Introduction

Blisters are commonly related to trauma and are known as fracture blisters. They may complicate arthroplasties, especially of the hip and knee, and may be related to dressing techniques (Cosker, Elsayed, Gupta, Mendonca, & Tayton, 2005; Hopper, Deakin, Crane, & Clarke, 2012). They may result in discomfort and postoperative morbidity and can lead to prosthesis sepsis and prolonged hospital stay (Hopper et al., 2012).

Fracture blisters are caused by dermal-epidermal separation secondary to strain created in the skin during initial deformation caused by the fracture (Giordano et al., 1995). When a critical strain is reached, the differing elasticity and viscoelastic properties of the dermis and the epidermis cause these two layers to separate (Giordano et al., 1995). Starling forces (hydrostatic and oncotic forces participating in movement of fluid through membranes) and an inflammatory cascade result in fluid extravasation into vascular and interstitial spaces creating cleavage sites between dermis and epidermis (Giordano et al., 1995). Fractures blisters are classified into clear or blood filled and are similar to second-degree thermal burns (Giordano, Koval, Zuckerman, & Desai, 1994). According to Uebbing et al., blood-filled blisters represent a more severe injury where the dermis is completely stripped of epidermal cells (Uebbing, Walsh, Miller, Abraham, & Arnold, 2010). According to this report, healing of these blisters occurs after an average of 16 days. The clear fluid-filled blisters have minimal injury to the dermis with some epidermal cells remaining attached and heal in approximately 12 days (Uebbing et al., 2010).

Predisposing factors to fracture blisters include the anatomic site (thinner skin without the underlying protection of muscle or adipose), conditions predisposing to poor wound healing and high energy injury (Uebbing et al., 2010; Varela, Vaughan, Carr, & Slemmons, 1993). The elbow accounts for a significant percentage of posttraumatic cases (36.7% of cases in Varela et al. series), the humeral shaft for 2.9% and the radius (shaft and distal) for 1.7% of cases (Varela et al., 1993). Zachary and Stern (1995) reported blisters as one of the short-term wound complications seen after wrist fusion. They reported this as part of a group of complications, including excessive swelling, hematoma, and/or partial dehiscence of the wound.

We present three cases with blisters after elective wrist surgery and their possible causes.

Case Report 1

A 36-year-old healthy woman underwent fusion of the index and middle carpometacarpal joints due to recurrence of carpal boss, 9 years after being treated with resection of the dorsal aspect of these joints. Two parallel transverse incisions were used to debride and fixate the carpometacarpal joints and to harvest bone graft from the distal radius. Tourniquet time was 1 hour and 35 minutes. The procedure was uneventful. The wounds were closed using subcutaneous sutures. No adhesive dressing or skin adhesive was used. The tourniquet was deflated following placement of a dressing and a plaster splint secured with an elastic bandage.

A week following the procedure, the patient was treated by a nurse because of an increase in burning pain under the dressing. The nurse loosened the superficial elastic dressing and noted blistering over the dorsum of the hand. Three clear blisters were noted on the first physician follow-up visit 2 weeks after surgery. The blisters were found between the surgical wounds (which healed nicely). The wound and blisters were treated with petrolatum gauze dressing changes and healed completely during the following 4 weeks. At 1-year follow-up, only a slight mark around the contour of the distal blister could be seen.

Case Report 2

A 17-year-old female with spastic hemiplegia due to encephalitis at the age of 9 years, with flexion deformity of the wrist and clenched digits, was treated with proximal row carpectomy, total wrist fusion, and fractional lengthening of digit flexors. Tourniquet time was 2 hours and 5 minutes. A 2.7 dynamic compression plate was used and the procedure was uneventful. The wounds were closed using subcutaneous sutures and wound closure strips (Steri-Strips) without skin adhesive were used to cover the wound. The tourniquet was deflated following placement of the dressing and plaster splint. After 4 days, the mother reported an increase in pain, significant swelling, and the appearance of multiple blisters. The wound and blisters were treated with petrolatum gauze dressing changes and healed completely within 4 weeks (Figure 1).

Case Report 3

A 53-year-old man with ischemic heart disease underwent open repair of a ligament tear following a neglected distal radius fracture, which resulted in significant deformity. The ligament was repaired with a bone anchor in a standard dorsoulnar approach to the wrist. Tourniquet time was 1 hour and 32 minutes, and the procedure was uneventful. The wounds were closed using subcutaneous sutures and wound closure strips without skin adhesive. The tourniquet was deflated following placement of dressing and plaster splint. During the first postoperative visit after 2 weeks, a single 3x3-cm blister was noted adjacent and proximal to the wound. The wound and blisters were treated with petrolatum gauze dressing changes and healed completely.

Discussion

Blisters following lower extremity and elbow trauma and after hip and knee arthroplasties are not uncommon. In lower extremity trauma injuries with blisters, Strauss et al. (2006) recommended unroofing the blister, and care of the skin with silver sulfadine, similar to a burn injury. Their cohort included severe combined injuries and approximately half of the patients had blood-filled blisters. This aggressive approach (in comparison with the treatment of the patients reported here) may be due to the different cohorts and is still controversial (Uebbing et al., 2010). Blistering following wrist trauma is rare and following elective wrist surgery has rarely been reported. In the report of wound complications after wrist fusion (Zachary & Stern, 1995), the authors do not differentiate between the cases with excessive swelling, hematoma, wound dehiscence, or blisters. They recommend elevation and compressive garments to all this group of patients. In the cases presented here, there was one case with significant swelling that was treated with limb elevation and the swelling had subsided by 2 weeks. All the wounds had healed adequately. At the time of the routine 2 week postoperative follow-up visit, there was no need to treat with compressive dressing any of the patients.

A clear film dressing with high moisture vapor transmission rates has been recommended to limit the occurrence of this complication (Cosker et al., 2005). In contrast, blistering after the use of stretching adhesive dressing has been reported following application of wound closure strips over laparoscopy wounds (Sanusi, 2011).

Several factors may have been involved in this complication. Significant postoperative swelling, compression from the patient's postoperative bandage, and pressure from the splint placed as part of the postoperative bandage may have played a role, although these were not found in the three cases presented, other than significant swelling in one patient during the first postoperative days. Parallel incisions at the wrist or on both sides of the wrist in an extensive procedure (in 2 cases) contributed to the injury to the soft tissue. In addition, the use of wound closure strips before deflation of the tourniquet (in 2 cases) may have caused a severe strain to the skin.

All Steri-Strip skin closures are to be applied without tension according to the manufacturer's instructions as performed in these cases. It has been reported that following deflation of the tourniquet, there is an increase in the circumference of the limb. This increase is more pronounced and is slower to decrease when the tourniquet is used for longer periods of time (Klenerman, Crawley, & Lowe, 1982; Silver, de la Garza, Rang, & Koreska, 1986). Although the wound closure strips were applied appropriately, swelling following deflation of the tourniquet may create tension on the wound, which may result in blistering.

Contact dermatitis must be considered as a possible cause of blisters as well. This has been reported after the use of antimicrobial agents, which were used in the presented cases as part of the routine preparation of the entire limb to surgery (Sheth & Weitzul, 2008). It is not probable that this is a significant factor in these cases due to the localized nature of the blisters around the surgical wound and not along the limb.

We found that reassurance of these alarmed patients was the most important part of their treatment. The clear fluid blisters resolved in several weeks without any significant sequelae.

References