Formal excisions of the wrist are undertaken for tuberculous disease. It is desirable that all the affected tissues be removed. To do this is difficult, on account of the number and extent of the various carpal bones and joints as well as the danger of injuring the important arteries, nerves, and tendons by which they are surrounded. To remove the diseased parts without inflicting avoidable injury requires an exact and skilful operator who has a precise knowledge of the anatomy of the region. Interference with the sheaths of the tendons will result in stiffness and loss of control and power in the hand.

Fig. 357.   Subluxation of the wrist from disease.

Fig. 357. - Subluxation of the wrist from disease.

Maisonneuve, Boeckel, and Langenbeck operated through a single dorsal incision along the radial side of the extensor indicis tendon. As this incision was found to give insufficient room, Lister, in 1865, advised an additional incision along the ulnar border. Oilier, of Lyons, modified Lister's radial incision by carrying it nearer the extensor indicis tendon to better avoid injuring the radial artery and the insertion of the extensor carpi radialis brevior tendon. Oilier also carried his incision somewhat higher on the wrist and raised the tissues with a periosteal elevator, and divided no tendons.

Fig. 358.   Excision of wrist, showing structures involved and Ollier's incisions. The solid line indicates the dorsal radial incision and the dotted line the palmar ulnar incision.

Fig. 358. - Excision of wrist, showing structures involved and Ollier's incisions. The solid line indicates the dorsal radial incision and the dotted line the palmar ulnar incision.

Ollier's Operation

Radial Incision. - From a point on the dorsum of the wrist midway between the styloid processes, downward and outward alongside of the extensor indicis tendon to the junction of the middle and lower thirds of the metacarpal bone of the index finger (Fig. 358).

Ulnar Incision

From a point 2.5 cm. (1 in.) above the styloid process of the ulna toward its palmar surface, downward to the base of the fifth metacarpal bone (Fig. 358).

When making the radial incision, branches of the radial nerve may be seen in the lower part of the incision and should if possible be avoided. In making the ulnar incision a cutaneous branch of the ulnar nerve should be avoided as it verges toward the dorsal surface below the styloid process.

The extensor indicis tendon is pulled aside and the extensor carpi radialis brevior beneath detached with the periosteum from the base of the third metacarpal bone. The incision is then extended higher up the wrist, care being taken not to injure the tendon of the extensor longus pollicis at the posterior radial tubercle. The periosteum is to be detached over the lower end of the radius, the radiocarpal joint opened, and the carpal bones removed one after another. The pisiform bone, unciform process, and trapezium are left when possible. In removing the unciform process the deep branch of the ulnar nerve should be avoided. If the trapezium is removed care must be taken not to wound the radial artery as it goes over the bone to dip between the first and second metacarpal bones, and also to avoid the flexor carpi radialis tendon as it crosses to the inner side of the ridge of the trapezium on its palmar surface.

The articular ends of the ulna and radius may be removed with a small saw if necessary. As Jacobson says, this operation is a tedious and difficult one, and we might add that it is liable to be an inefficient one, owing to the inability to remove all of the diseased tissue.

Operations Of Studsgaard And Mynter

Studsgaard of Copenhagen in 1891 (" Hospitalstidenden," Jan. 7, 1891) suggested, and Herman Mynter of Buffalo (Transactions of the American Orthopedic Association, 1894, vol. vii, p. 253) carried out the method of splitting the hand on the dorsum from the web between the second and third fingers to the lower edge of the radius, and on the palmar surface to the base of the thenar eminence.

Dr. Wm. J. Taylor (Annals of Surgery, vol. xxii, 1900, p. 360) modified the operation by employing only the dorsal incision. This operation gives full access and exposure to the parts, and all disease can most readily be recognized and removed with the scissors or other instruments. It is probably the best method of exposure and operation when simple incision and curetting does not suffice.