limit in the individual patient, “ take 
the bearings of the other leg,” as I once knew a shrewd cap- 
tain to state his method of treating a fracture at sea. 
Dr. Allis, who has studied fractures and dislocations, as 
you know, with such admirable discrimination, proposed 
some time since a new physical sign to diagnosticate a sciatic 
dislocation of the femur. He places the patient on 
with the legs elevated at right angles to the trunk, when the CLINICAL ANATOMY. 
dislocated leg will be as much shorter as the sciatic notch is 
behind the acetabulum. On the skeleton and in children 
this can be done exactly, but rarely will it be found practica- 
ble with adults except the knee be first flexed. This will 
impair the value of the method, since the measurement must 
then be made from the ant. sup. spine of the ilium to the tu- 
bercle for the tendon of the adductor magnus or to the pa- 
tella, both less accurately defined points than the malleolus. 
You will remark that I said “ on the skeleton and in chil- 
dren,” for we have here an interesting example of another 
fact which we doctors are apt to overlook. The best acro- 
bats of the circus, as a rule, are trained from childhood, when 
the limbs are so much more supple than in later life. Look 
at one of your children sitting on the floor, and see how 
without any effort—without even leaning back—he can raise 
his heels from the floor, making the hip the apex of an acute 
angle between the leg and the trunk ! The facility, too, with 
which young children can put their toes into their mouths 
every one knows. Now, this dexterity and flexibility do not 
only come from shorter legs, but from an anatomical differ- 
ence in the very structure of the muscles in childhood and 
adult life. Starting from adult life as we go backward 
towards adolescence, youth and infancy, we find progress- 
ively more muscular substance and less tendon in the mus- 
cles ; that is, more of the contractile and elastic tissue and 
less of the inelastic. With every year from birth to old age 
the fibrous tendon invades the belly of the muscles and re- 
duces our suppleness of joint and sinews. The caution I gave 
you, therefore, as to passive motion is to be modified some- 
what by the age of the patient. 
Between the hamstrings lies the popliteal space, and with 
our model standing on one foot and resting the other on the 
seat of a chair, you appreciate with ease the difference of the 
mechanical conditions; how readily the space is invaded W. W. KEEK. 
by pressure in the flexed leg, so that the artery can be com- 
pressed, while in the extended leg the surface is rigid, elastic, 
and instead of being a hollow is a projection. This is caused 
chiefly by the posterior projection of the large femoral con- 
dyles in extension, together with the tightening of the ham- 
string tendons and the fascia surrounding them. Directly 
through the middle of the space runs the internal popliteal 
nerve but a little distance below the skin, then comes the 
vein, then the artery next the bone, and therefore suscep- 
tible of such pressure by flexing the knee, that this is, as you 
remember, a recognized method of treating popliteal aneur- 
ism. It must not be forgotten that, while in the lower part 
of the ham these three overlie one the other, in the upper 
part the vein and artery lie successively a little internal to 
the nerve. The external popliteal nerve has even a more 
important relation than the internal. It lies immediately 
alongside of the tendon of the biceps and the head of the 
fibula to their inner border. It can be felt and snapped like 
a violin string in thin persons. In tenotomy of the biceps 
it is most carefully to be avoided, for, if severed, paralysis of 
the anterior muscles of the leg, and what may be called 
“ foot drop,” results. 
I must pass over, I find, several other interesting points 
about the knee, and come to the ankle-joint; and first note 
the two malleoli. How different their shape and position : 
the internal is square, the external conical; the external is 
not opposite to the internal, as in the lower animals, but is 
below and behind it. And this may aid us in fractures both 
in diagnosticating the line of fracture, if obscure, and in the 
accurate reposition of the parts ; for when the knee is straight 
forward the foot naturally is slightly everted ; or, if the foot 
be straight forward the knee is slightly inverted. In rickets 
and chronic periostitis, also, the enlargement especially of 
the internal malleolus may be of much diagnostic value. CLINICAL ANATOMY. 
15 
Again, the familiar mortising of the astragalus into the 
intermalleolar space, as I pointed out some ten years ago, 
may be of great value in diagnosticating Pott’s fracture of 
the fibula, and I have often found it present and decisive 
when the other usual signs were either obscure or absent. 
