The many different methods of amputating at the shoulder may for our purposes be divided into two classes, - the flap method and the racket method.

The Flap Method

One large flap may be made to the outer side and a short one to the inner side (Dupuytren) or they may be made anteroposteriorly (Lisfranc). The flap operations were done with long knives by transfixion, as they originated before the discovery of general anaesthesia and by them the member was removed with great rapidity (Fig. 263).

In Dupuytrern's method the arm was raised to a right angle with the body and the deltoid muscle grasped with one hand while the knife was inserted beneath it, entering just below the posterior portion of the acromion process (its angle) then passing under the acromion to emerge in front at the coracoid process. This flap was turned up, the capsule and muscles divided, the bone turned out, and while an assistant compressed the remaining tissues they were divided transversely.

Fig. 262.   Detachment of the epiphysis of the upper end of the humerus.

Fig. 262. - Detachment of the epiphysis of the upper end of the humerus.

Lisfranc's method consisted in transfixing the posterior axillary fold from below upward, entering the knife in front of the tendons of the latissimus dorsi and teres major muscles and bringing it out a little in front of the acromion. The joint was opened posteriorly, the bone luxated, and an anterior flap cut from within outward. Sir William Fergusson, probably the most skilful operator of his day, was partial to this operation.

The Racket Method

In this method the incision resembles in shape the ordinary racket, such as is used in tennis. The loop encircles the arm, while the handle begins above at the point'of the shoulder.

Fig. 263.   Amputation of the shoulder by anteroposterior flaps. The upper extremity of the incision passes between the coracoid and acromion processes. The posterior flap is the larger.

Fig. 263. - Amputation of the shoulder by anteroposterior flaps. The upper extremity of the incision passes between the coracoid and acromion processes. The posterior flap is the larger.

There are two operations by the racket method, which differ as to the position from which the upper portion of the incision starts.

Larrey' S Method

The operation usually ascribed to Larrey consists in starting the incision at the anterior end of the acromion process and continuing it straight down the arm for three centimetres (1 1/4 in.). It then parts, one branch sweeping gradually in a curved line to the anterior axillary fold and the other to the posterior axillary fold, an incision, through the skin only, passes across the inner surface of the arm joining the two branches. The flaps having been turned anteriorly and posteriorly, the joint is opened by cutting on the head of the bone, first posteriorly, then above, and then anteriorly. Tilting the head outward the inferior portion of the capsule is divided and the bone loosened from the soft parts. These are compressed by the fingers of an assistant and cut.