A Manual of the Operations of Surgery / For the Use of Senior Students, House Surgeons, and Junior Practitioners

by Joseph Bell

It is quite unnecessary to remove the head of the metacarpal, either for the sake of appearance, or to render healing more rapid, and its removal weakens the arch of the hand; where the cartilage is eroded by disease, the cartilage-covered portion can be scooped off by a gouge or removed entire by pliers, without interfering with the broad end to which the transverse ligament of the palm is attached. If required either for injury or disease, the metacarpal head may be easily removed by a single straight incision from the knuckle upwards, as far as the point at which it may be deemed necessary to saw it through, or better still, divide it with the bone-pliers. This incision should be made as a first step in the first incision for amputation of the finger, and the finger should not be disarticulated, but kept on, to aid by its leverage in separating the metacarpal head.

Amputation of the index or little fingers.—This operation differs from the preceding only in this, that care must be taken to make a good large flap on the free side of each; making the incision, which begins at the knuckle (Fig. i. 4), enclose a well-rounded flap, and not allowing it to enter the palm till it reaches the level of the web between the fingers. The metacarpal heads may here be cut obliquely with the bone-pliers, to prevent undue projection.

Amputation of one or more metacarpals.—These operations may be rendered necessary by disease or injury. If the latter demands their performance, no rules can be given for incisions or flaps, they must just be obtained where and how they can best be got. If for disease, a single dorsal incision (Fig. i. 5) over the bone will allow it to be dissected out of the hand.

N.B.—In no case, except that of the thumb, should any attempt be made to save a finger while its metacarpal is removed. (See Excisions of Bones.)

Amputation of first and fifth metacarpals.—Various special operations have been devised for speedy and elegant removal of these bones. Their disadvantages, etc., are fully detailed under Amputations of the Foot.

The vascularity and consequent vitality of the tissues of the hand and arm sometimes afford very encouraging and satisfactory results in conservative operations.

The following is an instance of what may be accomplished in a young healthy subject.

A. A., æt. 18, ploughman, was harnessing a vicious horse, when it caught his right hand between its teeth, and gave a severe bite. On admission, I found the middle and ring fingers completely separated at the metacarpal joints, but each hanging on by a portion of skin, the middle by the skin on its radial side, the ring by that on its ulnar. The back and the palm were both stripped of skin up to the middle of the third and fourth metacarpal bones, which were exposed, but not fractured. As it was important for him to maintain the transverse arch of the hand intact, I determined to make an attempt to save the metacarpals, and finding that the skin on the radial side of the middle, and ulnar side of the ring fingers, was still warm, and apparently alive, I carefully dissected as long a flap as possible from each, and then folded them down, one at the front, the other at the back of the hand. The flaps survived, and the result was admirable, the patient being able in a very few weeks to guide the plough. The sensation in his new palm and back of the hand is very peculiar, they being still the fingers, so far as nervous supply is concerned.

In amputations involving the metacarpals for injury, it is always important to avoid entering the carpo-metacarpal joint, hence if it can be done it is best to saw through the bones at the required level, rather than disarticulate. This rule should be observed even in those cases in which the thumb alone can be saved, for notwithstanding the isolation of the joint between the first metacarpal and the trapezium, it is very important for the future use of this one digit that the motions both of the wrist and carpal joints should be preserved entire.

No exact rules can be given for the performance of these operations, as the size and positions of the flaps must be determined by the nature of the accident and the amount of skin left uninjured.