Amputation; Artificial limbs; Orthopedics; Surgery, Military
The stump in its bucket is in fact a bone, furnished with soft parts
upon which we cannot exert vertical pressure, without squeezing them
back towards the base of the stump, thus exerting an upward tension
of the terminal soft parts over the end of the bone. This is bound to
occur unless there is a considerable length of soft parts beyond the
end of the bone, that is unless more bone has been sacrificed than was
necessary. In this way we get all the disadvantages of an end bearing
without its advantages.
3. _Direct end bearing._--This is only the principal bearing in
certain special stumps which we shall indicate in due course; in some
of these it is the sole bearing. In the case of apparatus for the
usual amputations, above the epiphyseal enlargements, it is never more
than a complementary or accessory bearing, although a very useful one.
To take pressure upon the end of the stump it is only necessary to
stretch across the bucket at the right height a piece of material
covered with felt. If the apparatus is made of leather, the support is
taken upon a circular band of metal fixed to the lateral steels.
In order that direct pressure upon the stump may be possible, two
conditions are indispensable: that there is no terminal scar; and
that the extremity of the bone is well covered with a thick and
nonadherent flap. Actually walking directly on the stump does not
involve simply support by pressure, but also inevitable friction,
of greater or less importance, caused by the backward and forward
movement. This is only realised under the most perfect conditions if
the skin is adapted by its structure to this movement. This is the
case with the sole of the foot: where the epidermis and dermis are
thick and the subcutaneous areolar tissue and deep fascia, continuous
with it, enclose little cavities filled with globules of fat; these
form a cushion, like little globules of liquid gliding over each
other. The skin of the point and of the posterior surface of the heel
is less suitable anatomically than that of the sole: it is, however,
good, and it is for this reason that after amputation above the
malleoli, it is possible to walk directly upon the cut surface of the
tibia.
Nevertheless skin which is not prepared in this way by its normal
structure can adapt itself to pressure and friction, provided that
it is padded by a thick muscular layer, sheathed whenever possible
with fibrous tissue. A skin which is not so lined, especially in
fair and stout people, with thin and delicate skin, ulcerates easily
as the result of friction or even of simple pressure, and bursæ and
callosities form. See what happens to the skin on the dorsum and outer
side of the foot in the case of talipes equino varus. The muscles of
the flap will not remain over the bone in the condition of muscular
tissue, they become fibrous--but they are useful because:
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