BACKGROUND: We presented our experience with definitive treatment of traumatic biliary injuries. METHODS: Six male patients (mean age 13 years; range 2 to 32 years) who were referred to our unit for definitive treatment of traumatic biliary injuries were retrospectively evaluated. Data were analyzed in terms of demographic characteristics, echanisms of injuries, associated injuries, previous treatments, symptoms on admission, treatment at our unit, and the results of treatment. Outcome was assessed using modified Schweiser and Blumgart criteria. RESULTS: The injuries were due to blunt abdominal trauma in all the patients but one who had a gunshot wound. In three patients, biliary injuries were missed at the initial operation. On admission, three patients had external biliary fistulas, two had biliary strictures. One patient was sent following inadvertent ligation of the hepatoduodenal ligament during attempts to control hemorrhage. Roux-en-Y hepaticojejunostomy was performed in three patients. Percutaneous biloma drainage was performed in two patients, esulting in fistula closure in 13 and 40 days, respectively. One patient was treated by endoscopic retrograde cholangiopancreatography and papillotomy, which enabled fistula closure
in three days. One patient was lost to follow-up. One patient died from hepatic failure 11 years after the trauma. At the end of a mean follow-up of 49 months (range 15 to 75 months), three patients were in excellent condition, while one patient experienced occasional attacks of cholangitis. CONCLUSION: In patients with undetected biliary injuries and in those with unsuccessful repair attempts, biliary reconstruction should be performed in experienced hepatopancreatobiliary surgery units.

BACKGROUND: We evaluated the patients who underwent surgical or nonoperative treatment for acute nonvariceal upper gastrointestinal bleeding. METHODS: The study included 31 patients (21 males, 10 females; mean age 60 years; range 19 to 82 years) with nonvariceal upper gastrointestinal bleeding. Surgical treatment was performed in 14 patients (10 males, 4 females; mean age 64 years), while 17 patients (11 males, 6 females; mean age 55.6 years) were treated conservatively. The two groups were compared with respect to age, sex, associated diseases, arterial blood pressure, pulse rate, and hematocrit values on admission, number of blood transfusions, endoscopic findings, cause of bleeding, and mortality. RESULTS: Upon admission, all the patients underwent endoscopic examination except for five surgically-treated patients. Peptic ulcer was detected in 74.1% of the bleedings. The incidences of duodenal ulcer and stomach ulcer did not differ between the two groups. No significant differences were found with respect to the causes of bleedings. The mean number of blood transfusions was 4.36 units preoperatively, and 2.29 units in those treated conservatively (p=0.013). The mean systolic (p=0.002) and diastolic pressures (p=0.029), pulse rates (p=0.003), and hematocrit values (p=0.011) obtained on admission differed significantly. Mortality occurred in only one patient (7.1%) due to cardiac failure in the postoperative period. CONCLUSION: Our study yielded elucidative data on the referral of patients to surgical treatment for nonvariceal upper gastrointestinal
bleeding.

BACKGROUND: We evaluated the efficiency of treatment of comminuted intraarticular fractures of the knee, involving direct reduction and rigid fixation for articular components, and indirect reduction and biological fixation for metaphyseal-diaphyseal components. METHODS: Twelve patients (9 males, 3 females; mean age 46 years; range 22 to 71 years) with distal femoral (n=6) and proximal tibial (n=6) intraarticular fractures were included. There were seven closed and five open fractures. Intraarticular fractures were fixed directly
through a lateral parapatellar incision; while comminuted metaphyseal-diaphyseal fractures were indirectly reduced and internally fixed with biological fixation methods. The patients were evaluated clinically and radiographically. Intraarticular bone and soft tissue changes were evaluated by conventional and threedimensional computed tomography. The results were assessed according to the HSS (Hospital for Special Surgery) criteria. The mean follow-up was 43 months (range 15 to 78 months). RESULTS: All fractures healed without any refractures, implant failures, or infections. The mean time to full weight-bearing was 25.5 weeks for tibial, and 24 weeks for femoral fractures. Leg length discrepancy occurred in all the patients with femoral fractures (1-2 cm), and in two patients with tibial fractures (1 cm). One patient with a femoral fracture had a valgus deformity of 10 degrees. According to the HSS criteria, the results were good in five cases, and moderate in one case for tibial fractures; good in one case, moderate in four cases, and poor in one case for femoral fractures. Tomographic evaluations showed articular congruity in all the cases without any signs of loose bodies. CONCLUSION: Combination of indirect and direct reduction techniques is an effective method for the treatment of comminuted intraarticular knee fractures.

