FRACTURE BLISTERS

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FRACTURE BLISTERS

• By Cheryl Kimber NP
• ONC MN(NP) MRCNA

Presented at the combined SAON and SAWMA
Education meeting May 2006
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Definition

• Fracture Blisters are tense vesicles or bullae
  that arise on markedly swollen skin directly
  overlying a fracture or severe sprain (Varela,
  1993)

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The skin

• Composed three layers Epidermis - outer layer
• Dermis second layer
• subcutaneous tissue inner most layer

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Presentation

• May occur singly, in multiples be quite large
• Blister roof generally tense, filled with clear
  or serous fluid
• But roof may also be soft fluid reddish colour
  these blisters are usually older filled with
  haemorrhagic fluid
• Associated with fractures or severe twisting type
  injuries

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Presentation

• Undue joint or limb manipulation
• Dependant positioning, heat application, or
  existing co-morbidity such as PVD or lymphatic
  obstruction can produce fracture blister in a
  relatively minor injury

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Fracture Blister Development

• Giordano (1995) biomechanical studies involving
  strain tests at several levels on cadaver ankle
  skin specimens found characteristic injuries at
  the dermal-epidermal junction producing complete
  or partial separation of the dermis from the
  epidermis.
• This study supported the hypothesis that a factor
  in fracture blister formation is injury to the
  dermal-epidermal junction that results from
  exposure to high strains in the skin during
  fractures

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Histology

• Histologically fracture blister is characterized
  by separation of the dermis from the epidermis
• Histologically very similar to 2nd degree burns

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Histologically - Fracture Blisters

• Blood- filled blisters where there is complete
  separation of dermis from the epidermis
• Clear fluid-filled blisters partial epidermal
  separation of epidermis from dermis with few
  scattered retained epithelial cells on the dermis
  (Giordano, 1995)

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Histology and Microbiology

• Blister fluid aspired from intact blister roofs
  sterile
• However, after roof ruptured the skin culture
  revealed colonization with common flora
  staphylococcus epidermis aureus
• In known HIV infected patient blister fluid
  positive for HIV virus (Varela,1993)

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Pathophysiology

• Following acute extremity injury typically in
  closed fracture or severe sprain with extensive
  tissue edema swelling developing
• The vasculature, microcirculation lymphatic
  drainage all disrupted

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Pathophysiology - two distinct forces

• 1st force - Swelling produces ? interstitial
  pressure thus ?filtration pressure
• ? pressure disturbs normal cellular cohesion
• Allows fluid to move to newly weakened space
  blister forms

• Second force -? in colloid osmotic pressure in
  epidermal gap pulls fluid into the gap created by
  the loss of cellular cohesion

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Pathophysiology continue

• Simply stated epidermis separates from dermis due
  to oedema fluid
• Epidermis detached from dermal blood supply
  ultimate result is necrosis of epidermal layers
• Integrity underlying dermal subcutaneous tissue
  subsequently at risk further necrosis

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Location, Location , Location ..

• Anatomical areas with tight, closely adhered skin
  constraints with little or no muscle or
  enveloping fascia
• Predisposed to area sparse or no sweat glands
  or hair follicles which anchor epidermal-dermal
  junction

• Areas of little skin mobility
• Ankle, elbow, foot, distal tibia

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Research Review

• Scarcity of information or research

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Research Review

• One comprehensive study review -Varela (1993)
• 3.5 retrospective review four hospitals in large
  metropolitan city

• 53 fracture blisters from 51 people with acute
  injuries
• Followed average 9 months (5days to 41 months)

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Research review- Incidence

• Occurred in 2.9 all acute fractures requiring
  hospitalization
• Injuries located at or near ankle, tibia elbow
  more likely than other anatomical sites develop
  blister
• When only these fracture sites counted incidence
  rises to 5.2

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Surgical Timing

• Early stabilization resulted decrease incidence
  fracture blisters
• Varela (1993) found that patients who had an
  ORIF within 24 hours of injury had significantly
  lower incidence blister developing (2) compared
  those patients delayed for greater than 24 hours
  (8)

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Surgical Timing

• Under ideal circumstance, early surgical
  stabilization can prevent blister formation
  (within 6-24hours)
• However, multiple injured patients , certain
  fracture patterns ie. Calcaneous, preclude early
  operative fixation

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Significance of Fracture Blisters

• Patient Outcomes
• Quality care
• Costs
• Length of stay

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Complications

• Wound infection
• Delayed fracture treatment
• Fracture nonunion (due to less than optimal
  treatment choice)

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Wound Care

• Fracture blister may herald injury of deeper soft
  tissue damage and subsequent full thickness skin
  loss
• Skin grafting /flaps may be needed to repair skin
  loss (Reed Jones 1984)
• Injured tissue may extend beyond edged actual
  blister implication for placement of surgical
  incision

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The Wound

• If open surgical invention needed, surgical
  incision is place away from blistered area but it
  may not miss entirely underlying soft tissue
  damage wound infection likely
• Giordiano, (1994) Varela( 1993) both described
  major wound infections secondary to an incision
  through the blister

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Infection Risk Why?

• Ruptured blister very rich environment for
  infection
• Moisture
• Food (serum)
• Absence of initial phagocytic activity and few
  competing organisms

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Management of the Wound

• OPTION 1
• Leave blister intact
• Immobilize fractured limb
• Apply dry dressing to intact blister

• OPTION 2
• De-roof blister in a controlled environment
• Apply silver dressing followed by an occlusive
  dressing
• Systemic antibiotics only if wound bed culture
  reveals clinically significant colonization with
  an infectious organism, such as S.aureus

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Research into options

• Giordano Koval (1994) in a prospective study of
  53 feet, evaluated methods treatment of blisters
  including aspiration, de-roofing with subsequent
  SSD cream, coverage with non-adherent dressing,
  leaving blister intact covered or exposed to the
  air
• No major difference, except with two patients
  where surgical incision passed through
  blood-filled blister resulting in wound
  complications

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BEST TREATMENT IS PREVENTION
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Prevention

• Identify persons at risk - type/area,
  Co-morbidities- PVD, Diabetes, smoker
• Immobilization of limb
• ORIF within 6-24hours

• Elevation to reduce edema vascular congestion
• ? Compression and ice
• Well padded non-constrictive cast

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Recommendation- RESEARCH

• What wound care practices best promote the least
  incidence of infection and the fastest rate of
  re-epithelialization?
• Do the prevention strategies suggested by
  literature work?
• What is the impact of early discharge?
• What is the effects of complications related to
  fracture blisters?

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Summary

• Fracture blisters relatively common in high
  energy injuries - ankle, foot, tibia
• Potential to complicate treatment outcomes of
  orthopaedic patient
• Patients at risk identified quickly,
  preventative treatment initiated, best practice
  in wound care promptly commenced
• Thus decreasing morbidity and potential
  complications