fully avoided. The same is forcibly drawn forth before the wound is sutured
and cut off as high up as possible.
DISARTICULATION OF THE ARM AT THE SHOULDER JOINT
(<r) Flap incision.
I. The patient lies at the edge of the table half on his healthy side, with
his thorax soniczvJiat raised. The more he is placed in a sitting position, the
more convenient it is for the operator, but the more dangerous for anaesthesia.
Fig. 672. DiSARTiCLLAiiu.N .\.i iiiL SuoLLDEK Joi.NT (flap incision)
2. On the external surface of the shoulder, a rounded square flap is out-
lined with the knife, the base of which extends from the coracoid process to
the root of the acromion, and the inferior border of which corresponds with
the ijifcrior limits of the deltoid muscle (Fig. 672).
THE TREATMENT OF WOUNDS
351
3. With long sweeps of the knife, penetrating more and more deeply
into the deltoid muscle, the flap is detached as far as the acromion, and
turned upward so that the outer surface of the shoulder joint is freely
exposed.
4. A bold incision across the head of the humerus, forced upward, above
the two tuberosities, divides the capsule together with the tendons lying
over it.
5. The head of the humerus is forced forward, the knife inserted behind
it, and the posterior capsule is divided.
6. The operator with his left hand draws the head of the humerus
toward himself, directs the knife with long sawing movements down along
the inner side of the bone as far as 6 centimeters below the axillary fold ;
WfA
Fig. 673. Disarticulation at the Shoulder Joint Fig. 674. Stump after Disarticulation at
Forming Second Flap on the Inner Surface the Shoulder Joint by Flap Incision
then he turns the edge inward (against the thorax), and divides with one
sweep all soft parts in which the large blood vessels and nerves are
coursing.
7. In such cases, where he does not succeed in arresting completely the
afferent flow of the circulation by covip7'essing the subclaviaii, an assistant,
before the last incision is completed, must reach into the wound from above,
and compress with his thumb the axillary artery against the skin (P^ig. 673).
8. Figure 674 shows the appearance of the wound after suturing.
352
SURGICAL TECHXIC
{b) Circular incision.
1. The arm is held in abduction. A circular incision at the level of the
ower limit of the deltoid muscle divides all soft parts down to the bone.
2. The bone is sawed off at the same level ; all visible blood vessels are
ligated.
3. A longitudinal incision from the anterior margin of the acromion to
the circular incision divides all soft parts down to the bone.
4. The lower end of the bone is grasped with strong bone-holding for-
ceps or with the left hand, and while an assistant draws apart with strong
retractors the margins of the wound of the longitudinal incision, the operator
removes the bone from the articulation by continuous rotations (Fig. 675).
Fig. 675 Fig. 676
Disarticulation at the Shoulder Joint (circular incision and longitudinal division)
a, disarticulation of the stump of the humerus; h. sutured stump
This disarticulation is made by short incisions ahvays directed agaijist the
bone, or in suitable cases by detaching the periosteum with elevators and the
raspatory.
5. In order to remove the acromion and the coracoid process, which pro-
ject into the wound, they should be resected as much as may be deemed
necessary (Helferich).
6. Figure 676 shows the appearance of the stump. The skin flaps can
also be rounded off by cutting off the lower edge.
THE TREATMENT OF WOUNDS
353
(c) Oval incision.
The point of the oval can be placed either on the ontside below the acro-
mion — in which case the deltoid muscle must be removed in part — (Fig.
6^"/), or the operator begins with an anterior longitudinal incision in an out-
FiG. 677. Disarticulation of the Shoul-
der Joint (Larrey's oval incision)
Fig. 678. Disarticulation of the Shoul-
der Joint (oval incision)
ward direction from the coracoid process below the clavicle, circumscribes
with the knife the border of the deltoid muscle, and then returns transversely
across the posterior side of the arm to the axillary fold, and from there
upward to its beginning (^KocJicr, Fig. 6'j'^\ If the edges of the incision in
Fig. 675 are largely rounded off, almost
the same incision is produced.
