Immediate amputation is, so to speak, never indicated in traumatisms through bullets. It is only admissible in cases of confirmed gangrene.
In the most comminuted fractures, neither very extensive damage of the soft parts, nor an extreme condition of comminution of the diaphyses, nor supposed nor evident lesions of the large vessels, nor injury to important nerves, can be looked upon as indications for amputation.
Very great disturbances of the soft parts can be repaired; it is possible to obtain union in the bones, even when a fracture is comminuted; lesions of the large vessels are not always followed by gangrene, and we cannot be absolutely precise in laying down the exact nature of wounds of important nerves by bullets.
Immediate and atypical amputation can only be called for in cases of complete smashing or of almost total tearing off of a limb by a big projectile or by a big fragment.
Later on, amputation may be necessitated by:
1. Confirmed traumatic gangrene.
2. Rapid extension of emphysematous gangrene, which is almost generalized in one limb.
3. Conditionally, by an enormous diffuse aneurysm, which threatens to rupture if the surgeon does not feel himself qualified to put on a direct ligature.
4. By very grave complications through suppuration, especially osteomyelitis.
Amputation must not be carried out during the period of shock, by reason of its extreme gravity. It should be carried out as soon as the indications for its performance are absolutely confirmed. The incisions should be made as low as possible.
Disarticulation is preferable to amputation when removal of the limb is rendered necessary by medullary lesions.
The circular method in cases of gangrene; in other cases the circular method and the method with square flaps should be preferred.
When there is danger of infection of the stump, the wound should be left open.
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