key: cord-005816-i54q5gsu
authors: nan
title: 10(th) European Congress of Trauma and Emergency Surgery: May 13–17, 2009 Antalya, Turkey
date: 2009-08-06
journal: Eur J Trauma Emerg Surg
DOI: 10.1007/s00068-009-8001-z
sha: 
doc_id: 5816
cord_uid: i54q5gsu

nan

Introduction and aims: Although liver is well protected by the thoracic cage, it is a frequently injured organ especially by penetrating traumas and also rarely by blunt traumas. Retroperitoneally located pancreas and duodenum injury with or without liver injury occur rarely but they are seriously life threatening injuries. For these reasons we aimed to investigate the traumatic liver, duodenum and pancreas injuries as a whole. Materials and methods: 55 cases of blunt and penetrating traumas occured in our district are included in this study. In these patients parameters of sex, age, etiology, admission time, stability and physical status on admission, concurrent organ injury, operation type, gradings of injuries, were investigated. Results: 51cases (92,7%) suffered from liver injury, while 4 cases (7,3%) suffered from hepaticopancreaticoduodenal injury. 31 cases (56%) were caused by penetrating injuries. 31 cases of liver injury group had isolated liver injury whereas 15 cases of the group has additional thoracic injury, 3 cases had great vessel injury, 1 case had orthopedic injury and lastly 1 case had head injury in addition to the liver injury. In the combined hepatic injury group mortality rate was 7,3%. Conclusions 1. In hepatoduodenopancreatic injury group blunt and penetrating injury rates are equal. 2. Duodenum-pancreas injuries occur rarely. Liver,with injury rates of 51 cases in this study, is the most frequently injured organ. 3. Mortality rate is higher in the subgroups of patients who admitted to hospital late, and who had concurrent thoracic, orthopedic, and head trauma.

Background: The incidence of blunt bowel and mesenteric injury (BBMI) has increased recently in blunt abdominal trauma and this is possibly due to an increasing number of high speed motor accidents and the use of seat belts.

Objective: In this study we sought to identify the factors determining the time of surgical intervention and how they affect the outcome of the patient with BBMI. This was achieved by reviewing our experience as a Major Victorian Trauma Service in the management of bowel and mesenteric injuries and how this compares to current literature. Methods: A retrospective study reviewing 278 consecutive patients who presented to the Alfred trauma centre with blunt bowel and mesenteric injuries over 6 years. Results: Of the 278 patients with BBMI 66% were male, 34% were female. 80% of the patients underwent a laparotomy, 17% of patients were treated conservatively and 3% were diagnosed post-mortem. The times from admission to laparotomy were: 0-4 h 67%, 4-8 h 9%, 8-12 h 3%, 12-24 h 10%, 24-48 h 4%, more than 48 h 7%, respectively. FAST (focused abdominal sonography for trauma) was done in 86 and 51% of this group had a positive FAST. While 44% of patients had a negative FAST and 4% of patients had an equivocal FAST. 13% overall group did not have a FAST. Computerised tomography (CT) scans were undertaken preoperatively in 68% of the patients and showed: free gas (22%), bowel wall thickening (31%), fat and mesenteric stranding or Hematoma (38%) and free fluid with no solid organ injury (43%). Conclusion: The timing of surgical intervention is mostly determined by the clinical examination and the helical CT scan findings in BBMI. FAST lacks in sensitivity and specificity in identifying bowel and mesenteric trauma. Delayed diagnosis of more than 48 h has significantly higher bowel related morbidity but not mortality.

6 Predictors for the Selection of Patients for Abdominal CT After Blunt Trauma: a Proposal for a Diagnostic Algorithm Introduction and objectives: Gastrointestinal and mesenteric injuries (GIMI) are not common in trauma, and their diagnosis is frequently delayed. Our aims were to determine the reliability of CT scan and to assess the clinical significance of a delayed diagnosis.

Methods: Retrospective analysis of cases confirmed at laparotomy. Patients were identified at the Severe Trauma Registry of our hospital, between 1993 and 2006. Results: We found 105 (16,6%) GIMI out of 632 patients with abdominal trauma, in a Registry with 1.495 severe trauma cases included. The mean ISS and NISS were of 20 and 25, respectively. Mortality was of 9 (8,5%) patients, 4 of them unexpected. A CT scan was performed in 56 (53%) cases, and only in 37 were there signs suggestive of a GIMI. Surgery was delayed for more than 8 h in 21 (20%) patients, the most common reason being a false negative result in the CT scan. There was no significant increase of morbidity or mortality in the delayed diagnosis group. Conclusion: The overall incidence of GIMI was high in our Registry (31% in penetrating and 10.7% in blunt trauma). Several factors such as the initial lack of symptoms, a low diagnostic sensitivity of the CT (34% false negatives), and the nonoperative management of solid organ injuries, have contributed to a delayed diagnosis in one of every five patients in our series, but this has not led to a significant increase in septic complications in this group. Author to editor: CT scan diagnosis of gastrointestinal injuries continues to be a matter of concern. There is controversy on the clinical significance of a delayed diagnosis of small bowel injuries 10 Management of Rectal Injury: Reappraisal of Old Techniques Introduction and objectives: Due to immunological functions, conservation of injured spleen following abdominal trauma is very important. For this reason nonoperative management (NOM) in the last 25 years has been accepted as the ideal treatment in those patents who are hemodynamically stable and do not require a laparotomy; however in case of multiple abdominal solid organ injuries (SOI) NOM is controversial. Methods: We report on a case of a 27-years-old patient with spleen and renal injury subsequent to blunt abdominal trauma. CT scan revealed a OIS IV injury (Third degree in Graz classification) and an OIS IV renal injury. Since chances for successful spleen angioembolization were judged poor by radiologist, a laparotomy and partial spleen resection with preservation of one-third of the spleen was performed. Immediately after surgery, angioembolization of the renal injury was successfully performed. Results: A contrast enhanced ultrasound (CEUS) performed on day 7 and day 30 after trauma revealed a hypertrophy of the residual spleen with diffuse distribution of contrast agent in the spleen parenchyma, confirming functional activity of the organ. Morphological and functional evolution of left kidney was normal.

Conclusions: Sequential treatment (surgical preservation of the most injured organ followed by immediate angiographic embolization) could be a valid option in case of multiple abdominal SOI; furthermore, CEUS is an interesting new tool to determine functional activity of residual spleen. Introduction: Precise timing of cholecystectomy procedure after biliary pancreatitis is still controversial. The major drawback of interval cholecystectomy is the recurrence of pancreatitis within the interval of 6-8 weeks. Early cholecystectomy (performed prior to discharge), however, have the disadvantages of increased technical difficulty and conversion rates. Methods: We reviewed 47 patients with recurrent biliary pancreatitis among a total number of 277 cases of biliary pancreatitis in-between January 2007 and January 2009. Results: The mean age was 64.5 (range 29-85), and male-to-female ratio was 0.4 (13:34). Seventeen patients (%36) had a history of previous cholecystectomy. Of these 17 patients, 8 (%17) have had early cholecystectomy, and 9 (%19) have had interval cholecystectomy. The rest of the patients (%64, n = 30) consists of those who have been scheduled for interval cholecystectomy but have had a recurrent episode during the 8-week interval (%6, n = 3) or after the 8-week interval (%57, n = 27). Conclusion: The majority of patients with biliary pancreatitis do not have any recurrent episodes even if they do not have a surgical or an endoscopic treatment. According to our data, however, an influenced percentage of recurrent pancreatitis develops in patients who do not have early cholecystectomy. Therefore, we prefer early cholecystectomy in means of reducing the risk of recurrent pancreatitis during or after the 8-week interval.

Introduction and aim: Nonoperative management (NOM) of splenic injury is currently the most common management strategy in hemodynamically stable trauma patients. Aim of this study was to asses if the success rates of 80-97% described, mainly in the North-American literature could be confirmed. Methods: We conducted a retrospective study of all patients older than 17 year with blunt splenic injury who were admitted to a Level I trauma center. A total of 120 patients were identified with blunt splenic injury during the 10-year study period (1998) (1999) (2000) (2001) (2002) (2003) (2004) (2005) (2006) (2007) .

Results: The majority were young men; mean age was 34 years. Thirty-three (27%) patients underwent immediate surgical management. Sixty-seven (56%) patients were treated with planned NOM and 20 (17%) patients underwent angiography and embolization (A&E). We did not encounter early complications following A&E. Fourteen patients failed observation due to ongoing bleeding. Of these, 10 were treated with splenectomy and three with A&E. The splenic salvage rate after observation was 84%. The splenic salvage rate after A&E was 80%. Four of the five patients with a rebleeding after initially A&E underwent splenectomy and one patient was treated with reembolization. The overall mortality rate was 7.5%. None of the patients died as a result of splenic injury treatment failure.

Conclusion: Nonoperative management in blunt splenic injuries in our trauma center is a well-tolerated treatment with a success rate of 84%. The splenic salvage and mortality rate is comparable with the literature which is mainly based on North-American studies. Mannheim peritonitis index (MPI) is a scoring system with prognostic significance. We applied MPI to patients with perforative peritonitis (on patients in Sri Ramachandra Medical College) to validate the scoring method. It is a specific score with accuracy and allows prediction of prognosis. Aim of the study (1) To study the incidence and aetiology of perforative peritonitis.

(2) To study the demographics of the study population.

(3) To analyse if Mannheim peritonitis index (MPI) is a valid scoring method.

P-Possum (p < 0.01) scores in the index surgery. Malignancy was the most frequent initial diagnosis in patients with SPP and benign diseases in TP. There were no differences on the interval between operations (11 ± 14 days TP vs. 10.8 ± 8 days SPP; p = 0.9) neither in the number of previous laparotomies (p = 0.2). TP was associated to emergency index surgery (p = 0.01) and ICU hospitalization (p < 0.001), mechanical ventilation (p = 0.0001) and vasoactive drugs (p = 0.002). There were no differences in any of the clinical and biochemical parameters analyzed, neither in SIRS (p = 0.08) or P-Possum scores after relaparotomy (p = 0.13). We found no differences regarding mean hospital stay (48 days TP vs. 45 days SPP; p = 0.7) and mortality rate (30% in SPP vs. 21% in TP; p = 0.43).

Conclusions: Although certain differences exist, the clinical course of postoperative peritonitis seems to depend more on factors other than their secondary or tertiary origin.

Background and Aim: Patients with primary ACS will often develop a secondary acute respiratory distress syndrome (ARDS). Mechanic pressure is mainly responsibe in pulmonary findings in ACS. We aimed the role of aspiration of gastric contents into lower airways in pulmonary complications of ACS.

Methods: The 50 rats were initially divided into five groups (Group I-V), and then these groups were divided again into two groups if they are unfed (Group Ia-Va) or fed (Group Ib-Vb). In animals in group I-V intraperitoneal pressure (IAP) was applied as follows: 15, 20, and 30 cm H 2 O by instillation of isotonic saline solution.

Results: Total scores of lung histopathologic findings were concordant with the degree of IAB. When the total scores of histopathologic findings in lungs were compared for each applied IAB with control group, the scores were higher in fed animals than unfed animals. Histopathologic findings in lungs were observed when increased-IAP to 15 mmHg (20 cmH 2 O) which was accepted as cut-off value. The comparison of the scores of histopathologic findings in two groups in which the applied IAB was lower then the cut-off value were not significantly different from the control group. However comparison of the scores of histopathologic findings equal to or above 18 mmHg were significantly higher then the control group. Conclusion: Our results show that that pulmonary aspiration related with passive regurgitation in ACS has a substantial influence on histopathologic findings seen in this disorder. Editor to Self: Secilmiş bildiri 50 Emergency Surgery and Delayed Abdominal Closure: Results in 16 Cases

Carlos Mesquita, Marco Serô dio, Francisco Castro-sousa 1 1 Emergency and General Surgery Departments, Coimbra University Hospital, Coimbra, Portugal

Delayed abdominal closure (DAC), in emergency surgery, must be economical, fast to execute and easy to maintain, allowing second look and definitive closure, with minimal prejudices to the abdominal wall. As an alternative to the vacuum closure systems, the AA have been utilising the Rotondo and Schwab technique (IATSIC-DSTC Course), by the interposition of a plastic towel between abdominal contents and wall. DAC has been utilised in 16 patients (8 male, 8 female, 2005-2008) , median age of 51 (32-90). In five, after abdominopelvic packing for hypovolemic shock conditions. In 11, after mediastinal and peritoneal decontamination procedures and lavage for septic situations with actual or potential compartment syndrome: three from acute necrotizing pancreatitis, six from dehiscent digestive sutures and two from strangulated hernias. Four patients died in the open abdomen situation, one from pancreatitis and three from dehiscent sutures. Primary abdominal closure has been possible in 11: in the 5 cases of packing and in 6 of the 7 of the cases of sepsis. In one case of pancreatitis it has been possible a secondary closure. DAC is now accepted like a safe procedure in damage control and compartment syndrome conditions which contributes to ameliorate the results in life threatening situations. than 40%. This report describes our experience with Vacuum Assisted Closure (VAC-)therapy in the management of EFs in an OA. Materials and methods: Nine patients with seventeen high output EFs in an OA were treated with VAC-therapy from January 2006 till January 2009. The abdominal wound was covered with fatty gauzes. Small EFs were covered with a patch of hydrophilic polyvinylalcohol foam. The entire abdominal wound was covered with polyurethane foam which promotes granulation and seals of the OA preventing further spillage of enteric contents. Continuous negative pressure at -125 mm Hg was applied. For large fistulas with protruding mucosa a hole was cut within the polyurethane foam and an ostomy bag was placed over the fistula mouth. Surgery with enterectomy was planned 6-10 weeks later.

Results: The VAC-dressing was changed every 4 days. Three EFs closed spontaneously. Time between onset of fistulisation and surgery was 52 days (median 51 days). No additional fistulas occured. One patient died postoperatively. Conclusions: Although previously considered a contraindication to VAC-therapy, the OA with EFs can be managed with VAC-therapy. A taylored application of the foam and a reduced negative pressure seem to allow a safe and reliable way to manage EFs. Partial enterectomy and abdominall closure is possible after several weeks. Introduction: It was the aim of the study to analyze the potential value of microdialysis in the rectus abdominis muscle (RAM) compared with conventional monitoring parameters currently in clinical use for the detection of the abdominal compartment syndrome (ACS). Methods: 30 pigs were anaesthesized, mechanically ventilated and continuously monitored. Microdialysis was performed in different abdominal organs, the RAM and cervical muscle (distant reference) for glucose, lactate, lactate-pyruvate ratio (LPR) and glycerol. IAH was maintained for 6 h. Three groups were analysed: control (A), IAH 20 mmHg (B) and 30 mmHg (C).Cardiopulmonary parameters, urinary output, blood gas analysis and venous lactate were recorded.

Results: Mean arterial pressure and abdominal perfusion pressure remained above clinically defined thresholds during the experiments for groups A and B. In contrast, group C demonstrated a persistent decrease below these thresholds. Significant reduction of urinary output was only seen in group C. Lactate levels also remained within physiological range in all groups. In contrast, microdialysis revealed a significant increase of LPR in all monitored organs in groups B and C, indicating ischemia and energy failure. Of interest, LPR in the RAM showed a significant increase already after 2 h of IAH in group B.

Conclusion: Microdialysis of the RAM detected local metabolic derangements in animals with IAH of 20 mmHg while clinically established monitoring tools failed to show organ dysfunction/tissue ischemia. Our data suggest that continuous microdialysis in the RAM may represent a promising tool for early detecting IAH-induced metabolic derangements before manifestation of clinically apparent ACS. Introduction: To avoid morbidity associated with open abdomen, subcutaneous linea alba fasciotomy (SLAF) was introduced for management of abdominal compartment syndrome (ACP) in severe acute pancreatitis (SAP). We analyzed the efficacy and safety of SLAF as a surgical decompressive technique. Methods: A retrospective study of a 3-year period identified 10 patients with SAP and ACS undergoing SLAF. Mean age was 46 (range 33-61) years, 9 were male and 9 had alcohol-induced SAP. SLAF was performed 1-17 days post-admission, in 6/10 cases within 48 h. Results: The mean (range) preoperative intra-abdominal pressure (IAP) was 31 (23-45) mmHg and immediate postoperative IAP 20 (10-33) mmHg. The mean decrease was 10 (2-17) mmHg and the decompressive effect was considered sufficient in 7/10 cases. Two of these developed recurrent ACS and required completion laparotomy, as did the 3 with insufficient effect (0-3 days post-SLAF). The mean preoperative SOFA score was 12 (4-17) and 11 (1-20) 1-5 days postoperatively, the decrease was > 5 in 3 patients with successful SLAF. Eventually four patients underwent necrosectomy, two following sufficient SLAF. The overall mortality and morbidity rates were 4/10 and 3/10, no complications were attributed to SLAF itself. Mean hospital stay was 35 (11-70) days. Of the survivors, fascial closure was achieved in two, and planned hernia in four (two with split-thickness skin graft and two with post-SLAF hernia). Conclusion: SLAF is a safe decompressive technique in SAP-related ACS. It is effective in about 50-70% of cases, but some require completion laparotomy and/or necrosectomy later on.

Methods: Between March 2007 and December 2008, 44 patients were managed with VAC technique (KCI, San Antonio). The mean age was 54.8 (28-87) , and M/F sex ratio was 1/4. Indications were severe abdominal sepsis in 12 patients, mechanical obstruction due to colorectal cancer in 10 patients, pancreatitis in 4 patients, posttraumatic abdominal compartment syndrome 8 patients, evisseration in 4 patients, enterocutaneous fistule in 6 patients. Results: As morbidity there were 2 fistulaes and 2 intraabdominal abscess in all 44 patients. Four of the patients were died with concomitant disease. There was no mortality related using VAC system. Thirty five patients (80%) was underwent a delayed primary closure, five underwent secondary healing by granulation, and four underwent split thickness skin grafting. Surgical outcomes of severe hepatic injury were retrospectively reviewed. (Methods) Among 567 patients with hepatic injury treated between 1975 and 2005, 247 patients who underwent surgery were included. The study period was divided into early (1975) (1976) (1977) (1978) (1979) (1980) (1981) (1982) (1983) (1984) (1985) (1986) (1987) (1988) (1989) (1990) (1991) (1992) , middle (1993) (1994) (1995) (1996) (1997) (1998) (1999) (2000) and late (2001) (2002) (2003) (2004) (2005) phases, and type of injury, surgical procedure performed and patients' outcome were retrospectively reviewed. (Results) (1) Percentage of patients undergoing surgery: 70% (161/274) underwent surgery in the early phase, 37% (66/192) in middle and 25% (25/101) in late phase.

(2) Timing of surgery: The numbers of patients underwent laparotomy in ER, urgent laparotomy in OR, and delayed laparotomy (after 24 h) were 42 (28%), 111 (67%) and 8 (5%) in early phase; 27 (41%), 33 (50%) and 6 (9%) in middle; and 11 (44%), 14 (56%) and 0 in late phase, respectively. (3) Surgical procedures performed: for type IIIb (JAST grading) cases, hepatectomy was performed in 88% and hepatorrhaphy was performed in 10%, giving a mortality rate of 25% in early phase, 23.5% in middle and 0% in the late phase. For IIIb + IVC/HV cases, hepatectomy was performed in all patients, giving a mortality rate of 60% in early phase, 40% in middle and 33.3% in late phase. (Discussion) With the increase in nonsurgical management, surgical treatment for hepatic injury is performed preferably in patients requiring immediate response, such as laparotomy in ER. The surgical outcome of hepatic injury has been improving, with a survival rate of approximately 90% for type IIIb cases and 60% for IIIb + IVC/HV cases.

Rifat Tokyay, Tolga Taymaz 1 1 Amerikan Hastanesi, Istanbul, Turkey

Objective: The aim of this study was to assess the unexpected returns (UR) within 1 month of the adult patients and the pediatric trauma patients initially seen in the _ Istanbul American Hospital Emergency Department. Design: All URs between 01.01.2005-01.01.2009 were recorded. Initial diagnosis, final diagnosis, initial treatment, final treatment, reason for readmission, and last medical condition were noted. Results: Eighty eight URs were recorded. Final diagnosis of 46 of these 88 patients were surgical. Forty one of these surgical patients had UR due to error in diagnosis and five due to error in treatment. Fifty two of these 88 patients returned on the same day or the next day, 13 between 2nd and 3rd days, 15 between 4th and 7th days and 7 between 7th and 30th days. Male to female ratio was 1 to 1. Three of the patients were pediatric trauma patients, 71 were between 15-65 years, and 14 were over 65. Missed final diagnosis were: Acute cholecystitis (10), acute appendicitis (10), missed fractures (8), pneumothorax (2) liver mass (2), urethral stone (2), ectopic pregnancy (1), diverticulitis (1), subarachnoid bleeding (1), others (9). Conclusions: Acute cholecystitis, acute appendicitis, and missed fractures were the most frequent surgical causes of URs after emergency department discharges. Liberal utilization of abdominal sonography and abdominal CT scan may reduce missed acute abdomen in abdominal pain patients and appropriate radiological imaging and meticulous evaluation of the X-rays may reduce unnoticed spinal, pelvic and facial fractures in trauma patients. Editor to self: Seçilmiş bildiri olabilir Introduction and aim: Bacteremia sepsis and septic shock might develop rapidly for the patients with infection in bile path. Early diagnosis, surgical treatment and antibiotherapy decrease mortality. In this study, the relation between choledocholithiasis, cholangitis and pancreatitis and treatment methods have been evaluated. Method: The demographic features, the treatments, the intensity of the illness and mortality rate of the 155 patients in Afyon Kocatepe University General Surgery clinic between the years 2006 Background: Enterocutaneous fistula continues to be a serious surgical problem. They are related with major electrolyte imbalances, malnutrition and delayed tissue healing. Our recent experience with enterocutaneous fistulas is reviewed hereby. Methods: We analyzed the charts of all patients with enterocutaneous fistula from January 2006 to December 2008. Fistulas were assessed for localization, type, output, etiology, use of somatostatin analog and fibrin glue, nutritional support, type of surgical intervention, wound VAC, and endoscopic findings. Results: We identified 20 patients. Fistulas were localized as gastroduodenal in five patients, jejuno-ileal in seven, and colonic in eight. There were 11 enterocutaneous and 9 entero-atmospheric fistulas. Endoscopy was performed in 12 patients. Output was low (< 400 ml) in 14, whereas high (> 400) in 6 patients. Seventeen patients developed fistulas due to iatrogenic reasons, six patients had an underlying malignancy, and three patients developed fistulas after pancreatitis. Somatostatin analogs were used in 12 patients. Conservative treatment was performed in 10 patients, primary surgical intervention in 3 patients, and secondary surgical intervention in 7 patients. Fibrin glue was used in 9 patients and was of benefit to 3. Healing was achieved in 18 patients (90%) after mean 19.3 days (range 14-75). Two (10%) patients were died.

Conclusion: There appears to be no strict rule for treatment of enterocutaneous fistulas. Liberal use of endoscopy, fibrin glue as well as restorative surgical intervention all play a major role, and should be employed selectively on an individual basis in the management of enterocutaneous fistulas. Aim: In this study we aimed to evaluate the patients whose admitted to neurosurgery and anesthesiology intensive care unit (NAICU) between 2004 and 2009. Matherial and methods: The patients whose admitted to NAICU between 2004 January 1 and 2009 January 1 evaluated retrospectively. Diagnosis, age, gender, mortality rate, staying day in ICU of the all patients were determined. Head traumas were obtained in trauma and multitrauma patients. Results: Total number of the patients those are admitted to NAICU were 1,768 and 716 of them because of head trauma (40.5%). 438 of the 716 cases were pure head traumas (61.2%) or politraumas accompanied with head traumas (HT).The rate of HT was 24.8% of all traumas.There were 351 men, 365 women. Mean age of men were 44.32 and women were 45.17. Staying ICU were obtained as 7.48 days. The mortality rate was found as 43.72% (313 cases). Operated cases were 350 (48.88%) and the cases followed without any operation were 366 (51.12%). Mortality rate between operated cases were 49.14% (172) and nonoperated cases were 55. 46% (203) . HT cases were evaluated by Glascow Coma Scale (GCS) as severe (GCS £ 6),intermediate ,moderate (GCS ‡ 11).The cases which had GCS £ 6 were 39(8.9%). Operated cases were 24 (61.54%) and 19 of them dead (79.17%). The mortality rate of operated cases (37 cases) which had GCS = 7-10 were 45.96% (17cases). The number of cases were 315 which had GCS ‡ 11 and the mortality rate of operated cases (87cases) were 18.39% (16cases) at this group. The mortality rate of nonoperated cases (228 cases) were 11.40% (26 cases). Conclusion: The higher rate was HT cases when the trauma patients evaluated and mortality rate of nonoperated trauma patients were higher then operated trauma cases.

Author to editor: This study send for giving knowledge about traumas which admitted to Kocatepe University School fo Medicine at a period of 51 months.

Introduction and Aim: This study has been carried out to compare conservative and surgical treatment for the acute pancreatic. Method: The treatment processes and radiologic outlook of the patients with acute pancreatitis in Afyon Kocatepe University General Surgery Clinic between the years 2006 and 2009 have been observed retrospectively.

Results: The average age of the 52 patients with acute pancreatic is 54 and 67.3% of them were women. While conservative treatment was applied on 29 patients, surgical treatment was applied on 23 patients. While the etiologic reason was based on a known source for the 55.7% of the patients, no reason was found for the 44.3% of the patients. ERCP was applied for six patients within the scope of conservative treatment. Necrotizing pancreatitis existed in five patients. Surgical debritment and abdominal washing were applied for four of the patients. Acute pancreatitis were diagnosed for the 51.9% of the patients after tomography. One of the patients which had surgical treatment died (0.23%). There was no mortality for the patients having conservative treatment. There was not a substantial distinction between the two treatment methods in terms of mortality. Ten of the patients had laparoscopic cholecystectomy, ten of the patients had open cholecystectomy (one of the patients with abdominal washing), one of the patients had choledochal exploration with t tube drainage and open abdomen.

Conclusion: The conservative treatment should be prefered though the treatment ways of acute pancreatitis under discussion. There is not a distinction between the tow methohds in terms of mortality.

Mü nevver Moran, Emre Gundogdu, Ismail Bilgiç, Hayrettin Dizen, Mehmet Mahir Ö zmen 1 1 Department of Surgery, Ankara Numune Teaching and Research Hospital, Ankara, Turkey

Our aim was to compare to efficiancy of different scoring systems as a prognostic indicator in acute pancreatitis. Medical records of 234 patients (125 female) with mean (range) age of 55 (19-92) years who are diagnosed as acute pancreatitis during 5 years were evaluated according to age, sex, etiologic factors, SIRS, APACHE II, Balthazar scores and Ranson scores at admission and at 48 h in order to evaluate the correlation with mortality. The commonest cause was gallstone seen in 157 (67%) cases followed by idiopathic in 48 (20%), alcohol in 24 (10%) and other in 4 (1%). There were 11 (4,7%) cases with mortality and 99 (42%) patients underwent operation. In 223 survivors mean (SD) age was 62 (21) years, SIRS score was 0.78 (1) , Ranson scores at admission was 1.4 (1.2) , Ranson scores at 48 h was 1.1 (0.8), APACHE II score was 6.2 (4.1), Balthazar scores was 2.6 (1.3). In the nonsurvivors group of 11 (4,7%) cases, the mean age (SD) was 55 (16). Admission SIRS score was 3.4 (0.54), APACHE II score was 13 (3.6), Ranson score was1.2 (0.8), Ranson scores at 48 h was 3.3 (0.5). When both groups were compared SIRS score, APACHE II score at the admission and Ranson score at 48 h were found to be statistically significant (p < 0.001, p = 0.001, and p = 0.001, respectively), and no differences observed in reference to Balthazarscore, hospital stay and ICU stay (p > 0.05). Although admission SIRS score, APACHE-score and 48 h Ranson score were all found to be important prognostic indicators, SIRS seems better and most promising indicator as it is easy to use and not requires sophisticated tests. normal in 52 patients (5%). The appendix was divided by endo-loop in 96%, intracorporeal suturing in 3% and endo GIA in 1% of the patients. The meso-appendix division was performed by endoclip (43%), Ligasure (54%) and bipolar cautery (3%) . Conversion to open procedure rate was (7%). Mean operating time was 42 min (20-150). Mean hospital stay was 1.9 days . Major complications were as follows: right iliac artery injury (n = 1), bladder injury (n = 1), post operative bleeding (n = 3), intraabdominal abscess (n = 9), appendiceal stump leakage (n = 4). Minor complications were trocar site infection (n = 32) and mechanical bowel obstruction (n = 3).There was no mortality. Conclusion: LA is associated with considerably decreased morbidity and might be considered as the treatment of choice in AA.

Hakan Yanar, Cemalettin Ertekin, Korhan Taviloglu, Ali Fuat Kaan Gö k, Emre Sivrikö z, Gü lay Sarıçam, Recep Gü loglu 1 1 Trauma and Emergency Surgery Service, Istanbul University, Istanbul Faculty of Mediine, Istanbul, Turkey

Background: Gastrointestinal stenting is increasingly employed to relieve passage. It provides a palliation in inoperable cases or anastomotic strictures. In left-sided colonic and rectal obstruction, it allows decompression for a definitive surgery to be performed. Methods: Between May 2006 and December 2008, 30 patients with acute mechanical intestinal obstruction were treated with endoscopic stenting. Localization of malignancy, stenting complications, and surgical interventions were assessed.

Results: There were a total of 30 patients undergoing gastrointestinal stenting. Sixteen patients received gastroscopic stents, four patients with esophageal, eight patients with gastric, four patients with duodenal tumors. Stenting failed in five patients (31%), and surgery was required in four patients. Nine patients were referred to adjuvant oncologic treatment. Fourteen patients received colonoscopic stents; in one patient with a left-colon, in nine patients with sigmoid colon, and in four patients with rectal tumors. Stenting failed in seven patients (50%), and six patients were operated emergently with a need for stoma in two patients. Ten patients were referred to adjuvant oncologic treatment. No patient was died related with procedure. Conclusion: Gastrointestinal stenting is a useful adjunct in the treatment of patients presenting with acute mechanical intestinal obstruction for palliation as well as for decompression before definitive surgical therapy.

Introduction and Objectives: Internal hernia (IH) is a rare entity which occurs due to the protrusion of an intraabdominal viscus through a normal or abnormal mesenteric or peritoneal aperture. IH can either be acquired through a trauma or surgical procedure, or constitutional and related to congenital peritoneal defects. Intestinal obstruction due to IH is very dangerous and lethal because it may be silent, and delay in diagnosis may cause severe abdominal conditions. In this report, we aimed to present 17 patients with IH.

Methods: Seventeen patients who were admitted to our clinic with the diagnosis of IH between January 1990 and January 2009 were included. Patients' demographic data, type of the hernias, type of surgical procedures, length of hospital stay, and prognosis of the patients are evaluated retrospectively.

Results: There were nine male, eight female patients. Mean age of the patients was 51. 1 years (15-83) . Postsurgical IH were seen in eight, paraduodenal in four, transomental in one, sigmoid mesocolon hernia in one patient, and the remaining three hernias were not classified. Laparotomy was performed in 15 patients, laparoscopy in 1 and conversion to open surgery in 1 patient. Small bowel perforation was found in three patients. Seven patients underwent intestinal resection and anastomosis. Mean length of postoperative hospital stay was 10.4 days (4-20). There was no mortality. Conclusion: IH is a rare cause of small bowel obstruction in adults and often present with complications. A high index of suspicion may lead to early surgical intervention and reduce morbidity and mortality. Introduction: Esophageal perforation is a serious surgical condition in which delay for surgery results in high mortality. Application of covered stents is an alternative for emergency surgery. The aim of this study is to analyze the results of esophageal stent application retrospectively.

The clinical data and outcome of 6 patients diagnosed and treated for esophageal perforation by endoscopic stent application between February 2006 and December 2008 were evaluated. Results: The mean age of these 6 patients was 34 (18-62) and male to female ratio was 3/3. Causes of perforation was mediastinal abscess (n ¼ 1), metal stent application (n ¼ 1), and balloon dilatation (n ¼ 4). Stents were applied immediately after perforation in three patients. Remained three patients were referred from other institutions and the mean time of delay was 4 h (2-8). Perforations were at proximal (n ¼ 1) middle (n ¼ 1) and distal esophagus (n ¼ 4). Self expanding covered metal stents were applied in an appropriate position to bridge perforation area in a fashion to cover minimally 2 cm distal and proximal normal esophageal mucosa to all patients under fluoroscopic control. No contrast leak was observed immediately after application and 48 h later. Patients were interned and observed under intravenous fluid and antibiotic therapy. Except one patient developing transient subcutaneous emphysema no complication was observed. All perforations were closed and the stents were removed at the end of fourth week. Conclusion: At the early phase of esophageal perforations covered esophageal stent application can be a better alternative to surgery.

Introduction: Upper GI bleedings are serious conditions which may be life threatening. In seriously bleeding cases the failure of the endoscopic interventions makes surgical intervention necessary. The aim of this study is to present the success rate of endoscopic interventions for upper GI bleeding performed by surgeons. Methods: Clinical data and the outcome of endoscopic interventions made to 359 of 1,943 upper GI bleeding patients admitted to a large community hospitals single surgical endoscopy center between January 2002 and September 2008 were analyzed retrospectively. Results: Hemostasis with endoscopic interventions was achieved in 336 (95.7%) at initial (n ¼ 231) or at second endoscopy (n ¼ 105). 23 patients underwent emerging surgery. There was no mortality at the patients treated by endoscopic interventions where as seven patients died after surgery (30.4%).

Conclusion: The outcome of surgery is poor in upper GI bleeding. Thus maximum effort should be given to achieve homeostasis by endoscopy. The success rate of endoscopic interventions in this study performed by surgeons is extremely high and satisfying.

Naomi Beks, Mariëlle Van Gameren, Sander Ten Raa, Armand Van Kanten, Gert Roukema 1 1 Emergency Department, Maasstad Ziekenhuis, Rotterdam, the Netherlands Analgesia use at the emergency department, how evidence-based do we work when dealing with patient with acute abdominal pain? Based on a pilot at our emergency department we concluded that it is still common practice to withheld a patient with acute abdominal pain from analgesia till examined by a surgeon or resident. This in contrary to evidence presented in literature which show no negative effect of analgesia use on accuracy of diagnosis in patients with acute abdominal pain. A total of 280 inquiries were send to nurses, physicians and surgeons working at the emergency department of teaching hospitals in the Netherlands. We questioned their standard policy on analgesia use in acute abdominal pain. A total of 108 completed inquiries were retrieved, resulting in a response rate of 39%. There is a difference between the response of nurses and doctors, 70 versus 30%, respectively. Compared to nurses, doctors are more optimistic about the moment analgesia is given.

Remarkable is the result that 46% of patients do not receive any analgesia even after examination by a surgical resident and 25% of the patients have to wait till they are examined by a surgeon is outshining. Patients are still withheld from analgesia till a resident or surgeon examines them even though this is not evidence-based medicine. There is no consensus in the Netherlands on analgesia use in patients with acute abdominal pain in the emergency department setting. A national guideline for patients with acute abdominal pain is recommended.

Introduction and objectives: The benefits of laparoscopic appendectomy remain debated in literature.

Methods: This is a monocentric, retrospective study to evaluate the differences between open and laparoscopic appendectomy for length of hospital stay, wound infection, major complications. Retrospective surgical site infection rate evaluation has been possible only for in hospital stay, no further clinical data has been collected regarding outpatient follow-up.

Results: From January 2007 to October 2008 we reviewed 150 patients undergoing surgery for acute appendicitis. 67 patients underwent laparoscopic appendectomy (44.7%) (Group A), 83 patients open appendectomy (55.3%) (Group B). Two different surgical teams, one for laparoscopy and one for laparotomy, performed the procedures. Complicated (perforated or gangrenous) appendicitis were 16 in group A (23.9%) and 28 in group B (33.7%). Mean hospital stay group A was 5.4 days, 4.9 (p = n.s.) group B. Mean hospital stay in complicated appendicitis group (A + B) was 6.2 days, in uncomplicated (A + B) was 4.7 days (p < 0.05). Laparoscopic appendectomy was associated with lower wound infection rate (group A 4.5% vs. group B 14.5%) (p < 0.05). Infection rate in complicated appendicitis (A + B) was 18.2%, in uncomplicated cases (A + B) was 6.6% (p < 0.05). No mortality in both groups has been observed. One conversion in laparoscopic group was reported. No cases of deep surgical site infection have been observed. Conclusions: Laparoscopic appendectomy seems to be associated to a lower rate of wound infection. Length of hospital stay and rate of major complication seems to be related to gangrenous or perforated appendicitis and not to the surgical technique.

significantly lower on postoperative third and seventh day, respectively.

Conclusions: In this model of general peritonitis, MB significantly reduced adhesion formation. MB is blocking the TNF alpha early postoperative days. Early blocking of the activity of TNF-alpha after peritonitis resulted in lower rates of adhesion formation macroscopically. The TNF-alpha can be an important factor for postoperative adhesion formation. Results: Laparoscopic surgery was performed in 105 patients due to peptic ulcer perforation. Seventy-five patients (71%) underwent laparoscopic repair alone or laparoscopic repair with omentoplasty.

In the remaining 30 patients (29%), the procedure was converted to laparotomy. Amongst 75 (59 men /16 women) patients who were included into the study, the mean age was 38.8 (15-88) . In 19 patients (25%, 19/75) preoperative diagnosis was unclear and the patients were taken to operating theater due to acute abdomen. In all patients, but one, the duodenal defect was repaired by primary suturing; in one patient, simply intra-abdominal lavage and drainage were performed because the omentum was found to seal the defect. Omentoplasty was performed in 39 (52%) patients. One and two abdominal drains were used in 51 (68%) and 24 (32%), respectively. Mean hospital stay was 6.3 (3-20) days. Morbidity was 7% (n = 5). Early morbidity included bile leakage in three patients, postoperative intra-abdominal bleeding in one. One patient had trocar site hernia. One patient (88-year-old female) died on postoperative day 2 due to sepsis in the intensive care unit. Conclusion: Laparoscopic primary repair is a safe and efficient method in peptic ulcer perforation.

Akın Tarım, Sedat Yıldırım, Cem Aydogan, Gö khan Moray, Mehmet Haberal 1 1 Department of General Surgery, Baş kent University, Ankara, Turkey

Introduction: Approximately 5% of multiple trauma patients sustain concomitant burns. Complicated management issues arise in these patients as burn and trauma care often conflict. The purpose of this study was to describe the different types of burn injuries seen in burn patients with additional forms of trauma, and to report the survival rate for this patient group.

Methods: In this retrospective study, 67 patients were admitted to our center with concomitant burns and trauma from 2000-2008. This study retrospectively analyzed the types of burn injury, extent of burns, types of other trauma associated with the burns, and outcomes. Results: Of this study group, 65 were male. Average age was 30.5 ± 13.0. Mechanisms included 8 motor vehicle collisions, 18 electrocutions with subsequent falls, one plane crashes, 23 LPG or oxygen tube explosions and 17 other type of explosions. Average burn size was 24.4 ± 21.7%. The most common traumatic injury was fracture and head injury (44). Management of fractures in burn patients and resuscitation in head injured burn patient represented the most common conflicts in patient care. There were 22 deaths in this series. Conclusion: Burns are a rare but significant complication in the trauma patient. Outcomes are dependent on rapid trauma evaluation as well as effective resuscitation and wound management. Given the complexities of their problems, these patients necessitate a balanced multidisciplinary approach to maximize their potential for full recovery. Thoughtful compromise between trauma and burn priorities is frequently necessary. Introduction: Fournier's Gangrene (FG) is a rapidly progressive, polymicrobial, synergistic necrotizing fasciitis. In this study we aimed to determine the risk factors effective on the prognosis of the disease. Methods: The files of 18 consecutive patients operated for FG during 2003-2007 were investigated retrospectively. The surviving and mortal groups of patients were compared for demographic data, etiological factors and treatment modality besides length of hospital stay and treatment cost. Results: The mean age of the patients was 54.5 years and female/ male ratio was 6/12. Mortality was seen in 6 (33.3) patients and significantly high in female (66.6%) (p = 0.035). The most frequent comorbid disease was diabetes (39.2%), etiological factor was perianal abscess (55.6%) and etiological source was anorectal region (61.1%); and they did not affect the mortality. The most frequent cultivated microorganism E.coli (66.6%) was significantly high in the mortal group (p = 0.012). Imipenem was the antibiotic used in all of the patients. The mean number of debridements was 4,67 and intestinal diversion was utilized for 22.2% of the patients. Fecal decontamination (38.8%) of the patients was performed by surgical (4) and nonsurgical (3) methods. The length of hospital stay in surviving group (34.17 days) was higher than the mortal group (10.50 days) (p = 0.002). There was no difference between two groups of patients for the length of hospital stay (p > 0.05). Conclusion: Female gender, duration of complaint prior to treatment, fournier gangrene severity point and cultivated microorganism (E.coli) were the factors affecting the mortality.

Aim: Post-traumatic coronary aneurysms (PTCA) are extremely rare. We report an asymptomatic PTCA in a young patient. Case: 26-year-old male, with no significant previous history. Admitted intubated and ventilated after a car runover. He had cerebral, thoracic, abdominal, pelvic and lower extremity trauma. Initial assessment disclosed eight left fractured ribs with associated pneumothorax; FAST was negative, head CT normal. Thoracic CT reveled small bilateral hemothoraces and pulmonary contusion, with no evidence of vascular lesions. He also had a fibular, clavicle, and pelvis fracture. Control angio-CT at day 40 showed pleural and pericardial effusions and raised the suspicion of left descending PTCA, subsequently confirmed with MRI. The patient remained asymptomatic with normal EKG and cardiac enzymes throughout this period. A coronariogram confirmed the PTCA, that had undergone spontaneous thrombosis, with no further treatment required. Discussion: Coronary aneurysms (true or false) may occur after blunt thoracic trauma. PTCA normally result from controlled rupture post myocardial infarction or cardiac contusion, with gradual wall rupture. Although in this patient the diagnosis was made without any clinical manifestation, suspicion is the main key for diagnosis. Aneurysms must be considered as a differential diagnosis in patients with thoracic trauma history associated with arterial emboli, congestive heart failure, arrhythmia, chest pain or dyspnea. Conclusion: Every trauma victim must be exhaustively evaluated. In any case a careful follow-up must be made in thoracic and abdominal trauma victims to decrease the possibility of missing injuries. Aim: Acute mesenteric ischemia (AIM) continues to be highly morbid cause of emergency. Early diagnosis and treatment may reduce severity of the disease. The aim of this study is to investigate causes for morbidity and mortality in AMI patients. Materials and methods: This retrospective study has 76 patients of AMI. The patients were classified according to their age, sex, clinical and laboratory findings, comorbidity, etiology, operative procedures, complications. And effect of these causes on mortality and survival was investigated. The results were statistically evaluated. Results: Of 76 patients 45 were male and 31 were female. Mean age was 64.3 for females and 62.1 for males. The most common symptom was abdominal pain. Only one third of patients had diagnosed correctly before operation. Amylase was high in 73% of patients. Plain abdominal graphy showed air-fluid levels in all patients. Mortality rate was high in patients aging over 60 years (p < 0.001). There were no relationship between mortality and gender. The patients those who had massive small bowel and colon resection developed high mortality rates (66%). Resection of ileocaecal valve also increased the mortality. Five patients all of whom developed perforation died. Majority of survivors had surgical intervention during first 24 h of ischemic attack. The patients those died due to perforation had delayed surgical intervention.

• There is no benefit of routine laboratory findings in early diagnosis of AMI.

• Massive intestinal resection, absence of ileocaecal valve and stomal procedure increased mortality rate. • Delay in diagnosis and treatment also caused high mortality.

Cem Aydogan 1 , Yahya Ekici 1 , Ebru Sakallıoglu 2 , Sedat Belli 1 , Mahir Kırnap 1 , Emin Tü rk 1 , Mehmet Haberal 1 1 Department of Generel Surgery, Baş kent University, Ankra, Turkey 2 Institute of Burn, Fire and Natural Disaster, Baş kent University, Ankara, Turkey

Introduction: More than 95% of all burn patients can be managed on an ambulatory basis. Appropriate management of minor burns minimizes further damage. Methods: The epidemiology, demographics, and outcomes of 611 ambulatory acute burn patients were reviewed at our center between 2003 and 2008. Patients who were in ABA referral criteria were excluded from the study.

Results: The patients' mean age was 30.25 ± 1.13 years (range, 1-85 years) . The percentage of patients whose first admission was to our center was 42.9%; the percentage of those referred from another center was 57.1%. Scald burns were the most frequently reported cause of burns (64.4%). The house was the most frequently reported place at which the burns occurred (88.3%). The percentage of stoverelated burns was 10.7%. The upper extremities (59%) and lower extremities (20%) were the most frequently reported places on which the burns occurred. Mean TBSA affected and superficial partial thickness burned area were 3.1 ± 0.09% and 2.07 ± 0.06%. The mean follow-up and the mean number of dressings applied to the burns were 7.54 ± 0.11 days (range 3-16 days) and 4.05 ± 0.05 (range 2-9). Four patients (0.65%) needed skin grafting, and two patients (0.32%) were hospitalized for debridement without grafting.

Conclusions: Close follow-up is important in minor burns to minimize further damage. Burn centers must play an active role in the care of all burns. The devastating effects of burns can be prevented and decreased by educational programs. Stove-related burns remain a problem in Turkey.

Results: Mean age was 26.25 ± 1.05 years. The percentage of the male patients was 89.5%. The mean TBSA affected was 27.85 ± 1.44%. The percentages of high voltage electricity injury, lightning injury, and lowvoltage current injury were 63.7, 25.8, and 10.5%, respectively. Place of employments (47.3%) and outdoors (33.9%) were the most frequently reported places at which the burns occurred. The burns mostly occurred in urban areas (70.4%).Upper and lower extremities were the most frequently affected regions. The percentages of the patients who underwent debridement, grafting, amputation and fasciotomy were 61.6, 54.2, 18.4, and 10,1%, respectively. The percentage of patients who had additional trauma other than electric burn injury was 10.5%. Mean hospital stay of patients was 29.31 ± 1.72 days. The mortality rate was 11.1%. Majority of the patients died from septic complications (50.1%) Conclusion: Aggressive multidisciplinary treatment modalities and early debridment, grafting and/or flaps are very important. Special considerations are required for public education about electricity and its hazardous effects. Governmental supports are needed both in prevention and in therapy.

Ahmet Erkilic, Harun Analay, Sabri Mehmet Barazi, Halil Ç eliksö z, Bayram Rü zgar 1 1 Burn Center, Av.Cengiz Gö kçek General Hospital, Gaziantep, Turkey

Early staged excision and autogenous skin grafting or temporarily wound coverage with biologic dressing or allograft until autogenous donor sites are available is now conventional treatment for fullthickness burns. Typically, tangential excision is performed with a handheld knife thus it may be difficult to control bleeding from the wound bed and difficult to assess the suitability of underlying for accepting a graft. A hydrosurgery system -Versajet Ò is available that can be used for tangential burn wound excision. This device offers an easy and more precise way of excising eschar and is particularly useful excising nonviable tissue from the concave surfaces of hands and feet, as well as the eyelids and ears. Totally, 134 hydrosurgical tangential excision (HTE) were performed for 107 patients with burn, in our Burn Center in one and half year. Several times performing were needed 27.1% of patients (n = 29). Wounds of patients with 10-15% total burned body surface were covered autogenous skin grafts subsequent to HTE. More extensive wounds were covered with biologic dressings temporarily and wounds as soon as suitable autogenous skin grafting was performed. At this interval, burn wounds were shrunk average 20-30% and donor skin poverty was increased. Frequently, delaying to excision and coverage of burn wounds may be awful. Early excision and early coverage of the burn wounds must be a golden standard for the current treatment of the burns. Also HTE is becoming a candidate to golden standard at burn treatment. Introduction: In our previous study, we examined the treatment results of burn patients older than 45 years, and found a significant increase in mortality with increasing age groups. The aim of the present study was to reevaluate this patient group and also compare these results with the previous study period of 1979 to 1998. Patients and Methods: One-hundred and fifteen patients older than 45 years were admitted to our burn unit during the last 10 years. These patients were divided to three groups with respect to their ages (Group A: 45-60 years, Group B: 61-59 years, and Group C: older than 70 years). Demographic properties of patients, etiology, and extend of burn injury, co-morbidity, length of hospital stay, and mortality rates were recorded. Results: During the last 10 years, demographic properties and etiology of burn injury did not changed significantly. However overall survival rate increased from 51.3 to 82% and LD 50 values for burn injury are significantly increased in all age groups. Length of hospital stay is significantly decreased in all age groups, especially in Group B (from 60.7 to 26.5 days). Co-morbidities did not change over time and sepsis is the leading cause of death in 16 patients (80%). Conclusion: In our burn unit, treatment results in patients older than 45 years showed a significant improvement during the last 10 years.

Introduction and objectives: Patients who has weakness of mental and motor functions are under more risk than normal burned injured population. We would like to focus on burn injured cases that have co-exiting morbidities. Methods: Comorbid 15 patients who applied to burn unit due to burn between January 2008 and July 2008 were taken into evaluation. Comorbid etiologies were seizures (7 case), mental retardation (5 case) and Down syndrome (3 case), respectively. Results: During follow-up period, one of the cases had aggrevated petit mal convulsion due to devastating effect of burn injury. In one case there was grade 1 pressure sore and urethral infection who was paraplegic patient. Weight loss was observed on a geriatric case that had seizure due to insufficient nutrition. Conclusion: Burn injured cases that have comorbidity, special care, and additional measures should be taken. Psychological, neurological or geriatric causes are the factors that affect the recovery of burn defects and success of operation. Detailed evaluation of coexisting disorder and additional care are the key points of the comorbid burn patient.

Aim: The present study was aimed to evaluate the gender differences of burned children in clinical course and outcome. Methods: Children (aged 0-15) admitted to our burn center between August 2008 and January 2009 were retrospectively evaluated. Total burn surface area (TBSA), levels of some acute phase markers, grafting need, and hospitalization time were analyzed. Results: Sixty three patients [45 (71.4%) males, 18 (28.6%) females] were included in this study. The mean age was respectively 2.41 ± 1.52 years and 3.06 ± 1.29 years in males and females (p = 0.117). The mean TBSA burned respectively 14.31 ± 7.32% and 16.11 ± 2.32% in males and females (p = 0.312). The mean WBC count in admission was significantly higher in males than females (17.6 ± 8.9 x 10 -9 /L vs. 12.6 ± 1.59 x 10 -9 /L, p < 0.05), but there was not any significant difference between females and males in CRP count. (p = 0.76). Skin graft operation was performed in 14 (31.1%) of males and in 7 (38.9%) of females (p = 0.554) and also, we did not find any significant difference between males and females in hospitalization time (11.5 ± 9.8 days vs. 12.6 ± 7.7 days, p = 0.689).

Conclusion: Although many studies have showed that critically ill females have a better outcome than critically ill males, any significant difference was not observed between burned male children and burned female children in most of the clinical parameters, except white blood cell counts.

Introduction and objectives: The goal of our study was to evaluate the preparedness of hospital physicians, Emergency physicians and Paramedics in the EU and the USA for a mass casualty incident. Methods: An online survey which contained 16 questions was sent to the head of the department of Trauma-surgery, Emergency Medicine and to Paramedics by e-mail. Among other things we questioned: existence of a hospital emergency-and disaster plan and the yearly exercise of the Plan. Coordination with the local rescue service as well as existence of decontamination facilities were asked for. Replies were analysed statistically with the one-way analysis of Variance (ANOVA) test and the Turkey-Kramer Multiple Comparisons test.

Results: Altogether, 238 assistant and emergency doctors as well as Paramedics answered. 30% were not conscious of the details of the disaster plan of her hospital while 14% did not know the plan at all. 35% of the interviewed doctors did not know her area of responsibility in the case of an internal emergency. 85% of the interviewed know what to do in case of an MCI. 30% of the interviewed doctors and 55% of the paramedics did not know her area of responsibility at the treatment of patients contaminated chemically, nuclearly or biologically.

Conclusions: The preparedness for doctors and paramedics in hospitals and in the preclinical rescue service in the EU and the USA on a MCI (mass casualty incident) are insufficient. The emergency medical education of doctors and paramedics should be adapted to the terrorist threats DISASTER 84 Preparedness of Chief Physicians and Hospitals In Germany, The EU and the USA for a Mass Casualty Incident

Introduction and objectives: The goal of our study was to evaluate the preparedness of hospitals in the EU and the USA for a mass casualty incident.

Methods: An online survey which contained 16 questions was sent to the Chief Physician of Hospitals by e-mail. Things we questioned: existence of a hospital disaster plan and the yearly exercise. Coordination with the local rescue service as well as existence of decontamination facilities. Replies were analysed statistically. Results: Altogether, 117 senior consultants, of this 72 senior consultants from Germany as well as 45 senior consultants from the USA and the EU, answered. All people claimed to have a hospital disaster plan. 65% of the German hospitals made an exercise of the plan with tabletop exercises. However, 92% of Chief Physicians in the USA and the EU made an exercise of the plan regularly with table top exercises. 84% of the hospitals in the BRD did not have any decontamination possibility of NBC (nuclear, biological, chemical) contaminated patients, while 70% of the hospitals had this possibility on the spot in the EU and the USA.

Conclusions: The exercise of the hospital disaster plan in Germany is insufficient, compared with the hospitals in the EU and the USA. Furthermore the German hospitals are badly equipped in the worldwide comparison to decontaminate patients on the spot. We demand for an increase of the ''Exercises'' of the hospital disaster plan (also by tabletop exercises) as well as an improved equipment for the decontamination of the injured. In the two big earthquakes that occurred in the North-west of Turkey in 1999 in short intervals within less than 3 months there were approximately 20,000 cases of death and around 100,000 were injured. There were several other deadly earthquakes in the whole world the same year. Main survival factors in the post-disaster period are prevention from injuries as well as detecting the location of the survivors and the rescued. The reality of the situation of persons who lost their lives in such traps, the severely injured, and the ones who survived must be analyzed. Rational prevention methods against possible crush injuries due to collapsing buildings have been con-sidered in the light of the field and simulation experience we gained and suggestions have been presented to reduce mortality and morbidity. Our work has been conducted with the aid of medicine based on proof, appropriate observation as well as sampling and experimental methods. A global approach concerning worst case scenario led by earthquakes has been proposed taking into consideration the different models of behavior in different countries and societies to increase the chance of survival to a maximum and to reduce injuries to a minimum level. Due to unlimited possibilities of travelling nowadays, it is not possible to estimate the place, the country or the circumstances under which a person could experience a disaster.

Carlos Alberto Godinho Cordeiro Mesquita 1 1 Ordem dos Mé dicos, Colé gio de Competê ncia em Emergê ncia Mé dica, Lisbon, Portugal

In Portugal there are three official ways to differentiate: specialty (vertical), subspecialty (vertical) and competence (transversal). Doctors may access to a subspecialty or a competence as a second step, after a specialty. Portuguese Medical Association (Ordem dos Mé dicos, OM) is the official entity that regulates all the medical and surgical activities in Portugal, being his duty to protect the public interest. Doctors must be registered with to practise medicine or surgery. OM also sets the standards and outcomes for basic medical education. After graduating from medical school and completing their foundation training, doctors usually complete a third and even a fourth stage of postgraduate training, whose standards are set by the colleges. These are responsible for promoting the development of postgraduate medical education and training for all, establishing standards and requirements and making sure they are met across the country. Emergency medicine exists as a competence since 2002 and goes behind the prehospital acute care. This College is strongly interested in the development of an autonomous College of Competence on Emergency Surgery (trauma surgery included) and it exists, since 2007, an official national Working Group on Emergency Surgery Education (Grupo de Trabalho para a Formaçã o Específica em Cirurgia de Emergê ncia), with 13 representatives of general surgery (7), neurosurgery (1), orthopaedics (1), thoracic (1), vascular (1) , urological (1) and paediatric surgery (1) . The general surgeons, IATSIC members and DSTC instructors, also integrate and lead the National Steering Committee for DSTC, after a recently signed memorandum of understanding. Author to editor: The point of the situation, from an organisational point of view, about trauma and emergency surgery education in Portugal and the importance for the relationship with portuguese speaking doctors around the world Introduction and objectives: Practical Training in emergency medicine should be an important part of undergraduate education, as every physician should be able to handle medical emergencies. However, adequate practical training is time and personal consuming. This work seeks to determine whether medical students (peer to peer education) can be trained as course instructors in emergency medicine training and if there are differences in the training outcome.