The latter methods are especially
adapted to cases in which the operation
is performed for tumors, when it is
desirable first to establish the diagnosis.
TJie longitudinal incision is made first,
and the circular or oval incision is
added to it.
For disarticulating the shoulder
girdle (shoulder together with clavicle
and scapula) for the removal of tumors,
it is best to make an oval ijicision (Fig.
679) with its point above the clavicle, which passes down in a curve in
front to the anterior axillary fold, posteriorly passes across the acromion,
and unites with the anterior incision in the axilla {Bei'ger).
2A
Fig. 679. Disarticulation of the
Shoulder Girdle
354
SURGICAL TECHNIC
AMPUTATIONS AND DISARTICULATIONS ON THE LOWER EXTREMITY
DISARTICULATION OF THE SEVERAL TOES
This is made in the same manner as the disarticulation of the fingers (see
pages 336-340).
DISARTICULATION OF ALL TOES IN THE PHALANGOMETATARSAL JOINTS
I. While the left hand forcibly flexes all the toes upward, a curved
incision beginning (on the left foot) at the median border of the first pha-
langometatarsal joint and ending at the lateral border of the joint of the
same name of the
fifth toe is made in
the groove between
the plantar surface
and the base of the
toes (Fig, 680).
(On the right
foot the incision is
reversed.)
2. A similar in-
cision, the ends of
which meet those
of the first, is made
under a forcible
plantar flexion of
the toes along the dorsal side of the base of all
the toes (Fig. 681). Both incisions penetrate
between the toes as far as the middle of the
web.
3. Both semilunar flaps are dissected back
as far as the heads of the metatarsal bones.
4. Next, each toe is separately disarticulated,
leaving the sesamoid bones at the head of the
first metatarsal bone in position.
5. Should the skin not be sufificient to cover conveniently the prominent
heads ^of the metatarsal bones, they can be singly removed with the pha-
langeal saw or the bone-cutting forceps.
6. Figure 682 shows the appearance of the stump.
Fig. 6S0. DlSARTICILATION UV AlJ
Toes (plantar incision)
Fig. 6S1. DlSARTICl'LATION OF
All Toes (dorsal incision)
THE TREATMENT OF WOUNDS
355
AMPUTATION OF ALL METATARSAL BONES
AMPUTATION
â– JAGERS METATARSAL
1. A cicrved incisioji is made from one border of the foot to the other
across the anterior limiting furrow of the plantar surface, and the semilunar
flap of the skin is dissected back to the place where the amputation is to be
made.
2. Upon the dorsum of the foot, a smaller semilunar flap is made, the
ends of which meet those of the plantar flap at the borders of the foot.
^Sk
Fig. 682. Stump after Dis-
articulation OF All Toes
Fig. 683. Amputation of Foot at
the Metatarsal Bones by Saw-
ing
Fig. 684. Wound
resulting from
Sawing off Meta-
tarsal Bones
Instead of the dorsal flap, a semiciradar incision can be made, provided the
skin of the plantar surface is sufficient for covering the surface of the wound.
3. At the base of both flaps, the soft parts are carefully divided with a
small knife upon and between the several metatarsal bones.
4. By means of small strips of sterilized gauze, which, with forceps, are
drawn between the several bones, the soft parts are drawn forcibly upward,
and all the bones close to them are sawed through at the same time (Figs.
683,684).
DISARTICULATION OF THE GREAT TOE TOGETHER WITH ITS
METATARSAL BONE
The oval incision is made in the same manner that has been described on
page 340, in disarticidation of the thnnib.
356
SURGICAL TECHNIC
On account of the great breadth of the base of the first metatarsal bone,
it is advisable to make upon the upper end of the incision a transverse
incision at a right angle across the
articulation (Fig. 685). This is about
4 centimeters in front of the eminence
of the tubercle of the scaphoid bone,
and the upper and lower flaps formed
thereby are dissected back until the
w^hole bone and the articulation are
exposed.
