15% of the long bone fractures occurring in childhood are salter harris fractures. Salter-Harris fracture is a common injury in children.

Types of Salter Harris fracture and their incidence

There were 5 types of salter harris fractures described by Robert B salter and W Robert Harris in 1963. However, 4 more rarer types were added subsequently added later making total 9 types of salter-harris fractures.

• TYPE I – V (described by Salter & Harris in 1963)
1. TYPE I : Transverse fracture through the physis (growth plate) – 6% incidence
2. TYPE II : Fracture through the physis and metaphysis, sparing the epiphysis – 6% incidence
3. TYPE III : Fracture through physis and epiphysis, sparing the metaphysis – 75% incidence
4. TYPE IV : A fracture through all 3 elements of bone, physis, metaphysis and eipphysis – 10% incidence
5. TYPE V : A compression fracture of physis (growth plate). This results in reduced space between epiphysis and diaphysis on x-ray – 1% incidence
• TYPE VI (Added by Mercer Rang in 1969)
• TYPE VI : Injury to the peripheral portion of the physis resulting in angular deformity as a result of bony ridge formation
• TYPE VII – IX (Added by JA Ogden in 1982)
• TYPE VII : Isolated injury of epiphyseal plate
• TYPE VIII : Isolated injurty of metaphysis with possible impairment of endochondral ossification
• TYPE IX : Injury to the periosteum with possible impairment of intramembranous ossification

Mnemonic for Salter Harris Classification of fractures

There’s a mnemonic for first five types of salter harris types of salter harris fractures.

Mnemonic for salter harris classification of fracutes is: S A L T R

Imagine a long bone with eipphyses at the base, then this mnemonic “SALTR” goes like this:

• I – S = Straight accross (separated / same). Fracture of the physis (cartilage of growth plate)
• II – A = Above. The fracture is ABOVE the physis and AWAY from the joint.
• III – L = Lower. The fracture is beLOW the physis in the epiphysis.
• IV – T = Thrugh. The fracture is through all 3, epiphysis, physis and metaphysis
• V – R = Rammed (crushed). The physis is crushed in this type.

Gustilo system of classification uses the amount of energy, soft tissue damage and the extent of contamination to determine the type and severity of the fracture.

Gustilo open fracture Classification :

I – Open fracture with clean wound. Wound < 1 cm in length

II – Open fracture with wound > 1 cm inlength without extensive soft-tissue damage and no flaps or avulsions.

III – Open segmental fracture or a fracture with extensive soft tissue laceration, damage or loss. Gustilo type 3 fractures include open fractures caused by firearm injuries, fractures requiring vascular repair or fractures which have been open for 8 hour prior to the treatment.

III A – Type III fracture with adequate periosteal coverage of the fractured bone despite extensive soft tissue damage or laceration.

III B – Type III fracture with extensive soft tissue damage / loss and periosteal stripping with bone damage. This type of gustilo fracture is usually associated with massive contamination. Gustilo Type III fractures usually require further soft tissue coverage procedure like free or rotational flap.

III C – Gustilo type III fracture with arterial injury, requiring repair. This is irrespective of degree of soft tissue damage.

Please note, there is no hard fast rule or routine to follow to keep the weight off from gaining again, so if you’ve got some other ideas, do share them too. I’ll share here what I find useful and follow them personally after losing almost 30kg myself in 3 months.

How to avoid weight gain once you’ve lost some kgs

Well, most of the things to do seem pretty obvious, but anyway, lets have a look at the list, and check which one’s are you missing:

1. Diet

Cut on your diet permanently. Take 2 meals a day only. 3 meals are only for those who’re training hard for some sports and think 2 meals aren’t enough to meet the energy expenditure.

NO SUGAR. No sugar in tea, coffee, this, that, bla bla bla, just NO SUGAR. Our tongue gets used to any taste very easily and finds tastes to give pleasure. So stop using sugar and it will be all fine in some weeks. If you find it very difficult to give up on sugar, use artificial sweeteners available in every market and general stores even (canderal, sucral) [some people say canderal and sucral are harmful! hell yeah! but I bet they're less harmful than the sugar]

No bread / nan / paratha / biscuits. These are one of the main reason for our weight gain. Make a habit of bran bread. Believe me, it will taste bad only for a few weeks (and that too for some people only) After a month or so, you will feel like you’re having a sugar coated bread if you eat normal bread instead of bran bread, and will realize how good bran bread is and how good it tastes. Also, for roti / nan, replace it will unrefined wheat (bgair channa hoa aata) Use it at home to make bread / roti.

