Abstract
Introduction
Post-traumatic blister is often encountered in high-energy injuries and following major limb surgeries. Currently, there is very limited evidence concerning blister management resulting in a lack of comprehensive guidelines for their management. The current survey-based study aims to appraise the current consensus in post-traumatic management among the practising orthopaedic surgeons and compare the same with the evidence in the literature.
Materials and Methods
We conducted an online questionnaire-based survey of orthopaedic surgeons concerning post-traumatic blister management practices. The questionnaire mainly focused on antibiotic prophylaxis, local invasive procedures, antiseptics dressings and additional treatment options regarding blister management.
Results
A high prevalence (~ 78%) of systemic antibiotics administration was noticed for post-traumatic blister management. Similarly, large section of respondents (66.4%) advocated for either de-roofing or aspiration of blisters. Approximately 42% of respondents preferred sending blister fluid for cultures. More than half of the respondents used some form of local dressing to cover the blister bed to provide a healing environment. Additional opinions mostly included anti-inflammatory and swelling reducing measures. Few respondents also advocated for oral steroids for inflammation control.
Conclusion
The limited evidence available in literature could be the potential contributing factor for varying clinical practices for post-traumatic blister management. The general measures to reduce soft-tissue oedema have been supported by the literature. However, the use of systemic antibiotics and steroids has not been supported by the literature and should be avoided unless indicated due to other reasons. Further evidence is required to strengthen the recommendations for post-traumatic blister management.
Keywords: Blister, Fracture blister, Orthopaedics, Questionnaires, Survey, Trauma blister
Introduction
Post-traumatic blisters result from extensive soft-tissue damage due to high-energy trauma and can often be post-surgical [1–3]. Such blisters contain either clear fluid (serous), blood (hemorrhagic) or a mixture of the two. The formation of these blisters has been attributed to the separation at the dermal–epidermal junction [4]. Blisters are commonly seen in areas with thin soft-tissue covers, such as the ankle and knee regions, but can sometimes be spotted in the arm and elbow [1, 2, 5, 6]. Numerous modalities of post-traumatic blisters management are described in the literature. Still, there is no standardised treatment protocol for their management. There is also a lack of consensus regarding the specific management of haemorrhagic and serous blisters. Furthermore, the effectiveness and acceptability of newer treatment modalities like negative pressure wound therapy are also yet to be established in the literature [7]. The current survey aims to appraise the current consensus in post-traumatic management among the practising orthopaedic surgeons and compare the same with the evidence in the literature.
Materials and Methods
The current study was conducted as a prospective questionnaire-based survey between 1 July and 31 Aug 2021, after obtaining clearance from the institutional review board (details concealed to ensure blind peer review and will be added once it completes). The target population for the survey was the practising orthopaedic surgeons with minimum qualification of a post-graduate degree in orthopaedics and who regularly manage trauma cases. A list of contact email IDs of qualified orthopaedic surgeons was prepared from the information on public domains of state and national institutions, and they were invited to participate in the current online survey. In addition, open invitations were sent to potential eligible surgeons through social media groups. The participants were given a deadline of one month to complete the questionnaire. The questionnaire included open-ended and closed-ended questions formulated by two senior authors (JJ and SK) with over ten years of experience in orthopaedic trauma management. The institutional review board validated the questionnaire for its content and applicability. The questionnaire was distributed to the participants through Google forms by one of the authors (SS), other than the analysis performing ones, to ensure blind review of the responses. The first section of the questionnaire consisted of demographic questions. The surveying author coded the patient identity to maintain blinding during the analysis.
The second section had closed and open-ended questions related to antibiotic prophylaxis, local invasive procedures, antiseptics dressings and additional treatment options regarding blister management. The first two questions confirmed the eligibility of the participants. The responses were considered for analysis for only those respondents who answered “yes” for both these questions. The questionnaire is presented in Table 1. The identity anonymised data entered in excel sheets were transferred to the two data analysing authors (AK and OAQ) for further analysis. The responses of closed-ended questions were charted in Microsoft Excel Version 16.52. The overall response rate (proportion of valid responders/invitations sent), individual responses’ frequency distribution were calculated. The free text of the responses to the open-ended questions was qualitatively analysed using an online free text analysis tool. The responses were then categorised based upon similarity of the responses and repetition of words. The two analysing authors independently categorised the responses, and the response categories were finalised after subsequent discussion and mutual consensus. The frequencies of each of the categorical responses were then calculated. The continuous data from the questionnaire were expressed as mean (range), and categorical data were expressed as proportions. A qualitative review of the interpretations obtained from the responses and available evidence in literature was then performed.