Methods: The undergraduate training consists of both basic life support (BLS) and advanced cardiac life support (ACLS) courses. After both courses, students have to pass a Multiple Choice test and have to complete a course evaluation. During the instructor training, all candidates, students and physicians were trained together with theoretical and practical training and were furthermore supervised during their first courses.

Results: Until now, 210 BLS and 185 ACLS trainings were conducted of which 71% (BLS) and 52% (ACLS) were run by medical students. There were no significant differences in the written examinations nor in the course evaluations (1 = very good to 6 = unsatisfactory) between courses by staff (1.38 for BLS and 1.10 for ACLS) or medical students as trainers (1.34 for BLS and 1.17 for ACLS, respectively).

Conclusions: Peer to peer education can be a useful tool in the manpower consuming practical training in emergency medicine without influencing the learning outcomes or the evaluation. Background: Non-invasive pelvic ring stabilization (pelvic binding, PB) in shocked patients is recommended by state and institutional guidelines regardless the fracture pattern. The purpose of this study was to determine the adherence to the guidelines, radiological efficacy of the technique, and identification of potential adverse effects associated. Methods: Analysis of the prospective database of a level 1 trauma center on high-energy unstable pelvic fractures. Collected data included patient demographics, physiology, fracture classification, application, and timing of PB, associated injuries and outcomes. Pre and post-PB radiographs were compared to evaluate the changes in fracture position. The potential effects of PB on soft tissue complications were assessed by independent experts. Results: During the 41-month study period a total of 43 PB was performed on 115 patients with high-energy unstable pelvic ring injuries. Stable patients were less likely to get PB (32%) than shocked patients (50%). The adherence to guidelines was 50%. Analyzing fracture types (AO/OTA classification) of shocked patients the adherence was: B1 80%, B2 20%, B3 20%, C1 66%, C2 86%, C3 33%. Better radiological appearance was detected in B1 100%, C1 80%, C2 83%, C3 100% types. One femoral artery, four bladder and three rectum injuries were identified in patients with PB applied. There were no association between the complications and the PB.

Introduction and objectives: In our country, the vast majority of circumsicion is stil not done by physicians. In this study, we evaluated the patients who treated for circumsicion complications in our clinic.

Methods: A total of 27 children who treated for cicumsicion complication in our clinic between 2005 and 2007 were evaluated. Results: Mean age during circumsicion was 19.5 months (5-7 years). 26 out of 27 had not been circumsiced by physicians. Complication was bleeding in 16 patients, burred penis in 7, complete glanular amputation in 3, and urethral fistula in 1 patient. One suture was enough to control bleeding for the majority of patients with this complications, while general anesthesia required for treating other complications.

Conclusions: Significant number of children still undergo circumsicion between 2 and 7 years old (fallic period) in our country. The vast majority of complications occur when circumsicion is not done by physicians; significant number of these complications require revision under general anesthesia. As a result, circumsicion is still a challenging both public and social problem in our country, and results in high morbidity because the majority is not done by experienced hand.

Arda Demirkan 1 , Salih Ekinci 1 , Onur Polat 1 , Serdar Gü rler 1 , Mü ge Gü nalp 1 , Semih Baskan 2 1 Department of Emergency, Ankara University, Ankara, Turkey 2 Department of General Surgery, Ankara University, Ankara, Turkey

Objective: Multiple trauma involves at least two systems of body which abdomen, extremities, chest and head-neck. The aim of this study is to show relationship between the severity of injury and electrolyte changes in multiple trauma patients.

Method: This is a prospective study which 45 adult multiple trauma patients (30 male and 15 female) were studied. The median age was 41.68 (range 16-87) . In all cases, serum sodium, potassium and calcium levels and Injury Severity Score (ISS) were obtained on admission to emergency department after trauma. Severity of injury was estimated with ISS. Degree of association between variables was evaluated by Spearman's Correlation Coefficient test.

Results: The mean sodium levels was 139.02 mmol/L, the mean potassium levels was 4.61 mmol/L, the mean calcium levels was 9 mg/ dL. There was a negative correlation between calcium and ISS, and this is statistically significant (p = 0.006). While other serum electrolytes (sodium and potassium) did not change according to ISS. Conclusion: Electrolyte abnormalities often occurs in critical ill patients, this imbalance has a prognostic importance particularly in multiple trauma patients. Electrolyte changes determinated in early period and appropriate resuscitation is indispensable. We suggest that low calcium levels can be considered for the severe injury. This condition may be related to interrupted calcium mechanism in critical trauma patients. Introduction and Objectives: Preparation is essential to meet the challenge of optimal care for a sudden unexpected surge of casualties due to a major incident. By definition, requirements exceed standard care facilities in qualitative and or quantitative respect and interfere with regular patient care. To meet the growing demand for disasterpreparedness a permanent facility to provide structured, prepared relief in such situations was developed. We describe this facility. Objectives: The aim of this study is to find out the effects of melatonin on the erythrocyte and kidney malodyaldehyde (MDA) and superoxide dismutase (SOD) levels in radiocontrast nephropathy. Methods: In this study, 24 New Zealand type rabbits were included. The test subjects were divided into four groups six rabbits in each (control, sham, hydration and melatonin groups). Blood samples of all subjects were taken in beginning of study. Renal tissue was obtained in the control group. The rest received 10 ml Diatrizoat sodium intravenously. Hydration group was given 10 ml/kg/day IV bolus 0.09% NaCl. Melatonin group was given 10 mg/kg IV melatonin four times with the same dose isotonic. It was blood and renal tissue samples were taken at the 48th and 72nd hours. MDA levels were determined with Ohkawa method, SOD enzyme activity was studied with RANSOD (Randox,UK) superoxide dismutase assay kit. Results: The mean renal SOD value of the melatonin group (1786.9 ± 188.1 nmol/g) was significantly higher than in the sham (1211.3 ± 163.7 nmol/g), control (1420.7 ± 373.2 nmol/g) and hydration groups (1492.1 ± 166.1 nmol/g) (respectively p = 0.012, 0.031, 0.029). The mean renal MDA value of melatonin group (43.1 ± 7.8 nmol/g) was significantly lower than sham (67.2 ± 6.9 nmol/g) and hydration groups (59.5 ± 8.4 nmol/g) (p = 0.012, 0.048 respectively).

Conclusion: Melatonin has a curative effect on the lipid peroxidation caused by the contrast substance in the kidney. In preventing nephropathy resulting from contrast substance, giving melatonin together with hydration can be more effective than giving hydration alone in the clinic. In addition, all datasets entered with voice recognition were complete and available in the system as soon as the patient left the trauma bay. Compared to the retrospective cohort 37% of the patients had incomplete data concerning the vital parameters. Conclusion: The introduction of voice recognition technology real time produces more accurate data more quickly. We are convinced that high tech technology will increasingly assist the trauma surgeon and if we are correct it looks like the prediction of Don Trunkey will come true viz: ''the current possibilities for using digital resources within medical care are merely limited by our own imagination''

Introduction and aims: Despite the improvements in the diagnosis and treatment, mortality rates are still high following urgent operation for perforated peptic ulcer (PPU). In this study, we analyzed the factors affecting the survival of the patients operated for PPU. Materials and methods: The records of the 147 patients operated due to PPU between January 1997 and January 2007 were analyzed. Age, sex, American Society of Anesthesiology (ASA) score, alcohol consumption, smoking, nonsteroidal antiinflammatory drug (NSAID) usage, the time passed from the onset of symptoms to operation, history of previous peptic ulcer disease, diameter and localisation of the ulcer, surgical technique, length of stay, postoperative complications and mortality rates were determined. Results: The mean age was 51 and ASA score was 2. Primary suture and omentoplasty was the selected procedure in 80 patients while gastrostomy was added to primary suture to another 31 patients. Twenty nine patients received primary suture, truncal vagotomy and gastroenterostomy and seven underwent resection. The mean length of stay was 7 days. Three patients suffered from atelectasis and pneumonia, one from empyema, eight from surgical site infection and four from leakage. Twenty three of the patients experienced respiratory failure and 10 died of multi organ deficiency (6.8%). Age and ASA score were found as factors significantly affecting survival. Abdominal cocoon (idiopatic sclerosing encapsulating peritonitis) is a rare disease of the peritoneum which refers to a condition where there is a total or partial encasement of the small bowel by a dense fibrous membrane. The abdominal cocoon is probably a developmental abnormality, largely asymptomatic, and is found incidentally at laparotomy or autopsy. It is an unusual cause of intestinal obstruction. Pre-operative diagnosis cannot be often made correctly. Complete recovery is expected after removal of the membrane surgically.

A 39-year-old man presented with abdominal pain, swelling and vomiting of two day's duration. There was no history of peritonitis, abdominal surgery or tuberculosis. Physical examination of the abdomen revealed a distended abdomen, hypoactive bowel sounds, tenderness and rigidity in the whole abdomen. A tender lump was palpated in the right lower quadrant. Routine laboratory workup revealed a total leukocyte count of 17030 cells/ml, and normal serum chemistry. PA X-ray of the chest normal. Plain abdominal X-ray showed few air-fluid levels. Contrast-enhanced abdomen-pelvis computed tomography showed a dilatation up to 4.5 cm in small intestine. Emergency laparotomy was performed through a right paramedian incision. In exploration, small bowel was observed to be dilated, its mesentery was edematous and the whole small and large bowel was covered by a dense whitish and approximately 2 mm thick membrane. The membrane was partially removed, and adhesiolisis of the intestinal loops was performed without bowel resection. After surgery, the patient was tolerated diet without any complication and was discharged, on hospital day 7. Methods: The data of Al-Ain Hospital Trauma Registry were prospectively collected over a period of 3 years (2003) (2004) (2005) (2006) . All trauma patients who were admitted to Intensive Care Unit (ICU) were included in the study. Univariate analysis was used to compare gender, age, nationality, mechanism of injury, systolic blood pressure and GCS on arrival, the need for ventilation, presence of head or chest injuries, AIS for both the chest and head injuries and the ISS. Significant factors were then entered into a direct logistic regression. Results: There were 202 patients (181 males). Mean (range) age was 30 year. 22.8% were UAE nationals. The two most common mechanisms of injury were road traffic collisions (62.9%) followed by fall from height (14.4%). The median (range) ISS was 17 . The mean (SD) ICU stay was 5.7 (6.7) days while the mean (SD) hospital stay was 17.7 (22). The overall mortality was 13.4%. Significant factors that have affected mortality included GCS (p < 0.0001), Mechanism of injury (p = 0.004), age (p = 0.004) and ISS (p = 0.02). The best GCS that predicted mortality was 5.5 while the best ISS that predicted mortality was 13.5 Conclusions: RTA is the most common cause of serious trauma in UAE followed by falls. GCS is the most significant factor that predicted mortality in ICU trauma patients. Introduction: Glutamine is an antioxidant which enhance glutathione levels. In this study our goal is to assess the safety and efficacy of parenteral glutamine on antioxidant capacity and organ dysfunction in septic patients. Methods: Prospective, randomized study of the septic patients admitted to the surgical intensive care unit (ICU). Patients were randomized to receive either glutamine (Group GLU, n = 12) or glutamine + N-acetylcysteine (group NAC, n = 11) or a control supplement-placebo (group PLA, n = 10) parenterally up to 10 days. Organ dysfunction and clinical outcomes were assessed by daily total Sequential Organ Failure Assessment (SOFA) score over the 10-day study period. Serum total antioxidant capacity (TAC) was measured by CUPRAC method. Also we evaluated procalcitonin (PRC) and C-reactive protein (CRP) levels as infection markers on days 0, 3, 6, and 10. Results: There was no significant differences between the patients' ages, APACHE II, SOFA scores and infection markers on the day of admission. Group GLU and NAC showed a significant decline of daily total SOFA score (GLU: p < 0.05, NAC: p < 0.001, PLA: p = 0.05) and CRP levels (GLU: p < 0.05, NAC: p < 0.001, PLA: p < 0.05). But PRC levels decreased significantly over time just in group GLU (GLU: p < 0.001, NAC: p = 0.2, PLA: p = 0.05). On the other hand, serum TAC measurements were not significant. The mean ICU length of stay were GLU: 29 ± 19.2, NAC: 12.4 ± 6.7, PLA: 12.5 ± 8.7 (GLU/NAC: p < 0.05, GLU/PLA: p < 0.05), but in group GLU the overall mortality was significantly lower than NAC and PLA groups (GLU: 25%, NAC: 45%, PLA: 40%). Conclusion: In septic patients, parenteral supplementation with glutamine results in significantly better recovery of organ function compared with NAC and PLA. We coud not find any significant relationship between TAC levels and clinical outcomes.

Background: Acute renal failure (ARF) requiring renal replacement therapy in ICU setting is related to high mortality. The purpose of the study is to assess any indicators of improved survival. Materıal and methods: Retrospective study of 64 trauma patients, who underwent haemodialysis over a period of 5 years (patients with penetrating, blunt trauma and burns). Information on pre-hospital and in-hospital resuscitation, trauma scores and physiological scores and daily ICU records were collected. The majority of patients were initially dialysed with CVVHD and later on with SLED. Results: Of the 64 patients, 47 died and overall mortality was 73.4%. This was highest in the group of burn patients (84%). Survival in all patients irrespective of mechanism of injury was unrelated to RTS, ISS, APACHE II and TRISS. The duration of haemodialysis be-tween the three different trauma mechanism groups was not significantly different. Age is not a significant predictor of survival. Patients with polyuria at time of initiation of haemodialysis had not a better outcome than those who were oliguric/anuric/normouric. Conclusions: ARF in trauma patients has a low survival rate. Controversial conclusions have been presented in the literature. In our study, none of the parameters reported in previous publications to affect survival was proven as correct, although our number of patients was comparable to that of other studies. As we are still at an early stage of understanding the predictors and the behaviour of renal failure in the trauma patients there is a need for the planning multicentric prospective studies. Weaning from mechanical ventilation constitutes a dynamic process, and represents one of the most challenging decisions in the management of critically ill patients. Success of weaning depends on multiple factors, and wrong decisions result either in prolonged mechanical ventilation, or reintubation and nosocomial pneumonia. Many mathematical indexes have been described and used for decision making with varying successes. We have developed a multiparameter fuzzy-logic decision support system for prediction of success of weaning from mechanical ventilator. After fuzzifying relevant numerical variables, this system evaluates the appropriateness of perfusion, arterial blood gases, mechanical properties, and gas exchange, and converts these to a weaning probability. System has been designed using jFuzzyLogic package and uses Mamdani center of gravity algorithm for defuzzification.

After optimization system has been tested over a software that creates random clinical scenarios within a range that can represent challenging patients. For each scenario Jabour' weaning index, rapid shallow breathing index (RSBI) and pressure time index have also been calculated and compared with fuzzy-logic system. Results indicate that currently used indexes and especially RSBI, disregard many important parameters and shown a potential to fail in many critical scenarios (in 52% of simulations). Additionally we would like to discuss the potential of fuzzy-logic in clinical decision support, and design and optimization issues. Trauma scoring systems used for uniform reporting and evaluation of trauma outcomes include physiologic, anatomic and combined systems. These systems have already been evaluated and shown to have accurate performance. We proposed a possible effect of response to resuscitation on the performance of trauma scoring. Data necessary for calculation of ISS, RTS, TRISS and ASCOT systems have been retrospectively collected from the records of last 150 consecutive trauma patients admitted to our surgical critical care unit. Score and mortality prediction calculations have been performed over a software developed in our department, at three time points, at admission to ER, after 1 h of resuscitation, and at ICU admission. Additionally a fuzzy-logic inference system which uses physiologic variables as input has been designed for trauma related mortality prediction and applied to the same dataset. Performances of scoring systems and fuzzy-logic inference system have been evaluated. Results indicated that all systems have good discrimination, but variable calibration characteristics. For all systems evaluated response to resuscitation has effected system performance and scores and predicted mortality values calculated after resuscitation have shown better discrimination. Fuzzy-logic inference system designed has shown discrimination characteristics comparable but not better then the other systems, which indicate the importance of inclusion of specific organ injuries in trauma scoring and mortality prediction. Daily monitoring of immune/inflammatory status is a fundamental procedure in the ICU. In small animal disease models such a surveillance is challenging given the limited blood volume available.

To validate a new method for daily immuno-inflammatory monitoring in critically ill (septic) mice, we followed their short/longterm survival, organ function and inflammatory status. Furthermore, the reliability of complete blood count (CBC) differential was tested in re-suspended blood cell pellet. Female OF-1 and CD-1 mice were subjected to cecal ligation and puncture (CLP). 20 ll blood samples were collected (facial vein puncture) from half of each strain daily for 5 days or on day 5 only. Additionally, 35 ll (diluted 1:10) volume was collected (OF-1 only) and divided to compare CBCs in whole versus resuspended blood. There were no differences in 5/28-day CLP mortality. For both strains, changes in circulating interleukin-6 and chemical parameters (ALT, LDH, BUN, glucose) were comparable between sampled subgroups. 20 ll sampling in OF-1 mice caused a decrease of 10% in RBC and 11% in Hb (both p < 0.05). In CD-1 animals, both RBC and Hb showed a similar decrease of 13% (p > 0.05). Platelet and WBC counts were unaffected. CBC comparison displayed a high correlation for all cell types (r > 0.9, slope > 0.9) except lymphocytes (r > 0.5,slope > 0.6). This was reproduced in non-CLP mice. The results indicate the minimal biological effect of daily sampling upon septic mice. CBC differential from resuspended pellet is highly reliable. This newly validated facial vein punture sampling protocol allows multi-directional monitoring in mouse models of critical illness such as acute peritonitis.

Introduction: A comparison of the amount of procalcitonin (PCT) with that of C-reactive protein (CRP) during various types of and severities of multiple trauma., and their relation to trauma-related complications, was performed. The aim of this study was to describe the amount of and the time course of PCT and CRP induction in patients with various types of and severities of high-velocity trauma. Background: To provide a score to predict the risk of early mortality after single craniocerebral gunshot wound (GSW) based on three clinical parameters. Methods: All patients admitted to Baragwanath Hospital, Johannesburg, South Africa, between October 2000 and May 2005 for an isolated single craniocerebral GSW were retrospectively evaluated for the documentation of (a) blood pressure on admission, (b) inspection of the bullet entry and exit site, and (c) initial consciousness (n = 214). Results: Conscious GSW victims had an early mortality risk of 8.3%, unconscious patients a more than fourfold higher risk (39.2%).

Patients with a systolic blood pressure between 100 and 199 mmHg had a 18.2% risk of mortality. Hypotension (< 100 mmHg) doubled this risk (37.7%) and severe hypertension ( 3 200 mmHg) was associated with an even higher mortality rate of 57.1%. Patients without brain spilling out of the wound (''non-oozer'') exhibited a mortality of 19.7%, whereas it was twice as high (43.3%) in patients with brain spill (''oozer''). By logistic regression a prognostic index (PI) for each variant of the evaluated parameters could be established: non-oozer: 0, oozer: 1, conscious: 0, unconscious: 2, 100£RRsys < 200 mmHg: 0, RRsys < 100 mmHg: 1, RRsys 3 200 mmHg: 2. This resulted in a score (0-5), by which the individual risk of early mortality after GSW can be anticipated.

Conclusions: Three immediately obtainable clinical parameters were evaluated and a score for predicting the risk of early mortality after a single craniocerebral GSW was established.

Gunshot wounds to the head are associated with poor outcome. We reviewed data to identify prognostic factors. We performed a retrospective study of all patients admitted to a Level 1 trauma center with isolated gunshot injury to the head during six and half years. Data collected included demographics, mechanism of injury, prehospital and resuscitation room data, and initial CT scan characteristics. The primary outcome measure was the Glasgow Outcome Scale (GOS). Seventy-two patients with isolated gunshot wounds to the head were admitted. Overall mortality was 58%. The mortality for patients with an initial GCS of < 8 was 81 versus 14% for those with initial GCS > 8 (p < 0.0001). Fifty percent had pupillary abnormalities on arrival at the Emergency Department. Mortality in this group was 78 versus 53% in those with normal pupillary reflexes (p = 0.06). Elevated plasma lactate was associated with nonsurvival. Thirteen percent of survivors were assessed as able to live independently after their injury. Civilian gunshot injury to the head is related to high mortality. Indicators of outcome are the admission GCS score, pupillary abnormality, metabolic acidosis, and CT pattern of severe injury. Introduction and objectives: The aim of this study is to compare the effects of the mannitol and melatonin on the levels of blood and brain malondialdehyde (MDA). Methods: In the study, 24 New Zealand type rabbits were used. The test subjects were divided into four groups; Sham (n = 6), control (n = 6), mannitol (n = 6) and melatonin (n = 6) groups. Blood cerebrum tissue samples were taken to research for MDA in the control group. Head trauma was applied with Feeney method to the rabbits in the other groups. Venose blood samples were taken before and after trauma to observe MDA. 100 mg/kg melatonin was given to the melatonin group, and 2 g/kg mannitol was given to mannitol (12%), between 9 and 12 in 33 (5.6%), and between 13 and 15 in 474 patients (81.3%). Mortality rate was 6% (n = 35). Patients who died had significantly higher ISS (p < 0.0001), lower GCS, (p < 0.0001), and higher head AIS (p < 0.0001).

Conclusions: Road traffic collision is the leading cause of head injury in our setting. In this study population, head injury was severe, more than one fifth of the cases were admitted to the ICU, and GCS was below 8 in 12%. Patients who died had significantly higher ISS, lower GCS, and higher head AIS.

Backgrounds and objectives: Benefits of emergency burr-hole craniotomy (or evacuation) for patients with critical head trauma remained unclear. Our study objective is to compare the effectiveness of burr-hole craniotomy to decompressive craniotomy using data from a large-scaled, multicenter and nationwide registry of hospitalized trauma patients in Japan. Materials and methods: Among a total of 20257 records registered in Japan Trauma Data Bank, we selected patients with critical head trauma which were scored as AIS 5 (critical injury on the abbreviated injury scale) on head and underwent either of burr-hole craniotomy or decompressive craniotomy. Parameters of the trauma injury severity score (TRISS) were used to adjust the baseline trauma severity. Univariate analysis and multivariate logistic regression analysis estimated the relative risk of inhospital death. Results: A total of 180 zygomatic and/or orbital fractures were identified with 74 subtarsal (41%), 56 subciliary (31%), 45 transconjunctival (25%) incisions, and 5 laceration (3%). The risk of ectropion was highest in subciliary incisions (13.2%, p = 0.018), however, only one case required operative management. Entropion was found in two cases after transconjunctival incisions (p = 0.108); both required operative management. Lid edema was present in 1.4% of subtarsal and 8.9% of subciliary incisions (p = 0.016). One hypertrophic scar was seen with the subtarsal and two cases with the subciliary approach (p = 0.545).

Conclusions: Lower eyelid malposition occurs after any lower eyelid incisions for facial fracture repair. Ectropion is most commonly seen in subciliary incisions, while entropion is rare. A subtarsal incision has a low risk of malposition, however is associated with hypertrophic scars. Although choice of incision can be based on surgeon preference, a thorough patient discussion must include potential complications with each approach. In traumatology things happen quickly, data are often incomplete and therefore misleading and there is also pressure for quick decision.

In dealing with the matter we distinct among wrong decisions based on insufficient data and errors due to systemic faults or individual incompetence or negligence. Possible systemic faults are at every level of treatment: taking history, clinical examination, diagnostics, decision making, treatment procedures and even rehabilitation. Most analysed errors occured when patient was handed over to another team or another level of treatment. Haste and insufficient or inadequate report leads to wrong assumptions and -if that is not discovered in time -to wrong treatment. On personal level usual mistake was being satisfied when one injury was found and others were missed to insufficient exam or diagnostics. Dealing with unfamiliar drugs lead to overdosage and sometimes death of the patient.

To avoid such disasters extra training was added to medical school and medical students systematically approach the subject. At the emergency department adherence to protocols is encouraged, especially in cases of unresponsive patients. On hospital level enough time should be provided for attending physicians to make thorough rounds. This should provide much needed redundancy in the age of maximum efficiency. Unfortunately we feel it is still not possible to implement measures of self-reporting as known by the airline industry due to inadequate law regulation! Author to editor: Measures for preventing medical errors in trauma department is showed.

Background and Aim: Missed injuries adversely affect patient outcome and damage physician, as well as institutional, credibility. Autopsies are useful in uncovering missed injuries or undiagnosed conditions that contribute to death after injury. The aim of this paper is to analyze and compare medical documentation and autopsies findings in searching for missing injuries in trauma fatalities treated in our hospital. Patients and Methods: We analyzed data for patients died after trauma in 4 years period (January 1st, 2004 -December 31st, 2007 Introduction: Immune suppression is a compensatory mechanism in acute inflammation e.g. following trauma. Multiple mechanisms underlying this phenomenon include decreased cytokine production, shifts in cytokine balance and unresponsive adaptive immunity. We show in a model of acute inflammation that neutrophils, apart from their established pro-inflammatory characteristics, possess multiple mechanisms mediating immune suppression. Methods: Healthy male volunteers were given 2 ng/kg E. coli lipopolysaccharides intravenously. Blood was taken at various time points. Neutrophils were stained with antibodies and isolated by FACS. Neutrophil receptor-expression, phagocytosis and oxidase were measured. Lymphocytes were cultured in the presence of neutrophil subsets and CD3/CD28 or PHA. Proliferation was measured by incorporation of 3H.

Results: Distinct neutrophil subsets were identified. 3-6 h after administration of LPS 40% of neutrophils displayed a two to threefold decreased expression in innate immune receptors, decreased phagocytosis and oxidase production. Another neutrophil subset (25%) inhibited lymphocyte proliferation by 50% (in the presence of CD3/CD28 or PHA) in a 1:1 ratio independent of IL-10, TGFb, arginase or indoleamine 2-3. Instead direct delivery of H 2 O 2 appeared to be the mechanism of immune suppression. Conclusion: In acute inflammation neutrophils utilize multiple mechanisms mediating immune suppression. Firstly refractory neutrophils appear in the circulation. Secondly another population of circulating neutrophils effectively suppresses adaptive immunity. These observations dictate an important role for neutrophil-mediated immune suppression following conditions such as trauma, contributing to the susceptibility to infections seen in these patients. sham-group) received a single intraperitoneal injection of either Zinc protoporphyrin (ZnPP), an HO inhibitor, hemin, an HO-1 inducer, or vehicle. 6 h later, rats were anesthetized and subjected to HTS, including bleeding, laparatomy, and reperfusion (inadequate and adequate phase) and were sacrificed 16 h later. HO-1 mRNA was determined by real-time PCR and HO activity was determined in liver homogenate. Free iron was measured by electron paramagnetic resonance spectroscopy in nonhomogenized liver tissue. HO-1 mRNA was elevated only in the HTS-group pretreated with ZnPP versus the sham-group. HO activity was increased in all HTS groups compared to sham groups, with the most distinctive increase seen in the hemin pretreated groups. Plasma bilirubin values showed a similar increase in the groups pretreated with hemin. No significant difference was found in free iron concentration among all groups. Our data show that changes of HO activity prior to HTS are not associated with elevated free iron, late after reperfusion, suggesting that free iron released from HO is efficiently deactivated.

Introduction: Cells of the innate immune system are essential in the development of inflammatory complications. The activation status of this system can be determined by analyzing expression activation markers on neutrophils in peripheral blood. Our research group previously showed that a combination of these receptors, the 'priming score', reflected the inflammatory status of individual patients.

Hypothesis: Systemic activation of the innate immune system attracts functional neutrophils into damaged tissues. Dysfunctional neutrophils stay behind in the circulation, causing a paralyzed innate immune system and increased susceptibility to late onset sepsis (>5 days Objectives: Our study objective is to stratify risk factors of the second (within hours) and third peak (within days) of trauma death independently. Materials and methods: 20,257 records from Japan Trauma Data Bank were retrospectively analyzed. As outcomes for the analysis, we defined the early and delayed death as deaths within 2 days and those after 3 days, respectively. Based on the framework of trauma injury severity score (TRISS), coded Glasgow coma scale (cGCS), coded systolic blood pressure (cSBP), coded respiratory rate (cRR), injury severity score (ISS) and coded age (cAge) were used as independent variables to determine the outcomes using proportional hazard analysis. Conclusions: In our observation, statistically-significant risk factors of early and delayed trauma death differed. Physiological severity largely affected the second peak. In contrast, the third peak mainly correlated to anatomical severity and elderly in age compared to risk for the second peak. Especially, an initial hypotension might no longer affect the third peak of trauma death independently.

regression analysis including all the parameters of RTS as explanatory variables showed the odds ratios of categorical SBP variables predicting the inhospital death.

Results: A total of 12,077 records matched the inclusion criteria. Score-0, 1, 2, 3, 4a and 4b in SBP subcategory consisted of 1, 043, 161, 298, 382, 9, 233 and 960 patients, respectively. Inhospital mortality of score-0, 1, 2, 3, 4a and 4b were 98, 66, 38, 21, 6 and 16%, respectively. After adjustment for RTS, the odds ratios for the inhospital death of score-0, 1, 2, 3, 4a and 4b were 26.7, 10.0, 4.9, 2.5, 1.0 (reference) and 2.2, respectively. Isolated head trauma were more frequent in score-4b compared to score-4a (46 vs. 29%, p < 0.0001).

Conclusion: A trauma patient with systolic hypertension ‡ 180 mmHg is scored 4 points in SBP category under RTS rule, however, exposed to higher mortality rate similar to patients with 3 points in SBP subcategory and maybe related to isolated head trauma.

Author to editor: To whom it may concern: We have received a e-mail replied from AbstractAgent.com which alert the exceed in limitations of abstract submission. The e-mail noticed us, the presenting author of this abstract (Akira Endo) posted 3 or more abstract as a presenting author, however, the authors of ''Increased mortality in trauma patients with systolic hypertension'' believed that Akira Endo in Department of ACCDM, TMDU, Japan surely posted this abstract only. The name ''Akira Endo'' is common in Japan. We suppose that ''Akira Endo'' of the other institutes were doublecounted. Editor to self: Seçilmiş bildiri

Background: The United Arab Emirates (UAE) is developing rapidly, with many foreign construction, farm, and industrial workers at risk of injury. Aims: To assess external causes, risk factors, severity, and anatomical region of work-related injuries using a trauma registry. Methods: Surgical admissions 03/2003 to 04/2005 were recorded in the registry at the main trauma hospital in Al-Ain region, population 348,000. Prevention-related variables were analyzed using SPSS and severity quantified by injury severity scores (ISS).

Results: There were 614 work-related injury hospitalisations, equating to an incidence of about 136/100,000 workers/year. Males accounted for 98%, ages 25-44 years 69%, and nonnationals 96%, with 70% of workers from the Indian sub-continent. External causes included falls 51%, falling objects 15%, powered machines 11%, animals 7%, burns 6%, and other 10%. At least 39% of falls were from relatively high levels. Median ISS was 4 for all six main external causes. Extremities were most frequently injured. Mean hospitalisation was 9.4 days. 4% (n = 22) were admitted to the intensive care unit and 1% (n = 5) died after admission. Conclusions: Main external causes were proportionately much more frequent than in industrialised countries, and admissions prolonged. Priorities include effective countermeasures for falls from height and falling objects, and for machinery injuries. Improved work injury data, access to occupational health services, specific regulations and frequent inspections at all construction sites, workshops, and farms, together with appropriate penalties for safety violations, are essential to reduce incidence and severity of occupational injury among vulnerable migrant workers in the UAE.

Introduction and objectives: Immobilization of the spine in trauma patients at risk of spinal damage is performed using a rigid long spineboard or vacuum mattress both during pre-hospital and inhospital care. However, disadvantages of these immobilization devices in terms of discomfort and tissue-interface pressures have guided the development of a new soft-layered long spineboard. We compared tissue-interface pressure and degree of comfort during immobilization on a rigid spineboard, a vacuum mattress and a newly developed soft-layered long spineboard. Methods: In this randomized cross-over trial, 30 volunteers were immobilized sequentially on all three devices for 15 min per device. Tissue-interface pressures were measured using an Xsensor pressure mapping device, including the peak pressure and the Peak Pressure Index (PPI). Comfort was rated on a visual analogue scale (VAS) after 1 min and after 15 min of immobilization. Results: Tissue-interface pressures were significantly higher on the standard long spineboard and the vacuum mattress than on the softlayered long spineboard. PPI for the sacrum on the soft-layered long spineboard was significantly lower than on both other devices, with an average PPI close to normal diastolic blood pressures. The participants reported significantly more comfort on the soft-layered long spineboard compared to the rigid long spineboard, both after 1 and 15 min (p < 0.0001). Conclusion: Using the soft-layered long spineboard, which imposes less pressure on the tissue and provides better comfort than the standard long spineboard and the vacuum mattress, means buying time to optimize the patient's treatment while minimizing tissue damage.

Background: Trauma and emergency surgery models differ all across Europe. No definitive model was accepted and work and surgical emergency load are different in each region. We performed a cohort study to analyze the impact of emergency (including trauma) surgery in the general surgical practice at a Portuguese University Hospital. Methods: Data on emergency surgical cases and admissions to the surgical service over a 3-month period were collected and analyzed; this included patient demographics, referral sources, diagnosis, operation, and length of stay (LOS Conclusion: Emergency workload represents a significant part of the work for the general surgeons. The emergency surgical cases and admissions had a significant impact in the mortality rates of the general surgery admissions. Resource planning and training should be based on more comprehensive, prospective data such as these.

Background: The long-term health outcomes and costs of helicopter emergency medical services (HEMS) assistance remain uncertain. The aim of this study was to investigate the cost-effectiveness of HEMS assistance versus emergency medical services (EMS).

Methods: A prospective cohort study was performed at a level I trauma centre. Quality of life measurements were obtained at 2 year after trauma, using the EuroQol-5D as generic measure. Health outcomes and costs were combined into costs per quality-adjusted life year (QALY). Results: The study population receiving HEMS assistance was more severely injured than that receiving EMS assistance only. The incremental costs for intramural care were e4,700 for HEMS treated patients compared with patients treated by EMS only, which was mainly determined by the costs of the intensive care stay and the used diagnostics. Finally, the costs for HEMS assistance instead of EMS assistance were e28,537 per QALY. The sensitivity analysis showed a cost-effectiveness ratio between e16,000 and e62,000. Conclusion: The costs per QALY for Helicopter Emergency Medical Services in the Netherlands remain below the acceptance threshold. Therefore, HEMS should be considered as cost-effective.

Author to editor: This study describes the long-term health outcomes and costs of helicopter emergency medical services (HEMS) assistance. It investigates the cost-effectiveness of HEMS assistance versus emergency medical services (EMS), and may serve as a reference for future quality of life and cost-effectiveness studies on the subject of HEMS and severely injured patients Introduction: In usual multi-trauma care (UTC) each partner has its own ''autonomous'' treatment perspective. Clinical evidence, however, suggests that an integrated multi-trauma rehabilitation approach ('supported Fast-track multi-Trauma Rehabilitation Service': SFTRS), featuring earlier transfer to a specialised trauma rehabilitation unit; earlier start of 'non-weight-bearing' training and multidisciplinary treatment; early individual goal-setting; co-ordination of treatment between trauma-surgeon and physiatrist, may be more (cost-)effective. The feasibility of a multi-centre trial examining the (cost-)effectiveness of SFTRS was assessed. Methods: Data from 1892 multi-trauma patients (ISS ‡ 16, complex multiple extremity injuries or complex pelvic fractures) were inventoried. Patient characteristics, trauma severity, quality of life, health status, anxiety and depression, and cognitive functioning were assessed in two Dutch trauma centres providing UTC or SFTRS.

Results: No differences in patient characteristics', trauma severity or discharge destination were found between SFTRS and UTC. Discharge destination was 'home' (49.4%), 'rehabilitation clinic' (20.3%), 'nursing home' (5.2%), 'other hospital' (5.8%), 'unknown' (6.4%). 12.8% of patients died. However, hospital length-of-stay differed: 10.4(SD: 10.4) days (SFTRS) and 13.9(SD: 13.5) days (UTC). Conclusion: Adequate patient numbers may be recruited, baseline patient characteristics did not differ between collaborating centres, hospital length-of-stay was reduced in SFTRS and adequate patient follow-up is possible. Based hereupon, a nonrandomised multi-centre clinical trial started. (ISRCTN68246661).

The trauma-region of North-West Netherlands has consensus criteria for mobile medical team (MMT) scene dispatch. The MMT can be dispatched by the EMS-dispatch centre or by the on-scene ambulance crew and is transported by helicopter or ground transport. Although much attention has been paid to improve the dispatch criteria, the MMT is often cancelled after being dispatched. The aim of this study was to assess the cancellation rate and the noncompliant dispatches of our MMT, and to identify factors associated with this form of primary overtriage. Methods: We conducted a retrospective case review of 605 consecutive MMT-dispatches during a 6 months period. By means of chart review, data pertinent to prehospital triage, patient's condition onscene and hospital course were collected and analyzed. All dispatches were evaluated by using the MMT-dispatch and mission appropriateness criteria Results: Median age was 35.9 years and 65.3% of the patients was male. Of these, 430 patients were trauma victims (86.7% blunt trauma). After being dispatched, the MMT was cancelled 203 times (43.5%). Statistically significant differences between assists and cancellations were found for overall mortality, mean RTS, GCS, and ISS, mean hospitalization and amount of ICU admissions (p < 0.001).

Almost 26% of all dispatches were neither appropriate, nor met the dispatch criteria. Fourteen (3%) missions were appropriate, but did not meet the dispatch criteria.

Conclusions: Nearly a half of MMT-dispatches were cancelled and almost 29% did not meet the dispatch criteria. Dispatch criteria for the mobile medical team in our trauma-region need further refinement and compliance. The ''Traumax Ò '' hip screw plate is a new device that allows the treatment the fractures both of the neck and the trochanteric area of the femur, expected subtrochanteric area. This plate conserves the characteristics of a dynamic hip screw (compression of the fracture site, good positioning of the pieces of bone, integrity of gluteus muscles) more specific characteristics: this device is modular, allows to choose the length of the barrel adapted to the length of the head screw, the diaphysal screws are locked by a tech nut according to the patented ''Surfix'' system. The locked screw gives a good stability even if the bone has a poor density and allows to use a short plate that preserves the piercing lateral vessels of the femur. This short modular screw plate can be implanted by a 3 cm minimal invasive approach using a particular instrumental pipe. During the presentation we will report the results of a prospective study colligating 250 cases of ten French hospitals. A preliminary study of 60 consecutives cases gives prominence to a few blooding with an average of 180 ml, a operative time of an average of 32 mn, a xr exposing time of an average of 16 s. Healing bone has been obtained in all cases. The head screw has been placed at the center or just below in 97%. No complication dues to the plate has been reported; in all cases only one approach has been used. Aim: To assess moderate-term outcomes of silastic joint replacements of the first metatarsophalangeal joint. Methods: The 32 patients (37 feet) that had silastic implants inserted were reviewed at an average of 2 years and 4 months (ranging 7 months to 5 years and 4 months). The mean patient age was 63 years. These patients answered a subjective questionnaire, had their feet examined clinically and radiographically and a pre-operative and post-operative AOFAS score was calculated for each. Results: The questionnaire revealed that every patient described that their pain had decreased after surgery and 17 feet (46%) were completely pain free. There was a significant improvement in patients' subjective pain scores after surgery (t value £ 0.0001). Preoperatively, the mean pain score for all 37 feet was 8.14, whereas post-operative the mean pain score was 1.32. The mean AOFAS score before surgery was 39.97. This increased to a mean score of 87.40 after surgery (p £ 0.0001). This again is a significant improvement. No patient was dissatisfied with the outcome with their surgery. Conclusion: These moderate term results are encouraging, with good subjective and objective results. However, long-term follow-up will be required to assess the longevity of this implant • Theatre staff should be trained for proper application and cleaning of the exsanguinators • Alcohol wipes are good alternative to current practice and should be used for decontamination • We must wash our hands before and after its use • We should use plastic bag over the limb first before using the exsanguinators It is presented one new minimally invasive method for closed fracture reduction and one extramedullary selfdynamisable internal fixator developed by the author. There is no contact between bone and internal fixator in fracture area. It has been widely investigated biomechanically.

In clinical use it has been applied to 1,050 patients in treatment of femoral fractures. The age of patients was from 14 to 87 years. This internal fixator is applied by two small incisions. Reduction is achieved using standard traction table or using special reduction device. This reduction device provides possibility of reduction with minimal using of fluoroscopy or even, after more experience without using of any imaging technique as fluoroscopy, ultrasound or computer navigation.

Received clinical results are promising, as it has been shown early callus formation and radiological union within the 3-4 months. It has been allowed to patients early full weight bearing. During the treatment it has been confirmed working of self-dynamisation concept, which probably all together with 3D configuration resulted in unexpectedly quick fracture healing. Follow up was 19 months (6-60). According to results obtained, it can bee concluded that new biological internal fixator is suitable for minimally invasive technique, without opening of fracture site. It can be used as primary method or soon after external fixation if damaging control concept used. (2000) (2001) (2002) (2003) (2004) and followed-up for a minimum of 2 years formed the study population. A retrospective review of data from electronic patient record (EPR), clinical coding, clinic and GP letters was made. Age, residential placement, Garden's classification of fracture, mode of injury, associated comorbidities, pre-admission mobilisation status, allergies, addictions and anticoagulation status details were collected. An indepth study was conducted to look into delays for surgery, length of stay in hospital, complications and treatment of these complications.

Reasons for re-admissions, re-operations and comorbidities developing as a result of these interventions was critically analysed.

Results: The mean age of patients was 68 years (range 18-96 years). The incidence of non-union was 8% and avascular necrosis at 1 year was 19%. Revision surgery was performed in 87 (27%) cases. Complications were more principally in patients who had end-stage renal failure (76%), diabetes mellitus (60%), osteoporosis (43%), and steroid use (67%). Conclusion: The complications and revision surgery rate was high in patients with particular co-morbidities despite being undisplaced. Comorbidities and patient's age were also strong predictors of healing in addition to fracture configuration. Outcome of hip fractures is influenced by complex interplay of multiple factors and not only by radiographic appearance. 

Methods: This is a 6-year of retrospective study. We had included 14 patients to our study (12 females and 2 males) with the average age of 56.6. We used Bryan and Morrey classification system and included type I and type III fractures.

Results: There were 11 type I and three type III fractures. Associated injuries were two dislocations with one MCL injury and two radial nerve symptoms. All the patients had ORIF with screw and two patients had supplementation of fixation with wires. Most patients were mobilized early in 2 weeks time. Nine of them treated with Miniacutrak screw fixation, four with Herbert screws and one lag screw (AO miniscrew). The approach was mainly postero-lateral but for five patients, it was antero-lateral. All patients were clinically and radiologically assessed. Average time for radiological union was 7 weeks. On the other hand, one patient had revision fixation because of failure of metalwork. Additionally, one patient had capsular release for contraction and another one had removal of screw for prominence of metalwork. Average follow-up was 33.7 months (8-72 months). Mayo elbow score was excellent for seven patients, good for three patients, and fair for three patients. One patient could not be fully scored due to learning difficulties.

We recommend open reduction and internal fixation for all type 1 and type 3 fractures so that function can be regained early. Objectives: To report the outcome and comparison of calcaneum fracture managements for intra-articular fractures.

Methods: A prospective study of the patients with intra-articular calcaneum fractures in the foot&ankle unit of a busy trauma hospital. All the patients were followed up with the calcaneal fracture score. We compared the outcome of surgical management Sanders type 2 (Group A) and type 3 (group B) fractures with conservative treatment (group C) at 2 years and assessed the medium term outcomes of groups A and B. Group C were a consecutive series of patients recruited to the study later than A and B, hence the smaller number in that group.

Results: 126 patients were included in our study. There were 70 in group A, 38 in group B, and 18 in group C. Mean follow-ups for the groups were A = 6 years, B = 5.5 years, and C = 2.34 years. Mean 2-year scores for the groups were A = 68.13, B = 63.78, and C = 51.36, with statistically significant differences between groups A and C (p = 0.0006), and between groups B and C (p = 0.04), but no significant difference between groups A and B. At medium-term follow-up (> 5 years), the scores for group A and B were 77.06 and 63.66, respectively. There were 7 deep, 5 superficial infections and 32 metalwork removals in total. Conclusion: On comparing the medium term outcome to the 2-year one, group A showed some improvement and group B stayed the same. In this series, contrary to published articles, there was a better outcome at 2 years with surgical treatment than conservative treatment.

Author to editor: All the authors have agreed with content of the abstract. There was not any conflict of interest for this study. Objective: To assess the effectiveness of mobile angiography with a digital subtraction angiography (DSA) technology directly into the emergency room (ER) for blunt trauma patients with pelvic injury. Materials-methods: This is a retrospective review of a cohort of blunt trauma patients with pelvic injury treated after the direct availability of mobile angiography by trained trauma surgeons into the ER for resuscitation. Data was collected including demographics, hemodynamic variables, resuscitation intervals form admission through completion of hemostasis, metabolic factors (pH and body core temperature), mortality and transcatheter arterial embolization (TAE) related complications. Results: Twenty-nine patients underwent TAE in the ER. Mean age, shock index, and injury severity score were 40 ± 17 years old, 1.1 ± 0.6, and 30 ± 14, respectively. The interval from the decision to perform TAE through initiation of TAE and the interval from the decision to perform TAE through completion of TAE were 31 ± 12 min and 110 ± 32 min, respectively. The mean Dbody core temperature (BT) from admission through completion of TAE was -0.2 ± 1.5°C. And the mean DpH from admission through completion of TAE was 0.02 ± 0.13. There were clinically significant correlations between DBT and resuscitation interval, and between DpH and resuscitation interval. TAE was successfully performed in all cases and mortality was 17%. No TAE-related complications were observed. Conclusion: Immediate availability of mobile angiography into the ER by trained trauma surgeons was effective to shorten the time required to restore normal physiology of trauma patients with pelvic injury without leaving the ER for resuscitation. Introduction: TGF-b1 is a regulatory protein, involved in fracture healing. The purpose of this study was to investigate the role of TGF-b1 in human fracture healing, and to verify whether TGF-b1 is a reliable marker of nonunion.

Methods: Serum samples of 114 patients with long bone fractures were collected over a period of 6 months. Patients were assigned to 2 groups: first group contained 103 patients with physiological fracture healing. Eleven patients with nonunions formed the second group. 33 healthy volunteers served as controls.

Results: In patients with physiological healing serum concentrations were initially high. Serum concentrations then decreased rapidly after 2 weeks and reached a plateau between weeks 6 and 8. Thereafter, another continuous slight increase of the concentrations was observed between weeks 12 and 24. In patients with impaired fracture healing TGF-b1 serum concentrations were initially similar to those with normal healing. A significant increase of the concentration was observed between weeks 4 and 6, followed by a continuous decline of the serum levels for the remainder of the observation period. Significant differences between the concentrations in both groups were observed at weeks 6 and 8. TGF-b1 as marker would have detected patients with nonunions at 6 weeks after fracture with a sensitivity of 100% and a specificity of 49%. Distal metaphyseal radial fractures are extremely common fractures in children (%20,2). High rates of displacement occurs during conservative treatment. The aim of this study was to determine the effect of Kirschner wire application after closed reduction of radial metaphyseal fractures with high risk of redisplacement.

In this retrospective study 40 cases were studied in two groups. In group 1 (n = 20), K-wire applied after closed reduction. In group 2 (n = 20), only cast was applied following closed reduction. The mean follow-up was 20 months. The compared clinical and radiological parameters were; pain, limb deformity, range of motion of the wrist, angulation of the fracture site, radial distal epiphyseal angle and severity of translation. Redisplacement rate was 10% in group 1 and 50% in group 2. This shows, Kirschner wire fixation had a positive effect in continuity of the initial reduction (p = 0.014). Age (p = 0.289), gender (p = 0.264), reduction quality (p = 0.970) had no effect on redisplacement. Concerning the severity of translation, the risk of redisplacement increases in stage 3 (50-100%) and stage 4 (> 100%) fractures (p = 0.003). Concomitant complete ulnar fracture had also redisplacement risk (p = 0.016). Redisplacement risk increases when the distance of fracture line to epiphyseal line was between 11 and 20 mm (p = 0.073). There was no significant difference between two groups after last evaluation based on radiological parameters and clinical results (p > 0.05). As a conclusion; this study shows that Kirschner wire fixation prevents redisplacement in early follow-up of first 3 weeks but there is no superiority after 20 months follow-up in distal metaphyseal fractures of children. Patients in group C showed the best functional results, the greatest ankle range of motion, the fastest full bearing, the fastest walking on toes and heels, and the shortest duration of physical limitations (walking on uneven ground and sports activities) (p < 0.001 for all). In group B, there were two reruptures, in group C one, and in group A there were no reruptures. Good functional results and a relatively small number of postsurgical complications advocate the usage of surgical techniques. The best and fastest functional recovery was attained in the group treated with the original technique of percutaneous fixation with two embracing and crossed loops. Open surgical reconstruction is indicated only in the case of rerupture after percutaneous suturing. Introduction: There are different techniques for arthrodesis of endstage arthrosis of the ankle-joint. Internal fixation is the favoured method in many institutions. We retrospectively examined the technique and clinical results of external fixation in a triangular frame.

Patients/methods: From 1994 to 2001 a consecutive series of 95 patients with end-stage arthritis of the ankle joint was treated. Mean age at the index-procedure was 45.4 years, 67 patients were male (70.5%). Via a bilateral approach the malleoli and the joint-surfaces were resected. An AO-fixator was applied with Steinmann-nails. Follow-up examination at mean 4.4 years included a standardised questionnaire and a clinical examination including the criteria of the AOFAS-Score and radiographs.

Results: In two cases, due to contracture a pes equinus position had to be accepted. In two cases a further bone transplant was performed at 6 and 9 weeks for unsatisfactory bony union. After mean 12.3 weeks, radiographs confirmed satisfactory union and the fixator was removed. In four patients a nonunion of the anklearthrodesis developed (4.5%). The mean AOFAS score improved from 20.8 to 69.3 points. Statistical analysis of the insurance status showed that patients insured under a workers injury compensation scheme had a mean score of 63.6 compared to 75.1 for the remaining (p = 0.027). Discussion: Nonunion rates and clinical results of arthrodesis by triangular external fixation of the ankle joint do not differ to internal fixation methods in literature comparison. The complication rate and the reduced patient comfort reserve this method mainly for infected arthritis and complicated soft tissue situations.

Implants with multidirectional locked screws have theoretical advantages in the treatment of periprosthetic fractures. In osteoporotic bone they provide a high stability. We concluded a retrospective study of a consecutive series of the outcome of Vancouver B1 and C femoral injuries using two specific locked-implants.

From 1996 to 2004 we treated 58 patients with a periprosthetic fracture of the femur with a locked plate. The mean age at the index procedure was 72.4 years, 40 patients were female (69%). In 32 cases (55.2%) we saw a hip endoprosthesis, in 21 cases (36.2%) a knee endoprosthesis and in 5 cases both (8.6%). Outcome measures were intra-and postoperative complications, bony union, degree of mobility and social status, Barthel-mobility-index and ''stand-up&go'' test. Union occurred in 56 cases (96.5%) after the index procedure. Twice the implant failed, we saw four general complications. The mean duration until full weight bearing status in these patients was 8.6 weeks. At follow-up 46 patients (78%) had maintained the same social status as before the fracture. Regarding the mobility status 52 patients (89%) had regained their previous level, 4 patients walking without aid before now required a cane and 2 patients a walking frame. The mean Barthel-Index was 85 points of 100. The mean stand-up&go time was measured as 22 seconds.

Conclusion: Overall failure rates of osteosynthesis after periprosthetic fractures of up to 35% are reported (20). With 3.5% implant related failures and 7% general complications, the presented methods achieve bony union and mobility in a high percentage of cases. 184 Arthroscopic-assisted Percutaneous Figure Introduction: We describe a new arthroscopic-assisted reduction and percutaneous tension band wiring technique for patella fractures that combines the advantages of minimally invasive surgery and stable internal fixation. Surgical technique: We reduce the fracture percutaneously by towel clips with the patient in the supine position. We insert two 3.0 mm Kirschner (K) wires in a caudocranial direction under arthroscopic control. We do four stab incisions to assign the inferolateral (IL) and inferomedial (IM), superolateral (SL) and superomedial (SM) portals besides the K wire tips. We insert a trocar with its cannula from SL portal to SM portal under the K wires. We take the trocar out and leave the cannula inside. We run 18-gauge cerclage wire through the cannula in SL to SM direction. We take out the cannula. We perform exactly the same steps directed from SM portal to IL portal, from IL portal to IM portal, and from IM portal to SL portal, respectively. Finally near the SL portal, wires are secured with a single knot. We check the fixation by C scope. Results: Radiographic consolidation was achieved in all five patients at an average of 2 months. All patients returned to the activity level previous to fracture.

Conclusion: This technique presents advantages over open techniques. It is minimally invasive and cosmetically pleasing, permits visualization of reduction and stability, allows concomitant intraarticular pathology to be exposed, and facilitates early rehabilitation. Although we did not attempted yet, we believe that even comminuted fractures can be fixed with this technique. (1) timing of the procedure, (2) accurate technique, (3) stable implants for early mobilisation. In this study we present our experience in the treatment of FTP with locking plates trying to define the role of a medial plate. Materials and methods: From 2005 to 2008 we treated 20 patients with a AO C3 FTP by ORIF with locking plates. Indications for a medial plate were: involvement of the medial joint surface, coronal fracture of the medial plateau and irreducible dislocated medial condyle. All the patients have been followed up clinically with the Lysholm and Rasmussen scores and radiographically until consolidation.

Results: All fractures united. One patient underwent knee amputation for septic complication. The mean Lysholm score was ''fair'' while the Rasmussen score was ''good'', that means that the subjective result was worse than the objective one. Patients treated by double plating had a worse clinical result that was not dependent on the quality of reduction. We had three cases of malalignment, one RSD, two superficial infections, two transient nerve palsy. Conclusion: Complications in our series were frequent and the clinical results not particularly good. The right timing and an accurate surgical technique are essential for a good reduction, newer implants control effectively the fragments but the high energy of the trauma remains the major determinant of the bad outcome of these fractures. Introduction: The high percentage of failure of fixation systems in periprosthetic fractures depends on the technical difficulty of the procedure, the presence of the cement mantle and the poor quality of the remaining bone. The LCP system offers an enhanced stability that reduce the implant mobilization, and preserves the bone vascularity, fastening the healing time. We present our results in the treatment of periprosthetic fractures with LCP. Materials and methods: 27 consecutive patients with Vancouver B1 fractures were operated on using 4.5 LCP. A standard open reduction of the fracture through a lateral approach was used. Patients were evaluated clinically and radiologically for a mean follow up time of 17.8 months.

