The accessory navicular is usually considered an asymptomatic variation. In most anatomic and roentgenographic examination, this is an incidental finding. But when traumatized, it can become the cause of clinical symptoms. The tension of the posterior tibial tendon, forceful plantar flexion and/or pronation and the sporting activities made by the feet cause chronic or acute medial foot pain centered over the medial side of the navicular bone. There are three types of accessory navicular variations. Type I is a sesamoid bone in the substance of the posterior tibial tendon. This ossicle accounts for approximately 30% of all the accessory naviculars; Type II is united to the navicular bone by a cartilaginous or fibrocartilaginous synchondrosis with a 1-3 mm. On radiographs, this ossicle is triangular or heart shaped and approximately 8 mm x 12mm; Type III, "the corniate navicular", is fused to the navicular bone by a bony bridge with a prominent posteromedial margin. Tip II and Tip III account for 70% of all accessory naviculars. Identification of this variation is of importance because the injury may occur as a result of chronic repetitious trauma and the ossicle may easily be mistaken for a fracture. In our study; the incidence, the types and female/male percentages in population of the accessory navicular were investigated. Clinical importance of this variation was discussed by the knowledge of literature.

The aim of the study is to discuss the localizations, clinical pictures, surgical interventions and the results of our patients who suffered from vascular trauma. Between September 1987 and April 1996, 87 patients were admitted to our clinic. The records of the patients were retrospectively reviewed. 91 arterial and 48 venous traumas were encountered. Primary repair (49%), saphenous interposition (30%), ligation (16%), greft interposition (3%) and saphenous angioplasty (2%) were applied to 91 arterial injuries. The mortality rate was 4%. Amputation rate was 4%. Early diagnosis and treatment are the most important factors. Immediate diagnosis and early accurate treatment are mandatory.

Anterior fixation of instability of the cervical spine with plate and bone grafts has been performed by combined plate and bone fusion since 1990. Synthes titanium plates have been used in all patients. In this paper patients were evaluated retrospectively and compared to the literature.

In this study, 48 penetrating colon injuries treated between 1986-1994 in Çukurova University, School of Medicine, General Surgery Department were evaluated retrospectively. 30 (62.5%) cases had gunshot wounds, 18 (37.5%) had stab wounds. Colon Injury Scores (CIS) were as follows: 32 (66.6%) grade II, 5 (10.4%) grade III, 8 (16.7%) grade IV, 3 (6.3%) grade V. Nine (18.7%) cases were managed by primary repair, whereas 39 (81.3%) cases were treated by colostomy procedures. The small bowel was the most frequently injured organ in colonic injury patients (50%). The complication rate was 20.8 percent. The mortality rate 14.6percent. The parameters increasing the risk of morbidity were as follows: CIS equal or greater than grade IV, Penetrating Abdominal Trauma Index (PATI) score over 20, Flint Colon Injury Score (FCIS) grade III, concomitantly organ injuries more than 2, blood transfusion over 3 units. Additionally to these parameters (excluded CIS), we observed that PATI score over 30 was increasing the mortality rate. Penetrating colon injuries without risk factors listed above, PATI score under 25 and FCIS grade I-II, can be managed by primary repair. In cases PATI score was over 25 and FCIS grade III, we believe that choosing colostomy procedures to be appropriate.

Cerebro-spinal fluid (CSF) fistula is leakage of fluid from sub-arachnoidal to extra-arachnoidal spaces when there is a defect of arachnoidea, dura, bone or epithelial tissues. This leakage can be through all the cerebrospinal axis but generally seen as rhinorrhea or otorrhea. The etiology of CSF fistulas in 80 of cases is trauma. It can be seen in 2-5% of closed head injuries. It may be detected either in the posttraumatic first week or within months and years after trauma as well. 85% of rhinorrheas and nearly all of otorrheas interrupt spontaneously at the end of one week. Meningitis is the most important complication of CSF fistulas. 52 cases of traumatic CSF fistula which were treated in our department between January 1990-June 1995 were reviewed retrospectively. Age distribution of the patients were 2-70 years and male/female ratio was 3/1. The most frequent etiological factors were traffic accidents and falling traumas. 79% of patients treated conservatively and even though were under control of antibiotic therapy meningitis in 11 cases and cerebral abscess in 1 case were revealed. Mortality rate of meningitis was 33.3% in our series. In this study, we saw that there was no any effect of prophylactic antibiotic treatment to meningitis rates and Klebsiella was the most frequent organism in microbiological investigations of patients with meningitis.

