Fracture Blisters in a Patient Admitted to Acute Inpatient Rehabilitation Hospital: A Case Report

Case Diagnosis: Fracture Blisters

Case Description or Program Description: A 90-year-old male presented complaining of right leg pain after an unwitnessed fall. X-ray demonstrated an acute fracture dislocation of the right ankle with anteromedial dislocation of the tibia relative to the talus and a laterally displaced oblique fracture of the distal fibula. The fracture was manually reduced and splinted. Orthopedic surgery recommended immobilization and non-weightbearing for 6-12 weeks. Subsequently, patient was discharged to an acute inpatient rehabilitation (AIR) hospital. Five days after the injury, nursing found the patient’s splint saturated in blood.

Setting: Acute Inpatient Rehabilitation Hospital

Assessment/Results: The on-call resident physician removed the dressing and found diffuse large hemorrhagic blistering, particularly over the medial and lateral malleoli. Bleeding was controlled and wounds were redressed. Fracture blisters were formally diagnosed and treatment included draining the blisters and re-dressing the wounds with Xeroform. The patient subsequently underwent an uneventful course of rehabilitation and was ultimately discharged home.

Discussion (relevance): Fracture blisters are defined as tense vesicles or bullae occurring in swollen tissue overlying a fracture. The incidence of fracture blisters ranges from 2.9% to 7.2% of fractures requiring hospitalization. Fracture blisters most commonly occur in anatomic areas with less muscle and adipose tissue. The hypothesized pathophysiology of fracture blisters includes post-traumatic edema and local tissue hypoxia, culminating in a damaged dermal-epidermal junction. These unique blisters closely resemble second-degree burns. Complications include heightened risk from surgical intervention, infection, poor wound healing, and scar formation. Notably, minimal literature and no consensus recommendation for treatment of fracture blisters exist. Treatment typically includes judicious wound care and deferring surgical intervention until blistering resolves. Applying silver sulfadiazine cream twice daily to unroofed blisters was reported to promote wound re-epithelialization and cosmetic satisfaction upon healing.

Conclusions: Physiatrists should be cognizant of this atypical complication imposing challenges, regarding recognition and treatment, on the AIR team and patients during their rehabilitation.