Transcription of UNDERSTANDINGFRACTUREBLISTERS: …
1 IN TR ODUCTIONTh e ove rly ingpr em is e to understandingtheet iol ogy,oc cur ren ce , and tre atmentof fracturebli stersis tha t ba si ca llytheyare a cl inic al eir trueetio lo gy is cu rrence an d lo cation of thi s tr ou bles omeconditio nrelativetova riousinj uries andinjurypattern s isunpredictab le. A mi noran kl e sprain or minor blu nt traumamaydevelop a fra ctureblisterwhere as a moremajor fractureor contusion un iver sal con sensusexis ts in ter msof treatment of fracturebli ster s orthe ir impactonsubsequent surgery. Prognosis is poorly underst oodin termsof outcomes based on a rang e of treat me nt opt io ns inva riouspossiblepatientpopulat ions.
2 Thisuncert ai nt y ispri ma rilydue to a relativesca rc ity of scientificatten tionorin vestiga occurrenceis moretroublesomeinter ms of imp lica ti onsimpact ingma na gement decisionsforth e und erl yi ng osseousor softtiss ue injury notth e blister it-sel f. Th is pape r is presentedto discuss an d revi ew curren tknowle dg e abo ut th is relativelycom moncon dit ion tha t isuni que to the dis tal extremiti elto n, in 1986,definedfractureblis tersas skinbu ll ae an dbl ist ersrepre se ntingareasof ep idermalne cr osiswit hseparation of thest ratifiedsquamouscell laye r fr omtheun der ly ingvasc ulardermalla yerby ede mafluid.
3 1Th ei reti ologyhas beenhypothesized as botha mechani cal she arof thesk in relativeto themechani sm of in ju ry or a rel easemechanism of tissuepressure as a re sul t of post-traumaticed em a. Their size , shape,location,pa tt ern,andpo si ti onare va ri ableandunpredi cta bl e. Fr acturebli st er s ar e in andof themselvespai nlessmu ch like a fri ct io n blisteror bli sterof a sec ondde gr ee pr im aryinjury it sel f maybe pai nfu l. Thereis no cor relation wi th age , sex , or rac tionhasbeennotedwi th ini tia l frac tu re car eor conc omitant in juryas wel l as the general healthstatus ofthe pat ctu re bl iste rs are mo re common ly associ atedwi thhig h- energytr auma(F igure1).
4 In a studyby Var ela et al,25% we re cl as sifi ed as low- ener gy tr auma su ch as sl ip s ortwi sti ng inju rie is fi ndi ng is li ke wi se not ed in acutecom par tm en t synd rome wh ere mild er injury can res ult inhig h compartmentpre ssur es whe re as morese ve re injuriesdo no t. Fra cturebli ste rs can be see n in op en frac ture s, bu tare rare . Fr acture blist er s can occas io nallybe seento fo rmev en aft er une vent fulelective foo t an d an kl e surgery(F igu re 2) . Fra ctu re bl iste rs ma y app ear as earlyas 6 ho ursfo ll ow ing an in ju ry or su rge ry or co ul d app ear as lat e as th reewe y ty pi call y oc cur within 24-48hours foll owinginj ur y.
5 The ir exac t onse t can be diff icu lt to determine ifov erly ing dressingswere cov eri ng and hi din g the ex tre mityinj ur y si te (F ig ure3) .If all frac tu res are con si der ed, the re is a fra ctureblis ter for mation. When comparingonlythoseinj uri es pro ne to for m fracture bl ist ers, th e inci denceri ses . The y canra re ly but occasio nal ly be notedaft ernon-tr aumatic ele ct ive re construc tiv e footandankle cturebl istersare typ ic all y lo ca te d di stalto themid-shaf tof the hum er us in th e up per ext re mit y an d dis tal to th e kneein the lowe r ex tre mi ty.
