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X-ray examination is obligatory not only to know the details of the fracture and displacement but also to assess the type of treatment which would be best suited for the particular case cheap viagra plus 400mg without a prescription erectile dysfunction medication with no side effects. The mechanism of posterior dislocation is a fall on the outstretched hand with the elbow in slightly flexed position discount viagra plus online erectile dysfunction houston. The coronoid process may pass posteriorly below the distal end of the humerus intact or may be fractured by the thrust against this part of the humerus. Very often the posterior dislocation is associated with lateral displacement of varying range. Clinically this condition may mimic the supracondylar fracture and the differentiating points between these two conditions should be borne in mind. Generally such a history can be elicited and the patient presents with a complaint of pain at the elbow. The elbow is more or less fixed in slight flexion and pronation; more flexion of the elbow and supination become painful and limited. On palpation one may find the head of the radius a little below and lateral to its normal position. When the displacement of the ulnar fracture is anteriorly and the head of the radius is dislocated anteriorly — this is known as Monteggia fracture-dislocation. When the displacement of the ulnar fracture is posteriorly and the head of the radius also dislocates backwards — this is known as reversed Monteggia. Mechanism is usually a fall on the hand and the body twists at the moment of impact thus forcibly pronating the forearm. A careful palpation will reveal radial dislocation besides rather easy detection of ulnar fracture-displacement. Movement of the elbow joint is completely restricted — both extension and flexion as well as supination and pronation. But two points deserve mentioning — (i) that the dorsal prominence is not at the level of the wrist but about one inch above it and (ii) that there is also a slight radial deviation which makes the head of the ulna more prominent. When the patient is asked to make a fist, the line of knuckles may not be on the normal line. In "mallet finger", which is caused by rupture of the extensor tendon at its insertion at the base of terminal phalanx, there is persistent flexion of the terminal phalanx. It must be remembered that normally the lower third of the radius is smoothly concave in front. In this case squeezing of the upper part of the radius and ulna together will elicit pain at the site of fracture. In order to demonstrate this, the clinician uses his two index fingers to locate the tips of the styloid processes in pronated forearm of the patient. The dotted line scaphoid bone is most important as very often fracture of the represents the horizontal level at the scaphoid is misdiagnosed as simple sprain and the patient tip of the ulnar styloid process. Moreover fracture of the scaphoid requires prolonged immobilization as this fracture is notorious for non-union and avascular necrosis of the proximal fragment. The scaphoid is palpated at the anatomical snuff-box with the wrist bent medially to expose the bone for palpation. If there is any fracture of the scaphoid bone, the patient will complain of pain as soon as a pressure is made over the anatomical snuff-box. This bone may be dislocated anteriorly and requires careful palpation for the diagnosis of this condition. For this, the examiner should run his finger along the length of the said bone to find out any gap, bony irregularity, bony tenderness or abnormal projection. A careful palpation of the metacarpo-phalangeal joints and inter phalangeal joints should be a must to exclude subluxation or dislocation of the said joints which are often missed. In case of metacarpal fractures movement of the metacarpo-phalangeal joints will be restricted. Similarly in fractures of the phalanges movement of the interphalangeal joints will be painful and restricted. In differential diagnosis complications of the important fractures around the wrist will be discussed in nut-shell. In all fractures, not only the fracture is diagnosed but also a careful study of the displacement of the fractured fragments will help the clinician in reduction of the fracture concerned. In this case, to reduce the fracture a pull is directed downwards, slightly medially and anteriorly holding the thumb and the heads of the metacarpals of the patient simultaneously, while with the two thumbs of the clinician the upper edge of the lower