fronfiTHE Philadelphia Medical Journal, June 1, 1901.) 
■ 
TWO SUCCESSFUL CASES OF SECONDARY SUTURE, 
ONE OF THE POSTERIOR INTEROSSEOUS NERVE 
AND ONE OF THE MEDIAN AND ULNAR NERVES. 
W. W. KEEN, M. D., LL.D., F.R.C.S. (Hon.), 
of Philadelphia. 
Professor of the Principles of Surgery and of Clinical Surgery, Jefferson 
Medical College, Philadelphia. 
CASE 1.-Division of the posterior interosseous nerve and 
common extensor muscle of the fingers, followed by total loss of 
extension of the fingers; suture after three months; entire re- 
storation of function* 
W. B. H., of Pine Bluff, Ark., aet.38, 6 ft. in. tall, 
weight 260 lbs., first consulted me November 6th, 1900, at 
the instance of Dr. J. L. Goree, of Pine Bluff. 
On August 1st, 1900, while camping out and standing in 
front of a guide, who was chopping down a tree, the ax- 
head flew off the handle and struck him on the back of 
the left forearm, 17 cm. below the olecranon and 12 cm. 
above the styloid process of the ulna, inflicting a wound 
5.3 cm. long, and almost precisely transverse to the long 
axis of the forearm. The wound extended down to the 
bones, but did not fracture them. A surgeon, who also was 
camping out in his neighborhood, but with no surgical in- 
struments or dressings with him, closed the wound with- 
out suturing the muscles or nerves.. The wound healed 
by first intention. 
On examination I found that he could extend the hand 
at the wrist by the radial and ulnar extensors, but exten- 
sion of the fingers was impossible. (Fig. 1.) 
Dr. Wharton Sinkler kindly examined the electrical con- 
dition of the muscles and reported as follows: "The ex- 
tensors of the left forearm above the incision all respond 
to the faradic current; below the wound they do not, and 
galvanically there is reaction of degeneration in the lower 
portion of the extensor communis digitorum. I would in- 
fer from this that the nerve had been severed at the same 
time with the muscles, and that it would be desirable, if 
possible, to find the ends of the nerve suture 
them." 
Dr. Spiller made an examination of the sensation and 
found that there was no loss, except over a small area just 
below the scar. 
♦Read 1 efore the Philadelphia Neurological Society, April, 1901. 2 
On comparing his two hands I found that he had a pecu- 
liarity of the two thumbs. Abduction of the meta- 
carpal bone of the thumb was very poor on both sides, and 
was scarcely greater on the uninjured than it was on the 
injured side. 
Operation, November 9th, 1900. I made a vertical in- 
cision 13cm. long in the long axis of the forearm. After 
reaching the muscle I was agreeably surprised to find that 
there was no visible evidence of any great gap filled with 
connective tissue at the point where it had been divided, 
but that there was only a recognizable linear cicatrix. 1 
Figure 1. 
Before operation, showing the scar of the accident, extension of the wrist 
but inability to extend the fingers. 
made a blunt dissection down to the interosseous mem- 
brane and endeavored to find the prolongation of the 
posterior interosseous nerve toward the wrist joint, but 
tailed to find it. I did find, however, the posterior branch 
going to the common extensor of the fingers. This I veri- 3 
fed by the battery. At the point of injury the nerve was very 
much attenuated below the wound and immediately above 
the wound it was considerably thickened. I first passed a su- 
ture both above and below the wound, next removed 7 mm. 
of the nerve, and then approximated the freshened ends to 
each other and closed the wound. 
His recovery was uneventful, the highest temperature 
once being 99.6°. He left the hospital November 17th, 
8 days after the operation. At that time slight extension 
of the fingers was already beginning to be possible. 
I directed that, after his return home, he should 
use the hot and cold douche in alternation, active and 
passive exercise and massage, and especially elec- 
tricity, beginning with the galvanic current and 
later the faradic. All this treatment he carefully 
carried out with the exception of the electricity, for 
which there was no apparatus available. His wife 
wrote under the date of January 3rd, 1901: "Mr. 
