In order better to protect the deltoid mus- 5, ramilications coursing towards the
cle and the branches of the circumflex nerve ^"""''l'' ^"'^ anconeus
(axillary. Fig. 814), and consequently avoid paralysis of this muscle, the
joint should be opened.
Ligaments of the Shoul-
der Joint
THE TREATMENT OF WOUNDS
415
BY OLLIER S ANTERIOR OBLIQUE INCISION
1. With the knife directed toward the head of the humerus, the incision
is made to correspond with the course of the fibres of the deltoid, from the
external border of the coracoid process obliquely down-
ward and outward across the lesser tuberosity and as
far as the shaft of the humerus, dividing all of the
soft tissues down to the bone (Fig. 814).
2. The lesser tuberosity and the bicipital groove
are immediately exposed, and can be easily cleared of
the attached soft tissues. Next, the arm is rotated
inward, and the greater tuberosity is detached. On
the whole, the procedure is the same as described in
the preceding operation.
Since from an anterior incision only the head of
the humerus can be removed conveniently (decapita-
tion), while the other portions of the articulation,
espe;.cially the glenoid cavity, can be inspected or
resected in a somewhat unsatisfactory manner, it is
better in all cases in which a more extensive disease
of the whole articulation necessitates free access to all its parts, to expose
the articulation of the shoulder by
Fig. 814. Ollier's Resection
OF THE Shoulder Joint
KOCHER S POSTERIOR CURVED INCISION
1. External incision from the acromioclavicular articulation over the
eminence of the shoulder to the middle of the spine of the scapula and in
the form of a curve downward toward^ the posterior axillary fold. Division
of the acromioclavicular articulation (Fig. 815, c). Longitudinal incision
through the fascia at the posterior border of the deltoid muscle. The
inferior portion of it is exposed and forcibly drawn forward ; the fibres
inserted farther on at the crest are divided.
2. The insertion of the cucullaris (trapezius) is detached from the spine
of the scapula upward, and the supraspinatus is raised with the elevator ;
the infraspinatus is detached downward until the external border of the
spine can be encircled.
3. After an elevator has been placed under the neck of the acromion for
protection, the crest {so') is divided with a chisel (from above downward)
(Fig. 815); an injury of the subscapular nerve coursing beneath the supra-
spinatus and infraspinatus muscles should be guarded against.
4i6
SURGICAL TECHNIC
4. After division of the bone, the acromial portion is rolled forcibly-
forward with a sharp bone hook, and dislocated in the acromioclavicular
articulation (Fig. 816), whereby the deltoid muscle (d) is elevated from the
muscles of the scapula.
5. The prominent head of the humerus is now exposed, covered by the
tendons of the supraspinatus and infraspinatus {ss, is) and of the teres
minor (/w).
6. At the anterior border of the insertions of these muscles (on the
great tuberosity and its spine), and at the posterior border of the palpable
groove of the biceps, a longitudinal incision is made over the bone, dividing
Fig. 815 Fig. S16
Kocher's Resection of the SnorLDER Joint
above the capsule {k) over the head of the humerus, and exposing the ten-
dons as far as the superior margin of the glenoid cavity.
7. The insertions of the supraspinatus and infraspinatus and teres
minor muscles are detached from the greater tuberosity and drawn back-
ward ; the tendon of the biceps, exposed in the bicipital groove, is drawn
forward ; the arm is rotated outward.
8. The insertion of the subscapular muscle, now appearing to view, is
detached anteriorly and posteriorly from the lesser tuberosity ; the vessels
passing below the teres minor and the axillary (circumflex) nerve must be
protected.
THE TREATMENT OF WOUNDS
417
9. When the head has been completely exposed and forced out from
the wound, an excellent view of the interior of the joint is obtained, espe-
cially of the glenoid cavity. All diseased portions can be easily recog-
nized and removed ; if necessary, the head can be resected. Finally, the
chiselled-off portion of the acromion is united again with the scapula by bone
suture.
This procedure also enables the surgeon by a partial resection to pre-
serve intact the anterior capsular portion, the subscapular muscle and the
coraco-humeral Hgament; thereby the frequent partial dislocation toward the
coracoid process is avoided.
If the articular portion of the scapula alone is injured, while the head of
the humerus has remained intact, it is necessary only to make
VON ESMARCH S RESECTION OF THE ARTICULAR SURFACE AND NECK
OF THE SCAPULA
1. A curved incision encircHng the posterior border of the acromion and
dividing the fibres of the deltoid muscle from
it exposes the posterior superior surface of the
capsule of the joint (Fig. 817).
