Fashion a long palmar and a short dorsal skin flap in a ratio of 2 : 1. Dissect the flaps proximally to the level of proposed bone section, and expose the underlying soft structures.

Draw the tendons of the finger flexors and extensors distally, divide them, and allow them to retract into the forearm.

Identify the tendons of the wrist flexors and extensors, free their insertions, and reflect them proximal to the level of bone section. Identify the median and ulnar nerves and the fine filaments of the radial nerve. Draw the nerves distally, and section them well proximal to the level of amputation so that their ends retract well above the end of the stump.

Just proximal to the level of intended bone section, clamp, ligate, and divide the radial and ulnar arteries, and divide the remaining soft tissues down to bone.

Transect the bones with a saw, and rasp all rough edges to form a smooth, rounded contour.

At convenient points in line with their normal insertions, anchor the tendons of the wrist flexors and extensors to the remaining carpal bones so that active wrist motion is preserved.

With interrupted nonabsorbable sutures, close the subcutaneous tissue and skin at the end of the stump, and insert a rubber tissue drain or a plastic tube for suction drainage.

Fashion a long palmar and a short dorsal skin flap (Fig. 18-2A). Begin the incision 1.3 cm distal to the radial styloid process, carry it distally and across the palm, and curve it proximally to end 1.3 cm distal to the ulnar styloid process.

Form a short dorsal skin flap by connecting the two ends of the palmar incision over the dorsum of the hand; atypical flaps may be fashioned, if necessary, to avoid amputation at a higher level. Reflect the skin flaps together with the subcutaneous tissue and fascia proximally to the radiocarpal joint.

Just proximal to the joint, identify, ligate, and divide the radial and ulnar arteries.

Identify the median, ulnar, and radial nerves and gently draw them distally into the wound. Section them so that they retract well proximal to the level of the amputation.

At a proximal level, divide all tendons and allow them to retract into the forearm.

Incise the wrist joint capsule circumferentially, completing the disarticulation (Fig. 18-2B and C).

Resect the radial and ulnar styloid processes, and rasp the raw ends of the bones to form a smoothly rounded contour. Take care to avoid damaging the distal radioulnar joint, including the triangular ligament, so that normal pronation and supination of the forearm are preserved and pain in the joint is prevented (Fig. 18-2D).

With interrupted nonabsorbable sutures, close the skin flaps over the ends of the bones (Fig. 18-2E), and insert a rubber tissue drain or a plastic tube for suction drainage.

Beginning proximally at the intended level of bone section, fashion equal anterior and posterior skin flaps (Fig. 18-3A); make the length of each about equal to one half of the diameter of the forearm at the level of amputation. Together with the skin flaps, reflect the subcutaneous tissue and deep fascia proximally to the level of bone section.

Clamp, doubly ligate, and divide the radial and ulnar arteries just proximal to this level.

Identify the radial, ulnar, and median nerves; draw them gently distally; and transect them high so that they retract well proximal to the end of the stump.

Cut across the muscle bellies transversely distal to the level of bone section, and allow their ends to retract to that level.

Divide the radius and ulna transversely, and rasp all sharp edges from their ends (Fig. 18-3B).

Close the deep fascia with fine absorbable sutures and the skin flaps with interrupted nonabsorbable sutures (Fig. 18-3C), and insert deep to the fascia a rubber tissue drain or, if preferable, a plastic tube for suction drainage.

If desired, a myoplastic closure may be done in this amputation as follows. After raising appropriate flaps of skin and fascia, fashion an anterior flap of flexor digitorum sublimis muscle long enough so that its end can be carried around the end of the bones to the deep fascia dorsally.

Divide the remaining soft tissues transversely at the level of bone section.

After dividing the bones and contouring their ends, carry the muscle flap dorsally, and suture its end to the deep fascia over the dorsal musculature. To prevent excessive bulk, the entire anterior muscle mass should never be used in this manner.

Close the stump as already described.

When good skin is available, fashion anterior and posterior skin flaps of equal length; if good skin is unavailable, fashion atypical flaps as necessary rather than amputate at a more proximal level. Reflect proximally to the level of intended bone section the deep fascia together with the skin flaps.

Just proximal to this level, identify, doubly ligate, and divide the major vessels.

Identify the median, ulnar, and radial nerves; gently pull them distally; and section them proximally so that their ends retract well proximal to the end of the stump.

Divide the muscle bellies transversely distal to the level of bone section so that their proximal ends retract to that level. Carefully trim away all excess muscle.

Divide the radius and ulna transversely, and smooth their cut edges. If the end of the stump is not at least distal to the insertion of the biceps tendon, resect the distal 2.5 cm of this tendon according to the technique of Blair and Morris. This lengthens the stump functionally and enhances prosthetic fitting. Even without biceps function, the elbow can be flexed satisfactorily by the brachialis muscle.

With interrupted absorbable sutures, close the deep fascia; with interrupted nonabsorbable sutures, close the skin edges. Insert deep to the fascia a rubber tissue drain or a plastic tube for suction drainage.