Amputation Below the Knee


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[See Also: Civil War Medicine, Amputation Overview, Amputation of the Leg, Amputation Below the Knee, Amputation of the Arm,

Amputation of Fingers and Toes]

Amputation: Amputation Below the Knee

(From "The Practice of Surgery", by Samuel Cooper, and notes by Dr. Alexander H. Stevens. This book served as the "How To" guide for Civil War surgeons)



Cooper's "The Practice of Surgery"In the thigh, amputation is done as low as the case will allow. In the leg, the common practice is to make the incision through the integuments sufficiently low, to enable the operator to saw the bones, about four inches below the lower part of the patella. This is necessary, in order to have a sufficient surface in front of the limb for the application of a wooden leg, and not to deprive the stump of that power of motion, which arises from the flexor tendons of the leg continuing undivided.

The tourniquet should be applied to the femoral artery, two-thirds of the way down the thigh, just before the vessel perforates the tendon of the triceps muscle; this is a much more convenient situation than the ham. The leg being properly held, the integuments should next be drawn upward by an assistant, while the surgeon, with one quick stroke of the knife, divides the skin completely round the limb.

Some recommend the operator to stand on the inside of the leg, in order that he may be able to saw the bones at once. No reflections could ever make me perceive, that any real advantage ought strictly to be imputed to this plan. I know, many fancy that it diminishes the chance of the fibula being splintered, as this bone is completely divided rather sooner than the tibia. But, as splintering the bones arises from the assistant, who holds the leg, depressing the limb too much, it would be difficult to explain, why the two bones should not be splintered, when a certain thickness of them had been sawn through, if the leg were too forcibly depressed.

Having made a circular division of the integuments, the next object is, to preserve skin enough to cover the front of the tibia, and the part of the stump corresponding to the situation of the tibialis anticus, extensor longus pollicis, and other muscles, between the tibia and fibula, including those covering the latter bone. Throughout this extent, there are no bulky muscles which can be made very serviceable in covering the end of the stump, and consequently the operator must here have sufficient skin, by dissecting it up, and turning it backwards.

On the posterior part of the leg, the skin should never he detached from the large gastrocnemius muscle, which, when obliquely divided, will, with the soleus, here form a sufficient mass for covering the stump. Hence, as soon as the skin has been separated in front, and on the outside of the leg, the surgeon is to place the edge of the knife in the incision of the integuments, and cut in the Alansonian way through the muscles of the calf, from the inside of the tibia, quite to the fibula. Then the flap, formed by the calf of the leg, is to be held back by the assistant, while the surgeon completes the division of the rest of the muscles, together with the interosseous ligament, by means of the catling, or a long, very narrow, double-edged knife.

In amputating below the knee, particular care must be taken to cut every fasciculus of muscular fibres, before the saw is used. Every part being divided, except the bones, the soft parts are next to be protected from the saw, by a linen retractor, made with three tails, one of which is to be drawn through the space, between the tibia and fibula.

In the leg, only three principal arteries require ligatures; viz. the anterior and posterior tibial, and the peroneal, arteries.

When the wound is to be dressed, the soft parts, preserved for covering the bones, should be brought together, so as to make the line of their union not transverse, but obliquely perpendicular, the lower end of it being more external than the upper. Thus the tibia and fibula may be effectually covered, without the strips of adhesive plaster forcibly pressing the skin against the sharp edge of the tibia. The plaster, which makes most pressure, should go over the. centre of the stump, at the point corresponding to the interosseous space.



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