2. The tendons of the extensor and
flexor longus hallucis are divided over
the articulation ; the articulation is
opened on the dorsal side, and while
the bone is constantly rotated around its axis in opposite directions, its con-
nections with the internal cuneiform bone are detached.
'•SitiiS,**'"
Fig. 685. Disarticulation of the Great
Toe together with rrs Metatarsal
Bone
DISARTICULATION OF THE FIFTH TOE TOGETHER WITH ITS
METATARSAL BONE
Flap incision.
1. This incision can be made in a similar manner as previously described
in the disarticulation of the thumb (page 340).
2. The left hand forcibly abducts the fifth toe from the fourth ; the right
hand carries a small knife from the /r-,
web with sawing movements between .#
the two metatarsal bones upward un-
til it meets with resistance (Fig. 686).
3. The end of the skin incision,
as well on the dorsal side as on the
plantar side, is extended about i cen-
timeter upward.
4. Under a forcible abduction of
the fifth metatarsal bone, its base is
first separated from the fourth meta-
tarsal bone, and next from the cuboid '
bone.
5. The knife is then carried around the tuberosity of the fifth metatarsal
bone projecting upward ; thence closely along the outside of the bone in
sawing movements downward; a tongue-shaped external flap is thus formed,
«>,^
Disarticulation of the Fifth Toe
together with its Metaiarsal Bone
THE TREATMENT OF WOUNDS
357
the point of which must be rounded off exactly at the level of the first incision
in the web (Fig. 686).
6. In the same manner, the second, third, and fourth toes, together with
their metatarsal bones, can be extirpated.
lisfranc s disarticulation in the tarso-metatarsal articulations
(exarticulatio tarsometatarsea)
1. Along the external border of the foot, between the cuboid bone and
the metatarsal bone, the joint lying directly i7i front of the tuberosity of this
bone is sought ; at the internal border of the foot, the
articulation is sought for between the internal cunei-
form bone and the first metatarsal bone, which is 4
centimeters in front of the tuberosity of the scapJioid
bone. The line is marked by small incisions with the
knife.
2. From one of these points to the other (from left
to right), while the foot is raised, a large semilunar flap
is circumscribed with the knife on the plantar sniface,
the convexity of which passes over the heads of the
metatarsal bones.
3. The foot is lowered and strongly flexed, the
knife is carried from one point of the plantar flap to
the other in a shallow curve, across the dorsum of the
foot, dividing all soft parts down to the bone (Fig.
689).
4. The small dorsal flap is drawn upward, the point
of the knife searches gropingly, to open the articulation
farthest to the
Fig. 687. Skeleton
THE Foot
Fig. 688. Lisfranc's Disarticulation of
Tarsometatarsal Articulation
left (on the right foot, the fifth
metatarsal joint), while the left hand
flexes the front of the foot strongly
toward th.Q plantar surface.
5. As soon as the joint gapes,
the knife is carried farther in a
curve slightly convex anteriorly ;
the knife opens the fourth and
third joints {a), slides across the
358
SURGICAL TECHNIC
base of the second metatarsal bone and opens the first articulation (r)
(Fig. 690).
6. The articulation of the second metatarsal bone, located about one centi-
vietcr JiigJier 'Ccizx^ that of the first, is opened by a small transverse incision
{b)\ the lateral connections of
the bone with the internal and
external cuneiform bones, be-
tween which the base of the
bone articulates, are divided by
inserting the knife with its
edge directed upward (Fig.
691).
7. All articulations are now
gaping more extensively ; the
knife divides the remaining
connections of the joint along
the lateral borders and on the
plantar side, and divides the
muscles on the plantar surface
for the greater part ; next, its
edge is directed forward in
completing the plantar flap
(Fig. 692).