H.'s arm has improved most wonderfully, and the 
loss of muscular force is hardly noticeable." A 
letter received May 1st, 1901, transmits two 
photographs showing that the fingers and wrist can 
be extended in a straight line, but he states that 
when the wrist is in extension he is not quite able 
to extend the fingers completely. (Fig. 2 shows the 
same arm with the wound and my incision making 
a X). 
CASE 2.-Division of median and ulnar nerves; secondary 
suture after six months; entire recovery. 
Chas. D., aet. 10, first consulted me about the middle of 
April, 1892. In October, 1891, he lost his balance, and, to pre- 
vent his falling, thrust his left hand through a pane of 
glass. The forearm was cut transversely, 2 cm. above the 
pisiform bone, and when I saw him showed a scar extend- 
ing from a point 2 cm. from the radial border of the fore- 
arm to the internal edge of the ulna. (Figs 4 and 5). Dr.Hor 
ton,of Peekshill,New York,where the boy was at school,states 
that the cut extended completely down to the bone, se- 
vering all the tendons, and divided the median and 
ulnar nerves and the ulnar artery. Dr. Horton ligated the 
artery and desired to suture the tendons and nerves at the 
time of the accident, but was overruled by an older prac- 
titioner. 
On examination I found that he had control over the 
thumb and forefinger in flexion and extension, but they 
were weak. The thumb could not be apposed to the 4 
Figure 2. 
Appearance of the arm six months after the operation, showing the gain in extension of the fingers. 5 
other fingers. The three ulnar fingers were all in a state cf 
flexion and could not be extended except partially 
upon strong flexion of the wrist. The thenar and hypothenar 
eminences were entirely wasted. His grasp was good if any- 
thing was placed in the flexed fingers. Sensation was with 
difficulty ascertained, but it was evident that there was no 
absolute anesthesia at any point. The radial surface of the 
little finger was the dullest, and even there a light touch 
was perceived, though not sharply. The whole hand was 
purplish and very cold. 
Operation, April 21st, 1892. A longitudinal incision was 
made over the ulnar nerve, the incision being extended fi- 
nally downward over the hypothenar eminence about 4 
cm. below the wrist and 9 cm. above the wrist. The upper 
bulbous extremity of the ulnar nerve wras easily found, 
but was fused in a mass of connective tissue. In order 
to find the distal end, the cut was prolonged, as stated, 
over the hypothenar eminence. The ulnar nerve was 
found there, not wasted, but above the normal size, the 
upper end being directly continuous with one of the 
superficial flexor tendons. Both ends of this nerve were 
loosened, resected and both stretched, the upper end es- 
pecially yielding. With some little tension the two ends 
could then be brought together and were sutured with one 
fine silk thread. Through the same incision the median 
nerve was then found with some difficulty. At the level 
of the cicatrix, the twro ends had united, and at the same 
point another flexor tendon joined them in a bulbous 
mass. I debated for some time whether to excise this' 
mass and attach the two ends of the nerve together after 
stretching, but finally decided to sever the connection of 
the tendon with the mass and let the nerve alone. If the 
nerve did not improve a later resection could be done. 
The tendons I found in one general cicatricial mass. 
As it was impossible to differentiate the individual ten- 
dons, I contented myself with elongating the deep flexors 
by the method of tenotomy which I devised. (Trans. 
College of Physicians, March 4th, 1891). The superficial 
flexors I severed obliquely and attached them at a distance 
by several strands of catgut suture. The gap between 
the two ends was 2 cm. The hand was then placed on a 
splint. 
