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mal phalanx with the left index-finger and thumb. Enter the tenotome beneath the fold of tissue pinched up. Extend the finger, and divide the tendons toward the bone. Close the wound as described.
Extensor Communis Digitorum, Extensors Primi and Secundi Internodii Pollicis.Pronate the forearm to bring the dorsum of the hand uppermost.
Pinch up the integument near the head of the metacarpal bone. Divide the tendon against the bone. Close the wound as described.
Flexor Carpi Radialis.-Supinate the forearm, and
pass the tenotome from the radial artery beneath the tendon from without inward.
Flexor Carpi Ulnaris.—Supinate the forearm, and pass
the tenotome beneath the tendon from without inward, avoiding the ulnar artery.
The extensors of the wrist need no special mention.
Biceps Flexor Cubiti. — Supinate the forearm. Extend the elbow to locate the tendon. Pinch
up the integument about an inch above the bend of the elbow over the tendon. Pass the tenotome from within outward beneath the tendon, facilitating its passage by semiflexing the elbow.
Extend the elbow, and divide the tendon toward the surface.
After the inner border of the tendon has been exposed in this operation, it is better to use a probepointed tenotome.
Flexors Longus and Brevis Digitorum and Flexor Longus IIallucis
be divided as the corresponding tendons in the hand; also the extensor proprius hallucis.
Extensor Longus Digitorum Pedis.—Place the subject on the back.
Locate the tendon by extending the ankle. Pass the tenotome beneath the tendon from within outward about an inch above the bend of the ankle.
Tibialis Anticus.—Pass the tenotome from without inward beneath the tendon about an inch above the ankle.
By adducting the foot and flexing the ankle, the passage of the tenotome beneath the tendon is facilitated. Tibialis Posticus.—Place the subject on the ab
. domen. Stand between the legs. Rotate the leg inward, and flex the ankle.
Locate the tendon immediately behind the internal border of the tibia. Draw the integument backward over the tendon, where it is felt about an inch above the inner malleolus. Pierce the tissues to the tendon, and then with a probe-pointed tenotome divide it against the tibia.
The tendon is made taut during its division by abducting the foot and flexing the ankle.
Peroneus Longus and Brevis.— With the subject lying on the abdomen, stand facing the outside of
Draw the integument backward over the tendons, as they are felt just posterior to the fibula about an inch above the outer malleolus. Make the tendons taut by adducting the floot and flexing the ankle. Cut toward the fibula. Tendo Achillis.—Place the subject on the abdo
Stand between the legs.
Introduce the tenotome beneath the tendon against its anterior surface a little above the level of the malleoli. Place the left thumb over the tendon, which is put on the stretch by flexing the ankle. Divide the tendon, taking care that the tenotome does not cut through the integument.
Biceps Femoris.—The subject on the abdomen, locate the tendon with the knee extended.
Push the tendon outward with the left thumb. Enter the point of the tenotome about two inches above the head of the fibula to the inner border of the tendon. By slightly moving the point of the tenotome, make the opening in the fascia larger. Pass a probe-pointed tenotome internally, and then beneath the tendon, the knee being slightly flexed. Care must be taken to hug the tendon to avoid the perineal nerve. Extend the knee and divide the tendon.
Semitendinosus and Semimembranosus. Locate the tendons, the subject being placed as in the last operation. Stand on the outside of the limb.
Draw the integument outward. Enter the tenotome from without inward on a level with the condyles of the femur. Divide the tendons.
The semitendinosus alone may be divided, or, by advancing the blade more and more inward, the semimembranosus and other internal ham-string muscles may simultaneously be divided.
Quadriceps Extensor.–Place the subject on the back. Stand on the outside of the limb.
Draw the integument above the patella inward. Enter the tenotome, or preferably a fasciatome, just external to the tendon above the patella, and advance it over the tendon. Partially divide the tendon, cutting downward until the deeper fibers can be ruptured.
It is best to avoid dividing the deeper fibers with the knife, lest the joint be opened.
Adductor Longus.—Locate the tendon just below the spine of the pubes, the hip being abducted. Draw the integument over its tendinous origin outward. Enter the tenotome from without inward beneath the tendon. Cut upward and inward.
From the foregoing operations it may be noticed that, when cutting in the proximity of important structures, the probe-pointed tenotome is used and passed from these structures.
Plantar Fascia (Fasciatomy).—Pass the fasciatome from within outward along the deeper surface of the band of fascia arising from the inner tuberosity of the os calcis. Divide the fascia, following the same rules given in tenotomy.
EXAMPLE OF TENDON SUTURING.
Biceps Femoris.—Make an incision three inches long over the course of the divided tendon. Expose the ends of the tendon, and cut them so that they will, when approximated, present oblique surfaces to each other. Securely stitch the ends together, making the sutures extend deeply into the substance of the tendon. The hip being extended, and knee flexed, the divided ends of the tendon are easily drawn together.
OPERATIONS ON NERVES (NEUROTOMY, NEURECTOMY,
STRETCHING, AND SUTURING).
NEUROTOMY OF THE LINGUAL.
Introduce the left index-finger into the mouth, and place it on the inner surface of the inferior maxilla in a line from the last molar tooth to the angle. Introduce a curved bistoury, and cut the tissues anterior to the finger.
The incision should be an inch in length, and parallel to the line in which the finger lies, and extend nearly to the last molar tooth. It should divide all the tissues through to the bone. The finger acts as a guide.
NEURECTOMY OF THE SPINAL ACCESSORY.
Place the subject on the back, and turn the head away from the side of the operation.
Make an incision three inches long just external to the anterior border of the sterno-cleido-mastoid mus. cle, with its middle point on a level with the angle of the jaw. Divide the integument and fasciæ, and open into the sheath of the sterno-cleidomastoid muscle. Retract the sides of the wound. Divide the muscular fibers in the middle of the wound on a di