Open questions

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  Should the surgeon proceed with immediate open reduction and internal fixation of the fracture in the presence of fracture blisters? If not, when should definitive management be undertaken?

  
  
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  How should the fracture blisters be managed?

  
  
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  If the soft tissue does not recover in time to safely perform definitive fixation, what are the treatment options?

Options and plan

The presence of fracture blisters (chapter 3.3.4) is a sign of significant skin injury. Whenever possible, incisions should not be made through fracture blisters until there is evidence that they are healing. However, the fracture still must be stabilized in order to allow the soft tissues to recover and to prevent further soft-tissue injury. Clearly, in this case, an external fixator is an option.

There is little convincing evidence to support any particular method of management of fracture blisters. The treatment is often based on tradition and personal experience rather than evidence. It is very important that the surgeon realizes that fracture blisters indicate severe injury involving deep soft-tissue compartments. Locally, there is edema, hypoxia and microvascular failure, thus creating a very high risk for further, immediate surgical trauma. Some surgeons prefer to unroof the fracture blister acutely and to cover the wound with a sterile dressing. Yet, one should keep in mind that the liquid of sterile blisters contains a lot of cytokines and growth factors stimulating and accelerating wound healing. Accordingly, the blisters may instead be kept intact until their spontaneous perforation.

There is a window of ~ 10–14 days during which the fracture can still be manipulated and an anatomical joint reduction achieved. After 2–3 weeks, a callus will already have formed, requiring removal, and hampering reposition and fixation. While the rough bone alignment of the fracture fragments may still be achieved after this period of time, beginning resorption of the fracture ends may preclude accurate positioning of bone fragments. However, to safely undertake an open anatomical reduction, the soft-tissue envelope has to be assessed. If the surgeon is able to flex the ankle dorsally or if pinching the skin around the ankle results in visible wrinkles, this is an indication that the edema has subsided sufficiently in order to safely close the skin after surgery.

In the case of fracture blisters, there should be reepithelialization of the blister within 14 days in most cases. Whenever the color of the skin changes from a deep red to a more normal skin tone and loses the glossy appearance of the acute fracture blister, it is relatively safe to incise through it. Meticulous handling of the soft tissues is required once the definitive procedure is undertaken, including restricted use of retractors, use of sharp rather than blunt dissection, and making the incision longer than normal in order to avoid retracting too hard on the damaged area of the skin (chapter 1). Note that a small incision will require much more traction in order to expose an area of 2 cm from the incision than a longer incision.

Occasionally, the skin does not return to a condition where it would be safe to perform definitive fixation, either because of persistent fracture blisters or edema. Often, these cases are crush injuries or circumferential injuries, which result in extensive internal degloving of the soft tissues and damage to the lymphatic drainage of the limb. In such cases, external fixation may turn out as the definitive treatment. There are some things that may be done during the early phase in order to reduce swelling. Plexipulse^® foot pumps are an effective method for rapidly reducing lower extremity swelling, although they are not well tolerated in patients with fractures of the foot and/or ankle. Strict bed rest and elevation of the limb above the level of the heart is usually most effective. Bulky dressings, such as Jones dressing (well-padded bandages to the extremity) may be used as well in order to protect soft tissues whenever a splint is required. Occasionally, the administration of diuretics may accelerate the deswelling process.

Case history

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  24-year-old white male patient

  
  
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  Coal miner

  
  
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  Single

  
  
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  Nonsmoker

  
  
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  Right-hand dominant

  
  
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  No other medical problems

The patient was attempting to remove an obstruction from in front of a coal car in a mine. When he removed the obstacle, the coal car rolled forward, pinning both arms under the car. Emergency personnel in the field began intravenous fluids, applied field dressings and splints to both arms, and transported the patient to a level I trauma center, arriving 60 minutes after injury.