Results: All the fractures united except two where a narrow 4.5 plate and too many cerclage wires around the fracture were used. All the patients showed at FU an HHS over 90 points. The anatomical reduction of the fracture led to a faster healing.

Conclusions: The effect of the position of screws and cerclages in relation to the plate and fracture are discussed. The Authors conclude that LCP system, has to be considered the golden standard in the osteosynthesis of Vancouver type B1 periprosthetic hip fractures, permitting early weight bearing and healing in physiological time. It is better to avoid narrow 4.5 plates and cerclages at the fracture site. Suggestions on the plate length and screw and cerclages position are given depending on the fracture type and length.

187 The Role of the Anatomical Prosthesis in the Treatment of Proximal Humeral Fractures

Ló ránt Bardó cz, János Csotye 1 1 Pá ndy Ká lmá n County Hospital, Gyula, Hungary, Traumatology

Introduction and objectives: We would like to present the results of the treatment of proximal humeral fractures with endoprosthesis. Methods: Between 1997 and 2007 we operated 74 patients with endoprosthesis for proximal humeral fractures. 11 were delta prosthesis, the results of these operations are the subject of an other presentation. 63 patients were treated with anatomical shoulder prosthesis. The results of these were controlled by personal examination (constant score, X-ray) and by the base of the clinical documentation. 61 was hemi-and 2 total endoprosthesis. In 50 cases the operation was acute and in 13 cases for chronic cases. The average follow up time was 76.9 month. We categorized our patients in different groups, based on the fracture type and the time of the surgery. Results: We compared the CS of the operated shoulder with the contralateral one in each patient group. We have to accentuate the importance of patient cathegorization, because the results can be analyzed properly only on base of these. On the X-rays the prosthesis were in good place, we found no evidence of losening.

Conclusions: When the indication is good, the prosthetic procedure is the choice for acute or chronic fractures of the proximal hunerus, and the results are good. We confirmed the statistically significancy of the efficacy of the treatment methods between the same analyzed groups. Aim: To discover if how often lateral X-ray change the management of fracture neck of femur fractures as an adjunct to the standard AP film. Method: 6 Orthopaedic consultants and 6 Registrar grade Orthopaedic surgeons were asked to decide the management of 30 neck of femur fracture solely from an AP film. At a second sitting the same films were shown in a different order in conjunction with the associated lateral hip X-ray. The surgeons were asked to comment on the adequacy of the lateral X-ray and their choice of management using the both films to make a decision. Results: Less than half of the lateral hip X-ray were adequate when reviewed on the monitors and very few operative decisions were changed with the addition of the lateral X-ray. Conclusion: A standard AP film is usually sufficient to plan management in a fractured neck of femur fracture and the additional time, money, and discomfort of obtaining lateral films does not seem justified in these circumstances.

An Sermon, Stefaan Nijs, Barbara Bosch, Paul Broos 1 1 Department of Traumatology, University Hospitals Gasthuisberg, Leuven, Belgium

Introduction: Humeral head fractures extending into the shaft often are a challenge to the surgeon. Although they are a rather rare entity, they often occur in osteoporotic bone and are difficult to stabilize. However, because of their intra-articular extension, a perfect reduction and stable osteosynthesis is needed. Methods: Between August 2005 and August 2008, 16 patients with a combined shaft and humeral head fracture were operated in our department. A long PHILOS plate was used in all cases through an extended deltopectoral approach. Postoperatively, immediate mobilization was allowed. Mean follow-up time was 11 months.

Results: There were three preoperatively existing radial nerve palsies of which two completely and one partially recuperated postoperatively. There occurred no radial nerve palsies which did not exist preoperatively. Revision surgery was necessary in two patients because of hardware failure and secondary fracture displacement within the first week after surgery. In both cases, again a long PHILOS plate was used. All fractures were radiographically healed within 6 months; there were no cases of avascular necrosis of the humeral head. Most of the patients were subjectively satisfied with the functional result although mobilization of the shoulder was only moderate in nearly half of the cases. Conclusion: In conclusion we can say the use of long PHILOS-plates for the treatment of combined shaft and humeral head fractures gives good results when carried out by experienced hands. Osteosynthesis with the use of locked nails is an efficacious method for the treatment of long bone fractures and nonunions of extremities. However, it is contraindicated in case of infection. One way to obviate this problem is to coat implants with antibiotic-loaded bone cement. The objective of this work was to evaluate the efficiency of antibiotic cement-coated interlocking nails for osteosynthesis of long bones in case of infection (infected nonunions) or at high risk of its development (severe open fractures).

In 2007-2008, nails with antibacterial cement coating were used to treat 29 patients including 15 ones with severe open long bone fractures (Gustilo-Anderson type IIIa-IIIb). These fixators were employed both at admittance of the patients (with an isolated injury) and within 5-6 days after it (in case of polytrauma). 7 patients of this group underwent one-step surgery combining osteosynthesis and the closure of soft-tissue defects with local muscular flaps. In 14 patients with infected nonunions of long bones, osteosynthesis was performed after seeding fistula discharge for microflora. None of the patients in the group with severe bone fractures suffered deep suppuration and all achieved consolidation of fractures. One case of recurrent infection associated with extensive necrosis of bone was documented in the group of patients with infected nonunions. The remaining patients had resolution of signs of infectious process, and their nonunions consolidated. The use of antibiotic cementcoated interlocking nails is a promising method for osteosynthesis of long bones in case of infection and at high risk of its development. Author to editor: Severe open fractures and infected nonunions are one of the most difficult problems in trauma orthopedic surgery. We had only one treatment option for this pathology down to resent times. It was an external fixator, but it has many disadvantages. In 2007 we start using antibiotic cement-coated interlocking nail, and we have promising first results. This results we would like to present in Eurotrauma 2009.

Hawar Akrawi, David Gordon Hargreaves 1 1 Department of Trauma and Orthopaedics, Southampton University Hospitals NHS Trust, Southampton, the United Kingdom Introduction: We describe our clinical experience with a new posterior approach for reconstruction of distal intercondylar fractures of humerus. The Maserati approach comprises of a midline proximal triceps split in conjunction with elevation of medial and lateral edges of triceps from the condylar ridges. This approach gives adequate access for accurate reduction and internal fixation of distal and intraarticular humeral fractures.

Methods: A single consultant series of 13 patients with distal humerus fractures (AO grade 13-A to 13-C) were treated using the Maserati approach and distal humeral locking plates over 4-year period at level 2 trauma centre. All cases were reviewed. There were 7 female and 6 male patients with age range from 17 to 79 year. Average follow-up was 12 months. These patients were assessed for:

1. Accuracy of reduction of fracture fragments. 2. Complications i.e. infection, triceps weakness, triceps lag and fracture union. 3. Elbow function as per the Mayo Elbow Performance Score (MEPS).

Results: Nine patients had anatomical reduction. No cases of Infection or nonunion. One case of delayed union. None of the patients exhibited triceps lag or weakness. The MEPS was 70-100 (mean 91). Discussion: The Maserati approach is a safe approach that provides good access to the articular surface of elbow without compromising the triceps muscle. Triceps continuity is preserved, allowing early rehabilitation without the possible co-morbidities associated with other posterior elbow approaches (non-union of olecranon, triceps weakness or triceps lag). Author to editor: Dear Sir/Madam, I will be very grateful if you could offer me the opportunity to give a podium presentation about this innovative approach. Patients with distal humeral fractures are difficult to manage and with oral presentation, I will be able to demonstrate clearly, with media presentation, the full advantage of this new approach. Results: Improvement of the neurological deficit was observed in 13 cases. CT control at least of 3 years follow up shows good bone integration of the iliac crest bone in majority of the cases. Two patients experienced temporary neurological symptoms, which showed complete remission.

The endoscopic procedure for reconstruction of the anterior load-bearing spinal column developed to a standard concept in trauma management. The minimal morbidity of the operative approach, good visualisation of the operative field and angle stable implant make it possible to restore the anterior column on a safe technique. Full weight bearing (painless) ranged (UN)14-32(ø20) and (RN) 10-36(ø20) weeks. X-ray healing ranged (UN) 10-32 (ø16) and (RN) 8-24 (ø14) weeks. There was one patient with delay union(32 weeks) in UN group. There were any infection; loss of reduction; re-operation and nonunion in both groups. Discussion: We started this study because many studies before preferred reamed nailing but we have long term experience with undreamed nail with the comparable results (retrospective analyze). Our hypothesis is that the biological advantages of undreamed nail should display if the perfect technical performance is done.

Conclusion: There are no significant differences between UN and RN groups in our study in this time. We expect recruiting more than 100 patients by the year end and during next 2 years we will be able evidence the data completely. This work was supported by the research project MOOFVZ 0000503

198 Septic Arthritis Following ACL Reconstruction

Péter Frö hlich 1 1 Zentralinstitution for Sportsmedicine, Budapest, Hungary

Infection after arthroscopic anterior cruciate ligament reconstruction is an uncommon complication, which could be a danger not only for joint function, but also for the joint integrity. We have to differentiate by the clinical recognition of this complication from swelling caused by other conditions (for example suffusion). There is no standardized opinion and method in the field of arthroscopic or open procedure, or necessity of aggressive graft removing. From a consecutive case series of 1,663 patients, who underwent anterior cruciate ligament reconstruction between 2004 and 2006. We report on 16 patients with postoperative septic complication. 4 of these were extraarticular, and 12 intraarticular manifestation. Our protocol is based on infection severity classification modified by Gä chter. Reliability and significance level of diagnostic criteria (clinical evaluation, laboratory tests, synovial fluid analysis, and bacterial culture) were analyzed. The outcome was determined by early recognition and consequent treatment. There is only one patient, whose ACL tendon graft has to be removed. The IKDC score shows the following result: A: 4, B: 5, C: 2, D: 1, it proved to be similar to the multicenter studies. In the last 2 years we have no more postoperative infection following ACL reconstruction by the application our protocol. We will review this protocol. Introduction: Early fixation of long bone fractures in the multiple injured patient has been recognized as beneficial in minimizing secondary lung and remote organ failure. Although early fracture fixation is expedient in px with multiple injury ETC may be associated with post-traumatic systemic complication.

In this study all pz from a consecutive series of 690 trauma patients with truama team activation admitted between 01/04 and 01/06 to department of emergency of Niguarda Hospital in Milan were included when they fulfilled all of the following criteria: directly admitted, ISS of more than 15, and survival of more than 24 h. Patients with fracture of long bones and/or pelvis with a clear indication for operative treatment and the necessity of immediate fracture stabilization where treat according with DCO. All other patients fulfilling the inclusion criteria with minor fracture or thus not requiring immediate fixation formed the control group. ISS, RTS and Ps was calculated at the admission and reevaluated later by the Trauma Leader. All injury was classified with AO and Gustilo classification Conclusion: The goals of DCO include stopping ongoing injury including local soft-tissue injury and remote organ injury secondary to local release of inflammatory mediators further thought to prevent pulmonary complications by allowing patients to avoid the enforced supine position. This study was conducted retrospectively to evacuate the effectiveness of the Trauma Team organization and to evaluate the concept of DCO by immediate external fracture fixation and consecutive conversion osteosynthesis with regards to time saving, effectiveness and safety. Introduction: Injury of the soft tissue results in a release of numerous cytokines, which activate fibroblasts of the surrounding tissue to proliferate and to undergo a phenotypic transdifferentiation into contractile myofibroblasts (MFs). In this study we analyzed the hypothesis, that human joint capsule MFs are specifically regulated by the cytokine IFN-c via the modulation of alpha-smooth muscle actin (a-SMA) which is responsible for the contractile phenotype. Methods: Joint capsules were obtained from patients undergoing orthopaedic surgeries. To investigate the functional effect of IFN-c, we cultured MFs in a three-dimensional (3D)-collagen gel contraction model. An alamarBlue assay in combination with the collagen gels was established to analyze the viability and the proliferative capacity of MFs upon IFN-c treatment. The effect of IFN-c stimulation on the gene expression levels of the specific MF markers a-SMA and collagen I is going to be determined by real-time PCR (RT-PCR). This part of the study is in progress.

Results: MFs cultured in the presence of IFN-c show a reduced proliferative capacity. Moreover, the addition of IFN-c reveals a dose-dependent decrease of collagen gel contraction. These effects were specifically blocked by a neutralizing IFN-c antibody. First results of RT-PCR analysis show an inhibition of a-SMA and collagen I gene expression by IFN-c.

Conclusions: IFN-c reduces MF viability and contractility in a dosedependent way, presumably by down-regulating MF specific genes. This study suggests that IFN-c might be effective in attenuating the contraction of soft tissue in fibrocontractive disorders. with an average age of 31.2 years old were included and a retrospective database study was performed. The outcome parameters we analysed were the radiological outcome, the functional outcome and the prevalence of complications.

Results: The fracture healed in an accurate anatomical position in all patients treated with ESIN (100%). Seven patients (26,9%) suffered from irritation around the entrance opening and in four patients (15.4%) the pen migrated medially. In eight cases (30,8%), this resulted in a reoperation, consisting of remodelling, reposition or removal of the pen. In two cases we saw a refracture after removing the pen. The overall complication rate was 38.5%. DASH scores showed an average functional outcome of 6.9 points (range: 0-100) at 14.5 months follow-up.

Conclusion: Operative treatment with ESIN in dislocated midclavicular fractures offers good mid-term radiological results and a good DASH score. The overall prevalence of complications was 38.5% and in 34.6% a re-operation was required. The results found in the available literature showed a re-intervention rate of 50%. Prospective randomised research is required in order to determine the right surgical indications and to find out what the long-term results of this relatively new method of fixation are. Aim: Our main aim was to find out whether there is a place for nonoperative treatment as a definitive primary option in patients with significant medical co-morbidity. Methods: We did this audit in 2007 collating information on 1,010 hip fracture patients across 14 NHS hospitals in England. 50 out of 1,010 (4.95%) patients were treated conservatively.

Results: There were 17 males and 33 females patients managed conservatively in our study. During hospitalisation, 4 became bedridden and 30 died. Among these 50 patients, 8 were deemed physically unfit for surgery by anaesthetists and 2 by medical consultants. The decision was made by orthopaedic consultants in ten cases and by multidisciplinary team in four cases. Five patients refused surgery and five patients were palliative due to terminal illnesses. Patients who did not proceed to surgery had significantly higher mortality rates (overall mortality rate 60%) suggesting that they were physiologically much worse group of patients. Conclusion: As the average life span of our population increases, some hip fractures are now treated nonoperatively because of the possibility of severe or fatal complications due to surgery. Often, refusal of surgery by the patient or the patients' family obligates the need for nonoperative treatment. It might be acceptable not to opt for the surgery if the patients are medically very high risk because of these reasons (e.g. acute cardiac event, severe aortic stenosis, multiorgan failure etc). The burden of patients with pubic rami fractures seems to be increasing. More patients with pubic rami fractures are admitted to hospital due to the absolute increase in the number of elderly people. Although pubic ramus fractures are generally considered a benign fracture for its inherent stability experience indicated that this fracture is accompanied with a high morbidity and mortality. In a case-control study patients aged over 60 years old with an isolated single fracture of the pubic rami admitted to the hospital were compared for morbidity and mortality to age-and gender matched hospitalized patients without fractures. Data was acquired by the patient files. During 14 years 99 patients, with a median age of 80.1 (range: 60-98) years, were admitted with a median length of stay of 10 days (range: 2-57). The mortality rates of patients with isolated pubic rami fractures at 1, 5, and 10 years were significantly higher in the patient group compared to our control group, being: 24.7, 64.4 and 93.8%, respectively (p < 0.05). One third of the mortality is explained by cardiovascular events. During hospital admission a complication rate of 20.2% was found, which was mainly caused by infectious diseases, including urinary tract infection and pneumonia. Thirty-three percent of the patients (temporarily) went to a nursing home, because of the incapability to mobilise independently.

In conclusion, patients admitted to the hospital for an isolated pubic ramus fracture have significant morbidity and mortality both during hospital admission and during 10-year follow-up. Purpose: Comminute fractures of the radial head are challenging to treat with open reduction and internal fixation. Radial head arthroplasty is an alternative treatment. The purpose of this study was evaluating our results of a closely followed cohort of patients in whom an unreconstructible radial head fracture had been treated with modular pyrocarbon/metallic prosthesis. Methods: From May 2003 to September 2007, 24 patients were operated for traumatic injuries in elbow. There were 12 female and 12 male with mean age 49 (34-70 years). The follow-up was a mean of 31 months (12-54 months). Fractures of the radial head have been classified by Mason with a subsequent modification by Johnston. The indication for a radial head replacement are comminuted type III fractures in 16 cases, type IV in 5 cases, and Monteggia variant with olecranon and radial head fractures in 3 cases. Results: By using the Mayo elbow Score, 18 patients had good/ excellent results, with 5 fair and 1 poor outcomes. Patients showed an average arc of motion from -10º to 135º. Complications were three implant dislocations, needed to remove the implant. Asymptomatic radiographic heterotopic ossification in elbow was showed in one case and bone lucencies were found in seven cases. We had not seen persistent instability, infection, synostosis, loosening, severe degenerative changes or impingement. Conclusion: The treatment of unreconstructible comminute radial head fracture with noncemented pyrocarbon radial head implant usually gives an optimal result depending on the severity of the initial injury and the presence of associated injuries. Methods: This retrospective clinical study is a follow-up examination of bony avulsion fractures of the intercondyloid eminence in adults and adolescents treated in our hospital in the last 7 years. After the medical history was recorded, the course of the accident and type of injury was documented (classification according to Meyers and McKeever) . Also the type of treatment (conservative, arthroscopic surgery or open surgery) and accompanying injuries were analysed.

The clinical follow-up examination took place after more than 12 months after the trauma. During the face-to-face interview, physical and radiological examination, the knee function, and especially the stability of the knee-joint were assessed. Furthermore the clinical outcome was determined using the Lachmann-test and the Lysholm-knee-score.

Results: The patient group consisted of 19 male and 9 female patients aged 11-74 years. The patients showed subjective and functionally predominant good to very good results. Despite subjective stability and absence of pain, in some patients remained a mild hyperlaxity of the anterior cruciate ligament. Conclusion: Fractures of the intercondyloid eminence are a rare but serious injury of the knee. The correct diagnosis, classification, and curative treatment of the fracture is indispensable for the flawless function and stability. An individual approach is necessary in every patient. Distal radius fractures are typical and frequent fracture of elderly woman with reduced bone density. The angle stable plate, often also multidirectional is today the most common stabilisation device. Because of the introduction of bulky and bended implants as the Micronail or Targon DR we decided to test the XS radius nail witch is a 4,5 mm or 3,5 mm straight nail and witch is introduced after guide wire placement and over drilling with a cannulated drill of the same diameter. It is locked parallel to the joint in 3 different directions with angular stability with threaded wires. Methods: 16 radius sawbones were osteotomised corresponding to a A3 Fracture and stabilised with a angle stable plate (8) and XS nail (8). 1,000 alternating load cycles from 20-200 N were performed and the deformation was registered. Also a FE analysis with the MSC Patran/Marc software were performed. Both types of osteosynthesis showed good stability.

The deformation of the XS group however was 20% lower. Also the calculated deformation in the FE study was 20% lower. Also deformation amplitude was lower with 0.31 mm compared to 0.42 mm in the plate group. The differences however were not significant. Both devices show good biomechanical results. The XS nail has the advantage of mainly intraosseus position, simple operation technique with introduction over a guide wire from the proc. Styloideus radii and over drilling with a cannulated drill of the same size. The exposure of the N rad.superf. must be performed. First clinical evaluation is presented.

212 Angioembolization in Severe Pelvic Fractures: Experience of a Tertiary Centre in United Arab Emirates Results: Twelve patients (all males) having a median (range) age of 25 (16-37) years were studied. Five were vehicle drivers, four passengers, two pedestrians, and one fall from height. Seven had abdominal tenderness while four had abdominal guarding. Median (range) systolic blood pressure before angioembolization was 87 (60-132) mmHg and 106 (0-123) mmHg after embolization. Nine patients had unilateral internal iliac artery embolization, one had embolization of the pubic bone artery, one had pudendal artery embolization, and one had bilateral iliac embolization and liver embolization. Six patients had external fixation of the pelvis after the angioembolization. Three patients had a laparotomy, the first had intraperitoneal urinary bladder rupture which was repaired, the second had pelvic packing and diverting colostomy for a severe perineal wound, the third had a liver injury and died on the table. One patient had a thoracotomy with interposition aortic thoracic graft. Eleven were admitted to the ICU having a median (range) ICU stay of 10 (1-18) days. The overall median (range) hospital stay was 33 (14-117) days. Only one patient died (8.3%).

Conclusions: Angioembolization of severe pelvic fractures with haemorrhage was successful in 93% of cases and played an important role in the initial management of severe pelvic fractures with haemorrhage. There were nine female and eight male patients passed with a mean age of 27.7 years. The knees were assessed at regular intervals and the mean follow-up period was 11.2 months (range 6-16). After initial assessment to confirm absence of trochlear dysplasia, the technique involves plication of the medial retinaculum with a nonabsorbable suture passed percutaneously using a long curved needle under arthroscopic vision and a small incision to bury the knot from the plication. Post operative rehabilitation was done with flexion restricted to 30°for the first 2 weeks followed by a gradual return to normal range of movements with Vastus Medialis Obliquus strengthening exercises.

Results: 16 patients reported good outcomes with no further episodes of dislocations. One patient who had persistent patellar instability requiring further distal bony-realignment procedure to achieve stability. None of the patients had major complications. Conclusion: We report good results with this relatively simple technique of medial retinacular plication and would advocate it as an effectiveless invasive surgical option for patients with recurrent patellar instability in the absence of major trochlear abnormality or significant mal alignment. in a lateral (group A) and 9 in a prone position (group B) with no significant difference in age (39.9/42.1 years) as well as pre-and insurgery parameters; no patients were excluded. The complication rate was analyzed by medical records, the radiographic outcome by plain X-rays and CT scans after an average of 9 months postoperatively. Comparison of the two patient groups utilized t-tests or chisquare testing of Pearson as determined by number of data points for each variable assessed.

Results: The adequacy of fracture reduction had significantly poorer findings according to Matta in A (p = 0.032), resulting in a significantly higher post-traumatic arthrosis rate (p = 0.049) defined as Helfet III or IV. No revision surgery was needed; no infection was detected in any group whereas 2 iatrogenic nerve damages (1 temporary, 1 persistent) were found only in A. There was no significant difference concerning extensive blood loss, femoral head necrosis, Epstein grades, heterotopic ossification classified by Brooker and secondary surgery needed.

Conclusions: Due to gravity the femoral head in the lateral position may constrain reduction leading to an inferior radiographic outcome. Purpose: The incidence of fracture Neck of Femur (NOF) has been increasing worldwide, due to an aging population. The commonest forms of analgesia are opioids and in some units regional blockade. But regional block is skill dependent and opiates are known to have many side effects. Paracetamol is an analgesia that is safe and has an excellent side-effect profile within standard doses. Intravenous paracetamol has a far higher predictable bio-availability than oral, within standard dosage. This study is to assess the suitability of using intravenous Paracetamol as an alternative. Method: Prospective study: a change in protocol resulted in all NOF's admitted under the care of the senior author being prescribed regular intra-venous paracetamol within standard dosage. PRN opioids were available for breakthrough pain. NOF's admitted under the care of other consultants remained on the established protocol. Opioid usage and pain scores (0-10) were measured. Results: Results of 72 patients were collected, 44 in intravenous paracetamol group and 28 in the original protocol group. There is a 65% reduction in opiate usage in the intravenous paracetamol group (p value = 0.015). There is only a 0.5 difference in average pain score between groups (p value = 0.173).

Conclusion: The use of regular intra-venous paracetamol results in a significant reduction in the need for opioid analgesia. The pain relief within this group was comparable to that in the control group. A simple change in analgesia protocol to a safer, more predictive agent can result in an improved pre/postoperative period. Author to editor: Funding: the study received no funding from any source. External fixation has already became on the end of last century as routine temporarily method of fracture bone fixation, especially in the light of damage control. But out of damage control, external fixation has been accepted in many developed countries as routine temporarily method in treatment of complex articular fractures (knee, ankle, elbow). The main reason was absence (night time, weekend) of experienced surgeon who can treat these complex particular fractures, as during the night. Sometimes, the skin problem can prolong such fixation for three or more weeks. However, external fixation of tibia and distal radius can be method of choose for definitive treatment not only in open but in closed fractures as well. It becomes justified when high mobile and relatively simple external fixation devices have been developed allowing addition correction of reduction. In this paper, we want to present possibility of using already applied, external fixation device as temporarily method. About 1 week after external fixation done (on femur or tibia) we developed technique existing external fixator to be used as a reduction device. Once, desirable fracture reduction achieved, internal fixation is very easy and we do not need fluoroscopy control for reduction, just for internal device fixation by minimally invasive method. Using this method, we already treated 10 patients with femur fractures and 12 with tibia fractures. From results obtained it can be concluded that external fixator developed by Mitkovic is suitable to function as accurate fracture reduction device providing condition for simple minimally invasive internal fixation. Results: With the antegrade nailing technique the mean postoperative Constant Score was 62.6 (Flexion 122.9°m Abduction 125.7°, Pain 14.6). The elbow extension was free in 77.8%. A correct axial alignment was found in 88%, in 12% we found a varus deviation of 10°-20°. In 17% the nail perforated. In complications there was one prolonged bone healing, one pseudarthrosis and one infection. Two thirds of the patients were very satisfied with the outcome. In the retrograde nailing technique the mean postoperative Constant Score was 75.4 (Flexion 152.2°, Abduction 148.8°, Pain 13.9). The elbow extension was free in 81.1%. Only 6% of the patients showed a mild discomfort at the operative approach at the elbow. A correct axial alignment was found in 88%, in 12% we found a varus deviation of 5°-15°. In 4% patients showed a postoperatively detected fracture in the supracondyle region. 71.4% of the patients were very satisfied with their outcome. Conclusion: The retrograde nailing technique is a save and sufficient method for treating humeral shaft fractures, especially because the rotator cuff is not disturbed.

Introduction and objectives: The bony Bankart lesion is an avulsion fracture of the glenoid that usually occurs after anterior shoulder dislocation. This injury is frequently missed and often creates shoulder instability. Therefore, open reduction and internal fixation (ORIF) of the fragment is recommended. In this study we looked at shoulder function, instability and pain after this operation. Postoperative X-rays were reviewed on anatomical reduction. Patients and methods: Between 2000 and 2008, 19 Bankart fractures were operated. They were classified according to Ideberg. Sixteen patients had an Ideberg type 1B fracture and three a type 2. These patients received questionnaires with a number of validated scoring systems. We used the ASES, Rowe shoulder score and the DASH questionnaire.

Results: The response was 73%. All respondents did get a stable shoulder after surgery. Two patients regularly experience mild pain. The average Rowe score was 90.8 (range 0-100). The average ASES score for ADL was 24 (maximum score 30, ADL unlimited). The median DASH score on the quality of life was 5.6 (where 0 means no loss of quality of life). There was a clear positive relationship between the radiological postoperative congruency of the joint, the shoulder function and quality of life. Introduction: Traumatic dislocation is the most severe form of ligament injury of knee.The purpose of this study is to report our cases in past 10 years. Methods: Between 1998 and 2008, 26 knees in 21 men and 4 women; 25 patients were treated for traumatic knee dislocation in our trauma center. The mean age was 32 (16-80) years at the time of injury. The mechanism of injury were motor vehicle accident in 19, fall from high in 4 and industrial accidents in 2 patients. 11 patients had additional extremity trauma. Vascular injury detected in 4 knees who required immediate reconstruction by vascular surgeons. The orthopaedic stabilization of the initial injury was bridging external fixation in 13 knees included all vascular injuries. 5 patients had fibular nerve palsy. In 14 knees Medial collateral ligament, in 13 knees lateral collateral ligament, in 26 knees anterior cruciate ligament, in 24 knees Posterior cruciate ligament and in 5 knees posterol ateral corner lesions were diagnosed. One had tuberositas tibia avulsion. Multiligament reconstruction was performed on a delayed basis in 13 patients for a minimum of 1 (1-12) month after the injury All patients had functional rehabilitation for a mean 18 (12-28) weeks. Results: At an average follow-up of 6.3 (1-10) years they were examined for stability and range of motion. All knees having multiligament reconstruction and 8 of the 12 patients in whom nonsurgical treatment was undertaken were stable. Patients having multiligament reconstruction had slightly lower knee range of motion Hypothesis: Computed Tomography (CT) is more accurate than bone scintigraphy for diagnosis of a radiographically occult scaphoid fracture.

Methods: In a study period of 1 year, 70 consecutive patients with a suspected scaphoid fracture but no fracture on scaphoid radiographs were evaluated with CT within 24 h of injury and bone scintigraphy between 3 and 5 days after injury. The reference standard for a true (radiographic occult) scaphoid fracture was either (1) diagnosis of fracture on both CT and bone scintigraphy, or (2) in case of discrepancy, clinical and/or radiographic evidence of a fracture.

Results: CT showed 6 scaphoid and 13 other fractures. Bone scintigraphy showed 17 scaphoid and 21 other fractures. According to the reference standard there were nine scaphoid fractures. The prevalence of true scaphoid fractures among suspected fractures was therefore 13%. CT had a sensitivity of 67%, specificity of 100%, accuracy of 96%, a positive predictive value (PPV) of 100% and a negative predictive value (NPV) of 95%. The prevalence corrected PPV was 100% and the prevalence corrected NPV was 95%. Bone scintigraphy had a sensitivity of 100%, specificity of 90%, accuracy of 89%, a positive predictive value of 53% and a negative predictive value of 100%. The prevalence corrected PPV was 53% and the prevalence corrected NPV was 100%. Summary: This study could not confirm that early CT imaging is superior to bone scintigraphy for suspected scaphoid fractures. Bone scintigraphy remains a highly sensitive and reasonably specific study for the diagnosis of an occult scaphoid fracture Introduction: The therapeutic management of scaphoid fractures is still surrounded by controversy. Immobilisation for non-or minimal displaced scaphoid fractures results in a union rate of more than 90%. Functional outcome is often measured using clinical examination and radiological consolidation. However, the indication of how successful the treatment has been is the functional outcome of the patient. Functional outcome of upper-extremity fractures can be measured reliably using the DASH (Disabilities of the Arm Shoulder and Hand) Outcome Measure. Materials-Methods: 39 consecutive patients with 40 non-or minimally displaced scaphoid fractures, treated conservatively, were included. The trauma mechanism, treatment modality, diagnostic modalities, duration of cast immobilization and complications were analysed for all patients. Functional outcome was measured using the DASH Outcome Measure. Results: 30 patients showed good clinical and radiologic outcome after 6 weeks of cast immobilization with a mean DASH of 4.6. Six patients consolidated within 12 weeks with a mean DASH of 11.8. Three patients with four fractures took more than 12 weeks to achieve clinical and radiologic consolidation and had a mean DASH of 38.5. The DASH questionnaires showed statistically significant differences between patient age, fracture location and duration of cast immobilization. Conclusion: Conservative treatment of non-or minimally displaced scaphoid fractures results in good functional outcome after 6 weeks of cast immobilization, particularly in young patients with distal or waist scaphoid fractures. Objective: Pedicle screw instrumentation is the most common procedure in stabilizing fractures of the throracolumbar spine, but yields an immanent potential for iatrogenic damage due to malpositioned pedicle screws. Methods-materials: 99 patients undergoing posterior instrumentations were included. Preoparative CT scans were used to determine fracture level and classification. Postoperative CT scan were evaluated for screw positions of all pedicle screws. Cobb angles were compared to calculate the degree of reduction. The position of all pedicle screws was determined according to the classification proposed by Zdichavsky.

Results: 426 pedicle screws were assessed. 305 pedicle screws were classified as optimal (Ia, 72%), 39 Ib, 23 IIa, 48 IIb, 11 IIIa and 8 IIIb.

Malpositions were more often the more cranial pedicle instrumentation was performed (11% increase per level, p < 0.01). Malpositions (Ib-IIIb) occurred more often on the right side of the patient (p < 0.05). The mean reduction was 10°.

Discussion: This study confirms the hitherto felt but unproven suspicion that malpositioning occurs more often in the upper thoracic spine. Even more remarkably is the side-dependency in malpositioning. We attribute the higher rate of malpositioned screws on the right side of the patient to the circumstance that the surgeon usually stands on the left side of the patient and visual control of the direction of the pedicle screw during insertion is probably more difficult on the opponent side. We recommend envisioning this fact and -if navigation is not used -changing the position during the procedure. Background: U-shaped sacral fractures are rare and highly unstable pelvic ring injuries. Surgical stabilization may facilitate early mobilization and reduce mortality. However, limited evidence has prevented the development of a standard treatment algorithm. Furthermore, little is known about the quality of life in these patients.

Purpose: To assess the injury characteristics, choice of treatment and quality of life of patients with U-shaped sacral fractures. Methods: Eight patients with U-shaped sacral fractures were identified over a 6-year period. Neurological outcome was classified by Gibbons' criteria. Quality of life was evaluated using the EuroQoL-6D questionnaire.

Results: There were five women and three men; the median age was 29 years. The Injury Severity Score ranged from 17 to 45. Definitive internal fixation was established after 2 to 22 days. Percutaneous iliosacral screws were used in two patients with relatively stable fractures. Transsacral plate osteosynthesis was used in one patient with minor displacement. Triangular osteosynthesis with transsacral plating was used in four patients with multilevel sacral fractures, highly unstable fractures or traumatic spondylolysis L5-S1. One patient with an associated L2 fracture received a triangular osteosynthesis without transsacral plating. Early partial weight bearing was encouraged whenever possible. Follow-up ranged from 5 to 65 months (median 36 months). Four patients kept severe bowel and/ or bladder dysfunction. In the EuroQoL-6D, pain, mood disorders and mobility problems prevailed. Conclusion: U-shaped sacral fractures are rare and complex injuries. Operative stabilization is tailor-made on the individual fracture characteristics. Outcome is dominated by neurological deficits, pain, mood disorders and mobility problems. Background: Traumatic amputations are important causes of acute stress disorder and post-traumatic stress disorder. In this study, we aimed to present traumatic amputated patients needed more psychiatric support than the other trauma patients during the hospitalization period in the orthopaedics and traumatology clinic and in the later periods more post-traumatic stress disorder could be observed in this patient group. Patients and methods: Twenty-two traumatic amputated patients who have been treated in our clinic were evaluated retrospectively. During the early post-traumatic period, between the 2nd and 20th day, it was observed whether they needed any psychiatric support treatment. After the 6th month of the trauma, the patients were referred to the psychiatry department, and it was evaluated whether they needed any psychiatric support treatment by measuring the 'post-traumatic stress disorder scale' (TSSB-Ö ).

Results: Twenty-one (%95.5) of twenty-two patients were male, one (%4.5) of them was female. Introduction: Intramedullary nailing is challenging in proximal tibia fractures, associated with high rates of malalignment. To date, no studies report the potential of lateral tibia nail insertion to correct primary valgus malalignment, commonly seen in proximal quarter fractures. Materials and methods: 18 fresh-frozen cadaver lower extremities were used to simulate an AO/OTA 41-A3 fracture. Six nails (Expert Tibial Nailing System, Synthes, Salzburg, Austria) were inserted at the lateral third, six nails at the middle third and six nails at the medial third of the lateral tibia plateau. After nail insertion, alignment in the coronal plane was recorded. Results: Mean varus malalignment was dependent on the entry point at the lateral tibia plateau. Mean varus malalignment was 16°if nails were inserted at the lateral third, 10°at the middle third and 4°after nail insertion at the medial third. If nails were inserted from the medial third, valgus malalignment was recorded in two specimens. Discussion: The effect of correction of coronal malalignment in proximal tibia fractures is dependent on the point of nail entry at the lateral plateau. Primary valgus deformation up to 20°can be corrected by inserting tibia nails at the lateral third of the lateral tibia plateau. Surgeons should be aware of possible varus deformity and valgus malalignment despite lateral nail insertion. Introduction: Treatment of patients with distal radial fractures is primarily based on radiologic parameters. However, correlation between these parameters and functional outcome is questionable.

Objective: Determine the value of radiological parameters for the appropriate treatment of patients with distal radial fractures. Methods: A retrospective analysis was performed for a consecutive series of patients with conservatively treated distal radial fractures. Axial radial shortening, radial displacement, radial angle, dorsal angle, and dorsal displacement were measured on the postero-anterior and lateral X-rays. Functional outcome was measured using the Quick DASH-score (QDS). Minimal follow up was 24 months. The radiological findings of patients who met the criteria for conservative treatment were compared to those of patients that met the current criteria for operative treatment (dorsal angulation > 10°, radial angle > 10°, radial displacement > 2 mm, radial shortening > 5 mm and step off > 2 mm) but who had been treated conservatively instead. Results: In a 2-year period 396 patients were treated conservatively for a distal radial fracture. The QDS was performed in 256 (65%) patients. Male female ratio was 1:3, the average age was 60 years (range 18-94). The mean QDS was 12 (SD ± 18; range 11-84). Age and female sex associated negatively with the QDS. None of the radiologic findings was associated with the QDS. Half of the patients met the current criteria for operative treatment. The QDS of this group corresponded however with that of the correctly conservatively treated patients. Introduction: Conservative treatment is generally preferred for simple elbow dislocations. In this study, the clinical and radiological results of conservative treatment are retrospectively evaluated. The patients were treated with closed reduction, plaster splint and brace. Methods: Dislocations of all 21 patients were towards posterior and the average length of immobilization was 20.2 days (7-30 days) after closed reduction. The patients were assessed clinically for range of motion, instability, and atrophy after 33.9 months of mean follow up. Mayo Elbow Performance Score (MEPS) was used to evaluate functional outcome. Standard elbow X-rays were evaluated for degeneration, heterotopic ossification, and concentric reduction. Results: The average age of the patients was 35.4 (12-81) years. None of the patients had muscular atrophy. Four patients (19.1%) reported mild pain with heavy activity. Six patients (28.6%) had neurological complaints related with ulnar nerve. The average flexion arc and average rotational arc were 131°and 172°, respectively. The differences between the contralateral elbow motions were 10.9°for flexion arc and 3.1°for rotational arc. Four patients (19%) had minimal residual instability. Three patients (14.3%) had mild radiographic signs of arthrosis and 14 patients (66.7%) showed minimal-mild degree of heterotopic ossification. An average score of 96.9 was obtained using MEPS. Only four patients (19%) considered themselves fully recovered. Conclusion: Closed reduction and immobilization is a universal method for simple elbow dislocations. However, although functional scores were excellent, most of the patients did not consider themselves fully recovered. Anterior odontoid screw fixation (AOSF) is a valuable treatment after OF, reported union rates in the elderly vary between 70 and 100% when assessed on plain radiographs. In this study union-rates in OF treated with AOSF in patients aged ‡ 60 years were revisited and risk factors for non-union analyzed. Retrospective data review of a prospectively gathered C2-fracture patients treated with AOSF for OF and age ‡ 60 years were included for study. Asides demographics and common injury characteristics, injury radiographs and CT-scans were assessed for fracture displacement, type, atlantodental osteoarthritis and particularly focussing on the square surface of OF. Follow-up CT-scans were assessed for technical failures, odontoid union, number of screws in AOSF, square surface of screws used and the related healing surface. There were 13 male (72.2%) and 5 female (17.8%) patients with a mean age of 78.1 ± 7.6 years at injury (60-87y). Mean follow-up with CT-scans was 75.7 ± 50.8 months (4.2-150.2mo). Intervall injury to AOSF was 4.1 ± 5.3 days (0-16 days). Mean square surface of fractures was 127.1 ± 50.9 mm 2 (56.3-215.9 mm 2 ) and mean osseus healing surface was 84.0 ± 6.8% (67.6-91.1%). CT-based analysis revealed osseus union in nine (50%), while the remaining nine patients (50%) revealed non-union. In two patients, symptomatic non-union indicated posterior fusion of C1-2. Union-rate significantly correlated with increased fracture surface (p = 0.02).

Observable was the trend that using two screws for AOSF correlated with increased fusion-rate compared to one screw (p = 0.06). Lifethreathening hemorrhage is often seen in pelvic ring fractures. Efficient treatment of this hemorrhage is critical for survival in these patients.

The purpose was to analyse the causes of death in hemodynamically unstable patients with a pelvic ring fracture and to determine if standardized treatment will reduce mortality. Retrospectively, all data were reviewed of hemodynamically unstable patients with a pelvic ring fracture in the period 1/1/1999 till 1/9/2006. Of all patients, the pathway of treatment was analysed and compared with the standardized treatment protocol in our clinic. All injuries were categorized in injuries in Airway, Breathing, Circulation and Disability according to ATLS Ò principles. Death was classified as directly related to the pelvic fracture if the patient required massive transfusions, died within 24 h after admission and had no other body area injury with AIS ‡ 4 responsible for persistent hemorrhagic shock. We reviewed the data of 115 patients. 26/115 patients died (23%). These patients were significant older and had a significant higher ISS and shock class than survivors. Two patients died of pulmonary trauma (7%), 11 patients (43%) died of exsanguination(C) and 7 patients (28%) died due to major head trauma. In 6 patients (21%) there was a combination of injuries, which caused death. Thus, overall hypovolemic shock contributed to mortality in 17 cases. Only in three patients death could be directly related to hemorrhage from the pelvis. Two nonsurviving patients (8%) were not treated according to our standardized treatment protocol. In the survivor group this was only one patient. There is no consensus on the treatment of the acute total Achilles tendon rupture. Treatment modality is chosen on the basis of patient characteristics or the preference of the attending surgeon. Using ultrasound, the distance between the two tendon ends in equinus position can be measured. This could form the basis for decision making between conservative-and surgical treatment. This cohort study consists of 164 consecutive patients, between January 2000 and January 2007. Using ultrasound, patients were assigned to a surgicalor conservative treatment group. A gap of more than 2 mm in maximal equines position was an indication for surgical treatment. Seventy-two patients, 60 men and 12 women, received a conservative treatment. In 91 patients the Achilles tendon was primarily sutured.

In the surgical group the post operative treatment was identical to the conservative treatment. The male-female ratio did not differ significantly (p = 0.738). The average age was 41 years. Sports caused 88% (n = 144) of all injuries. The surgical group showed six re-ruptures versus nine in the conservative group (p = 0.195). On average, a rerupture occurs after 55 days. No significant difference in major and minor complications (p = 0.500). Outpatient treatment was needed 75 days for the surgical treatment group versus 85 days for the conservative treatment group (p = 0.357). Ultrasound measured distance between the two ends of the Achilles tendon in equinus in an acute total rupture can be used as a selection method in making a decision between surgical and conservative treatment. Introduction: Missile wounds induced by aviation bomb splinters pertain to grave injuries, due to large wound area and high risk of complications. Material-methods: 11 patients with large defects, in 7 of casescombined with long bone fractures caused by missile injuries were treated by us in the period of August-November in 2008. Every cases were subjected to radical primary debridement with complete drainage. After relevant preparation for soft tissue plastic repair (involving primary radical debridement, primary external fixation, complex drug therapy and repetitive regular debridement) the following repair procedures were undertaken: In four cases, soft tissue defects were covered via rotation of local flaps. In three cases, defects were covered through transplantation of free skin grafts. In four cases, large soft tissue defects were overlayed by vascularized thoraco-dorsal (LD flap). In two of these, bone defect repair was simultaneously performed applying avascular graft taken from hip bone crista.

Results: In seven cases, transplanted flaps adhered perfectly, without trophic or infective complications. In one case, rotated local flap necrotized due to interrupted perfusion, which was subsequently replaced by free skin transplant. In five cases, fracture consolidation was completed in 4-5 months. In remaining two cases (after bone defect repair), consolidation process still proceeds with satisfying rate.

Conclusion: Transplantation of vascularized thoraco-dorsal flap is especially effective for covering large soft tissular defects. Soft tissular plastic repair has the double advantage of defect reconstructive ability and prevention from secondary infections, with additional stimulation of bone tissue regeneration. Introduction: Shoulder arthroplasty remains a valuable treatment for complex fractures of the proximal humerus. However the success of anatomical arthroplasty is mainly dependent of anatomical healing of the tuberosities. Even with specific prostheses and fixation techniques in 25-40% of cases anatomical healing is not achieved. Using a nonfracture specific trauma prosthesis we achieved better elevation and abduction; however endorotation, exorotation, subjective shoulder rating and complication rate did score poorer than in anatomical arthroplasty. We assumed that the impossibility to refixate the lesser and greater tuberosity fragment, and subsequently the subscapularis and infraspinatus-teres minor tendons, are the main cause for this observation Material-methods: We developed a fracture specific reversed shoulder prosthesis allowing for anatomical refixation of the tuberosities. We included 20 patients in the reversed fracture arthroplasty group. Function is scored using the constant Murley-score. Radiographically we evaluate for evidence of scapular notching. Complications are recorded. We compare our results to an historical series of Delta III prostheses. Results: At 6 months the mean Constant score is 51.5 points. There was no case of notching. There was one complication, an early infect. The mean Constant score in the Delta group was 42 points. There was notching present in 55% of cases. In the Delta group there were five reoperations in three patients because of dislocation.

Conclusion: There is a strong trend to better functional outcome using the fracture specific design. There are less complications and less notching. The possibility to refixate the tuberosities leads to better results. Introduction: As fractures of the femur are severe injuries and patients mostly suffer from extensive pain they quickly attract the physician's attention in the emergency room. The literature has shown that injuries to the ipsilateral knee can occur accompanying such injuries. In most cases, these injuries though were diagnosed on delay. Excluding cases in which a knee injury was apparent already on admission, we sought to investigate the number and severity of initially undetected lesions to the knee accompanying a femoral shaft fracture and give an overview of the literature. Methods: Charts and X-rays of patients treated for a femoral shaft fracture from January 2000 until December 2007 were reviewed. Patients, in whom any other injury of the affected limb apart from a midshaft femoral fracture was initially diagnosed, were excluded. Also patients, in whom an injury to the knee had been diagnosed on admission, were excluded. Results: Fifty-three patients with midshaft femoral fractures were available for analysis. An injury to the knee was diagnosed in 3 cases (5%). There was one partial tear of the posterior cruciate ligament and two grade 2 lesions of the medial meniscus. All lesions were conservatively treated. The shoulder is the most mobile joint of the human body. It has a great range of movement that takes place in all three Cartesian planes. This is a complex phenomenon. There is considerable controversy over an ideal method for the functional assessment of shoulder joint complex. Various methods have been used but they are often inaccurate and unreliable. Thus, a better technique, that is reliable as well as repeatable, is required to measure the movements. The aim of this study is to assess the shoulder movement by Fastrak Ò and Vicon Ò systems and to compare their repeatability.

Methods-materials: The functional movement of the shoulder joint was assessed by Fastrak Ò and Vicon Ò systems. A difference between the two systems was determined and a comparison of repeatability was carried out. A population of healthy male volunteers were asked to perform six different tasks that covered all the movements occurring at the shoulder. These tasks were repeated twice on each side on two different days. The measurements were recorded and a custom-made programme, prepared for each system separately, calculated the angles.

Results: The recorded data was analysed using Repeated Measure Analysis of Variance. It was found that the coefficient of repeatability of Fastrak Ò was better than the Vicon Ò system for each task and there was no significant difference (p < 0.05) between the two sides.

Conclusion: The Fastrak Ò system is better than the Vicon Ò system for assessing shoulder movements. It can be used in clinical practice. (19-25). We applied Sarmiento cast without any padding or little padding immediately. We encouraged the patients moving their arms. The treatment ends upon the presence of a bone callus and absence of pain at the fracture site. During the whole therapy the skin condition is monitored and emphasis is put on the prevention of reflex sympathetic dystrophy. We evaluate the result of the treatment with a focus on the any restriction of the range of motion of joints and the presenting any angulation of the humeral shaft. Average follow up time was 6 months (4-48). All fractures were healed without any major problem and we did not face any nonunion and no major angulations axis of the humerus. Average union time was 3 months (2-4). The results of nonsurgical treatment of the humerus mid and distal thirds shaft fractures are reported as a less complicated way and have a higher rate of union. This method is practical, efficient, cheap, and safe, if a good cooperation with patients is established and close observation is done. (2004). The aim of this study is to evaluate the surgical anatomical aspects of the minimally invasive hip surgery procedure in cadavers.

Methods: The MIS approach was performed on four specially embalmed cadavers. All cadavers had a normal 'Range Of Motion' of the hip joint. The difference in muscle length and work space were measured in all leg positions. Additionally the difference in muscle tension in anterior and posterior luxation was compared with regard to the accessibility of the femoral shaft.

Results: The length of the medial-and minimal gluteal muscles is reduced in abduction. A difference of more than 1 cm was found between 20°to 30°abduction and full abduction. The working space (6.3 · 5 cm), is limited in the maximum (50°) abduction position. Posterior luxation gives a better femoral shaft approach and less/ none muscle tension/damage compared to anterior luxation.

The optimal approach to the femoral neck during MIS of the hip is achieved during 20°-30°abduction of the ipsilateral leg combined with 10°retroflexion. The best femoral shaft approach for prosthesis insertion is the posterior luxation. No additional damage, excluding the skin and fascia incision, was seen during posterior luxation. Posterior luxation and exorotation of the leg enables straight and direct access to the femoral shaft compared to the access obtained during anterior leg luxation. Background: It has been stated that acromial morphology plays an important role in the etiology of rotator cuff pathology. The system most widely used to describe the morphology is the Bigliani classification. Recently Nyfeller introduced the acromial index. We wanted to examine whether there is a correlation between these two parameters and the presence of a rotator cuff tear or an impingement syndrome.

Methods: We assessed both parameters in four groups of 100 patients each. The first group consisted of patients with operatively treated rotator cuff tears (average age 62.29 years) and the second group of patients known with impingement syndrome but documented intact rotator cuff (average age 52.37). For both groups, an age and gender matched control group was constructed. Results: Type three acromions were significantly more prevalent in the rotator cuff tear group than in the control group (p < 0.05). The average acromial index was 0.698 + 0.0766 in the rotator cuff tear group and 0.683 + 0.0733 in the rotator cuff control group, which is not statistically significant (p = 0.16). In the impingement group, the acromial index was 0.647 + 0.0784 and 0.680 + 0.0744 in the impingement control group. This difference was found to be statistically significant (p < 0.005).

Conclusions: Patients with a rotator cuff tear appear to have more frequently Bigliani type three acromion than age and gender matched, asymptomatic patients. There is no correlation between acromial index and acromial type or age. Objective: Extracorporeal membrane oxygenation (ECMO) is rarely used successfully in trauma. Transfusion related acute lung injury (TRALI) is also rare in plasma containing blood product transfusion.

Methods: This is a case report of a trauma patient with life-threatening TRALI following trauma that was rescued successfully using ECMO.

A 24 year old patient was struck by an automobile and suffered a grade II splenic injury, grade IV-V right renal injury as well as multiple orthopedic injuries. An attempt at angiographic embolization failed as the patient required multiple transfusions and became progressively hypotensive. The patient underwent emergent nephrectomy but rapidly became hypoxic with the PaO 2 becoming less than 20 mmHg for over an hour. Despite aggressive attempts at ventilation and oxygenation, the endotracheal tube was filled with fluid and hypoxia pursued despite low right heart filling volumes.

Rescue ECMO was instituted with successful oxygenation. After 48 h the patient recovered from TRALI and was able to have ECMO discontinued. The patient was weaned off the ventilator within 12 days and the patient had full recovery. The patient did not suffer any hypoxic brain insult. Conclusions: Although it is often thought that ECMO is unsuccessful in trauma patients, this case demonstrates its potential use in trauma patients.

Author to editor: Will also present as poster Findings: A total number of 14 patients (all male; 22.9 ± 8.7) were found. Injuries were resulting from gun shot fires (n = 5; 35.7%) or stab wounds (n = 9; 64.2%). Injury sites within the heart were the right atrium (n = 2; 14.3%), the right ventricle (n = 4; 28.6%), the left atrium (n = 3; 21.4%), and the left ventricle (n = 7; 50.0%) (More than one site was observed in 2 patients). The accompanying injuries were observed in the spleen (n = 3; 21.4%), the lung (n = 2; 14.3%), the liver (n = 1; 7.1%), and the stomach (n = 1; 7.1%). In 10 (71.5%) patients emergent thoracotomy was clinically decided with suspicious findings of hypovolemic shock or cardiac injury including low blood pressure, jugular fullness, deeply heard heart sounds, filiform pulse, narrowing of pulse pressure. The rest patients (n = 4; 28.5%) were operated after major blood drainage from tube thoracostomy. All the injuries were repaired with sutures, and pericardial fenestration was done in all. Mortality was observed in two cases (14.3%).

Patients with penetrating regional wounds should be suspected for penetrating cardiac injuries, since immediate surgical intervention may decrease the risk of mortality. Introduction: The use of ''pan-CT'' is discouraged in settings of high imaging demand. This study compared clinical and plain chest film findings to determine need for, and results of, chest CT. Methods: During recent 9 month period, 400 patients sustained blunt chest injury either isolated or in setting of multisystem trauma. Data was tabulated by a combination of prospective and retrospective analysis. Initial injury assessment followed ATLS protocol. Supine chest film, followed by chest CT, were performed in all patients and compared with clinical findings. Results: Significant clinical findings were defined as tachypnea, decreased air entry, chest wall tenderness and initial oxygen saturation less than 95%. The presence of two or more of these clinical findings occurred in 138 patients (34%). CT findings in this group included multiple rib fractures ± flail chest, sternal fractures, pneumothoraces, hemthoraces, and pulmonary contusions. Higher AIS and need for interventions occurred in this group. The co-existence of tachypnea and desaturation correlated with the need for tube thoracostomy in 91/138 patients(65%) -15 pre-CT, 76 post CT.

Conclusions: In patients with blunt chest injury, the presence of two or more of the clinical signs -tachypnea, decreased air entry, chest wall tenderness, oxygen saturation < 95% -is associated with: (1) significant chest injury demonstrated on chest CT; (2) higher correlation with CT findings than plain films alone; and (3) Introduction: Complex Regional Pain Syndrome (CRPS) sustained after trauma has a great negative impact on rehabilitation and activities of daily living. Treatment is most often unrewarding. Aim: To analyze prospectively the efficacy of endoscopic thoracic sympathectomy (ETS) in reducing pain and disability associated with CRPS. Patient and methods: Over a 5-year period, 15 patients (7 females and 8 males; mean age 48.9 ± 2.2) with posttraumatic CRPS underwent unilateral ETS. The median duration of CRPS symptoms before ETS was 4.1 months (range: 1.2-194) . The sympathetic chain was resected from the second to fifth rib. Mean postoperative follow-up was 18.7 ± 3.4 months (range: 1-40.9). Pain was assessed, at rest (passive) and during movement (active), using a visual analogue scale (VAS) from 0 to 10. Results: One patient (6.7%) had a hydrothorax and three patients (20%) complained about contralateral compensatory hyperhydrosis. At 1 month (n = 12), 2 months (n = 8), 6 months (n = 11) and 1 year (n = 10) after ETS, there was a significant decrease in passive and active VAS (P < 0.05). Ten out of 14 patients (71,4%) needed less analgesics after surgery, and seven (50%) did not need analgesics at all. The mean sleep duration improved significant from 2.7 ± 1.6 h preoperatively to 6.0 ± 1.1 h postoperatively (p < 0.05). Overall, patient satisfaction was 85% (11 out of 13 patients). Conclusion: ETS is efficient for decreasing pain and improving quality of life, and therefore should be considered in the treatment of CRPS.