fragment is pushed anteriorly so that the normal alignment of the radius is restored. After discussing the general points, the peculiarity of the X-ray examination of the scaphoid requires special mention. Very often the orthodox antero-posterior and lateral views fail to detect a minor crack fracture of the scaphoid. For this an oblique view and views from different angles are very much essential to diagnose fracture of the scaphoid bone. If clinical findings go very much in favour of the diagnosis of fracture of the scaphoid, one should treat the case according to that and take another X-ray after ten days, as by that time the fracture line often delineates itself. The victims are usually elderly ladies, which is attributed to the osteoporosis in post-menopausal women. The fracture line lies about 2 cm proximal to the distal articular surface of the radius. The distal fragment is displaced dorsally, proximally, slightly laterally and angulated backwards. On examination, there is tenderness and bony irregularity of the lower end of the radius. The radial styloid process does not remain lower than the ulnar styloid process which is normal. On the contrary it remains at the same level or a little higher than the ulnar styloid process. Again the usual victims are the elderly women and diagnosis both clinically by anterior projection of lower fragment and radiologically is not very difficult. The mechanism is due to a fall on the dorsum of the palmar-flexed wrist and not to a fall on the palm of the outstretched hand. A commoner injury at this region with anterior displacement is the fracture dislocation of the lower end of the radius. In this case the radial fracture is obliquely vertical extending upwards and forwards from the wrist joint and separated anterior fragment of the radius shifts proximally carrying the hand with it. The fracture line is usually transverse extending laterally from the articular surface of the radius and the fracture is more often undisplaced. The mechanism seems to be fall on the hand with a rotational force superimposed on it. The most important test which most clinicians forget to perform is to look for ulnar nerve lesion — a common associate with this condition. On inspection there is a very prominent dorsal displacement of the lower end of the ulna. While majority favour congenital theory, yet the advocates of acquired theory postulate that repeated minor injuries may delay growth of the radius while the ulna continues to grow forcing the lower end of the ulna to subluxate.

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As the ingested material fills in the diverticulum it develops caudally and may even reach the superior mediastinum viagra plus 400mg low cost erectile dysfunction treatment dallas texas. For more detail description of aetiology cheap viagra plus 400 mg with mastercard impotence organic origin definition, clinical features and treatment see page 630. While the last one appears late when the diverticulum is quite large, the other two appear quite early, particularly the cervical dysphagia which seems to be the first symptom of this condition. Weight loss is a noticeable feature and may confuse this condition with malignancy. Regurgitation is particularly prominent during sleep and this may wake the patient up during sleep. Due to regurgitation recurrent episodes of airway contamination and aspiration pneumonitis may result. One may perform manometric study to find out inco-ordination of muscles during swallowing. Similarly presence of pneumonitis or lung abscess should be dealt with first before surgery of this condition. Surgery is always done under endotracheal anaesthesia and rapid sealing of the airway with a cuffed balloon should always be performed. Oblique left cervical incision parallel to the anterior border to the sternomastoid muscle is made. The sternomastoid muscle and the carotid sheath with its contents are retracted laterally while the thyroid and the trachea are retracted medially. The diverticulum is located and gradually dissected off the surrounding structures. Where automatic stapler is not available, the diverticulum is excised very near to the neck and the gap is closed with atraumatic suture. After completion of myotomy and resection of the diverticulum, a nasogastric tube is inserted by the anaesthetist into the upper oesophagus. Air and saline are insufflated and the oesophagomyotomy and the suture line are tested for no mucosal tear. Cricopharyngeal myotomy, with or without diverticulectomy is the most effective treatment of this condition and is the