2. From the middle of the same, the knife
penetrates as far as the posterior superior border
of the glenoid process of the scapula, divides in
a sagittal direction the articular capsule between
the tendon of the supraspinatus and infraspi-
natus muscles as far as the middle of the g/eater
tuberosity, and at the same time the skin and
the deltoid muscle in the direction of its fibres.
3. While the soft parts are forcibly drawn
apart with retractors, from the border of the
glenoid process the operator detaches the ten-
don from the long head of the biceps and the
capsule, in connection with the periosteum of
the neck of the scapula, all around to such an
extent that the articular end can be removed
with the metacarpal saw, or the fractured por-
tions of the comminuted bone can be liberated
with the knife.
4. The after treatment is the same as in
resection of the shoulder joint.
2 E
Fig. 817. Von Esmarch's Resec-
tion OF THE Articular Surface
AND Neck of the Scapula
41 8 SURGICAL TECHNIC
RESECTION OF THE SCAPULA BY VON LANGENBECK S ANGULAR INCISION
This operation is performed only in the case of tumors ; the muscles
covering the scapula are not preserved (extirpation of the scapula).
1. One line of the angle takes its course on the upper side, the other
over the centre of the scapula downward ; the skin flap formed thereby is
detached from the underlying tissues in the direction of its base, and turned
outward.
2. Next, the insertions of the rhomboid muscles and of the levator anguli
scapulae are detached from the internal border, those of the cucullaris
(trapezius) and deltoid from the acromion and spine, the omohyoid from the
superior border, the teres major and minor from the external and inferior
border. While the bone is elevated at its middle border from the thorax,
the knife detaches it with shallow sweeps from its base (serratus magnus
and subscapular muscles).
3. An incision in the form of a horseshoe across the head of the hu-
merus divides the capsule of the shoulder joint, the insertions of the supra-
spinatus and infraspinatus muscles on the greater tuberosity, and the
acromioclavicular articulation.
4. The bone can then be elevated outward ; and after the remainder of
the articular capsule, the insertions of the biceps and triceps muscles, have
been detached from the border of the glenoid cavity, and the pectoral minor
muscle and the coracobrachial from the coracoid process, it is removed.
5. After careful ligation of all the bleeding vessels, the large wound is
covered with the skin flap and sutured, and a drainage tube is inserted into
the lower angle of the wound.
But if the overlying soft parts must be preserved, for instance, in oper-
ations for jiecrosis of the bone, this can be readily done by removing the se-
questered scapula subperiosteally.
OLLIER S SUBPERIOSTEAL RESECTION
1. A transvo'sc incision is made over the spine of the scapula from the
acromion to the inner border, penetrating down to the bone ; the insertions
of the cucullaris are detached with knife and elevator.
2. A vertical incision takes its course along the inner border of the
scapula, exposing the median insertion of the supraspinatus and infraspinatus
muscles (Fig. 818).
THE TREATMENT OF WOUNDS
419
3. By blunt dissection, the soft parts of the fossa infraspinata are dis-
placed outward ; then, in the same manner, those of the fossa supraspinata
are detached from the bone and retracted
upward and outward.
4. While the bone is elevated from
the thorax, the underlying soft parts are
detached with the raspatory as far as its
anterior border and the neck.
5. Next, as described above, the oper-
ator divides the acromioclavicular articu-
lation from below ; likewise, the articular
capsule and the muscular insertions ; fi-
nally, the insertions of the muscles and
ligaments of the coracoid process ; it is
easier, however, to remove this process by
detaching it from the scapula with the ^^, o o /> , t^
^ ^ tiG. 818. Ollier's Resection of the
saw. Scapula
PARTIAL RESECTION OF THE SCAPULA
This operation must be adapted to each individual case. Portions of the
spine and the acromion can be chiselled or sawed off through a simple
incision; likewise, the flat portion of the scapula can be removed, leaving
the articulation intact (amputation of the scapula).
RESECTION OF THE CLAVICLE
This can be made very easily by an incision extending along the whole
length of the bone, from which the periosteum is reflected toward both sides.
The operation is facilitated by dividing the periosteum transversely on both
sides, I 1. Next, the middle portion to be removed can be easily excised
with the metacarpal or chain saw.