Cut down on oils. Use minimum oil in your meals. Use them though, but it should be like “there is oil in the food” not like “theres food in the oil”.

NO MILK – thats right! no milk specially the processed ones which come in the market (nestle, olpers, haleeb, etc) ! Please let me know if someone wants to argue about benefits of milk and harmful affects of not having it . . .Milk products are fine, yoghurt, ice cream, but have the skimmed ones. Skimmed yoghurt, etc)

NO DRINKS – no soda, milkshakes (unskimmed ones), no pepsi, no coke. They not only cause obesity and fat accumulation, but also damage ur stomach, and also affect iron, calcium and other minerals absorption in body, causing their deficiency.

Plenty of water – have atleast 8-12 glass of water a day.

2. Exercise

Exercise is important for living and being healthy.

Exercise means something with exertion. You should get a high pulse and sweating to say you’re exercising.

Exercise atleast 30 minutes, 3 times a week. Have a jogging session, hike, martial arts, football, basketball, aerobics, swimming, any exercise (NO CRICKET is not an exercise neither a sport)

Exercise not ony makes you slim, but also keeps you healthy and keeps heart problems away from you. Bones get strong not by milk, but by exercise and sports.

3. Mindset / nature

When we’re sad we eat alot. Why ? you’re sad right ? then don’t eat! punishing yourself by overeating? huh? punish by not eating! man! Just cut the crap, don’t ruin your eating schedule due to emotions.

Infact, don’t have any unhealthy item in your fridge or home, so that you don’t consume it when you’re emotionally unstable.

Similarly, when we’re happy or have done a good job, we treat ourselves, or ask friends for treat, why man? are we dogs? that once we’ve done something good, have a biscuit or cookie ? comeon! show some difference. Eating isn’t the only reward, for humans atleast. Prove it though!

Eat only what you know you should.

Hopefully these will help you keep some weight off your tummy!

Pulse Pressure (PP) is the difference between systolic and diastolic blood pressure values. In lay mans terms, pulse pressure is the difference between the highest and the lowest values of your blood pressure.

For example, if you have a blood pressure of 120/80 then your pulse pressure would be 120 – 80 = 40.

 There are three components to any blood pressure reading:

• systolic pressure
• diastolic pressure
• pulse pressure

Normal value of Pulse pressure:

Studies have shown that pulse pressure shouldn’t be more than 60 mm hg. i.e, 140/80 is better than 140/70 as in later one, pulse pressure is 140 – 70 = 70.

Significance of Pulse Pressure

If pulse pressure is above 60 mm of hg, it poses higher risk of cardiovascular events, specially in elderly patients.

Studies have shown that the risk of coronary event is associated more with higher pulse pressure (70 or more) than with hypertension. Which means Pulse Pressure might be a stronger predictor of heart risk than hypertension alone.

Predictive factors with age

We can divide population in three groups depending upon main predictive factors for coronary events:

1. less than 50 = diastolic pressure
2. 50 – 59 = systolic pressure
3. 60 or more = pulse pressure

Pulse pressure is a sensitive marker for coronary artery stenosis, increased risk of stroke, coronary heart disease and sudden death associated with it.

So a blood pressure of 140/90 is better than 140/70 because of the pulse pressure.

How to reduce pulse pressure

Pulse pressure can be controlled by diuretics and calcium channel blockers, most of them work by lowering the systolic pressure, thus reducing the pulse pressure.

Natural methods to control pulse pressure are weight control, exercise, decreased salt intake etc.

The person who bought him to the hospital claimed that another car hit him and they have bought him here due to humanity, but POLICE still took the driver in custody, who was a 18 year old boy whose mother was weeping over her sons “kind” heartiness.

The patient was aged near 55 or so. Unknown obviously. Had multiple syringe pricks on his forearms, suggesting, along with his dressing and appearance, that he was an addict. His reports showed hep-C positive too.

He was first of all seen by the CMO on duty and General Surgery team was called to resuscitate him. However, the team on call wasn’t even able to pass the canula to the patient. Not even in jugular vein and venous cut down in leg was refused by the senior most PG immediately. And the catheter wasn’t passed too. No ABG’s were done.

The patient had multiple rib fracture, right shoulder dislocation along with scapula fracture.

Within few minutes, General Surgery team labelled the patient as: “clear from G/S team” and handed him over to neurosurgery department to rule out any intra-cranial or spinal injury.

The neurosurgery team was efficient enough to label the patient as: “clear from n/s team” upon seeing the CT scan of brain. (some argued that CT showed hemorrhage atleast, anyhow..)

