Types of fracture blisters
Two types of fracture blisters have been identified: clear fluid-filled and blood-filled. The blood-filled blisters have been shown histological to have complete separation of the dermis from the epidermis, whereas the clear fluid-filled blisters demonstrate partial epidermal separation of the epidermis from the underlying dermis, with a few scattered areas of retained epithelial cells on the dermis. It is believed that blood-filled blisters are the result of injury to the papillary vasculature, allowing blood to escape into the blister. These represent a more significant injury histological and clinically. Due to detachment of the epidermis from the underlying dermis, eventual necrosis of the epidermis often ensues. Edema and venous stasis resulting from the injury induce collapse and thrombosis of affected blood and lymphatic vessels, thus adding to circulatory compromise.
Fracture blisters may appear as early as six hours after injury or as late as three weeks after trauma. These blisters signify underlying soft tissue damage and may result in increased infection rates for both operatively and no operatively treated fractures. Treatment recommendations have consisted of benign neglect, debridement, aspiration and surgical delay until reepithelialization occurs. Fracture blisters are defined as skin bullae and blisters representing areas of epidermal necrosis with separation of the stratified squamous cell layer by edema fluid. Fractures blisters contain sterile fluid but demonstrate colonization with multiple organisms once ruptured. Bacterial colonization was shown to be present until reepithelialization. This coupled with the resultant epidermal necrosis and hypoxia. It leads to an increased susceptibility to wound infection and dehiscence that is double the overall complication rate compared to fractures void of blistering.
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