Looking at this ligamentous preparation, we see that this 
mortise is exact. It allows no 
lateral “ play ” to the astra- 
galus. 
But when the fibula is bro- 
ken three or four inches 
above the ankle, if you grasp 
the leg with the left hand at 
this point, the upper end of 
the lower fragment approach- 
es the tibia; the lower end, 
the malleolus, must be tilted 
outwards, thus widening the 
intermalleolar space consider- 
ably. Seize, now, the foot 
with the right hand, the palm 
being under the sole and the 
thumb and fingers grasping 
the astragalus from below, 
push it sidewise towards the 
fibula as far as you can, as 
you see me attempt in this 
unbroken leg; then suddenly shove it sidewise towards the 
tibia, against which it will come with an easily-perceived 
impact if fracture exist. If none exist, the astragalus can- 
not be separated from the tibia, and, therefore, cannot strike 
it. One caution is needed. You must not mistake lateral 
flexibility of the foot at the medio-tarsal joints for the tibio- 
fig 5. pott's fracture of fibula, 
SHOWING WIDENED INTER-MALLEOLAR 
SPACE. IV. W. KEEN. 
tarsal lateral movement—a mistake very easily made unless 
we are on our guard. 
In extension, as you can readily see, both on the model 
and in this ligamentous preparation, a surprisingly large por- 
tion of the articular surface of the astragalus is amenable to 
our touch (Fig. 6), and the two ridges between the lateral 
FIG. 6.—THE ANKLE JOINT IN EXTENSION 
and upper surfaces are perceptible even to the sight, as well 
as to touch. This it is very important to recognize in cases 
of accident. In one obscure case of comminuted fracture 
of the astralagus, with dislocation of the fragments, I was 
enabled to determine the nature of the accident chiefly by 
this sign, the dislocated part being thrust between the tibia 
and the tendo Achillis, but recognizable by its shape. It is 
not to be forgotten, also, that the articular surfaces of the 
astralagus do not form a rectangle, thus f j, but a trun- 
cated wedge, like this / \. 
Not uncommonly as a result of sprains, the inner wall of 
one of the malleoli through tension on the ligament may be 
broken. You see how thick the malleoli are, and how 
readily a sliver of the articular surface may be broken off. CLINICAL ANATOMY. 
Crepitus may rarely be obtained, but by no possible means 
can the broken fragment be felt on the exterior; and yet, 
the joint may be most seriously injured, and its usefulness 
even destroyed. Mr. Callender has named such accidents, 
very happily, “ sprain fractures.” 
Placing the model now on one foot, you notice how, as his 
equilibrium is disturbed, several tendons in front of the ankle 
repeatedly spring into relief and subside again, in the effort 
to maintain the erect posture. This—the most prominent 
one just in front of the internal malleolus, and running ob- 
liquely to the inside of the foot—is the tibialis anticus; 
next it is the extensor proprius pollicis, and next to that the 
several tendons of the extensor longus digitorum. All the 
tendons are held down by the anterior annular ligament— 
the anterior tibial very loosely, the others much more firmly. 
In Dr. Fisher’s admirable series of papers on the older anat- 
omists, you will remember an excellent illustration of this 
use of the annular ligaments taken from Vesalius. (See 
ANNALS for January, 1880, page 37.) 
Behind the external malleolus you note also during the 
same unstable equilibrium of the body on one foot how the 
long and short peroneal tendons alternately become promi- 
nently visible and relax, displaying admirably their func- 
tion. Between the inner malleolus and the heel there 
are three others, perhaps even more important on ac- 
count of their relation to the posterior tibial artery and 
nerve. Like all the other tendons, they too, are kept in 
place by an annular ligament. In a line from the malleolus 
to the heel the artery is the middle one of five structures— 
viz.: 1. The tendon of the tibialis posticus; 2. The flexor 
longus digitorum ; 3. Artery; 4. Nerve; 5. Tendon of flexor 
longus pollicis. Of all these, the last is most easily felt on pas- 
sive motion of the great toe, and this, with the midway meas- 
urement from malleolus to heel, will give us exactly the W. W. KEEN. 
position of the artery, and next it the nerve. Wyeth has 
shown that its bifurcation is indicated by a line from the tip 
of the malleolus to the middle of the heel—an important 
point in Syme’s operation. The posterior tibial tendon can 
also be felt at three points—viz.: above the malleolus, at 
the internal border of the tibia ; below and in front of the 
malleolus; and between the malleolus and the scaphoid. 
