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Neurological disorders of micturition Urinary continence is affected by varied neurological lesions alongside the micturition pathway as summarized in antibiotic and pregnancy buy zitrotek 100mg. Lesion of each afferent and efferent nerves A lesion of both afferent and efferent nerves virus and spyware protection cheap zitrotek 500 mg on line. Lesion within the superior frontal gyrus this might be the result of a stroke and leads to: Reduced want to urinate Difficulty stopping micturition once began. It types a spectrum of defects, leading to various degrees of bladder dysfunction. The bladder symptoms that develop depend upon the level at which demyelination occurs. Pelvic surgical procedure the nerve provide to the bladder could be injured during surgery, leading to postoperative urinary retention. Spinal wire lesion A lesion to the spinal twine above the sacral micturition centre. This is spinal shock After shock has handed: the voiding reflex returns, however with no control from greater centres, so the patient has no voluntary management over voiding Occasionally: hyperactive voiding might be seen Eventually: bladder capability falls and the wall hypertrophies � spastic neurogenic bladder. Stress incontinence that is involuntary leakage of small amounts of urine related to a rise in intra-abdominal stress. It is brought on by: Pelvic ground laxity (usually the result of childbirth) Bladder neck sphincter impairment (more common in middle-aged, obese, multiparous women) Surgery affecting the urethra or prostate. Kegel) are an efficient, noninvasive remedy but require cooperation and commitment from sufferers. Duloxetine, a serotonin and noradrenaline (norepinephrine) reuptake inhibitor, can be used for stress incontinence. The management of detrusor instability entails the behavioural techniques of bladder drill and training, regulating then growing the period of time between voiding. This is an automated reflex, triggered by filling of the bladder to a crucial strain. Both can be because of: Uninhibited bladder exercise Urinary an infection Neurological disease Obstruction. After urinary tract an infection has been excluded, no further investigation ought to be carried out if the child is beneath 5 years � unless there are any urinary signs. Treatment ought to concentrate on behaviour remedy with star charts or alarms that wake the kid when beginning to micturate. Overflow incontinence that is involuntary leakage of urine when the bladder is full. It is usually due to chronic urinary retention secondary to obstruction or an atonic bladder. The causes are: Outlet obstruction: faecal impaction, benign prostatic hypertrophy (enlarged prostate) Underactive detrusor muscle Bladder neck stricture Urethral stricture a-Adrenergic agonists Use of anticholinergics, calcium channel blockers, sedatives Bladder denervation following surgical procedure. It may be unilateral or bilateral, complete or incomplete, and of gradual or acute onset.

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Plastic sheath cannulas are inclined to antibiotic resistance finder buy genuine zitrotek on-line kink and run the risk of being sheared off into the peritoneal cavity virus united states order zitrotek 250mg fast delivery. The needle ought to be inserted slowly in 5-mm increments to detect undesired entry of a vessel and to assist forestall unnecessary puncture of the small bowel. Continuous manual aspiration should be averted because it could entice bowel or omentum to the end of the paracentesis needle with resultant occlusion. Clinical assessment for detection of spontaneous bacterial peritonitis by emergency clinicians is simply 75% delicate. Therefore, in a medical setting appropriate with ascitic fluid an infection (fever, belly pain or unexplained encephalopathy), all patients ought to obtain empiric antibiotic remedy awaiting culture outcomes. When ascitic fluid is collected in a syringe or tube, constructive cultures are obtained in about 50% of circumstances in contrast with 80% if inoculated right into a blood culture bottle previous to administration of antibiotics. Answer: C Lactulose, a nonabsorbable disaccharide, is the first-line treatment in sufferers with hepatic encehalopathy. It is efficient via varied mechanisms: � It reduces the intestinal production and absorption of ammonia, which is achieved through a laxative effect. Lactulose must be given at 30 mL orally, 1�2-hourly initially to induce a fast laxative impact. Once a laxative impact has been achieved, the dosage should be reduced to lactulose 30 mL orally, 3�4 times day by day. Antibiotics such as neomycin cut back intestinal ammonia production by acting in opposition to ureaseproducing micro organism. However, a nonabsorbable oral antibiotic, rifaximin, has been proven to reduce repeated episodes of hepatic encephalopathy, even in patients taking lactulose regularly. If no precipitant of acute encephalopathy is quickly identifiable, the affected person should be began on empirical remedy for an infection while waiting for the results of a septic work-up. One gram of intravenous ceftriaxone day by day or 1g of cefotaxime 8-hourly are instructed regimens. When culture results turn into available, modify the antibiotic therapy appropriately. Continue remedy till the scientific indicators of infection have resolved (usually for 5�10 days). Transmission is often by the faecal�oral route and incubation period is 2�6 weeks. He will be infectious approximately 2 weeks earlier than the onset of jaundice till 1 week after the onset of jaundice.