Author to editor: Complex Regional Pain Syndrome (also known as Sudeck or Reflex Sympathetic Dystrophy) is a complex disease that trauma surgeons frequently encounter in the post-traumatic period. Endoscopic thoracic sympathectomy is not well known among trauma surgeon, although it is an good option in relieving the pain and improving the quality of life.

monitoring is accomplished with chest X-ray (CXR), but ultrasound (US) is nowadays established as more sensitive than CXR in detection of PTX. Patients and methods: From October 2005, thoracic views for detection of PTX are systematically included in the EFAST protocol during primary survey for every trauma patients (pts) admitted to our Level I Trauma Center. Among hospitalized pts, a selective USguided aspiration for small PTX was applied in three pts (two with a slow reabsorption time, one in a pt requiring hyperbaric oxygen therapy for a soft tissue infection of the leg). In supine position, delimitation of the area of anterior PTX was done with a linear probe, searching for lung points in adjacent intercostal spaces. Under local anesthesia, a 8 Fr catheter was inserted in the PTX and aspiration monitored in real time by US, until restoration of sliding lung. The day after, after confirmation of normal gliding lung, two pts were discharged and one deemed suitable for hyperbaric oxygen therapy. Discussion: Small traumatic PTX is generally monitored without treatment. In some pts, drainage is however required, but the procedure is blind if performed on the basis of CXR findings. US allows to precisely define the site and the limits of PTX, insert a small catheter in the right area, monitoring reexpansion of the lung and complete aspiration of PTX and shortening recovery. Background and objectives: Occult diaphragmatic injuries are associated with significant mortality, if the diagnosis is delayed. We report our experience in diagnostic and therapeutic thoracoscopy in a selected group of patients with penetrating thoracoabdominal injuries.

Methods: The patients who underwent thoracoscopic management of thoracoabdominal stab injuries between June 2001 and June 2008 were included into the study. The data were retrospectively analyzed.

Results: Eighteen selected patients with thoracoabdominal stab injuries were managed by thoracoscopy. The procedures were performed under general (n = 17) or local anesthesia (n = 1). Diaphragmatic injuries were repaired by intracorporeal sutures in seven cases and bleeding was controlled in another two cases by electrocautery coagulation. The procedures were simply diagnostic in nine patients. The mean operating time and hospital stay were 36.4 min and 4.7 days, respectively. There was neither intraoperative or early postoperative complication, nor mortality. In a patient who had intra thoracic adhesions due to prior tuberculosis, unmentioned by the patient preoperatively, adequate exploration could not be achieved during thoracoscopy. The procedure was converted to laparoscopy and laparoscopic gastric and diaphragmatic repairs were performed. Conclusion: Thoracoscopy seems to be a safe, quick and efficient method in the diagnosis and treatment of diaphragmatic wounds, due to thoracoabdominal penetrating injuries. The nonoperative management is gradually more used in abdominal stab injuries and surgeons can resort to thoracoscopy and laparoscopy as a minimally invasive, diagnostic and therapeutic tool. Trauma surgeons should be aware of the benefits of thoracoscopy and must have sufficient skills to carry out this technique. Summary: Generating Acute Lung Injury by smoke inhalation and analyzing a method to pursuit standardized smoke.

Methods: A standardized glass, measures of 25 cm width, 25 cm length and 25 cm height used as a closed area. We established a valf system under the glass which allows air inside but does not let it outside. With a hole above the glass, we attached the system to pomp with a hose. And the pomp was attached to a 20 cm radial length balloon by another hose. We put a four ampere electricity owen in to glass and put 2 g cotton to the oven. We burned the cotton for 180 s in the closed area and we fullfilled the balloon with smoke by the pomp in 120 s. Rabbits were entubated after being anestesized. We waited 180 seconds for the smoke to reduce down to room tempe rature to avoid thermal damage. After that, we seperated the balloon from the pomp and put it right through rabbits by ambulant air flow and inhalated in 5 min.This procedure repeated for each rabbit. After the procedure ended,the entubation tubes were pulled away and the rabbits were left to spontaneous respiration. Rabbits were allowed to standart rabbit bait and water at the 12th hour.

Results: We think we used a standardized smoke inhalation model in this study. Methods: Ten wistar rats were anesthetized and heparinised before the femoral artery was pierced to initiate bleeding. Rats were than randomized to control and study groups. MPH was poured into the bleeding site and a mass was placed on it. After 30 s, the mass was removed and assessment of hemostasis was done. If bleeding ceased the test was scored as ''passed at 30 s''. If not, additional dose of MPH and compression was reapplied for an additional 30 s. If bleeding has stopped after the second application, the test was scored as ''passed at 60 s''. If not, the same procedure was repeated for the last additional 30 s. If bleeding stopped now test was scored as passed at 90 s. Similar sequence of trials was done in the control group but without MPH. The difference between bleeding periods in two groups was observed.

Results: Application of MPH resulted in complete cessation of bleeding in four of five and one of five rats at 60 and 90 s, respectively. In the control group hemostasis could not be achieved in all five rats, even at 90 s. The statistical difference between the groups was significant (p < 0.05 (1.4-15.6 year) with supracondylar humeral fractures were treated operatively. According to Gartland 12 (27%) were type-II, 31 (73%) were type-III. At the time of arrival at emergency department, four (9%) children sustained vascular impairment with pink pulseless extremity persisting after reduction. In three cases, a cubital approach was performed. Two arteries showed a major lesion (one direct suture, one Saphenus vein graft), and one artery showed an entrapment. All lesions showed a normal postoperative pulsation. Another three (7%) children sustained a complete paralysis of the radial nerve. These cases were conservatively treated with complete neural restitution. Conclusions: Urgent anatomical reduction and fixation are crucial. In persisting vascular impairment after reduction, surgical exploration for the restoration of arterial patency should be performed, even in the presence of a pink hand. Conversion to open surgical repair was needed in one case due to retroperitoneal bleeding from the iliac arteries. Early postoperative mortality was observed in 2(20%) patients; due to massive coagulation disorder and hemodynamic instabiliy in postop 1st day and 11th day. Mean follow-up was 12 months (range 1-41 months). Late mortality was not observed. Overall reintervention rate was 20% (n = 2); proksimal re-stenting was needed due to type 1 endoleak in one patient. Embolectomy for crossfemoral bypass was needed in one other patient after stenting for aneurysmal abdominal aortic rupture, this patient underwent re-crossfemoral bypass surgery later on. Introduction: Dislocations of and fractures around the knee are accompanied by injuries of the regional vessels to a certain extent. In any case of suspicion at the scene of accident an immediate transport to an adequate trauma center is the precondition for successful limb salvage.

Methods: Between 1994 and 2007, 20 patients with arterial injury after dislocation of or fractures around the knee have been treated.

Retrospective analysis was performed in order to acquire epidemiologic data. Furthermore we investigated the sufficiency of preoperative management and diagnostics. We explored peri-and postoperative complications, such as compartment syndrome, secondary thrombosis, infection and number of revision surgeries and related the data to the final follow up after 12 and 24 months. Results: Arterial injury was found in four cases of knee dislocation, in seven cases of proximal tibial fracture, and in nine cases of distal femur fracture. Seven patients underwent acute angiography, since the year 1998 all patients were assessed with CTA. Seventeen cases were treated with venous interposition, one with a venous patch, and two with direct suture. Fasciotomy was performed in all cases. Limb salvage was successful in 13 cases. In seven cases secondary amputation was necessary, six of these patients were polytraumatized. Discussion: Sufficient time management is crucial for the survival of vessel injured extremities, as the time of ischaemia must not exceed 6 h. Perfect interdisciplinary coordination and the establishment of specific algorithms are needed in order to decrease the risk of complications and amputations of lower extremities.

289 The Survey on the Epidemiology of Car-motor Related Accidents in Children in Kashan, Iran Iman Ghaffarpasand, Maneli Dorudian Tehrani 1 1 Department of surgery, kashan medical University, Kashan, Iran Introduction: The most common cause of death in children is accident and reinforced a lot of taxes on the society. Kashan has the second position in trauma ranking of Iran so we studied this important issue in the children.

Methods and material: In this descriptive study, data has been gathered by trained hospital nurses during 12 month in traumatic patients refered to 400-bed teaching hospital, Kashan. the main method is questionnaire filling by direct interviewing. Findings: Among 98 cases of trauna 45(45.91%) of them was children below 19 years old that 32 cases (71.1%) were due to car accident, 9 cases (9.18%) were due to motor accident and rest of them (5.42%) were pedestrian accident. Boys involved 3.5 times as girls the most injuries happened was head-injury (73.3%).

Conclusion: These finding suggest that we have to pay more attention to this age group specially 16-18 because of the high rate of their involvement. finally as you see the last but not the least, these findings emphasise on protective cap wearing for every persons.

290 Managing Blunt Splenic Injury in a Level II Trauma Center: The Laparoscopic Option

Background: The past 2 decades treatment modality of blunt splenic trauma was a point of discussion. Where nowadays explorative laparotomy remains the standard of care for hemodynamic unstable patients, treatment of hemodynamic stable patients is less uniform. In this stable population maximum conservative approach seems preferable, though level 1 evidence is still absent. Failure of the conservative pathway is backed up by percutanous angioembolisation or laparoscopic salvation. The evolution to minimal invasive access makes laparotomy as a primary care for hemodynamic stable isolated splenic injury superfluous.

Methods: This paper discusses the initiation of explorative laparoscopy and successive splenectomy in two patients scoring a grade III posttraumatic splenic injury. Grading was based on CT scan imaging using the Spleen Injury Scale defined by the American Association for the Surgery of Trauma (AAST). Conservative treatment was abandoned because of moderate hemoperitoneum and continuing need for transfusion.

Results: An uncomplicated laparoscopic splenectomy was performed in both patients. Perioperative spleen preserving measures failed because of the extent of the parenchymal lesion. Conclusion: Performing laparoscopic splenectomy seems a good procedure when conservative treatment for splenic injury fails. This accounts for a rural level II trauma center where the accommodation to perform safe angioembolisation is missing, knowing that laparoscopic splenectomy is not a straight forward procedure but is made easier because of the growing skills of our surgeons. Hepatic portal venous gas (HPVG) is often associated with serious intra-abdominal pathology like ischaemic bowel disease and necrotizing enterocolitis, with reported mortality rates above 75%, with most requiring urgent operation. However, HPVG has been reported seen on ultrasound or computed tomography (CT) scans immediately after blunt trauma, followed by spontaneous resolution. Gastric pneumatosis (GP) has rarely been reported as a trauma-related entity. The combination of HPVG and GP after blunt trauma has been described in very few patients. We report the case of a 16-year-old woman who presented with an EDH requiring craniotomy and an initial abdominal CT scan showing only an OIS grade 2 liver injury. A transient increase in serum amylase combined with abdominal distension led to a repeat abdominal CT scan 48 h post injury to rule out pancreatic and duodenal injuries, revealing GP and HPVG. Endoscopy demonstrated mucosal erythema of the posterior gastric wall from the fundus to the pylorus. However, the clinical status of the patient was benign, and did not mandate surgical intervention. The patient was treated nonoperatively with nasogastric decompression and antibiotic coverage, and underwent a successful recovery with no abdominal complications.

To our knowledge, only one other adult patient has been described with HPVG and GP occurring after an initial normal abdominal CT scan. A gastric resection was performed, and operative treatment was recommended for this combination of entities in trauma patients. Our patient shows that treatment strategies in these cases probably should be guided by the clinical status of the patient.

Introduction and Aims: While the number of colorectal injuries due to penetrating trauma are increasing, increased traffic accident rates also cause the number of blunt rectal injuries associated with trauma in traffic accidents to be increased. Rectal injuries occur rarely. Because of post operative septic complications, morbidity and mortality rates are high. Early admission, stability, operation type all play important roles in the fate of the patient. We aimed to investigate these criteria in our patients who have colorectal injuries. Material-method: 21 cases who had penetrating or blunt trauma in our district during last 10 years were included in this study. Aim of this study is to present three cases with torsion of omentum, that often resemble acute cholecystitis or appendicitis, and the diagnosis is made at the time of exploratory laparotomy. Case description: The first case, a 30-year-old men, presented with a 7-day history of right hypocondrial abdominal pain, fever and vomiting. The pain increasing in severity while the patient is standing and relieved in supine position. Laboratory findings were normal, except for mild leucocytosis (12,500/cc). The patient underwent U/S examination, which showed an encysted mass in the right abdomen. A mass, originating from the omentum, was revealed after laparotomy. The mass was excised and an appendectomy was also performed. The second patient, a 43-year-old female, was admitted in our department with abdominal pain, associated with vomitus. A mild leucocytosis (13,700/cc) was observed. An U/S was carried out, which revealed a mass 5 · 6 cm lying besides a stone-free gallbladder. The patient underwent diagnostic laparoscopy and a cystic mass, which was twisted, was resected using bipolar forceps. Sixteen of all laparotomies did not reveal any internal organ lesion. Of these 16 laparotomies with negative findings, 13 had been operated for stabbing injury and 3 had been operated for gunshot injury. Twenty-one cases had single organ injury; whereas, multiple organs were affected in 43 cases. Frequencies of organ injuries were as follows: 18 small intestine, 12 colon, 12 stomach, 8 liver, 8 diaphragm, 6 spleen, 3 kidney, and 2 pancreas. The mean duration of hospitalization was 5.9 ± 2 days. After surgery, four cases needed intensive care unit; therefore, they were referred to a higher-level healthcare center. Among cases whom the treatment was completed in our institution, 8 had complication.

Conclusion: Penetrating abdominal injuries mostly occurred in young males and stabbing injuries were more common. Most penetrating injuries can be treated at secondary care centers. However, they should be referred to a higher-level institution after the initial intervention, when necessary. Background: Both nonoperative management (NOM) of blunt hepatic trauma and the damage control laparotomy are significant advances in the management of massively injured trauma victims.

Methods: This study is a retrospective evaluation of 29 patients admitted with liver trauma during 2008. 12 of them required early surgical procedures, 7 damage control surgery and 10 followed NOM. Patients were stratified by age, mechanism of injury, AIS, initial blood pressure, heart rates, and blood transfusion volume. Initial outcome data included major complications, intensive care unit and hospital length of stay, and mortality. Readmission data including the number of admissions, surgical procedures, and hospital length of stay were then analyzed.

The average age of the study group was 39, 58 years. Almost all of these patients were males (75, 86%) and car crash was the main mechanism involved (51, 72%). Liver injuries were frequently an element of multiple trauma and was associated with cranio-cerebral trauma (65, 51%) and spleen lesion (37,93%). The overall mortality during the first admission was 41, 13%, yet 17.24% attributable to the liver trauma and only 6.8% after damage control.

Conclusions: Damage control surgery offers a simple effective alternative to the traditional surgical management of complex or multiple injuries. Phase I can be done at a local hospital before transfer to a major trauma center for resuscitation and definitive repair. Reasonable surgical procedures based on classification of liver injuries and damage control principles increase the survival rate of severe liver trauma. Background: At our department, a simple scoring system based on three criteria (blood pressure below 90, BE below -7.5 and body temperature below 35°C) has been used to determine the suitability of individual patients as candidates for DCS. Objectives: The present study was undertaken to establish a valid strategy for the treatment of severe pancreatic injury and to test the validity of the scoring system used at our department for identifying suitable candidates for DCS. Subjects and methods: The subjects of the study were 12 patients with the grater and equal of grade III (Organ Injury Scale (OIS))pancreatic injury treated surgically (type III in 3 cases and IV or V in 9 cases). Results: Resection of the pancreatic body and tail was performed in both the groups to treat type III injury, and all of the cases with type III injury had favorable outcomes. Among the cases with type IV or V injury, all of those patients satisfying two or fewer than two of the criteria of the DCS scoring system survived DCS, while two patients satisfying all the three criteria of the DCS scoring system died after DCS. The two patients who underwent pancreatic duct-forming surgery needed prolonged hospitalization. Discussion: Our results suggest that DCS should be selected in cases where at least one of the three criteria of the DCS scoring system is satisfied. As a procedure for radical operation, resection of the distal pancreas may be recommended for type III, and pancreatoduodenectomy for type IV or V. Author to editor: Our results suggest that DCS should be selected in cases where at least one of the three criteria (systolic pressure below 90, severe hypothermia with body temperature below 35°C, and acidosis with BE below -7.5) of the DCS scoring system is satisfied. This DCS score is accords with the score of another abstract (Abs Ref 0087). We did not show the details of the score in another abstract (0087). Please refer in our another abstract (Ref 0087 Iatrogenic and traumatic lesions involving common hepatic duct and duodenum can be treated with a primary and contemporary reconstruction, at the condition of hemodynamic stability. We propose a technique which include the following steps: cholecystectomy with intraoperative cholangiography; transection of the common bile duct above the tear, oversewing its distal part; kocherization of the duodenum; a 80 cm long Roux-en-Y jejunal loop is constructed and brought up retrocolically in the right sub-hepatic space, orientating its antimesenteric side towards the corresponding duodenal wall; termino-lateral hepatico-jejunostomy with a transanastomotic temporary stent in case of small biliary duct's size; a side-to-side jejuno-duodenostomy performed 40 cm distally; a feeding jejunostomy. We remark the following advantages of this procedure: (1) the Rouxen-Y biliary diversion reduces the risks of stenosis and cholangitis, frequent after a direct repair of the common bile duct;

(2) an adequate distance between the biliary and duodenal anastomosis prevent entero-biliary reflux;

(3) the duodeno-jejunal anastomosis appears more appropriate, considering the complications after direct repair of large duodenal tears.

More aggressive options, such as duodeno-cephalo-pancreatectomy, pancreas-preserving-duodenectomy and segmental duodenal resection, must be considered more risk solutions. Introduction: The liver is the most commonly affected organ in abdominal trauma. In our Department, the majority of traumatic liver injuries are treated conservatively. This option involves the monitoring of possible complications, such as late rupture, hemobilia, arterio-venous fistula, pseudo-aneurysm, biloma and abscess formation.

Case: A 19 year-old patient was admitted after a 8 m fall. Established diagnoses were: multiple facial fractures, right pneumothorax with pulmonary contusion, right renal artery thrombosis and grade 3 hepatic laceration. The patient was discharged on the 21st post-trauma day (PTD), after an uneventful course. On the 61st PTD, he was readmitted for abdominal pain. Thoracoabdominal CT revealed an intra-hepatic arterio-venous fistula. Angiographic superselective embolization was performed, and the patient was discharged following a control abdominal CT scan that showed resolution of the fistula. He was again readmitted on the 84th PTD, with abdominal pain, jaundice and gastrointestinal bleeding. An abdominal ultrasound raised the possibility of hemobilia, confirmed by upper endoscopy. A new angiography did not reveal any active bleeding, and an abdominal CT showed satisfactory evolution of the liver lesion. The patient was discharged on the 97th PTD, asymptomatic. At 6 month follow-up, the patient presents no complaints, other than a new-onset arterial hypertension of renovascular origin. Conclusion: Arteriovenous fistulae and hemobilia are relatively uncommon sequelae of abdominal trauma. However, these diagnoses should be actively sought in the presence of abdominal pain, especially when associated with jaundice and gastrointestinal bleeding. A multidisciplinary approach is essential for a successful treatment. Diaphragmatic hernias constitute frequent complications after thoracic and abdominal trauma (0.8-5%), especially on the left side (90%) and the diagnosis is frequently delayed. Clinical presentation is variable and may include respiratory distress and abdominal pain, frequently attributed to intestinal obstruction, pancreatitis, biliary colic or peptic disease. The authors present a case report of a right diaphragmatic hernia diagnosed 2 years after a thoracoabdominal blunt trauma. The male patient, 64 years old, was admitted in the Emergency Room with epigastric pain, bloating, slight abdominal distension with 6 months of evolution and recent worsening. He suffered a previous thoracoabdominal trauma 2 years ago, consecutive to a downfall of about eight meters high with lumbar vertebrae fracture (L1) and was submitted to conservative treatment in an orthopaedic ward; X-ray signs of diaphragmatic hernia were unrecognized. Actual chest X-ray revealed an elevated right hemidiaphragm and presence of abdominal content in the right hemithorax. MR demonstrated a right hemidiaphragmatic rupture and the presence of abdominal content in the thoracic cavity. Patient was operated by laparoscopic approach; a diaphragmatic hernia grade III (A.A.S.T. classification) was observed and submitted to prosthetic repair. Postoperative period was uneventful. Patient remains asymptomatic with no signs of recurrence after 3 years. This case is paradigmatic of the difficulty of immediate diagnosis of diaphragmatic hernias, especially at the right hemidiaphragm. High index of clinical suspicion is needed for its early recognition in context of blunt trauma. Laparoscopic treatment revealed to be safe and efficient, with the known advantages of minimally invasive procedures. Results: Their ages were between 5 AND 69, 168 were male and 35 were female. The type of injury was penetrating in 122, blunt in 80 and blunt and penetrating in 1 patient. In 117 patients, the left kidney was injured, in 80 the injury was at right kidney and in 6 injuries was bilateral. The average transport time to hospital was 112 min (30 min-10 days). One hundred and seventeen out of 203 patients were explored immediately as they hemodynamically unstable position. Remaining 86 patients were evaluated with ultrasonography, intravenous urography and computerised tomography. Sixty four of these patients were followed conservatively. The injuries in patients followed conservatively were in 46 patient's grade 1, in 15 grade 2, in 3 grade 3. 145 renal units of 139 patients were operated. Nephrectomy was done in 78, nephropathy was done in 54 and renal artery repairing was done in 1 patient. Conclusion: Nephrectomy and mortality were high because of the long transport time, frequent high grade and high rate of associated organ injuries.

Rojnoveanu Gheorghe Sigmoid volvulus is seen more frequently at elderly ages and early diagnosis and treatment decreases its mortality and morbidity rate. We reviewed sigmoid volvulus cases treated in our clinic. 24 patients hospitalized and treated due to diagnosis ofsigmoid colonic volvulus in Dr. Lü tfi Kırdar Kartal Education and Training Hospital during 2004-2009 were analysed. Treatment modalities, morbidity and mortality rates were analysed. 12 patients were male, 8 were female. Mean age was 69 (52-87). Sigmoid colon resection and end colostomy was done to 12 patients, sigmoid colon resection and end to end anastomosis was done to 8 patients and nonoperative colonoskopic decompression was applied to 4 patients with sistemic illness and they were prepared for elective sigmoid colon resection and end to end anastomosis. In one patient with anastomosis, anastomotic leakage was detected and end colostomy was applied. Two emergently operated patients with sistemic illness died. Mortality rate was%8. In conclusion, sigmoid volvulus patients with sistemic illness should be prepared to elective surgery with colonic decompression. We think that the best treatment for early diagnosed cases is sigmoid colonic resection and end to end anastomosis. Introduction: Onset of World War II, the report concerning diverting colostomy declared reduced mortality rates for colon injury, compared to World War I. In spite that nearly 70 years has passed away, although all therapeutic options, this method -used for the management for colon injury -still include some controversial points. Methods: Ninety-five patient's characteristics were compared in two groups (patients with or without diverting stoma). Clinical findings and patient's characteristics, injury mechanism, localisation of the wound, blood transfusion requirements, fecal contamination, Colon Injury Score (CIS), Penetrating Abdominal Trauma Index (PATI Score), evidence of shock, morbidity rate, mean hospital stay, main and additional surgical procedures of 95 patients who admitted to our clinic from 1996 to 2008 were reviewed retrospectively. Results: We have no mortality in both groups, except the first postoperative 24 h. Diversion colostomy was performed in 58 patients and primary repair in 37 patients. Median hospital stay for primary repair and diversion groups were 8 and 13 days, respectively, (p < 0.05). Respiratory system, septic complications, clinical anastamosis leakage and other complications were similar in both groups.

Conclusions: Although all articles that prompt primary repair, this approach includes some inconvenient points. It is acceptable in military or war originated injuries. Diversion mostly is necessary in wounds, related to highly potent and energic fragments. Nevertheless, nearly all of the civilian colonic injuries can be treatment with primary repair without diversion since the mechanism of the wound is different than war injuries.

Dogan Gö nü llü 1 , Oguz Ç atal 1 , Nilü fer Yazgan Yıldırım 1 , Tayfun Yucel 2 , Ferda Nihat Kö ksoy 2 1 Taksim Trainig and Research Hospital, _ Istanbul, Turkey

Background: The management of haemodynamic stable penetrating injuries of the flank has not been well defined; laparoscopic exploration, closed abdominal examination and triple contrast computed tomography (CT) are alternative modalities. Our aims are to explain our experiences in these cases. Methods: We reviewed the patients with isolated penetrating flank trauma admitted between 2003 and 2008. The flank was defined as area between the anterior and posterior axillary lines, inferior to the fifth intercostal space superior to the iliac crest.

Results: There were 79 haemodynamic stable patients (7 gunshot and 72 stab injuries). There were three patient groups: laparotomy (G1) (n = 9), laparoscopy (G2) (n = 14) and only closed clinical observation with triple contrast CT scan (G3) (n = 56). 7 patients in the G1 were gunshot injuries; the other two gunshot injuries were tangential and were included in the G2. In the G2 there were four left diaphragmatic injuries, all repaired laparoscopically. One patient with splenic laceration and another with small bowel injury were converted to an open exploration. There were eight negative laparoscopies (8/14).Two patients of G3 (2/56) with negative tomography were submitted to laparotomy after 3 day of closed observation. The mean length of hospitalization in the groups was respectively 10.2, 3.0 and 3.5 days. Introduction: Intra and retro abdominal hemorrhage are common following blind and penetrating abdominal trauma. Liver, spleen and kidneys are known to be prone to injury and to bleed after an abdominal trauma. Hepatocellular carcinoma is a well known disease. However, a renal mass from a primary origin in the liver is rare. This paper presents a patient, who was treated with right nephrectomy for traumatic bleeding from a ruptured renal mass. End diagnosis was metastatic hepatocellular carcinoma. Case: The patient was 50-years-old man. He had no positive medical and surgical history, and no complaint. He was referred to Emergency service after traffic accident. During his initial assessment abdominal rigidity and tenderness were found, which were accompanied with tachycardia and hypotension even after fluid resuscitation. FAST revealed that there was free fluid in his abdomen, so we decided to operate him. At laparotomy we observed a bleeding tumoral mass in the right kidney and in his liver. He was treated with right nephrectomy and irregular hepatectomy. Pathologic examination demonstrated a metastatic hepatocellular carcinoma. Conclusion: Hepatocellular carcinoma is a well known disease with its common acute complications such as rupture and bleeding. In this case, we observed HCC metastasis to the right kidney although the patient had no medical and surgical history including HCC. Bleeding was induced after a blind trauma, was treated with resection.

Gall bladder (GB) injuries either following penetrating or blunt abdominal trauma is a rare entity and usually misdiagnosed with a delay in diagnosis. The incidence of GB injury is reported to range between 0.5 and 8.5% among the surgically treated patients following abdominal trauma. Cholecystectomy is the definitive treatment even in severe contusion of a nonperforated GB. Simple suture repair or cholecystostomy are also advocated as alternative surgical interventions by some authors. GB is afforded significant anatomic protection from external trauma, since it is partially embedded in the relatively massive liver parenchyme, cushioned by the surrounding omentum and intestines, and shielded by ribcage. Clinical symptoms may be minimal or nil initially but gradual clinical deterioration, related to spillage of bile into the peritoneal cavity, can follow. Bilous fluid taken by paracentesis or diagnostic peritoneal lavage can only be helpful after a delay as abdominal computed tomography. An 18year-old male was admitted to our emergency department for the fifth time because of penetrating abdominal trauma of at the right upper quadrant by a knife in a 15-day-period. He was hospitalized in three of them and operated on at last, because of acute abdomen, since paracentesis revealed bile coloured free abdominal fluid in addition to abdominal guarding, leucocytosis(19,000/mm 3 ), and fever.The ultimate ultrasonography and computed tomography revealed large amount of free fluid (bile) and minimal intrahepatic hematoma. At laparotomy; full-cut hepatic and cholecystic perforation (both anterior and posterior surfaces) resulted in cholecystectomy. He was discharged on the fourth postoperative day. Since almost all reports about the delayed rupture of GB are usually unrecognized GB perforations,a diagnostic delay can only be avoided by a high clinical index of suspicion. Sixty-three patients were treated conservatively, whereas 22 patients had laparotomy and 2 patients underwent angiography. Of 47 patients transported by ambulance or helicopter, 83% arrived at the emergency unit within 60 min after prehospital alert. In 57% the time on scene were longer than 10 min. In this group only 31% were diagnosed by CT within 60 min after arrival to the emergency unit. Conclusion: Low volume in trauma care results in substandard handling time. In hospitals with a low volume exposure to trauma, the prehospital response teams and surgeons achieves limited experience, especially in penetrating trauma. Exchange programs must be emphasised.

Author to editor: This study describes the complete workload in primary handled trauma patients in a typical Nothern European Universtyhospital with very low incidence of penetrating trauma and low volume of blunt trauma. Our trauma registry covers 100% of patients admitted to the hosptial. It is the only hospital in the area, and patients do not bypass the system and are treated elsewhere. The study will point out that prehosptial responsetime and inhosptial procedures are is acceptable, but emergencyroom handlingtime is to long, due to lack of practice. National or European exchange programs for surgical trauma care must be practiced. Introduction: Explosives create and energize particles that act as projectiles prone to further fragmentation in the body. These fragments may result in secondary injuries. This has been repeatedly described in the orthopedic and neurosurgical literature. In this paper we demonstrate that such a process is also possible for abdominal injuries during or after fascial penetration. Material-method: In all abdominal wall injuries, despite negative physical examination of conscious and alert patients we used local wound exploration as a standard approach. Finding a full thickness fascial defect, we assumed an intraperitoneal injury and performed laparotomy.

Result: Using this method, we found hollow organ injuries in 7 of 8 (87.5%) patients. In 3 (37.5%) of these patients at laparotomy, we found multiple, projectile induced injuries in a sprayed distribution. These injuries were found far from the trajectory, in the absence of bone fragmentation. The mean number of peritoneal defects was 1.7, however, for each peritoneal defect, we found an average of 6.8 intraabdominal injuries when through and through injuries were excluded. Conclusion: Local wound exploration is an accurate indicator of possible intraabdominal injuries. Although fragments of projectiles would be expected to be distributed along the trajectory, meticulous exploration of abdomen is mandatory because this is not always true. Despite a single peritoneal defect, there may be multiple intraperitoneal injuries due to further fragmentation of the projectile.

Introduction and objectives: Nonoperative management of penetrating abdominal stab wounds has been established as standard care recently. It decreased negative laparotomy rate without any increase in morbidity and mortality. In this study we evaluated the outcome of patients managed due to penetrating abdominal stab wounds. Intraabdominal injury due to blunt abdominal trauma usually presents acutely. In the absence of peritoneal irritation findings or shock the patients may be treated conservatively. Delayed small bowel obstruction after blunt trauma is very rare clinical entity. It may be caused by subclinical bowel perforation, localized bowel ischemia or mesenteric vascular injury. We present a 34 years old man of blunt abdominal trauma that was treated nonoperatively. Despite the success medical treatment, 2 months later, the patient presented with abdominal pain and vomiting. The radiologic studies suggested a mechanical intestinal obstruction. At the operation a conglomerated terminal ileal segment causing obstruction was found and the patient is treated by a resection and primary anastomosis. The operative findings may be explained by a subclinical perforation at the time of the trauma. This kind of complication should be suspected in patients with post traumatic patients which presents with signs of intestinal obstruction in weeks after the trauma.

Nevin Kanan, Ayfer Ö zbaş 1 1 Department of Surgical Nursing, Istanbul University, Florence Nightingale School of Nursing, Ankara, Turkey

With traumatic injury, kidneys can be thrust against the lower ribs, resulting in contusion and rupture. Up to 80% of patients with renal trauma have associated injuries of other internal organs. Injuries may be blunt (automobile and motorcycle crashes, falls) or penetrating (gunshot wounds). Approximately 80-90% of all renal trauma cases are blunt trauma injuries; penetrating renal trauma accounts for the remaining 10-20%. Blunt renal trauma is classified into one of four groups which are contusion, minö r laceration, majö r laceration and vascular injury.

• With a contusion of kidney, healing may take place with conservative measures (i.e. bed rest) • If minö r laceration is present, the patient is hospitalized and kept on bed rest until the hematuria clears. • Depending on the patient's condition and the nature of the injury, major lacerations may be treated through surgical intervention or conservatively (bed rest, no surgery) • Vascular injuries require immediate exploratory surgery because of the high incidence of involvement of other organ systems and the serious complications that may result if these injuries are untreated. The patient is often in shock and requires aggressive fluid resuscitation.

For the management of patient with renal trauma, nursing diagnoses are:

• Inefective tissue perfusion (renal) related to interruption of arterial flow • Anxiety related to physical injury • Acute pain related to physical injury • Impaired urinary elimination related to renal damage and shock Background: Penetrating abdominal buckshot wounds are believed to necessitate emergent laparotomy to rule out any hollow or solid organ injury. Recently, nonoperative management has been suggested in selected patients. This paper aims to present two cases with penetrating abdominal buckshot wounds, treated nonoperatively. Materials-methods: A chart review has been conducted for patients operated in our institution for abdominal buckshot wounds. Demographics, evaluation tools and follow-up parameters has been analyzed and documented.

Results: A total number of two patients (both male; 23 and 16 years old) were found. Both were shot on their left thoracolumbar regions. Left and bilateral chest tubes were necessitated after initial examinations, but both denied any abdominal tenderness, although computed tomography showed multiple abdominally located pellets. Gastroscopy (n = 1), echocardiography (n = 1), intravenous pyelography (n = 1) were necessitated for further evaluation, but showed no abnormality. The patients were followed up with routine abdominal examinations, vital signs and routine laboratory tests and discharged from the hospital on days 4 and 5 after uneventful recovery periods. Discussion: Patients with penetrating abdominal buckshot wounds may be followed with nonoperative management instead of routine laparotomy. Objective: Treatment procedures in cases who were operated due to colon injuries were investigated in this study. Material-methods: Thirty-two cases who were operated due to colon injuries in our clinic between 2002 and 2008 were investigated retrospectively. Cases were investigated with regard to age, sex, type of trauma, hemodynamic condition, interval between injury and surgery, additional organ injury, transfusion volume, injury site and severity, faecal contamination, surgical procedures, postoperational complications and mortality and factors affecting morbidity and mortality were determined. Colonic Injury Severity Scale (CISS), Abdominal Trauma Index (ATI) and Flint classification were used for evaluating severity of colon injury,severity of additional organ injury and faecal contamination, respectively. Systolic blood pressure less than 80 mmHg on admission was referred to as ''shock''. Results: Males comprised 28 out of 32 cases and mean age was 35.7 (range:17-72) years. Twenty-five cases were injured due to penetrating trauma and left colon injury was the most common (12 cases) type of injury. Additional intraabdominal organ injury and extraabdominal injury were observed in 21 and 6 cases, respectively. Mean interval between injury and surgery was 2.7 (range 0.5-8) h. Fifteen cases received blood transfusion. Five cases had shock on admission. Seven cases received stoma surgery while all cases with Flint grade more than III or ATI score higher than 25 received colostomy. Only cases with high CISS score received resection and anastomosis surgery. Complications were observed in 11 cases while mortality occurred in two cases due to hemorrhagic shock. Conclusion: Routine primary repair cannot always be performed in colon injuries since many factors affect the decision for type of surgery. Primary repair may be performed safely in hemodynamicallystable cases with ATI score less than 25 and Flint grade I-II. Seat belt syndrome is defined as a seatbelt sign associated with lumber spine fracture and bowel perforation. An isolated rectal perforation due to seatbelt syndrome is extremely rare. There is only one case reported in the Danish literature and non in the English literature. Hereby, we report a 48-years old male who was a front seat restrained passenger involved in a head-on collision. He has presented with lower abdominal and back pain. Seat belt mark was seen transversely across the lower abdomen. Initial trauma CT scan was normal except for burst fracture of L5 vertebra which was operated by internal fixation on the same day of admission. The patient continued to have abdominal pain and distention which became clear on the third day. Repeated abdominal CT scan on the third day has shown free intraperitoneal air. Exploratory laparotomy has revealed a perforation of the proximal part of the rectum below the recto sigmoid junction. Hartmann's procedure was performed with end colostomy. The abdomen was left open and temporarily closed using saline IV bags sandwiched between 2 layers of Steri-Drape. Peritoneal toileting was performed four times under general anesthesia with gradual closure of the abdominal fascia over a period of 2 weeks. Postoperatively, the patient had urinary retention due to a quada equina injury although he could walk. The presence of seat belt sign and a lumber fracture should rise to the possibility of a bowel injury. Author to editor: Seat belt syndrome is defined as a seatbelt sign associated with lumber spine fracture and bowel perforation. An isolated rectal perforation due to seatbelt syndrome is extremely rare. There is only one case reported in the Danish literature and non in the English literature. Hereby, we report such a case.

Fuat Ipekçi, Muharrem Karaoglan, Hü seyin Toptay, Hasan Ş ahin 1 1 Department of General Surgery, Tepecik Education Hospital, Izmir, Turkey Introduction and Aims: Meckel's diverticulum results from incomplete degeneration of omphalomesenteric duct. It is usually diagnosed incidentally during appendectomy; however, sometimes perforation or bleeding may lead the surgeon to the diagnosis. We aimed to investigate the frequency of Meckel's diverticulum during emergency laparotomy performed for acute appendicitis and clinical and pathological characteristics of the patients with Meckel's diverticulitis and appendicitis. Material-method: The material consisted of 1,372 patients who admitted to our hospital and treated by appendectomy during a 10-year interval between the years 1998 and 2008. Of these patients 824 (60,05%) were male and remaining 548 (39,95%) were female. All patients were investigated for Meckel's diverticulum weather they have acute appendicitis or not.

Results: Meckel's diverticulum was found during 20 out of 1,372 appendectomies (0.01%). Of the cases, 16 were asymptomatic but four patients were symptomatic with inflamed diverticulitis. Of these four patients two have normal appendix and other two have secondary appendicitis due to Meckel's diverticulitis. All four symptomatic cases were treated by diverticulectomy and appendectomy. All 16 asymptomatic cases were treated by appendectomy alone. No mortality or major morbidity was detected.

Conclusions: Despite of its rarity (0.01% in our appendectomy series), Meckel's diverticulum must be searched weather the appendix is normal or inflamed.

Introduction: Illegal drug smuggling is a widespread problem. Drug packs carried inside body cavities may leak its contents and be dissolved inside the body and signs of toxicity (aka. Body Packer Syndrome) become evident. This case was reported to represent the very first proven patient in Turkey. Case: A 36 year-old man were brought in the emergency department (ED) from the airport because of severe tremor, palpitation, restlessness associated with hypertension and tachycardia. The patient was cooperative and oriented. On examination, his blood pressure (BP) was 210/150 mmHg, pulse rate 124/bpm, whereas other systems were unremarkable. He was put on cardiac monitor and infusion of glycerol trinitrate was instituted (10 mcg/min). Urinary toxicologic screen was positive for cocaine and benzodiazepine. After admission to the ED he complained of epigastric distension and abdominal pain and admitted that he had swallowed cocaine packs. His abdominal Xrays showed gas-fluid levels and opaque round-shaped mass images. A nasogastric catheter was inserted and gastric contents (approximately 1,500 mL) were drained. He was consulted with surgery clinic with a diagnosis of an ileus due to swallowed packs. He was hospitalized in the surgical ward. After supportive treatment and repeated enema applications he excreted 104 cocaine packs in 2 days. He was discharged following clinical stabilization and abdominal X-rays were repeatedly normal.

Conclusion: Toxicologic analysis must be employed in patients who are suspected to have intoxication, to identify life-threatening drugs and vasoactive substances. Advanced imaging methods must be exercised to exclude bowel obstruction in these patients. Background: Pseudoaneurysm is a well recognized complication of pancreatitis. Angioembolization is considered to be the first option of treatment. To our knowledge, the case we hereby report is the first one with successful re-angioembolization.

Case: A 41-year-old man, with AIDS, history of CNS toxoplasmosis, chronic pancreatitis with pseudocyst secondary to alcohol abuse, was hospitalized for pneumonia. During his hospitalization, he developed abdominal pain and hypotension. After resuscitation, CT angiogram of the abdomen revealed active bleeding into a pseudo-aneurysm, near the head of the pancreas, measuring 2.7 x 1.8 cm and arising from superior and inferior pancreaticoduodenal arteries. This was confirmed by angiogram. Angioembolization distal and proximal to the bleeding area was performed using coils. Eight days later, the patient became hypotensive and dropped his hemoglobin again. He was taken for an emergency laparotomy which revealed a 5 cm pancreatic pseudocyst with hemorrhage. The pseudocyst was opened through the medial wall of the duodenum, ligation of the bleeding intracystic vessels, and cysto-doudenostomy were performed. His postoperative course was uneventful and he was discharged home on postoperative day 16. Five days later he was readmitted with hematemsis and anemia. Celiac angiogram revealed bleeding from the gastrodoudenal artery which was embolized. He died 5 months later due to HIV nephropathy without any evidence of re-bleeding. Objectives: Any sort of discomfort in the abdominal cavity that lasts less than 1 week is defined as acute abdominal pain. The purpose of the study was to evaluate the outcome of hospitalized patients with unspecified acute abdominal pain following initial clinical and laboratory evaluation. Method: From January 2008 to December 2008, 114 patients with acute unspecified abdominal pain were admitted to surgery department. Gender, age, definite diagnosis, time from hospitalization to surgery and hospital length of stay were retrospectively reviewed. Results: Fifty-six of the patients with acute unspecified abdominal pain were females (49%) and 58 were males (51%), median age was 34 years (range 16-82). While definite diagnosis was confirmed in 70 patients (62%), the initial diagnosis was not changed in 44 patients (38%). Distribution of new diagnoses were appendicitis (n = 24), gastroenteritis (n = 7), genitourinary disorder (n = 17), Familial Mediterranean Fever (n = 6), inflammatory bowel disease (n = 2), mesenteric adenitis (n = 2), peptic ulcus perforation (n = 1), constipation (n = 1), diverticular disease (n = 1), pneumatosis intestinalis (n = 1), hepatobilier disease (n = 7) and intra abdominal tumor (n = 1). Depending on the cause of abdominal discomfort, 28 patients (25%) required surgical intervention. Median time from hospitalization to surgery was 20 h (range 4-55 The use of temporary skin substitutes (TSS) is a useful technique in the treatment of full-and partial thickness burn wounds affecting a large body surface area. Early excision of the eschar is mandatory. But if we cannot find sufficient donor site, TSS using seems to best choice. The ideal TSS must be has some properties: adherence, control of water loss, safety, flexibility, stability on wound surfaces, bacterial barrier, and ease of application, ease storage and cost effectiveness. Case report: A 2-year-old girl was admitted to our burn center with deep flame burns affecting face, thorax, upper and lower extremity (45%). She underwent an early burn excision on day 4 post-burn day. The whole area excised with hydrosurgically was covered with Biobrane Ò and compressive dressing. Seven days after we removed Biobrane from the upper and lower extremities and grafted the wound bed. Face healed spontaneously under the TSS and TSS covering the thorax was rest intact. After 10 days thoracic TSS was removed and grafted and we covered the thorax with Biobrane Ò over the grafts again. After 10 days a second grafting was needed. Patient was discharged from the hospital 56th post-burn day. The use of Biobrane Ò as a TSS after burn wound excision was satisfactory, because it enabled us to delay auto grafting until we were sure of good conditions in the wound bed. Also it proved to be a good dressing over the meshed autografts. It reduces the healing time and improved the quality of grafts. Introduction: Endoscopic examination of the colon during the diagnostic or treatment purposes, perforation incidence is reported between 0.01 and 0.3%. Determination of risk factors may decrease the incidence with early recognition of the serious complications of surgery may reduce interference. Method: We have examined retrospectively the patients in whom colon perforation appeared due to endoscopic analysis of colon carried out at endoscopy unit between January 2007 and December 2008.

Results: Total colonoscopy and rectosigmoidoscopy were applied to 7,881 patients. In 7 patients (0.088%) perforation was observed. The median age was 74.5 (66-85), M/F: 5/2. All colonoscopys were made for diagnosis; anemia in two, hemorrhodial disease in one, subileus in two, anal prolapsus in one, right colon tumor suspation in one patients. One sigmoid polypectomy was applied, diverticulosis disease of the colon in two patients, dolichocolon in one, one previous pelvic surgery were observed. Perforation zone was observed in sigmoid colon in all patients. Four patients were diagnosed in the process of colonoscopy (57.1%), 2 were diagnosed in 24-48 h (28.5%), 1 was diagnosed 5 days later. Laparotomy was applied to all patients. Perforation zones of 5 patients were fixed primarily and these 5 patients were discharged as cured. One patient who was applied to diversionary ostomy was reoperated due to abdomen collection. No mortality was observed. Conclusion: Colonoscopic perforation is a rare, serious complication. Sigmoid colon is the location where the perforations are mostly observed. Although primary fixation is generally efficient in cases of early diagnosis, morbidity increases seriously due to late diagnosis.

with more than one stomas. Eleven patients were discharged with planned ventral hernias. Primary abdominal closure succeeded in four patients. Fasciitis due to severe peritonitis and stomas prevented primary closure. Eighteen of 34 patient died during treatment, 16 were discharged. Sixteen of 21 patients with more than one bag were died, five survived (Mortality 76.2%).

Conclusions: Morbidity and mortality were higher in patients with more than one stoma than patients with single stoma. Second stoma has a negative effect on primary fascial closure. Fasciitis due to severe peritonitis also prevents fascial closure.

347 Acute Diaphragmatic Hernia after Minimally Invasive Esophagectomy The aim of this study was to evaluate the disease profile and mortality ratio of patients presenting with acute abdomen. Four hundred fifty eight patients who underwent surgery with the diagnosis of acute abdomen were analyzed retrospectively. The effects of age, sex, American Society of Anesthesiology (ASA) class, accompany disease, admission time after the onset of the symptoms, follow up interval before the operation on mortality and length of hospital stay were evaluated. Male/female ratio was 0.72, and mean age was 72.3. Main causes were biliary system disease (34.1%), intestinal obstruction (27.1%), peptic ulcer perforation (17%) and acute appendicitis (14.4%). Median ASA class was 2 and 73.6% of the patients had at least one preexisting disease. Mortality ratio was 19.4%. ASA class, age, preexisting diseases other than malignity, period between the onset of symptoms and admission, follow-up time was significantly effective on mortality.

Background: Resveratrol is a strong antioxidant with antiinflammatory effects. We aimed to investigate the effects of resveratrol on oxidative injury, histopathology and bacterial translocation in induced I/R injury in rats.

Methods: 32 Female Wistar-albino rats were randomly allocated into four groups; Sham-operated group(laparotomy without I/R injury), I/ R group (laparotomy plus 60 min of ischemia followed by 60 min of reperfusion), Alcohol group (only 0.5% ethyl alcohole 0.3 ml/day intraperitoneally for both 5 days before surgery and 15 min before ischemia), Resveratrol group (15 mg/kg Resveratrol intraperitoneally both 5 days before surgery and 15 min before ischemia. Intestinal tissue samples were obtained for investigation of tissue levels of malondialdehyde (MDA), nitric oxide (NO), superoxide dismutase (SOD), myeloperoxidase (MPO) and histopathologic evaluation Bacteriological translocation (BT) in mesenteric lymph node (MLN), liver and spleen was also studied. Results: Resveratrol significantly decreased MDA, NO and MPO levels in I/R injury (p < 0.001). SOD activity of resveratrol-treated group was significantly lower than sham group and significantly higher than I/R and I/R + Alcohol groups (p < 0.05). Histopathologically, the median intestinal injury score in I/R and I/R + Alcohol groups was significantly higher than in sham and resveratrol-treatment groups (p < 0.001 and p < 0.05, respectively). The incidence of BT differred between the groups I/R and I/R + Alcohol in MLM, spleen and liver (p < 0.001). Nevertheless, the treatment with resveratrol reduced BT to MLN, spleen and liver, compared to other I/ R groups (p < 0.01 Gastrointestinal stromal tumors (GISTs) represent rare neoplasms of the gastrointestinal tract. Here we describe a case with GIST and thrombocytosis presenting as an acute abdomen. Our knowledge, the co-existence of GIST and thrombocytosis has not been reported so far.

Case: A 66-year old female was admitted to the emergency room with epigastric pain and vomiting over duration of 3 days. Physical examination showed abdominal distension, rebound tenderness, and a palpable RLQ mass. The laboratory findings were, WBC:16.740/l, PLT 574 · 10 -9 /L and C-reactive protein 289.4 mg/l. A computed tomography scan of the abdomen showed conglomerate of small bowel. The abdominal exploration showed that a 6 · 6 · 6 cm mass was located on small intestine. The mass was completely resected and enteroenterostomy was performed. The histological examination demonstrated whirling sheets of spindle cells which were stained positively for CD 117 (c-kit) and CD34, mitotic index > 10/50 HPF, while smooth muscle actin and vimentin were focally positive, and keratine, desmin, S-100 protein were negative. This specific immunophenotype characterized GIST. During the post operative follow up, platelets were above normal levels 400 · 10 -9 /l. Therefore, bone marrow biopsy was performed. Hiperplasia in megakaryocytes were found. The patient was negative for BCR-ABL and Philadelphia chromosome. Discussion: Here we describe a case with GIST and thrombocytosis presenting as an acute abdomen. Ten percent to 30% of these tumors are biologically aggressive; signs of malignant potential are metastases and invasion. The current treatment for localized disease is surgical resection. Co-existence of thrombocytosis and GIST has never been reported. Laboratory tests showed no abnormality except white blood cell count of 11600/ll.Plain abdominal X-ray and CT did not show any abnormal findings including free air (Fig.1) . Endoscopic examination of the stomach revealed an ingested toothpick protruding from the prepyloric antrum (Fig.2) . The toothpick was deeply fixed into the antral wall. The whole toothpick 2.2 cm in length was removed using a loop without damage to the gastrointestinal wall, bleeding or any other complication. After endoscopic removal of the toothpick, her epigastralgia resolved. On the second hospital day, the patient was asymptomatic. Medical therapy with proton pump inhibitor was stopped and she was discharged on the third hospital day.

Conclusion: Accidental ingestion of foreign bodies is common and in general harmless. A perforation of the gastrointestinal tract by ingested foreign bodies is rare, occurring in less than 1% of ingested bodies like toothpicks are involved in less than 0.1%. Occasionally, the passage of the swallowed item may stop at one of the anatomic bottlenecks of the gastrointestinal tract, which may lead to perforations that may require operative or endoscopic interventions. Results: We analyzed the number, causes and rates of emergency operations. The total number of emergency operations was 1,147 and 1,021, for the first and second groups, respectively. We observed an 11% decrease in number of emergency operations for the second group. We also observed that the cause of majority (70% for the first group, 71% for the second) of the emergency operations was acute abdomen and the rate between the groups did not change. Lower extremity amputation and strangulation hernia operations decreased 51 and 22%, respectively. The number of operations which are caused by ileus and acute cholecystitis increased 25 and 74%, respectively.

Conclusions: Difference in distribution of emergency operations between two groups was statistically insignificant. However, we observed both an increase and a decrease in small numbers of some subgroups. It is believed that this is related to the change in patient profile and technological improvements in surgery. Aim: We hypothesized that one of the most widely used anesthetic agents, propofol, may reduce inflammatory processes, and organ injury induced with cecal and ligation puncture Study design: Bacterial peritonitis was induced in 18 rats by cecal ligation and puncture. The rats were randomly assigned to three groups. Group 1 (n = 6) received propofol, group 2 (n = 6) received intralipid, group 3 (n = 6) was control, which did not receive any injection. All animals were killed 14 days later so we could assess the adhesion score. Tissue antioxidant levels were measured in 1-g tissue samples taken from the abdominal wall. Results: The adhesion score was significantly lower in the propofol group than in the control group (P < 0.05). The catalase levels were higher in the intralipid and control groups than the propofol groups. Conclusions: Intraperitoneal propofol reduced the formation of postoperative intra-abdominal adhesions without compromising wound healing in this bacterial peritonitis rat model. Propofol also decreased the oxidative stress during peritonitis Approximately, 20 min after the onset of the operation, a sudden decrease in end-tidal carbon dioxide from 32 to 11 mmHg was noticed. Soon after, both systolic arterial pressure and heart rate decreased dramatically. Arterial blood gas measurements showed that pCO 2 was 41 mmHg at that moment. Surgery and insufflation of gas was stopped, ephedrine 5 mg was given intravenously and ventilation with 100% O 2 was started. Trendelenburg position was achieved immediately. A catheter was introduced through the right juguler vein to the right atrium rapidly and 3-4 ml gas bubble was withdrawn. Soon, hemodynamic measures were recovered. Since substantial amount of blood in the peritoneum was noticed, conversion to laparotomy with subcostal incision was performed. At exploration, through and through tear of 3 mm in inferior vena cava was detected. The defect was sutured with 6/0 polypropylene. Anesthesiologist and surgeon must be aware of this dangerous complication. The emphasis is given to the prevention and prompt recognition of this event to the use of available tools in the management of cardiovascular complications. Aim: Obstructive jaundice, develops accompanied with high morbidity and mortality rates. The absence of bile in bowels leads to bacterial translocation and ultimately to endotoxemia and septice-mia. _ In our study, observing changes on bowel level during obstructive jaundice and examining its contribution to bacterial translocation have been aimed. Material-methods: The study has been carried out at _ Istanbul University _ Istanbul Faculty of Medicine Experimental medical Research Center (DETAM) with approval of _ Istanbul University _ Istanbul Faculty of Medicine Ethical Board for Animals. Two groups out of 20 male Wistar Albino rats have been formed. One hour after injecting D-xylose to first group the rats were put to sleep (anesthetized) and specimens of tissue (liver, spleen, mesenteric lymph nodes) and blood were taken for microbiological and biochemical examinations. In the second group an obstructive jaundice has been established by ligation of common bile ducts. The same specimens were obtained after 7 days. Findings: In the first group no proliferation on tissue and blood cultures were detected. An obstructive jaundice has been shown in biochemical investigation of blood. D-xylose was found to be 102.7 ± 33.1 mg/dl. In the second group, proliferation, of mainly E. coli, were detected on cultures and D-xylose was found to be 151.0 ± 37.9 mg/dl. Statistically significant increases were assigned between groups, between tissue and blood cultures (p < 0.001) and D-xylose values (p < 0.007). Results: Detecting statistically significant increases in D-xylose levels in the second group leads to the conclusion that increases in bowel permeability plays an important role in bacterial translocation. Conclusions: While wound infections were higher in open appendectomy procedure group, surgical time was higher in laparoscopic procedure group. The achievement of optimal results will be based on increasing surgical laparoscopic experience.

Objectives: Intraabdominal hypertension (IHT) in intensive care units is a common problem. Investigation of the effects of dexmedetomidine on respiratory system in rats with IHT was aimed. Patients and methods: 32 adult Wistar-Albino male rats were anaesthetized by rata ''ksalazin/ketamin'' combination. Experimental model of IHT(12-15 mmHg) was induced via pressure cuff. Rats were left to spontaneous respiration for 2 h prior to randomly division into four groups. The first group underwent no process (control group). In SF group; 1 cc of 0.9% NaCl,in the third group; 0.2 lg/kg DXMT and in the last, 0.7 lg/kg DXMT were intravenously administered. Thereafter 30 min passed to observe the effects of DXMT. The rats were killed via cervical dislocation prior to surgery. Lung tissues were fixed in 10% formalin and stained with HE. Whereas the other cross sections were stained with TUNEL method,the rest were stained with anti-caspase3,8,9 and anti-Fas/FAsL antibodies for immunohistochemical analysis.