In this study; The records of 57 patients with traumatic colon injuries treated at the Ankara Numune Hospital-Emergency Surgery Department during a 5 year period from 1990 to 1995, were retrospectively reviewed. Twenty-three patients of 57 (40%) had gunshot wounds, 22 (39%) had stab-wounds and 12 (21%) had blunt colonic injuries. Right colon injuries were found in 17 patients (30%), transverse colon injuries in 18 patients (31%), and left colon injuries in 22 patients (39%). Primary repair, including suture repair and resection with anastomosis, was performed in 44 patients (77%) and colostomy in 13 (23%). Patients were evaluated according to the risk factors such as location of colonic injury, associated visceral injuries, penetrating abdominal trauma index (PATI), colonic injury severity scale (CISS), the time from injury operation, hemodynamical status and estimated blood loss. Mortality rate was 14% and hemodynamic instability, long acting shock, delaying time between injury and operation, and multiple visceral injuries were found co-efficient factors to prognosis.

It is still an issue of debate that just how much the rate of negative laparotomy should be in cases of blunt and penetrating abdominal injuries. The rate of explorative laparotomy with negative findings is especially high in patients with minimal symptoms and signs where the existence of an actual organic injury is doubt. Recently, routine preoperative invasive and non-invasive tests and application of various techniques of intraabdominal visualization have caused a significant drop in the rate of negative laparotomy. But this may create a false feeling of security and may cause a rise in the morbidity and mortality through neglection. Being conservative may be hazardous in some as being invasive yet in another. Therefore at the Surgery Clinic of Taksim Hospital out of a pool of 358 patients with blunt and penetrating abdominal injuries we followed the occurrence of early morbidity and mortality in a total of 53 patients with negative laparotomy. 31 patients had blunt and 22 penetrating trauma. 22 patients (%38) had additional systematic and organic injuries. Patients were divided in two groups: one with pure abdominal and another with abdominal and extraabdominal injuries. Both groups were compared in relation to the occurence of major complications such as atelectasis, pneumonia and intestinal obstruction and minor ones such as phlebitis and wound infection. Results were analyzed with the Fisher's exact t test. The use of local exploration and peritoneal lavage in penetrating and peritoneal lavage and computed tomography in blunt injuries have caused a dramatic decrease in the rate of negative laparotomy. But in patients with especially blunt trauma who poses some signs of intraabdominal injury the easiest and the most quick method of evaluation is explorative laparotomy. The morbidity of this procedure is measurable and minimal.

Results of twenty five open fractures in twenty three patients between the years 1989-1996 were reviewed. The patients were between three and fifteen years old (mean age 10). Thirteen of the cases were male (57%), ten of them were female (43%). The average follow-up period was one year. Of 23 patients, 14 (60.9%) had been injured in motor vehicle accidents, and 43.3% per cent had associated injuries. Four (16%) fractures were graded as Grade I, five (20%) Grade II and sixteen (64%) Grade III open fractures according to the classification of Gustilo. Seventeen patients had lower extremity fractures and eight had upper extremity fractures. Twenty two patients were treated with immediate debridement, irrigation, open reduction and internal fixation and three (13%) Grade IIIC open fractures were treated with amputation. All patients received intravenous antibiotic treatment at the emergency room. Fourteen (60.9%) patients needed a second operation for soft tissue reconstruction. On follow-up, one (4.3%) patient died, one (4.3%) patient had acute renal failure, three (13%) had soft tissue infections and four (17%) had some restriction of range of joint motion. Open reduction and internal fixation with careful debridement and irrigation has positive effects on the early results in children with open fractures.

Patients presenting with penetrating eye trauma at Dept. of Ophtalmology Istanbul Faculty of Medicine between 1988 and 1991 were evaluated, and examination findings, performed surgical interventions and follow-up findings were investigated. Initial findings affecting later visual outcome were assessed. 246 cases were under 16 years; 175 were male and 71 were female. The majority of cases (42.27%) were between 6 and 10 years. 203 cases had an initial vision of 0.1 or less. The most common site of injury was the cornea. Initial examination findings and factors affecting vision noted during follow-up according to injury characteristic were: Hyphema (p<0.001), lens injury (p<0.02), lacerated corneal injury (p<0.02) (only corneal injuries), corneal laceration greater than 3mm (p<0.04) (only corneal injuries), street injuries (p<0.04).