Resection of the articular extremities offers no especial difficulty. The
sternal end is divided by a longitudinal incision down to the articulation ;
the bone is sawed through at the external angle of the wound upon an
elevator very carefully inserted subperiosteally to protect the large veins
lying directly behind it; the short portion is drawn forward, detached
at its posterior and inferior surface from the soft parts adhering to it, and
finally the articular capsule is divided.
In resecting the acromial end, an incision is made from the extreme end
420
SURC;iCAL TECHNIC
of the clavicle to about the coracoid process ; at its inner border, an elevator
is inserted behind the bone, and the latter is divided ; next, the acromio-
clavicular articulation is disconnected, and finally the portion of bone is
enucleated from the periosteum.
If the zvliole clavicle must be removed, the operation can be facilitated
by sawing the bone through in the middle, and by extirpating each half
separately. The temporary resection of the clavicle for ligating the sub-
clavian artery is mentioned on page 261.
RESECTIONS OF THE LOWER EXTREMITIES
RESECTION OF THE ARTICULATIONS OF TOES
is made according to the same rules as those which have been laid down in
the resection of fingers, with longitudinal incisions extending laterally along
the extensor tendon (Fig. 819, i and 2). Of frequent necessity is the
ARTHRECTOMY OF THE ARTICULATION OF THE GREAT TOE
in inflammations, tuberculosis (and in some cases of Jiallnx valgus). Ferdi-
nand Peterseiis broad opening furnishes a very good survey. Instead of a
longitudinal incision made at the median side of the articulation, he divides
Fig. 819 Fig. 820
Petersen's Arthkectomy of the Articulatujn of the Great Toe
I, 2, resection of the articulations of the toes; 3, resection of the metatarsus
the web between the first and the second toes as far as the neck of the con-
dyle of the metatarsus and a little nearer toward the great toe (Fig. 819).
The two toes are forcibly reflected, and the first articulation of the toes of the
metacarpus is opened. With resection incisions, the soft parts are detached
THE TREATMENT OF WOUNDS 42 1
in a dorsal and plantar direction by preserving the insertions of the muscles
and tendons until the toe can be more and more extended, and finally be
turned over completely (Fig. 820). The articulation is then exposed. All
vestiges of disease can easily be removed, all proliferations of the bone
can be nipped off with the forceps, etc. Finally, the toe is reposed in
its natural position and the skin wound is completely closed by a few
sutures.
In the same manner, the articulation of the little toe can be opened.
The resection of a metatarsal bone is made as in that of the fingers, from a
longitudinal incision passing over the bone and extending beyond the next
articulations (Fig. 819, 3). For the removal of all metatarsal bones an
incision is used as in Fig. 703. The articular surfaces of the tarsal bones
and the toes can be vivified for the purpose of producing a firmer coales-
cence, in case the surgeon is not content with the simple disarticulation,
which is made similar to Fig. 704.
RESECTION OF THE ANKLE JOINT SUBPERIOSTEALLY
BY VON LANGENBECK's BILATERAL INCISION
1. After the foot has been placed upon its inner side, an incision 6 centi-
meters long is made vertically along the posterior border of the fibula down-
ward, turning at the tip of the external
malleolus, next along its anterior border
i^ centimeters, and penetrating every-
where down to the bone (hook-shaped
incision. Fig. 821).
2. With the raspatory and the eleva-
tor, the periosteum, in connection with the
skin, muscles, and sheaths of the tendons,
is detached at the anterior and posterior
surface from the bone until the metacar- Fig. 821
pal or chain saw can be inserted behind
the fibula at the upper end of the incision (Fig. 822). The tendon sheath
of the peroneus longus muscle must be preserved if possible.
3. The fibula is sawed through ; the sawed-off portion is grasped with
bone forceps, gradually drawn forward more forcibly (Fig. 823), and detached
from the interosseous ligament ; finally, from within and above, the posterior
ligament of the external malleolus (the inferior, very firm end of the inter-
osseous ligament. Fig. 824), and the three strong accessory ligaments
422
SURGICAL TECHNIC
Fig. 822. Exterior Side of the Left Articulation of the Foot
(according to Henke)
FibiUa
lig. inteross^
lig. malleoli
ext. post.
lig.fib.calcan.
Tibia
Calcaneus
Fig. 823. DisARTicirLATiox of the Lower Fig. 824. Ligaments of the Ankle Joint
Extremity of Fibula (Posterior side)
« lig. deUdd.
lig. tali fib.
post.
THE TREATMENT OF WOUNDS
423
(Fig. 825) (the talofibular ligaments and the caicaneofibular ligament) are
cut close to the malleolus.