Diseases

• Acrodysplasia scoliosis
• Cholestasis, progressive familial intrahepatic
• Spondylometaphyseal dysplasia, Schmidt type
• Gamma aminobutyric acid transaminase deficiency
• Trigonocephaly ptosis mental retardation
• Ethylmalonic adipic aciduria

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Lastly antibiotic premedication for dental procedures buy 500 mg zitrotek visa, cortisol blocks the discharge of histamine from mast cells and sero tonin from platelets antibiotic that starts with l cheap zitrotek 100 mg with mastercard, thereby inhibiting allergic reactions. Cortisol additionally contributes to vascular tone via inhibition of nitric oxide synthase, decreasing the manufacturing of the vasodilator nitric oxide. Important determinants of aldosterone secretion are: � � High serum potassium increases secretion. These further sodium channels promote sodium reabsorption and reduce sodium excretion within the urine. The web impact is a rise in extracellular quantity, which, over time, can cause arte rial pressure to rise. Enhanced sodium reabsorption is accompanied by elevated potassium secretion into the tubule lumen. Nonetheless, during several durations of development, adrenal androgens take on a extra important position. Adrenarche: Adrenarche is a stage of adrenal maturation marked by elevated synthesis of androgens, resulting in pubic and axillary hair growth throughout puberty. Androstenedione produced by the adrenals and ovaries is periph erally converted to estrone by the enzyme aromatase. The steroid precursors are shunted into the production of excessive portions of sex hormones. Cushing Syndrome Cushing syndrome refers to the signs and signs of extra cortisol and is mostly attributable to exogenous glucocorticoid therapy. A 24-h urinary free Overnight dexamethasone suppression check 24-h urinary cortisol excretion check. Primary aldoster onism is mostly as a outcome of a benign adenoma within the zona glomerulosa. Secondary causes embrace: � � � Renin-secreting tumors, renovascular disease corresponding to renal artery stenosis, and malignant hypertension. In Conn syndrome, or primary hyperaldosteronism, extreme aldosterone is produced by adrenocortical adenomas, carcinomas, or hyperplasia of the zona glomerulosa. Sodium suppression take a look at: Sodium-load affected person after which measure for appropriate aldosterone suppression. Addison Disease Addison disease outcomes from adrenal gland failure and is mostly due to autoimmune destruction of the adrenal glands. Pheochromocytoma Pheochromocytoma is a catecholamine-producing tumor that arises from chromaffin cells, that are mainly situated within the adrenal medulla (1 zero % are extra-adrenal). Clonidine suppression test if above exams are equivocal, clonidine nor mally decreases catecholamines, however they remain elevated in patients with pheochromocytoma. Medi cal therapy entails use of a-blockers (phenoxybenzamine, phentolamine) and 13-blockers. Pheochromocytoma rule of l Os: 1 0% familial 1 0% bilateral 1 0% malignant 1 0% in kids 1 0% extra-adrenal Pa ncreas the pancreas is a multifunctional organ of the endocrine and digestive sys tems. The endocrine pancreas performs a vital role in carbohydrate, lipid, and protein metabolism via the secretion of two hormones: insulin and glucagon.