Table 1.
Questionnaire for post-traumatic blister management practices among orthopaedic surgeons
| Section I |
|---|
| Name and institute (coded and anonymised before analysis) |
| Age (in years) |
| Gender (male/female/other) |
| Years of experience in trauma management (0–5 years; 5–10 years; 10–15 years; 15–20 years; more than 20 years) |
| Section II |
|---|
| Question 1: do you routinely perform trauma surgeries or manage trauma patients? (Yes/no) |
| Question 2: have you encountered blisters in orthopaedic trauma patients? (Yes/no) |
| Question 3: what are the most common site where you have seen post-traumatic blisters frequently? (Open question) |
| Question 4a: do you routinely start systemic antibiotics in patients with post-traumatic/fracture blisters? |
| (a)Yes, for all patients developing blisters |
| (b)Yes, only for haemorrhagic blisters |
| (c)Yes, only for serous blisters |
| (d)Not at all |
| Question 4b: if yes, what is the route of administration of antibiotics? (Oral/intravenous/both) |
| Question 4c: what antibiotic(s) do you routinely use in post-traumatic blisters? (Open question) |
| Question 4d: what is the overall duration of the antibiotic course? (Open question) |
| Question 5a: what are your preferred procedures for managing post-traumatic blisters? |
| (a)Allow blisters to resolve on their own (conservative management) |
| (b)Aspiration of blisters |
| (c)De-roofing of Blisters |
| (d)Use all of the above |
| Question 5b: do you send blister fluid for culture? (Yes/No) |
| Question 6a: do you use any modality for dressing the blister bed? (Yes/No) |
| Question 6b: describe the dressing modalities that you use for the blisters? (Open question) |
| Question 7: would you like to share any additional information regarding the management of fracture blisters? (Open question) |
Results
The questionnaire was sent to 560 practising orthopaedic surgeons via electronic media, of which 342 were valid respondents (response rate of 61.1%). All 342 respondents were male orthopaedic surgeons with an average of 36.45 years (25–68 years) of age. Most of the responding surgeons had up to ten years of experience in trauma management (Fig. 1).
Fig. 1.
Experience duration of respondents related to trauma management
All respondents were involved in routine care of trauma patients and had encountered post-traumatic blisters in their clinical experience. The most common site of post-traumatic blisters was the proximal tibia (78%), followed by the distal tibia (22%). The responses suggested a widespread use of systemic antibiotics in post-traumatic blister management. Almost half of the respondents used systemic antibiotics in all blisters irrespective of serous or haemorrhagic nature (Fig. 2a). Concerning the route of antibiotic administration, approximately 2/3rd of the respondents preferred the intravenous route over oral administration (Fig. 2b). The discrete antibiotic names were classified into the broad classifications of antibiotics and their generation to present results in a standardised manner. The most preferred antibiotics were third-generation cephalosporins followed by the second-generation ones and Amoxicillin–Clavulanic acid (Fig. 2c). Few respondents combined Gram-negative covering antibiotics with the above. The mean duration of the antibiotics course was 5.54 days (2–14 days). Less than half of the respondents used to send cultures of blister fluid routinely (Fig. 2d).
Fig. 2.
The characteristic of responses related to the antibiotics use (a), their route of administration (b), and their classification (c) has been shown. The preference of sending blister fluid cultures has also been shown (d)
Almost 2/3rd surgeons preferred either aspiration or de-roofing of the blisters, while only 1/3rd advocated for conservative management, i.e., plain observation (Fig. 3a). In addition, approximately 2/3rd of the respondents used some sort of dressing for the blisters (Fig. 3b). Among the surgeons using dressing modalities, normal saline dressings (most common), betadine-based local dressings, paraffin dressings were the common local treatment modalities (Fig. 3c). Hygroscopic dressings were the less common local treatment modalities. Additional opinions were provided by 22.8% of the respondents. The free-text categorisation revealed options of local cold packs application, limb elevation, close observation for compartment syndrome, avoiding constrictions and tight bandages, early stabilisation of the fracture through less-invasive modalities like external fixator, delaying internal fixation and initiation of oral pharmacological agents including enzyme therapy and steroids (Table 2).