4. The foot is then placed upon its external side ; around the inferior
border of the internal malleolus a semilunar incision 3 to 4 centimeters in
length is made (Fig. 826), and
from its middle a vertical in-
cision 5 centimeters long as-
cends upward over the inner
side of the tibia (anchor incision).
Fig. 825. Ligaments of the Ankle Joint
(Outer side)
Fig. 826. Incision upon the Internal
Malleolus (Anchor incision)
5. The incisions penetrate through the periosteum down to the bone.
The periosteum is elevated ivitJi the skin from the inner surface in the form
i. Achill.—
lig. tibio-naviciiL
m. tib. post..-
m. flex, dig.—
m. jtex. hal.—
art. tib. post. -
Fig. 827. Inner Side of the Ankle Joint (according to Henke)
of two triangular flaps (Fig. 827), tuith the tendinous sheaths of the dorsal
flexors from the anterior surface, zvith the tendinous sheaths of the plantar
424
SURGICAL TECHNIC
flexors from the posterior surface of the tibia, and, finally, the deltoid liga-
ment is cut off from the margin of the malleolus (Fig. 828).
6. At the upper end of the longitudinal incision, the tibia is sawed
through with the metacarpal saw or the chain saw (in an oblique direction
on account of the limited space); the sawed-off portion is grasped with bone
forceps ; and, while the elevator retracts the periosteal surface of the inter-
osseous ligament from above, it is gradually rotated out of the wound. The
protection of the interosseous membranes is of especial importance for the
subsequent regeneration of the bone {von La}igcnbtxk).
7. The bone is then held only by the anterior and posterior insertions of
the articular capsule. They are divided with the knife, but the tendon of
the tibialis posticus must not be
injured.
8. If the superior articular
surface of the astragalus is to
be removed, the excision is made
with the metacarpal saw ; in the
direction of the semilunar skin
incision, the trochlear surface is
sawed off from before backward,
while the plantar surface is
pressed firmly with both hands
upon the plate of the table.
( Von Langcnbcck advises saw-
ing off from the first incision
the superior articular surface of
the astragalus directly after the
division of the fibula, but not to the detached bone until the articular end
of the tibia has been excised.)
9. If the astragalus is severely comminuted or splintered as far as and
into its tarsal articular surfaces, or diseased, the whole bone must be removed.
(The modern treatment of comminuted gunshot fractures of joints does
not justify primary resection or even extraction of the fragments. Such
injuries are repaired m a most satisfactory manner by conservative treatment
under strict antiseptic precautions.)
10. For this purpose, the vertical incision is extended on the inner side
from the tip of the internal malleolus in a downward convex curve and par-
allel with the tendon of the tibialis posticus as far as the tuberosity of the
scaphoid bone; the tendon of the tibialis anticus and the anterior tibial
Y\Q. 828. Ligaments of the Ankle Joint
(Inner side)
THE TREATMENT OF WOUNDS 425
artery are retracted outward, the tibionavicular ligament (Fig. 827; and the
astragaloscaphoid ligament (Fig. 828; are divided, and the joint is opened
over the scaphoid bone from above inward.
1 1. On the outer side, the incision is carried from the tip of the external
malleolus horizontally over the sinus tarsi; its firm masses of ligaments are
divided (the anterior talofibular ligament and the external and internal astrag-
alocalcaneal ligaments (Figs. 825 and 828), and, finally, by rotating the
bone out of the joint with the elevator the remaining portions of the articular
capsule.
12. After careful ligation of all the bleeding blood vessels, a short drain-
age tube is inserted on both sides as far as the division of the bone, and the
wound is united by the suture.
13. If the entire astragalus is to be removed, it is advisable to drive
in a long nail through the os calcis into the tibia from the plantar surface, to
effect fixation between the bones at a right angle to one another.
14. After applying the usual dressing, the limb is placed upon a ]^olk-
'tnann splint with the foot placed at a right angle; in cases where great sup-
puration necessitates a frequent change of dressings, the interrupted or arch
splints fsee Figs. 225, 229, 234) will meet the additional indications.
Opening of the ankle joint by
konig's two anterior lateral inxisioxs
is also applicable in many cases.
1. The internal incision begins 3 to 4 centimeters above the ankle joint
over the tibia, to the inner side of the extensor tendons, and extends along
the a7tterior malleolar border to the tuberosity of the scaphoid bone ; the
external incision begins at the same level as the internal, and extends over
the anterior malleolar border to the sinus tarsi (joint line; at a level with the
astragalonavicular articulation. The articulation is opened directly by these
incisions.
