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Abstract Uniqueness Background Clinical Significance  Fracture blisters may occur following high-energy trauma in an athletic environment and without.

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Presentation on theme: "Abstract Uniqueness Background Clinical Significance  Fracture blisters may occur following high-energy trauma in an athletic environment and without."— Presentation transcript:

1 Abstract Uniqueness Background Clinical Significance  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 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. On- field 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. Post- reduction 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.  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. Conclusions  Fracture blisters occurring following athletic injuries and in the absence of a fracture are rare  Reported that fracture blisters occur in 2.9% (43 or 1,468) of all acute fractures requiring hospitalization 1  Most occur following acute fractures caused by high traumatic incidences 1.Varela CD, Vaughan TK, Carr JB, Slemmons BK. Fracture blisters: clinical and pathological aspects. J Orthop Trauma. 1993;7(5): Shelton M. Complications of fractures and dislocations of the ankle. In: Epps CH. Complications in orthopaedic surgery. Philadelphia, PA: Lippincott;1994: Giordan CP, Scott D, Koval KJ, Kummer F, Atik T, Desai P. Fracture blister formation: a laboratory study. J Trauma. 1995;38(6): 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: Ballo F, Maroon M, Millon SJ. Fracture blisters. J Am Acad Dermatol. 1994;30:  Immediately following reduction of the posterior elbow dislocation, Ace ® wrap was applied to the elbow.  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.  Compartment syndrome  Friction blister References  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.  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.  However, the importance of controlling edema at the injury site may outweigh the importance of reducing the risk of fracture blister formation. Clinical Implications Differential Diagnosis  Post-injury immobilization helps limit any additional movement and prevents any ongoing injury.  Post-injury elevation helps reduces edema and vascular congestion  Post-injury compression may hinder venous blood return 2  Fracture blisters should not be aspirated in order to reduce the risk of infection 4  Apply a soft, dry, sterile dressing with triple antibiotics or silver sulfadene 1  After blister ruptures, the roof should remain overlying the site 1  Usually resolved within 6-21 days 2,5  Educate athlete on proper treatment of fracture blisters and about possible signs and symptoms of infection Treatment  Fracture blisters are defined as skin bullae representing areas of epidermal necrosis with separation of the stratified sqaumous cell layer by edema fluid 2  Typically found in areas with tight, closely adhered skin with little or no muscle or enveloping fascia 1  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 injury 1,2  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 gap 1,3  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  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 Discussion Improving Clinical Outcomes Fracture Blisters Following a Posterior Elbow Dislocation: A Case Report Jodi Burrer, Dr. Pamela Hansen, Dr. Kevin Miller, Dr. Bryan Christensen North Dakota State University Department of Health, Nutrition and Exercise Sciences, Fargo ND NDSU Athletic Training


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