Then the patient was in the hands of ortho team. He had 1st, 4th, 7th and 9th rib fracture at that time. Later on he developed flial chest too the next day. His dislocated shoulder was fixed by ” Hippocrates method”.

The patient was then cleared by Orthopaedic team too.

Oral and Maxillofacial team didn’t bother seeing him.

Pulmonology team “cleared” him too.

His bp when he was bought to ER was 90/50.

After some time it was 80/nil and no urine output for many hours.

After more time, it was nil . . . unrecordable. Peripheral pulses were absent too.

Medicine department didn’t like to see patient and trying to manage him.

Cardio department was shown his ECG, who “cleared” him saying his ECG was fine.

Nephorology department said that their work begins once bp is recordable, as no blood is coming to kidney due to low bp, so no nephro intervention required. However, unlike medicine, cardio and gen surgery, they were kind enough to advice dopamine / dobutamine to him.

Surgical ICU refused to admit pt in icu saying no bed was available (after exactly 6 hours, a staff members mother was lucky enough to get a bed in surgery icu though)

And there was the patient, lying in the resuscitation room, unattended, unconscious, but, “CLEAR” from all departments.

And well, no, thats not he died. He died a different death. Some off duty doctors kept monitoring him and managing him though and he survived, but not out of the shock.

Next day, the other CMO on duty was informed about this unknown patient. CMO was kind and nice enough to hand him over to the Gen. Surgery deptt to manage the patient for shock who left him as “clear” the day before.

General Surgery team now wanted to have CT scan chest and abdomen of him and while moving him from ER to CT room, his broken 4th rib probably injured right ventricle. Or probably it got injured while they were examining his chest ? Whatever it was, it was blunt enough to cause damage to the heart.

And he died after some time. Story ends. File closed.

Tests this year were very much transparent! Each candidate was given a carbon copy of his answer sheet which he can tally with the final result displayed on the result day so there was no chance of incorrect marking which was rumored last year.

After that, the interview was just about seeing the candidate once and asking him which department he wants to join (among the available seats in each one) and not meant to test or ask him questions again.

Overall, the housejob tests this year were very much fair and fine.

Final list of house officers for each departments will be displayed tomorrow on 6th February 2012 and Joining will commence within couple of days.

Good luck to all those who got selected for the housejob!

During winters, skin becomes tight, dull, dry and lacks moisture due to cold weather. It can even result in skin conditions like cracking, flaking and eczema in some patients. Ignoring your skin in winter means bad skin in winter ofcourse, but the same bad skin continues in the summer until it gets fixed . . . or more ruined.

We’ll discuss some of the common bad practices in winters which lead to damage to the skin.

1. Discontinuing Sunscreen / sunblock

One thing which almost all people do, is discontinuing sun screens in winters. Sun is still out there, with same ultraviolet rays, same glare and harmful affect which can cause skin darkening, wrinkles and aging affect, specially around the eyes. Keep using sunblock all round the winters like you do in summers, to protect your skin from the harmful affects of direct sunlight before going out in the sun.

2. Keep the skin moisturized

Skin needs alot of moisturization in winters. The harsh weather causes the skin to lose natural oils. Also, heaters dehydrate the skin further, making it more fragile and prone to damage. Make a habit of moisturizing the face and body on daily basis. Use moisturizing soaps for shower too.

Make sure you use the proper moisturizer in winter. The same moisturizers which work in summer not always are best for winters. Use an oil based moisturizer which will help create a protective layer on your skin and retain more moisture. Don’t use any oil as it may damage by clogging the pores and cause more skin problems. Non clogging oils are avocado, mineral, sandalwood or primrose. Shea oil shouldn’t be used.

3. Don’t take too hot showers

Hot showers make the skin dry. Try to avoid hot showers. Warm the water only to the required and acceptable range and take shower from it. Make sure you don’t take “cold” showers in winters as it might lead to other complications too! Just a normal temperature thats just under the acceptable range.

4. Heaters and humidifiers

Indoor heaters dry out the air in the rooms, thus affecting skin too. Use humidifiers to keep the air in the room humidified. Placing a big open bowl of water in front of gas heaters specially help in humidifying the room air.

Both male and female skin needs to be cared all round the year and not just summer. Make sure you keep good care of your skin in winters to keep it beautiful and attractive and healthy ofcourse.

So coming to the point, how to lose 1 kg in 1 day ( or 2 kg in 2 days and so on).

You might already be knowing that losing initial 5 kg weight is relatively easy to losing weight after 5 kg.

Also, its easiest to lose weight the first time you wake up out of your sedentary life style and decide to get slim. With each repetitive try your body becomes more hard to shed weight.

