Simple, closed calcaneal (heel) fracture. What comes to mind? Treatment may include a short leg cast, crutches to assist with non-weight bearing, perhaps some pain medication. Possibly surgery.

What would you say if I told that there lurks a relatively uncommon but insidious complication which can lead to infection, osteomyelitis, amputation, even death? Well, there is. It’s called a fracture blister. Left undetected or improperly treated, these complications are more than possible. The person is at high risk.

What are fracture blisters? They are areas of skin bullae (bubbles) that arise where there is markedly swollen skin over a fracture or severe sprain. The sites most at risk are fractures of the ankle, elbow, foot, or distal tibia (lower shin bone).

Fracture blisters can resemble second-degree burns. The outer layer of the skin (epidermis) separates from the second layer of skin (dermis) due to the buildup of fluid. The epidermis becomes necrotic. The underlying dermal and subcutaneous (innermost layer) tissue are at risk for further necrosis. Eventually, there can be full thickness skin loss, which may require skin grafting.

Fracture blisters can be filled with either clear fluid or with blood. Blood-filled blisters represent a more significant injury. Circulatory compromise can occur due to the swelling and venous stasis (decreased blood flow) associated with the fracture.

If the blister is ruptured, the patient is at increased risk for developing significant infections, including MRSA (Methicillin Resistant Staph Aureus), in the wound. Left untreated, full blown osteomyelitis (infection in the bone) can develop. This can be difficult to treat and may require long-term antibiotics. The patient may require multiple debridements of the wound. If the osteomyelitis persists or progresses, amputation may eventually be required. Yes…for “just” a blister!

Other complications of fracture blisters include delayed surgical repair of a fracture and non-union of a fracture. If surgical repair is performed after the development of a fracture blister, the patient is at higher risk for developing a wound infection. Patients may also develop additional skin breakdown and chronic ulcers. Prolonged, painful hospital stays may be inevitable.

People at higher risk for developing fracture blisters include those with other medical problems including peripheral vascular disease (poor circulation in their legs), diabetes, and smokers. To help prevent the development of fracture blisters, the limb should be immobilized and elevated to reduce swelling. If surgical repair of a fracture is required, it should ideally be done within 6 to 24 hours, before any fracture blisters develop.

Patients should be carefully assessed for the development of fracture blisters, which may occur as early as 6 hours after the fracture. There is disagreement about the treatment of fracture blisters and whether or not to leave them intact.

Early diagnosis and treatment of infection in the wound can help to prevent the progression to more devastating conditions and complications. Patients with other medical problems or impaired tissue healing should be closely followed. They should be admitted to the hospital if fracture blisters develop for treatment and to avoid further complications.

Just a blister…think again!

We have two cases right now involving blisters that led to osteomyelitis. In one case, we’re summarizing pain and suffering associated with the extensive care needed to treat the osteomyelitis, which was unsuccessful in avoiding a below the knee amputation. In the other case, we supplied an expert witness.

Med League provides medical expert witnesses to trial lawyers. Please call us at (908)788-8227 or contact us today to discuss your next case.