BACKGROUND: We evaluated the results of surgical or non-operative treatment of knee dislocations and the effect of associated soft tissue injuries on the planning of treatment.
METHODS: The study included 12 patients (10 males, 2 females; mean age 34 years; range 17 to 75 years). Knee dislocations were caused by low-energy injuries in five patients, and by highenergy injuries in seven patients. All the knees were dislocated posteriorly. Three dislocations were open. Three patients had popliteal artery injuries and three patients had peroneal nerve injuries. Dislocations affecting the anterior and/or posterior cruciate ligaments were treated surgically (n=6), whereas the medial collateral ligament and lateral ligament injuries were treated non-operatively (n=6). The Lysholm scores and the range of motion of the knees were compared between surgically and conservatively treated groups. The mean followup period was 46 months (range 26 to 82 months). RESULTS: The mean range of motion of the knees (116° versus 72°; p<0.01) and the mean Lysholm scores (84.6 versus 74; p<0.01) differed significantly between patients undergoing surgical and non-operative treatment. Chronic laxity occurred in two knees (one with surgical, one with conservative treatment). Arthrofibrosis developed in four patients (one with surgical, three with conservative treatment). There were no deep infections. Superficial infections occurred in two open dislocations. CONCLUSION: Knee dislocations should be regarded as significant limb-threatening injuries. Evaluation and immediate treatment of vascular insufficiency is of primary importance. Then, treatment depending on the presence and severity of ligamentous injuries is essential to provide a stable and functional extremity.

BACKGROUND: We evaluated the results of surgical treatment of type III acromioclavicular joint dislocations by a modified Bosworth technique. METHODS: Thirty-four patients (9 females, 25 males; mean age 35 years; range 20 to 53 years) were treated with a modified Bosworth technique for type III acromioclavicular joint dislocations. Dislocations were caused by falls (n=18), traffic accidents (n=8), and during contact sports (n=8). Involvement was on the right side in 23 patients, and on the left side in 11 patients. The mean time to operation was two days (range 1 to 4 days). Functional evaluations were made with the use of the Constant scores. The mean follow-up was 35 months (range 12 to 57 months). RESULTS: The mean postoperative Constant score was 93 (range 46 to 96). No complications were seen during operation. The results were excellent in 24 patients (70.6%), good in seven patients (20.6%), and poor in three patients (8.8%). None of the patients had to change their jobs or give up any previous sports activities. Radiographically, the distal clavicle appeared normal in 32 patients, atrophied in one patient, and enlarged in another. Functional results were good in 12 patients (35.3%) in whom calcifications were detected in the coracoclavicular ligament. Dislocations recurred in three patients (8.8%). Two patients developed superficial infections. CONCLUSION: Surgical treatment of acromioclavicular joint dislocations by the modified Bosworth technique is a convenient option with regard to short- and long-term results.