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The estimated incidence is 2 per 1000 sufferers handled with typical antipsychotics antibiotics to treat staph buy zitrotek 100mg low price. These patients often require aggressive supportive remedy together with intravenous fluid resuscitation and measures to management temperature treatment for recurrent uti by e.coli buy zitrotek 100mg without a prescription. Early consideration should be given for intubation as this can cut back contraction of muscles and production of heat and fever. Use of drugs similar to dantrolene (along with supportive care) should be considered, particularly in sufferers with severe muscular rigidity. Postnatal melancholy is most appropriately described as melancholy that has its onset inside 3�6 months following childbirth. This is much less frequent than postnatal blues however it may be essentially the most frequent major psychiatric dysfunction seen after childbirth. In addition to maternal morbidity and mortality, postnatal melancholy can lead to reduced interaction with kids and household. It is more prone to be present in mothers with previous depression, little family or social helps, unplanned being pregnant, excessive parity, complications during pregnancy and/or delivery. It may also be triggered by tough temperament of the baby and presence of colic or reflux. Common presenting features are persevering with postnatal blues signs, unfavorable emotions in regards to the child, not desirous to hold baby, lack of eye contact, incapability to sleep or excessive sleep, feeding difficulties, and anger and frustration about life circumstances. With obsessions of kid hurt after baby birth, the mother experiences repeated thoughts about harming the child but may take precautions. She might turn out to be distressed about the modifications in her physique because of the pregnancy and childbirth similar to weight achieve, stretch marks and scars. It can also be seen as a recurrence in people who had earlier related episodes. The recurrence can regularly happen as a end result of re-exposure to small amounts of amphetamine. In the very acute stage, along with mood and delusional signs, the psychotic patient could have disturbances to their consciousness with confusion and disorientation (a delirium syndrome). After restoration from each the psychotic and delirium syndromes these patients usually have amnesia to the whole or part of the episode. In addition to psychosis, amphetamines might induce manic or hypomanic symptoms during intoxication, and depression during withdrawal. Other points include amphetamine-induced sleep problem, anxiety dysfunction, sexual dysfunction and different psychological and bodily symptoms. Among the psychological symptoms, mood swings, lack of concentrating capability, paranoia and hallucinations are frequent. It is out there in oral, rapid dispersible (wafer) and intramuscular preparations.

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Drugs with a low or slim therapeutic index have a smaller dosing margin that separates desired effects from toxicity antimicrobial toilet seats cheap zitrotek 250 mg line. Therefore virus 1918 generic zitrotek 500 mg with amex, drugs with a low therapeutic index should be used precisely and serum levels ought to be monitored closely. Pharmacokinetics Pharmacokinetics describes the movement and metabolism of medicine into, out of, and within the physique. Each of those routes of administration has advantages and disadvantages in phrases of cost, convenience, ache, danger of infection, rate of onset, and the power of drugs to cross the barrier. Table 8-2 compares the 2 most common routes of administration: oral and parenteral. Bioavailability = amount of drug reaching systemic circulation/ amount administered. The exceptions are the mind and the testes, that are comparatively shielded from the final systemic circulation by physiologic obstacles. The drug can then unfold or distribute from the bloodstream into nonvascular organs and tissues, similar to muscle, fats, and bone. The extent to which a drug distributes among the many varied compartments in the body depends on a number of elements, together with the chemical nature of the drug, the quantity of the individual compartments, and the variety of drug receptors in these compartments. This is because of the reality that nonvascular tissues must usually be saturated before the plasma focus reaches regular state. For example, drugs which have a lipophilic or nonpolar construction are readily taken up by adipose tissue. Intravenous: 100 percent bioavailability Plasma drug focus Nonintravenous route (eg, oral, subcutaneous, or intramuscular) the place not all the medication delivered are available: 75% bioavailability Time FiGure 8-4. This is in contrast to nonintravenous route of administration where the plasma drug focus takes time to build up because the medicine is being absorbed. The equation takes into consideration tissues that act as sinks, and therefore the calculated quantity of distribution could also be many occasions the precise fluid quantity in the body. Drugs with a big quantity of distribution usually require the next preliminary dose to achieve a therapeutic concentration than medicine with a small quantity of distribution. When plasma drug levels are measured, the measurement is usually of the total drug concentration, which incorporates each free and protein-bound parts. Theoretically, competitors for binding websites on albumin and other proteins can produce drug-drug interactions. All orally ingested drugs are first metabolized by the liver earlier than they enter the systemic circulation; that is called first-pass metabolism.