Figure 693 shows the appearance of the wound before its union ; Fig.
694, that of the stump.
If the well-defined extent
of the disease permits it, the
surgeon should endeavor to
preserve the healthy meta-
carpal bone or bones (atypi-
cal amputation. Kilstcr ob-
tained a good success by dis-
articulating the second to the
fifth metatarsal bones. He
preserved the first metatarsal
bone as well as the great toe, Fig. 691
whereby the important sup-
port of the foot, the condyle of the first metatarsus, was preserved (Fig.
695). Else the surgeon can disarticulate the first metatarsus and saw off
Fig. 689 Fig. 690
LisFRANc's Disarticulation of the FtKxr.
incision; b, dividing articulation
a, dorsal
LisFRANc's Disarticulation Opening Second
Metatarsal Articulation
THE TREATMENT OF WOUNDS
359
only a portion from the other metatarsal bones, whereby likewise the impor-
tant support of the tuberosity of the fifth metatarsus is left in position. If
the tJiree ameifdnn bones must be removed, the cuboid bone, together with
Fig. 692 Fig. 693 Fig. 694
LiSFRANC's Disarticulation. «, forming plantar flap ; iJ, wound
surface; c, stump
Fig. 695. LiSFRANC's
Disarticulation.
Preserving hallux
the tuberosity of the fifth metatarsus, can be preserved. But it is better to
make in that case a transverse amputation by dividing transversely the
cuboid bone at an equal height with the anterior line of articulation of
the scaphoid bone (intertarsal disarticulation, yii>£'r, Bona).
CHOPART S DISARTICULATION AT THE TARSUS MEDIOTARSAL
DISARTICULATION
1. The disarticulation is made in the joint connecting the scaphoid bone
with the head of the astragalus, and the cicboid bone with the as calcis (Fig.
696).
2. The line of the joint is found and marked along the internal border
of the foot, I centimeter above the tuberosity of the scaphoid bone, and at the
external border of the foot, 2 centimeters above the tuberosity of the fifth
metatarsal bone.
3. Across ^ho. plantar surface of the raised foot, a cin-ved skin incision is
made, extending from the point marked on the left anteriorly along the
border of the foot, a thumb's breadth behind the heads of the metatarsal
bones, transversely across the plantar surface, and along the other border
of the foot back to the point on the right side (Figs. 697-699).
\6o
SURGICAL TECHNIC
4. The foot is lowered and forcibly pressed downward, the knife is in-
serted in the left angle of the wound and carried in a small curve across the
Fig. 696
Fig. 697
Fig. 698
Fig. 699 Fig. 700
Ch(Jpart's Disarticulation at the Tarsus
dorsum of the foot, only through the skin, as far as the right angle of the
wound of the plantar incision (Fig. 700).
5. The little dorsal flap is retracted forcibly, a deep incision transversely
across the articulation divides all tendons, and penetrates at once into the
THE TREATMENT OF WOUNDS
361
articular connection (most safely, first above the tuberosity of the scaphoid
bone, ivhicJi can be distinctly felt).
6. Under the edge of the knife, carried across the union of the joint
(slightly ~-shaped curve), the joints are opened with a cracking noise.
The point of the knife divides the tense
ligaments everywhere, last on the plantar
side, until the front of the foot can be
completely pressed downward against the
heel.
7. After a somewhat deeper incision
has been made of the plantar flap on both
borders of the foot, the edge of the knife,
directed forward, is applied to the lower
side of the freed scaphoid and cuboid
bones, and drawn forward by sawing
movements until the plantar flap is com-
pleted (Fig. 701).
8. Figure 702 shows the appearance
of the stump.
The anterior inferior edge of the os
calcis, which projects conspicuously and
is apt to produce decubitus of the stump,
can be chiselled off to
some extent (Helfericli).