6 Co nc lusi onsba sed on the pre senceofUNDERSTANDING FRA CTUREBLISTE RS:Ma na gementand Impli cati onsTho ma s F. Sm it h, DPMRi char d P. Bui , DPMCat hy O. Co ke r, DPMCHAPTER28 Figure1. Blood-filledfractureblisterassociatedwit ha ac tureblis ter s ar e in con cl usi ve in terms of th e seve rit y ofthe inj ur y, tim ingof the injury, or theappropriaten ess oftrea tm ent or patient complianc e as wel l as th e healthhi storyof th e pat YTwoty pesof fra ct ureblis tersare possible, namelycl ea rfl uid -fi ll ed andblo od -fi lledfra ct ure bli sters . Bot h ty pe s mayoccu r on the sam e patientoverthe samefracture (F igu re 4).
7 Neit herfluid-norblood-fil ledfr ac tur e bli st ersareapre di ct or of the se ve rit y of th e inj uryor thegeneralheal thst atu s of th e pat ie nt. Cl ear flu id -fi lled frac turebl ist ersde mons tra te a cle av ag e wi thi n the epid ermis itsel f wi th apa rtia l epi der ma l an d der ma l ba se. Cl ear fl ui d-filled frac turebl is te rs ar e termed subc or ne al in terms of hi sto lo gi calloc ationwi thintheep idermis of the skin. The cle av age tofo rm the clea r fl ui d-fi lled fra ct ure bli ster occ ur s abovethegra nul ar lay er of theepi de rmi s.
8 Thesefracture bl iste rs he alwithout sc ar or pi gmenta ti on cha nge s to the ski ood-fill ed frac turebl iste rs de monstrate se parationor clea vageof the epid erm is fro m the derm is . Theroofof th eCH APT ER ist er comprisesthe entire epi der mi s andthe baseis theder mis . In blo od-filled fractureblis ter s, th e vas culatureofthepa pillary dermisis damagedallowing bleeding in to thebl ist er blistersrepresenta mor e signifi can tin ju ry to the sk in bot h his tologic al ly andclinical ly. Theen tire epidermisoverthebl is tersite be com es nec ro ti od-fi lledfrac tu re blisters canhe al wi th dermalsc arr ingandpi gmentationchangesto theski n.
9 Late r ev id en ce ofsca rr ingor pigmentationchanges to theskinmay be usedto clini ca lly determi ne the fo rm er presenceof a blo od-fille dfr act ur e bl ister ove r a flui d-f il le d frac ture bli sumpti on s canbe mad e, ho we ver , if suchscarring ispr es en t of thefor mer se veri ty of th e injuryor itsma na gem ent at th e time. Re-e pithia lization is expe cte d by13 day s in clear fl ui d-f il le d fr act ure blistersan d by 16 days inbl ood-fille d frac tu re bl iste rs. The fast er he ali ng ti me of cle arflu id-f il le d fra ctu re bl iste rs ma y be rela te d to ret ent ionof ade greeof epidermisto the frac tureblis te r bednotpre se nt inth e bl ood-flui d fille d bl iste uid wi thi n a fr act ure bli st er is sterile, butCHA thesamepatientwitha widedistributionof fractureblistersevento thedigitswithtraumato te s significantcol onizationwit h mu lt ipl eorganismsuponrup fl uidis an ideal cu lt ur emediumwith no co mpetingor ga ni smsan d th e ab se nceofph agocyte s.
10 Mostorganismsnotedareopportun ist icres ident sk in flora, primari on ca n eas ily oc curin th is area of skincompro frac tur e blister fluidmediumand the compromisedmicr oci rc ula tionof theder mi s, esp ecially in blood-fi ll edbl is ter s, invitecol on izationandth e potentia l fo r infe pe rsistuntilre- ep ithelial iz at ionoccu rs to pr ote ct the cultures do nottypicallypre sentuntilan averageof 12 da ys af ter bli ster ruptur e,wh ic h is an avera ge of 18 da ys fol low ingtheinjury. Thefra cturefluidits el f in termsof his tologyandch emi calan alys is is similar tothatseeninfrictionbli st pa rtm entpressu re measu rements havebeennotedtobe mark edl y elevatedbefore fra ct ureblis ter fo rmationandred ucedafterfr actureblisterformati hav esymptomsor signsof compa rtmentsyndrome as soci at edwi th fr ac tu re blis tersdu e to the rela ti ve lac k of und erl yingmuscl e in thoseanatomic areaspr oneto frac turebli st ersfor ma tio n.