Syndromes

• Looking at the heart structure and blood vessels using echocardiogram or MRI of the heart
• General discomfort (malaise)
• Take acetaminophen or ibuprofen.
• Throat swelling (which may also cause breathing difficulty)
• Mild acids
• Loss of sensation
• Urine leakage from the vagina or to the skin (fistula)
• Coma

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Hydroxycobalamin is beneficial because the first-line remedy in severely poisoned sufferers and for a affected person in cardiac arrest due to antibiotic brands buy zitrotek 500 mg amex suspected cyanide toxicity infection blood order zitrotek 500mg free shipping. Sodium thiosulphate is efficient within the therapy of gentle to moderately poisoned sufferers and in addition as a diagnostic trial in suspected instances. Its efficacy has not been proven and as a second line therapy should be used with different cyanide antidotes in extreme cases. Answer: A Eucalyptus oil is a sort of commonly out there essential oil and is a hydrocarbon. Aspiration of hydrocarbons may produce a chemical pneumonitis characterised by preliminary coughing and subsequent tachypnoea, hypoxia, wheeze and pulmonary oedema. Consequently, the chance of growth of long-term neuropsychological sequelae is low. Answer: B Widely used household products include corrosive substances that will lead to damage to younger children because of poor storage practices. Among those family substances, oven and drain cleaners (potassium hydroxide and sodium hydroxide) have excessive potential to cause mucosal burns. This may be because of the extended floor contact expected form powders and tablets. Endoscopy supplies the best information in assessing the early danger of perforation and late sequelae of corrosive burns. In youngsters with relatively restricted symptoms makes an attempt at neutralisation ought to be prevented but dilution of corrosive with consuming water is appropriate, especially for acids. Answer: B Organophosphates inhibit acetylcholinesterase, resulting in elevated acetylcholine levels at cholinergic receptors (both muscarinic and nicotinic). Along with bradycardia, the muscarinic effects of acetylcholine excess could be remembered by the next mnemonic. In organophosphate poisoning giant doses (up to a hundred mg) of atropine could additionally be required. The end points of treatment with atropine are drying of airway and oral secretions, decision of bradycardia and achieving good air entry with decision of bronchospasm. Fully dilated pupils means extreme anticholinergic toxicity because of over administration of atropine and together with this different anticholinergic poisonous features could additionally be discovered. No additional atropine should be administered whereas these toxic features are present. Answer: B Serious toxicity after ingestion of concentrated H2O2 solutions (>10%) is related to: � direct corrosive harm � systemic gasoline embolism � distension of hollow viscera. The direct corrosive injury to the gastrointestinal tract can cause ulceration of oral mucosa, vomiting, haematemesis and melaena. Also laryngeal oedema and laryngospasm might result in respiratory distress and airway obstruction. Rapid deterioration of neurological function and seizures often occur due to venous and arterial gas embolisation.

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Answer: C Cervicitis is usually as a result of virus detector buy generic zitrotek 250mg on-line Chlamydia trachomatis infection; in girls treatment for early uti buy zitrotek 250mg on-line, infection may be asymptomatic or be a cause of infertility; different presentations include signs and indicators of pelvic inflammatory illness, dyspareunia and vaginal discharge or lower stomach pain if symptoms have been longstanding. Men are usually symptomatic with urethritis and a watery discharge; infection may also trigger epididymitis, orchitis, proctitis and prostatitis. Treatment entails either 7 days of doxycycline 100 mg po, or a single dose of azithromycin 1 g po; the latter is beneficial the place compliance may be poor. Due to the common co-infection of sufferers with Chlamydial infections, treatment for N. Complications of chlamydial an infection include pelvic inflammatory illness, infertility and ectopic being pregnant. Bacterial toxin effects are answerable for the native necrosis causing the pseudomembrane; the toxin is unfold by way of the circulation and causes the delayed extrapharyngeal results of myocarditis, cranial nerve palsies and skeletal muscle paralysis. Management involves airway management, ventilation and critical care support; specific therapy entails early intravenous administration of antitoxin 20,000�150,000 models adopted by penicillin to stop additional toxin manufacturing. All sufferers must be nursed in isolated negative pressure rooms with staff sporting N95 masks plus robes, gloves and eye protection. Contacts should have nose and throat swabs cultured, obtain prompt erythromycin prophylaxis, and should be examined every day for 7 days for proof of illness. In addition, erythematous macules and papules, vesiculaobullous lesions and urticaria may happen in this condition. Pyoderma gangrenosum is a dermatosis with dense dermal infiltrate of neutrophils (a neutrophilic dermatosis). It is commonly related to inflammatory bowel illness, rheumatoid arthritis and leukaemia. Although very uncommon, these situations are triggered almost completely as idiosyncratic reactions to a spectrum of medications. As the utilization of drugs increases with age these conditions are more frequent in older age groups than within the younger. Initial misdiagnoses are frequent; nevertheless, a quantity of days later the affected person appears very unwell and is in severe ache. There is intensive involvement of mucosal surfaces and at least two surfaces are concerned. These include eyes, lips and oral mucosa, oesophagus, trachea and bronchi, urinary tract, genital mucosa and gastrointestinal tract. In adults, the elderly with renal failure are extra doubtless to get affected than others. The small blisters coalesce to form giant flaccid blisters or bullae that often burst giving rise to the attribute look of a scalded skin. In infants and young youngsters the extensive exfoliation of pores and skin is often confined to the upper physique however in neonates the entire pores and skin floor may be affected. The mainstays of administration of those youngsters are intravenous fluid resuscitation much like a burn patient, immediate initiation of antibiotic remedy to eliminate Staphylococcal focus and supportive care in a specialised burn unit or an intensive care unit.

