With higher energy injuries or with fragile skin (e.g. due to age, steroids, rheumatoid arthritis) an injury may jeopardise the viability of the overlying skin
A protruding spike of bone or tension on the skin from deformity can lead to devitalisation and necrosis with skin breakdown
In the situation where a fracture is causing excessive pressure on skin, as manifested by tenting of the skin and 'blanching', the fracture should be reduced as an emergency (under analgesia +/‐ sedation) to avoid subsequent necrosis
De-gloving
Avulsion of the skin from its underlying blood supply as a result of a shearing force on the skin
Can result in skin ischaemia and necrosis
The skin will not 'blanch' on pressure and may be insensate
Underlying haematoma may also increase pressure on the skin occluding capillaries
The de-gloved area may take a few days to declare itself (demarcate)
May require skin grafting or flap coverage
Swelling, bruising and blisters
The amount of soft tissue swelling and bruising (contusion) is usually a reflection of the energy of the injuries involved
Fracture blisters can occur due to inflammatory exudates causing lifting of the epidermis of the skin (like a burn)
A surgical wound through swollen and contused skin and soft tissues is not advisable as the wound may not be able to be closed which would leave a route for infection, or excessive tension on the wound may lead to necrosis and wound breakdown
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