Amputation; Artificial limbs; Orthopedics; Surgery, Military
1. They interpose a fibrous layer of greater or less thickness between
the bone and the skin, so that the latter remains movable over the end
of the bone and is not directly compressed;
2. They adhere to the cut section of the bone forming a tendinous
insertion, which renders their action on the bony lever more powerful.
A flap bears weight badly when the muscles have retracted around the
bone, over which there is then nothing but skin. It is the same when
the flap is stretched tightly across the end of the bone, _the soft
parts must remain soft and free_.
Among the hundreds of cases of amputation of the leg or thigh that
have passed before us in being fitted at the _Fédération des Mutilés_,
there were many in which the presence of a terminal scar rendered the
fitting of an apparatus difficult; we have never found this the case
with a lateral scar; we have never seen the latter ulcerate rapidly as
the result of pressure or friction in a properly made wooden bucket.
So that it cannot be admitted that the proper covering of a stump is
ever a matter of secondary importance.
Consequently we should consider, as a matter of principle, the
circular method of amputating only as a last resort, and we ought to
arrange the section of the soft parts so as to cover the end of bone
as adequately as possible, and to bring the scars to one side.
We realise that in practice war surgery often necessitates deviations
from the ideal. We often find ourselves in a dilemma--either the stump
must be good but too short; or, being long, must be poor or even bad.
In the special case of the thigh, circular amputation in the lower
third when it is carried out through healthy tissue and has not
suppurated can be trimmed and sutured in such a way as to give an
excellent scar, which is transverse and slightly posterior. In this
situation after these routine amputations, a linear scar which is
supple and has healed by first intention, separated from the bone
by a good cushion of muscular and fibrous tissue, causes little
embarrassment, whatever its position; at the end of a few months it
stands pressure and friction without harm. But we are considering
war surgery and consequently we are often called upon to fit stumps
in which the cicatrix is large, hard, and more or less irregular, in
which the bone has suppurated and in which the neighbouring soft parts
are indurated and scarred. These stumps are not, however, the results
of the work of the worst surgeon.
Amputating through infected parts, resigning himself to healing by
granulation and subsequent trimming by operation, he must take time
and trouble to attain in the end a result which is good functionally,
although at first sight unsightly. But it is this surgeon who is on
the right road, rather than he who sends us good stumps which have not
suppurated, because he has amputated through the thigh for a wound of
the middle of the leg, or through the leg for a wound of the foot or
even of the front of the foot.
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