AMPUTATING THROUGH THE FOREARM

For the general method see Section 56.1.

AMPUTATING THROUGH THE PROXIMAL FOREARM

Abduct the patient’s arm on an arm board or side table, and place it supine. If you cut the flaps with his arm prone, they will later be twisted.

If there is enough good skin, make equal anterior and posterior flaps. If skin is scarce, make the best flaps you can.

Reflect the skin flaps with the deep fascia to the site of section. Tie, and cut his radial and ulnar arteries just above this site. Find his median, ulnar, and radial nerves, pull them gently, and cut them proximally. Cut his muscles transversely distal to the site of section, so that they retract above it. Trim away all excess muscle. Saw his radius and ulna and smooth their cut edges.

Release the tourniquet, control bleeding, drain and close the stump as usual.

Start elbow and shoulder movements as soon as possible.

AMPUTATING THROUGH THE DISTAL FOREARM

Start at the site of section and cut equal anterior and posterior flaps, as in Fig. 56-9. Make them as long as about one half the diameter of the forearm at the amputation site. Reflect the flaps proximally to the site of bone section.

Clamp, tie, and cut his radial and ulnar arteries just proximal to the site of section. Find his radial, ulnar, and median nerves, pull them gently and cut them high up so that they retract above the end of the stump. Saw both bones.

Release the tourniquet, control bleeding, drain and close his stump as usual (56.1).

DISARTICULATING THE WRIST

Make a long palmar and a short dorsal flap. Start the incision 1.5 cm distal to the patient’s radial styloid, extend it distally towards the base of his first metacarpal. Carry it distally across his palm, and then proximally to end 1.5 cm distal to his ulnar styloid. Make a short dorsal flap by joining the two ends of the palmar incision over the dorsum of his hand. Bring the dorsal flap distally level with the base of his middle metacarpal. If skin is scarce, vary the design of the flaps.

Reflect the flaps proximally with the underlying fascia to his wrist joint. Tie and cut his radial and ulnar arteries just proximal to the joint. Gently draw his median, ulnar, and radial nerves distally into the wound, and cut them short. Cut all tendons just above his wrist and let them to retract into his forearm. Cut round the capsule of his wrist joint and remove his hand.

Saw or nibble off his radial and ulnar styloids. Rasp the raw ends of the bones smooth and round.

CAUTION! Don’t injure his radioulnar joint or its triangular ligament. If you injure them, he will be unable to rotate his forearm, and the joint will be painful.

Release the tourniquet, control bleeding, drain and close tha stump as usual (56.1).

AMPUTATING THROUGH THE CARPUS

Make a short dorsal flap and a palmar one twice as long. Reflect the flaps proximally to the site of bone section, and expose the soft tissues under them.

Pull the flexor and extensor tendons, of his wrist distally, cut them, and allow them to retract into his forearm. Find the four tendons which flex and extend his wrist (flexor and extensor carpi radial is and ulnaris), free their insertions, and reflect them proximally to the site of bone section.

Find his median and ulnar nerves and the fine filaments of his radial nerve. Pull them distally and cut them well proximal to the site of section. Tie and cut his radial and ulnar arteries proximal to the site of section.

Cut the remaining soft tissues down to bone. Saw across his carpal bones, and rasp all rough edges smooth. Anchor the tendons of his wrist flexors and extensors to his remaining carpal bones in line with their normal insertions.

Release the tourniquet, control bleeding, drain and close the stump as usual (56.1).

AMPUTATING THROUGH THE METACARPUS

Do this as for amputation through the carpus, but preserve what you can of the patient’s metacarpals, and especially his thumb.