BACKGROUND: Falls are the major cause of hip fractures in elderly patients. The aim of this prospective study was to investigate the underlying causes of fall-induced hip fractures in the elderly. METHODS: The study included 32 patients (18 males, 14 females; mean age 78 years; range 57 to 95 years) who had proximal femoral fractures following an unexpected and sudden fall from about a meter height at a moment of lying, sitting, or standing position. Underlying causes of falls were sought, including previous falls, stroke, polyneuropathy, motion disorders, dementia, vision problems, fainting, vestibular pathologies, and cardiac diseases. RESULTS: Eight patients (25%) had a history of previous falls and 12 patients (37.5%) had a history of stroke. Polyneuropathy, Parkinson's Disease, and dementia were diagnosed in eight (25%), three (9.4%), and five (15.6%) patients, respectively. Twenty-one patients (65.6%) had neurologic diseases, 11 patients (34.4%) had cataract or other vision problems, eight patients (25%) had osteoarthritis and rheumatoid arthritis, 10 patients (31.3%) had vestibular pathologies, and 17 patients (53.1%) had cardiac diseases such as heart failure, orthostatic hypotension, ischemic heart disease, and arrhythmia. CONCLUSION: In order to prevent recurrent falls, risk factors associated with falls should be determined and preventive treatment and measures should be put into practice in elderly patients who have fall-induced injuries.

Foreign bodies were detected in the rectum in four male patients with ages ranging from 36 to 64 years. The materials were an iron rod, a specially shaped wooden device, and in two cases, deodorant caps. They were extracted with the patients in lithotomy position after anal dilatation, under general anesthesia in three cases, and spinal anesthesia in one case. No procedure-related complications occurred and the patients were discharged 24 hours after the operation.

Several etiologic factors have been proposed in the development of meningiomas, including trauma, radiation, oncogenic viruses, chromosomal abnormalities, and hormonal factors. We presented a 71-year-old female patient who had undergone an operation for a head trauma 27 years ago. Brain computed tomography scans showed a contrast-enhancing intracranial mass lesion, 5x4x4 cm in size, leading to diffuse edema in the left frontal region. At surgery, a tumoral mass was detected below the former craniotomy flap, with dural invasion, and a total excision was performed. Two silver clips were also noted in the previous surgical site. Histopathologic diagnosis was made as a transitional meningioma. No recurrences were detected within a year follow-up period.

Trichobezoars are concretions of hair casts in the stomach associated with trichotillomania and trichophagia. The condition is termed Rapunzel syndrome when formation of a huge trichobezoar extends to the small bowel, resulting in gastrointestinal obstruction. We present a 19-year-old girl who had complaints of colicky abdominal pain, nausea and vomiting seven years after surgical treatment for a gastric trichobezoar. Gastric endoscopy was performed with an initial diagnosis of recurrent trichobezoar, which revealed a huge one. The patient underwent laparotomy, during which a huge trichobezoar with a long tail was totally removed by an anterior gastrotomy. Following removal of the lesion, the antrum was observed with multiple ulcers secondary to extensive pressure. Postoperative period was uneventful. A subsequent psychiatric consultation revealed depressive personality disorder.

A twenty-four-year-old male patient developed a high level gastrointestinal obstruction during hospitalization in intensive care unit following a head trauma. He suffered from vomiting and weight loss and was unable to tolerate nasoenteral feeding. Barium radiographs revealed obstruction in the third portion of the duodenum. Upon failure of conservative treatment, laparotomy was performed, which showed compression and obstruction of the third portion of the duodenum by the superior mesenteric artery. A side-to-side duodenojejunostomy performed yielded complete relief of compression symptoms. The patient was symptomless in the sixth postoperative year. Although primary treatment of superior mesenteric artery syndrome is conservative, surgical treatment should be considered in unresponsive patients.

Although air bags have been shown to reduce mortality and morbidity in motor vehicle crashes, they are associated with specific injuries. Burns due to air bag deployment account for more than 5% of all air bag injuries and typically involve upper extremities or head and neck. Aside from friction burns, thermal and chemical burns are also seen resulting from the use of certain chemicals for the deployment mechanism. We reported a female patient who presented to the emergency department with a second-degree burn in her left breast, six days after a motor vehicle crash. She was treated with irrigation with saline solution and 2% sodium fusidate oint. The burn area healed within a week, without any further
treatment. Only a slight scar tissue remained after a six-month follow-up.