Results: Histological changes in group 3 were the less. There were no atalectatic changes in the same group. PNL infiltration and interalveolar thickness were higher in the 0.7 lg/kg DXMT group than others. In indirect immunohistochemical studies, in the 0.2 lg/kg DXMT group, immunoreactivity of caspase 8 and 3 were increased. However, the caspase-3 immunoreactivity was less than caspase-8. These results supported that 0.2 lg/kg DXMT administration led apoptosis, even though to be delayed, to start and showed that extrinsic pathways was used through apoptotic pathways. It was concluded that low dose of DXMT caused to delay in apoptosis in the lungs. Results: A total of 93 microorganisms were responsible for the 81 CRIs, of which 22 (23.6%) were Gram-positive bacteria, 63 (67,7%) were Gram-negative bacteria and 8 (8.6%) were Candida species. Isolated from the 93 microorganisms were: Klebsiella pneumoniae 12 (19%), Acinetobacter 4 (6.3%), Enterobacter 4 (6.3%), Rroteas mirabilis 3(4.7%) Pseudomonas aeroginosa 17 (27%), Staphylococcus 14 (63.6%).12 patients (14.4%) developed CRBSIs and in 9 patients with positive blood cultures CRIs were negative. In our study, femoral venous access was associated with a significantly higher incidence of CRI and CRBSI than jugular and subclavian access; and jugular access was associated with a significantly higher incidence of CRI and CRBSI than subclavian access Conclusion Our results suggest that the order for punction, to minimize the CVC-related infection risk, should be subclavian (first order), jugular (second) and femoral vein (third).

Introduction and objectives: Undescended testis is a risk factor for the testicular carcinoma, especially a seminoma. Seminoma can be seen at any age, but it is considerably rare in elderly patients. We describe a patient who presented with acute abdomen secondary to an ileum perforation due to the involvement of seminoma.

Case: A 48 year-old man complaining with right lower abdominal pain and a palpabl mass with a 2-week history was evaluated. An abdominal computed tomography was showed a large, solid, welldefined intraabdominal mass, measured about 16 · 14 ·x 10 cm in right quadrant of lower abdomen. An exploratory laparotomy was adjudged to perform. Whilst the preoperative investigations for surgery were continued, the patient admitted to the emergency service with acute abdomen symptoms, which was started suddenly. He had peritoneal irritation signs. He underwent an urgent laparotomy and a large mass located on terminal ileum mesenter through the retroperiton was detected. Dilated ileum segments with omentum wrapped along the antimesenteric border of the distal ileum was found. On separating omentum from ileum, perforation along the antimesenteric border was noted. Extended right hemicolectomy and an end ileostomy was performed. Histopathologic examination revealed a classical seminoma with extensive tumor necrosis and showed evidence of vascular invasion. Conclusions: Undescended testes should be considered in men with an intraabdominal groin mass and should be aware of its potential complications.

department with diagnosis of acute cholecystitis and on exploration giant gallbladder with giant stone and gallbladder adenocarcinoma. Case: A 78 years old female was applied to emergency department with abdominal pain, nausea and vomiting. On physical examination, right upper quadrant tenderness and defence were detected. Murphy sing was positive and gallbladder was palpable on subcostal space. In laboratory tests, white blood cell count was 16,000/mm 3 , glucose was 137 mg/dl and liver function tests were minimally elevated. In hepatobiliary ultrasonography, the gallbladder was hidropic (14 · 7 cm) and there was a stone (5 cm in diameter) and a mass (8 · 6 cm) in the gallbladder.Cholecystectomy operation was performed. Acute cholecystitis + cholelithiasis + adenocarcinoma were reported in the histopathological evaluation.

Conclusion: The carcinomas of the gallbladder were associated with gall stones in 80-90% of the patients. We concluded that the presence of the symptoms in our patient was delayed due to the magnitude of the gallstone and the excessive size of the gallbladder. 373 Perforation of the Gallbladder by Trans-gastric Migration of a Sewing Needle _ Ingestion of foreign bodies is a common problem, especially in the elderly, pediatric, and psychiatric population, but fortunately, most of them pass spontaneously and uneventfully within 1 week.The perforation and migration of ingested foreign objects into the abdominal cavity is very rare and usually leads to a laparotomy. Perforation of the stomach by sewing needle with migration to the gallbladder is extremely rare, and none cases have been reported in the literature. A 30-year-old woman was admitted because of abdominal pain and a history of a swallowed sewing needle 1 month ago. She had been followed-up at her local hospital and referred to our hospital because of the failure of progression of the foreign body. Physical examination showed right upper quadrant tenderness, guarding, and a positive Murphy's sign. Blood analysis showed increased white blood count. She was submitted to abdominal plain X-rays, which revealed a radio-opaque objects in the liver area with the form of the sewing needles. The patient was clinically stable, and a semi-urgent laparotomy was planned. At laparotomy the needle was in the gallbladder and that the end of the needle could be palpated and the site of gastric perforation. Removal of the intra gallbladder needle did not cause any problem. We was performed cholecystectomy and primary gastroraphy. The postoperative period was uneventful and the patient was discharged on seventh day of the operation. If there is a history of sewing needle ingestion and failure of progression and also signs of an acute abdomen, the surgeon must carefully evaluate gallbladder.

Introduction: Sigmoid volvulus is an unusual intestinal obstruction form (1) . It is most common in the middle aged, elderly, institutionalized or neuropsychiatric patients (2). Patients and methods: Twenty-one sigmoid volvulus patients were reviewed retrospectively between 2004 and 2008.The recorded data were age,gender,admission symptoms,physical examination,radiological, and operative findings, surgical procedure, postoperative complications, mortality, and hospital stay.There were 10 male and 11 female patients. The mean ages of the patients was 66.5 years (34-84).The most common symptoms in acute abdomen patients were pain, and tenderness. Abdominal distension were the most recorded sign in patient without peritonitis. The mean admission time was 3.9 days (2-7). Five patients had a history of sigmoid volvulus (23%). Leukocytosis and high fever were found in 12 (57%) patients. Radiological evaluation of the patients revealed sign of intestinal obstruction (n = 7, 33%),Frimann-Dahl sign (n = 12, 57%) and bilateral free air under diaphragm due to perforation of the twisted sigmoid colon (n = 2, 9.5%). No patient underwent contrast enema examination of the colon. The mean hospital stay was 10.4 days (1-26 days) . Two patients without signs of peritonitis were treated by sigmoidoscopy and operated on elective course.Patients with signs of acute abdomen were operated urgently. The patients had several associated diseases such as atherosclerotic heart disease, diabetes mellitus, hypertansion, chronic obstructive pulmonary disease, cerebrovascular disease. Eight patients (38%) died due to sepsis. Morbidity rate was 33%. Wound infection, evisseration pneumonia, and acute renal failure were found in 7 (33%) patients.

The principal strategy in treatment of sigmoid volvulus is early nonoperative detorsion followed by elective surgery consist of colectomy and anastomosis on well-hydrated patient. Urgent laparotomy is indicated in case of peritonitis. Sigmoidopexy is an alternative option but it is usually ineffective and has high recurrence rate. Results: Ten men and four (six) female were enrolled in the study. Mean age was 56 years (range 23-81). E.coli and acinetobacter were the common organisms cultured. All patients were treated with a common approach of resuscitation, broad spectrum antibiotics, and wide surgical excision. Objectıves: Acute appendicitis is one of the most common nonobstetric surgical pathology. Clinical symptoms and findings are masked due to anatomical and physiological changes of peregnancy, so diagnose and treatment of acute appendicitis in pregnancy generally late. The curent study reported the cases which were diagnosed acute appendicitis in pregnancy and promptly operated in our general surgery clinic. Material-methods: We evaluated sixteen cases' data between October 2006 and October 2008 who admitted to emergencey department with abdominal pain, vomiting, nausea and anorexia complaints and diagnosed as acute appendicitis in pregnancy and operated.

Results: The average of the cases were 29.3 (range 20-44) and thirteen of them were second, two of them were third and one of them was in the first trimester. The time interval between the onset of the complaints and operation was 1.5 (range 1-6) days. Upon physical examination, there were rebound tenderness present in 13 cases, muscular rigitide in three cases, right lower quadrant pain in nine cases and widely irration of all abdominal guadrant in four cases. There were not any maternal mortality and morbity after operation, however in only one case fetal mortality was observed inevitable abortion due to vaginal bleeding. Conclusion: In our cases acute appendicitis was diagnosed frequently in the second of the pregnancy with abdominal pain symptoms and rebound tenderness findings. Recognition is important because early diagnose and prompt surgical intervention can reduce maternal and fetal mortality and morbity in acute appendicitis.

Introduction and objectives: Conservative management of penetrating trauma has been mainly advocated in centres with a high incidence and large experience with those injuries. Our aim was to assess the preventable death rate in our patient population, and the failure rate of conservative management. 

Introduction and objectives: The data about role of amelogenin that is an extracellular matrix protein, during the healing process of the gastrointestinal anastomosis is lacking. In this study, the effects of amelogenin treatment on normal and ischemic colon anastomosis were evaluated. Methods: Adult male Wistar Albino rats weighing 200-250 g, were divided into four weight-matched groups: normal colon anastomosis group (n = 8); amelogenin treated normal colon anastomosis group (n = 8); ischemic colon anastomosis group (n = 8); amelogenin treated ischemic colon anstomosis group (n = 8). Sufficient equal volume of amelogenin to entirely cover the anastomosis area had been applied. All animals were killed on postoperative day 4. Bursting pressure levels were measured. Peri anastomotic colon tissue hydroxyproline, catalase (CAT), Cu-Zn superoxide dismutase (SOD), glutathione (GSH), malondialdehyde (MDA) and nitric oxide (NO) levels were assessed to evaluate oxidative stress.

Results: Bursting pressure levels of the ischemic colon anastomosis group is significantly lower than the normal colon anastomosis, the amelogenin treated normal colon anastomosis and the amelogenin treated ischemic colon anastomosis groups respectively (p = 0.003, p = 0.05, p = 0.011). Hydroxyproline level of the amelogenin treated normal colon anastomosis group is significantly lower than the normal colon anastomosis and the ischemic colon anastomosis groups respectively (p = 0.026, p = 0.003). GSH level of the ischemic colon anastomosis significantly lower than the amelogenin treated normal colon anastomosis group and the amelogenin treated ischemic colon anstomosis group respectively (p = 0.019, p = 0.002).

Conclusions: Amelogenin treatment could support the physical strength of ischemic colon anastomosis and effect oxidant/antioxidant response positively. Introduction: Meckel's diverticulum is the most common congenital anomaly of the gastrointestinal tract, occuring in 2-3% of the population. In the majority of patients, Meckel's diverticulum is asymptomatic. We report our experience with the management of complicated Meckel's diverticulum in adults.

Methods: Between april 2005 and January 2009, the data of seven patients (5 males and 2 females) aged 17-65 years who underwent surgery due to complications of Mechel's diverticulum was retrospectively evaluated. Results: Of the seven patients, three presented with acute surgical abdomen, two had abdominal pain mimicking acute appendicitis, one had incarcerated incissional hernia, and one had intussusception. Intraoperative diagnoses were as follows; Littre's hernia in one, ileoileal intussusception due to Meckel's diveticulum in one, diverticulitis in two, perforation of the diverticulum in three patients. While diverticulectomies were performed in five patients, two had small bowel resections. In addition to, appendectomy was performed in four patient. All the patient had an uneventful recovery except one, who experienced a postoperative wound infection. The hospital stay was 4-16 days. Ectopic gastric mucosa was found in two cases. In one case, neuroendocrine tumor was detected in the appendix. Conclusions: Meckel's diverticulum is an uncommon cause of acute abdominal disease in adults. Meckel's diverticulum presents distinctive challenges to a clinician, as it is prone to varied complications such as intestinal obstruction, diverticulitis, perforation. The diagnosis of Meckel's diverticulum is difficult to establish preoperatively, and index of suspicion is necessary in patients with an acute abdominal illness.

Introduction: Pneumatosis cystoides intestinalis is a pathologhy which is rarely incidentally seen and is characterised with submucosal or subserosal air cysts. There is no surgical indication in asymptomatic cases. Surgical treatment is needed in the development of complication or the possibility of risk. A patient who is hospitalized with diagnosis of pyloric stenosis and is detected pneumatosis cystoides intestinalis incidentally at the operation is presented.

Case: 54 year old male was admitted our emergency department with vomiting weight loss complaints. Pyloric stenosis was diagnosed by radiologic and endoscopic examination. He was hospitalized and acute abdominal signs developed. Free air was detected in radiologic examination. Surgery was performed. Pyloric stenosis and pneumotosis cystoides intestinalis in jejenum were diagnosed. Biopsy specimen was obtained from the cysts in jejunal serosa. Subtotal gastrectomy, gastrojejunostomy and bilateral truncal vagotomy were performed for the pyloric stenosis.

Result and discussion: There is no surgical indication in asymptomatic cases. Pneumotosis cystoides intestinalis commonly accompony pyloric stenosis and perforation of the cysts may bring out acute abdominal symptoms. Knowing this pathology, we may avoid unnecessary emercent laparotomies. Aim: In urgent surgical procedures for peptic ulcer perforation, there is considerable postoperative morbidity and mortality. This study aimed to describe and analyze the risk factors that determine beforehand morbidity and mortality in cases with perforated peptic ulcer. Materıals-methods: Age, sex, co-morbid diseases, symptom duration, abdominal air, amount of intra-abdominal liquid, location and diameter of perforation, operation, and the Mannheim Peritonitis Index (MPI) score were prospectively analyzed in 128 cases. Significant risk factors that cause morbidity and mortality were determined through a statistical study.

Results: The study sample consisted of a total of 128 cases (113 males and 15 females) with a mean age of 37 (range 20-84). Duodenum and stomach perforations were detected in 93 and 5.5% of the cases. In 12 cases (9.4%), a total of 14 complications were detected. The mortality rate was 4.7%. Statistical analyses revealed significant relationships between morbidity and > 50 age (p = 0.000), co-morbid disease (p = 0.006), perforation location (p = 0.010), type of operation (p = 0.011), and MPI score (p = 0.005). The factors significant for mortality included > 50 age (p = 0.002), co-morbid disease (p = 0.017), > 8 h of symptom duration (p = 0.07), > 500 cc intra-abdominal liquid (p = 0.047), a perforation diameter of > 0.5 cm (p = 0.001), omentopexy (p = 0.025), and a MPI score of > 21 (p = 0.000). Conclusion: Factors such as age, co-morbid disease, prolonged perforation duration, amount of intra-abdominal liquid, perforation diameter, type of surgical operation, and MPI score were significant for mortality. The present study found that primary suture is a safe procedure for cases with peptic ulcer perforation. Introduction: The presence of foreign objects in the rectum is a rare encountered situation. These objects are usually inserted transanally or swallowed as foreign objects. This study was conducted to investigate the results of patients admitted to our clinic with a rectal foreign body. Methods: Data of 30 patients who admitted to our clinic between 1980 and 2008 were evaluated retrospectively Results: Mean age of the population was 51.3. The foreign object was taken out in the proctological position in 18 patients. In 4 patients these methods failed and laparatomy was performed and the objects were taken out transanally without colotomy. In three patients symptoms and signs of peritonitis were significant at admission and all of them were lost because of rectum perforation followed by septic shock. Distribution of foreign objects was: six deodorant lids, five glass bottles, two aubergine, a glass, a salt cellar, a piece of plastic pipe, a vibrator, a plastic cover, a chocolate cover, a chicken bone, a fish bone, needles, a spiral, coins and key, a piece of thermometer, teeth prosthesis and soap. Mortality was seen in three patients.

The presence of foreign objects in the rectum is a rare encountered situation which should always be kept in mind for differential diagnosis. Most of these objects can be taken out transanally. If this fails, all efforts must be shown to take it out without opening the colonic lumen. Because of potential complications, the surgeon must be careful during intervention. Median age of the alive was 54. Median leukocyte number at the moment of appliance was 13.9, median debridement 2.6 and median inpatient stay were determined as 27 days. Median age of the dead 63. Median leukocyte number at the moment of appliance was 31.5, median debridement 2.5 and median inpatient stay were determined as 19 days. The most common reason of the aetiology was determined as perinal abscess. Diversionary ostomy was applied to six patients. Chronic kidney failure, and type 2 diabetes was exist in four patients of dead-group. In addition, in one patient type 2 diabetes and hypertension was observed. Conclusion: Chronic kidney failure related to hemodialysis and high level of lekucyte number at the moment of appliance are the important prognastic factors of deaths related to FG. Computed Tomography (CT) has become the mainstream of evaluating all hemodynamically stable patients with acute problems when the attending doctor, is urging for diagnosis. Basing a diagnosis solely on radiological data sometimes ignoring medical history and physical examination may lead to unexpected errors. Wrong interpretation of radiological images or images with equivocal findings which may delude the radiologist and technical errors (artifacts) are all potential sources of mistakes. The aim of this study is to draw attention to the danger of the modern imaging diagnostic modalities to misguide the treatment of patients who need emergency care. We present some cases we faced in our clinic where radiological images showed pathologic entities which in fact did not exist (false positive errors) but forced us to inappropriate treatment. Two patients underwent negative laparatomies with imaging diagnosis of a ruptured gallbladder in one case and free air under the diaphragm in the other. A patient with a severe head injury and a CT scanning showing pneumocephalous was transferred to a tertiary centre to be proved on repeated images that initial diagnosis was mistaken due to a wrong calibration of the gantry. Imaging findings do not necessarily represent reality. Almost always surgeons rely on CT scans for treatment decisions. it is a hard task for a surgeon to question or ignore the pictures to treat a patient based on medical history and physical examination. Experience of radiologist is essential and close cooperation with the attending surgeon is needed to avoid radiological misfindings in emergency cases. Author to editor: To be presented as a poster. A full text is available on demand.

Intentional own insertion of rectal foreign bodies in a married, claimed to be straight male, using antidepressive medicaments because of sexual orientation disorder, resulted in resurgery with the same reason of mechanical intestinal obstruction after 7 years in the same surgery clinic by the same surgery team as an emergency intervention. Failure of the nonoperative measures under local, spinal and general anesthesia led to the surgical treatment of the 54-year-old patient in 2002 and 2009, who is now 61 years old during the second event. Large bottles were removed through laparotomies and colotomies followed by primary repair to reverse the ongoing ileus, which resolved on the 5th postoperative days in both events. A surgeon who is called to see a patient with retained foreign body should answer whether the patient had rectal perforation and whether the foreign body could be removed transanally without regional or general anesthesia with or without surgical intervention. In case of children; habitually self inserting objects in her vagina or sexually aggressive behaviour with others, e.g. for a boy ''humping'' toys in sexual positions can be a behavioural indicator of child sexual abuse or assault. Hence message is: if in a patient perforation of sigmoid colon or rectum history after anal insertion of foreign body in an otherwise healthy adult becomes habitual,the patient should be send to psychiatric counselling. Discussion of the nonoperative measures to remove rectally inserted objects is also an utmost important opportunity constituting the largest part of the report of the present case. Necrotizing fasciitis is a highly morbid and mortal condition. As a result of aggressive debridement, wide tissue defects occur. Wound cleaning from infective material, granulation process and grafting of wound requires a long time. Recently, a vacuum assisted therapy system has begun to use for this kind of wounds. This study discuss the treatment result of vacuum assisted therapy (VAC Ò Therapy TM ) in two patients with giant abdominal wall defect in view of current literature. Case1: A 44 years old man had an operation because of an accident on railway. At the time of admission there was a wide defect with necrotizing fasciitis on the right lombar region and anterior abdominal wall. There was a full thickness defect about 40 · 30 cm after an aggressive debridement. It was successfully treated with VAC and the patient has been discharged after tissue grafting on the postoperative day 85. Case2: A 22 years old man had an operation because of an accident.

He was admitted at postoperative day 4. He underwent an aggressive debridement because of necrotizing fasciitis. The skin, rectus abdominus, transversus abdominus, internal and external oblique muscles and some part of quadriceps femoris on the left side was excised. The sacroiliac joint was also broken and pubis was separated. VAC abdomen has been applied on two different sites and the wound has become available for grafting after 65 days of therapy. As a conclusion, vacuum assisted therapy provides safe and accelerated wound healing, improves proper tissue granulation in patients with giant abdominal defect. Introduction: Bogota bag (BB) is a device used for the temporary closure of the abdominal wall (AW). Despite its potential benefits, their use is not widespread and remains controversial in the present. Aım: To describe our experience in its management for the temporary closure of the AW in emergency situations. Methods: For a period of 4 years, BB has been used in 10 patients (pts), with an average age of 58.7 years. Six had a secondary peritonitis, one tertiary peritonitis, two haemoperitoneum and one a compartment syndrome established. The technique consisted of the placement of a bag of sterile serum, stitched to the skin with nonabsorbable material.

Results: The average of bags placed by year was 2.2. No morbidity was associated with the placement and/or replacement of BB. The average time of hospitalization was 88.9 days and the average time of income in the ICU was 26.2 days. In 5 pts, the bag was replacement one or more times. The average number of surgical interventions by patient during the income was 3.3. The average time of permanence of the patient with the bag was 22.4 days. Sixty percent of patients are alive today. Objectıves:

The aim of the current study is to assess the role of ultrasonography in the management of acute appendicitis. Methods: Ultrasonography was performed to 318 patients with acute appendicitis suspicion between 2004 and 2008. Appendectomy was performed to patients with acute appendicitis diagnosis according to clinical examination after ultrasonography. Patients who had a diagnosis different from acute appendicitis with clinical examination were observed. The histopathological findings of patients with appendectomy were compared with their USG findings. Results: 254 of 318 patients had acute appendicitis diagnosis by ultrasonography. Hystopathological examination showed acute appendicitis in 242 of these patients. 12 patients did not have acute appendicitis. USG showed that 64 patients did not have acute appendicitis. Ten of these patients showed gynecological pathology, and six of them showed urinary pathology, and they were all treated appropriately. In eight patients the appendicitis findings became evident in clinical observation; resulting in appendectomy, and histopathological examination showed acute appendicitis. Forty patients showed improvement at follow up. No spesific treatment was needed. Misdiagnosis rate was determined as 4.58%. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy percentage of ultrasonography in the diagnosis of acute appendicitis was 96.8, 82.35, 95.27, 87.5 and 93.71%, respectively. Conclusion: Ultrasonography has a high degree of accuracy in the diagnosis of acute appendicitis. However, we also conclude that Ultrasonography results should always be interpreted in combination with clinical findings.

Background: Hydatid cyst disease is frequent in some regions of the world, including our country Turkey, and is most commonly located in the liver and lungs. The hydatid cysts may rupture spontaneously or as a result of trauma. Herein, we describe a rare case of retrovesical hydatid cyst which was resulted from rupture of spontaneous rupture of liver hydatic cyst intraperitoneally. Case: Fifty-four years old male was admitted to emergency department with complaints of frequent urination and abdominal pain lasting for 10 days. There was general abdominal tenderness on physical examination. There was no history of trauma or operation. In his abdominal ultrasonography and tomography there were primary cyst (11 · 6 cm), ruptured cyst (6 · 4 cm) and retrovesically located cyst (15 · 13 cm). Indirect hemagglutination test was positive for echinococcus granulosus (1/4,096) . Laparotomy was performed and all the cysts were excised by partial cystectomy. There was no postoperative complication. The patient was externalized on postoperative 5th day with albendazol treatment. Conclusion: Retrovesical localization of hydatic cyst is a very rare. These cysts mostly occur as a result of surgical inoculation caused by inadequate surgery or free intraperitoneal rupture of primary hydatic cyst. In endemic regions, possibility of hydatic cyst should be kept in mind in differential diagnosis of intrapelvic cysts and masses. Background: Wegener's granulomatosis (WG) is a systemic necrotizing vasculitis of unknown etiology characterized mainly by involvement of the upper airways, lungs, kidneys and may rarely involve the gastrointestinal tract. Intestinal involvement may be asymptomatic. We herein report a WG with massive lower gastrointestinal hemorrhage due to colonic involvement. Case: The patient complained of dyspnea which started 2 months ago, fatigue, generalized arthralgia and myalgia together with loss of sensation on right upper extremity was applied to emergency and hospitalized by internal medicine department. Physical examination revealed a very ill-looking patient, there were positive lung findings for WG and c-ANCA was positive. We consulted the patient because of hematochesia with abrupt drop of hemoglobin and platelet count. On colonoscopy whole mucosa was full with fresh blood from sigmoid to anal canal. On angiography multiple foci of bleeding were demonstrated on descending and sigmoid colon. Embolectomy was not performed because of multiple foci. hemoglobin decrease continued and his clinical condition deteriorated; an explorative laparotomy and total left colectomy was performed. His melena persisted for 34 days but hemoglobin was maintained at 9 after 8 units transfusion after operation. Conclusion: We herein report a case with clinical WG who developed a gastrointestinal hemorrhage and treated by surgery. The uremic state and cytotoxic agents given to patients may detoriated the gastrointestinal bleeding. Immunosuppressive therapy might exacerbate gastrointestinal complications. The clinicians should be aware of this situation, therefore treatment of these must be performed in centers where angiography and endoscopy are available. Background: The aim of this study is to determine the strength and proceeded efficiency of MDA, SOD, and catalase levels that are indicators of oxidative stress in generalized peritonitis.

Material-Methods: This study was conducted as prospective and randomized with patients who applied at Dicle University, Department of General Surgery between March-September 2008. Patients were composed as group 1 (n = 50); generalized peritonitis, group 2 (n = 50); laparotomy under elective conditions and not present peritonitis; group 3 (n = 50) as control group. In order to measure limits of MDA, SOD, CRP and catalase, blood samples were drawn from the patients in group 1 and group 2 on before operation day (BOD), 1st and 3rd days.

The MDA values of group 1 on before operation day, 1st and 3rd days were compared to group 2 and 3, the difference were found statistically meaningful. Statistical differences noticed between group 1 and 2 MDA values on BOD, 1st and 3rd days. Statistical differences were noticed between catalase values measured BOD and 3rd days when group 1 and 2 values compared to group 3. The SOD values of group 1 and group 2 on 0 day were compared to group 3, meaningful statistical difference was found. Statistically meaningful difference was found between the SOD values group 2 and 3 on 1st day.

Conclusion: Values of SOD, MDA and catalase were noticed usable parameters for the following and detection of severity of generalized peritonitis

Sinan Cumhur Karakoç, Gü rkan Yetkin, _ Ismail Ethem Akgü n, Mehmet Uludag, Bü lent Ç itgez, Hamdi Ö zş ahin, Cabbar Kartal 1 1 General Surgery Departmet, Ş iş li Etfal Training Hospital, Istanbul, Turkey Objectıve: We aimed to evaluate the effects of early cholecystectomy on morbidity and patient comfort in patients with acute biliary pancreatitis. Methods: 58 patients who underwent cholecystectomy for acute biliary pancreatitis in our clinic between 2004 and 2009 were evaluated retrospectively. The patients were divided into three groups as early, late and elective cholecystectomy cases. Fındıngs: 20 patients who had undergone cholecystectomy operation in the first 10 days until the administration to hospital were classified as the first group (early cholecystectomy). 12 patients who had undergone cholecystectomy between the 2nd and 10th weeks until the administration to hospital were classified as the second group (late cholecystectomy). 26 patients who had undergone cholecystectomy after 10 weeks were classified as the third group (elective cholecystectomy). In Group 2, no patient had pancreatitis attacks; 8 of 26 patients in Group 3 had recurrent pancreatitis attack in the preoperative period and treated in our clinic. In order of these data, age, height, weight, gender, SGOT, SGPT, amylase, bilirubin and the time for waiting for the operation were compared and evaluated statistically. The time for waiting for the operation was found to be p > 0.001, and it was shown to be significant. Results: There is a tendency to perform cholecystectomy in patients with acute biliary pancreatitis, after the acute attack is resolved. We believe that the early cholecystectomy prevents the patient from the additional morbidity in patients with acute biliary pancreatitis, by showing this with a statistically significant result in our study. Traumatic right sided diaphragmatic hernia is clinically rare and may present with complications in a later period. On the right side presence of liver is thought to be a protective factor for both development of diaphragmatic injury itself and for its complications. We present a case of right sided diaphragmatic hernia due to blunt trauma, which was asymptomatic for 57 years and has been presented with intestinal obstruction. The patient, 76 years of male, has presented with intestinal obstruction and abdominal pain which has been relieved after nasogastric decompression. Despite conservative treatment patient has not shown further improvement and has been operated on a semi-elective basis. Significant part of small and large bowel, distal portion of stomach, and almost whole of liver had been herniated and reduced by right thoracoabdominal approach. 10 cm wide defect in diaphragm has been repaired with prolene mesh, laparotomy has not been closed and Bogota bag has been applied. In the early postoperative period transaminase levels have increased 4,000 U, and CT-angiography has revealed patchy areas of low per-fusion in both lobes of liver. After therapeutic anticoagulation liver function has recovered completely, abdomen is closed and oral feeding commenced.

At the 9th postoperative day respiratory insufficiency has occured after witnessed aspiration of gastric contents, followed by multiple organ failure. This case represents a quite late presentation of right sided traumatic diaphragmatic hernia, for which treatment was complicated. This case clearly shows the importance of detailed evaluation and timely treatment of all traumatic diaphragmatic hernias.

Cem Ibis, Dogan Albayrak, Fedayi Calta, Eren Taskin, Mehmet Ali Yagci, Ahmet Hatipoglu, Irfan Coskun 1 1 Department of General Surgery, Medical Faculty, Trakya University Edirne, Turkey

Introduction: Amyand hernia is first described by Claduis Amyand in London in an 11 year old male. It is a rare condition and described as appendix vermiformis in the hernia sac. We present a case of an incarcerated inguinal hernia with appendix vermiformis inside. Case: Sixty nine years old male with bulging and pain in the right inguinal region is evaluated. Right inguinal hernia was detected. After opening the hernia sac, the appendix and ceacum were observed. Lichtenstein procedure was performed. The patient was discharged in the second postoperative day. Discussion: Although the incidence of appendix vermiformis in the hernia sac is 0.5-1%, the incidence of acute appendicitis in the hernia sac is 0.13-0.62% in various reports. The treatment of Amyand hernia is related to the appendix found inside. The application of appendectomy to normal appendix in routine hernia repair procedure is controversial due to infection risk. We do not routinely perform prophylactic appendectomy in such patients. We thought that a patient tailored approach is more acceptable.

Introduction and objectives: Hydatid disease is typically asymptomatic. It can become symptomatic due to expansion, rupture or pyogenic infection. Rupture of the cyst is the most common complication, followed by secondary infection, jaundice, and anaphylaxis. Methods: In this study, we analyzed demographic and clinical characteristics of the cyst hydatic patients who admitted the emergency service due to complications of the cyst hydatic.

The medical records of patients, with a final diagnosis of complicated cyst hydatic were reviewed for demographic information, admission symptoms, laboratory findings, evaluation techniques, and outcome. Results: Ten patients (7 men, 3 women) with final diagnosis of complicated CE (Cystic Echinococcosis) included the study. All of the patients had abdominal pain. While the pain was diffuse in the entire abdomen in seven patients, it was located in the right upper quadrant in three patients. Patient's complaints were nausea, vomiting, jaundice, ileus and urticaria. The clinical signs and symptoms of HC rupture are not always severe, but hydatid fluid can irritate, which can cause peritonitis as occurred in our series of patients, all of whom had acute abdominal signs. In this study, 100% of the patients with ruptured CE had abdominal pain. Thus, the clinical presentation of CE rupture is not always silent. The severe clinical presentation and infrequency of CE perforation has been held partially responsible for the misdiagnosis by the surgeon. Conclusion: In conclusion; complicated HC may be admitted to emergency service with different clinical pictures especially in endemic regions and must be considered in differential diagnosis.

Background: To evalute the changes in the pattern of Iatrogenıc bılıary injury and consequentıal effects on treatment strategy and outcome.

Methods: Seventy-three patıents treated for Iatrogenıc bılıary injury (IBI) between 2003 July and 2008 November at a tertıary care center In Izmir, Turkey were retrospectıvely analysed.

Results: Underlyıng diseases were; missed tumor (N: 2, 2.7%), biliary surgery (N: 67, 92%) and hydatıc dısease (N:4, 5,3%). In recent years wıth a gradual increase in the avaılabılıty of endoscopıc and radiologial expertise the majorıty of patıents underwent extensıve preoperatıve diagnostic and therapeutıc procodures includıng endoscopıc retrograd panceratography for 26 cases(35.6%) and percutaneus transhepatıc cholangıography for 11 cases(16%). Defınıtıve surgery was performed In all patıents except 9(12.3%) of them. Roux-En-Y hepatıco-jejunostomy was the primary reconstructıon technıque and performed for 35 cases (48%). There was only one (1.36%) hospıtal mortalıty. Restenosıs developed In 2 (2.7%) cases and was reoperated. Percutaneus baloon dilatation was faıled In three patıents as a fırst treatment optıon. None of patıents died of dısease related causes durıng the follow-up perıod. Conclusion: Increased experınece in laparoscopıc biliary surgery might be caused to attempt more challengıng cases and increased bılary tract injurıes.

Tolga Kafadar, Ercan Gedik, Sadullah Girgin, Bilsel Baç, _ Ibrahim Halil Taçyıldız 1 1 Department of General Surgery, Dicle University, Diyarbakir, Turkey

The aim our study was to determine the independent risk factors affecting patients with upper gastrointestinal hemorrhage who underwent surgery. Materials and methods: The medical records of 62 patients with upper gastrointestinal hemorrhage who underwent operation were reviewed for variables including age, gender, shock, association with co-morbidity, pulse rate, hemoglobin levels, white blood cell count, serum urea, creatinine, sodium and potassium levels, time of opera-tion, number unit of blood transfusion, Rockall risk score and length of hospital stay. In order to determine the independent risk factors mortality and morbidity, we carried out Entered logistic regression analysis.

Results: Morbidity and mortality rate were 35.4% (22 patients) and 29.1% (18 patients), respectively. The independent risk factors affecting morbidity were serum albumin level [odds ratio (OR) = 1.442, 95% confidence interval (CI) = 1.060-1.962, p = 0.020] and Rockall score ‡ 5 (OR = 0.027, CI = 0.001-0.690, p = 0.029), and the independent risk factors affecting mortality were advanced age (OR = 1.048, CI = 1.008-1.090, p = 0.0189), and high Rockall score (OR = 0.578, CI = 0.370-0.903, p = 0.016). Conclusion: To decrease the postoperative morbidity and mortality rates in patients with UGIH requiring surgery, patients preoperative risk factors should be demonstrated. We believe that establishment of interventional indication on time and evaluation of intraoperative surgical region and technique in combination with the patient-and disease-related factors in patients requiring surgery would help reduce morbidity and mortality rates. Blunt thoracic trauma leads to various clinical conditions, such as hemothorax, pneumothorax, pulmonary contusion, and respiratory tract hemorrhage. Especially, respiratory tract hemorrhage resulting from pulmonary contusion is so critical to require a clinical challenge. Of our experienced survivors, 3 trauma victims (male 3/3, 19-23 years old) with blunt thoracic trauma associated with motorcycle accident were transferred to our emergency departments. They similarly suffered respiratory failure (average respiratory rate of 32) and hypotension (average shock index of 1.2) on arrival. Immediate after the rapid-developing respiratory failure in relation to lung contusion and endobronchial bleeding, bronchial blockade device and extracorporeal membrane oxygenation (ECMO) were urgently introduced at an average of 32 and 104 min, respectively, and achieved rapid resolution of their respiratory crisis. All of them withdraw from ECMO within 5 days. Pulmonary contusion sometimes follows fatal progress, and we consider that quick bronchus blockade and ECMO introduction is the key of survival. Emergency departments (ED) in Greece are incorporated to the departments of the hospital and are divided in two major areas: one for internal medicine and one for general surgery. Every patient has free access to the (ED). The workload and the conditions treated in ED in Greece are geographically and social -economically depended. The National Health System is represented by one hospital for each prefecture. The General Hospital of Trikala, is categorized as an urban hospital, with 300 beds, and is covering a population of approximately 150,000 people, living in the town and in villages situated in the surrounding mountain area. The department of general surgery is stuffed by 8 general surgeon specialists and seven residences. During 2008, 15,833 patients were examined in the surgical ED. In this study we analyze the characteristics of the patients, the number and causes of admissions in the various departments of our hospital and also the transferals to a tertiary center. Aim: Pneumotosis cystoides intestinalis is a rare entity, and may be associated with pyloric stenosis. Materıals-Methods: Data of a patient operated for pyloric stenosis and pneumotosis cystoides intestinalis in our institution are presented.

Results: Patient was a 50 year-old addicted male, and his body mass index was 18.5 kg/m 2 . He had been suffering from nausea/vomiting, bloating and constipation for a few months. A gastroscopic examination revealed atonic gastric dilatation, duodenal ulcer and related pyloric stenosis, and positive serology for Helicobacter pylori. An eradication treatment in conjunction with long term proton pomp inhibitors were given, however the patient readmitted to our department with worsening symptoms including vomiting, pain and weight loss after 2 months. Repeated gastroscopies and gastric meal X-ray examination revealed pyloric stenosis and the patient decided to have an operation instead of repeated medical treatment. During laparotomy, subserosal foamy air bubbles were observed on the serosal wall of ileum. A partial resection of ileum was necessitated for the suspicion of perforation. Vagotomy with Finney pyloroplasty was performed in order to cure the pyloric stenosis. The postoperative period was uneventful and the patient was discharged from the hospital on day 8. The patient has not have a recurrence, gained weight and have no problem since 2 years postoperatively. Conclusion: Pneumocytosis cystoides intestinalis may be observed in the presence of a pyloric stenosis and necessitates resection if any doubt for perforation is present.

Granulosus. In this study, a rare appearance of the disease is presented as an abscess located in the retroperitoneal space. Results: The patient was 75 years-old male with several comorbidities admitted to our emergency department with fever and left lumbar pain. He had had operated for hepatic hydatid disease 20 years before the admission. Physical examination revealed local tenderness and slight hyperemia on his left lumbar region. His laboratory findings showed leucocytosis, and a computed tomography demonstrated a huge retroperitoneal abscess located between spleen and pelvic entrance and denied any pathological finding regarding to the left kidney or adrenal gland. Since the general condition of the patient did not allow an operation under general anesthesia, the abscess was drained through a 7 cm long incision located on the hyperemic area under local anesthesia. After complete removal of the abscess and daughter cysts, a drain was left behind, and removed on day 7. The patient was discharged out of hospital on day 2, after an uneventful recovery period. Discussion: To best to our knowledge, this is the first hydatid disease case presented as a retroperitoneal abscess in the literature. Hydatid disease may be kept in mind as a differential diagnosis in the presence of a cystic retroperitoneal mass in endemic regions.

Ali Uzunkö y 1 , Zekeriya Sayın 2 1 Harran University School of Medicine Department of General Surgery, Sanliurfa, Turkey 2 OSM Ortadogu Hospital, Sanliurfa, Turkey

Introduction and objectives: Giant true splenic artery aneurism is rare lesions. These aneurisms have risk of rupture and bleeding. We have performed a giant true splenic artery aneurism. Case: The case is a 38 year old female patient. She applied to hospital with complaints of abdominal pain. At the physical examination, there were a moderate splenomegaly and a pulsatile mass in the left upper abdomen. It was shown a giant splenic aneurism at the abdominal computed tomography and colour Doppler ultrasonography. Colour-Doppler abdominal ultrasonography showed about 50 mm splenic artery aneurism. Computed abdominal tomography showed a hypo dense mass situated anterior and superior to the pancreas tall and corpus extending up to the splenic helium. The diagnosis was confirmed by CT angiography. The patient was performed with general anaesthesia and left subcostal incision. At the exploration, splenic arterial dilatation and aneurismal sac was shown and aneurysmectomy with splenectomy was performed. There was no complication intraoperatively and postoperatively. The patient was discharged at the postoperative fifth day. There was no complaint at the control examination at the fifteenth day after discharging.

Conclusions: Although giant splenic artery aneurism is rare, but they have risk of rupture and bleeding. There are two options for treatment of these lesions. One of them is aneurysmectomy. It is frequently performed with splenectomy. Other option is embolisation. In our opinion, surgery for giant splenic artery aneurism is performed successfully without important complication. Author to editor: Saved by LookUs Introduction: An association between the administration of paracetamol and relative hypotension in critically ill patients has been reported by the staff working in the surgical and trauma intensive care unit of Istanbul Faculty of Medicine. Methods: A prospective, observational study was undertaken to investigate the effect of paracetamol on systemic blood pressure in two groups of critically ill patients. A dose of 500 mg of paracetamol was administered intravenously to both groups in 15 min time. Blood pressure, heart rate were recorded at baseline, at the end of infusion and then at 15, 30, 60 min after administration. The differences occured over the observation period was measured by Friedman analyse. Results: Twenty-eight patients with sepsis, were enrolled to group-1 (anti-pyretic effect) and 20 postoperative patients were enrolled to group-2 (analgesic effect). Analysis of data from all patients showed that systolic arterial pressure (SAP) and mean arterial pressure (MAP) were reduced significantly over the observation period in both groups (SAP:p < 0.001 for both, MAP:group-1 p < 0.05, group-2 p < 0.001). SAP and MAP in group-1 and group-2 decreased by an average of approximately 7 and 10% respectively. However, no significant decrease in DAP was noted in group-1. Conclusions: Utilization of the intravenous paracetamol for febrile and/or postoperative patients caused a significant decrease in systemic blood pressure after administration. This drug-induced hypotension was clinically relevant to control the required blood pressure. Thus, clinicians should be aware of this potential effect, especially in critically ill patients.

Yazile Sayın 1 1 Faculty of Health, Surgical Nursing Division, Cumhuriyet University, Sivas, Turkey

Background: Pain is considered one of the most important symptoms which guide diagnosis, treatment and nursing care in the emergency departments. Aım: To discuss pain evaluation by nurses in emergency departments and to attract attention towards nurses' responsibility for pain evaluation.

Methods: Qualitative and quantitative data from 18 studies on pain evaluation by 520 nurses were evaluated. Results: All studies reviewed showed that about three fourths of the nurses in the emergency departments did not make pain evaluation based on the standards (using pain rating scales, reporting the conditions likely to affect pain evaluation etc.). The nurses included in 10 studies assigned significantly lower scores for pain than the researchers(p < 0.05;p < 0.001). All studies revealed the following reasons why triage nurses did not play an effective role in pain evaluation: insufficient knowledge, the idea that doctors are responsible for pain evaluation, doctors not appreciating the value of pain data provided by nurses, insufficient cooperation among members of the health staff, work overload, time constraints, errors in reporting data on pain evaluation and conflicting attitudes and beliefs concerning pain evaluation. It has been reported that only 30-40% of the patients presenting with pain to emergency departments received effective pain management. The most important reason for this low rate has been shown to be deficiencies in pain evaluation due to insufficient multidisciplinary cooperation.

Conclusion: It can be concluded that nurses in emergency departments are not efficient enough to use interventions which help to evaluate pain for effective pain management. Introduction: Diverticulosis of the colon is a common condition.

Complications of diverticulitis often require surgery. Perforated diverticulitis may rarely present with spreading superficial sepsis. Case: Male, 54 years, history of chronic depression. Admitted in the emergency department after a 15-day history of abdominal pain in the left lower quadrant (LLQ), associated with asthenia, anorexia and weight loss, without diarrhea, constipation or fever. The patient examination showed edema and thickening of the abdominal wall with swelling and redness in the LLQ. Blood chemistry revealed leukocytosis with neutrophilia and elevated C-reactive protein. A diabetic ketoacidosis was diagnosed. The abdominal CT confirmed abdominal necrotizing fasciitis with an abscess, without other intra-abdominal changes. The patient was then submitted to emergency surgery with debridement of the necrotising fasciitis and drainage of the abscess. He was admitted to the ICU. Further debridement was necessary 48 h later. At D6, fecal contamination of the wound was detected, leading to a subsequent laparotomy with identification of a sigmoid inflammatory mass attached to the site of the fistula's external orifice. A Hartmannprocedure was performed (histology confirmed the diagnosis of perforated diverticulitis). The patient developed a SIRS complicated with a right-side necrotizing pneumonia requiring multiple antibiotic treatment and pulmonary decortication. Death occurred at the 54th hospitalization day. Conclusion: Necrotising fasciitis as a consequence of perforated diverticulitis is an uncommon but potentially lethal condition requiring prompt surgical intervention. When accessing an abdominal necrotising fasciitis without recognisable source, an elevated index of suspicion is necessary to link it to complicated diverticulitis.

Fatih Baş ak, Kü rş ad Ö ztü rk 1 1 Tc Sb Bozkir Community Hospital

Introduction: Care of trauma patients may be difficult in small community hospitals. These hospitals are usually staffed by a small number of general practitioners and, perhaps, a general surgeon, and a significant number of trauma cases are brought to them.

The records of minor and major trauma patients who admitted to Bozkir Community Hospital between June 2007 and December 2008 were evaluated. Mortality and transfer rate were recorded. General surgeon was not present in first 12 months. The rates of last 6 months when general surgeon has been present were calculated separately.

Results: 738 trauma patients were admitted in first 12 months 139 (18.83%) of these were transferred to larger centers. Treatment of remaining 599 (81.16%) patients continued in our hospital. Mortality rate of first 12 months was 0.6%. Three patients requiring immediate surgery died because of absence of general surgeon. 898 patients were admitted in last 6 months. 147 (16.3%) of these were transferred to larger centers. Mortality rate of last 6 months was 0.3%. Three gunshot wound and one penetrating cardiac wound patients were saved with emergent surgery.

Conclusions: Regardless of the sophisticated techniques for dealing with trauma that exist in larger centers, it is the staff of smaller hospitals that often shoulder the initial burden of trauma care. Transfer rate is between 16 and 18% of all trauma cases. Our hospital is 1.5 h away from larger centers. Presence of general surgeon in last 6 months mainly affected the care of patients that requiring immediate surgical attention.

Metin Kement, Hakan Acar, Ilhami Soykan Barlas, Uygar Dü zci, Cem Gezen 1 1 Burn Center, Kartal Education and Research Hospital, Istanbul, Turkey

Aim: Fecal contamination which may result in septicemia, graft loss and wound healing delay is the most serious problem for burns in perineal, gluteal and upper thigh regions. Temporary fecal containment devices can be used for diverting feaces from burned area. The aim of this study was to evaluate early results of using of these devices in our burn center. Methods: Twelve patients, who were applied temporary fecal containment devices in our burn center, were retrospectively evaluated in this study. Results: 7 (58.3%) of the patients were male.The mean age was 37.33 ± 17.34 year.The mean TBSA burned was 32.08 ± 14.05%. 6 (50%) of the patients had burn in all three regions (perine, gluteus and upper thigh). Three (25%) of the patients had burn in upper thigh. And 3 (25%) of the patients had burn in gluteal region. The devices were placed intra-rectally on the first admission days of all patients.The mean application time was 14.25 ± 4.51 days. Except minimal fecal leakage in 2 (16.7%) patients, any complication was not observed in our cases. Local infection confirmed by tissue culture was observed in 4 (33.3%) patients including two patients with fecal leakage. Besides, in one of these four patients, septicemia was developed and managed successfully with antibiotics and supportive treatment in intensive care unit of our center.One patient with 70% burn was died on 5 days of application due to multiple organ failure.

Conclusion: Temporary fecal containment devices aim to protect patients' wounds from fecal contamination by diverting feaces. If the safety of these device is proved in further studies, they may reduce the necessities of diverting stoma operation in burn patient.

Metin Kement, Ilhami Soykan Barlas, Uygar Dü zci, Hakan Acar, Cem Fazlı Gezen Burn Center, Kartal Education and Research Hospital, Istanbul, Turkey

Aım: Reactive thrombocytosis which develops secondary to infection, trauma, malignancy or surgery is the most common ethiology of thrombocytosis. Although thrombocytosis is a benign and self-limiting condition in most cases, it may result in some thrombotic and hemorrhagic complications. The aim of this study was to evaluate the reactive thorombocytosis in burn patients. Material: Thrombocyte counts was retrospectively evaluated in 158 consequent burn patients admitted to our burn center between August 2008 and January 2009. The correlations between thrombocyte counts and demographic data, total body surface area burned (TBSA), hospitalization time and levels of some acute phase markers also analysed.

Results: The mean thrombocyte counts were respectively 317.910 ± 150.380/mm 3 , 379.750 ± 174.430/mm 3 on admission day and second day (p < 0.05). The number of patients with thrombocytosis was 25 (14.6%) in admission, 21 (84%) of them were children. The rate of thrombocytosis was 21/63 (33.3%) in children,whereas the rate of thrombocytosis was only 4/95 (4.2%) in adults (p < 0.001).

The mean thrombocyte counts in children and adults were respectively 400.520 ± 175.920/mm 3 , 250.330 ± 77.900/mm 3 in admission (p < 0.001). The mean WBC count was significantly higher in patients with thrombocytosis than patients with normal thrombocyte count (p < 0.05), but there was not any significant difference in CRP count (p = 0.58). And also,we did not find any significant difference between patients with thrombocytosis and patients with normal thrombocyte count in TBSA and hospitalization time (p = 0.690 and 0.895, respectively) Conclusion: Reactive thrombocytosis is seen more frequently in burned children than burned adults and mostly unrelated to degree of burn. Background: Electrical injuries are related with multiple organ dysfunction as well as high morbidity and mortality. Pulmonary compromise is rare, if compared to other organ dysfunctions related with electrical injuries. In this study, we presented a case with pulmonary hemorrhage associated with electrical injury. Case: A 24-year-old previously health man was brought to our Emergency Department (ED), 1 h following the accident, with electrical injury. Initial examination findings were blood pressure 80/ 40 mmHg, heart rate 79/min, respiratory rate 37 breath /min. Glasgow coma score was 3. Decreased breath sounds, bilateral rales and wheezing were determined. There were small necrotic wounds (typical contact injury) on the first finger of left hand and under the right foot of patient. There was no trauma in thoracic wall. Blood gas analysis revealed respiratory and metabolic acidosis. The INR and platelet levels were normal. When chest radiograph and thoracic computed tomography were assessed, air bronchograms and symmetric consolidations were determined in the both lungs. Patient was intubated and fresh blood was aspirated from endotracheal tube. Mechanical ventilatory support was performed the patient due to lung hemorrhage and respiratory failure. Patient died after 4 h of admission in the ED. Conclusion: Multiple organ dysfunction and necrotic skin lesions could be occurred in electrical injuries. Electrical injuries on the chest may cause lung infarction because of the direct effect of the electrical current and vascular embolism. Possibility of lung injury should be investigated after electrical injury especially in patients with respiratory failure.

Nebahat Yıldız 1 , Aysel Gü rkan 2 , _ Imren Aş ar 1 , Ayş e Hale Uysal 1 1 Trauma and Emergency Surgery Service,Istanbul University, Istanbul Faculty of Mediine, Istanbul, Turkey 2 Health Science of Faculty Marmara Universty, Istanbul, Turkey Introduction and objectıve: The outcome of burn treatment is measured not only by mortality and morbidity, but also by post-burn psychological factors. The purpose of this study was to investigate whether difference in length of hospitalization exist between burn patients with and without mental health problems and if so, why. Methods: The descriptive study was retrospective review of 448 patient with burn injuries who had received care at one burn unit in the Istanbul from October 2004 to December 2008. Socio-demographic features of patients, burn criteria (kind, depth, size, location), duration of hospital stay, and psychological problems were tabulated. Results: Psychological impairment was found in 69 of 448 hospitalized burn patient. There were acute stress disorder in fifteen patient, anxiety in nine, adjustment disorder together with anxiety in eight, depression in seven, post-traumatic stress disorder in six patient. Fortyone (59.4%) patient had burns which were between I and II degree and 28 (40.6%) patient had burns which were between II and III degree. In 44 patient, burned area has been 21% or more. Patients with psychologocal impairment were longer hospital stay and intensive care unit than patients without psychologocal impairment. Sixty-four (92.7%) patients with psychologocal impairment had been discharge either getting better or recovering completely but unfortunately 5(7.2%) patients died. Conclusion: The presence of psychological problems in burn patients have an impact on their burn care. Psychological interventions can contribute towards successful outcomes.

Introduction and objectives: Major burns can cause disseminated intravascular coagulation (DIC) and is a serious clinical problem. We would like to present 2 DIC cases whose burn rate is 40% according to total body surface area (TBSA) which developed after late postoperative period. Methods: Two cases over 40%, 2nd and 3rd degree burn injury admitted to our facility. First case who was 9 year old female developed S. aureus and second case was 18 years old female developed P. aeruginosa sepsis which was confirmed by blood culture. In first case DIC developed at postburn 18 day and in second case at postburn 26 day. In both cases DIC developed after postsurgery day 7. Results: On patients, bleeding points, as leaking, were detected on all over burn areas. At the same period thrombocyte values decreased sharply (88.9 K/UL). Increase in prothrombin time (PT) (38.2 second) and active partial thromboplastin time (aPTT) (108 second) values, decrease in fibrinogen levels was observed. Cases were discharged from hospital in 35th day, without any problem. Patient was taken for 9 IU erythrocyte suspension and 6 IU platelet suspension in this time totally. Conclusion: DIC occurs in early period of burning; but it can be formed in later periods, even after defects were recovered by operation. Rapid establishment of DIC table just before the discharging term from hospital is an unusual and interesting situation. The patients in our study can be accepted as an example of the necessity of observing coagulation parameters in every periods of burn damage. Methods: Sphere Project Handbook reviewed by experts in the field of each section, the terms of our country's adaptation has been made. Within the framework of the project dissemination, Sphere workshops have been organized in various provinces. The PPT Slides were adapted to Turkey's needs. The project's outcomes have been observed through the pre-post tests and the workshop evaluation forms.

Results: Expert review and the end of the first study, with a high risk of disaster in our country, the handbook was understood to be necessary and useful. In addition to this, the control lists in details but useful and also, the summary tables are useful to take a decision in emergencies. It is also understood that preliminary results from the project is compatible with Literatur data. Conclusions: Developed in each country is adapting to the local experience of the Sphere, significant experience with disasters in our country the right to contribute are welcome. Indeed, the first application of the new approach by the Sphere project's coordination center is monitored with interest. Introduction: (1) Initial assessment of trauma patients is a period with a high frequency of treatment protocol deviations and an elevated number of avoidable complications.

(2) The majority of medical errors are diagnostic or cognitive, whereas operative technical complications accounted for less than 8%, and (3) general surgery residents (GSR) do not feel well-trained on the management of major trauma patients. Aim: Describe initial experience with one approach to foster quality improvement in trauma care modifying the method by which we train surgeons.

Methods: We integrated in the GSR Program, simulation based training sessions with other educational tools as lectures and workshops. The scenario objectives were based on research data indicating major deficiencies in trauma care (TC). We incorporated team training and crisis resource management sessions. To review trauma life support diagnostic and therapeutic standardized protocols we run scenarios to train initial assessment, and head, thoracic and abdominal trauma. After every clinical case, residents participated in a video assisted debriefing session leaded by a specialized instructor. An evaluation interview was made after the course.

Results: All resident viewed the experience as a ''very good'' training modality. Many of them felt their time was better spent in the simulator session than in the operating room, and wanted to do it more often or in a scheduled way. Some of them complained about evaluating the mannequin and the equipment when compared to the one in their actual work setting.

Conclusions: Integrating patient simulation with traditional surgical training may strength the approach to TC education.

Introduction: Pulmonary embolism is a life-threatening condition and its diagnosis is generally based on clinical suspicion. Case: A 34 years old male had been admitted to another hospital with acute dyspnea and syncope and after initial evaluation he had immediately been undergone an operation due to epidural hematoma. He was referred to our emergency department with early diagnosis of acute coronary syndrome after operation because intraoperative and postoperative tachycardia could not be controlled.

