CHAPTER XXII. SOME PRACTICAL AMPUTATIONS. (Part 1)

CHAPTER XXII. SOME PRACTICAL AMPUTATIONS. ‘The primary aim of an amputation is to conserve the life or health of the patient; the secondary aim is to conserve, as much as possible, the function of the member, ‘The first requires that as much as neces- sary be removed; the second, that no more than necessary be removed The good surgeon will always adjust and harmonize these wo prin- ciples and they will determine the time and technic of the particular operation. ‘The time element is of especial concern in traumatism and gangrene, for if the operation is dane too early, too much may be removed in one case and too little in the other, In traumatism, tissue that at first sight seemed beyond remedy may survive; in gangrene, tissue that scemed viable may be left, only to necessitate another dangerous operation; so that following traumatism it is better not to operate until the limit of the devitalized tissue has been definitely determined; and in the case of gangrene, until the line of demarcation has definitely formed. ‘The technic is principally concerned with conservation of function, and looks to the formation of a good stump. “A stump to be service- able, should be sound, unirritable, with good circulation and abundant leverage" (Bryant, Operative Surgery). To produce a stump with these qualities requires prevision of the flaps, particularly their shape, length, and vascularity, Upon their shape will depend the position which the cicatrix will take; upon their length, the comfortable ad- justment of skin and bone; upon their vascularity, the prompt repair, proper nutrition, and subsequent freedom from disease. ‘The cicatrix should fall where it will be least subject to pressure and friction wherever that may be done without the sacrifice of useful tissues. In determining the position of the cicatrix, one must then consider the occupation of the patient and the possibility of an arti- ficial limb being worn. Ga9 AMPUTATION OF FINGERS. 6st (B) In case the bone is more extensively destroyed than the soft parts, as in tuberculosis, sarcoma, etc., one has more option; he can fashion the flaps in any manner desired, for usually much that is healthy will have to be removed. The position of the cicatrix can be determined and such is the typical amputation. FINGER AMPUTATIONS. Practical anatomical points (Jacobson, Operative Surgery): “The three creases in front almost correspond to the joints, The lower crease is just above the joint; the middle is opposite the joint; the highest, nearly 3/4 of an inch distal to the metacarpo-phalangeal Joint, “The prominence of the knuckles is formed by the higher of the two bones; by the head of the metacarpal bone, the lead of the first phalanx, the head of the second phalanx for the three joints respectively. Fie. a1. —Typical arhputation of finger; palmar flap, dorsal scar. (Farcivu).) “The joint in each case is below, or distal to, the prominence; the metacarpo-phalangeal joint is about 1/3 inch below the knuckle; the second joint, 1/6 inch below the knuckle; the terminal joint 1/12 inch beyond the knuckle. “Tn the distal and interphalangeal, the joint is concave from side to side and presents a concavity toward the finger tips. In the meta» carpo-phalangeal joint, the convexity is toward the finger tip, “From the readiness with which the tendons conduct infection, care should be taken to keep even so small an amputation as that of a finger strictly sterile, and in amputating through damaged parts the flaps should not be too closely united with sutures.” It isa rule with but few exceptions to save as much of the finger as possible, and it will almost always happen ia removing part of a finger ~ that an atypical amputation will be indicated, Let the sear G-wnexe ATYPICAL FINGER AMPUTATION. 653 Local anesthesia (Figs. $ and 9), Circular constriction at the base will control bleeding and prevent rapid absorption of the solution. Begin by making a dorsal linear incision an inch long down to the bone (Fig. 483). Liberate the whole circumference of the bone one-thi hup, cither with a rugine or a bistoury (Fig, 484), and at that level divide the bone with bone forceps (Fig. 485). Employ two or three sutures with drainage if there is much chance of infection (Fig. 486). Fre 484 —Litemting the bone (Veaw.) iG. a8s.