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Woman, 57, with Painful, Swollen Ankle Candice N GRANDROUNDS Woman, 57, With Painful, Swollen Ankle Candice N. Short, DNP, FNP-C, RN, Retha Gentry, DNP, FNP-C, RN, Lisa Ousley, DNP, CS-FNP, RN 57-year-old horticulturist is working with subsequent increased filtration pres- Candice N. Short, on a ladder leaned up against a tree sure and colloid osmotic pressure in the Retha Gentry, and Lisa Ousley are trunk when the ladder slips, causing epidermal gap.3 This causes a disruption A Assistant Professors her to fall six feet onto concrete. Her right that allows fluid to move into the weakened at East Tennessee foot and ankle sustain the force of the fall; area.3 Areas most at risk for fracture blister State University in she is in excruciating pain and unable to formation are those with tight, closely ad- Johnson City. bear weight on the foot. She is immediately hered skin without muscle or enveloping transported to a local emergency depart- fascia, where there is less soft tissue be- ment for evaluation. tween the skin and bone prominences (eg, Physical exam reveals a tearful middle- ankle, elbow, foot, distal tibia).2-4 aged female in moderate distress and acute Approximately 3% of all patients with pain. There is moderate swelling of the right acute fractures requiring hospitalization medial and lateral malleolus, as well as the midfoot, with blue and purple discoloration FIGURE 1 on the medial and lateral malleolus. Ra- diographs of the right ankle identify non- displaced fractures of the distal fibula and tibia. Foot x-rays are unremarkable. A splint is ordered. The patient is given crutches (non-weight-bearing status), pain medica- tion, and a referral to orthopedics. On day 3, the patient presents to ortho- pedics, where the splint is removed. An ir- regular, 4 × 3–in (at largest diameter), se- rohemorrhagic blister is discovered on the medial aspect of the lower leg, above the right malleolus (see Figure 1). Multiple 1- to 3-mm vesicles surround much of the ante- rior border. Moderate edema is noted from the top of the lesion to the midfoot, concen- trated around the lateral and medial malle- olus. Extensive blue, purple, and black dis- coloration is seen below the malleolus. The patient is diagnosed with a fracture blister. DISCUSSION Fracture blisters are taut, bullous, subepi- dermal vesicles that can accompany frac- tures or severe twisting injuries. They overlie markedly edematous soft tissue and histo- logically resemble a second-degree burn.1,2 Physiologically, blisters are caused by in- On day 3 postinjury, the patient was found to have an irregular, creased interstitial pressure due to swelling, 4 x 3–in, serohemorrhagic blister on the medial aspect of the lower leg. mdedge.com/clinicianreviews MARCH 2018 • Clinician Reviews 29 GRANDROUNDS FIGURE 2 The differential diagnosis for fracture blisters includes friction blisters and dis- orders such as epidermolysis bullosa and bullous pemphigoid. Friction blisters form when the epidermis is subjected to repeat- ed friction or shear forces (eg, from a cast or splint).5,6 These forces mechanically sepa- rate epidermal cells at the stratum spino- sum layer.7 The pressure that moves across the skin forces fluid into the deeper open spaces, filling them but leaving the surface layer intact.1 Epidermolysis bullosa (EB) is a group of rare inherited cutaneous and mucus mem- brane disorders. EB involves fragility and detachment of subepithelial tissues, which results in blistering and erosions.8,9 The blisters tend to develop in areas subject to minor trauma, such as the extensor aspects of the elbows and the dorsal aspects of the hands and feet.9 They can also be triggered by exposure to heat, friction, scratching, and adhesive tape.10 Bullous pemphigoid, a chronic autoim- mune skin disorder, is characterized by pruritic, bullous lesions. When IgG autoan- The case patient’s fracture blister was electively unroofed tibodies bind to certain hemidesmosomal on day 3 postinjury. antigens, complement activation causes a subepidermal blister.11 While bullous pem- develop a fracture blister.4 Any condition phigoid most commonly affects those older that predisposes a patient to poor wound than 60, it can also occur in children. Diag- healing (eg, peripheral vascular disease, nosis is confirmed by skin biopsy and im- diabetes, hypertension) increases risk for a munofluorescence testing.11 fracture blister.2 Recognizing which patients are at greatest risk is vital, as implementing Treatment and management prevention strategies and intervening when Although several recommendations have fracture blisters do form can help decrease been published, there is no gold standard complications—including infection and and treatment of fracture blisters remains delayed surgery—and improve fracture controversial. Early surgical intervention resolution. In this patient’s case, the extent for fractures could decrease the incidence of the injury and force of the fall caused the of fracture blisters.1,3 fracture blister to form. The goal of treatment is to achieve re- IN THIS epithelialization of the