So anyway, losing first 1 kg or 2 kg of your body is not an issue at all. Seriously. You can lose 1 kg per day for 2 to 3 days easily if you’re really determined to do so.

How to lose 1 kg in 1 day

This will include 2 things, as usual, 1 exercise, 2 diet control

As for the diet part, simply follow these:

• Don’t take carbohydrates (bread, potato, rice, etc)
• eat protein normally (not like eat all protein that you can, but try to live on protein – meat, pulses low in carbohydrates, egg white only, etc)
• almost no fats (avoid any fats as much as possible)
• no junk, no soda, no nothing, nothing goes in your mouth, and no fruits too! yeah!
• have plenty of desired water

That was pretty simple han? to lose 1kg per day! yeah right. Here’s more to it.

If you follow this diet only, believe me you’re gonna lose atleast half kg in 1 day (or lose 1 kg in 2 days)

If you’re fine with it, perfect, otherwise add these exercises to your routine to get to lose 1 kg in 1 day.

Well there are no specific exercises for that, just tips to keep in mind while trying to lose 1 kg per day:

• don’t lie flat on the bed!
• do normal daily tasks
• do atleast 40 minutes (or 1 hour if possible) jogging + walking (walk when you’re unable to jog, regain strength and jog again)
• hike or swim if possilbe, nothing is better than that.

Ok there, 1 more thing, don’t jump on the scale straight away to check if you lost weight or not right after 1 day.

Your intestines still need to be empty before they show you some real weight of yours. So go empty yourself and see if you really lost 1 kg in 1 day or not ?

Let me know your experience regarding following these steps to lose 1 kg per day.

Its much more painful than it seems, so should be treated promptly.

Signs and Symptoms of Acute Otitis Externa (swimmers ear)

Signs and symptoms of AOE (actue otitis externa) include diffuse pain and infection in external ear of acute origin.

There is associated tenderness of tragus and pinna

Sometimes temporomandibular joint (TMJ) is tender too due to acute otitis externa.

Patient has a feeling of fullness in his ear.

Itch is present

Decreased hearing due to canal occlusion occurs secondary to edema.

The external ear canal can be erythematous with purulent (watery) discharge.

Differential Diagnosis of Acute otitis Externa

Differential diagnosis of Acute Otitis Externa include:

• Acute otitis media with tympanic membrane rupture
• Acute otitis media with otorrhea secondary to a chronic perforation or tympanostomy tube in place
• furunculosis
• herpes zoster / viral otitis externa
• sequele of foreign body in external ear
• fungal external otitis
• contact dermatitis (secondary to contact by offending cosmetics, nickel, drugs, plastic in some hearing aid, etc)

Diagnosis is confirmed on the basis of history and examination by ruling out the possible differentials.

Causes of Acute Otitis Externa

Acute infection in the external ear occurs when the normal epithelial barrier is disrupted.

Infection is 98% bacterial in origin and very uncommonly fungal.

Acute Otitis Externa usually develops secondary to Pseudomonas aeruginosa usually and seldom secondary to Staphylococcus aureus.

Risk factors include trauma from aggressively cleaning ear by the patient, removal of wax, chromic skin conditions like eczema and water exposure (thus named swimmers ear).

When there is enough wax to block the canal, water gets trapped behind it, providing the best medium for bacterial growth in the external ear canal.

Treatment of Acute Otitis Externa

Acute Otitis externa (swimmers ear) requires immediate treatment.

Opiods such as codeine combined with acetaminophen or anti inflammatory drug are given.

Topic therapy via ear drops is the main treatment of choice for acute otits externa.

Bacterial resistance is not a major issue with topic drops.

Culturing the ear is not required prior to treatment.

Irrigation of external ear canal with water and or saline are not recommended in a patient with acute otitis externa. It can even make condition worse.

Oral therapy don’t have any specific use in treatment of acute otitis externa. It’s used usually when the infection has spread to pinna and skin around the ear.

If celulitis has developed as in severe cases, I/V therapy is given.

Treatment is typically effective in first 24-48 hours after which AOE starts to resolve.

If the condition of AOE persists, then referral to a senior or ENT specialist is required, also to rule out carcinoma (squamous cell carcinoma).

Ear drops are safe generally if the tympanic membrane is intact.

Some drops used for ear have a combination of antibiotic and steroid which help in reducing the inflammation and infection in the external ear which can reduce the discomfort and pain associated with the presenting complain or active disease.

So before advising any ear drops to a patient, make sure that the tympanic membrane is intact otherwise it will enter the middle ear and cause further damage in some situations.