—Seetion of the bone. (Weaw.) If the dorsal linear incision opens into a joint, the section may be made there—disarticulate. Divide first the dorsal ligament, then the lateral ligament to the left, and a the phalanx is twisted toward the left, divide the lateral liga- ment to the right. Suture as before, It may be necessary to slice off the head of the remaining portion of the digit if it fs too prominent. TYPICAL AMPUTATION OF THE WHOLE FINGER. General anesthesia is usually necessary. The method of procedure is different for the middle and ring fingers, the index and little fingers, and the thumb, AMPUTATION OF THE MIDDLE FINGER. 655 Lift up the hand so that you face the palm and cut transversely to the left (Fig. 488). Now lower the hand and complete the incision, bringing it obliquely upward and backward to the knuckle, the starting- point (Fig. 489). Having outlined the incision in this manner, repeat the movement, cutting to the bone, Retract the flap, exposing the articulation atm le Gager: ~ Pro. 4B Amputation of tho midle ewer: Lifting the band while Disarticulate. Pull on the finger to separate the joint surfaces, which helps to locate the joint tine. Hold the bistoury vertically, and with its point divide the Jateral ligament to the left, then the dorsal ligament (Fig. 490), then the ligaments to the right, at the same time bending the finger to the right. ‘Tie the digital arteries, usually one on each side, and suture (Fig. 491). (il) Index and Little Fingers.—In these two instances, toe smn AMPUTATION OF THE LITTLE FINGER. 057 obliquely through the joint cavity and approximates the adjoining finger. Tn the case of the little finger, begin the iucision just below the joint line on the ulnar side of the extensor tendon, and carry it obliquely downward and forward and then across the palmar surface, inscribing Pio. gge—Almpratation’of the mkdile finger completed (Van) @ regular semicircle which ends at the free border of the web between the little and ring fingers. Complete the incision by cutting from this point to the starting-point, inseribing a semicircle with its concavity toward the web. Follow this same track again, cutting to the bone. Denude the bone completely (Vig. 492). You will observe that the ex tensor tendon is difficult to divide and requires especial attention. Disorticutate. Pall on the digit to expose the joint line and dine 2 658 SOME PRACTICAL AMPUTATIONS. Fc. e¥y-—Amowtation of mg Utte tinge: Fas. aaa. Aetpunation of che, ite See od (ran) lett ven AMPUTATION OF THE INDEX PINGER. 659 the lateral ligaments to the left and then the dorsal, facilitated by slight flexion. Next, rotate the finger to the left and divide the lateral ligaments to the right. The joint is completely opened and the rest is easy (Fig. 493). The appearance of the flap is indicated in Fig. 494. Employ three or four interrupted sutures (Fig. 495). rf 196 ion index: i .— Amputation of index and Utthe “Bowing formed tape haan” Wo: isgers completes (Veo) ‘The removal of the index finger is conducted along the game lines, ‘The first semicircular incision is carried wround the radial side and completed by a second, following the web of the finger, The appear- ance of the flap Is Indicated in Fig. 496, and the final result in Fig. 497- Tf the patient isa laborer, it is necessary to render the band as weetoh as possible, nor must eee eee ee bith. sary to reduce the size of the heads of the Fic nat of he mesure Sead ol eae eae eae oblique section of the radial side; of the little finger, the ulnar side: of the ring finger, by transverse section (Fig. 498). With regard to the middle finger, the head of its metacarpus should not be removed unless shapeliness rather than strength is desired (see page 99). P16 499.—Liews uf section of the metacarpal Bema (Vann) ATYPICAL AMPUTATION OF THE ENTIRE FINGER. In the case of the ring or middle finger mashed off near the mete carpo-phalangeal joint, it is useless to try to save the stump, ax ite presence will be an actual hindrance to the other fingers. Disarticulate. Make a dorsal incision (Fig. 499), extendiag = centimeter above the metacarjal head. Raising the Bnger amd cutting: from left to right, carry the incision around the base near the limit ot the sound tissue (Fig, soo), Denude the bone, exposing well the metacarpal | AMPUTATIONS OF THE THUMD. 