121. Mr. Luke performs the operation by two flaps on the same principle as in the thigh. There is a close resemblance in the manner of amputating the arm by the double-flap operation to that adopted for the amputation of the thigh. The first flap is made posteriorly to the bone, by transfixing the limb, for which purpose the knife is entered at the mid-point between the anterior and posterior surfaces, carried transversely across the limb, and made to cut toward the posterior surface, in an oblique direction, until all the soft structures are divided. It is necessary, in entering the knife, to bear in mind that the bone lies opposite to the mid-point, and that, in carrying the knife across the limb, it would strike against the surface of the bone, unless means were adopted for its prevention. This is easily done by grasping the structures which are to form the posterior flap between the fingers and thumb of the left hand, and by drawing them backward during the time the knife is entering at the mid-point and being carried across the limb. Having formed the posterior flap, the anterior one is formed as in amputation of the thigh, by cutting inward from the surface toward the bone with a sweep, which will make this flap equal in length to the posterior. The operation is completed by dividing the remaining soft parts by means of a cut carried circularly around the bone, and by sawing the bone in the line of division. The after-treatment is the same as in the thigh.
122. Excision of the elbow-joint.—An incised wound of moderate extent into the elbow-joint, cutting off with it a part of the condyle of the humerus, or the head of the radius, or a part of the ulna, demands the removal of the injured piece of bone only. The forearm should be bent, and the antiphlogistic treatment fully carried out. A ball fracturing the olecranon, or other portion of a single bone, although opening into the joint, does not immediately require any operation.
If a ball should lodge in the lower part of the humerus, or in either of its condyles, it should be removed as quickly as possible by the trephine, or other appropriate instrument.
When the articulating ends of the humerus, radius, and ulna are wholly or in part injured by a musket-ball, it was formerly the custom to amputate the arm in such instances of great mischief—an operation which should be superseded by that of excision of the joint, by which the forearm will be saved, and considerable use of it retained.
To perform this operation, a straight, strong-pointed knife is to be pushed into the joint behind, immediately above but close to the olecranon process, and exactly at its inner edge, to avoid the ulnar nerve, which lies between it and the inner condyle, to which it may be considered to be affixed. The incision thus begun is to be carried outwardly to the external part of the humerus, dividing the insertion of the triceps. At each end of this transverse cut an incision is to be made upward and downward for about two inches each way, the three resembling the letter H. The flaps thus made being turned up and down, the olecranon should be sawn across, together with the great sigmoid cavity and the coronoid process of the ulna, the insertion of the brachialis internus having been previously separated from the coronoid process. Before this is done, the ulnar nerve should be separated with its attachments from the inner condyle, and turned aside to avoid injury. The joint being now fully exposed, the head of the radius may be sawn off or cut through with the strong spring scissors if possible, above the tubercle into which the biceps tendon is inserted. The extremity of the humerus should next be pushed through the wound, and the broken end sawn off, a spatula or other thin solid substance being placed underneath it, to prevent the brachial artery or median nerve being injured. Any hemorrhage which there may be having ceased, the forearm is to be bent, the bones are to be placed in apposition, and the incisions approximated by sutures and sticking-plaster, duly supported by compress and bandage, so that union may take place if possible, particularly of the transverse wound first made. The arm should be supported by a sling, and dressed early, as the shot-hole or holes must remain open and discharging. Some motion of the new joint to be formed may be expected under gentle passive movements; but as a stiff joint cannot always be avoided, the arm should be kept bent.
123. Amputation of the elbow-joint has been recommended, but not frequently performed. It may be done in any way by which good covering can be obtained, and it has been supposed that the long stump thus made is more useful if the olecranon process be sawn across, and left with the triceps attached to it, than if it be removed. When the parts are sound, a flap may be made in front by introducing a straight, double-edged knife over the outer condyle, and carrying it across and through the soft parts over the opposite or inner condyle, when by cutting downward and outward a flap is to be formed of from three to four fingers’ breadth in length. A shorter flap is to be made behind, when both are to be raised, and the bleeding vessels previously secured, the external lateral ligament being divided. The radius is to be separated from the humerus, when the olecranon may be sawn across, or, if the arm be bent, separated from the humerus without difficulty. The flaps are to be brought together and retained in the usual manner.
124. Amputation of the forearm is seldom required after wounds from musket-balls. The bones can be readily got at, and large pieces removed with ease. The arteries can be cut down upon and secured without difficulty, except at the upper part, and even there with some little sacrifice of muscular parts, which are not to be spared. The fascia may be divided freely in every direction, and as mortification from defect of nourishment rarely takes place in the fingers, as it does in the toes, when the great arteries of the limb have been injured, every effort should be made to save a forearm, however badly it may at first appear to be injured.
The flap operation is to be preferred to the circular, particularly when done a little above the wrist; to which operation Baron Larrey and the surgeons of France particularly objected during the late war. Having done it most successfully since 1806, however, it is recommended as preferable to any other, even when the injury admits of its being done neat the carpus. When the nature of the injury does not admit of two equal flaps being formed, it must be done by two unequal ones, or even by one, it being important for the fixing of an artificial hand or other help to have a long stump.
The arm being placed and held firmly in the intermediate position between pronation and supination, with the thumb uppermost, so that the radius and ulna are in one line, a sharp-pointed straight knife is to be entered close to the inner edge of the radius, and brought out below at the inner edge of the ulna. It is then to be carried forward for half an inch, and made to cut its way out with a gentle inclination, so as to form a semicircular flap. Re-entered at the same point as before, a similar flap is to be made on the outside, the position of the bones being a little altered to admit of its easy execution. The two flaps are to be turned back; the tendon of the supinator radii longus, and all other tendinous, muscular, or interosseous fibers, not cut through, are then to be divided, and the linen retractor run between the bones, which are to be sawn across at the same time. All pressure being taken off, the tendons and the vessels, if long, are to be cut short, and the arteries to be tied, after which the flaps are to be brought together by sutures, and retained by sticking-plaster, compress, and bandage.
125. When the operation is to be performed above the middle of the arm, it may be done by the circular incision.