Joseph Bell - A Manual of the Operations of Surgery

2. In the progress of the flap operation fewer stages can be defined. Made by cutting from within outwards, after transfixion of the limb, the flaps varied in shape, size, position, and numbers, from the single posterior one of Verduyn of Amsterdam, to the two equal lateral ones of Vermale, and the equal anterior and posterior ones of the Edinburgh school.

Then came the battle of the schools: flap or circular.

Flap. —Speedy, easy, and less painful; apt to retract, and that unequally.

Circular. —Leaving a smaller wound, but more slow in performance, and apt to leave a central adherent cicatrix.

3. The last era in amputation began after the introduction of anæsthetics. Now speed in amputation is no object, and the surgeon has full time to shape and carve his flaps into the curves most suited for accurate apposition, and suitable relation of the cicatrix to the bone. It has also been brought clearly out that different methods of operating are suitable for different positions, and also that even in the same operation it is possible to unite the advantages of both the flap and the circular method.

In the modified circular, which is best suited for amputation below the knee, in the long anterior flaps of Teale, Spence, and Carden, we have illustrations of the manner in which the advantages of both the flap and circular methods have been secured, without the disadvantages of either. The long anterior flap, not like Teale's to fold upon itself, but like Spence's and Carden's to hang over and shield the end of the bones, and the face of a transversely-cut short posterior flap, seems to be now the typical method for successful amputations. There may be exceptions, as when the anterior skin is more injured than the posterior, or where an anterior flap would demand too great sacrifice of length of limb, but as a rule it will be found the best method for the patient.

Fig. i.

Amputation of the Upper Extremity.—The extreme importance of the human hand, its tactile sensibility, its grasping power, and the irreparable loss sustained by its removal, render the greatest caution necessary, lest we should remove a single digit or portion of one that might be saved. In cases of severe smashing injuries involving the fingers, it is the surgeon's bounden duty not recklessly to amputate the limb with neat flaps at the wrist-joint, but carefully to endeavour to save even a single finger from the wreck, though at the risk of a longer convalescence, or even of a profuse suppuration. While a toe or two, or a small longitudinal segment of the foot, may be comparatively useless, and a good artificial foot, with an ankle-joint stump, certainly preferable, a single finger, provided its motions are tolerably intact, will prove much more valuable to its possessor than the most ingeniously contrived artificial hand.

However, while in cases of extensive smash we endeavour to save anything we can, the case is very much altered when it is only one or two fingers that are injured. Here we find another principle brought into play, and our conservative surgery must be limited by the following consideration. In endeavouring to save a portion of the injured finger or fingers, will the saved portion interfere with the important movements of the uninjured ones? These two principles—1. Generally to save as much as we can; 2. Not to save anything which may be detrimental or in the way,—will guide us in describing the amputations of the upper extremity.

Fig. ii.

Amputation of a distal phalanx. —This small operation is not very often required. In cases of whitlow in which the distal phalanx alone has necrosed, removal of the necrosed bone by forceps is generally all that is necessary. In cases of injury, however, in which nail and distal phalanx are both reduced to pulp, it will hasten recovery much to remove the extremity. There is no choice as to flap, the nail preventing an anterior one, so a flap long enough to fold over must be cut from the pulp of the finger in either of two ways (Fig. i. 1):—1. Holding the fragment to be removed in the left hand, and bending the joint, the surgeon makes a transverse cut across the back of the finger, right into and through the joint, cutting a long palmar flap from within outwards as he withdraws the knife.

Note. —Some difficulty is often felt in making the dorsal incision so as exactly and at once to hit the joint; the most common mistake being, that the transverse incision is made too high, and the knife, instead of striking the joint, only saws fruitlessly at the neck of the bone above. To avoid this, the surgeon should take as a guide to the joint, not the well-marked and tempting-looking dorsal fold in the skin, but the palmar one, which exactly corresponds with the joint between the proximal and middle phalanges, and is only about a line above the distal articulation.—(Fig. ii.)

2. Making the long flap by transfixion, it may be held back by an assistant, and the joint cut into.

Amputation through the second phalanx. —If the distal phalanx be so much crushed that a flap cannot be obtained, two short semilunar lateral flaps may be dissected (Fig. i. 2) from the sides of the second phalanx, which may then be divided by the bone-pliers at the spot required.

In cases of injury which do not admit of either of the preceding operations, it is quite possible to amputate either at the first joint, or even through the proximal phalanx. Patients are sometimes anxious for such operations in preference to amputation of the whole finger. The surgeon should, however, never amputate through a finger higher up than the distal end of the second phalanx, unless absolutely compelled by the patient, for the resulting stump, being no longer commanded by the tendons, will prove merely an incumbrance, and may possibly require a secondary operation at no distant date for its removal.

This rule is applicable in cases in which a single finger is injured, and two or three complete ones are left; in cases where all the fingers have been mutilated every morsel should be left, and may be of use.

Amputation of a whole finger. —(Fig. i. 3)—This is an operation of great importance, from its frequency.

If the third or fourth digits require amputation, it should be performed as follows:—The vessels of the arm being commanded, an assistant holds the hand, separating the fingers at each side of the one to be removed. The surgeon holding the finger to be removed, enters the point of a long straight bistoury exactly (some authorities say half an inch) above the metacarpo-phalangeal joint, and cuts from the prominence of the knuckle right into the angle of the web, then, turning inwards there, cuts obliquely into the palm to a point nearly opposite the one at which he set out.

Note. —While most authorities agree with the direction in the text regarding the palmar termination of the incision, I believe, in most cases, it is not necessary to go so far, and that the incisions may fitly meet in the palm at a point midway between a point opposite to the knuckle, and the centre of the well-marked "sulcus of flexion."

He then repeats this incision on the other side, makes tense the ligaments, first at one side and then at the other, by drawing the finger to the opposite side, and cuts them. The tendons being cut, the finger is detached. The vessels being tied, one point of suture is put in on the dorsal aspect, and the fingers on each side tied together at their extremities, with a pad of lint between them.

Modification. —Lisfranc's method is too long in its minute description to give in detail. The principle is to make a semilunar flap at one side (the one opposite the operator's right hand), by cutting from without inwards, then to open the joint from this cut, and, still keeping the edge of the knife close to the head of the phalanx, cutting the other flap from within outwards. This can be very rapidly done, but the last flap is apt to be irregular and deficient, especially in those common cases, in which, after whitlow or the like, the tissues are hard and brawny, and the skin does not play freely.