The patient was examined on arrival to the trauma center by trauma surgeons and the orthopaedic team. The patient was intubated shortly after arrival for pain control. The initial assessment on presentation to the trauma bay revealed normal chest, abdomen, pelvis, and spine.

Significant findings in the secondary survey included:

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  considerable gross contamination in both arms

  
  
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  extensive crush injury to the right arm extending from elbow to wrist with almost subtotal amputation, absent pulses in the wrist

  
  
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  crush injury to the left forearm including the first web space and palm of the hand, present radial and ulnar pulses

  
  
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  subtotal amputation of the left index finger.

Wound conditioning: none.

Present status

In consultation with the trauma and vascular teams the orthopaedic team elected to move immediately to the operating room for a detailed assessment of what was viable, while fluid resuscitation continued. The injuries were rapidly determined to be isolated, since trauma to chest, abdomen or head had already been excluded. No nerve examination could be performed prior to anesthesia because the patient had been intubated in the trauma bay for pain control.

Intraoperative examination of both arms revealed the following:

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  pulses not restored after reduction of the right forearm fractures by traction

  
  
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  very significant muscle damage to the entire flexor and extensor compartments

  
  
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  abundant muscle tissue crushed and lacerated ( Fig 12.2-1a )

  
  
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  gross contamination of the skin, subcutaneous tissue, muscle, and bone

  
  
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  numerous lacerations and fractures of the hand ( Fig 12.2-1b )

  
  
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  numerous fractures of both radius and ulna, involving the better part of the diaphyses of both bones, including the distal humerus.

Examination of the left arm revealed:

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  large superficial laceration along the posterior forearm ( Fig 12.2-2a )

  
  
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  gross contamination of the wound

  
  
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  large laceration of the first web space in the hand ( Fig 12.2-2b )

  
  
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  capillary refill in the second digit absent.

Decision making

Options and plan

The initial assessment was that the right forearm was not salvageable. Even if the vessels could have been repaired, the function of the hand and forearm would most likely not have been restored. Making the decision to amputate the dominant arm is always difficult, but in this case, the extensive, contaminated crush injury of the forearm with overwhelming muscle damage, including massive bone trauma and damage to major vessels and tendons in the hand left no other option and led to this decision.

The left arm appeared to be viable, though there was significant damage to the hand. Certainly, the index finger was not viable due to neurovascular damage. There was muscle damage to the forearm, but its extent could not be determined prior to surgical exploration. The arm and hand would require further reconstruction by a hand surgeon in order to optimize functional outcome.

Having someone knowledgeable about the reconstructive options after emergency debridement facilitates decision making. In this case, the hand surgeon on call was not available for immediate consultation. However, the operating surgeon did discuss the findings with the hand surgeon by phone while still in the operating room immediately after having fully assessed both arms.

Plastic surgeons were not required in this case, because at this stage with grossly contaminated wounds, any type of reconstructive measure was not an option. The vascular surgeons, who were consulted in the emergency department, did not have any hope of salvaging the right arm due to the extensive soft-tissue injury.

Our initial impression was that the patient would need a transhumeral prosthesis for the right arm and be left with a 4-fingered hand on the left, but with reasonably good function of both arm and hand. Yet, this question could not be answered until a full intraoperative assessment of the left arm had been performed.

Certainly the loss of the dominant arm causes the surgeon to think carefully about any drastic measures which might allow salvaging the arm. Nerve grafts, microvascular repair of the arteries, free tissue transfers, and large allografts were all briefly considered in this case. However, even if the finest surgeons working with unlimited resources and sufficient time were to attempt salvage of this arm, the functional result would, nevertheless, be far less than that obtainable with a prosthetic arm. The attempt would, furthermore, involve intensive physical therapy over a long period of time and still would, most likely, only result in a stiff and painful right arm and a hand with negligible function.

Related posts:

Cases (I) Cases (IV) Cases (V) Cases (III) Humerus, shaft—introduction Femur, shaft: wedge fracture, fragmented wedge—32-B3

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