Fig. 3.
The use of locally invasive measures at blister sites (a), use of local applicants (b), and their types (c)
Table 2.
Additional opinions provided by the respondents that were relevant to post-traumatic blister management
| Additional opinions | Number of respondents (% of total respondents) |
|---|---|
| Cold pack application | 10 (2.9%) |
| Limb elevation | 9 (2.6%) |
| Early Stabilization of fracture through less-invasive means | 10 (2.9%) |
| Observation for compartment syndrome | 9 (2.6%) |
| Oral Steroids | 11 (3.2%) |
| Systemic enzyme therapy | 13 (3.8%) |
| Delayed internal fixation | 12 (3.5%) |
| Avoid covering with slab/cast/tight bandage | 4 (1.2%) |
Discussion
Post-traumatic blisters indicate the extent of severity of soft-tissue injury following trauma or after extensive surgical procedures. The local skin condition can jeopardise the healing process and is often not safe for surgical incision, considering the risk of wound-related complications. The current evidence in post-traumatic blister management is limited and heterogeneous. The same is probably the reason behind the lack of consolidated guidelines in post-traumatic blisters management. There are several treatment options for post-traumatic blisters, and often the choice is left to the treating surgeon(s). In addition, the initial management is the potential determinant of the trauma and treatment-related outcomes. The current survey suggests a wide disparity among the practising orthopaedic surgeons concerning post-traumatic blister management.
Furthermore, the management options included invasive as well as non-invasive ones. Thus, the overall picture suggests a present non-consensus situation over treatment modalities for post-traumatic blisters. The following point-wise discussion explores the evidence available in the literature and compares the same with our survey results.
Initial Management of Blisters
Literature suggests that the initial treatment of post-traumatic blisters aims to control the inflammatory phase, which occurs over the initial 24–72 h after injury [3]. Passive treatment options like limb elevation and cryo-therapy and active management like intermittent pneumatic compression devices have been described [8–10]. However, less than one-fourth of our respondents opined regarding inflammation controlling measures like using ice packs, limb elevation, enzyme therapy, delaying definitive fixation, and avoiding tight dressings. Therefore, a change in practice is required to control the inflammatory phase in post-traumatic blister management aggressively.
Role of De-roofing or Aspiration of Blisters
The de-roofing and aspiration of blisters were practised by the majority of the respondents in our survey. However, there are very few studies regarding the use of these methods in blister management. De-roofing has been described by Bleakley et al. [8], Ballo et al. [11], Wallace et al. [12], and Strauss et al. [2]. Following de-roofing, the authors used some form of antimicrobial treatment like sliver sulfadiazine or antibiotic spray to protect the blister bed. Borrelli et al. [5] recommended de-roofing in case the blisters get disrupted. Aspiration was described by Uebbing et al. [3], Giordano et al. [4], and Lal et al. [13]. In their study, Varela et al. [14] concluded no difference in healing if the blister was punctured or ruptured spontaneously. Giordano et al. [4] studied the effects of aspiration followed by dry dressing, de-roofing followed by silver sulfadiazine cream, de-roofing and silver sulfadiazine cream with a non-adherent bandage and leaving blisters intact with or without coverage with loose dressing gauze on healing outcomes. They concluded that there were no significant differences in the outcome of soft-tissue injury treated with various modalities and re-epithelialization.
Role of Prophylactic Antibiotics in Fracture Blisters
The use of prophylactic oral or intravenous antibiotics has not been described in the literature. A majority of respondents started antibiotics in fracture blisters. Almost half of the respondents started antibiotics irrespective of the nature of the blister, and most preferred the use of 2nd- or 3rd-generation cephalosporins. Given the sparse evidence regarding prophylactic antibiotic use, it is logical to start broad-spectrum antibiotics only when they are disrupted, considering the risk of colonisation by bacteria. Blisters are often disrupted to expedite healing to perform early surgery, primarily keeping the hospital stay duration and surgery in mind. Our literature search suggested that only local antibiotics have been used to manage blister beds [2, 11]. In addition, care must be taken to avoid antibiotic ointments/creams that cause local reactions like neomycin/bacitracin. Also, in the case of intact blisters, it may not be wise to use systemic antibiotics unless added for other reasons, considering the risk of antibiotic resistance development. Blister fluid cultures and microscopic examination could be a potential answer to justify the need for systemic antibiotics. However, less than half of practising surgeons sent cultures for blisters.