During the healing pro-
cess the foot must be
placed in strong dorsal flexion (if necessary, by making
tenotomy of the tendon of Achilles). After the healing, a
sole extending obliquely upward is useful for walking, since
the stump is apt to assume the talipes-equinus position.
To prevent the same, Hclferich advises, after a previous
tenotomy of Achilles, to open the astragalo-crural articu-
lation from Choparfs wound, and, after removal of its
cartilaginous surfaces, to effect a coalescence (arthrodesis),
the limb being placed in a right-angular position.
If the disease involves only the metatarsus, the dis-
articulation can be made in CJwpm'f s joint, thus preserving
the toes {Linck, 1887, Witzel).
From the extremities of the dorsal transverse incision longitudinal
Fig. 701. Chopart's Disarticulation
AT THE Tarsus. Finishing plantar flap
Fig. 702. Stump af-
ter Chopart's
Disarticulation
AT THE Tarsus
362 SURGICAL TECHNIC
incisions are made along the exterior and interior border of the foot toward
the toes and beyond the diseased portion. The extremities of these incisions
are connected by a dorsal transverse incision, so that a square soft-part flap
is produced thereby (Fig. 703).
2. Disarticulation in CJioparf s joint and amputation of the diseased
bones from the plantar soft parts, after the metatarsal bones have been
sawed through either transverse!}", or after they have been disarticulated in
the joints of the toes.
Fig. 703 Fig. 704
Chopart's Dlsarticclation preserving Toes (Witzel)
3. Ligation of the dorsal artery of the foot and of the communicating
branch of the plantar arch in the metatarsal interstice.
4. The portion of toe hanging loosely at the plantar bridge is united by
wire suture with the skin of the upper dorsal flap, whereby a strong trans-
verse roll of soft parts is formed on the plantar side (Fig. 704), which con-
tracts after a few weeks. It is drained on both sides, and an immobilization
dressing is applied for 4 weeks.
5. The result is a well-formed, but considerably shortened, small foot
without any arch ; it does not assume any talipes-equinus position, and is
well movable in the astragalo-crural articulation. The dorsal extension of
the toes, of course, does not take place, since the sutures of the tendons have
been omitted.
MALGAIGNE's disarticulation of the foot — BELOW THE ASTRAGALUS
I. Two lateral flaps are formed by an incision, beginning behind
directly above the tuberosity of the os calcis and detaching the tendon of
Achilles from it ; encircling the external malleolus in a large curve, it extends
across the lower half of the os calcis (Fig. 705) and thence ascends across
the middle of the cuboid bone to the dorsum of the foot, over the anterior
margin of the scaphoid bone (Fig. 706) ; it then descends perpendicularly
downward along the internal side of the metatarsus (Fig. 707), until it
reaches the middle of the plantar surface (Fig. 708); from here it turns at
THE TREATMENT OF WOUNDS
363
a right angle backward, meeting the beginning of the incision at the inner
border of the tendon of Achilles.
Fig. 705
Fig. 706
Fig. 707 Fig. 70S
Malgaigne's Disarticulation between the Astragalus and the Os Calcis
(below the astragalus)
2. The two flaps are detached from the bone until both lateral surfaces
of the calcaneum and of Choparf s articulation are exposed. Care must be
taken not to come too near the tips of the malleoli, for fear of injuring the
tibiotarsal articulation.
364
SURGICAL TECHNIC
3. By the disarticulation of CJwparf s joint, the amputation is completed.
4. With bone forceps, the anterior border of the os calcis is grasped, and
while the bone is pressed downward and held in supination, the calcaneo-
fibular ligament is divided
with a small knife i centi-
meter below the tip of the
external malleolus ; it next
enters the joint, divides
the firm intertarsal liga-
ment, while the bone ro-
tates around its long axis ;
Fig. 709. Disarticulation of the Foot
below the astragalus
finally the external astrag-
alocalcaneal ligament is
freed about 3 centimeters
below the internal malleolus (see illustrations of ligaments
in resection of the ankle joint).