treatment of choice. Though this diverticulum typically occurs near the bifurcation of the trachea, yet this may occur anywhere particularly in the middle third of the oesophagus. The diverticulum is always associated with granulomatous infection of the mediastinal lymph nodes, particularly the subcarinal and parabronchial lymph nodes. Tuberculosis is the most common of the granulomatous disease, though histoplasmosis may be seen in a few conditions. Only when a fistulous communication is formed between the oesophagus and the respiratory tract due to necrosis of the granulomatous process, surgery may be required in the form of division of the fistula, suturing of the mucous membrane of the oesophagus and the respiratory tract and interposition of adjacent normal tissue. It is again due to oesophageal motility disturbance and may be associated with diffuse spasm, achalasia, oesophageal sliding hiatus hernia, reflux oesophagitis and stricture. Due to mechanical distal obstruction raised intraluminal pressure is responsible to blow out the mucosa and the submucosa through the muscle of the oesophagus. But as mentioned earlier it is usually associated with other oesophageal lesion like hiatus hernia, diffuse oesophageal spasm, achalasia, reflux oesophagitis and even carcinoma. Manometric study and oesophagoscopy should be performed later on to know more about functional abnormalities of the oesophagus and presence of other associated lesions. When symptoms like severe dysphagia and chest pain are bothering the patients, operation is justified. Resection of the diverticulum alongwith a long thoracic oesophagomyotomy from the level of aortic arch to the oesophagogastric junction should be performed. They have atrophic oral mucosa, spoon shaped fingers and brittle nails, long-standing anaemia and cervical dysphagia. A fibrous web partially obstructing the oesophageal lumen at its upper end a few millimetres below the cricopharyngeus muscles seems to be the cause of the cervical dysphagia. The only problem is that this condition has been considered as a pre-malignant lesion and in approximately 10% of patients carcinomas develop in the oral cavity, hypo- pharynx and oesophagus. The reason is the sudden increase in intra-abdominal pressure during vomiting transmitted to the oesophagus against closed glottis. The similar mechanism also causes spontaneous rupture of oesophagus when the force is too much. A history of vomiting followed by either melaena or haematemesis suggests the possibility of this syndrome. Coeliac angiography may at ■ I • mes demonstrate the site of bleeding when bleed­: ing is quite profuse. The blood clots are evacuated from the stom- K ach and the mucosal tear is oversewn. One thing must be remembered that it usually is associated with sliding hiatus hernia. Only when it is associated with reflux oesophagitis, an anti-reflux operation is justified. These are: (i) Corrosive oesophagitis, (ii) Tuberculosis, (iii) Syphilis, (/v) Herpes, (v) Radiation oesophagitis, (vi) Crohn’s disease, (vii) Secondary to reflux oesophagitis, (viii) Schatzki ring and (ix) Secondary to Plummer Vinson syndrome. Here only corrosive oesophagitis will be described, since other conditions have already been discussed. At present this type of oesophagitis is not very common, only a few stray incidents may be obtained where children have ingested lye, a strong cleaning agent containing sodium hydroxide and sodium carbonate. In case of acid ingestion, the oesophagus frequently escapes injury as squamous epithelium is relatively resistant to acid and as the shrot time the acid is exposed to the oesophageal mucosa. But it usually causes destruction in the stomach as pylorospasm caused by acid keeps it longer time in the stomach, produces gastritis, necrosis and even perforation when the acid is quite strong. The superficial layer sloughs out which is followed by fibrosis and delayed re-epithelialization. Patient will complain of pain in the mouth and larynx and may feel nausea and vomiting. After 2 or 3 weeks if there is stricture formation, patient will complain of dysphagia only. Endoscopy may be performed, but upto the upper most area of corrosive oesophagitis. Under no circumstances the oesophagoscope should be passed into the zone of corrosive oesophagitis. Steroids have been advocated by a few surgeons, whereas others have avoided it since it may mask the dreaded symptoms of oesophageal or gastric perforation. Only when the stage of acute inflam­ mation has been subsided and definite stricture has been formed, dilatation by bougie should be advised.