Dressing Modalities that have been Described in the Literature to Manage the Blister Bed
Multiple dressing modalities have been described for the management of the blister bed. Buckley et al. [15] had described the use of bismuth tribromophenate gauze after de-roofing the blister. Silver sulfadiazine, traditionally used for burn management, has been described by several authors to manage the fracture blister bed [2, 4, 14, 16]. The use of paraffin-based dressing has also been described as an alternative for dressing the blister bed [2, 4, 5, 17]. Approximately 1/4th of respondents in our study preferred using normal saline, and few used paraffin-based dressing modalities for dressing the blister bed. Nevertheless, these modalities are well known for managing raw surfaces and providing a healing environment.
Besides the above-discussed points, additional supportive modalities need to be considered that can help in improving the soft-tissue condition. The blisters are actually the indicators of soft-tissue damage, and therefore, to reduce blisters formation and help blister healing, the inflammation needs to be reduced [18]. When asked to provide additional suggestions at the end of the questionnaire, we found that practising surgeons use cryo-therapy, limb elevation, and early fracture stabilisation, which all help reduce inflammation and oedema of the injured side, thereby promoting healing environment. In addition, few respondents had an opinion of systemic enzyme therapy, e.g., trypsin: chymotrypsin and serratiopeptidase and even oral steroids. The enzyme therapy is known to have anti-inflammatory action through the inactivation of mediators and toxic products, thereby restricting oedema and pain [19]. However, there has not been any published evidence supporting the use of any form of steroids in post-traumatic blisters.
The current survey has some limitations. First, the survey is based on the responses received from a small section of orthopaedic surgeons, and those may not reflect the real picture of the post-traumatic blister management practices. Second, the mode of survey conduction was online, limiting the reach to the orthopaedic surgeons who are not familiar with internet use. Third, the survey discusses some relevant issues about blister management, and those may not be all-inclusive of blister management. Fourth, the blister management and outcomes can be affected by the host factors like general condition, comorbidities, fracture pattern, additional injuries, etc. These would need detailed analysis and are beyond the scope of the current survey. Lastly, due to limited evidence in literature concerning post-traumatic blisters management, it would be difficult to support or contradict the currently followed practices. Nevertheless, the survey finds its strength in touching a topic of great clinical importance which has not been sufficiently addressed in the literature. Hence, it provides a huge collection of potential research questions that can help research formulate studies to analyse effective management of post-traumatic blisters.
Conclusion
The current study suggests a wide variation in the post-traumatic blister management practices among orthopaedic surgeons. The limited evidence available in literature could be the potential contributing factor for such differences in clinical practices. The general measures to reduce soft-tissue oedema include cryo-therapy, limb elevation and rest, anti-inflammatory measures, splinting, and non-invasive measures like limited external fixation, blister aspiration and de-roofing in large blisters, and local antimicrobials moist dressing have been supported by the literature. However, the use of systemic antibiotics and steroids has not been supported by the literature and should be avoided unless indicated due to other reasons. Further evidence is required to strengthen the recommendations for post-traumatic blister management.
Author contributions
SS, AK contributed with concept, design, data analysis, manuscript preparation, manuscript editing, and manuscript review. JJ, OAQ contributed with manuscript preparation, and manuscript editing. SK, AM contributed in literature review, manuscript editing, and manuscript review.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Data Availability
Data assessed can be provided on request.
Declarations
Conflict of interest
None of the authors has any conflicts to declare.
Ethical Approval
The study was approved by the institutional review board.
Consent to Participate
Appropriate consents were obtained from the involved participants.
Consent to Publish
Not applicable (No human or animal subjects related information involved).
Footnotes
Publisher's Note
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Contributor Information
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data assessed can be provided on request.