Active but resisted adduction of the foot with extension, you 
will readily find, on trial, reveals it best. The same action 
with flexion shows the anterior tibial tendon. Both of these 
being powerful adductors, are naturally productive of talipes 
varus if their action be unbalanced by spasm of their muscu- 
lar bellies or paralysis of the peronei, their natural antag- 
onists. 
With the bony landmarks of the foot and ankle you are 
to a large extent so familiar, that I venture to enter into 
detail only in a few points, some of which, I think, are gener- 
ally overlooked or forgotten. Starting from before backward, 
first on the inside (Fig, 7), we find very easily— 
1. The tuberosity on the base of the first metatarsal, at 
which the operation of Lisfranc is done. This is in general 
readily found. 
2. The internal cuneiform. This is not readily found, as 
a rule, for the projection is slight; but it can be easily de- 
termined in two ways: {a), it is nearly midway between the 
base of the first metatarsal and the scaphoid ; and {b) a line 
drawn transversely across the foot from the base of the fifth 
metatarsal, will strike usually the joint between the internal 
cuneiform and the scaphoid. One inch (scant) in front of 
this, and therefore obliquely across the foot lies the joint 
between the internal cuneiform and the first metatarsal. 
You will find these points of value in determining the point 
for Lisfranc’s operation, and in cases of caries, necrosis and 
injuries of the foot. CLINICAL ANA TOM V. 
3. The scaphoid tubercle is very easily determined. Be- 
hind it the operation of Chopart is done. 
4. On a line and nearly half-way from the scaphoid to the 
internal malleolus the internal border of the head of the 
astragalus can generally be easily perceived. This forming 
the keystone of the antero-posterior arch of the foot and 
resting on the elastic calcaneo-scaphoid ligament is a point 
of great value in cases of injury. 
FIG. 7.—INNER BORDER OF FOOT. 
5. The sustentaculum tali is a point usually entirely over- 
looked. Yet there are few feet, and those only very fat 
ones, in which it cannot be felt just behind and nearly an 
inch below the internal malleolus and behind the tendon of 
the tibialis posticus. The tendon of the flexor longus polli- 
cis lies close under its shelter. 
6. Behind and about half-way between the level of the 
sustentaculum tali and the internal malleolus, and nearly 
half-way towards the tendo Achillis is another projecting 
tubercle. This is not like the sustentaculum on the calcis, 20 
W. W. KEEN. 
but is the posterior projection of the astragalus. Behind it 
also lies the tendon of the flexor pollicis. 
7. The internal malleolus. 
1. The base of the fifth metatarsal. Just behind it the 
Lisfranc operation is done, and midway between it and the 
external malleolus is the calcaneo-cuboid articulation for 
Chopart’s operation. In operating on the right foot we 
must be very careful not to forget that the line of the inci- 
sion is an italic v n and not a simple convex line —other- 
wise in going from within outward we shall get into the 
deep hollow between the astragalus and the calcis, and be- 
hind the calcaneo-cuboid articulation. 
Next on the outside we feel— 
2. Another guide in Chopart’s operation to this same ar- 
ticulation is a tubercle on the anterior edge of the calcis in 
front of the external malleolus, and about on a level with it. 
It lies also just behind the extensor brevis. The articulation 
is just in front of the tubercle. 
3. The peroneal tubercle. This lies directly below the 
external malleolus nearly an inch away, and the peroneus 
longus tendon passes behind and under it on its way to 
the sole of the foot. When well developed, and it some- 
times projects as much as half an inch, this is easily found ; 
but like the last tubercle this varies much, and is not seldom 
nearly absent. 
4. The external malleolus. 
I should like to continue with you the study of the foot, 
its arches, both antero,- postero- and lateral, the anatomy of 
the sole of the foot in its outline and axis, its arteries, 
nerves and muscles, and many other points of interest and 
usefulness, but time forbids.  OF j/\_NATOMY and Surgery, 
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