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Elastin is produced by fibroblasts and clean muscle cells virus 09 buy 500 mg zitrotek, and its synthesis parallels collagen manufacturing virus leg pain generic 250mg zitrotek. Elastin synthesis entails two main steps: n n Secretion of tropoelastin (elastin precursor). In people with Marfan syndrome elastin-associated fibrillin microfibrils are absent, resulting in the formation of abnormal elastic tissue. The severity of the disease varies; affected people might die younger or reside basically regular lives. Transient Cells Wandering cells that have migrated into the connective tissue from the blood in response to particular stimuli (usually throughout inflammation). Polysaccharides (starch) and oligosaccharides (sucrose and lactose) are converted into disaccharides and monosaccharides. Ultimately, these are oxidized, stored as glycogen, reworked to fat (triglycerides), or transported as glucose by way of the circulation. Glycolysis FunCtion Initial step in the metabolism of glucose to produce energy for the cell. Glycolysis normally occurs underneath cardio environments, but can happen underneath anaerobic circumstances. Pyruvate kinase deficiency is the second most common (9% of all cases) and results in hemolysis. These deficiencies are exacerbated by certain medication (sulfa drugs, antimalarial agents). As electrons are transported down the electron transport chain, they launch vitality that allows these complexes to pump protons across the mitochondrial membrane. Brown fat: uncoupling of electron transport chain through protein known as thermogenin permits protons to cross the mitochondrial membrane, bypassing active transport release of heat. Ribulose-5-phosphate Nucleotide synthesis, fructose6-phosphate, glyceraldehyde3-phospahte (glycolysis) intermediate). The role of the pentose phosphate pathway within the glutathione peroxidase reaction of erythrocytes. Fructose is phosphorylated by hexokinase to fructose-6-phoshate in muscle and kidney. Fructose-1-phosphate aldolase deficiency results in hereditary fructose intolerance, characterized by severe hypoglycemia upon sucrose or fructose ingestion). Galactose-1-phosphate is converted by galactose-1-phosphate uridyl transferase to glucose-1-phosphate. Deficiencies in galactose-1-phosphate uridyl transferase lead to severe galactosemia with progress and mental retardation and possibly early demise. Glycogen Metabolism FunCtion Helps keep glucose homeostasis by forming (glycogenesis) or breaking down (glycogenolysis) glycogen. Insulin promotes the removing of glucose from the bloodstream, thereby rising glycogenesis and decreasing glycogenolysis. Glycogen Storage Diseases tyPe I disease Von Gierke illness enzyme Glucose-6phosphatase.