5. In spite of the very irregular form of the inferior
surface of the astragalus (Fig. 709), this operation yields
a very useful stump for walking (Fig. 710).
6. To improve this form of the stump, especially in
cases in which the soft parts are scanty, the head of the
astragalus can be sawed off. Hancock applied osteoplastically the sa wed-off
tubercle of the os calcis to the vivified inferior surface of the astragalus.
After disarticulation below the astragalus Ssabanejejf \\q.2\q^ that part of the
foot in front of Chopart's joint (having been sawed off in Lisfranc's line) to
the vivified surface of the astragalus (similarly as in Fig. 704).
Fig. 710. Stump
AP'TER Disarticu-
lation OF THE
Foot below the
Astragalus
SYME S DISARTICULATION OF THE FOOT MALLEOLAR AMPUTATION
1. The foot flexed at a right angle is well elevated, and an incision pene-
trating everywhere down to the bone is made from the tip of one (the left)
malleolus to that of the other (the right) transversely across the plantar sur-
face (Figs. 71 1-713).
2. The foot is lowered and forcibly pressed downward with the left hand,
and a second incision is made from one tip of the malleolus to the other,
transversely across the anterior side of the tibiotarsal articulation (Fig. 714).
3. A transverse incision across the articular surface of the astragalus
opens the articulation in front ; two incisions below the two malleoli divide
THE TREATMENT OF WOUNDS
365
the lateral ligaments, and the superior articular surface of the astragalus is
freely exposed.
4. The left hand forces the foot more and more toward the posterior side
of the leg ; next, while it is rotated around its axis in turns, first to one
Fig. 711
Fig. 713
Fig. 712 Fig. 714
Sy.me's Disarticulation of the Foot
side and then to the other, the os calcis is enucleated from the skin covering
the heel, " Fersenkappe " (sustentaculum tah), and detached from the tendon
of Achilles by incisions closely following each other, and alternating, now
from above, now from the sides, and finally from behind and below, but
always directed toward the bone. (Care should be taken not to injure the
posterior tibial artery behind the internal malleolus.) (Fig. 715.)
3^^
SURGICAL TECHNIC
In inflammatory diseases, it is well to enucleate the os calcis from the
periosteum, not with the knife, but subperiosteally with the elevator and the
raspatory ( Oilier).
5. The heel flap and
the skin are drawn up-
ward all around over
the malleoli ; a circular
incision closely above
the articular surface of
the tibia divides the
other soft parts (tendons
and periosteum).
6. The sazo divides
the bones in such a man-
ner that only the two
malleoli and a tJiin layer
of cartilage are removed
from the articular surface of the tibia (Figs. 716, 717). ^^'^- 7i6. saw-
^, ,, ,. 1 . ■> rr • 1 1 ..• r I^'G THROUGH
The malleoli can be nipped off with bone-cutting forceps, ^^^ j^^^.j,
as was done repeatedly by Syme.
Fig. 715. Syme's Disarticulation of the
Foot (Disarticulating the os calcis)
Fig. 717 Fig. 718 Fig, 719
Syme's Disarticulation of the Foot, a, wound surface; b, fresh stump, anterior view;
c, healed stump, lateral view
THE TREATMENT OF WOUNDS
367
7. After ligation of all bleeding vessels, the skin over the outer side of
the tendon of Achilles is divided with a small knife, a drainage titbe is
inserted through the opening, and the wound (Fig. 717) is united by suture
(Figs. 718, 719).
pirogoff's disarticulation of the foot (amputatio tibiocalcanea
osteoplastica)
1. The soft parts are divided in the same manner as in Symes method
(page 209).
2. After disarticulation of the joint, the foot is forcibly flexed until the
posterior border of the astragalus appears to view.
Fig. 720. Pirogoff's Disarticulation of
THE Foot (Sawing off the os calcis)