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After appropriate bowel preparation discount viagra plus 400mg overnight delivery erectile dysfunction caused by anabolic steroids, an elective 48 Concepts in Surgery of the Large Intestine 431 one-stage procedure is done purchase 400 mg viagra plus erectile dysfunction treatment houston tx, resecting the diseased segment from 3 to 9 % (Varma et al. Prosthetic materials can of colon and performing the anastomosis in noninvolved, also be used to fix the rectum to the sacrum. Ripstein procedure involves posterior fixation of mesh to the sacrum with attachment of the ends of the mesh to the lateral rectum. The ventral mesh rectopexy avoids postero- Rectal Prolapse lateral mobilization of the rectum. Thus, the presence of circumferential folds As any form of rectopexy can produce new-onset or wors- seen on examination distinguishes full-thickness rectal pro- ened constipation, some surgeons advocate a concomitant lapse from prolapsed hemorrhoids or mucosal prolapse sigmoid resection. The rectum may spontaneously reduce or may division of the lateral stalks during rectal dissection of require manual reduction, and on rare occasions it may incar- these abdominal approaches remains controversial (Varma cerate, requiring urgent surgical intervention. Division of the stalks has been shown to reduce uncommon, a neoplasm may form the lead point for a rectal recurrence rates but to increase the risk of postoperative intussusception; thus, all patients should undergo a colonos- constipation. If the prolapse cannot be produced during the physical ations for rectal prolapse are few, consisting mainly of examination, a defecography may be performed to confirm anastomotic dehiscence and, when a mesh is used, obstruc- the diagnosis. As many patients will present with concomi- tion secondary to mesh wraps or sepsis related to the for- tant fecal incontinence or constipation, anorectal physiology eign body. All abdominal operations for rectal prolapse testing may be performed to provide postoperative prognos- have been performed laparoscopically with equivalent tic information for patient counseling. For patients with sig- recurrence rates (4–8 %) compared with open approaches; nificant chronic constipation, a preoperative colon transit however, improvements in pain control, length of stay, and study should be performed to assess whether a concomitant return of bowel function have been observed with laparos- total abdominal colectomy should be considered (Varma copy (Varma et al. Two general surgical approaches are of the anus and excisional rectosigmoidectomy. The surgical approach encirclement, the Thiersch procedure, has evolved over is chosen based on the patients’ comorbidities and bowel time but has been relegated to historical curiosity due to function as well as the surgeon’s preference and experi- high rates of recurrence and septic complications. The abdominal approaches generally have the lowest rectosigmoidectomy involves a full-thickness resection recurrence rates and are the preferred treatment for health- of the rectum and sigmoid colon through the anus with ier patients. However, although morbidity and mortality a coloanal hand-sewn or stapled anastomosis (Altemeier rates are low after an abdominal approach, they are slightly et al. Compared with an abdominal approach, this higher than rates associated with perineal repairs (Varma operation involves a shorter hospital stay and has lower et al. The perineal approaches result in reduced mor- complication rates (10 %), which include anastomotic bidity, pain, and hospital stay; however, recurrence rates are bleeding, pelvic abscess, and, rarely, an anastomotic leak; higher than those for abdominal operations. Furthermore, however, recurrence rates have been reported to be as high as the rectum is removed, suboptimal functional outcomes as 16–30 %. A Delorme procedure, circum- Abdominal approaches include rectopexy, with or with- ferential mucosal sleeve resection and imbrication of the out a segmental resection. Fixation of the rectum in the pel- muscularis layer with serial vertical sutures, can be per- vis with suture, first described by Cutait in 1959, aims to formed for short full-thickness rectal prolapse or mucosal correct the telescoping of the redundant bowel and causes prolapse. Recurrence rates are higher for this procedure fixation of the rectum from the resultant scarring and fibro- than for perineal rectosigmoidectomy, and the recurrence sis (Cutait 1959; Madoff and Mellgren 1999). The recur- rates for all perineal procedures are higher than for all rence rates for suture rectopexy are generally reported to be abdominal procedures. The second stage is gen- erally a restorative completion proctocolectomy with ileal Mucosal Ulcerative Colitis J-pouch-anal anastomosis and a diverting loop ileostomy. It is confined to the colonic the “J”-pouch configuration is the most widely used because mucosa and characteristically starts in the rectum and of its simplicity, suitability for fitting into the pelvis, and extends proximally without skip lesions. A stapled pouch- 50 % of cases have disease confined to the rectum, 30 % anal anastomosis is then performed 1–2 cm from the dentate have disease extending to the left colon, and 20 % have line. Backwash However, if the patient has a history