Transcript Background - North Dakota State University

Fracture Blisters Following a Posterior Elbow Dislocation: A Case Report
NDSU
Athletic Training
Jodi Burrer, Dr. Pamela Hansen, Dr. Kevin Miller, Dr. Bryan Christensen
North Dakota State University
Department of Health, Nutrition and Exercise Sciences, Fargo ND
Abstract
Objective: To present a case of fracture blister formation
following posterior elbow dislocation in the absence of
fractures.
Background: A 21 year old, male college football athlete with
no prior history of elbow injury extended his right arm while
being tackled. Simultaneously, an opposing player fell on his
left shoulder causing more force on the outstretched arm. Onfield evaluation showed gross deformity of the elbow joint. The
physician on-site diagnosed the injury as a posterior elbow
dislocation and immediately reduced the joint. Thirty-six hours
after reduction, four clear-fluid blisters each ~2.25 cm in
diameter were noted over the medial aspect of the distal
humerus. At a follow-up visit 48 hours post-injury, the physician
diagnosed the blisters as fracture blisters.
Differential Diagnosis: Compartment syndrome, friction blisters
Treatment: Following reduction, the athlete’s arm was
immobilized with a SAM® splint, Ace ® wrap, and sling. Ice was
applied for 20 minutes after immobilization. No treatments
were initiated for the fracture blisters at the time of injury as
they were not discovered until 36 hours post-injury. Postreduction radiographs were taken 48 hours post-injury and
were negative for fractures. The physician recommended not
aspirating the blisters in order to decrease the risk of infection.
The blisters dissipated with conservative treatment within 14
days. The athlete underwent rehabilitation focusing on
decreasing edema, pain, and restoring full ROM. The
physician cleared the athlete for full athletic activity six weeks
post-injury.
Uniqueness: Fracture blister formation following athletic injuries
and in the absence of a fracture are rare.
Conclusions: Athletic Trainers must be aware that fracture
blisters may occur concurrently with high-energy trauma in an
athletic environment, but do not pose much of a health risk to
athletes or a significant complication for rehabilitation if
handled conservatively.
Differential Diagnosis
 Compartment syndrome
 Friction blister
Background
Improving Clinical Outcomes
 21 year old, male collegiate football athlete (ht=187.9 cm mass = 92.9 kg)
 No prior history of elbow injury or known comorbid condition that could have contributed to the formation of fracture
blisters
 Extended right arm in approximately 90° shoulder abduction and 45° horizontal flexion while being tackled.
 Simultaneously, an opposing player fell on the back of athlete’s left shoulder
 Physician on-site diagnosed injury as a posterior elbow dislocation and immediately reduced the joint
 Significant edema, eccymosis, and muscle guarding was noted
 36 hours after reduction the athlete noted four clear-fluid blisters, each apx 2.25 cm in diameter over the medial aspect
of the distal humerus.
 At a follow-up visit 48 hours later, the blisters were diagnosed as fracture blisters.
 Immediately following reduction of the posterior elbow
dislocation, Ace® wrap was applied to the elbow.
Treatment
 Post-injury elevation helps reduces edema and vascular
congestion
 Treatment of elbow dislocation
 Joint immediately reduced and immobilized
 Ice applied to all aspects of elbow for 20 min
 After follow-up visit 48 hours post-reduction athlete was placed in a Bledsoe® brace set at 90 ° flexion, compression
sleeve, and iced 3 time a day for 20 min
 Began rehabilitation focusing on decreasing edema and pain and restoring full ROM
 Post-injury compression may hinder venous blood
return2
 Treatment for fracture blisters
 Covered with antibacterial cream and sterile gauze which was changed 3 times daily
 Not aspirated in order to reduce the risk of infection
 Fracture blisters dissipated within14 days post-diagnosis, but scarring is still present
 No complications or infection occurred during or after rehabilitation
 After blister ruptures, the roof should remain overlying
the site1
Discussion
 Fracture blisters are defined as skin bullae representing areas of epidermal necrosis with separation of the stratified
sqaumous cell layer by edema fluid2
 Typically found in areas with tight, closely adhered skin with little or no muscle or enveloping fascia1
 Most commonly reported in elbow, ankle, foot, and distal tibia
 Unwarranted joint or limb manipulation, dependent positioning, heat application, or an existing comorbid condition can
produce fracture blisters in an otherwise relatively minor injury1,2
 What causes fracture blisters to develop?
 Injury → Tissue damage → Increase in edema → Increase in interstitial pressure and filtration pressure
 Injury also causes strains on the skin causing damage at the junction of the dermis and epidermis
 A disruption of cellular cohesion and an increase in colloid osmotic pressure pulls fluid into the epidermal gap1,3
Uniqueness
Clinical Significance
 Fracture blisters occurring following athletic injuries and
in the absence of a fracture are rare
 Athletic Trainers must be aware that fracture blisters may occur concurrently with high-energy trauma in an athletic
environment and in the absence of fractures.
 Reported that fracture blisters occur in 2.9% (43 or
1,468) of all acute fractures requiring hospitalization1
 Athletic Trainers may need to use caution when adding immediate compression to injured areas with tight, closely
adhered skin and with little or no muscle mass or fascia. This may hinder venous blood return and actually contribute to
the formation of fracture blisters.
 Most occur following acute fractures caused by high
traumatic incidences
 However, the importance of controlling edema at the injury site may outweigh the importance of reducing the risk of
fracture blister formation.
 The compression may have hindered venous blood
return which may have increased interstitial pressure
and, in turn, may have helped lead to the
development of the fracture blisters.
Clinical Implications
 Post-injury immobilization helps limit any additional
movement and prevents any ongoing injury.
 Fracture blisters should not be aspirated in order to
reduce the risk of infection4
 Apply a soft, dry, sterile dressing with triple antibiotics or
silver sulfadene1
 Usually resolved within 6-21 days2,5
 Educate athlete on proper treatment of fracture blisters
and about possible signs and symptoms of infection
Conclusions
 Fracture blisters may occur following high-energy
trauma in an athletic environment and without the
presence of a fracture
 Do not pose much of a health risk or any significant
complication for rehab if handled conservatively
References
1. Varela CD, Vaughan TK, Carr JB, Slemmons BK. Fracture blisters:
clinical and pathological aspects. J Orthop Trauma. 1993;7(5):417427.
2. Shelton M. Complications of fractures and dislocations of the
ankle. In: Epps CH. Complications in orthopaedic surgery.
Philadelphia, PA: Lippincott;1994:597-599.
3. Giordan CP, Scott D, Koval KJ, Kummer F, Atik T, Desai P. Fracture
blister formation: a laboratory study. J Trauma. 1995;38(6):907-909.
4. Marpls RK, Kligman AM. Bacterial infection of superficial wounds: a
human model of staphylococcus aureus. In: Mailback HI, Rovee
DT, Epidermal Wound Healing. Chicago, IL: Year Book
Medical;1972:241-254.
5. Ballo F, Maroon M, Millon SJ. Fracture blisters. J Am Acad Dermatol.
1994;30:1033-1034.