2. The bridge of soft parts formed between these two incisions is elevated
from the underlying bones, tibia, and astragalus with the knife and the
elevator, and the anterior synovial bursa is extirpated, if it is diseased.
3. While the bridge flap is strongly elevated with a blunt retractor, the
foot being in dorsal flexion, the entire anterior field of the articulation can
be well inspected, and diseased portions are removed with the chisel or the
sharp spoon. The astragalus can easily be extirpated. If the removal
of the malleolar ends is necessarv, first the external lamellse are detached
426
SURGICAL TECHNIC
with a broad chisel applied obliquely ; next, the articular end of the tibia
is removed with the chisel, and, finally, also the astragalus, or at least its
trochlear surface, is chiselled away or sawed off.
4. By strong extension of the foot, the posterior capsular wall becomes,
finally, accessible for extirpation.
For a better inspection of the articular cavity, such methods are practical,
which, after the division of the soft parts, permit inversion of the foot suf-
ficiently so that the articular surface of the astragalus and the tibia can be
surveyed with one glance. For this purpose, the articulation is opened by
kocher's external lateral transverse incision
I. An external incision is made at a level with the line of the ankle joint
from the outer border of the extensor tendons {Ec) in a curve across the tip
of the external malleolus as far as the tendon of Achilles (Fig. 829).
Fig. S29
2. After division of the fascia, the extensor tendons and the peroneus
tertius (/) are drawn inwardly. The capsule of the joint and the ligaments
are detached from the anterior border of the tibia and the fibula and closely
around the external malleolus.
3. At the posterior border of the malleolus, the sheath of the peroneus
muscles is opened upward as far as and over the line of articulation ; the
tendons of the peronei {P) are forcibly retracted backward, or, if sufficient
space is not created thereby, divided (and subsequently united by suture).
The external saphenous nerve (S) passing behind these tendons must be
protected as far as possible.
4. Next, the posterior wall of the sheath of the extensor tendons and the
capsule (k) on the anterior and posterior border of the tibia are detached as
far as the internal malleolus.
THE TREATMENT OF WOUNDS
427
5. The foot can then be dislocated by a
strong lever movement across the internal
malleolus toward the median line, so that the
internal border of the plantar surface lies in
apposition to the inner side of the leg, and is
directed upward (Fig. 830).
6. If from the projecting tip of the inter-
nal malleolus the ligaments are carefully
detached, all parts of the articulation can
be freely inspected, and all diseased parts
can be removed, and the astragalus can easily
be resected. If the astragalus is to be saved
the operator has to guard against opening
the astragalocalcaneal articulation on the
posterior and lateral circumference of the
astrasralus.
Fig. 830. Kocher's Resection of
THE Ankle Joint
BY GIRARD S EXTERNAL OBLIQUE INCISION
I . The external incision begins on the external side vertically above the
tip of the external malleolus between the tibia and the fibula, and descends
obliquely downward as far as and over the tip of the malleolus, meeting an
oblique incision extending from the
external border of the tendon of
Achilles, past the tip of the exter-
nal malleolus to the tendon of the
peroneus tertius (Fig. 831).
2. The tendons of the peroneus
longus and brevis are exposed and
divided between two silk ligatures ;
the skin flaps are dissected back
until the ankle joint and the astrag-
alus are exposed.
Fig. 831. Girard's Resection of
Joint
the Ankle
3. The capsule of the joint is divided and detached with the ligaments
so that the foot can be strongly supinated.
4. The astragalus can then be extirpated without any difficulty, and, if nec-
essary, the foot can be adducted sufficiently to expose the joint cavity freely,
when all diseased tissue can be removed through the large gaping wound.
5. Finally, the foot is replaced into its normal position, the divided tendons
are united by sutures, the cavity of the wound is drained, and the external
incision is sutured.
428
SURGICAL TECHNIC
Fig. 8^,2.
Lauenstein's Method of opening
Ankle Joint
Laiienstein opens the ankle joint by a long curved incision on its outer
side, extending from the middle of the fibula over the external malleolus,
across the heads of the extensor brevis
digitorum and behind the tendon of
the peroneus tertius in front, to a
level with the astragalonavicular
joint (Fig. 832).
The skin is dissected off in front
and behind, the fascia at the anterior
border of the fibula is divided, the
ankle joint is opened in front of the