dermis.3,12,13 Once ARTICLE Diagnosis a blister forms, management techniques • Diagnosis, Diagnosis of a fracture blister is based on vary. Some recommend keeping closed page 30 clinical presentation. There are two types: blisters covered with a dry dressing to 3 • Treatment, hemorrhagic blisters and clear fluid-filled protect them from damage. Strauss et al page 30 blisters. Hemorrhagic blisters indicate recommend unroofing to avoid traumatic • Care more severe injury and longer healing time rupture; however, this does increase risk 12 outcome, (approximately 16 d), while clear fluid-filled for infection. Recommendations differ de- page 32 blisters demonstrate minimal injury and pending on provider preference and each therefore are quicker to heal.2,4 patient’s individual situation. 30 Clinician Reviews • MARCH 2018 mdedge.com/clinicianreviews GRANDROUNDS FIGURE 3 mended as needed for pain. She was reas- sessed the following day and, due to partial refilling, the blister required additional un- roofing. The patient was instructed to re- sume previous wound care orders. No surgical intervention was required. CT of the right foot and ankle without con- trast (performed on day 4 postinjury) con- firmed a nondisplaced transverse fracture of the medial malleolus and a sagittal avul- sion fracture of the anterior-inferior lateral malleolus. Multiple smaller fracture frag- Complete resolution of the fracture blister ments were noted posterior and medial to occurred 21 days after initial discovery, the medial malleolus as well as inferiorly and the patient sustained no cutaneous along the course of the deltoid ligament. complications. There was a small, nondisplaced avulsion fracture of the medial malleolus at the an- terolateral and posterolateral tibial plafond. Elective unroofing of a blister is typically Due to the extent of the swelling, mul- followed with one of several treatment op- tiple fractures, and blister formation, the tions. These include covering the open blis- patient was essentially bed bound for the ter with a topical antibiotic cream (eg, silver first three weeks; complete resolution of sulfadiazine 2%); applying a nonadherent, the fracture blister occurred 21 days after occlusive bismuth-tribromophenate-petro- initial discovery (see Figure 3). The patient leum gauze dressing; or elevating and im- did not experience cutaneous complica- mobilizing the affected extremity.12,13 tions. Her lower extremity was then casted Treatment of spontaneously ruptured in a short-leg removable cast for 10 weeks. fracture blisters entails She underwent physical therapy, and after • Unroofing the blister completely and 12 weeks, the patient was weight-bearing applying a topical antimicrobial (eg, sil- and was discharged from orthopedics. The ver sulfadiazine, polymyxin B, neomy- patient reported refractory pain and swell- cin, bacitracin). ing for an additional eight weeks following • Applying a hydrocolloid dressing to injury, warranting daily ibuprofen. keep the environment moist. • Using a first-aid gel containing mela- CONCLUSION leuca (tea tree) oil. Fracture blisters are rare, and experience • Initiating prophylactic oral antibiotics. and knowledge about them in primary care • Using whirlpool treatments. is lacking. But clinicians need to be able to • Elevating and immobilizing the affect- identify, diagnose, and refer at-risk patients ed extremity.3,12,14 to orthopedics in a timely manner. Current management and treatment OUTCOME FOR THE CASE PATIENT recommendations are inconsistent. Treat- The fracture blister was electively unroofed ment varies depending on the site, severity, (see Figure 2, page 30) based on provider type, and status of the blister and the overall preference. The patient was instructed to health of the patient. Fracture blisters may clean the wound daily and apply topical be left intact, electively unroofed, or treated cream (silver sulfadiazine 2% bid) to the after spontaneous rupture. More research is wound and cover it with gauze. The patient needed to clarify management recommen- was made non-weight-bearing to the right dations, specifically regarding the decision lower extremity. Continuous elevation was to unroof a blister or leave it intact. Early highly encouraged except for bathing and surgical intervention may prevent the de- restroom use, and an NSAID was recom- velopment of a fracture blister. CR continued on page 33 >> 32 Clinician Reviews • MARCH 2018 mdedge.com/clinicianreviews GRANDROUNDS >> continued from page 32 REFERENCES SALARY BY SEX 1. Wallace GF, Sullivan J. Fracture blisters. Clin Podiatr Med Surg. 1995;12(4):801-811. 2. Halawi MJ. Fracture blisters after primary total knee arthroplasty. Am J Orthop. 2015; 44(8):E291-E293. 300 3. McCann S, Gruen G. Fracture blisters: a review of the literature. Orthop Nurs. 1997; NPs 16(2):17-24. 4. Uebbing CM, Walsh M, Miller JB, et al. 250 Women Fracture blister. West J Emerg Med. 2011; Men 12(1):131-133. 5. Kirkham S, Lam S, Nester C, Hashmi F. The effect of hydration on the risk of friction 200 blister formation on the heel of the foot.
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