April 25th, (fourth day). No opportunity was offered for 
testing sensation through the dressing,excepting by touching 
the last two joints of the fingers that were exposed. This 
showed that the ring and little fingers were devoid of 
sensation, the ring finger not only on the ulnar, but on the 
radial side. The sides of the other two fingers and the 
thumb showed sensation. To-day he perceived a prick 
over the ulnar fingers for the first time. He returned the 
next day to Peekskill. 6 
June 2nd (six weeks later), Dr. Horton reports the cir- 
culation in the forearm good, motion of the wrist, thumb 
and forefinger normal, with the exception of extreme ex- 
tension of the wrist. Sensation of the three ulnar fingers 
is not very acute, but is improving. The blueness of the 
nails which was first noticed is rapidly passing away. 
November 25th, 1892, (seven months). I examined him 
to-day. The general condition of the hand is good, the 
ring and little fingers are a little purplish and also a little 
cold, but not at all to the same degree as before the opera- 
tion. Sensation exists in all parts of the hand. He can move 
any part of the hand, except the ring and little fingers, and 
even over these two fingers he can feel and localize a pen- 
cil point. Motion in the thumb, middle and index fingers 
is excellent, and he can grasp objects, though not with 
great strength. Flexion in the two ulnar fingers is lim- 
ited to the last phalanges, there being as yet no flexion at 
the knuckles of these fingers. 
Ever since the operation he has been using continuously 
massage, electricity, hot and cold 'douche, active and pas- 
sive exercise. 
April 9th, 1893, (one year later.) His hand has improved 
immensely. He can touch the tip and the base of each 
finger with the end of his thumb, can make a fist, the fin- 
gers being in almost complete flexion and his grip is good, 
little, if any difference being perceptible in the grasp of the 
two hands. Each finger can be moved independently of the 
others, the motion of the little and ring fingers now being 
nearly normal and the others quite so. Sensation is also 
perfect. 
December 22nd, 1899, (seven years). I re-examined the 
hand to-day. His grip is wonderfully strong, his fist is as 
last described. Practically the hand is as useful as ever. 
May 15th, 1901 (nine years). He sends me the 
accompanying photographs (figs. 3 and 4) just taken 
to show his power of flexion and extension of the 
fingers. Though he cannot quite close his fingers, 
yet practically his hand is as useful as a normal 
hand. 
The photographs presented are the best evi- 
dence of the excellent results of the two operations 
here recorded. Both hands were useless, practi- 
cally, for the same reason-the want of the power 
of extension-but from wounds of two entirely dif- 
ferent nerves. The wound of the posterior inter- 
osseous prevented extension at the knuckles by the 
common extensor of the fingers, while the wound 7 
Figure 3. 
Nine years after the operation showing good flexion of the fingers 8 
Figure 4. 
Nine years after the accident, showing good extension of the fingers. 9 
of the ulnar and median, in the second case, pre- 
vented extension of the last two phalanges by the 
interosseous and lumbrical muscles. I would call 
attention to the late periods (three and six months) 
at which the secondary suture was done. In the first 
case, also, the very speedy return of motion was 
surprising. It began within a week after the oper- 
ation and was practically complete within two 
months. This is the more gratifying, as the pos- 
terior interosseous is so small a nerve that I doubted 
whether I could find it in so muscular a patient, or 
if I did whether it would hold a thread. Suturing it 
before excising the point at which it had been 
wounded was excellent. Had I first excised, the cut 
ends would have been considerably, and possibly, 
irreparably injured by forceps or other means used 
to seize them and steady them while passing the nee- 
dle. So far as Dr. J. C. Merrill, of the Surgeon Gen- 
eral's Library, in Washington, who kindly had his 
records looked over, or my own references, show, 
this is the only case as yet recorded of operation 
on this nerve. 
The second case shows how a younger 
man, well up in the latest surgical procedures, may 
be hampered by an older practitioner, who has 
not kept up with the progress of surgery. Had Dr. 
Horton's advice been followed and tendon been 
sutured to its appropriate tendon and nerve to nerve 
when the accident occurred, in all probability no 
later operation would have been necessary. That 
the operation has resulted so happily is remarkable, 
especially as the tendons had to be united hap-haz- 
ard, one above to one below, with no possibility of 
ascertaining which belonged to which. The 
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