High energy injury, such as falls of an average of 18 feet, motor vehicle accidents, pedestrian vs. Risk factors for development of fracture blisters include anatomical sites with thinner skin without the underlying protection of muscle or adipose (ankle, wrist, elbow, foot, and distal tibia) and any conditions that predispose to poor wound healing, such as peripheral vascular disease, collagen vascular disease, hypertension, smoking, alcoholism, diabetes mellitus, and lymphatic obstruction. Blisters can form as early as six hours post fracture and the majority within 24–48 hours. 1 These forces combine to cause an injury which resembles a second-degree burn rather than a friction blister. Venous stasis due to thrombosis of injured vessels and fragile lymphatics also contribute to local tissue hypoxia leading to epidermal necrosis and blister formation. 1 The blister formation is proposed to result from the increased interstitial pressure of post-traumatic edema, which acts to decrease cohesion between epidermal cells and facilitate fluid transport into a blister cavity. Anatomic areas where tight, closely adhered skin without a muscle or enveloping fascia is present appear to be the sites most predisposed to this type of injury. Physical exam revealed interval formation of large, palm-sized, mixed clear and hemorrhagic blisters along the anterior distal mid calf to the medial and dorsal aspects of the left foot ( Figure 1 and and2 2).įracture blisters are hypothesized to result from large strains applied to the skin during the initial fracture deformation, 2 causing a cleavage injury at the dermo-epidermal junction. He did admit to walking on his splint to get back and forth to the bathroom, but said that he thought it was only a sprain. The patient presented two days later complaining of blisters bulging from his splint. The patient was advised on non-weightbearing status and follow up with orthopedics in one week. Radiograph showed a non-displaced left fibular fracture, which was stabilized in a posterior splint in the ED. Physical exam revealed no evidence of injury other than swelling and tenderness to palpation over the left lateral ankle. Vital signs were temperature, 98.7☏ blood pressure, 200/93mmHg pulse, 83 beats/min respiratory rate 14 breaths/min SpO 2, 96% room air.
He has a past history of hypertension, tobacco and alcohol use. A 63-year-old male presented to the emergency department (ED) via emergency medical service after slipping on ice and twisting his left ankle.
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