In his physical examination GCS: 15, arterial blood pressure 120/ 80 mmHg, heart rate 180/min and breath rate 25/min. ECG, Echocardiogram and thorax CT findings complied with pulmonary embolism. Venous Doppler ultrasonograpy findings complied with chronic deep venous thrombosis. Thrombolytic or antiaggregant medication could not be started because of epidural hematoma operation. At postoperative 72 h low molecular weight heparin and at 96 h warfarin was administered. In follow-up period his symptoms regressed and there was no complication due to epidural hematoma surgery. He discharged from hospital at day 15. Conclusion: In trauma patients, one of the important issues that have to be considered during clinical evaluation is the primary reason leading to trauma. In this case, the investigation for syncope etiology revealed the haemorrhage and thrombus diagnosis concomitantly. These two diagnoses have opposite treatment strategies and due to this condition we had difficulty in management of the patient. Although there are intracranial haemorrhage cases due to pulmonary embolism treatment (thrombolytic or antiaggregant), a similar case report cannot be found in the available literature.

Introduction and objectives: Different societies have different type of snake bites. _ In our actually series, two patient from U.K. and seven patients from south-eastern part of Turkey presented with lıke compartment syndrome result of was bitten by a snake to their fingers. Methods: Four of nine patients applied to our clinic at the day of event, the other five were referred to us after the emergency treatments have been done. All bites were over or distally to the PIP joint. After being bitten by snake, patients admitted to our accident and emergency department because they had like as compartment syndrome on the forearm. Two of the patients were referred to us very late stage and one of them had partial necrosis and the other had total necrosis already. None of patients had signs of systemic envenoming. Results: Two patients with local swelling and no other symptoms were discharged. Coverage of the defects were performed with full thickness skin grafting in two patients, cross-finger flap in one patient, reverse dorsal digital arter flap in one patient and dorsal interosseous metacarpal flap in two patients. One patient had amputation. None of patients had fasciotomy. Conclusions: This study represents the clinical effects and current approaches for the treatment of snake bites to distal finger. All patients presented with compartment syndrome like symptoms on the hand or forearm. These patients should be followed-up very closely. Final wounds should be closed either with skin grafts or local flaps. Simultaneously, systemic envenoming should be considered.

The aim was to evaluate the geriatric patient with abdominal pain in Emergency Department (ED). Methods: The preliminary retrospective study included the period between January 1 and June 30, 2008, Ankara. Data were achieved from registration notebooks, manually. The patients separated within age to three groups as 65-74, 75-84, 85 and over. The finalization of management, hospitalization, operation rate, mortality were studied. Results: There were 113 (0.63%, annually) patients. The mean age was 74.8 ± 7.0 (65-100), the mean hospitalization duration was 6 days (1-23). The sex and the age of patients can be seen in Table 1 . 46.02% (n = 52) of them discharged from ED. Abdominal CT and USG usage were 33.62% (n = 38), 38.06% (n = 43) in ED. 0.97% (n = 11) patients had both CT and USG. Abdominal CT and USG results are showed in Tables 2, 3. Finalization of patient management was demonstrated in Table 4 . The operation rate for all patients was 33.33% (n = 13). General surgery hospitalization and operation rate were 33.63 and 10.62% (n = 38, n = 12). The mortality rate was 7.69% (n = 3) in admission. There were not any significant difference between the groups of 65-74 and 75-84 according to sex, finalization, CT, USG utilization, operation rate (p = 0.866, p = 0.135, p = 0.786, p = 0.822, p = 0.3120) with SPSS 15 X 2 test, while the number of advanced geriatrics was unsuitable for statistics. Conclusions: Females and the 65-74 age group were common with a complaint of abdominal pain in ED. Most of them had hospitalization indications and the primary yard was general surgery with brid ileus. Mortality rate was lower than 10% Introduction: Nontraumatic epigastric and left upper caudran pain is a common complaint in Emergency Department. It can include lifethreatened various reasons as cardiac, respiratory, and serious gastrointestinal problems, rarely. Case: A 47 year old man had an emesis with recurrent epigastric and left upper caudran pain admitted as second turn to ED in 24 h. Physical examination except a slight epigastric sensitiveness, EKG, urine test and biochemical tests, complet abdominal ultrasonography, X-rays were nonspesific on the first day. WBC was 12.2 on CBC. His complaints relieved with semptomatic treatment with an 50 mg ranitidine, 10 mg metoclopramide, serum sale on his observation and discharged with suggestions. In second admission with nonspecific physical examination findings, computerized tomography (CT) revealed splenic unenhanced parenchymal areas consistent with splenic infarcts. Computerized tomography angiography (CTA) showed a small aneurysm of the celiac trunk, a characteristic pattern of caliber irregularities and arterial wall thickening of the splanchnic arteriesincluding splenic artery, common hepatic, right and left hepatic arteries-, suggesting splanchnic arterial mediolysis (Figures 1 and 2 are presented with permission of patient's written consent). He was hospitalized to general surgery and started low molecular weight heparin. As clinical and radiologic findings were degrated, he was discharged without an operation. Conclusions: Splanchnic (segmental) arterial mediolysis is a rare noninflammatory vascular disease of the abdominal splanchnic arteries with slight symptoms. CT for vasculary and internal organs should be performed to diagnose in recurrent complaints beside observing the physical findings. Introduction: It is well documented that healing of peptic ulcer perforation (PUP) is possible with conservative therapy in selected cases. Thus a spontaneously closed PUP diagnosed at exploration may not require surgical repair. Methods: Study included three patients in which diagnostic laparoscopy suggested spontaneously closed PUP between 2007 and 2008. Suggestion criteria were; fibrin cloth on duodenum with or without subhepatic fluid collection, no visible perforation, otherwise normal exploratory findings. Omentum minus was dissected and cautiously observed. The stomach was filled with 500 ml diluted methylene blue fluid via nasogastric tube, operation table was tilted to right and up, a gentle pressure on the stomach was made with the shaft of laparoscopic irrigator to fasciculate the passage while the descending section of duodenum was compressed with the shaft of a grasper. Duodenum was cautiously observed for 10 min to detect dye leakage in all patients. If no leak was observed, operation was terminated after abdominal irrigation and inserting a catheter to the subhepatic area. Therapy for PUP was given postoperatively.

Results: All patients were male and the mean age was 32 (26-42), no leak of dye was observed at operation. Nasogastric tube was removed and food intake was allowed at postoperative second day. All patients were discharged on third day. Conclusion: Although the perforation site is almost always identified at operation, to meet a spontaneously closed PUP is also possible. Irrigation and drainage alone may be sufficient for these cases after blue dye test as described in this study. The complicated appendix with/without abscess was delivered through the umbilical incision for an open technique safely. This gave our patients the maximum benefits of the minimally invasive surgery with better visualization, reducing equipment needs, less postoperative pain, rapid discharge, no postoperative infections, and excellent cosmetic results. All patients were quite satisfied during follow-up.

Conclusions: It is concluded that hybrid appendectomy seems to be feasible and reliable for children with complicated appendicitis not suitable for conventional laparoscopic technique. VATA was successfully accomplished with obvious advantages, and avoided conversion to the open fashion.

Background: Appendicectomy remains the most frequent emergency operation. The management of these patients varies between surgeons and hospitals. At our centre, it was a routine to review post operative children at 3 months. Aims: Is to evaluate the need for a routine follow up in children who had appendicectomy. Methods: It is a retrospective observational study for 100 consecutive patients between 2006 and 2007. A parallel questionnaire was sent to the parents of all the children.

Results: The average age was 11.6 years. 14% of the patients were found to have normal appendices. 70% of the patients were discharged within 2 days. 37% of the patient had intravenous antibiotics for 1 day and 15% were discharged with oral antibiotics. 94% had a routine follow up appointment in 3 months time. In 88% of cases there was no change in the management. On the questionnaire 85% of the parents thought they were given enough information regarding the procedure. In terms of routine follow ups, 68% of the parents found it very useful while 19% found it a little or not useful.

Conclusion: This study shows that there is no change of the management or a clinical need for the routine follow up. However the patients and their families like to keep a follow up appointment. It is more convenient for the patients and their family to arrange other sorts of follow up like a phone call conversation or a general practitioner follow up.

Yavuz Savaş Koca, Mustafa Ugur, Celal Ç erçi, Recep Ç etin 1 1 Department of General Surgery, Sü leyman Demirel University, Isparta,Turkey

The aim of this study was to evaluate the disease profile and mortality ratio of patients presenting with acute abdomen. Four hundred fifty eight patients who underwent surgery with the diagnosis of acute abdomen were analyzed retrospectively. The effects of age, sex, American Society of Anesthesiology (ASA) class, accompany disease, admission time after the onset of the symptoms, follow up interval before the operation on mortality and length of hospital stay were evaluated. Male/female ratio was 0.72, and mean age was 72.3. Main causes were biliary system disease (34.1%), intestinal obstruction (27.1%), peptic ulcer perforation (17%) and acute appendicitis (14.4%). Median ASA class was 2 and 73.6% of the patients had at least one preexisting disease. Mortality ratio was 19.4%. ASA class, age, preexisting diseases other than malignity, period between the onset of symptoms and admission, follow-up time was significantly efective on mortality.

438 Reliability of Ultrasonography for Diagnosing Acute Appendicitis

Aylin Hande Gö kçe 1 , Acar Aren 1 , Feridun Suat Gö kçe 2 , Hakan Ö zkan 1 , Alper Dursun Ş agban 1 , _ Ibrahim Aydın 1 , Gü rhan Ç elik 1 , Gü rol Kö roglu 1 1 S.B. _ Istanbul Eg itim Ve Araş tırma Hastanesi, Istanbul, Turkey 2 Balıklı Rum Hastanesi, Istanbul, Turkey

Purpose: Abdominal ultrasonography is the most commonly used diagnostic tool for diagnosing acute appendicitis,which is one of the most common causes of acute surgical abdomen. _

In this study, we examined the reliability of ultrasonography for diagnosing acute appendicitis.

In this prospective study we performed abdominal ultrasonography on 235 patients admitted to our surgical emergency department and diagnosed as acute surgical abdomen according to the physical examination and laboratory findings during 2007. These patients were surgically treated by appendectomy and the materials were pathologically examined. Results: 235 patients were admitted to this study.193 of these patients (82.1%) were diagnosed as acute appendicitis, and 42 (17.9%) of them diagnosed differently. 133 (88.67%) of 150 patients diagnosed as acute appendicitis on ultrasonography examinations were reported as acute appendicitis on histopatological examination. 60 (70.58%) of 85 patients diagnosed differently on ultrasonography examination were reported as acute appendicitis on histopathological examination. Conclusion: The sensivity of abdominal ultrasonography for diagnosing acute appendicitis is high (89%), but the specificity is low (p = 0.01). We calculated that the specificity is 0.29, positive predictive value is 0.69, negative predictive value 0.60, accuracy is 0.67. Abdominal ultrasonography is a helpful diagnostic tool for diagnosing acute appendicitis.However, it should not be seen superior to anamnesis and physical examination findings.

Poisoning: A Case Report Background: Mushroom poisoning is an important clinical problem which may cause serious complications and death. Acute pancreatitis is a rare complication of mushroom poisoning. In this study, we presented a case that developed liver damage and acute pancreatitis following wild mushroom ingestion. Case: Sixty-six years old women admitted to emergency department with complaints of nausea, vomiting and abdominal pain. It was learned that patient was ingested wild mushroom before 24 h of admittance and her complaints were started after 2-3 h of ingestion. In initial examination, general appearance and vital signs of patients were normal and there was epigastric discomfort. Laboratory findings were leukocyte 5,300/lL (4.1-11.2), aspartate aminotransferase 235 U/L (8-46), alanine aminotransferase 193 U/L (7-46), amylase 529 U/L (28-100), lipase 1,090 U/L (13-60) on admission. Liver and pancreas was determined as normal in abdomen ultrasonographic examination. Computerized tomography of the abdomen showed minimal peripancreatic fluid. The patient was observed in emergency intensive care unit and symptomatic therapy was performed. Hepatic transaminases and pancreatic enzymes were decreased progressively during the observation. The patient was discharged from the hospital after 5 days clinical course, without complication. Conclusion: Mushroom poisoning and acute pancreatitis have similar gastrointestinal symptoms and sings. Therefore, possibility of acute pancreatitis as well as other organ dysfunctions should be investi-gated in patients with mushroom poisoning. Early recognition and appropriate therapy for acute pancreatitis and mushroom poisoning may lead to an improved prognosis and complications.

Mehmet Mustafa Altıntaş 1,2 , Ayhan Ç evik 1,2 , Yekin Ö zcabı 1,2 , Gü lay Dalkılıç 1,2 , Hü seyin Ekinci 1,2 , Nejdet Bildik 1,2 1 Dr. Lü tfi Kırdar Kartal Education and Training Hospital, Istanbul, Turkey 2 General Surgery Clinic, Istanbul, Turkey

Diagnostic emergency laparoscopy is very helpful in diagnosing acute abdomen and evaluating abdominal trauma. Parallel to developments in laparoscopic techniques, its emergency applications are increasing. We reviewed our diagnostic emergency laparoscopy procedures applied to patients with acute abdomen and could not be diagnosed after 24 h of follow-up. We applied diagnostic emergency laparoscopy to 24 patients in Dr. Lü tfi Kırdar Kartal Education and Training Hospital during 2007-2008. In 15 patients laparoscopy indication was undiagnosed acute abdomen. There were four acute appendicitis, two peptic ulcus perforation, two small bowel necrosis, one perforated hepatic hydatid cysts, one iatrogenic urinary bladder perforation, one postlaparoscopic cholecystectomy bile fistula and 4 non-surgical adnexial pathologies. Diagnostic emergency laparoscopy was performed in five patients with penetrating abdominal injury. There were small bowel injury in two patients, colonic injury in two patients and no injury in one patient. Diagnostic emergency laparoscopy was performed in four patients with blunt abdominal injury. There were grade 2 splenic laceration in two patients, grade 3 liver injury in one patients and intraabdominal bleeding in one patient.

In conclusion, diagnostic emergency laparoscopy is a suitable technique in undiagnosed acute abdomen patients which could not be diagnosed after physical examination, laboratory, radiology and follow-up and helps surgeon to diagnose the disease. Also diagnostic emergency laparoscopy performed by experienced surgeons prevents negative laparotomy especially in abdominal trauma patients.

Mehmet Ali Yagcı, Atakan Sezer, Ahmet Rahmi Hatipoglu, Irfan Coskun, Zeki Hoscoskun, Aydın Altan 1 1 Department of General Surgery, Trakya University School of Medicine, Edirne, Turkey

Introduction: Appendectomy is known as the most common nonobstetrical operative procedure in pregnant women with an estimated frequency of 1/1,500 of all pregnancies.Pregnancy continues to obscure the accurate diagnosis of acute appendicitis due to gestational physiological changes.Diagnostic delay increases the incidence of perforation, hence increasing maternal and fetal morbidity and mortality. Patients and Results: Four patients of appendicitis during pregnancy were concluded in study between 2002 to May 2008 ( Table 1 ). The mean age was 25 (range 21-36). Three patients presented during three trimester and one in first trimester.The mean time interval of symptoms to the admission is 72 h (range 24-120).Abdominal pain, vomiting, and nausea are the most common complaints.Rebound was the main sign observed in all patients.Fever was noted in two patients. Mean value of WBC count was 18,000 per l (range 9,700-26,900). Ultrasonographic examination was performed to all patients with the diagnosis of acute appendicitis.Three patients were operated under general anesthesia and one under regional anesthesia. Paramedian incision was applied to three patients and McBurney to the other one. The exploration findings were two perforated, one phlegmonous appendicitis and a normal appendix. No maternal or fetal mortality occured. Cesarean section was performed on 37-week pregnancy during appendectomy due to early onset contractions. Adhesiolysis was performed in same case because of postoperative ileus.

Conclusion: The accurate diagnosis of appendicitis during pregnancy requires a high level of suspicion and clinical skills. Delay of operation correlates to more inflammatory changes in the appendix and to higher maternal and fetal complication rates. Early laparotomy with appropriate preoperative diagnosis will reduce the fetal and maternal morbidity and mortality. Introduction: Paraesophageal hernias occur most commonly in elderly and account for 5% in all hiatal hernias [1] . Although the fundus or corpus of the stomach are most commonly the contents of a paraesophageal hernia, we reported a case in which the gastric fundus and corpus incarcerated in the paraesophageal space, followed by perforation.

Case: 64-year-old woman admitted to state hospital following sudden onset of abdominal pain.Previously she was diagnosed as esophageal hiatal hernia. On physical examination, abdominal distension with mild tenderness was recognized. Pulse rate and blood pressure were 120 per min and 80/50 mmHg. The initial laboratory investigations revealed WBC 3,700 per ml, urea 230 mg/ dl, creatinine 6.3 mg/dl. Chest graphy revealed unusual gas shadow in the left thorax (Fig. 1) . CT demonstrated intraperitoneal free air, ascites, and the prolapsed stomach in the left thorax (Fig. 2 ). An urgent laparotomy was performed revealing dirty ascites.The gastric fundus and corpus were incarcerated in paraesophageal space (Fig. 3) . A perforation 15 mm in size was recognized in the fundus. The perforation was sutured primary and cruroraphy was performed. The patient required respiratory support and died on the 14th postoperative day due to multiple organ failure and septic shock.

Conclusion: The contents of paraesophageal hernia commonly include the gastric fundus or corpus. Paraesophageal hernias can cause lethal complications, including gastric obstruction, strangulation, perforation, and hemorrhage. Paraesophageal hernias can usually be repaired easily, even using the most recent laparoscopic technique (2). Thus, because of the very serious potential complications inherent in cases such as ours that can result from an untreated paraesophageal hernia, we recommend that elective repair be carried out, even in asymptomatic patients.

Introduction and objectives: The solitary fibrous tumor (SFT) of peritoneum, especially arising in lesser omentum is extremely rare. We report a case of lesser omentum soliter fibrous tumor, causing pain and abdominal fullness with its mass effect.

Case: A 56-year-old male was admitted to our hospital, due to an intraabdominal mass lesion, epigastric pain, abdominal fullness and vomiting episodes. On physical examination, a hard, non-tender mass was palpated in the epigastric region. Computed tomography (CT) showed, an approximate 11.5 · 8.5 · 7.5 cm sized solid mass with fibrous capsula between left liver lobe and stomach. At laparotomy, a yellowish brown solid tumor with hard consistency was found on the lesser omentum. The tumor was not adhered to the adjacent structures and could be resected completely. Postoperative course was uneventful and no recurrence was determined during follow up.

Results: Histopathologic examination diagnosed the mass as a SFT. The tumoral cells were spindle-shaped and did not present mitotic activity or atipies and showed very low proliferation index with Ki 67 (<1%) and immunohistochemical positivity for CD 34 and negativity for c-Kit (CD 117), actin, and S-100. Conclusion: Although SFT are rare, especially in the abdomen of adults, are generally benign but malignant cases have been reported. In our case, the tumor has a benign character shows neither mitotic activity nor nuclear atypical. This is the third case of soliter fibrous tumor of the lesser omentum described in the English literature.

Introduction and aims: A single hamartomatous adenoma of stomach is rare. Gastric hamartomatous polyps are usually multiple, familial and assosciated with other syndromes. They are also associated with chronic Helicobacter pylori infection, acid hypersecretion and predisposition to gastric cancer. This is the first case of gastric hamartoma which is coexistent with duodenal ulcer perforation. Case: A 59-year old male admitted to our hospital with complaints of stomach ache, nausea and vomitting. Because there was free air under right subdiaphragmatic surface on chest X-ray, an emergency operation was performed. There was a perforated ulcer on the first part of duodenum and a large quantity of bile mixed with blood in the abdominal cavity. On further exploration a tumoral mass which was about 3 cm in diameter was found on the stomach corpus. Because of possibility of malignancy, a subtotal gastrectomy including the perforation zone was performed. Histologically the tumor was well circumscribed and it consisted of uniform, clear cells. At first, it was thought to be metastatic lesion from kidneys or other organs. In this context, all body was scanned however no pathology has been identified. Later on, the tumor was approved to be hamartomatous adenoma and Helicobacter pylori was positive. Postoperative course was entirely uneventful. Objectıve: The aim of this work is to determine the level of apoptosis, which is believed to hold an important role in septicemia process that affects mortality and morbidity in obstructive jaundice, in lingers of rats that were experimentally subjected to obstructive jaundice. Materials and methods: The experimentals were separated into two goups of eight. Choledoch was isolated in each group and while surgery was ended at this level in the control group, choledoch was tied with 4-0 silk from two different places and cut between ligatures full fold. Experiment animals were operated for the second time in the postoperative seventh day for liver sampling and sacrificationaimed histological analysis through the old incision with anaesthesia provided. To exhibit the p53 expression immunohistochemically, anti-p53 Clone DO-7 was used as the primer antibody and HRP as the secondary antibody. Samples taken for the determination of apoptosis were painted by the TUNEL method. Fındıngs: In the evaluation of apoptotic cells in liver cells, apoptotic cells were observed to widely exist in the liver tissue and it was determined that they exhibited dense accumulation in some regions.

In the immunohistochemical evaluation made for evaluation of p53 expression in hepatocytes, p53-positive hepatocytes were determined to exist quite widely in the tissue samples taken from the livers of rats in the experiment group.

Result: Consequently, in this study we determined that in the obstructive jaundice group, both apoptotic index and, as a result of the immunohistochemical studies, p53 expression increases in the liver.

Introduction: The risk of leakage from an anastomosis is higher in large intestine. In emergent colon operations primary anastomosis is avoided especially on the left colon, and multi-step procedures are preferred if there is a dirty abdomen. The aim of this experimental study was to compare different suture materials in left colonic anastomosis in presence of peritonitis.

Metods: This study was conducted on 21 Wistar-Albino rats by dividing them in 3 groups of equal numbers. After median laparotomy, the whole layer of left colon was cut 2 cm over the pelvic peritoneum and fecal contamination was performed. One day later, the abdomen was opened again under general anesthesia. The abdomen was washed with SF before starting colonic anastomosis. For colonic anastomosis; vicryl + silk was used in the 1st group rats, PDS was used in the 2nd group rats, and coated vicryl plus antibacterial suture and silk was used in the 3rd group rats. Results: Tissue hydroksiproline, anastomosis bursting pressures and histopathologic findings on the anastomosis line were evaluated on the 10th postoperative day. The highest anastomosis bursting pressure was found in Group III (p < 0.05). The highest tissue hydroksiproline level was found in Group III (p < 0.005 Group I-III, Group II-III). When histopathologic findings were evaluated by comparing three groups, the healing of the intestine tissue score was found to be highest in Group III (p < 0.005, Groups I-III). Conclusion: Consequently, it was observed that using antibacterial suture increased resection safety in the presence of peritonitis and anastomosis safety in primary anastomosis.

Introduction and objectives: The chance of finding the vermiform appendix within an inguinal hernia occurs in approximately one percent of the cases, and is known as amyand's hernia. Appendicitis within an inguinal hernial sac is rare. Materials and methods: We present two amyand's hernia cases: one with a vermiform appendix and one with a perforated appendicitis. Case 1: An 86-years-old man presented with a 20 years history of bilateral inguinal mass. Ultrasound examination described a hernia which contains mobile bowel segments inside, on the right side. The appendix was obsereved edematous and hyperemic in the hernial sac. An appendicectomy was done. Further exploration of the bowels revealed a meckel diverticulitis which was managed by a wedge resection. Case 2: A 57-years-old woman presented with one week history of an inguinal mass, pain and anorexia. Abdominal computerized tomography demonstrated an incarcerated right-sided inguinal hernia.The hernia sac was filled with the perforated appendix. Appendicectomy was carried out. Results: Postoperative recovery was uncomplicated, the patients were discharged without any complication. Discussion: Acute appendicitis or perforation of the appendix within the hernia sac simulates perforation of the intestine, and does not have specific symptoms or signs. Preoperative clinical diagnosis is very difficult and the diagnosis is made intraoperatively. Since the absence of any pathognomonic radiological features, the value of preoperative computed tomography is limited. Treatment of hernial appendicitis is an appendicectomy with suture hernial repair. The management of a non-inflamed appendix is debatable. The usual practice covers reduction of the appendix, and mesh repair. In the immediate post-operative period the patient had a high output jejunostomy and was dependent on total parenteral nutritional support. A Bishop-Koop procedure was performed on day 11 and by day 37, the patient was completely independent of any adjuvant nutritional therapy. Five months from primary surgery colostomy was closed.

Introduction and objectives: The management of pancreatic pseudocysts which occur after blunt abdominal trauma in children is still controversial. In this study, we present our experience therapeutic approach of pancreatic pseudocysts that occur after trauma. Methods: We evaluated 9 patients with traumatic pancreatic pseudocysts who admitted to our clinic between 2003 and 2007. We performed ultrasonography, computerize tomography (CT) and blood amylase level for all patients.

Results: There were eight males and one female. The average age was 9.2 years (range 6-15 years). The mechanism of injury was bicycle handle bar injury in four, falls in three, assault in one and motor vehicle accident in one patient. Abdominal pain was the most common symptom. The median size of cysts was 10.3 cm (range 5-17 cm). The time interval between trauma and pancreatic pseudocysts was 17 days (range 9-30 days). Of the nine patients, four (44.4%) occurred in less than 2 weeks. All patients were initially followed up conservatively. Three patients (33%) were successfully treated conservatively, while 6 patients (66%) required intervention either by percutaneous radiological drainage (4), cystogastrostomy (1) and external drainage with laparotomy (1). Complication developed in two patients (septic shock, persistent hyperamylasemia). No patient died. Conclusion: Traumatic pancreatic pseudocysts may occur short after traumatic injury in children. All patients with traumatic pancreatic pseudocysts should be managed by conservative approach initially. However, if the cyst is cause of gastric outlet obstruction or the size of cyst is bigger than 6 cm, interventional management may be required. Introduction: Splenic abscess is a rare entity,with a frequency of 0.14-0.7% in autopsy series.Mortality rate is still high, up to 47%, and can potentially reach 100% among patients who do not receive antibiotic treatment. Case 1: 63 year-old woman presented with fever and left upper abdominal pain for 15 days. Hepatomegaly and tender splenomegaly were present.CT of the abdomen revealed 5 · 8 cm hypoechoic lesion in the spleen (Fig. 1) . Initial laparoscopic approach was performed but failed due to inappropriate anatomy. Conventional splenectomy was done and at exploration there was 6 · 8 cm abscess in spleen. The patient was dischared on the eighth day of operation. Case 2: 43 yearold woman admitted with femoral artery thrombosis.Thromboembolectomy and leg amputation was performed by cardiovascular surgeons.She was consultated with fever and left upper abdominal pain on the second day of operation. CT of the abdomen revealed a 14 · 8 cm mass with air fluid levels in the spleen (Fig. 2) . Splenectomy was performed and a 12 · 10 cm abscess was observed in spleen.The patient died on the second day of operation due to sepsis. A proximal stoma after resection of the perforated small bowel and colon, closure of the distal stump in case of severe generalized peritonitis without the possibility to perform a primary anastomosis. A loop ileostomy to prevent bacterial translocation in case of pancreatitis. Retrospective analysis of clinical data of patients admitted between 2004 and 2008 for emergency operation requiring laparotomy and the construction of one or more small-bowel stomas. 32 patients had ileostomies created for temporary fecal diversion after emergency surgery including bowel obstruction was the most frequent cause of peritonitis (11 cases),followed by anastomotic leakage and peritonitis (7), acute mesenteric infarction (4 cases), intestinal perforation (3 cases), strangulated incisional hernia (3 cases), acute abdomen of Crohn disease (2 cases), peritonitis carcinomatosa and frosen pelvis (2 cases), Mean age was 57.5 years (range 23-87), being 16 males and 16 females. Overall mortality was 62% (20 patients). 11 patients died on the first 7 days postoperatively. Indications, morbidity, mortality and problems involving the ileostomies in emergency abdominal surgery urgency are herein discussed. In the majority of patients with acute abdomen doing ileostomies,lacking of vital capacity of bowel wall as well as insufficiency of previously laid sutures were revealed, which forced a surgeon to resort to resection; in such cases the method of choice for decompression should be the application of ileostomy.

Postoperative jaundice is often multifactorial. A precipitating or causative factor may be identified but seldom can a specific therapy be offered. The late complications were mainly presented by the biliary ducts cicatricial stricture, the jaundice and cholangitis recurrency.

In this report, we described an extremely rare case of a 29-year-old woman presenting with pain in the right upper quadrant, jaundice, and weight loss in whom a Whipple procedure was performed. USG and MR cholangiography showed that dilatation of intrahepatic and extrahepatic bile ducts and hepaticojejunostomy line. MRCP also showed that, there was a closed jejunal loop related with hepaticojejunostomy. Obstruction by local tumor recurrence and infiltration of the efferent jejunal conduit between the proximal hepaticojejunostomy and the duodenojejunostomy led to closed loop syndrome and jaundice. Frozen sections by direct incisional biopsy revealed a recurrent tumor invasion. A previously unreported late complication after Whipple resection of the head of the pancreas was recognized as ''closed efferent loop syndrome'' mimicking obstructive jaundice. The case was accepted as inoperable because of tumor invasion to the jejunum, transverse colon, and surrounding tissue. Roux-en Y type jejunojejunostomy was performed. The patient had an uneventful postoperative course. Introduction: The form of mechanical asphyxia where respiration is prevented by the external pressure on the body: a large weight compressing the chest or abdomen, wedging of the body within a narrow space death in large crowds is traumatic asphyxia. Case: A 19-year-old man was found compressed by a motorboat in the garage while he was working for installation of the boat. The face, neck and upper part of the chest were congested and many petechiae were observed on the conjunctivae. Ecchymotic bruises were observed on the right cervical, lower chest, upper abdominal regions and open fracture of the right humerus, ecchymotic abrasion on right anterior superior iliac spine line were detected. Subcutaneous haemorrhages in the chest wall and bleeding without subcutaneous haemorrhage in the inferior part of the right sternocleidomastoid region were observed during the internal examination. Fractures of the right third and fifth ribs which were accompanied by bleeding in the surrounding soft tissues and muscles, and ecchymoses over the right sixth rib without any fracture were also observed. Macroscopic examination of the lungs revealed congestion, subpleural superficial bleeding areas and histopathological examination showed hemorrhagic alveolar oedema. All the internal organs and big vessels were intact. There was no hemorrhage in the thoracal and abdominal cavity. Toxicological analysis was negative.

Conclusions: In the presented case, the impact cause of the chest compression was distinctly determined by the autopsy and criminal investigation. Death was reported as asphyxia by the thorax compression without other lethal factors. Purpose: The purpose of this prospective study was to evaluate safety of early surgical interventions in the repairment of animal bites with tissue injuries. Materials and methods: Tissue repairment and/or reconstruction were done, total in 34 patients. 20 of them were dogs', 14 of them were horses' or donkeys' biting between the years 2003-2007. Wound sterilization and debridement were made before repairment. Rabies and tetanus prophylaxis were done for all patients. Tissue repairments after animal biting were made early and promptly. Patients having animal injuries, apart from biting were not included in the study.

Results: 22 of the patients were male and 12 of them were female. The minimum age of the patient was 1.5 and the maximum was 84, and the average age was 39. In 24 cases head-neck, in eight cases extremities and in two cases body were biting areas. Horses' or donkeys' bitings were seen particulary in ears. In these animals' biting tissue lose was emphased. We prefered primary saturation in 20 cases, skin greft in ten cases and repairment with flap in five cases. Finger amputation was required in one of the patients. Total ear reconstruction was done gradually in a patient. No infections observed in patients after the surgical interventions.

Conclusion: We concluded that, early tissue repairments may done after wound sterilization and debridement, safely. treatment plan. Multidetector computed tomography (MDCT) imaging is an improving and being a widely used method recently in many areas of medicine. It is possible to evaluate the peripheric vascular structures, anatomic variations or vascular pathologies with MDCT angiography (MDCTA). Methods: The arcuate foramen is an anatomical variant of the atlas vertebra: anterior and posterior osseous bridges or ponticles can arch over the vertebral artery, to a greater or lesser degree, transforming the arterial groove into a canal. Dissection of the vertebral artery leading to thrombotic occlusion or ischaemia from narrowing of the arterial lumen has been described in trauma. There are fistula between a dural branch of the spinal ramus of a radicular artery and an intradural medullary vein in spinal vascular malformations. MDCT angiography is feasible and is an alternative technique in diagnosis spinal vaskü ler malformations. The craniovertebral junction (CVJ) is a funnel-shaped structure comprised of the clivus and foramen magnum and the upper two cervical vertebrae. The most frequent neoplastic lesions of the craniovertebral junction are meningiomas, neurinomas, chordomas, paragangliomas, epidermoids, dermoids and chondrosarcomas.

Conclusion: In this presentation, pathologies seen in craniocervical junction (congenital variation, trauma, vascular malformation and tumor) were discussed with figures and compared with the literature.

Introduction and Objectıves:Small bowel obstruction (SBO) is very rare. Although the diagnosis is straightforward, some patients with intermittant and low-degree symptoms could be misdiagnosed as psychiatric disease. We presented here a patient with intermittant symptoms of ileus treated as psychiatric disease Case: A 44 year old male patient was referred from phsyiciatry clinic to our department with complaints of weight loss, nausea and malnutrition. His medical history revealed a laparoscopic appendectomy 6 months ago. He emphasized that his complaints started shortly after the operation and increasingly got worse. He was admitted to hospital 3 days after operation with symptoms of ileus and managed conservatively. The intermittant abdominal pain and nausea continued. Since the pain was intensified after meals, patient refused eating. During the period of 6 months he lost 20 kg of weight. After numerous radiological and endoscopic investigations patient was referred to psychiatry due to persistent anorexia. After short psychiatric medication, he was referred to our surgical unit. Multislice abdominal computerized tomography and and enteroclysis of small bowel clearly demonstrated an obstruction in the jejunal segment of the intestine. At laparotomy, small bowel obstruction was detected and segmental resection was performed. Postoperative period was uneventful and patient was discharged from hospital on postoperative day 6. Conclusions: The diagnosis of anorexia and nausea due to SBO is relatively difficult. The patients were sometimes misdiagndosed as having psychiatric disease. Before starting psychiatric medication, they must be reevaluated for all putative causes of SBO. Introduction: Endoscopically placed biliary stents are a well-established procedure for the treatment of benign and malignant biliary disease. Duodenal perforation may occur at the time of insertion of a biliary endoprosthesis or following endoscopic manipulation of such a stent. Methods: We report a case of duodenal perforation complicating stenting for biliary fistula in surgery for hepatic hydatid cyst.

Case: A 74-year-old man was admitted to a local hospital following the sudden onset of abdominal pain,distension with nausea and vomiting. He developed a biliary fistula after surgery for hepatic hydatid cyst 2 months ago. Endoscopically placed biliary stent was performed for the treatment of biliary fistula at the same hospital 2 months ago.On examination, marked abdominal distension with mild tenderness was recognized. His pulse rate and blood pressure were 120/min and 80/50 mmHg, respectively. Abdominal X-ray showed two foreign body images and subdiaphragmatic free air. Emergency laparotomy revealed dirty ascites and perforation of the third portion of the duodenum by the plastic stents. The second stent was found at pericecal area. After extraction the plastic stents and irrigation with isotonic sodium chloride solution, the site of perforation in the duodenum was primary reparing and triple tube placement performed. Conclusion: Endoscopic retrograde cholangiopancreatography (ERCP) is considered to be the most difficult endoscopic procedure in gastrointestinal endoscopy, and is associated with potentially severe and sometimes life-threatening complications such as duodenal perforation. Surgical statistics indicate the importance of early diagnosis and treatment for duodenal perforation.

Introduction and objectives: Ticks play an important role in transmitting several infectious agents, such as viruses, bacteria, spirochetes, rickettsia, and parasites. In this study, we analysed the demographic and clinic characteristics of the patients who admitted to emergency service due to tick bite. Methods: In this study, patients were selected from cases of tick bite admitted to the department of emergency medicine of Ankara Numune Hospital during the 2007-2008 periods. Detailed histories and some blood tests of patients were taken, and the body of the tick grasped gently avoiding to inject more salivary toxins. Results: Totally 301 patients admitted to hospital in this period. The most frequent symptoms at administration were malaise, myalgia, and fatigue. Hemorrhagic manifestations were observed in 28 patients and bleeding was from multiple sites in 15 patients. Other symptoms were watery diarrhoea, skin eruption, macular rash, and petechia-ecchymosis. In the comparison of the clinical features and laboratory results of the surviving and the patients who died, we found that the rates of fever during hospitalization, confusion, neck stiffness, bleeding from multiple sites and presence of petechia/ecchymosis were higher in the patients who died than in the surviving ones. Additionally, the mean values of ALT, AST, LHD, CK, PTT, international normalized ratio (INR), and urea were also higher and mean PLT counts were lower in the patients who died. Conclusion: The acute tick-bite reactions show special histologic features, which are unquestionably related to the particular morphology and physiology of the mouthparts of these arthropods. Results: Totally 46 patients (33 men and 13 women) were evaluated. The mean age was 55.7 (20-97) years and the mean follow up period was 38 (7-68) months. The localization of the hernias were as follows: 33 inguinal hernias, seven femoral hernias, two umblical hernias, two paraumblical hernias, one epigastric hernia and one inguinal + femoral hernia. All of these strangulated hernias were treated with prosthetic graft repairing. In addition to these hernia repairs, in the same operation sessions three hydrocele repairs, three omentum resections, two partial small intestine resection and anastomosis, one lymphadenectomy, one orchiectomy and one laparotomy were done when necessary. In the early post operative period four patients died because of other diseases not related with the surgical procedures or hernia itself. Wound infections were observed in three patients and they were treated with antibiotics and anti inflammatory drugs. We report a rare case of ileal perforation caused by an ingested 15cm long fork. A 43-year-old man presented to the emergency department with exhaustion, weight loss and abdominal pain. He had been having pain in the abdomen, nausea and vomiting for the previous 2 days. The patient had received psychiatric treatment, and started to experience weight loss and exhaustion 3-4 months previously. No conclusions could be drawn from physical examination for abdominal tenderness and defence. Direct X-ray showed an appearance conforming to a fork in the intestine and subdiaphragmatic free gas. The patient was sent for emergency surgery, with a diagnosis of ileal perforation and foreign-body ingestion. Most of the ingested foreign bodies that reach the stomach pass through the alimentary tract without complication. Perforation occurs in, 1% of all cases of foreign-body ingestion, usually in the oesophagus. Other sites where perforation can occur are the pylorus, the duodenum, the duodenojejunal flexure, the ileocaecal region and any site of congenital anomalies. Long, thin or sharp objects, as seen in our case causing ileal perforation. Foreign-body ingestion is a possibility to be borne in mind at presentations to the emergency department, especially those with symptoms described in psychiatric cases. Appendicectomy is a common emergency operation, its major complications are uncommon. Most complications of appendicectomy occur in the early postoperative period and easy amenable to treatment with conservative medical therapy. Appendicitis, usually a benign disease, can have its prognosis worsened in case of postoperative fistula. The latter occurs rarely after open appendicectomy but accounts for 10% of the morbidity rate. Schloffer Tumor (inflamatory granuloma or abscess in the abdominal wall at the operative scar) is rare complication that usually develop months to years postoperatively and late postoperative enterocutaneous fistula has been described in literature as a rare complication of acute appendicitis.

We describe one such case where the patient presented with a tender mass under the incision site six months later after appendicectomy.

Findings of computed tomography were demonstrated thickening in the abdominal wall and abdominal wall abscess like Schloffer tumor. Abscess was drained. There were not produced any microorganisms in the wound culture. After conservative therapy healing was completed in a short period.

One year later, the patient was admitted with complaints. On the examination, passage of undigested food particles through a sore in the appendicectomy incision site. Computed tomography were demonstrated fistula tract extending from appendicectomy site to skin. Enterocutanous fistula was occured at the appendicectomy incision 1 year later after operation and successfully treated with en-block fistulectomy and right hemicolectomy. Postoperative course was uneventfull. Patient discharged from hospital at seventh day after operation. Objective: Vascular insufficiency may lead to hypoxic injury in intestines. The lesions in the colon are called ischemic colitis. Mesenteric ischemia is more prevalent in patients getting hemodialysis.

In this study we report 3 hemodialysis patients admitted to the emergency department because of acute abdominal symptoms. Case 1 39 year old woman was chronic hemodialysis patient admitted to the emergency room with acute onset abdominal pain.The initial diagnosis was acute appendicitis and she underwent laparotomy. Peroperatively isolated cecum necrosis was seen. Right hemicolectomy and ileotransversostomy was performed. She died 43 days after surgery because of sepsis. Case 2 38 year old man was chronic hemodialsysis patient admitted to the ER because of abdominal pain persisting for 24 h. With an initial diagnosis of acute abdomen a median incision was performed. Peropertively widespread peritoneal adherences and isolated cecum necrosis were seen. Cecum was resected and side to end ileocolostomy was performed.He died 12 days after his first operation. Case 3 77 year old man was chronic hemodialysis patient admitted to the ER with pain localizing to right inferior abdomen. With an initial diagnosis of acute appendicitis laporotomy through a Mc Burney incision was performed. There was 2 · 3 cm cecum necrosis. Cecum resection and end colostomy and ileostomy was performed. The patient was discharged 9 days after the operation without any problem. Discussion: Ischemic necrosis of cecum is a rare variant of ischemic colitis. In hemodialysis patients requiring colon resection due to ischemic colitis, primary anastamosis should be avoided, diversion stomies should be preferred. Agitation is a non-specific constellation of comparatively unrelated behaviours that possess a risk to the safety of the patient or caregiver, impedes the process of care giving or impairs a person's function.

The management of agitated trauma patient contains hospital, prehospital, in emergency department and inside of the hospital transports. The reasons of the agitation hypoxia, hypoglycemia, hypovolemia, pain, traumatic brain injury, anxiety disorder, drug and alcohol abuse, psychiatric disorders. Pain management has had a limited role in the management of trauma patients, primarily because of the concern that side effects (decreased ventilatory drive and vasodilatation) of narcotics may aggravate preexisting hypoxia and hypotension. Health professionals should monitor pulse oxymetry and serial vital signs if any narcotics are administered to a trauma patient.

Small doses of benzodiazapine sedatives should be titrated cautiously because of the potential side effects of hypotension and ventilatory depression.

To control agitated patients with traumatic brain injury include haloperidol, midazolam, and propofol. In the emergency setting, they are most often indicated to control agitated or psychotic behavior that constitutes an imminent danger to the patient or others.

To control agitated patients should be a part of the trauma management. We present a protocol for trauma team. There were 294 males (82.8%) and 61 females (17.2). Eighty percent of the patients were between 5 and 45 years of age. The overall mortality was 11.5% (41 patients). Eighty percent of deaths occured in comatose patients (p < 0.000). Comatose state, precence of focal motor signs, respiratory irregularities and Hypertansion-Bradycardia, pupillary changes were determined as the bad prognostic factors. A midline shift greater than 10 mm, hematoma volume greater than 150 ml, accompanying intracerebral and extracranial traumatic pathologies significantly increased the mortality rate. There was no significant statistical correlation between the outcome and the age, sex of the patient, trauma-to-operation interval, thickness, localization and origin of EDH and aetiology. Results: The primary factor on outcome is Glasgow Coma Scale Scores of the patients at the time of surgery. Therefore early surgery is crucial in the management of EDH which is a dynamic process. Introduction: In this study, we have evaluated the incidence and clinical characteristics of the patients for traumatic brain injury (TBI)-associated coagulopathy after TBI retrospectively. Methods: Retrospective study of all patients admitted to the Trauma and Emergency Surgery Intensive Care Unit (ICU) from January 2005 through December 2008 with TBI. Criteria for TBI-coagulopathy (TBI-C) included a clinical condition consistent with coagulopathy in conjunction with a platelet count < 100,000 mm3 and/or international normalized ratio (INR) > 1.2 and/or activated partial thromboplastin time (aPTT) > 29 s and/or prothrombin time (PT) > 14.5 s. The following potential risk factors were included to identify independent risk factors for TBI-C and its association with mortality, age, mechanism of injury (blunt (B) or penetrating (P)), Glasgow Coma Scale (GCS), Injury Severity Scale (ISS), presence of polytrauma, ICU length of stay (ICU-LOS). Results: A total of 82 patients met study criteria. TBI-C occured in 86.5% (n: 71) of all patients (B: 66.1%, P: 33.9%). In patients with TBI-C, mean age was 36.42 ± 17.03 years. The averages of GCS was 7.9 ± 2.74, ISS was 33.14 ± 14.12, ICU-LOS was 11.51 ± 6.77 days, polytrauma was considered 57.7% (n:41) and the overall mortality was 21.1%(n: 15) in patients with TBI-C. Conclusions: In our study, TBI-C occured more frequently among patients sustaining blunt versus penetrating injuries. To our knowledge, TBI patients are at considerable risk of developing coagulopathy and anesthesiologists should be aware of this life-threatening syndrome, especially in TBI patients with blunt injuries. Erythropoietin (EPO), glycoprotein hormone, is a mainly produced by the kidney that stimulates proliferation, growth and differentiation of erythroid precursors in the bone marrow. Recently, anti-inflammatory, neuroprotective, antiapopitotic, angiogenic and vasodilatator effects of EPO have been also determinated. The purpose of this study was to investigate the effects of rHuEPO in reducing the severity of experimental spinal cord injury (SCI). Ninety adult Sprague-Dowley rats weighted 200 g (± 15) were used for the study. Through a dorsal incision, T6-9 laminectomies performed in prone position and clip compression had made for ischemic injury as Tator method. The rats divided in three groups. Systemic 200 l (1,000 U/kg) rHuEPO had given 24 h before the trauma in the first group, 30 min. later after the injury in the second group and the third was the control group. The rats were killed with high dose intraperitoneal ketamin 24 h later after the injury. The histological examination of injured spinal cord specimens for the potential neuroprotective effects of rHuEPO was done. Further more the axial spine sections stained with TTC (triphenyl tetrazolium chloride). The ischemic areas were evaluated with a imaging calculation program. We use wet-dry method for determination of ischemic tissue edema. We concluded that administrating a single dose rHuEPO (1,000 U/ kg) has potential neuroprotective effect on experimental spine injury by reducing severity of inflammation and tissue edema in the secondary ischemic area. It has known both early surgery and high dose steroid treatment prevents the neurological function and viability caused of the traumatic secondary spine injury. We present surgically treated a traumatic rotation-compression spinal cord injury caused by a motor vehicle accident. The patient referred to our clinic 45 h after the injury. At the time of admission, he had a localized pain at the thoracic 10-11 vertebrae level, loss motor and sensorial function under the level T10 classified as ASIA grade A. He was incontinent. In the radiological evaluation we found loss of height at the thoracic 10th and 11th vertebrae body, serious spinal column injury include T10-11 burst fracture, laminas and facet joints fractures with three colon damage (Denis F). We detected the spinal instability criteria in . We did not see penetrating injury or primary spinal cord injury signs but spinal canal tightness for 30 percent in CT and MRI scans. We took the patient to surgery in unusual classical surgery timing. First, decompressing surgery applied to the T10-11 laminas and posterior stabilization with transpedicular screw-rot system. One day after the first operation, T10 and T11 corpectomy applied for anterior stabilization with cage-screw system. Mega dose steroid had given also before the first surgery. Postoperatively early neurological evaluation, he had ASIA grade C, after second month ASIA grade D without incontinence. In our opinion the decompressing surgery that applied in 48 h in the patients without complete primary spine injury, has a positive neurological feedback. Introduction: It is a rare occurrence with the rate of 1% in the subjects with spinal infestation cyst hydatic Echinococcus granulosus. Intradural hydatic cyst is relatively rare when compared with other spinal hydatic cysts. We are presenting here a 68-year-old female case who applied to emergency service with backache and paralysed legs and was diagnosed with spinal intradural extramedullary hydatic cyst.

Case: A 68-year-old female patient applied to emergency service with complaints of a backache started two days ago, paralyses in both legs and being unable to walk. In her neurological examination, a complete motor power loss in the lower extremities and bilateral sensation loss compatible with T11 dermatoma were detected. In the torako-lomber spinal Magnetic Resonance Imaging (MRI), multiple cystic characterized nodular lesions having peripheral contrast with regular contour including right neural foramen and paravertebral zone at the level of T11-T12 and L1 in the intradural distance were determined. The patient was diagnosed with common spinal intradural extramedullary hydatic cyst exhibiting bone involvement. As the lesion was very broad had paraplegia, we did not consider operation.

Conclusions: Hydatic cyst infestation is a benign disease. If it is not diagnosed early and treated when it involves in some systems rarely as it did in this study, the results can be serious. Diagnosis should be confirmed quickly with increasingly common advanced radiological diagnosis methods. The aim in these cases is to eradicate the cysts surgically, however, chemo-therapy and percutaneous drain methods have become more significant recently. Introductıon: Several guidelines advocate multiple chest radiographs during primary resuscitation of trauma patients. Several local hospital protocols include a repeat radiograph before leaving the trauma resuscitation room (TR). The purpose of this study was to determine the value of routine repeat radiograph. Methods: One year data of all radiological imaging in our TR were prospectively collected for all patients presented to the TR of the hospital. We counted and assessed the radiographs and classified our findings as either 'new injury detected', 'presence of intervention equipment', or 'deterioration of previously detected injury'. Results: In total, 674 patients were included. More than 75% had two radiographs. Eight (2.1%) new injuries without clinical relevance were found on the repeat radiograph after an initial normal radiograph. In total 61 patients (9%), had a repeat radiograph to verify the effect of an intervention or position of equipment. In 28 patients (22%) with two abnormal radiographs, newly diagnosed injuries (n = 9) or deterioration of known injuries (n = 19) were found. In 411 patients (81%) the results of the repeat radiograph had no clinical consequences. Conclusıon: Our study supports a strategy of omitting a routine repeat radiograph in trauma patients whose initial radiograph is normal. Introduction and objective: The neck region is affected in only about 5-10% of all trauma cases, and isolated neck injuries, especially from a blunt mechanism, is even more rare. Our objective was to assess the incidence, disability from spinal cord injuries, and preventable deaths in our patients with isolated neck trauma. Material and methods: Patients were identified at the Severe Trauma Registry of our hospital, between 1993 and 2006. The TRISS method was used to assess preventable deaths. Results: We found 117 (7.4%) patients with neck injuries out of 1.575 patients included in our registry, 70 (60%) from blunt (BNT) and 47 (40%) from penetrating trauma (PNT). Only 9 (13%) BNT and 19 (40%) PNT were isolated. The mean ISS of the BNT and PNT groups was of 25 ± 7 and 14 ± 9.5, respectively. In the BNT group, 6 (67%) patients had spinal fractures (with 2 spinal cord injuries with permanent disability), 3 had airway injuries and 1 a vascular injury.

In the PNT group, 1 patient had a spinal fracture, 7 had vascular injuries and 4 airway injuries. Overall mortality was of 4 (14%) patients, 2 in each group, and only one of them was deemed preventable.

Conclusions: Isolated neck trauma is a rare cause of disability and preventable death in our area. Most penetrating injuries have a lowto-moderate degree of anatomic severity (AIS £ 3).

for each group. However about applications increased gradually with a peak at 17 o'clock in all groups. Patients treated at ED were mostly stricken (58.5%) and the busy period was between 12-24 h with two peaks at 17 and 22 o'clock. Totally, 231 patients were hospitalized mostly in group III (48.9%) regardless of cause (p < 0.01). Patients referred to another hospital were frequently in group III (39.9%) and also in group IV (32.3%). Mortality was slightly high in group III. However higher rate (1.1%) was seen among patients in group II. Conclusion: Midnight hours seemed safe in terms of mortality and severity of trauma. Whether the reason for a higher transportation rate at night hours is the severity of trauma or sedation of ED staff is not clear. Introductıon: In this study we aimed to investigate and compare the features of child and adult injuries due to bicycle accidents admitted to our emergency department. Patients and Methods: The study was carried out retrospectively by searching the files of patients admitted to the emergency department due to bicycle accidents, in the emergency department and archive records between the dates of January 2005 and December 2008. The patients were divided into two groups as adults and children. Age and sex of patients, season or month of injuries, place and mechanism of injury, injury site of the body, diagnosis and treatment modalities, discharge and hospitalization rates were evaluated. Results: Totally 150 patients were included in the study. 79% of the patients were in child age group, 21% were adults. It was determined that number of accidents increased especially in the summer months. 71.4% of accidents concerning children and all of adult accidents occurred in the streets. Falling down from the bicycle was the most common injury mechanism in children (91%) and adults (90%). Head and neck region was the most common body site subjected to the injury both in children (32%) and adults (40%). 78% of child patients and 84% of adult patients were discharged after emergency department follow up and treatment. There was a significant difference between two groups with respect to injury severity. Conclusıon: As a conclusion most of the injuries due to bicycle accidents happen in children, in the streets, in summer months and school vacations. Conclusıons: Road traffic collision is a major cause of trauma and death in Al-Ain city. Seatbelt compliance is alarmingly low and should be enforced.

Introduction and Objectives: The controversy between the ''scoop and run'' versus the ''stay and play'' approach in severely injured trauma patients has been an ongoing issue for decades. The present study was undertaken to investigate whether changes in prehospital care for patients with severe traumatic brain injury in the Netherlands, have improved outcome.

Methods: In this retrospective study, files were analysed for all patients admitted to one of six hospitals in the Limburg region in the Netherlands with a GCS < 8 on admittance over the period January 2006 -December 2008. All patients had proven traumatic brain damage on CT or MRI. Relevant prehospital and clinical data from a similar study conducted 20 years ago were compared to data from the present cohort. The main outcome was mortality.

Results: The two research groups had similar characteristics. In the historic cohort, Basic Life Support (BLS) and the 'scoop and run' method in patients with major traumatic brain injury (TBI) was common, with an average time on scene of 7.5 min. Nowadays, prehospital care is performed mainly on the level of prehospital Advanced Life Support (ALS), with average time on scene about four times as long as in the historic cohort. However, the overall mortality rate for the current cohort compared to 20 years ago has not decreased. Conclusion: Despite more on-site ALS in major TBI nowadays, there was no reduction in mortality. The team is provided to be ready all the time by making monthly and yearly national education exercises. These exercises are planned with two Methods:

(1) As demonstration during education (2) By creating extraordinary condition simulations

Aim: _ Interpret the support of exercises plans on UMKE operational agility and to accomplish next plans through this way. Material -method: 16 UMKE teams are divided into two parts after geting their basic educations. First group is planned to exercise in education room with demonstrations. The second is planned to exercise the extraordinary situation simulations in which people(not from the groups) made up and acted as injured and moulage is also used in this group. After the exercises, results are compared according to the criteria for assessment. In the first group's demonstrations it is worked by giving roles to team members in the education atmosphere with existing equipments (Chair, table, ladder…). In the second group, worked with the moulaged volunteers and extraordinary situation simulations just like the real(Wreck, avalanche, fire…) The results are considered statistically by t test. Findings: According to the assessment criterias the first group's average point is 5.5 and the second is found as 8.38. (P < 0.0001). Discussion and result: Exercises in a form of extraordinary situations effected team's performance, operational success and involvement positively. Planning the exercises with this data will increase the quality of the educations which planned in the future.

