Painful wrist with loss of function.
E: In all suspected fractures of the wrist, examine range of function, peripheral pulses, sensation and neighbouring joints (e.g. elbow). Colles' fracture: 'Dinner fork' appearance of wrist and hand (see Fig. 13). Smith's fracture: Swelling and tenderness, may appear as a Colles'. Scaphoid fracture: Tenderness in the 'anatomical snuffbox' (on dorsal surface), scaphoid tubercle (on palmar surface) and pain on compressing thumb longitudinally.
_p The blood supply to the proximal pole of the scaphoid comes from distal nutrient vessel; hence fracture involving the waist of the scaphoid or proximal fragment can interrupt this and the proximal fragment undergoes avascular necrosis.
_I: Radiographs: AP and lateral views of the wrist. May be necessary to view other joints for associated fractures.
Scaphoid fracture: Special scaphoid views including oblique views are needed. May need to be repeated after several days for fracture to become visible.
M: Conservative: If there is no displacement of the bones and no complications. Analgesic, splint the wrist with plaster of Paris and review in fracture clinic. A scaphoid cast should be used if there is any suspicion of a scaphoid fracture (extends from elbow to knuckles).
Manipulation of Colles' fracture is necessary in displacement: performed by Bier's block or haematoma block. The wrist is manipulated with disimpaction of the distal fragment, repositioning with wrist flexion and ulnar deviation and immobilisation in a below-elbowcast. Postreduction X-rays should be performed. Surgical: Closed reduction of the fracture under anaesthesia is indicated in Smith's fractures, grossly displaced fractures or complicated fractures (or if there is normal angulation of the articular end, which is reversed in Colles' fracture). Fixation (external or internal) may be necessary. Non-union of scaphoid fracture may be treated by a bone graft or Herbert screw placed along the fracture line. Established avascualar necrosis may require excision of the fragment, radial styloid or even wrist arthrodesis.
Physiotherapy: following healing to strengthen muscles.
P: Generally good in undisplaced uncomplicated fractures.
^^ ^I^Di Malignancy of the gallbladder. ^^ ^T^Aj Unknown.
0|a/R: Strongly associated with gallstone disease (80% of patients). A 'porcelain'-bladed gallbladder (resulting from chronic cholecystitis) has an " incidence of developing into malignancy. May also be associated with choledochal cysts ^^ and PSC.
Fifth most common GI malignancy, age usually >65 years. Female:male is 2-3:1.
^Ih: It is usually discovered incidentally on investigation for gallstone disease. The patient may present with symptoms mimicking gallstone disease, right upper quadrant abdominal pain, nausea and vomiting. Other features include ^^ weight loss, anorexia, jaundice, abdominal distension and pruritus.
UE: A palpable right upper quadrant mass may be found on abdominal examination.
P: 90% are adenocarcinomas, 5% squamous carcinomas and 5% anaplastic carcinomas. They appear as gallbladder wall thickening and induration. Most common sites are in the fundus and neck of the gallbladder. Spread: Local direct invasion into the hepatic bed, lymphatic spread into the cystic nodes, hiatal nodes, and then to the superior and posterior pancreatico-duodenal nodes and the periaortic nodes. Blood-borne spread via the portal vein to the liver.
_I: Abdominal USS: May show gallbladder wall thickening or a mass filling the gallbladder, which would be suggestive of malignancy. CT or MRI scan: Show a mass in the region of the gallbladder. Arteriographic CT portogram: Where contrast is injected into the superior mesenteric artery, allows accurate assessment of the extent of the disease and its resectability.
M: Surgical: Simple cholecystectomy for tumours confined to the mucosa or sub-mucosa (T1a). For tumours invading the muscularis, cholecystectomy with hepatic wedge resection, resection of the cystic duct and en bloc dissection of regional lymph nodes in early-stage disease. If pericholedochal nodes are involved, the common bile duct may be resected with restoration of biliary-enteric continuity with a Roux-en-Y hepaticojejunostomy. Surgery is inappropriate for advanced disease.
Chemotherapy or radiotherapy: Some agents have partial responses (e.g. 5-fluorouracil). Radiotherapy is also used.
Palliative: Most therapy is directed at symptomatic relief. Obstructive jaundice can be managed with endoscopic or percutaneous stenting. Pain relief is a prime concern, and may be helped by percutaneous coeliac nerve block or chemical splanchnicectomy.
C: From disease: Obstructive jaundice, pain.
From surgery: Biliary peritonitis, haemorrhage, ascending cholangitis.
P: With the exception of cases detected incidentally at cholecystectomy, prognosis is poor as many are detected late and are not amenable to surgical resection. Overall 5-year survival of < 15%.
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