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On examination with an ophthalmoscope antibiotic drops for swimmer's ear trusted 250mg zitrotek, the pigmented epithelium underlying the macula reveals via antimicrobial bath mat purchase discount zitrotek line, giving it a darker appearance than the rest of the retina. The optics of the eye Light from a point of visible fixation is bent (refracted) so that a clearly targeted picture seems on the retina. This happens mainly at/within the cornea: Between the anterior chamber and the lens Between the lens and the vitreous body the lens for the visible system is a compound lens with interfaces of different refractive power (measured in dioptres, D). B gentle from a close to point Accommodation the refractive power of the lens is changed by lodging. This reduces the stress within the suspensory ligament and permits the elastic lens to turn out to be fatter and shorter. This has the effect of increasing the refractive power of the lens allowing gentle from close to targets (which reaches the floor of the eye as divergent rays) to be targeted by convergence onto the retina. The lens is an elastic construction in younger people, however it steadily hardens with age and can not readily change shape. Near vision, due to this fact, turns into impaired with increasing age, a phenomenon called presbyopia or long-sightedness. However, if the affected person is asked to abruptly focus on an object near their face, the pupil constricts. � There is a blood�retina barrier on the endothelium of the capillary community on the anterior surface of the retina from the central retinal artery, and at the endothelium of the capillary community in the choroid (the center layer of the wall). The photoreceptors are situated in the deepest layer of the retina (the outer nuclear layer;. This signifies that mild has to travel by way of a quantity of cell layers before reaching the photoreceptors. Retinal perform and image processing Light is transformed to electrical impulses and this data passes to the visible cortex for interpretation. The photoreceptors contain receptor proteins (called opsins) and a prebound receptor agonist molecule (retinal; a spinoff of vitamin A). Remember the precept of synaptic transmission � when a presynaptic terminal is depolarized it releases neurotransmitter. In the outer plexiform layer each photoreceptor is in synaptic contact with two kinds of retinal neuron: bipolar and horizontal cells. Bipolar cells synapse with ganglion cells (the output cells of the retina) and horizontal cells feed information laterally so as to influence the activity of neighbouring bipolar cells. Thus cells are maximally active when mild causes the discount in glutamate launch from photoreceptors which allows depolarization. Thus these cells are maximally lively in the useless of night and turn out to be hyperpolarized within the presence of sunshine.

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In these kids the collateral branches of the brachial artery keep an enough blood supply to the forearm and hand regardless of the injury to the brachial artery antibiotics for uti sulfamethoxazole effective 250 mg zitrotek. Gartland kind lla fractures may be managed conservatively with orthopaedic enter on the time of presentation k. pneumoniae antibiotic resistance generic zitrotek 100mg otc. Under enough analgesia the elbow ought to ideally be flexed to no much less than 90 degrees and the forearm ought to be saved at a neutral position. However, growing flexion might cause vascular compromise due to the related swelling of the elbow. If the radial pulse is misplaced during hyperflexion of the elbow, the elbow ought to be extended till the radial pulse is palpable once more and a further leisure of 10 degrees is advised before splinting is applied. Once the heartbeat is palpable and vascular provide is established, a plaster slab could be applied. The child can usually be discharged residence with appropriate recommendation and a definitive arrangement to comply with up throughout the subsequent 24 hours. Answer: B Lateral condylar fractures account for 15�20% of all elbow fractures in kids (most common between 6 and 10 years) and should be sought in elbow accidents in kids. The ossification centre for the lateral condyle seems between 18 months and 2 years of age and the ossification centre for the lateral epicondyle seems between 11�13 years. These fractures are unstable even with cast immobilisation as a end result of the pull from the forearm extensors. The lateral view could show the fracture line more clearly, however oblique views are considered the best to decide the diploma of displacement and rotation. Multiple indirect views could also be needed to precisely differentiate a non-displaced fracture from a displaced one. Medial condylar fractures are rare (<1%), in contrast medial epicondylar fractures/avulsions occur in 5�10% of kids. The ossification centre for the medial epicondyle appears round 5�6 years of age; it fuses with the humerus at 18�20 years of age. In youngsters older than this, the presence of the medial epicondyle ossification centre must be confirmed when reviewing X-rays in elbow injuries. Answer: C Femoral shaft fractures in children are comparatively widespread and could also be secondary to a selection of mechanisms. Shock is very unlikely to be resulting from an isolated femur fracture in a child. If shock is present, different traumatic causes for the shock corresponding to splenic, liver or pelvic damage should be thought of. The rotational stress on the distal tibia through the fall causes an indirect distal tibial fracture. When suspected, the fracture must be handled with an extended leg cast and the child should be referred for orthopaedic follow-up.