Nurhan Babaoglu, Tayfun Cucioglu, Gö khan Akbulut 1 1 National Medical Rescue Team, Ministery of Health, Afyonkarahisar, Turkey Entry: UMKE designed as serving medical rescue in extraordinary circumstances. They carries their approaching skills to the top by managing regional and national exercises. The teams in different cities coordinate and share their knowledge and agility by this exercises. Aim: After the workshop oriented educations, criteria are needed to improve and decide the affect of the exercises as numerical which supplies standardization of the teams. Material-method: 17 teams are evaluated according to 10 criteria and graded from 1 to 10. After the exercises, results and the importance of criteria shared with teams. 1 month later same teams evaluated again in exercises. Criteria:

(1) Equipment (2) Team accordance and work discipline (3) Security and to define work risks (4) Approach to the injured (5) Evaluate the injured people (6) Convert the theory to practise (7) Usage of materials correctly and in proper place (8) Packaging (9) Taking out the injured safely (10) Cleanness of the materials and control of medical bag Findings: After Antalya UMKE basic education, 17 team's evaluated and average score was 7.82. This results shared with teams and in next exercises in Isparta mean score founded as 9.00. (P < 0.0001) Discussion and result: When the evaluation criteria and results shared with the teams, it is confirmed that the teams react better in ongoing situations. It is considered that it will also increase the quality and effectiveness of the education. The criteria for evaluation going to help standardization which can be used by all medical rescue teams will provide a common manner between the groups.

Hasan Ç elik, Gö khan Akbulut, Nurhan Babaoglu, Tayfun Cucioglu 1 1 National Medical Rescue Team, Ministry of Health, Afyonkarahisar, Turkey UMKE teams are established in 2004 in 81 cities in order to act in disasters and extraordinary circumstances as a medical rescue team. Members are chosen among the volunteered medical crew. The team's mission is to support the search and rescue teams medically in extraordinary circumstances. Team starts with the first intervention and maintain the stabilization of the injured person before the transport so that prevents the second insult. Working principles was not obvious during the establishment phase and this caused chaos at the beginning. By designating the teams responsibilities work distribution reached to the standard. National medical rescue team is consisting of 5 medical personnel who are named as 1 leader, 1 logistic, 1 pigeon, 1 squirrel and 1 courier. The team leader who is chosen from doctors who has experienced in disaster medicine and have knowledge about leadership, provides a common manner and motivation among the team. Also directs the intervention to the injured person and coordinates with search and rescue teams just after the fast arrive in extraordinary circumstances. Squirrel communicates with injured at first and starts his intervention with the direction of the leader. Logistic is responsible for all equipment (spin board, medical bags…). Courier provides the equipment transportation between logistic and squirrel. Pigeon is responsible for photographing, recording and communicating with the center. This organization type performed in regional and national practises from 2006 to 2008 and also in train accident in Kü tahya. _ It helped maintaining standardization and acquired successful results. Author to editor: Bu yazıyı Ulusal Medikal Kurtarma Ekiplerini (UMKE) tanıtmak amacıyla hazırladık. Eg er uygun gö rü rseniz, Umke yi tanıtıcı bir stand açıp medikal çantamızı ve dig er kullandıg ımız malzemeleri tanıtabiliriz. Ayrıca bu gü ne kadar katıldıg ımız (Pakistan depremi, Isparta uçak kazası, Kü tahya tren kazası) afet, tatbikat ve eg itimlerimizi(ameliyathane konteynırımızı) power point olarak sunabiliriz.

508 Helicopter Use as a Part of Trauma Care Introductıon: Rapid transport and persistence of prehospital care is crucial to decrease the mortalities and morbidities of combat related injuries. Hence, helicopters are effectively used by the military although they are austere environments that offer limited space, equipment and resources for the crew and requires higher level of skills for prehospital trauma care. Materıal-Method: The data were collected from 60 consequent casualties, by the helicopter medical team (a surgeon, anesthesiology technician and a paramedic). During the flight, we triaged the casualties according to wound characteristics (severity, mechanism, location), physiological parameters, and provided basic life support stated by trauma resuscitation course (TRK). We transmitted these findings to the military trauma center to provide hospital preparedness. Result: Injury mechanisms were 70% explosives and 30% highvelocity weapons. Time to hospital admittance was < 50 min after the injury. Most frequent sites of injury (AIS 1-5) were extremities (75%) and thorax (38.3%); the frequency of ‡ 2 anatomical site injury was 35%. Capillary refill rates were; < 2 seconds 74.3%, > 2 seconds 25.7%. Mean SaO2, GCS, HR, Respiratory Rate values were 97.2 ± 3.2, 14.1 ± 2.34, 87.6 ± 20.5, 17.5 ± 3.1, respectively. During uninterrupted care, 6 (10%) intubations were performed and 67% of casualties were operated upon admittance without any onboard mortalities. Conclusion: The high energy and lethality of the wounding agents in combat render the helicopter evacuations indispensible. Additionally, civilian major trauma patients may benefit from expeditious transport to the closest trauma centers or from rural inaccessible areas within the 'golden hour of trauma'. The most important steps for the treatment of the combat injury causalities are to stop or reduce bleeding and to start fluid resuscitation. Peripheral intravenous (iv) line placement is one of the most important procedure in the battlefield conditions. Most of the time, fluid resuscitation would be the only available medical treatment for the injured combatant because of the prolonged evacuation period in the battlefield. Also, this procedure would be very difficult and time consuming especially under hostile gunfire. Excessive blood loss and hypotension may cause the peripheral venous collapse and makes the procedure more difficult.

Here we described a simple method to make this procedure easier. We offer the forward medical team personal to perform the upper extremity peripheral venous mapping of the combatant before the operation. The medical providers (doctor or paramedic) who would perform the first medical intervention would examine the upper extremities of baddy just before the operation. The medical care provider should determine the suitable situations for the iv line placement. Then he should remark the both site of the appropriate vein by camouflage paintings, leaving the probable angiocath insertion sites non-painted. We believe that this method would make the peripheral iv line placement easier and faster for the forward medical team personal in the war conditions. One probable disadvantages of this method is the negative psychological effect on the combatant that makes them to estimate the risk of wounded in a few hours.

Introduction and objectives: Ambulance and emergency care technicians are the key personnel for pre-hospital care of trauma. This study reviews the work anxiety states of some of the students in Ambulance and Emergency Care Technicians Department, Vocational School of Health Services, Marmara University by comparing it with those of the students in Radiology Department of the same school.

Methods: This study was developed as a sectional type of study and was conducted on 94 volunteer students from the above mentioned departments. The data were analyzed using the SPSS 16.00 software and employing the frequency distribution, t-test for individual groups, and unidirectional variance analysis methods.

Results: The study group of subjects was 81.9% female and 18.1% male. 57.4% of the subjects expressed anxiety over their employment in the future; 42.6% of them expressed no work anxiety. The work anxiety points of the subjects were compared in terms of their genders, academic years and departments, and said comparison did not reveal any statistically significant difference (p > 0.05).

Conclusions: The work anxiety state is one of the major factors having an impact on professional success, and is a negative state having an impact on one's performance, success and, in turn, psychological state. It would be proper to study the issue of work anxiety by obtaining psychological support, and to cooperate with the actors in this sector to develop solutions. It is concluded that further studies should be conducted on work anxiety and its reasons. In general, emergency patients should be transported to the closest appropriate hospital. If the emergency medical services have identified a specific hospital with better resources to treat seriously injured patients, the patient should be transported to that institution, bypassing closer hospitals. The cooperation is expected between the hospitals, and the development of formal transfer agreements, describing all of the legal, economic, and medical aspects of the relationship are encouraged. Ideally, the entire trauma system in a city should be designed on the basis of need and existing resources, with all affected parties involved in the planning, development, and implementation. The goal of the system is to match the needs of an injured patient to the resources of the available facilities so that optimal and cost-effective care is achieved. We conduct six essential questions for the preparation of trauma. Is there a legal authority to formally designate hospital's trauma response in your city? What sources were used as a basis for standards of the trauma response in your service area? Were the number of hospitals identified for your service area limited based on the results of needs assessment? What type of transport practice occurs in your service area when a field assessment identifies a trauma patient with severe injuries that threaten loss of life or limb? Is a trauma registry present in your service area? Is there a designated trauma advisory committee that evaluates the performance of trauma care delivery within your service area? We evaluated the role of primary hip arthroplasty (consisting of both total hip replacements and hemiarthroplasty) in these comminuted, osteoporotic or neglected fractures. These patients at-risk were in need of a single definitive surgical plan for early ambulation and preventing complications. Typically these patients were elderly with poor mobility and had multiple other medical condition to be able to withstand multiple surgeries. There was a need to obtain the best results with the single, rapid procedure for pain relief and early ambulation. Excellent to very good results were obtained in about 77% of these patients. Good results were obtained in about 19% of these patients and poor results in about 4%. Most of the poor results were the outcomes of complicated medical conditions rather than the failure of the orthopaedic procedure itself. We advocate arthroplasty in neglected, osteoporotic or severely comminuted per-trochanteric fractures for immediate mobilization and optimising outcomes. The role of intra-articular steroids or hyaluronic acid injections in early arthritis may be warranted and perhaps safe. But for patients waiting for a knee replacement these can prove positively dangerous. A meta-analysis has revealed that intra-articular injections given in patients waiting for a knee replacement procedure is fraught with dangers. Apart from a high risk of post-operative infection and failure of the procedure, several other side-effects or complications make this risky. There is a higher-than-average chance of quadriceps tendon rupture, delayed wound healing, superficial infections and slower rehabilitation. In comparison hyaluronic injections have been found efficacious in the short term and do not contribute to complications normally attributed to steroids. Thus intra-articular injections should be used with caution, repeated injections are best avoided and are certainly contraindicated if a procedure is anticipated to be performed within six months. Introduction: Pediatric forearm fractures are common. The majority has satisfactory outcome. But poor results do occur and malunion can compromise rotation. We belief that the angulation of the fracture depends on the action of the body and that we can reduce the fracture by completing the action. This way we can perceive a stable anatomic reduction without internal fixation. Methods: We undertook a prospective study of distal forearm fractures in children. We included 21 children with a non-displaced angulated metaphyseal distal forearm fracture. The angulation was between 15°and 42°.We all reduced them by completing the action of the body. This means a volar angulated fracture is reduced by pronation of the hand and a dorsal angulated fracture is reduced by supination. After the reduction they were casted in an upper-arm cast in pronation or supination depending of the reduction manoeuvre. Afterwards the all received 3 weeks of upper-arm cast and 3 weeks of lower-arm cast.

Results: They all healed without loss of reduction and without further treatment. They all had full recovery of function. Conclusıon: Non-displaced angulated metaphyseal distal forearm fractures in children can be treated conservatively by closed reduction and plaster cast. Background: Vascular endothelial growth factor (VEGF) plays an important role in the bone repair process as a potent mediator of angiogenesis and influences directly the osteoblast differentiation. Inhibiting VEGF suppresses angiogenesis and callus mineralization in animals. However, no data exist on systemic expression of VEGF with regard to delayed or failed fracture healing in humans so far. Methods: One hundred fourteen patients with long bone fractures were included into the study. Serum samples were collected over a period of 6 months following a standardized time schedule. VEGF serum concentrations were measured. Patients were assigned to 2 groups according to their course of fracture healing. The first group contained 103 patients with physiological fracture healing. Eleven patients with delayed-or non-unions formed the second group of the study. In addition, 33 healthy volunteers served as controls.

Results: An increase of VEGF serum concentration within the first 2 weeks after fracture in both groups with a following decrease within 6 months after trauma was observed. Serum VEGF concentrations in patients with impaired fracture healing were higher compared to the patients with physiological healing during the entire observation period. However, statistically significant differences were not observed at any time point between both groups. VEGF concentrations in both groups were significantly higher than those in controls.

Conclusıon: The present results show significantly elevated serum concentrations of VEGF in patients after fracture of long bones especially at the initial healing phase indicating the importance of VEGF in the process of fracture healing in humans. First, DSBLS is applied to 2.5 cm proximal to most prominent point of medial malleol of tibia. The DSBLS was inserted parallel to the joint surface in frontal and horizontal plane. After the DSBLS is applied the selected nail is inserted. Reamed IMN is used for the tibias with narrow isthmus (6). The success of DI is checked following the insertion of nail with set screw on the DSLBS. The unsuccessful attempts are repeated after the reason is removed. The DI of 36 tibias were successful and 4 were unsuccessful at the first attempt. In unsuccessful cases, the nails were at the posterior (2), anterior (1) and lateral (1) Collum femoris fractures accounts 4.5-5% of all fractures. However it is very rare in children (1%). In this study we evaluated 12 pediatric patients who were operated due to collum femoris fracture in terms of avascular necrosis and functional outcome. Age of the patients ranged from 3 to 14. There were seven girls and five boys. Two of the patients were admitted to the emergency department due to a fall from height, therefore they had multi system trauma. The remaining ten patients had isolated collum femoris fracture. Fractures was classified according to Delbet classificaion; seven transcervical and five cervicothrochanteric. Locking plate-screw fixation was applied to one patient, other fractures were fixed with two or three cannulated screws. Open reduction was applied to four patients and closed reduction to eight. Five of the cases were operated in the first 24 h of the fracture, however the remaining seven patients were operated after the first 24 h (2-10 days) due to late admission. Range of motion of the hip joint was limited in only one patient who had polytrauma and operated after the first 24 h. There were three avascular necrosis as acomplication. All of them operated after the first 24 h and all the fracture types were cervicotrochanteric. Open reduction was applied to two patients and closed reduction to one. Pediatric collum femoris fractures are rarely seen in children but treatment is challenging and open to complications. Fracture type, surgical methods, did not effect the outcome, but timing of surgery did. Author to editor: In this study we discussed the outcome of pediatric collum femoris fractures, which is a very rare fracture in orthopaedic experience. Surgical management of humerus shaft fractures is an increasing interest nowadays. We want to discuss the outcome of conservative, open reduction and internal plate fixation (OR _ IF) and intramedullary nailing (IMN) methods in adults (22-80 years old). 10 patients had conservative treatment with modified custom made Sarmiento brace and 9 of them had union with 5°-20°of malunion. None of the nine have complains and the avarage union duration is 10 weeks (8-12). One patients did not tolerate bracing and undergone surgery. 14 Patients had OR _ IF and 2 had gone second operation for nonunion and 4 had elonged wound drainage. All the fractures healed eventually with in 10 weeks (6-16). No neurovascular complication was observed. 18 Patients had IMN treatment and 4 had delayed union up to 6 months, 2 had undergone reoperation with OR _ IF for non-union, 1 had intraoperative fracture of elbow and 6 had shoulder problems with impingement and rotatory cuff problems. Avarage union duration was found 9 weeks (7-12). Surgical treatment is getting more popular for long bones nowadays. Early return of work and social life, anatomic reduction, using no sling or such devices and easy follow up protocols are the facts that popularising the surgical management. But in our series, we had seen multiple types complications that are as high as they are mentioned in literature. With the experience of those 42 patients that had been treated with in this year, conservative treatment methods have to be conserned firstly in suitable and tolerable patients for us. Intoduction and Objectives: Correction of sagittal deformity is important in thoracolumbar burst fractures. The clinical maneuvers needed for reduction and the assessment of correction of the fractured vertebra is not well described. In this prospective series we used the length of the interspinous ligaments as reduction parameter. Our aim was to evaluate the efficacy of this assessment technique in achieving good correction. Methods: From 1999 to 2005 25 patients (M/F 14/11, mean age 34.7) with unstable thoracolumbar burst fractures were treated by posterior fusion with a standard construct by a single surgeon. All patients were treated with segmental posterior instrumentation with two levels above and two levels below the fracture level fixation by means of pre-contoured rods and distraction technique. With these maneuvers the length of the injured level was tried to be equalized to the mean of upper and lower levels. Anterior column was assessed by radioscopy. Preoperative and postoperative radiographs were analyzed and local kyphosis (LK), Farcy's sagittal index (FSI) and compression percentage (CP) were measured. Results: The preoperative LK decreased from 18.96°to 3.44°, FSI decreased from 18.2°to 3.8°and CP decreased from 28 to 46.8. After a minimum follow-up time of 2 years all patients continue to do well with no statistically significant decrease in these parameters. Conclusions: Assessment of thoracolumbar burst fracture reduction with pre-contoured rods and distraction technique can be made safely by intraoperative measurement of the length of the interspinous ligaments. Case: An 85-year old lady was admitted in our emergency department with a Neer 3-part fracture of the right proximal humerus caused by a fall. She was operated on and received a shoulder hemiarthroplasty. During cementation of the stem the patient became bradycard and acute respiratory arrest occurred. She was resuscitated, but eventually died 9 h postoperatively. Postmortem examination revealed embolic bone marrow occluding the pulmonary capillaries. Comment: Pulmonary embolus after upper extremity surgery is a rare complication. Fatal pulmonary embolus is even more rare. When reviewing literature there is no previous case of fatal pulmonary embolus caused by fat emboli described. Fat embolism syndrome was first described by Zenker in 1861, but its frequency today is still unclear. Usually it presents as a multisystem disorder. The most often and most seriously affected organs are the lung, brain, cardiovascular system and skin. It is a self-limiting disease, therefore treatment should be mainly supportive.

Purpose: Lack of knee flexion is a possible complication in severe femur fractures. Two different techniques for the treatment of this problem were applied. Materıals-Methods: From 2006 to 2008, 3 patients with severely arthrofibrotic knees were managed with two different operative techniques. The mean age of the patients at the time of the operation was 45 years. We recorded the clinical outcome of 1 patient using Judet quadricepsplasty with a follow-up of 28 months, and of two patients using extra-articular mini-invasive quadricepsplasty and intra-articular arthroscopic lysis of adhesions during the same anesthesia session with a mean follow-up of 14 months. All patients were evaluated according to the criteria of Judet and The Hospital for Special Surgery knee-rating system. Results: The average maximum degree of flexion increased from 33°p reoperatively to 65°at the time of the most recent follow-up. According to the criteria of Judet, the result was good for 2 knees, and fair for one. The average Hospital for Special Surgery knee score improved from 48 points preoperatively to 58 points at the time of the most recent follow-up. A superficial wound infection occured in one patient. Conclusions: If you select the appropriate cases, the Judet procedure and mini-invasive operation for the severely arthrofibrotic knee can be used to increase the range of motion and enhance functional outcome. Purpose: Floating Knee and Elbow injuries are complex injuries. The types of fractures, soft tissue and associated injuries make this a challenging problem to manage. We present the outcome of these injuries after surgical management. Materials and Methods: Two patients with floating knee injuries(classified by Blake and McBryde) and one patient with floating elbow injuries were managed over an average of 22 months. Both fractures of the floating knee injury and the three fractures of the elbow injury were surgically fixed using different modalities. The associated injuries were managed appropriately. Assessment of the end result used the Karlströ m criteria after bony union. Results: Mechanism of injury was road traffic accidents in two patients (floating knee) and falling from height for one patient (floating elbow). There were 2 associated injuries, patient 1 was TipIIA, patient 2 was TipIIB. Both these patients had intramedullary nailing for femur fractures. Patient 1 had ilizarov external fixation for segmenter tibia fractures, patient 2 had a proximal medial plate for proximal tibia fracture. Patient 3 had plates afıxed to all fractures.Complications were knee stiffness and delayed union of femur in a patient (second operation required). The bony union time average from 32 weeks for femur fractures, 18 weeks for tibia, 12 weeks for upper extremities. According to the Karlstom criteria the end results was acceptable. The average elbow score was 85/100 (good). 

Patients with Tibial Bio-screw Fixation There is insufficient evidence from randomized trials to determine the optimal intervention in patients with displaced four-part fractures of the proximal humerus: head preserving surgery with problem to obtain and maintain reduction until bone healing, implant failure, AVN of the head, HA with > 50% tuberosities related complications-resorption, displacement, RSA with high complication rate, moderate function due to restricted rotation and insufficient long-time follow-up. In our presentation we will discuss:

• New RSA designs, which improve function and lessen complication rates • Question of tuberosities fixation to RSA in proximal humeral fractures • Literature overlook of RSA in proximal humeral fractures The goal of RSA is to minimize shoulder immobilization and to start functional rehabilitation immediately. Indications are same as for HA + tuberosity osteoporosis and comminution + week or absent RC. Decision for IF, HA or RSA is often intraoperative. Tuberosities fixation is debatable (prolonged immobilization, prosthesis dislocation). Functional results are more consistent than in HA, but complication rate is higher (it may be lowered by new prosthesis designs).

536 Frequent CT Scanning Due to Incomplete 3-View X-ray Imaging of the Cervical Spine Background: Conventional C-spine imaging is still widely used, despite increasing replacement by CT scanning. The aim of this study was to analyze the frequency of incomplete C-spine X-rays (3-view series) in blunt trauma patients. Methods: During a 2-year period we analyzed the frequency and value of 3-view series of the C-spine. Secondary we assessed the reasons for subsequent CT scanning after the 3-view series according to the following classification: inevaluability, incomplete 3-view series, evaluation of findings on 3-view series or for unexplained, persistent clinical symptoms. Furthermore we evaluated predictors for incompleteness.

Results: 88 C-spine injuries were diagnosed in 1283 blunt trauma patients (6.9%). 159 patients (12%) had their C-spine cleared based on the NEXUS criteria. 717 patients were primarily evaluated with 3view series and 395 patients primarily with CT scanning. Within the population with primarily 3-view series 249 (35%) were repeatedly incomplete and 16 (2%) were inevaluable. In the major part of the incomplete 3-view series no apparent reason could be determined. However, the presence of clavicular fractures (resulting in incomplete radiographs in 68 vs. 43% without a fracture; p < 0.001) and rib fractures (56 vs. 34%; p = 0.008) were associated with incomplete 3-view series. Conclusion: In more than a third of the patients primarily assessed with 3-view series, the results are incomplete or inevaluable necessitating CT scanning. Therefore, the diagnostic value of 3-view series is questionable. In patients with clavicular and rib fractures 3-view series can be omitted and primary CT scanning is advised. The treatment of open distal tibia fractures is still discussed controversially and they are a great challenge for surgeons. It is still not clear if there should be initial stabilization with an external fixator or primary osteosynthesis with an intramedullary nail or plate. We retrospectively examined 20 patients with II°and IIIa°open distal tibia fractures which were treated during the last 4 years in our level one Trauma Center. We treated 16 male and 4 female patients with an average age of 31 years. Ten patients were treated with an external fixator and 10 patients were treated with an intramedullary nail or plate osteosynthesis in acute surgery. The patients, firstly treated with an external fixator, were stabilized with reamed intramedullary nailing in eight cases and with locked plating in two cases after wound closure. There was no difference in the duration until bony union in any groups. Fewer unplaned revisions (n = 3) and no deep osseous infections were found in those patients treated with an external fixator in the acute phase of the injury. Patients treated with a definitive osteosynthesis underwent unplaned revisions in six cases and developed deep osseous wound infections in four cases. We therefore recommend that initial treatment with an external fixator should be preferred and after consolidation of the soft tissue, the definitive stabilization should be done with a stabile osteosynthesis system. Author to editor: This topic remains of a high interest among trauma surgeons, especially now, that angle stable intramedullary fixation systems run the market. Fractures of the clavicle shaft are common and have been typically addressed to nonoperative treatment. But favorable results with the precontured anatomic plates are facilitating surgeons for primary surgical treatment. This study reports the surgical results of 10 adult clavicle shaft fractured patients (age range 18-76) that had been operated with in last 18 months. All fractures were displaced and none of them was open nor had neurovascular injury. Avarege healing time was found 8 weeks (4-50 weeks). All patients had anatomic reduction postoperatively. 5 of the patients fracture site was grafted with DBM. 4 of 10 patients had sterile wound drainage which was lasted for 2 weeks postoperatively (all were grafted with DBM), 5 of them re-operated (3 of them for early implant failure and 2 early implant removal for plate disturbance) and one patient was operated for 5 times (2 of them was in another center) for early implant failure, nonunion,wound problems and neurovascular complications. 9 of 10 was healed eventually. 9 of 10 patients were satisfied with the treatment and had a full range of motion at final follow-up and were able to return to pre-injury occupational and activity levels. Nonoperative treatment of displaced shaft fractures may be associated with a higher rate of nonunion and functional deficits. However, our study shows that surgical treatment also has high complication rates. There is currently considerable debate about the benefits of primary operative treatment of these injuries because it remains difficult to predict which patients will have these complications. Platelet Rich Plasma (PRP) is applied in orthopaedic, maxillofacial and plastic surgery with variable outcome. Different growth factors and cytokines are stored in platelets, including Platelet Derived Growth Factor (PDGF), contributing to the potential positive effects of PRP. The aim of our study was to investigate the properties of PDGF administered locally in a rat femoral non-union model. In our experiment a critical sized osteotomy was performed in the rat femur, which was filled with a spacer, inhibiting bone formation for a period of 4 weeks. In a second operation this spacer was removed and the test item was applied into the defect. We compared the PDGF group (d = 250 ng, c = 1 lg/ml of PDGF in fibrin matrix) with the FIBRIN alone and BLANK control groups. Four weeks after the second operation, specimens were analysed by X-ray, lCT imaging and histology.

In group PDGF we found a lCT confirmed union in 0 of 7 specimens and the lCT evaluated bone volume was median 7.2 mm 2 (q1 = 6.1/ q3 = 10.8). In the control groups there was a bony bridge in 3 of 7 FIBRIN and in 2 of 8 BLANK specimens. The bone volumes were median 15.7 mm 3 (q1 = 8.0/q3 = 18.4) FIBRIN and median 9.1 mm 3 (q1 = 7.1/q3 = 22.7) BLANK, respectively. We did not find a strong tendency for new bone formation in the group treated with PDGF. In our model we observed even a tendency to inhibit bone regeneration for PDGF.

Introduction and objectıves: Hand traumas are one of the most common encountered complex traumas. Closing the defects on either dorsal or palmar side of the hand is sometime difficult because of limited local tissue and to provide a tissue the tendon glides underneath. In spite of high risk of donor side morbidity and sacrificing a major artery of the hand, radial forearm flap is the most frequent choice to close the defects at this region. Method: In a year time, five patients with severe hand traumas who admitted to our clinic, treated with perforator based three radial artery and two ulnar artery adipose-fascial forearm flaps. The adipose-fascial island flap was raised on one or two of these perforators without sacrificing a major vessel.The flap was transposed to defect region and covered with STSG. In all five patients' donor side was closed primarily.

Results: The biggest flap size was 10 · 8 cm. There was no flap loss except one patient who had partial flap necrosis and it healed secondarily. The donor side was healed uneventfully in all the patients. There was no tendon adhesion. Conclusıon: Perforator based radial or ulnar artery adipose-fascial flap is a safe and reliable method for closing defects on the hand. It has both less donor side deformity and fascial component of the flap provides better tendon gliding and less tendon adhesion. However, it requires more experience to raise adipose-fascial flap. Introduction and objectıves: One of the most common causes of the lower extremity defect in adult is a road traffic accident. The most challenging issues is to close the defect on the 1/3 of lower extremity because local tissue is very limited and mostly damaged due to high energy injury. We investigated the difficulties of how we close the defect on one third of the lower extremity particularly in children, in our unit. Method: In a year time, 7 patients under 6 years old admitted to our unit. All patients had Gustillo IIIB injury and the biggest size of the defect was 20 · 13 cm. One patient had 2 different lesions on the heel the other was on the anterior aspect of tibia. After radical debridement, the wound closed with ALT free flap with in first week of admission. 2 different defects on a lower extremity were closed with ALT and Vastus lateralis muscle free flap with a single pedicle.

Result: The biggest flap size was 22 · 13 cm. An average pedicule length was 6.3 cm and the diameter of the vessel was 1.2 cm The average operation time was 5 h 53 min. One flap had partial necrosis and healed secondarily. They had uneventful recovery and discharged on average 8 postoperative days. Conclusıon: In children even less than 6 years age, one of the good and suitable options for closing the defect on the one third of the lower extremity is ALT as a free flap. Stable odontoid fractures can be treated with external immobilization using, e.g., a Philadelphia collar (PC) or a halo thoracic vest (HTV). It is important to delineate the capacity of both orthoses, Halo and Philly, for immobilization of the atlantoaxial complex (AAC), e.g., for their use in odontoid fracture care. In this in-vivo biomechanical comparison 20 volunteers (mean age = 30.9 ± 4.2) were subjected to flexion-extension radiographs immobilized in a modified HTV and a PC. Radiographs were analyzed for the segmental rotation angle of C1-2 in sagittal plane (SRA C1-2) and the absolute rotation angle of C2-7 (ARA C2-7). Separation angles (rSRA C1-2 and rARA C2-7) were calculated from flexion-extension views. Concerning restriction of subaxial sagittal plane motion, the HTV was more effective than the PC. The difference for the rARA C2-7 between the PC (mean 20.7°) and HTV (mean 9.2°) yielded significance (p = 0.01). But, concerning restriction of flexion-extension at the AAC, there was no statistical significant difference for the rSRA C1-2 between the PC and HTV (p = 0.3). PC (mean 1.3°) was superior to the HTV (mean 3.3°) in restricting sagittal motion at C1-2. In comparison to normals atlantoaxial motion was restricted by 88.5% (PC) and 70.8% (HTV). The current study demonstrated that there was no significant difference in restriction of sagittal motion at C1-2 between the PC and HTV. In light of the current biomechanical data and a selected review of literature it is concluded that the use of a PC is sufficient for the treatment of stable odontoid fractures. Introductıon: Although most ankle injuries are associated ligamentous structures, some types of fractures mimic to ligamentous sprain and misdiagnosed as well. Most of the ankle sprains undergo radiographic examination and some of type fractures easily are missed even X-ray. The aim of this study is to evaluate the missed talar neck fractures and to emphasize the missed fractures. Materıals-Methods: Misdiagnosed 8 cases were included in the study. Average age at the time of trauma was 28 (20-40). All cases evaluated prospectively. If the patients had ankle sprain and their initial X-rays show no evident of fracture, they were involved in the study. The diagnosis of the fracture was figured out by control X-ray, CT scan and MRI (except 1 case). All patients were evaluated by the scoring system of American Orthopaedic Foot and Ankle Society (AOFAS Introductıon and objectıves: Treatment of proximal humeral fractures remains controversial, because of complexity of this kind of fractures. The purpose of this study is to present our first experience using angular stable fixation in 3 and 4 part proximal humeral fractures Method: In last 6 mounts we treated 19 patients with this method, 9 men and 10 women (mean age 62). Anterior approach was performed in every case (MIS technique in two cases), and every patients underwent to early rehabilitation. Periodical clinical and radiographic control were performed. Results: Short term results are good with satisfaction of the patient, no pain and acceptable range of motion. We have 1 case of deep infection that need revision surgery and antibiotic treatment. Preoperative diagnosis of appendiceal diverticulitis is rare. The incidence of appendiceal diverticulitis ranges from 0.004 to 2.1%. 60% of the diverticulitis of colon cases appear above 70 years of age, and they are mostly in the left colon. Case: A 73 year-old male, who had a 1-year history of episodic right lower quadrant abdominal pain was admitted to the surgical emergency department for worsening of his complaints. The physical examination was only notable for right lower quadrant abdominal tenderness. Laboratory findings was normal. On ultrasonography examination signs of acute appendicitis was noted. As the radiological findings did not match with the clinical status of the patient, he was followed up. Later, acute abdominal symptoms appeared, and the patient was admitted to the operating theatre. Two 1 cm long nodules were seen on the appendix preoperatively. Appendectomy was done. The patient was discharged on the first postoperative day. The histopatological examination revealed acute appendicitis signs and two 10 mm long diverticula one of which is inflamed in the middle and the other in the distal part of the specimen were reported. Conclusıon: The most common cause of acute appendicitis in adult population is fecaloid. Lymphoid hyperplasia, carsinoid tumors, mucosel, parasites, fruit and vegetable seeds are other causes. Although appendiceal diverticulitis is rare, clinicians should be aware of its occurrence and tendency for appendiceal perforation.

Introduction and objective: Traumatic intracranial hematoma is the most common complication of the head injury requiring emergency intervention. As most of them are located supratentorially, they can be seen less frequently in the posterior fossa. This study aims to evaluates the clinical, radiological and surgical aspects of traumatic posterior fossa hematomas in patients who were treated at our center. Methods: The records of 16 patients with of traumatic posterior fossa hematomas that had been treated at our center between 1998 and 2008 were reviewed. Results: Of the 16 cases, 10 had cerebellar hematomas and 6 had epidural hematomas. Fall was the most common cause, followed by animal kick, assault and traffic accident. Diagnosis and management decisions were determined by cranial computed tomography scans. Surgical intervention was performed in 8 cases. The outcome was good in 13 patients. Three patients died who had low GCS at admission and additional cranial lesion.

Conclusions: Patients with occipital trauma should be evaluated immediately using cranial computed tomography scans. Early diagnosis of traumatic hematomas and prompt surgical intervention in those having mass effect provide good results. Introduction: Transcranial stab wounds made with a knife mostly produce a classic slot skull fracture and underlying tract hematoma, and often cause severe neurological deficits. An unusual case with combined pareses of oculomotor and trochlear nerves due to penetrating stab wound to the brain is presented.

Methods: A 14-year-old boy was admitted to our clinic after an altercation that resulted in the patient sustaining stub wound to his head. Results: He was conscious. Neuro-ophthalmic examination showed that the left eye had limited adduction, supraduction, and infraduction, incomplete convergence and left sided ptosis with dilated pupil. An emergency computed tomographic scan of his brain was obtained, which revealed a left slot fracture at the squamous portion of the temporal bone of the anterior cranial fossa and a frontotemporal intracerebral stub tract hematoma. He underwent emergent surgery. Fractured bone pieces and lacerated brain tissue were removed. Neurological deficits remained unchanged at 12 months follow-up. Conclusions: Cranial nerve injury related to the knife wound to the brain is very rare. The penetration site, depth of penetration and trajectory of the object are important in occurring of this injury. Prognosis seems to be poor in these cases. Introductıon: Large number of knee X-rays are done incidentally for patients presenting with knee trauma in accident and emergency. Using only one lateral view knee X-ray as a screening tool would reduce the cost by 67% as per A. Verma et al., an interesting proposition. Method: We investigated the validity of lateral view knee X-rays alone as a screening tool for detecting fractures around the knee in acute knee trauma. 102 randomly picked X-rays were reviewed. The AP and lateral views were interpreted by a Consultant Radiologist and the findings used as Gold Standard for the study. The lateral views alone were independently interpreted on two different occasions by the (a) Radiographer (b) Emergency Nurse Practitioner Accident & Emergency (c) Middle Grade Doctor Accident and Emergency (d) Consultant Orthopaedic Surgeon.

Results: There was significant inter observer variation in sensitivity which ranged from 66 to 86% with the highest sensitivity being achieved by the radiographer. The specificity was generally high with a range from 84 to 97%. Though there was a high validity in the case of the radiographer the sensitivity for the other observers was low. Conclusıon: Though there could be a significant saving in terms of resources and unnecessary radiation by doing lateral views alone as opposed to the routine AP & lateral views as first line X-rays, we do not recommend using the lateral views alone as a safe screening tool in knee trauma because of high inter observer variation in sensitivity.

Tk Gullett, Charalambous P. Charalambous, Ajay Sahu, Matt J. Ravenscroft 1 1 Stepping Hill Hospital, Stockport, UK Introductıon: In distal biceps tendon ruptures, re-attachment to the radial tuberosity should ensure an adequate tendon to bone surface contact to achieve a sound repair and fast tendon to bone healing. Method and Technique: We are describing a L-configuration reattachment of distal biceps tendon rupture, using a single anterior transverse incision at the cubital fossa crease. Each pair of sutures from the most distal anchor is passed through the distal part of the tendon. One strand of each pair is passed in a zig zag fashion through the tendon whilst the other strand is simply passed straight through the tendon in a posterior to anterior direction. The four strands of the proximal anchor are passed so that they form two mattress sutures through the proximal part of the tendon. Tightening is then performed in a specific sequence with initially pulling on strand A and B to bring the tendon down to bone and then tightening these to the corresponding suture strand of their pair. The two pairs of sutures are then tied to each other. This second anchor tightening ensures that the tendon is brought down onto the bone in an L configuration increasing the contact surface area between tendon and bone. Results: We have used this technique in 26 patients till now with excellent results and no re-ruptures. Discussion: Our technique is simple to perform and provides a sound repair with a large surface area of contact between tendon and bone. Results: Out of a 66% (n = 494) response rate, 305 respondents (101 male, 204 female) were included in the study. We excluded people with previous hip, knee or back problems. In our study, the symptom scores that is Lysholm, Oxford and Visual analogue scale for pain and function did not show any significant decline with age. On the other hand, the scores measuring activity levels that is Tegner and UCLA scales declined significantly with increasing age. Our normal scores were far ahead of age-matched post operative scores following total knee replacement. There was no difference between males and females. The symptom scores declined with increase in medical problems. Conclusıon: Our age matched scores were superior to post operative total knee replacement (TKR) scores from the NJR. This furthered our motive to create a set of reference knee scores in the normal population which could be used by other studies to compare their results and help improve postoperative outcomes. Mesenchymal stem cells (MSCs) are multipotent stromal cells that have extensive proliferative potential and the ability to undergo multilineage differentiation. Traditionally, osteogenic differentiation of mesenchymal stem cells has been studied in cells isolated from bone marrow and iliac crest. However, these harvest techniques are associated with several problems, including donor morbidity, pain, and limited amount of cells. Only a few years ago, adipose tissue has been identified as another source of mulitpotent MSCs, which are referred to as Adipose Derived Stem Cells (ADSCs). The aim of our study was to provide a comparative analysis of primary osteoblasts from the iliac crest and osteogenic differentiated MSCs from adipose tissue, using osteoblast-specific protein expression. In 21 patients the cells were differentiated into the osteoblast lineage using osteogenic medium (ADOBs). Primary osteoblasts were isolated from iliac crest specimens in 30 patients undergoing osteosynthesis with spongioplasty (female: 16, male: 14, mean age 54 ± 14.7). Phenotype marker expression of osteoblast-specific proteins osteocalcin, alkaline phosphase, type I collagen, and CBFA-1 (Runx-2) was analyzed up to 21 days following incubation using RT-PCR, western blot, and immunocytochemistry. Additionaly, the following surface proteins of ADSCs were analyzed: nucleostemin, CD34, CD105, CD 10, CD 13, CD 59, and CD 166. RT-PCR analysis revealed that the non-differentiated ADSCs contained different types of stromal cells with a large variety of CD marker expression. Surface protein expression (CD) did not differ significantly in cells isolated from either fat tissue or bone. Author to editor: Saved by LookUs. Background: At our department, classification of the responsiveness to fluid resuscitation and a simple and practical damage control surgery (DCS) scoring system have been used to determine the efficacy of the treatment strategy in trauma patients. Cases and Methods: We examined 247 out of 289 hepatic injury patients, excluding cardiopulmonary arrest cases. The present study was undertaken to establish a valid strategy for the treatment of hepatic injury, and further improvement of the survival rate was evaluated based on the grater and equal of grade IV [Organ Injury Scale (OIS)] hepatic injury necessitating emergency room laparotomy. Result: Interventional Radiology (IVR) treatment cases were all stable or responder patients and all survived with effective hemostasis. Transient responder or non responder patients that needed hemostasis were treated by emergency laparotomy, and all the cases that eventually expired needed DCS. The mean injury severity score (ISS) was 42.3 and the mean probability of survival (Ps) was 0.413, and hemostasis treatment was started within a mean of 39.1 min, yielding a survival rate of 42.9% in the cases with grater and equal grade IV (OIS) liver injury that needed emergency room laparotomy. Conclusion: Our criteria for deciding the therapeutic strategy based on the response to the initial fluid resuscitation seemed to be useful from the viewpoint of hemostasis for liver injury. The key to securing quality regional trauma care is to designate a trauma care hospital as a trauma center and to transport severely injured patients to the center as rapidly as possible.

Author to editor: We show that our classification of the responsiveness to fluid resuscitation and a simple and practical damage control surgery (DCS) scoring system is very effective for liver injury strategy. Fractures of the proximal femur are, more than ever, an important challenge in the field of traumatology. The Gamma-nail, a combination of advantages of the sliding screw with the intramedullary nail, represents an efficient technique in the management of these fractures. A series of 70 fractures of the proximal femur in which this nail was used is reported. The average age of patients was 81.5 years (range 50-97 years). 72.2% (51 patients) of the cases were female. The average duration of the operation recorded was 42 min. In all cases closed reduction was achieved. The mean healing time was 8.5 weeks in 97.1% of the cases. There were two cases of delayed consolidation but no pseudarthroses. Postoperative complications occurred in 12 cases (17.1%). One case of migration of the proximal screw was the most important complication. The most frequent complications (7 cases) were seromas and hematomas of the surgical wound, which resolved satisfactorily in all cases. Superficial infections (4 cases) also evolved favorably, once the appropriate antibiotic treatment had been instituted. No breakages or failures due to implant fatigue were seen. The patient's recovery after suffering the fracture and the operation was evaluated and the 80% (56 patients) recovered their previous walking ability. The overall mortality was 8.6% (6 patients) with 2 of the deaths occurring while in hospital.

In conclusion, this preliminary study has shown that Gamma-nail can be safely used by the average surgeon in the average hospital to treat a common and sometimes difficult fracture.

Valerio Ranieri, Loris Trenti, Aldo Rossi, Antonio Manenti 1 1 Departement of General Surgery, University of Modena and Reggio Emilia, Modena, Italy A 27 years old Nigerian woman, at the end of the 2nd pregnancy, was submitted to a caesarean section for uterine atony. Post-operative thrombo-prophylaxis was given. From POD 3, fever, abdominal pain and increasing tenderness in the right lower quadrant with leucocytosis appeared. Ultrasonography showed only small amount of fluid in the Douglas pouch, while a contrast-enhanced CT and a RMN revealed a dishomogeneus cylindrical mass of 2.5 cm in diameter extending from the right parauterine space towards the duodenum, suggestive of thrombosis of the ovarian vein. Laparotomy followed: uterus, ovaries, appendix and bowels were normal. After mobilizing the right colon the ovarian pedicle appeared enlarged and firm; it was dissected, starting from the vena cava, and completely excised preserving the adnexa. Post-operative course was uneventful. Histology confirmed a suppurative thrombophlebitis; the haematological study ruled out any coagulation abnormality. The patient completed a 6 months low-molecular-weight-heparin treatment.

Ovarian vein suppurative thrombophlebitis can seriously complicate a caesarean section, till to require a surgical treatment. The imaging is essential for a prompt diagnosis. Purpose: To prospectively study the mechanism, distribution of injury, and outcome of patients hospitalized with camel bite injury. Methodology: All patients admitted to Al-Ain Hospital with a camel bite were prospectively studied over 6 years (October 2001 -October 2007 . Mechanism of injury including behavior of the camel, distribution and severity of injury, patient's demography, and outcome were studied. Results: All 33 patients were males having a median (range) age of 27 (10-58). Almost half of them were Pakistani. Twenty-five were camel caregivers while five were camel riders. Seven patients were raised up by the camel's mouth and thrown to the ground while the other patients were only bitten. Majority of the injuries were in the upper limb (21) followed by the head and neck (8). 10/21 upper limb injuries had associated fractures. Two patients who were bitten at the neck were admitted to the ICU. One of them died due to massive left-brain infarction and the other had complete quadriplegia due to spinal cord injury. The median hospital stay was 6 days. One patient died (3%). Conclusıon: The behavior of the camel is occasionally unpredictable and the canine teeth of the camel, which are long, can cause severe penetrating trauma despite the small puncture on the skin. Care should be taken when handling the camel. Author to editor: Dear colleague: This is the only prospective clinical study of camel bites in the literature that took us 6 years to collect. The data is very unique and is of great interest. Fikri Abu-Zidan Gastrointestinal cytomegalavirus infections occurs predominantly in immunocompromised patients.Involvement of the gastrointestinal tract in acquired immunodeficiency syndrome (AIDS) patients is frequent. However the prevalence of cytomegalovirus appendicitis is exceedingly rare. Case: A 44 year-old male infected with the human immunodeficiency virus, who had chronic abdominal pain with subsequent development of acute right lower quadrant tenderness was admitted to the surgical emergency department. His physical examination revealed no other finding than a mass in the right lower quadrant. His abdominal ultrasonography and abdominal CT revealed a plastron appendicitis. So he was hospitalized for medical treatment and discharged after 10 days of treatment. His control abdominal ultrasonography and CT at the second month showed that plastron appendicitis persisted, therefore the patient was rehospitalized. He was discharged after 10 days of medical treatment. After 3 months the patient experienced severe abdominal pain. Appendectomy was performed and histopathogic examination revealed a cytomegalovirus infection. The problems related to diagnose cytomegalovirus appendicitis and therapeutic management of cytomegalovirus infections are discussed. Conclusion: Aggressive use of ultrasound and abdominal computed tomographic scanning, along with early surgical intervention, is recommended. Introduction: Spontaneous intramural hematoma of intestine due to anticoagulan therapy is an unusual reason for acute abdomen. The first symptom is usually severe abdominal pain, nausea and vomiting. The most useful radiographic methods is computed tomography. The treatment approach is conservative and surgical. We present four patients treated our clinics due to intramural hematom. Two patients are treated surgically and two patients are treated conservatively. Material and method: We carried out four patients diagnosed and treated for intramural hematoma of small intestine between 2003 and 2008 years in Haydarpasa Numune Training and Research Hospital second surgery department. We examine in this patients age, sex, etiologcy, hematologic parameters, the treatment approach (conservative and surgery), hospitalization times. Results: The mean age of the patients was 60.2 years (range 38-78). All patients were male. The etiological factor was warfarin treatment due to aort valve replacement in three patient and ischemic cerebral disease in one patient. Laboratuary parameters were elevated leukocyte counts in all patients. Two patients was treated by surgical treatment due to intestinal obstriction and ishemia Two patient was treated conservatively (nasogastric decompression and total parenteral nutrition). Median hospitalization time was 8.7 day (8-11). Discussion: When patients using anticoagulan therapy applied to emergency unit with abdominal pain, Physicians must remember intramural hematoma as reason of acute abdomen. First choice is conservative treatment however cases of acute abdomen with intestinal obstriction and ischemia require surgical intervention. Introductıon: Motorcycle accidents continue to be a source of severe injury. The joy and exhilaration of riding motorcycles brings with it the risk of morbidity and mortality associated with these accidents. Case: It concerns a 47-year-old man that in 21/10/07 entered the emergency room after suffering a motorcycle accident. At the admission he had pain, swelling and deformity of the left knee. Radiographs showed tibial plateau fracture type VI of Schatzker. He was submitted to surgical treatment with open reduction and ostheosynthesis with LISS plate and was orientated to rehabilitation. Six months after, the fracture was healed in correct alignment, had normal gait, normal knee range of motion and returned to work. Eight months after surgery he suffered another motorcycle accident with left leg trauma, radiographs showed a supracondylar femoral fracture type 33.A3 AO-ASIF and diaphyseal tibial fracture below the plate. He underwent surgical treatment with open reduction and osteosynthesis of the supracondilyan femoral fracture with LCP plate, extraction of the LISS plate and ostheosynthesis with diaphyseal LCP plate. Eleven weeks postoperatively, he was able to walk without crutches. Five months after had normal range of motion of the left limb and was working. Conclusıon: Tibial plateau fractures are serious injuries and stable fixation without compromising the soft-tissue envelope is often difficult but with the LISS plate we can achieve fixation of an associated metaphyseal/diaphyseal fracture component with minimal approach. Multiple consecutive fractures are an important source of limb deformity and impairment, which we could prevent in this case. Introduction: The optimum management of non-united humeral diaphyseal fractures remains unclear. A number of implants are available utilising varying operative philosophies and balancing operative complication risks. We present two cases of humeral shaft non-union treated with an intramedullary compression nail, a technique which is previously unreported. Cases: Case 1: A 23 year old male with a closed fracture of the humeral diaphysis (12-A3). Initial failed open reduction and internal fixation with an anterior placed 4.5 mm dynamic compression plate (DCP) was subsequently revised to a posterior 4.5 mm DCP plus bone graft 3 months later. One year post revision, the fracture had failed to unite and was referred to the senior author. He underwent a 2 stage reconstruction with the T2 Humeral Intramedullary nail in compression mode. At 6 month review the fracture had united and at 2 years postoperatively he had full range, pain free shoulder and elbow movement. Case 2: A 90 year old female with a closed diaphyseal humerus fracture (12-A1) treated conservatively in a U slab and functional brace developed a mobile, painful non-union. She underwent the same procedure as above and at 6 months the fracture had united. She was pain free and had full range of elbow movement. Shoulder movement was restricted due to co-existing glenohumeral osteoarthritis.

Conclusion: Key tenets of fracture and non-union surgery include the ability to obtain stability and compression. This paper describes the first reported use of an intramedullary nail in compression mode for humeral diaphyseal non-union. Fingertip amputations are the most common type of amputation injury in the upper extremity and they are important because of an often disproportionately long period of convalescence. Different surgical procedures are available for reconstruction, but none is absolutely satisfactory. Twenty-two cases (19 patients) of fingertip amputation have been treated by primary skin closure using the V-Y plasty (Tranquilli-Leali). There were 14 men and 5 women. The average age was 38.7 years. The procedure was carried out under regional anaesthesia using a tourniquet. All devitalized tissue was excised and the bone was smoothed. A triangular flap with a distal base was developed. The width of the base should be the same as the amputated edge of the nail or the nailbed, and the length should be a little longer than the width. The flap was mobilized and sutured to the nail or the nailbed. Finally the volar gap was closed. The average follow-up period was 18 months, ranging from 6 to 27 months. All of the flaps survived and achieved normal or adequate two-point discrimination. Two patients had some loss of distal interphalangeal joint extension and five patients had cold hypersensitivity. Rapid return to work was possible in most cases. The technique is simple and presents an excellent method for fingertip reconstruction in Allen type I, II and III injuries. Bilateral anterior shoulder dislocation is rare, and his aetiology is via various traumatic insults, atraumatic occurrences, and through extreme muscular contractions like epilepsy. In epileptic seizures is more common to occur posterior bilateral dislocation. The aim of this work is to describe a rare case of anterior bilateral shoulder dislocation after a convulsive crisis. It concerns a case of a 35-year-old male, with alcoholism history, who entered the emergency room in 25/05/08 with a generalized tonic-clonic seizure. After, he had bilateral shoulder deformity and swelling. Radiographs demonstrated a bilateral anterior shoulder luxation and bilateral greater tuberosity fracture. The dislocation was reduced and both shoulders were immobilized. 1 month later, radiographs showed bilateral reduction maintenance and bilateral greater tuberosity fracture deviation. The patient had extremely restriction of active and passive ranges of motion in both shoulders: in the left had 5º of active external rotation and 60º of abduction; in the right 0º of active external rotation and 50º of abduction. At this moment surgical procedure was done with bilateral open reduction and osteosynthesis with ''phylus'' plate and was orientated to physical rehabilitation. At the 2 month follow up, he had significantly improved both shoulders range of motion, and returned to the normal daily activities and 2 months later returned to work. Displaced fractures of the greater tuber-osities after shoulder dislocation may result in motion limitation and functional disability. Open reduction and stable fixation allows for early passive motion of the joint and early return to activities of daily living. Introduction and objectıves: Direct inoculation, hematogenous spread or underlying medical illness which can predispose a patient easily for osteomyelitis are the causes of a vertebral infection. This case report represents a vertebral osteomyelitis of a patient seen after spine trauma.

Case: An 11 year-old girl was admitted to our out-patient clinic with a history of progressive back pain. Her inflammatory markers were high, physical examination revealed only spinous tenderness to palpation and she had a spine trauma history when she was at nine. Radiological evaluation demonstrated lumbar 1 and 2 mild anterior compression, an incomplete intervertebral fusion and endplate irregularities with an intact spinal cord. Bilateral sequential transpedicular drainage from L1 vertebra was performed without any complication. She has a pain free course of 6 months with negative inflammatory markers.

Conclusions: The management of vertebral osteomyelitis is often challenging and in case of continuing pain and progressive kyphosis, surgical treatment is indicated. Beside aggressive surgical procedures, minimally invasive techniques can be an option for the treatment of such cases. 1. Instead of standard screws with diameter of 8 mm using screws with diameter of 9.5 mm 2. Instead of 2,2 diameter cannulated tunnel using 3, 2 mm cannulated tunnel

Results: In use of this new modified method the time of surgery is shorter, the percutaneous surgical technique is simplified, the blooded lose is minimalizied, the surgery can be performed by two persons: the surgeon and the scrub nurse and few special instruments required.

Conclusion: Based on our results we recommend this modified minimal invasive percutaneous osteosynthesis in case of Garden III femoral neck fractures, in Garden IV one, especially immobile patients and patients with poor general conditions (ASA score IV). Introduction: Pelvic fracture is one of the serious skeletal injuries, resulting in substantial mortality. The large amount of kinetic energy necessary to fracture the bony pelvis often leads to concomitant thoracoabdominal injury. Pelvic fracture and combined injuries need effective initial resuscitation. However, it is hard to predict the mortality due to the complexity of multiple injuries. Therefore, the Introduction and objectıves: In this study, we aimed to investigate the distribution of the diagnosis in patients who underwent urgent surgical intervention in the operating room. Methods: Distribution of the diagnosis in patients who underwent an orthopaedic urgent intervention in the year 2008 are evaluated retrospectively from the medical records.

Results: 18 patients with orthopaedic complaints [17 male, 1 female; mean age 28.8 (3-56) years] were operated on urgently in the year 2008. 10 patients (7 shoulder, 2 hip and 1 lisfranc dislocations) had traumatic acute joint dislocation in which closed reduction was unsuccessful without general anestesia, one had supracondylar humeral fracture, one had distal femoral epiphyseal type II fracture, one had isolated radial shaft fracture with neurovascular injury, one had T12 spinal fracture dislocation with paraplegia, one had type III acromiaclavicular ligament rupture, one had quadriceps muscle laceration due to knife wound, one had tendo calcaneus rupture and one had patellar tendon rupture with medial meniscal injury due to knife injury. The mean time from admission to operation was found 4.5 h (range 1-6). Conclusıon: It was concluded that the closed reduction of joint dislocations under general anestesia were the major group in orthopaedic urgent intervention.

589 Why Ankle Should be Reduced Urgently?

Shahzad Sadiq, Tariq Mahmood 1 1 Worcester Acute Hospital, Worcester, UK Fracture dislocation of ankle is common orthopaedic emergency. It is paramount that to avoid soft tissue damage, the ankle is reduced as soon as possible. Despite all efforts ankle dislocations could lead to significant blister formation. We reviewed a case series in which ankle joint was reduced with external fixator until skin healing Methods: The cases who were admitted to our emergency department between August 2006 and2008 and were exposed to traumatic extremity amputation were studied. The medical records such as age, sex, education level, occupation, the way trauma occurred, the affected anatomic zones, performed interventions and hospitalization duration parameters were evaluated.

Results: The data of 309 subjects were evaluated in this study. Mean age was 29, the rate of female/male was 1/4.5. There was a reverse correlation between the education level and occurrence prevalence. 48.12% of the cases were laborers, 30.45% various free self employed and 12.40% were farmers. According to their occurrences, industrial accidents 65.69%, pinching finger in the doorway 17.15% and home accidents 8.73% formed the first three rank. Hand finger amputation was 93.85%, toe amputation 3.24% and others were 2.91%. While 209 cases were treated at the emergency service and discharged, 93 cases were referred to related clinics. Five cases were referred to other centers and two subjects willingly left our clinic. The mean length of stay was 3.8 days.

Conclusıons: Traumatic amputation concerns particularly the young and the people in active work life. Since the majority of the cases have hand injuries, they are striking because they cause workforce lose in addition to cosmetic and functional defects. Introduction: Distal radius fractures are one of the most common injuries regardless of age group. Due to their localization they pose a serious threat to the fine wrist movements. For most of the patients the perfect functional result is of a vital importance. Open reduction and stable osteosynthesis may help to produces desired outcome. Methods: We have compared 15 distal radius radius fractures treated with open reduction and stabilization with 3.5 mm Synthes LCP and 15 treated with Synthes 2,4 mm LCP. We have compared the functional results, neurological damage and patient comfort with questionare form. Measurements from X-rays were also compared. We have included 30 patients of age between 24 and 68 years, with distal radius fracture. 18 of them with intraarticular fracture. Results: Intraarticular fractures of distal radius treated with Synthes 2.4 mm LCP show better functional results compared to Synthes 3.5 mm LCP. There is no relevant difference depending on used material in extraarticular fractures. Conclusıons: We recommend the use of Synthes 2.4 LCP for intraarticula distal radius fractures for its greater diversity and abillity to stabilize even a small fragments.