This study was conducted to analyse the association of risk factors and clinical course of upper gastrointestinal bleeding (UGB) and evaluate the approach to UGB. 595 cases (%64.9 males) of UGB admitted to medical emergency department of Istanbul University School of Medicine between 1991-1996 were assessed. Patient age over 50, hematemesis at admission, a history of UGB or peptic ulcer disease and a positive Tilt testing were considered to be important factors in the clinical course of UGB. The subgroup of patients with any risk factors required more units of blood transfusion than patients without risk factors. The subgroup of patients with only a positive Tilt test or a history of UGB required surgical intervention more frequently.

Minitracheotomy was performed in 9 of 239 patients who were hospitalized for thoracic trauma. All were smoker males. Their ages were between 36-72 with an average age of 54. All had multiple rib fractures and pulmonary contusion. The procedure was performed under local anesthesia. Duration time was 3-12 days (average 4.2). No complications besides hoarseness in one patient occurred. The deadly consequences of thoracic trauma such as sputum retention, atelectasis, pneumonia and respiration failure due to pain can easily be prevented with minitracheotomy which can be easily performed with low morbidity rates.

In order to perform life saving procedures for every case of acute disease and trauma, perfectly organized emergency clinics are required. In our country the importance of the first aid and ambulance transport services isn't considered sufficiently. Our emergency clinic, which was established in 1993, serves in all branches, both medical and surgical, so that all mind of acute intervention can be carried out under the same roof. With these features, it is one of the first examples in this area in Turkey. Our emergency clinic consists of reanimation ward, policlinics, laboratories, computerized tomography, theatre rooms and intensive care unit. In 1994, 107768 patients were admitted to our emergency clinic (mean 295.2 patients/day) and operations were performed for 1891 of them (mean 5.2 operations /day). 709 patients were kept under supervision in the intensive care unit for while (mean 1.9 patients /day). We think that contemporary emergency clinics-the staff and equipment of which are being supplied by educational hospitals-are appropriate for our country's conditions.

In this prospective study, 97 critically injured patients were evaluated at Dicle University Department of Emergency Surgery between January April 1996. The predictive power of injury severity score (ISS) and Revised trauma score (RTS) for the outcome of individual patients was studied. 72 patients were admitted to the hospital, 25 patients to the ICU. 9 patients died in the ICU, for a total mortality rate of 9%. The mean ISS was 9.99±8.58 in hospital survivors and it was 26.87±21.84 and 48.78± 22.98 in ICU survivors and non survivors respectively. The mean RTS was 7.75± 1.17 in hospital survivors, 6.70±1.14 in ICU survivors and 2.86±2.53 in ICU nonsurvivors. Both RTS and ISS separated survivors from nonsurvivors statistically (RTS t=5.41 p<0.001, ISS t=4.56 p<0.001.

In our study, among 40 patients who were admitted to the Emergency Surgery Unit of Istanbul Medical Faculty from June 1994 to May 1995, as an invasiv diagnostic procedure only peritoneal lavage (DPL) was performed for 15 patients and only laparoscopy (DL) was performed for 15 of them, but first DPL and subsequent DL were performed for the rest 10 patients. Among 25 DPL patients positive lavage result rates indicating laparotomy was found in 12 patients (48 %) and lavage results were considered as negative for 13 patients (52%). Eleven laparotomies were performed for lavage positive patients (44%). In one patient (4%) non-bleeding minor hepatic trauma was diagnosed by laparoscopy and laparotomy was cancelled. No laparotomy was necessary during the follow-up for 9 lavage negative patients (36%). Laparotomy was necessary for 4 of them (16%) for different purposes. In 10 DL patients (40%) laparotomy was indicated and laparotomy was performed for all of them. There were no findings requiring laparotomy among the rest 15. One of them (4%) was diagnosed with non-bleeding minor hepatic trauma. Retroperitoneal duodenal rupture was diagnosed by laparotomy in another patient (4%) later on. No complications were recorded among DPL patients while there were two pneumothorax cases among DL patients with diaphragmatic injury.

Long term oral use of anticoagulant at prophylactic doses increase the tendency towards bleeding and can cause spontaneous bleedings. Although spontaneous bleedings often occur as hematemesis, melena, epistaxis and menorrhagia, they can rarely manifest as intraabdominal bleedings. This kind of bleeding can be misleading since it can be diagnosed as an acute abdominal syndrome. A rare emergency case of acute abdominal syndrome due to intraabdominal free blood is presented.