661 flaps well back out of the way. Divide the tendons in the manner al- ready indicated for the amputation of the finger (Fig. 501). Steady the head of the bone and pinch off with a bone forceps (Fig. 502). (UD) The Thumb.—The thumb must be treated with the utmost conservatism. The smallest part must never be removed unneces- sarily, a8 it is almost as useful as the rest of the fingers together, Fes. 490. —Crth of ring finger requiring atyoiea} amputation, Dorsal incision to ‘expos articulation. (Lejars,) and nearly always after a traumatism, it is best to do an atypical amputation, In the typical amputation, employ a palmar flap. Begin on the dorsal surface just below the articular line and incise to the right, reaching the edge of the palmar surface just above the interphalangeal crease. Now go back to the starting-point and make an incision to the Ve& 662 SOME PRACTICAL AMPUTATIONS. similar to the first, and complete it by a transverse incision joining the first. The “U".shape is indicated (Pig. 503). Repeat the incision, cutting to the and dissect up the dp Strip back all the soft parts down to the while an assistant holds the thumb. : Disarticulate. Take bold of the thumb again and direct the a soo.—Atypacnl wnpwtation of the ratice Anger: Asverior clrvaiiar imeem. (ater) sistant to retract the flaps. Make strong traction and cut the liga ments to the left, above, and then to the right, twisting the thumb i make them tense, Suture. AMPUTATION OF A FINGER AND ITS METACARPAL Typical amputation (infrequent): (1) Middle and Ring Fingers. —Begin the incision over the care metacarpal line (on the linc drawn between the bases Of the mete carpals of the thumb avd (ithe finger) and descend along the bene; _ i SOME PRACTICAL AMPUTATIONS. 663 ¥i0, s02.—Atypical amputation of Ue entine finger: Resection af the Real Of the metacarpus (Lepars.) 664 SOME PRACTICAL AMPUTATIONS. follow the web, cross the palmar surface, and ascend to the starting point (Fig. sos). Denude, ‘This is sometimes diffcult, Dividing all the tisus around the head of the metacarpal, work up and toward the wrt remembering particularly that the deep palmar arch crosses the middle of the bone and i touch with it. It must not be injerd Disartientate by dividing the bone at its base with a bone forceps (2) The Index and Little Fingers.—The procedure is the same = before except that the incision on the side opposite the axis of the fant (3) The metacarpal of the thumb may be regarded as a finger make the same sort of racket incision, Save all of the metacarpal possible (Figs. 05, 506, 507) Atypical Amputation of the Hand,—(Traumatiom of the mice arpals) (Fig. 503) It is often inad visable to amputate at Once, for parte that seem de vitalized may survive. AMPUTATION OF THE HAND. 665 Secure hemostasis and carry out a most rigorous disinfection, suture with ample drainage and await the course of events; the limits of jable tissue can soon be determined, Amputate before gangrene sets in. Rather, as Lejars says, you do not amputate, but trim up. It is the rule to remove the projecting bone without any regard to a typical amputation, P10, se —Denuding metacarons preparstney eestrey- tex bute Pare Paseet fe meacarr wo ita section. (hela Denude the bone as far back as the skin flaps demand (Fig. 509). Use bone forceps (Fig. 510). Suture loosely with ample drainage (Fig. 511). Apply & moist dressing, which is to be changed daily; and if the temperature rises, remove the sutures and give the hand a pro- onged immersion in hot normal salt solution and renew the dressings. Similar amputation, thumb saved (Fig. 512). 666 SOME PRACTICAL AMPETATIONS. AMPUTATION OF THE FOREARM. Disurticulation at the wrist is very rarely done in general Ti a tuberculosis of the wrist calls for intervention, ammpatate the arm (Fig. $13). Following traumatism, do an atypical amputation, conseryiag much as possible of the member, ‘Typical amputations of the forearm are most easily performed at aa level, by a modified circular incision; the dissection of the cull is facil tated by two lateral vertical incisions if at thelevel of thesection the ment ber is conical. Determine firs: where you propose to divide the hea) The section of the skin must fall some distance below that of the bam ‘The section of the bone should be made about the distance equal sol diameter of the timb above the skin seetioa, = .—c oo SOME PRACTICAL AMPUTATIONS. 