CASE REVIEW Fracture Following a Posterior Elbow Dislocation: A Case Report

Jodi L. Burrer, MS, LAT, ATC • Rolla High School; Pamela J. Hansen, EdD, LAT, ATC; Kevin C. Miller, PhD, LAT, ATC; and Bryan Christensen, PhD, CSCS • North Dakota State University

Fracture blisters are skin bullae that tion and 45° of horizontal adduction while develop following soft tissue damage and being tackled. At the same time, an opposing edema formation in the area separating player fell on the back of his left shoulder, the epidermis and stratified squamous cell which imposed additional force on his out- layer. Damage to the capillaries following stretched arm. The athletic trainer observed causes cell death and an increase in a gross deformity of the elbow joint, with the interstitial fluid pressure. Cellular cohesion is ulna projecting posteriorly in relation to the disrupted and blisters form.1 The occurrence humerus. The team physician diagnosed the of fracture blisters is rare and usually associ- injury as a posterior elbow dislocation and ated with high-energy immediately reduced the joint at the site. Fol- impact (e.g., motor vehi- lowing reduction, the physician identified no Key PPointsoints cle accident). Fracture strength, neurological, or circulatory abnor- Fracture formation following ath- blisters are estimated malities. However, significant edema (i.e., letic injury is rare. to occur in 2.9% of all estimated to be twice the normal circumfer- acute fractures requiring ence of the uninjured elbow), ecchymosis, Fracture blisters may develop in the hospitalization.1 The fre- and muscle guarding were observed. The ® absence of a fracture. quency of occurrence of athlete’s arm was immobilized with a SAM fracture blisters follow- splint, compression wrap, and sling, and ice Fracture blisters present minimal impedi- ing athletic is was applied to the elbow for 20 minutes after ment to rehabilitation if properly treated. unknown. The purposes immobilization. of this case report are At 36 hours postinjury, the athlete (a) to present the unique case of a collegiate removed the splint, compression wrap, and football running back who developed fracture sling, and he identified four clear-fluid blis- blisters following a posterior elbow disloca- ters (~2.25 cm in diameter) over the medial tion and (b) to inform clinicians about the aspect of the distal humerus. At a follow-up prevention and treatment of fracture blisters. visit at 48 hours postinjury, radiographs were deemed negative for the existence of a frac- Case Report ture. The team physician diagnosed the blis- ters as “fracture blisters” and recommended A 21-year-old college football player (height against aspiration to prevent infection. A 187.9 cm; mass 92.9 kg) extended his right conservative treatment approach was pre- arm to approximately 90° shoulder abduc- scribed, consisting of elbow immobilization

© 2013 Human Kinetics - IJATT 18(2), pp. 17-19 international journal of Athletic Therapy & training march 2013  17 (90° flexion), continuous daily use of a compression alcohol abuse, or smoking).1,4 The athlete whose case sleeve that extended from mid-forearm and mid- is reported did not have any predisposing conditions, arm, and icing for 20 minutes, three times per day. heat was not applied, and the joint was properly The athletic trainer covered the fracture blisters with splinted. antibacterial cream and sterile gauze, and the dressing Healing of fracture blisters requires 6 to 21 days.4,5 was changed three times per day. Rehabilitation was Factors such as tissue viability, oxygenation, injury initiated at 72 hours postinjury, which was focused on location, depth, and systemic conditions may decreasing edema and pain and restoring full range of increase the amount of time required for healing. motion. No infection or other complications occurred We observed that the fracture blisters had resolved during the rehabilitation process. The fracture blisters at approximately 14 days postinjury with conserva- had completely resolved at 14 days postinjury, but tive treatment (e.g., antibacterial cream, gauze). This noticeable scarring was present. The team physician treatment did not affect the athlete’s ability to perform cleared the athlete for full participation at 6 weeks elbow rehabilitation exercises and did not delay his postinjury. return to full participation. Clinicians should be aware that aspirating fracture blisters may result in infection,6 Discussion which may delay return to play. No report of fracture blisters occurring as a result of Clinical Implications an athletic injury, nor the formation of fracture blisters in a patient without a fracture, have been reported in Fracture blisters may occur despite proper manage- the literature. We suspect that the incidence rate for ment of the acute injury that preceded their formation development of fracture blisters following an athletic (e.g., compression, immobilization, cryotherapy). The injury is substantially lower than that reported for proper treatment of fracture blisters is similar to that fracture cases in the general population. for friction blisters. The roof of a blister contains a layer The cause of fracture blister formation in the of keratinized cells that presents a barrier to harmful reported case is unknown. They are believed to occur microorganisms, which provides an ideal environment following rapid edema formation that separates the for wound healing.7 The roof functions like a sterile bio- epidermal and dermal junction.2 Fracture blisters are logical dressing. A ruptured blister encourages infection typically observed in body areas that have little muscle by providing moisture, serum, the absence of internal mass or in areas of tight skin (e.g., elbow, foot, , phagocytic activity, and few competing organisms.7 and distal tibia).1 These areas are thought to be most A soft, dry, and sterile dressing should be applied to prone to fracture blister formation because edema is protect the intact blister during healing.1 concentrated within a relatively small tissue space Fracture blisters should be regularly inspected for and more readily dispersed into the skin layers.1 In signs of infection. After a blister ruptures, the roof the reported case, substantial swelling following injury should be left in place to continue acting as the biologi- probably forced fluid between the skin layers as inter- cal dressing. Antibiotic ointments or antiseptic solu- stitial fluid pressure increased. Because the medial tions should be used with caution, because agents such elbow area does not have a substantial amount of as povidone iodine, hydrogen peroxide, and rubbing subcutaneous tissue space or highly compliant skin, alcohol can impede reepithelilization;8 however, triple the development of fracture blisters is not surprising. antibiotics or silver sulfadene (sulfadiazine) cream has Fracture blisters most often occur following frac- been shown to enhance wound healing.6,8,9 The use tures or severe twisting-type injuries.3 Among patients of an antibiotic ointment did not appear to hinder nor who develop fracture blisters, 76% have sustained enhance fracture blister healing in the reported case. high-energy injuries (e.g., falls from heights or motor vehicle accidents).4 However, some patients who sus- Conclusions tain low-energy injuries develop fracture blisters, which may result from joint dislocation reduction, improper The formation of fracture blisters following an athletic splinting, dependent positioning, heat application, or injury is rare. The formation of fracture blisters in the a preexisting condition (e.g., peripheral vascular dis- reported case was likely due to the large amount of ease, lymphatic obstruction, diabetes, hypertension, edema that developed to the elbow area after a pos-

18  march 2013 international journal of Athletic Therapy & training