of low rectal cancer or ileitis (inflammation of the most distal terminal ileum sec- dysplasia, a mucosectomy and hand-sewn ileoanal anasto- ondary to reflux of stool from the cecum (Gordon and mosis may be performed (Lovegrove et al. Prior to Nivatvongs 2007)) may occur in up to 10 % of patients and the third operation, closure of the diverting loop ileostomy, resolves after surgery. The progression of the disease may the integrity of the anastomosis is assessed with a pouchos- be insidious, acute, or fulminant. Typically, patients include chronic disease refractory to medical management, have excellent outcomes following this procedure, averag- complications of medical management, dysplasia or can- ing approximately six to ten bowel movements per day with cer, fulminant colitis, growth retardation (in children), or good control and no urgency. The goal of surgery is to cure the patient Patients with all other surgical indications may be candi- from disease and, whenever possible and desirable, to dates for a two-stage procedure: restorative proctocolec- restore intestinal continuity. This procedure may be per- tomy and ileoanal pouch anastomosis with diverting loop formed in one to three stages. Prior to largely depends on the patient’s current nutritional status, offering a restorative proctocolectomy with ileoanal pouch medical fitness, recent use of immunosuppressant medica- anastomosis, the surgeon must have diligently excluded any tions, and sphincter function. This confirmation can be achieved by of Truelove and Witts and is defined as colitis with more a detailed history and examination to exclude any perianal than six bloody stools per day, fever (temperature >37. In approximately 40 % of patients, there is a are malnourished, receiving high-dose steroids (>40 mg/ disparity in diagnosis between general and specialist pathol- day) or tumor necrosis factor inhibitors, or who have inde- ogists; thus a preoperative review of previous colonoscopic terminate colitis (The Standards Practice Task Force of The biopsies by a gastrointestinal expert pathologist is important American Society of Colon and Rectal Surgeons 2005 ). It is important at this first operation that the presacral alternate procedure is a total proctocolectomy and continent space be preserved and the integrity of the stapled rectosig- ileostomy (“Kock pouch”) which is constructed from 45 cm moid stump be assured. If there is any question about this of distal terminal ileum with intussusception of the ileum seal, the staple line may be oversewn, or a mucous fistula just back into the pouch to create a nipple valve. This procedure is often has not gained widespread acceptance because of its intricate well suited for a laparoscopic approach. In addition to mini- construction and its high rate of complications, namely, val- mizing scars, pain, and disability, the laparoscopic method vular dysfunction requiring revisions. In this setting, the authors recommend delay of the pouch anastomosis have been demonstrated in the elderly, completion proctectomy and ileoanal pouch reconstruction with physiologic age, rather than chronological age being a to allow a period of observation for the clinical evolution of determining factor (Takao et al. If after 6–12 months, there is no evidence of Crohn’s disease, an ileoanal pouch reconstruction can be offered to Obesity the patient after an informed discussion. Pouch failure rates Ileoanal pouch reconstruction is feasible in patients with a for indeterminate colitis may be as low as those for ulcer- body mass index >30 kg/m2; however, it is associated with ative colitis or slightly higher (2–10 %) (Delaney et al. Furthermore, it is the authors’ experience that obesity decreases the ease and likelihood of pouch reach. Accordingly, treatment focuses on safely alleviating Laparoscopy has been shown to be safe and effective, disease symptoms and restoring quality of life while attempt- and in most cases superior for two- and three-stage restor- ing to maintain continuity of the intestinal tract. Surgery is indicated for complications of disease (nondrainable abscesses, per- Pouch That Does Not Reach foration, chronic bleeding and anemia, stricture formation, There are several maneuvers that can be performed if there fulminant colitis, and the development of dysplasia or adeno- is inadequate pouch length to perform a tension-free pouch- carcinoma) and failure of medical management (including anal anastomosis. First, it is important to ensure complete dependence on high doses of immunosuppressive agents and mobilization of the small bowel mesentery up to and ante- steroids) (Standards Practice Task Force of The American rior to the duodenum. Second, a slightly more proximal por- Society of Colon and Rectal Surgeons 2007 ). Third, superficial inci- colitis should undergo a total abdominal colectomy with end sions on the anterior and posterior aspects of the small ileostomy (Standards Practice Task Force of The American bowel mesentery along the course of the superior mesen- Society of Colon and Rectal Surgeons 2007 ). Fourth, selective division of anemia, malnutrition, and sepsis rapidly resolve following mesenteric vessels to the apex of the proposed J-pouch can colectomy. Last, division of the ileocolic vessels can be mended in select patients who demonstrate minimal mucosal performed.