667 Pic, gop ——The metaearpals are denuded upward ter an lode dun wht savol. (Veum.) 668. SOME PRACTICAL AMPUTATIONS. Circular Incision —Begin by dividing the skin In front (Fig. sta). and complete the circle posteriorly (Fig. 515). Divide nothing bet the skin and fascia, Lateral incisions are to be made extending upward two or thre fingers’ breadth (Fig. 516). Transix, Direct the assistant to hold the hand supinated ant flexed to relax the flexor muscles, while the point of the knife is intw Pio. sro —Gretan of @eracarpals with bone-catting forors (Vem) duced laterally at the upper end of the nearest vertical incision (Fie sty). Elevate the point of the knife as it approaches the bane so that it grares over the bone. Drop the point into the inleresseous space | and elevate again as it comes in contact with the Second bone, Whew it emerges at the opposite side at the Same level, the Knife is swept | downward, its cutting edge held close 10 the bones, tnd Uhe Sanuen are | cleanly divided longitudinally until the level of the eireatar whi ia “a _ SOME PRACTICAL AMPUTATIONS. 669 cision is reached, when the blade is made abruptly to cut toward the surface (Fig. 518). As the section toward the surface is made, the assistant should extend the hand slightly, the tense tendons being more easily divided. Pass the blade posteriorly in the same manner, and as the knife cuts Fin. grt—Amputation completed. (Veaw.) toward the surface the hand should be flexed. The muscles which fill in the interosseous space as well as those which are closely attached to the bones are yet to be d stg indicates the manner in which this is accomplished. The intcrosseous membrane requires special attention. Denude the bones of periosteum from below upward ig, =). 670 SOME PRACTICAL AMPUTATIONS. ‘The adjacent surfaces of the bones difficult to denude, but take the time for it. Pam a sterile compress between the twa bones and one ‘on cither side to act as retractors while the bone: are sawed, Saw the bones at the level of the periasted flaps. Notch the ulna first, then completely dirite the radius and finally the ulna. ‘The median nerve will be found in the mite of the Se ot ee ae internally, the posterior imterosseous is more Fics 01.55 Amur cult to find posteriorly, Resect them high enough hum saved Come) to escape the scar, Draw the periosteal Bap over | the cnd of the bones and if desired, they may be sutured with catgut. Suture the skin and muscle flaps, and, If necessary, drain (Fig. 524). AMPUTATION AT THE ELBOW-JOINT. Make a circular incision three inches below the joint, involving the skin and fascia, Turn back the cuff to the joint, Divide the muscles over the joint line. Divide the lateral Bga- ments, Open the outer side of the joint first and, directing the assistant to make traction on the arm, separate the ulna and divide the triceps, “Tie the arteries, resect the nerves, and suture. AMPUTATION OF THE ARM. Apply an Esmarch tube high up near the axilla, of an assistant may compress the artery in the upper part of the arm or behind the clavicle. Stand fo the outer side of the arm, Retract the skin with the left hand if operating on the right arm, or direct the wsistant to retract the SOME PRACTICAL AMPUTATIONS. on ¥ 10. s4—Amputation of the forearm: Bewinning the circular incision. (Ven) Fix $16 —Ampulation of the forearm: Completing the cirewat treiakin. (Wea 672 SOME PRACTICAL AMPUTATIONS, skin if operating on the left arm, "The skin section mest lic about one diameter below the proposed bone section (Fig. 522). Divide the tegument and fascia anteriorly first and then posterierty. When dividing internally, remember that the artery is quite superficial Tf a long blade is used, the complete incision of the skin may be accomplished by a single cirewlar sweep; the band carrying the kelle is passed under the limb until the heel of the knife rests on the top ef the limb, and then with slight sawing movements, the knife is made te Y Pic. s14—~Lateral teciabons (Powe) encircle the arm, dividing the skin successively above, internally, below, externally, and above again, reaching the surting-paiet 1 may be necessary to make the pass a second time to divide the Retract the skin freely; fi may be necessary to free the fascial ai tachments with the point of the knife. Do not “hattor-Hole” the fas The adhesions are most marked internally over the The divided skin retracts about one and one-half inches (Fig, In the