Second hit phenomenon: existing evidence of clinical implications.

The last two decades extensive research evidence has been accumulated regarding the pathophysiology of trauma and the sequelae of interventions that follow. Aim of this analysis has been to collect and categorise the existing data on the so-called "second hit" phenomenon that includes the biochemical and physiologic alterations occurring in patients having surgery after major trauma. Articles were extracted from the PubMed database and the retrieved reports were included in the study only if pre-specified eligibility criteria were fulfilled. Moreover, a constructed questionnaire was utilised for quality assessment of the outcomes. Twenty-six articles were eligible for the final analysis, referring to a total of 8262 patients that underwent surgery after major trauma. Sixteen retrospective clinical studies including 7322 patients and 10 prospective ones, including 940 patients were evaluated. Several variables able to reproduce a post-operative second hit were identified; mostly related to pulmonary dysfunction, coagulopathy, fat or pulmonary embolism, and the inflammatory immune system. Indicative conclusions were extracted, as well as the need for further prospective randomised trials. Suggestions on the content and the rationale of future studies are provided.

Ipsilateral floating second metatarsal and ankle fracture dislocation: complications and outcome of a rare type of injury.

Lisfranc fracture dislocations are complex lesions which, when combined with additional trauma of the ankle and foot region, create a difficult to treat injury pattern. This article presents a case of a patient with Lisfranc fracture dislocation combined with metatarsophalangeal dislocation of the second toe and ankle fracture-dislocation. The sequence of medical acts and complications included: reduction of dislocations, cast immobilization, compartment syndrome and fasciotomies, external fixator application, fasciotomies closure, and final internal fixations. The following examinations were performed: radiography, computed tomography (CT), and intracompartmental pressure measurement. Despite the compartment syndrome incidence, which was effectively managed, the patient regained an ankle- and foot-pain-free full range of motion. Although this is an isolated case of a rare injury, several recommendations can be made. Early CT scan should be used for injuries of the Lisfranc joints to fully assess the distorted anatomy of the midfoot and forefoot, which is essential for preoperative planning, medicolegal issues, and prognosis of the injury. The use of a spanning external fixator, especially in complex injuries as the one described, should be preferred to cast immobilization and should be performed as a priority surgical procedure early on in the patient's admission. The development of compartment syndrome should be monitored and intracompartmental pressures measured especially in unconscious patients. There should be a high degree of suspicion for early complications in complex fracture patterns, even if the initial clinical assessment is reassuring.