Introduction and objectives: Surgical treatment of fractures by using resorbable implants is not too expanded alternative to classical steel or titanium implants. Indication for using are intraarticular and periarticular fractures at first of all. The most advantage is no necessary of implants extraction. Another one is propagation of load callus during the degradation of material. Possibility of making profitable CT and NMR is indispensable.In this paper author presents experiences with using of resorbable screws. Methods: At our department there are resorbable cortical screws 2.7, 3.5 and 4.5 mm Bionx made from polyamide polymer with minimal stronghold for 20 weeks and total absorption after 4 years. This screws are determinated for cancellous bones in periarticular areas.

We are using them in cases of fracture posterior wall of acetabulum, distal humeral intraarticular fractures, radial head. It can be used for treatment children¢s fractures too. The follow up is same like in ''classical'' osteosynthesis.

Results: There were no infection's complications, no malfunction screws in our group of patients. The postoperative and ambulatory treatment including physiotherapy was same like in group with classical osteosynthesis. The only one failure was during surgery -we have wraped screw four times because of insufficient pre-drilling and using too much power during insertion.

We could recommend resorbable screws as suitable alternative in some type of surgical treatment intraarticular fractures at most. The indication have to be well look over and way of using has to be well understand as well as careful manipulation during surgery. The benefits are no metal material, no extraction in future and profitable CT and NMR.

598 Heart Valve Lesions in Blunt Cardiac Trauma -Mechanism, Diagnosis and Treatment Robert Lipovec, Granc Gregorcic 1 1 Department of Cardiac Surgery, University Clinical Center Maribor, Maribor, Slovenia

Because of the variation in diagnostic criteria, cardiac involvement in blunt chest trauma is estimated at approximately 15%. In contrast to cardiac contusion which is often difficult to validate, traumatic valvular lesions are usually associated with some degree of hemodynamic impairment. Patients with positive findings on clinical examination, ECG, CXR and troponine should be screened for valvular lesions by transthoracic echocardiography. Blunt injury to cardiac valves can lead to progressive ventricular failure often requiring surgical management. Patients with structural damage to the left sided heart valves usually require immediate surgical repair, while right sided valvular lesions can be managed in a delayed fashion. The management is based on type of structural injury and hemodynamic compromise. Valvular reconstruction is usually attempted, if possible. The paper outlines historical perspective, mechanisms of injury as well as our experience with diagnosis and treatment of traumatic valvular lesions. Two case reports are presented. One patient had a traumatic mitral chords rupture and the other had a tricuspid papillary muscle rupture. Both cases were diagnosed immediately and surgically corrected. The ruptured mitral valve was urgently replaced. The tricuspid valve was repaired by delayed surgery.

Patients in Al-Ain City, United Arab Emirates 13.18%, respectively. Only the difference between Group IIA and IIB was found to be statistically significant. Dıscussıon: Rib fractures increase the pain and have a negative effect on breathing during postoperative course. Ineffective breathing may cause athelectasis, fever and infection which is associated with increased morbidity. The incidence of rib fractures are higher in anatomical resections in whom the thoracic cavity should be opened widely. A longer incision and step to step opening of the thoracic cavity may decrease the incidence of this undesirable complication. Objectıve: This case report describes a surgical method to treat multiple rib fractures by using arch bars. Case: A 52 year old male patient was admitted to emergency unit with bilateral flail chest, bilateral multiple rib fractures, bilateral hemopneumothorax and pulmonary contusion. The patient was initially tachypneic and had a shallow breathing. Because of the respiratory arrest he was intubated. Physical examination revealed crepitation from subcutaneous and oseeous tissues especially on the left hemithorax. After left sided tube thoracostomy 1500 cc hemorrhagical drainage and massive air leak was observed. CT scan showed bilateral rib fractures extending from the first to the eleventh ribs, bilateral hemopneumothorax and bilateral pulmonary contusion (Picture 1,2). Therefore tube thoracostomy was also administered on the right hemithorax and 150 cc hemorrhagical drainage and air leak occured. Because of the thoracic deformity, persistant hemorrhagical drainage and air leak from the left hemithorax, the patient underwent exploratris thoracotomy and damaged pulmonary parenchyma was repaired. Multiple rib fractures which damaged the thoracic wall stability severely were fixed by using arch bars (Picture 3). The patient required mechanical ventilation for 20 days postoperatively. The latest CT scans of pulmonary parenchyma and thoracic wall after arch bar application are seen in Pictures 4 and 5.

Conclusıon: In this case the conventional rib fixation procedures with Kirschner wires or plate plaques could not applied because of multiple small fractured segments. Despite various materials suggested in literature, the use of arch bars to repair flail segments with multiple small pieces are not mentioned.

Tariq Siddiqui, Kimball Maull 1 1 The Trauma Center at Hamad, Hamad General Hospital, Doha, Qatar

Introductıon: Intrathoracic fluid following blunt chest trauma is almost always blood, and derangement in the patient's cardiorespiratory status is directly related to the volume of blood accumulated in the pleural space and the associated compression of pulmaonary parenchyma. Tension chylothorax in the setting of bilateral chylothoraces is a rare cause for such a condition.

A 40 year old man fell from a height of three meters and presented with back pain. Examination disclosed abrasion and tenderness over the right paraspinal area. He was discharged home. Four days later, he returned in severe respiratory distress -hypertensive, with rapid pulse, tachypneic and with peripheral cyanosis. There were no breath sounds on the right side and decreased air entry on the left, and bedside ultrasound showed fluid in the right chest. Chest X-ray confirmed complete opacification of the right hemithorax and loss of the costo-phrenic angle on the left side. A right tube thoracostomy yielded 2,500 ccs of pinkish-white fluid with immediate improvement in cardiorespiratory status. Computed tomography disclosed bilateral 10th and 11th rib fractures, spinous process fracture of the 12th thoracic vertebra and bilateral effusions. A left chest tube brought back 600 ccs of additional similar fluid. Diliatation of the cisterna chyli in the abdomen with collapse of the thoracic duct were confirmed by MRI.

Conclusıons: Post-traumatic tension chylothorax causing cardiorepiratory compromise is rare. In this report, the patient responded to chest tube decompression and dietary measures without complication.

Author to editor: This report is complimented by excellent illustrations, including CT and MRI findings, showing the anatomy of the injury… conducive to poster display. Introduction: Blast lung injury (BLI) is a unique injury rarely seen in the civilian population. Our objective was to assess its severity, prognosis and associated injuries as compared to victims with chest wall trauma following explosions. Material and methods: Retrospective study of victims of the March 11 terrorist bombings in Madrid who were treated at the closest hospital. We compared the group with pure BLI (bilateral infiltrates in a butterfly pattern, and absence of chest wall fractures) (Group I) with that of patients with peripheral infiltrates and chest wall fractures (Group II). Results: Of 58 patients included in the Registry, 45 (78%) had thoracic injuries. 17 (40%) were included in group I, and 27 (60%) in group II. The mean ISS in groups I and II was of 25.8 ± 7 and 20.6 ± 9.5, respectively. Among the critical patient population in both groups (n = 27), those belonging to group II were in need of a longer period of ventilatory support and had more ventilator-associated pneumonias. In group I, the most frequent associated injuries were tympanic perforation (94.4%), 2º-3º burns (83.3%) and abdominal trauma (33%). In group II, 1º-2º burns (92%), followed by tympanic perforation (89%) and skeletal trauma (52%). One patient died in each group (5.6 vs. 3.7%).

Conclusions: Pure BLI patients had a greater degree of anatomic severity, had more severe burns and abdominal trauma than patients with lung infiltrates and thoracic wall fractures. Overall prognosis was excellent in both groups. Aım: Aim of the study was to determine the rate of injuries detectable by ultrasonography in patients suffering from blunt thoracic trauma.

Materıals-Methods: This study include the patients suffering from blunt thoracic trauma who have not any pathological findings in routine radiological diagnostic procedures. Ultrasonography of the thorax was prospectively performed in patients with blunt chest trauma additionally to the routine radiological diagnostic procedures. Ultrasound findings referring to the rate of detection of fractures, pneumothorax, pleural effusions, lung contusions, haematomas of the lung and chest wall was performed. Results: We studied 50 consecutive patients suffering from blunt thoracic trauma who has any pathological findings in routine radiological diagnostic procedures. The findings detectable by ultrasonography were the following: pleural effusion 18%, haemopneumothorax 16%, haematoma of the chest wall 4%, contusion of the lung 2%. Conclusıon: Rib fractures and pleural effusions are commonly diagnosed by ultrasonography in patients with blunt thoracic trauma. This study showed that ultrasonography may have superiority to chest-X-ray in diagnosis of rib fractures, pneumothorax, haemothorax, haematomas of the chest wall and pulmonary contusions in blunt thoracic trauma patients.

Ş adiye Emircan 1 , Ö zlem Kö ksal 1 , Fatma Ö zdemir 1 , Halil Ö zgü ç 2 1 Department of Emergency Medicine, Uludag University, Bursa, Turkey 2 Department of General Surgery, Uludag University, Bursa, Turkey

Aım: The purpose of this study is to define the epidemiologic properties of patients that have been subject to thorax injuries and general body traumas, analyze their condition when they are brought to our emergency department, to determine the correlation of physiological and anatomical risk factors with the mortality rate, and to ensure early diagnosis of severe trauma. Methods: 371 trauma cases that had been subject to general body trauma have been retrospectively examined in this study. Epidemiological properties of the cases have been determined, their initial condition during initial admission to emergency department have been analyzed, and cases have been assessed in terms of mortality developments. Survival probabilities and unexpected mortality rates have been computed using Trauma Revised Score-Injury Severity Score (TRISS) methodology. Results: Mortality rates was 22.6%. Univariance analysis revealed that hypotension, age, pathologic respiration pattern, blunt injury, accompanying injury, abdominal trauma, high Injury Severity Score (ISS), low Glascow Coma Scale (GCS), Revised Trauma Score (RTS), TRISS were the factors affecting mortality. In logistic regression analysis, presence of blunt injuries, TRISS < 85, ISS > 22

and GCS < 13 have been found independent prognostic factors. Strongest factor indicating mortality has found to be TRISS.

In presence of factors affecting mortality, patients with thorax trauma should be evaluated as being of high risk group and therefore diagnosis and treatment strategies must be aggressive. Case analysis based on TRISS model shall further reveal the mistakes that may be made in patient care and may improve patient care. Introductıon: Penetrating thoracal and cardiac wounds are asssociated with high mortality. We aimed to present our experience in such cases. Materıals-Method: Twenty three patients with penetrating thoracal stab injury, between 2004 and 2008, were investigated retrospectively. Gender, age, injured areas, extent of thoracal damage, accompanying organ damages and outcomes of these patients were evaluated.

Results: All patients, except one, were male with a mean age of 30.9 years (between 19 and 63 years). In 15 patients penetrating abdominal injury accompanied thorax trauma and one of these patients died peripoeratively. 10 patients out of 23 thoracal trauma had an additional cardiac stab wound and half of them were only pericardial injury. One of these cases went into emergency coronary artery bypass surgery due to LAD injury. Only four patients required intensive care postoperatively and four patients were lost perioperatively all of which had additional cardiac injury. Conclusıon: The overall mortality rate was 18%, but mortality of patients with additional cardiac stab injury was higher, with a rate of 40%. Suspect of cardiac injury should be considered in patients who are injured close around cardiac area and one should intervene quickly both in diagnosis and treatment. Introduction: Abdomen and thorax blunt and penetrating injuries, common cases of emergency surgery, cause less complication with proper analysis and surgical intervention. Material and method: We retrospectively evaluated 31 patients operated due to thoraco-abdominal blunt and penetrating trauma in _ Istanbul Training and Research Hospital last year. Results: Median age was 33.1 (9-78) and all were male. Patients were operated due to blunt abdomen in 8, penetrating abdomen injury in 18, abdomen and thorax penetrating injury in 5 by general surgeons. Abdominal exploration in 5 (16.1%) were negative laparotomy.

Background: We described a patient with dysfunctions of all the nerves and ruptured brachial artery and vein due to closed injury caused by spontaneously reduced dislocation of the elbow. Case: A 42-year-old man fallen down onto his left elbow with small skin erosion and a large area with ecchymosis on the elbow presented. Left radial and ulnar pulses were nonpalpable but no sign of acute ischemia was noticed. He had drop hand and could minimally make flexion, opposition, abduction and adduction of fingers. Strength of fingers, wrist flexion and thumb adduction were weak. Radiography was normal. Emergent surgical exploration was performed with prediagnosis of severe closed soft tissue injury and vascular damage. Brachial artery and vein had complete disruption with rupture of brachial muscle and the anterior joint capsule. Elbow joint could be posteriorly dislocated. Artery and vein were repaired with saphenous vein graft. Median and ulnar nerves had normal appearance. At postoperative 12th hour nerve injuries showed complete recovery. He could have normal range of motion in the wrist and hand. Sensorial examination was normal. He had a well perfused arm. Conclusıon: Spontaneously reduced dislocations of the elbow can be sometimes missed. Large hematoma and neurologic dysfunction in closed injury of the elbow indicate severe trauma of joint also in case of normal bone structure in radiography. Immediate diagnosis and operative treatment of brachial artery injury is mandatory. Closed elbow dislocation and multiple nerve injuries may have good results with conservative treatment. We present the case of a 53 y male, with his left lower limb severely damaged by a caterpillar vehicle. He was admitted in the ER about 90 min after the accident. He presented with exposed fractures of the femur and leg bones, extensive soft tissue and muscle damage, class III shock, and an umbilical clamp in the exteriorized femoral artery in the thigh, placed by a fireman in site. The MESS (Mangled Extremity Severity Score) calculated for this patient was 9. After the initial assessment in the ER the patient was transfered to the OR. He had a complete transection of the femoral artery and vein with a severe ischemic foot. Despite the MESS score, a vascular and bone repairs have been considered. Two temporary shunts were placed in both femoral vessels (artery and vein) followed by external fixation of the femur and leg fractures. The definitive vascular repair of the artery and vein was made with autologous saphenous vein after the bone fixation. Some damaged skin and necrotic soft tissues were removed, and the reminder skin was only proximated. The limb was functionally and anatomically preserved, with no obvious neurologic deficit, despite subsequent debridements and skin grafts. The authors concluded that in similar cases:

Introductıon: Trauma is responsible for 3.2 million of death, 80% of them in young people. Vascular injuries of the upper extremity represent 50% of all peripheral vascular lesions, the majority of them at the braquial artery.

Objectıve: Report a case of chemical injury of braquial artery. Methods: 41-year-old man was admitted in the emergency room with third degree sulphuric acid burn in the middle third of arm (2% of total body surface area). The radial and ulnar artery pulses were palpable. At the 20th day after injury, haemorrhage was noted and disruption of braquial artery was clear. A braquial-radial reversed long saphenous vein interposition graft was performed. After surgery palpable radial and ulnar pulses were present, without evidence of nerve injury.

Results: The chemical burns severity depends on the concentration, properties of the agent and the duration of skin contact. Sulphuric acid causes coagulation necroses, with thrombus formation in the microvasculature. Its corrosive properties are accentuated by exothermic reaction with water. Its burns are more serious than those compared with strong acids, and, as observed in this case, it causes frequently third-degree injuries. Besides this, it has the ability to cause continuing tissue destruction, from 6th hour to 28th day after injury. This fact could explain why there was no artery lesion at the admission but at the 20th day. Conclusıon: Sulphuric acid burn is potential devastating and tend to be prolonged in time, obliging to a continuous monitoring and multidisciplinary approach. Introduction and objectıves: The medicolegal studies show that the most frequent mechanisms of the lethal major vascular injuries were stab wounds followed by gunshot wounds and blunt trauma. During the blunt traumas, simple lethal major vascular injuries without any fracture are seen rarely. We experienced a case of common femoral artery and vein transection as a cause of death without any femoral fractures which were caused by blunt trauma.

Case: During the transportation of wood blocks, a wooden log fell from the truck over the forester, 34-year-old man. He sustained a crush injury and died in the emergency service on the same day of the trauma. It was learnt that no medical intervention was performed on the case. Ecchymotic bruises on the left abdominal-pelvic, femoral, right inguinal, genital region, deformation under the right knee were observed during the autopsy. It was determined that there was a traumatic transection on the left common femoral artery and vein, which was accompanied by massive bleeding in surrounding soft tissues and muscles without any fracture of the left femur. All the internal organs were intact and showed paleness. Death was due to internal hemorrhage caused by the transection of the femoral artery and vein.

Conclusıons: During the examination of the cases who were exposed to the blunt trauma, peripheral vascular injury must be investigated without any delay. If vascular injury was determined in the early times after the trauma, surgical and medical treatment could be performed successfully and the case could survive. Introductıon: Traumatic Internal Carotid Artery dissection is a rare and grave cause of embolic strokes occurred especially in young age group. If it is not diagnosed early and required treatment is not given, thrombosis can be a serious trouble with permanent neurological deficit and high mortality rate up to 40%. Case: We presented a delayed diagnosed traumatic carotid artery dissection in a 21 year-old female case. There were no ischemic infarct findings in the cerebral CT on admission, but there were cerebral infarct findings in the cerebral CT taken twice because of the left hemiplegia noticed 7 days later when the patient regained her consciousness. We made the diagnosis of the case, forwarded to our emergency service with acute cerebral infarct diagnosis, certain through arterial Doppler ultrasonography, cerebral MRI, diffusion MRI and MR angiography. We did not consider invasive treatment since the neurological damage was permanent and dissection grade was IV according to angiography findings. We did not administrate anticoagulant treatment considering that the patient can turn her ischemic infarct into hemorrhagic infarct. The case was discharged within a week and advised physiotherapy. Conclusıon: Although the advances in diagnostic methods, diagnosis with traumatic carotid artery dissection is still missed out or delayed as in the case we presented. Early diagnosis enables permanent neurological damage to be decreased or vanished. However, the vital factors for early diagnosis are the obtained anamnesis to direct to radiological examinations, detailed physical examination and high clinical doubts. Introduction: Acute arterial occlusion is a serious clinical condition resulting death of patient or related organs. These are usually older patients with a lot of comorbid conditions. Method: _ In our clinic, We retrospectively examined the records of 73 patients who underwent surgical treatment for acute arterial occlusion between January 2005 and December 2008. Mean age of patients was 66.8 years. 35 (48%) of these patients were female, and 38 (52%) were male. Embolic occlusions were found in an upper extremity in 13 (18%) patients and in a lower extremity in 60 (82%). The most common source of these emboli was cardiac origin. Atherosclerosis, trauma and arterial catheters were the other causes of emboli. 35 (48%) of patients were admitted less than 6 h preoperatively, 18 (25%) were admitted 6-24 h preoperatively, 20 (27%) were admitted after a delay of longer than 24 h preoperatively. 27 (37%) of patients were in sinus rythm, 46 (63%) were in atrial fibrillation preoperatively. Motor dysfunction of extremity was found in 24 (33%) of patients preoperatively. Diagnosis was based on the findings of physical examinations and emergent doppler ultrasonography. Any other invasive evaluation was not performed to decrease acute occlusive ischemic period. Surgical intervention had performed immediately Results: The overall mortalıty rate was 12% (9). _ In 10 (13.6%) of patients, after setting of demarcation line, amputation was performed. Conclusıon: Early diagnosis, catheter embolectomy and use of anticoagulation are very important therapeutic modalities for limb salvage and reduction of morbidity and mortality. There was a comorbidity in all patients and cardiac disease and hypertension were the most common ones. The most common laboratory abnormalities were leukocytosis, hypoalbuminemia, hyperamylasemia. There was superiory vasculary necrosis in 16 patients, inferior vasculary necrosis in one patient.One patient had nonocclusive mesenteric ischemia. Segmentery resection was performed to 13 patients. Abdominoperineal resection was performed to the patient with inferior mesenter artery occlusion. We performed duodenotransversostomy on two patients and only laparotomy on two patients. Reoperation was required in five patients. Causes of death was multiorgan insufficiency in seven cases, cardiac death in two cases.One patient died due to short intestine syndrome. Results: The patient was discharged on postoperative 16th hours without any complications. Conclusıon: Single incision laparoscopic appendectomy is a safe and effective technique that can be performed in well experienced centers success.

Jorge Pereira, Luis Filipe Pinheiro 1 1 Surgery Department, Sã o Teotó nio Hospital, Viseu, Portugal

Trauma represents one of the most important causes of death and disability of today. The exponential growth of the major cities, the continuous building of roads and the uprising of terrorism, foresee that trauma will keep is importance as a major cause of disease.

Recently, the management of the trauma patient as been modified, with the introduction of the ATLS method. This fact has produced great improvement, proven and reproducible, decreasing mortality and morbidity of trauma. The teaching of this new method, albeit its good results, has not seen many changes over the years. However, in recent days, we have seen the introduction of new computer technologies in teaching. This methods use simulation, e-learning and even interaction as learning techniques. Taking advantage of the mentioned techniques, the authors produced an animated video, using computer-animated drawings that allow demonstrations difficult to reproduce in real life. Using simple software and computer video editing, the authors invite you to watch a trauma patient in the Emergency Room, since his arrival to the end of the Primary Survey, watching demonstrations of life saving techniques and the stabilization of the patient. The authors present a video of a young male, 28 years of age, ± 100 Kg victim of a motorcycle crash, with a fall over cut branches of trees, 30 min before his admission in the E.R. He sustained an impalement with a stick in the fourth right anterior para-sternal space. At admission he was conscious, GCS = 15, BP = 140/80, HR = 90/m, SatO 2 = 94%, hemodynamically normal. Breath sounds slightly diminished in the left. A left anterolateral thoracotomy as been done, as well a left subcostal lararotomy, since the stick also had penetrated the left hemidiaphragm. The patient had no significant thoracic or abdominal injuries despite the violence of the trauma mechanism. The ''foreign body'' was successfully removed by combined abdominal and thoracic route, and a left chest tube was put in place. The patient recovered very well and was discharged in the eighth day. Author to editor: ''English'' corrections are welcome, please!

Berker Bü yü kgü ral, Mehmet Bekerecioglu

Al-marashda 1 , Amgad Elsherif 1 , Hani O. Eid 2 , Fikri M

Univariate analysis was used to compare patients who died and those who survived. Significant factors were then entered into a backward stepwise likelihood ratio logistic regression. Results: Out of 2,573 patients of the registry, 477 patients (18.5%) had chest trauma with a mean (SD) age of 35.2 (14.6) years. 428 (90%) were males 87. 304 (63.7%) got injured in the street or highway, 90 (18.9%) at work place, and 45 (9.4%) at home. The main mechanism of injury was road traffic collision in 315 (66%) fall from height in 80 (16.8%). 88 (18.4%) were admitted to ICU. The median (range) ISS was 5 (1-43). 175 (36.7) of patients got isolated chest injury, 130 (27.3%) had head injury, 119 (25%) lower limb injury, 118 (24.7%) upper limb injury

Iatrogenic Rib Fractures During Thoracotomy: Comparision of Posterolateral and Anterolateral Thoracotomies

Operations for thoracic trauma, extended lung resections and re-thoracotomies were excluded. Posterolateral thoracotomy incision was performed for Group I (463 patients; 78.8%), and anterolateral thoracotomy incision for Group II (125 patients; 21.2%). Groups were also divided into two groups for the type of resection

The percentages for rib fractures for Group IA, IB, IIA, and IIB were 53.34, 33.6, 41.17, and 1. Damage control principles can a be used in all surgical fields 2. General Surgeons must have experience in vascular repair skills 3. The reperfusion of the limb

João Filipe Coutinho Vasconcelos 1 , Sandrina Braga 1 , Pedro Brandão 1 , Daniel Brandão 1 , Miguel Maia 1 , Joana Ferreira 1 , Paulo Barreto 1 , Vítor Martins 1 , A. Guedes Vaz 1 , Leonor Rios 2

Vila Nova de Gaia, Portugal 2 Department of Plastic Surgery

Rectal prolapse describes the protruding of the entire rectum or some parts of the rectum from anus. It is caused by the weakening of the ligaments and muscles that hold the rectum in place.It is associated with advanced age, long term constipation or diarrhea, childbirth, previous surgery, and sphincter paralysis. Trauma may cause sphincter paralysis and can be associated with rectal prolapse. It usually begins with prolapse of the rectum during defecation or Val Salva movement and usually progresses to a chronic stage. Long term prolapse can cause ulcerations, bleeding and in some cases perforation if not reducted. A 51-year-old male presented with rectal prolapse, bleeding, abdominal pain. He stated that he could not replace the prolapsed segment for 2 days and has been suffering for 20 years since after he fell from a tree and he had massive bleeding during the last 8 h. Physical examination revealed that a 15 cm segment of the rectum was prolapsed with the whole layers. There were ischemic and necrotic areas and active bleeding from the mucosa. Reduction trial was not successfull. Emergent laparotomy was performed. Bimanual reduction failed.Thus transanal intervention, with sigmoid resection was performed. End colostomy was preferred. No complications occurred the following 6 months and colorectal anastomosis was performed with a preventive ileostomy. Although rectal prolapse is usually a benign condition it may cause fatal complications such as perforation, necrosis if not reduced for a long time and surgery should be performed promptly in these cases.ing to the age, diagnosis, treatment results, mortality rates between the years of 2006 and 2008. Results: Summarised in the Table 1 .In conclusion, the most of our multitrauma cases caused by traffical accidents, were young. The mortality rate 34% for multitrauma cases, the percentage of multitrauma cases were 8.8% of all intensive care patients. Preventing the accidents is as much important as treatment strategies for multitrauma cases.

Arif Tü rkmen, Ertan Gü nal, Mehmet Bekerecioglu, Berker Bü yü kgü ral 1 1 Department of Plastic and Reconstructive Surgery, Gaziantep University School of Medicine, Gaziantep, TurkeyIntroduction and objectıves: As personal problems dealing with health, jobs, financial status and the family problems increasing, more suicide attempt subjects are consulted in emergency rooms day-byday. Although gunshots to the oro-facial region form 4-12% of the total victims, it is important that seconder deformities resulted with aesthetic, functional and psychological problems were usually encountered after primary surgery. This study reviews 11 cases of self-inflinct gunshot injuries of face and our experiences in early and late managements over a 5-year period.Methods: This study is based on 11 subjects who attempted suicide resulting in extensive facial deformities, not in death between 2000 and 2008. Demographic details, mechanism and direction of injury, early and late management and seconder deformities were recorded. Results: After establishing the airway control and completing the primary survey, all patients underwent debridement and bleeding control. Reconstruction of maxillofacial fractures were performed in 8 patients on the day of admission and the remaining 6 within 5 days of injury. Following procedures as scar revisions, rhinoplasty, mandible reconstruction, ectropion operations or coverage of palatal defects etc. were performed after earliest 6 months from primary operation.Conclusıons: After stabilization of life-threatening injuries, the goals of early management are regenerate of anatomic form and function to include dental occlusion and mouth opening to prevent scarring, contractures of mobile structures and ankylosis. Seconder operations required for aesthetic and functional problems should be performed earliest after 6 month from primary operation that all the scar formations and wound healing's were completed.

Background: Injuries of maxillofacial region in patients with polytrauma are frequent but are rarely treated primarily. In order to achieve satisfactory treatment results trauma treatment team must include a maxillofacial surgeon.Materıal-Methods: The study shows treatment results of 29 polytraumatized patients with maxillofacial injuries. Dominant trauma was: maxillofacial in 17%, craniocerebral in 38%, locomotor in 17%, thoracic in 14% and abdominal in 14% of cases. Treatment of maxillofacial trauma was in 28% of cases surgical and in 72% conservative. Treatment of other traumas was operative in 17% and conservative in 83% of patients. Results: Early mortality rate was 21%. Four exitus were recorded during the first 24 h, 1 exitus on the 4th day and 1 exitus on the 6th post-trauma day. Dominant trauma was in 4 exitus craniocerebral, in 1 exitus thoracic and in 1 exitus severe locomotor. Long-term treatment results in remaining 23 patients were: for maxillofacial regiongood in 16 patients (70%), satisfactory in 3 patients (13%) and poor in 4 patients (17%); for other regions -good in 20 patients (87%), satisfactory in 1 patient (4%) and poor in 2 patients (9%). Conclusıon: Existing maxillofacial trauma in polytraumatized patients usually directs treatment toward conservative methods.Reasons for this are insufficient number of maxillofacial surgeons in trauma teams and delay of surgical treatment of other present traumas due to difficult anesthesia application. Unfortunately, conservative treatment approach induces inadequate treatment results from both functional and esthetic point of view. However, as revealed by hospitalization, transportation, and mortality data, women were exposed to more severe trauma. In addition, poisoning and fall caused more death. The rate of mortality of women seems to be less when compared to literature. Conclusıon: Bicyclists in non-fatal frontal crashes with cars suffered the most serious injuries from the impact to bonnet and windshield, likely due to highest energy transformation. Bicycle helmets, collision mitigation system that alerts the driver or automatically brakes the car, and external airbags protecting the bicyclists from hitting bonnet and windshield, may reduce injuries.Author to editor: This is a complete analysis of mechanism of injury in crashes carfront versus bicyclist. Journals were completed with traffic notes from police at scene, patents own history of the crash from the injury database and furthermore interview. The catch area is welldefined with no other hospitals in the area and total cover of all injuries in the database. This gives a good picture of the dynamics of the the crash and mechanism of injury. or street (11 AIS2 +). Third impact in 42 patients gave 29 injuries (16 head/neck) at windshield (9 AIS 2 +) or street (4 AIS 2 +). Thirteen persons, who hit the street as the fourth impact point, sustained three injuries (zero AIS 2 +) as contusions of the pelvis and lower back. Conclusıon: Pedestrians in non-fatal frontal crashes with a car suffered the most serious head injuries at second impact in bonnet, windshield or street. Safer passageways for pedestrians might preclude the crash. Mechanisms preventing the pedestrian of hitting the bonnet and windshield, may reduce the injuries. Author to editor: This is a complete analysis of mechanism of injury in crashes carfront versus pedestrian. Journals were completed with traffic notes from police at scene, patients own history of the crash from the injury database and furthermore interview. The catch area is welldefined with no other hospitals in the area and total cover of all injuries in the database. This gives a good picture of the dynamics of the the crash and mechanism of injury. One of the primary characteristics which professions possess is to make the members of a profession have autonomy in decision making and practice. Nursing practice is evaluated in relation to professional practice standards and guidelines, rules, etc… Application of professional standards requires that nurses use critical thinking for the good of individuals or groups. Critical thinking also requires the use of scientifically based and practiced-based criteria for making clinical judgments. These criteria may be practice based on standards developed by clinical practice guidelines developed by individual clinical agencies. For example, intensive care units (ICUs) are designed to meet the special needs of acutely and critically ill patients. A patient is generally admitted to the ICU for one of three reasons. The patient may be physiologically unstable, at risk for serious complications and require intensive and complicated nursing support. Despite the emphasis on caring for the patient who can survive death is common in ICU patients. It is reported that 10% of patients admitted to ICUs will die, and another 20% may leave the ICU but will not survive to discharge. This suggests a need for caution and coordination of care when transferring patients from ICUs to general units. In this article, the practice guideline which titled ''Patient Appropriateness for Adult ICU Admissions and Discharge'' will be discussed. The terminology for pelvic fractures and its recent modifiers are confusion to the trainee to say the least. We surveyed 70 orthopaedic trainees in the latter part of their surgical rotations. The same set of radiographs were shown to all trainees and their classifications recorded. the same set of radiographs were shown to the trainees again after a period of 21 days. We found significant inter-observer variability (45%) and wide intra-observer variability (15%). Though trainees were adept at identifying basic fractures patterns and identifying individual column or lip/wall fractures the complex fracture patterns seems to generate different answers from the same observer at different times. The CT scan was the most effective tool identified for accuracy of the fractured fragments but the more complex assignments resulted in the trainees grouping them differently. Results: Twenty-one fractures (87.5%) healed without complication including five fractures where external fixation was converted into internal one. The mean time to union was 6.5 (4-9) months. There were two pin-track infections, two deep infections, and only one nonunion. The femur length was equal to the healthy side in 19 cases, and was shorter by 1-2 cm in five cases. Mean active knee flexion was 90°. Knee flexion was more than 110°in 9 patients. Conclusions: External fixation is a useful technique for the stabilization of severe open and close highly comminuted femoral shaft fractures. It is safe procedure to achieve temporary rigid stabilization of femur fracture in critical polytraumatized patients before delayed internal fixation (damage control orthopedics).

purpose of this study was to determine the factors predicting mortality.Methods: A retrospective study was performed on 174 cases of pelvic fracture who visited to Emergency Department from January 2003 to June 2008. Data were collected regarding demographic characteristics, mechanism of injury, injury severity score (ISS), Abbreviated Injury Score (AIS), Simplified Acute Physiologic Score II (SAPS II), transfusion requirements, fluid requirements, the finding of angiography, Hemoglobin, platelet, prothrombin time ( Fractures were managed by using an intraarticular, chevron-shaped olecranon osteotomy in all patients. Methods: The mean age was 39.1 years. A straight posterior surgical incision was performed. A thin oscillating saw was used to begin the olecranon osteotomy. A small osteotome was then inserted and the osteotomy was completed through the subchondral bone. The posterior elbow capsule was incised. The olecranon fragment and the triceps muscle were reflected proximally to expose the distal humeral articular surface. Osteotomy fixations were performed with two intramedullary Kirschner wires and dorsal tension band in 23 patients. In four patients, an intramedullary screw and a tension band were used for fixation. Results: At the final control, the Jupiter Classification system was used for the evaluation of the patients. Eighty one percent of the patients revealed good and excellent results at the long-term followup. None of the patients showed osteotomy nonunion. The most frequent complication was skin problem due to subcutaneous prominence of the implants.Conclusions: The goals of treatment of distal humerus fractures are anatomic articular restoration and rigid fixation. Olecranon osteotomy provides good visualization for rigid fixation especially in Type C distal humeral articular fractures. This is a useful method for excellent anatomic reduction of the articular surface. 

Conclusions: There could be some steps during primary treatment for discussion. But real mistake was vacillation and delay of reosteosynthesis and spongioplasty even it was cause by risk for infection and possible failure of flap. Our case demonstrate that sometimes too much care could be hurtful. Introductıon: The population who applied to the public emergency services due to the injuries related to butchering the sacrificial animals during the feast of sacrifice were evaluated. Materıals-Method: Eighty-nine patients who admitted to the emergency services in Kirikkale during the feast of sacrifice in 2008 were evaluated according to age, sex, application day and time, state of experience, type and mechanism of injury and medical treatment. Results: The age average was 43 ± 13 and 80% of them were male. Eighty-eight percent of the patients admitted in the first day. Seventy percent of the injuries were penetrating injuries and 30% of them were blunt. The average time passed after the trauma was 120 min. Almost half of the cases were wounded with a knife, 18% were wounded unintentionally by the others and 36% of the cases were due to hit of animals. Fifty-seven percent of the patients had butchering experience before. Ninety-one percent of the cases were hand injuries. Thirty percent of the cases had fractures. Nine percent of all cases had tendon injury, 55% of the cases were treated primarily skin suturation. Conclusıon: The injuries related to butchering of the sacrificial animals sometimes can be serious. In extremity injuries, the number of tendon cuts and bone fractures can not be underestimated. Both equipments and medical staff support for the injured people should be provided and preliminary arrangements should be done during the feast of sacrifice. Every butchering job in this period should be given to professionals. Introduction: Osteoporotic fractures of the trochanteric area are often treated with a gamma-nail or similar implants utilizing a screw applied into the femoral head. One of the main problems of these techniques is the cut out in the femoral head. We biomechanically evaluated a novel technique of cement augmentation of the bed of the screw in a standardised osteoporotic bone model and its capability to reduce the cut out rate. Material and methods: Utilizing a polyurethane-foam osteoporotic model that has been previously described (specific gravity 0.192 g/cm 3 ), a biomechanical testing of a neck of femur screw (TGN, STRYKER, Duisburg, Germany) was performed. The screw was implanted according to manufacturers instruction, the migration characteristics were then biomechanically tested (Zwick testing machine) with a static stepwise load increase (50 N). First these tests were performed without, in a second series with the augmentation of a fast hardening biopolymer (Corthoss, Orthovita, USA). Each series was repeated five times. The transfer from a stable to an unstable condition was biomechanically determined.

Results: On average the applied load at the moment of failure with critical cut out was 1431 N for the non-augmented screws. With augmentation, the average load was 1,987 N, the difference was statistically significant.Discussion: It appears in biomechanical testing that augmentation of the femoral head can improve the load bearing capabilities and thereby possibly reduce the rate of cut-out failure in osteoporotic bone. We proceed now with further biomechanical testing, grant of the local ethics committee for human testing has been applied for. Introductions and objectıves: The aim of this study was to examine the relationship between childs' favourite cartoon stars who can fly and falling down from a high place in two cases. Methods: In this paper we presented two similar cases who were seen with a history of falling down from a high place. The first case was a 4-year old girl who fell down from the third floor of their apartment. On her examination it was learned that she wanted to fly like her favourite magical cartoon star girls. The second case was a 5-year old boy who fell down from the second floor. While falling down he was screaming to his friends that he was flying.Results: On the physical examination of the first case, deformity and crepitation in right femur were found. X-rays showed right femur distal epiphysis Salter Harris type IV fracture. She was hospitalized due to the pneumothrax in pediatric surgery intensive care unit. The procedure of closed reduction and fixation with multiple kirschner wires was performed under general anestesia. Closed body fracture in the left femur was found in case II. Introductıon: The purpose of this study was to compare the biomechanical properties of different possibilities of screw placement in multidirectional palmar fixed-angle plate in distal radius osteotomy cadaver model under loading conditions. Methods: An extra-articular fracture was created in 16 pairs of fresh frozen human cadaver radii. The 32 specimens were randomized into four groups. All radii were plated with a volar fixed-angle plate. There were 4 different possibilities of screw placement in the distal fragment:Group a: 4 screws were used in the distal row of the plate. Group b: 4 screws were used alternately in the distal and proximal row. Group c: 3 screws were used in the proximal row. Group d: 7 screws were used filling all screws holes in the distal and proximal row of the plate.The proximal fragment was fixed with 3 screws each. The specimens were loaded with 80 N under dorsal and volar bending and with 250 N axial loading. Results: Group d had the highest stiffness of 429 N/mm under axial compression and was statistically significant stiffer than the other groups. Group b had a stiffness of 208 N/mm followed by group a with 177 N/mm. Group c showed only a stiffness of 83 N/mm. There were no statistically significant differences under dorsal and volar bending.Conclusıons: Occupying all screw holes in the distal fragment offered the highest stability. Using only the proximal row with 3 screws showed an unstable situation. It is therefore recommended to use at least 4 screws in the distal fragment. Perilunate dislocations are the most common type of carpal dislocation. They can be produced by high-energy injuries. The population primarily at risk is male young adults. In perilunate dislocations, the proximal articular surface of the lunate retains contact with the distal radius. The dorsal-perilunate/volar-lunate dislocation is more common. We performed a retrospective study of perilunate dislocations from 2006 to 2008. A total of 5 were reviewed. Mean age of the patients was 28.6 (range 18-48). All the patients were male. The trauma mechanism was fall from height in 3 and motor vehicle accident in 2. All the dislocations were dorsal-perilunate/volar-lunate dislocations. All the dislocations were together with ipsilateral scaphoid fractures. All were closed injuries and all were reduced by closed reduction maneuvers. Percutaneous pinning was applied for the dislocation and scaphoid fractures. Mean follow-up time was 11 months (range 6-18 months). When compared with the non-injured wrist, there was limited range of movement in only one patient.No limitation of range of motion in the other patients could be obtained. The patients did not have pain and instability. Radiologically no arthrosis of the wrist could be obtained but in all patients there was scaphoid pseudoarthrosis. Functional range of motion of the wrist after a perilunate dislocation is independent of the concomitant scaphoid fractures.

Bostjan Sluga, Tomaz Malovrh 1 1 Traumatology Department, University Clinical Centre, Ljubljana, SloveniaInfective complications of tibia fractures result in nonunion, bone defects and soft tissue envelope impairment. Several methods of treatment have been described to deal with bone defect including callus distraction, fibula transfer, muscle flap and bone grafting. There are many possibilities to encourage bone healing; bone morphogenic proteins, platelet rich plasma, electrical, ultrasound or shockwave stimulation and hyperbaric oxygen therapy. A patient with both tibias infected nonunion is presented. High energy trauma primarily and inadequate debridement secondarily were probably the cause of the healing complications. A middle-age man was injured in a gas explosion and suffered comminuted closed fractures of both distal tibias. After an immediate external fixation we operated him on the 28th day after the injury, anatomical reduction and internal fixation on both sides was done. An infection developed after 3 weeks. Ankle joint arthrodesis was necessary on one side and implant removal, repetitive debridement with bone grafting on the other. We could not cure the infection and the fracture did not heal. After 2 years, 7 operations, 277 days of ciprofloxacin, 60 days of gentamicin, 57 days of vancomycin, 40 days of implanted gentamicin antibiotic beds and the use of cultivated autogenous steam cells clinically evident nonunion was still present. Surgery was performed again, a resection of 9 cm of bone and callus distraction with an unilateral frame. Despite a fast progress in knowledge and improvement of methods, a radical debridement, preservation or reconstruction of soft tissue coverage, systemic and local antibiotic therapy and appropriate stabilization is still a keystone in infected nonunion treatment. Some people who live in some regions of our Country trust in bonesetter's skills more than these ones of professional orthopaedist in the hospitals. The fact that some bonesetter's particular skills to cure the non-operative back pain seems to make them credible on closed reduction too. In this case report, right humerus proximal body fractures due to falling were discussed. The case was 9-year-old male. In the treatment of this case, velpau bandage, closed reduction and plaster cast-splint has been applied after that he was called to the clinic control, but he did not come to control. The parents of the case were aware of the fact he cannot raise enough the right upper extremity and he was taken along to the hospital. From his anamnesis, it has been learnt that the bonesetter has removed the castsplint and, tried to perform closed reduction. Actual physical examination showed that there was an arm pain, crepitation and deformity. A diagnose has been made: there was an union right humerus proximal body fractures, so he has to be hospitalised. Under general anaesthesia, closed reduction and bandage Velpeau were applied. On the 3rd day of the hospitalisation, the case was externed and was advised to come for a polyclinic control. Because of the importance of epiphysis lines of bones and of other complications from the upper extremities fractures, the treatments have to be performed by the orthopaedists or in accordance with them. About this medical issue, families should be made conscious by healthy authorities. There were 3 women and 20 men. The mean age was 39.7 years (range 19-55 years) and mean follow-up period was 23 months (range 9-56 months). Posterior Kocher-Langenbeck approach was used at 21 patients and ilioinguinal approach was used at two patients.Results: There were 10 both column, 6 posterior column with posterior wall, 4 transverse with posterior wall and 3 posterior wall fractures. Anatomic reduction was obtained at 18 patients and adequate reduction at 5 patients according to Matta criterias. Harris scoring system revealed excellent at 13, good at 4, moderate at 2 and bad at 4 patients. Over 70% of these patients had satisfactory function. There were any pulmonary embolism, deep infection or nonunion detected. One of four patients whom had developed osteoarthritis, managed with total arthroplasty. Postoperative sciatic nerve injury was developed at one patient. Conclusıon: Secondary arthrosis, nonanatomic reduction, unstable fixation and nerve injuries were associated with poor results. Our clinical experience for acetabulum fractures were similar to that reported previously at the literature with over 70% of satisfactory results

Sedat Kocak, Birsen Ertekin, Esma Erdemir, Abdullah Sadik Girisgin, Basar Cander 1 Introduction and objectives: Quadriceps muscle tears are usually seen in middle-aged and older people. Particularly people with chronic diseases (such as diabetes mellitus, renal failure and gout) are prone to develop quadriceps muscle ruptures. We present a case of partial rupture of the quadriceps muscle in a 4-year-old girl after intramuscular injections. We thought that this patient could be the youngest patient reported with a quadriceps muscle rupture. Methods: Patient presented to our clinic with left knee pain, limitation in knee flexion and a localized palpable swelling at the anterolateral side of thigh. There was no blunt trauma but it happened while she jumping on the sofa. In her detailed history we learnt that she had a serious upper tract respiratory infection a week ago and used some parenteral antibiotics (twice a day, intramuscular Clindamycine for 7 days).Results: Plain radiographies were normal. MRI showed a partial tear of the vastus lateralis muscle matching with the injection sites. The patient was placed in a long leg half-cast which was maintained for 3 weeks. She treated with conservative treatment successfully.Conclusions: MR imaging is useful to diagnose and differentiate in this pathology. Multiple intramuscular injections may contribute to damage muscles and make them prone to tears with muscle contractions. Quadriceps muscle ruptures in children can be treated successfully with conservative treatment. Twenty year old female attempted suicide by jumping from a four story high building, resulting in multiple fractures of the limbs and a complex fracture of the body of the fourth lumbar vertebra (L4) resulting in paralysis of the inferior limbs. The L4 fracture was treated by a Neurosurgeon with the extraction of the body of the vertebra, insertion of a cage device and arthrodeses of the third and fifth vertebras using a metal plate and screws, thereby stabilizing the affected segment and decompressing the medullar channel. The approach was achieved by a General Surgeon using the technique of Localio, that consists in a paramedian incision of the abdomen and the dissection of the retroperitoneal space without entering the abdominal cavity, dissecting and isolating the left ureter and the main vascular structures (iliac vessels and the left iliolumbar vein) in order to allow a good exposure of the three vertebra bodies involved. The patient recovered the complete function and control over the limbs, resulting no neurological sequelae from the fracture. It is of major importance that this procedure be performed by a multidisciplinary team of surgeons, involving a Neurosurgeon and a General Surgeon, in this way achieving a better result and a lower risk of complications.

Josef März 1 1 Department of surgery, Regional hospital Karlovy Vary, Czech RepublicAbdominal ultrasonography or CT were applied to 5 (62.5%) patients with blunt trauma and 8 (34.7%) patients with penetrating trauma. One (12.5%) negative laparotomy was applied to patients with blunt trauma. 2 to 3 splenic injuries was splenectomy. 1 sigmoid perforation, 1 diaphragm rupture, 1 bladder rupture were observed and were fixed primarily. One patient died during surgery due to liver and vena cava injuries. Patients with penetrating injury were operated due to firearm injury in 6 (26%) and stab wound in 17 (74%), mortality was not. Negative laparotomy was applied to 5 (21.7%) patients. Multiorgan injury was observed in 6 patients. Tube thoracostomy was inserted to 4 patients. 6 of the intestine injuries and stomach injury was fixed primarily. Two resection and anastomose and three diversionary ostomy were done. Conclusion: Proper examination must be considered according to the formation of trauma. _ Imaging methods have been used less in penetrating trauma, and negative laparotomy is reported to be applied more than in cases of blunt traumas Introductıon: Chest tube insertion is frequently used by thoracoabdominal surgeons in urgent conditions. Occasionally, this invasive procedure may be associated with lethal complications in inexperienced hands. In this study, we analyzed 6 patients with visceral and/or diaphragmatic injuries due to chest tube insertions. Methods: Six patients with diaphragmatic and visceral injuries subsequent to chest tube insertions between 2003 and 2006 were evaluated. The diagnosis was established with roentgenogram, biochemistry of the fluid drained from the chest tube and confirmed with computerized tomography in all patients. Results: Pleural effusion accompanying respiratory distress was the main indication for chest tube insertion in all patients. In five patients, coexistent gastric perforations with diaphragmatic ruptures were detected, also the esophagus was additionally perforated in one patient. Partial gastrectomies were performed in three patients, whereas total gastrectomy in one and primary repair required in two patients respectively. Five of the patients died from septic complications. The only survived patients with early diagnosis and primary repair was discharged from the hospital on the 12th day. Conclusıon: Penetration of a drainage tube through viscera is a wellrecognized but seldom reported phenomenon. In the majority of patients with diaphragmatic rupture, abnormalities can be found at initial chest radiography. If transdiaphragmatic herniation is missing, diaphragmatic rupture is difficult to diagnose by chest radiography alone. Computed tomography is often necessary to reveal the correct diagnosis. Early diagnosis and treatment are extremely important in the management of these patients. Bronchobiliary fistula is a rare condition, arising as a complication of hydatid disease of the liver, hepatic tuberculosis, hepatic malignancy, chronic pancreatitis, hepatic trauma or surgery. Conservative treatment is directed at non-surgical approaches of relieving biliary obstruction to allow for normal flow of bile into the duodenum via endoscopy or percutaneous routes. However in complicated cases which failed conservative non-surgical therapy, surgical intervention is usually required. We report a 35-year-old man who presented with bilioptysis from a bronchobiliary fistula resulting from firearm injury after 15 days. For his current admission, the patient reported a 5-day history of cough productive of yellow-green sputum coupled with fevers and malaise.This was successfully treated surgically with a right medial lobectomy and t-tube drainage. Paget-von Schroetter Syndrome(PSS) refers to spontaneous thrombosis of the subclavian vein and constitutes 0.5-1% of all venous thromboses. It is prevalent among young and healthy adult males who engage in sports. A 42-year-old male presented with pain and swelling of the left arm after a sequence of intense, repetitive weight lifting exercises. Upon questioning, He disclosed that he had been engaged with weight lifting for a long time and had complaints for a while. Bases on these findings, upper-extremity effort thrombosis was suspected. Contrast-enhanced MR Angiography revealed near-complete occlusion of the proximal left subclavian vein and collateral formations in the distal were observed. Color Doppler US showed a heterogeneous thrombotic mass that filled almost the entire proximal segment of the left subclavian vein thrombosis extended into the proximal segment of the left internal jugular vein. Furthermore, extensive venous collateral formations were present the left proximal cervical localization. Both MR angiographic and sonographic findings were consistent with PSS. As the patient had already developed extensive venous collaterals, no surgical intervention was performed. Instead, treatment with lowmolecular weight heparin and anticoagulants, was initiated and was continued along with the follow-up for bleeding parameters. As of 3 years clinical follow-up the patient is doing well, and treatment is continued with oral anticoagulants and acetylsalicylic. PSS should be considered in the differential diagnosis of effort induced upper extremity pain and swelling. Conservative non-operative treatment is acceptable and can be successfully used with favorable long-term outcomes. Although, blunt trauma of the extremities is a common diagnosis in emergency clinics, compartment syndrome associated with vascular injury following blunt trauma may be difficult to diagnose. Urgent diagnosis and treatment of compartment syndrome is of particular importance for limb salvage or even to save the patients' life. 43 years old male patient was referred to emergency clinic due to blunt trauma of the right lower extremity. Right thigh was echimotic and swollen. Pallor, coldness and severe pain were present at the lower part of the trauma level. Distal pulses were not palpable. Acute compartment syndrome of the right thigh was diagnosed that led to an emergent operation. Intraoperatively, popliteal artery rupture was diagnosed and repaired with end-to-end anastomosis. Fasciotomies were performed at the anteromedial and anterolateral portions of the right leg and anteromedial part of the thigh for the treatment of compartment syndrome. In early postoperative period, distal pulses were palpable. Preoperatively present pallor and coldness improved in the first few h. Fasciotomies were closed with skin grafts at the 10th postoperative day. Patient was discharged at the 19th postoperative day with palpable distal pulses and failure of dorsal flexion of the right ankle representing mild neurological injury. Possible vascular injury should be kept in mind in a patient with compartment syndrome following blunt trauma of extremities. Success of surgical repair depends on the early diagnosis and treatment. Late repair may result in neurological complications or even the loss of extremities.Conclusıon: Acute mesenteric ischemia is highly mortal emergency which should always be suspected in elderly patients with cardiac disease suffering from abdominal pain.624 Acute Ischemia of the Lower Member after Injury by Firearm -Case Report Patient with 48 years, male sex, admitted at the Urgency Department after injury of the left lower member by firearm. At the admission presented loss of substance and hemorrhage in the medial and lateral faces of left leg and foot with signs of ischemia. An arteriography of the member was carried out showing infrapopliteal arterial lesions of the three axes. During surgery, fracture and losses of peroneum substance was observed with macroscopic tibial and peroneal common nerves integrities. He was submitted to tibial interposition grafts with subsequent reversed contralateral internal saphena vein bypass.In the 21th postoperative day it was carried out surgical debridement and plastia with partial skin graft. He presented good cicatricial evolution, with hospital discharge 7 days after, oriented to external consultations of Vascular Surgery, Plastic Surgery, Physical/ Rehabilitation Medicine and Pain Consult. Five months after surgery, pain was controlled with the medication instituted, with improvement of the left lower member limitations with physiotherapy, good cicatricial evolution and posterior tibial and dorsalis pedis pulses palpables. Dıscussıon: The incidence of arterial wounds following penetrating injury of the members is 10%. The vascular trauma occurs more frequently in the lower extremities, being the most common clinical presentation acute isquemia. The most frequent causes are vehicle accidents, falls and firearm wounds. In the United States, injuries by firearm represents the first cause of death in young individuals of male sex. The arterial bellow-knee injuries by firearm remain like a challenge, with an associated rate of amputation of 20 to 54%.

Jorge Pereira, Luis Filipe Pinheiro 1 1 Surgery Department, Sã o Teotó nio Hospital, Viseu, PortugalTrauma represents one of the most important causes of death and disability of today. The exponential growth of the major cities, the continuous building of roads and the uprising of terrorism, foresee that trauma will keep is importance as a major cause of disease.Recently, the management of the trauma patient as been modified, with the introduction of the ATLS method. This fact has produced great improvement, proven and reproducible, decreasing mortality and morbidity of trauma. The next stage of treatment implies surgery. The DSTC course, and other similar ones, allow the teaching of surgical damage control to surgeons. In this courses, the surgeon not only learns the theoretical basis of the surgical techniques but also acquires the skills to perform them. More importantly, he learns trauma pathophysiology, so he can perform the difficult task of surgical decision-making. Using the same computer-animated drawing technique as in a previous video (Primary Survey), the authors continue to present a trauma patient, after the stabilization of the Primary Survey, at the Operating Room. The patient has a severe abdominal trauma and needs Damage Control of his lesions, for he is already suffering from the deadly triad: hypocoagulation, acidosis and hypothermia. A 66 year-old male patient was admitted to our hospital for severe abdominal pain. Thoracoabdominopelvic CT scan demonstrated incarcerated bowel loops in the right hemithorax. Strangulated transverse colon segment and omentum through the defect at the dome of right diaphragma was found at diagnostic laparoscopy. Diaphragmatic hernia was primarily repaired with endostitches, and supported with a polipropylene mesh fixed with endotuckers subsequent to reduction of strangulated organs to the abdomen. Resection of necrotic intrabdominal organs and a side-to-side stapled colocolonic anastomosis was performed through a subcostal minilaparotomy. Drainage of right hemithorax was provided with a tube thoracostomy. The patient was discharged on the 5th post-operative day without any major complications. Introduction And objectıves: Single incision laparoscopic procedures are accepted as a step towards pure natural orifice transluminal endoscopic surgery. However, loss of requirement of any perforation of visceral organ and an endoscopic equipment make this technique more popular and easily performable. Here in we report our first appendectomy case who was performed with single incision laparoscopic surgery (SILS) technique. Methods: 32 years old male patient with the diagnosis of acute appendisitis underwent single incision laparoscopic appendectomy. A