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September 2020 Volume 4 Issue 5

BRIEF ARTICLES

Blistering Rash over Broken Ribs

Kathleen R. Graham, MD1, Bethany R. Rohr, MD2, Victor J. Marks, MD3

1Department of Internal Medicine, Summa Health System, OH
2Department of Dermatology, University Hospitals, OH
3Department of Dermatology, Geisinger Health System, Danville, PA

Fracture blisters are the result of skin
separation with fluid collection at the dermal
epidermal junction (DEJ). These bullae are
an uncommon complication of fractures.
Following a traumatic injury, patients should
be monitored for the formation of fracture
blisters. Bullae usually develop within 24-48
hours after injury, but have been
documented as early as 6 hours.1 Prompt
recognition and identification can improve
management plans. We present a case of a
55-year-old man with fracture blisters found
in a previously undocumented location.

A 55-year-old man presented to the
emergency department one day after a fall
while intoxicated. After chest X-ray was
performed, he was diagnosed with right-

sided 5th and 6th rib fractures, a pulmonary
contusion, and a pneumothorax secondary
to the impact (Figure 1). Dermatology was
consulted for a blistering rash overlying the
site of the rib fractures. The patient reported
that the blisters were not initially present at
the time of injury but were noticed the next
morning at the time of this encounter. He
denied associated pain, pruritus, or a
personal or family history of blistering
diseases. Exam revealed a six-centimeter
pink patch with multiple overlying clear-to-
yellow serous fluid filled bullae and an
erosion at the site of a ruptured bulla on the
right lateral chest wall overlying the rib
fractures (Figure 2). Differential included
fracture blisters, Varicella zoster virus,
Herpes simplex virus, bullous pemphigoid,
bullous arthropod. Routine bacterial culture
and viral polymerase chain reaction for
Varicella-zoster virus and Herpes simplex
virus types 1 and 2 from the base of a
ruptured bulla were negative, and the patient
was diagnosed with fracture blisters. The

ABSTRACT

Fracture blisters are painless fluid-filled bullae most commonly located over fractures of the
distal tibia and humerus. They are diagnosed clinically. Invasive procedures and treatments
increase the risk of wound infection and should be avoided. While there is no consensus on
management, evidence supports leaving the blisters intact and treating erosions with topical
barrier ointments or topical antibiotics. We present a rare case of a 55-year-old man with
fracture blisters located superficial to trauma-induced rib fractures that were successfully
treated with topical mupirocin.

INTRODUCTION

CASE PRESENTATION

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September 2020 Volume 4 Issue 5

patient quickly improved with topical
mupirocin ointment and gauze dressings
applied to the bullae and erosions. At one-
month follow-up, the patient noted complete
resolution of the bullae without subsequent
rash.

Figure 1. AP Chest X-ray during expiration. The top
three arrows point to the pneumothorax, and the right
bottom arrow points to the rib fractures.

Fracture blisters are subepidermal bullae
that form superficially to an underlying
fracture.1,2 Traumatic injury creates shearing
forces, hypoxia, and increased interstitial
pressure that contribute to epidermal-dermal
separation and fluid collection.2-6

The epidermis and dermis differ in
biomechanical properties, which allows for
shearing forces to cause separation at the
DEJ.1,3 The more severe the mechanism of
injury the greater the risk for fracture blister
formation. The patient in our case
experienced a fall while intoxicated and was
unable to provide more details regarding the
mechanism of injury. The presence of his

pneumothorax and pulmonary contusion
suggests a high-energy trauma, which
placed him at higher risk for developing
fracture blisters. Certain comorbidities that
impair skin integrity can further contribute to
fracture blister formation- including smoking,
alcoholism, and diabetes mellitus.1,4 Trauma
patients often have multiple comorbidities
placing this population at a higher risk for
fracture blister development.7

Figure 2. Image of the right lateral chest wall
overlying the 5th and 6th ribs shows a six-centimeter
pink patch with multiple clear-to-yellow serous fluid
filled bullae and an erosion.

Fracture blisters are a clinical diagnosis and
identification can prevent unnecessary
biopsies or other interventions. The blisters
are classically painless. Blood-filled blisters
are flaccid, while serous-filled blisters are
tense.1 Blister formation is typically noticed
within 24-48 hours of injury, but has been
recorded at as early as 6 hours and as late
as 3 weeks after injury.1,2 Typical blister
locations include the distal tibia and
humerus.1,2,5,8 The patient in our case
developed fracture blisters over fractured

DISCUSSION

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September 2020 Volume 4 Issue 5

ribs, which is a location that has not been
previously documented.

Prevention strategies include elevation of
the affected extremity and early surgical
fixation before presence of blisters.1,5 There
is no consensus on the treatment for
fracture blisters.4 Current evidence
recommends avoiding surgery when fracture
blisters are present. If the patient requires
an emergent operation, then incision directly
through blood-filled blisters should be
avoided as it is associated with higher
morbidity.3 There is conflicting evidence on
whether to leave the blisters intact or de-roof
them.1,4 Fracture blister fluid is sterile, but
when blisters are de-roofed, bacterial
colonization occurs rapidly and can be a
source of morbidity.1 The use of topical
barrier ointment, silver sulfadiazine, or a
topical antibiotic on spontaneously ruptured
blister beds is recommended.3,6 A recent
case study described the addition of an oral
antibiotic with blister rupture to prevent
complications.9 On average, serous filled
blisters re-epithelialize in 12 days and blood
filled blisters in 16 days.3

Fracture blisters are an uncommon
complication of trauma-induced fracture.1,8
While typically found at the distal tibia or
humerus, fracture blisters can be found at
other locations. Clinicians should maintain a
high index of suspicion for fracture blisters
when evaluating trauma patients as early
identification can improve patient care by
providing proper management and
preventing invasive procedures.

Conflict of Interest Disclosures: None

Funding: None

Corresponding Author:
Kathleen R Graham, MD
Department of Internal Medicine
Summa Health System
55 Arch Street, Ste 1B
Akron, OH 44304
Phone: 330-714-3978
Email: grahamkat@summahealth.org

References:
1. Refs Varela C, Vaughan TK, Carr J, et al.

Fracture Blisters: Clinical and Pathologic
Aspects. J of Orthopedic Trauma. 1993;7(5):417–
27.

2. Wallace GF, Sullivan J. Fracture Blisters. Clin
Podiatric Med Surg. 1995;12(4):801–12.

3. Giordano CP, Koval KJ, Zuckerman JD, Desai P.
Fracture blisters. Clin Orthop Relat Res.
1994;(307):214-221.

4. Strauss E, Petrucelli G, Bong M, Koval K, Egol K.
Blisters Associated with Lower Extremity
Fracture: Results of a Prospective Treatment
Protocol. J of Orthopedic Trauma. 2006
Oct;20(9):618–622.

5. Ballo F, Maroon M, Millon SJ. Fracture blisters. J
Am Acad Dermatol. 1994;30:1033-1034.

6. Finklea LB, Becker LE. Hemorrhagic and serous-
filled vesicles and bullae. Fracture blisters. JAMA
Dermatol. 2013;149:751-756.

7. Tan CP, Ng A, Civil I. Co-morbidities in trauma
patients: common and significant. N Z Med
J. 2004;117:U1044.

8. Uebbing CM, Walsh M, Miller JB, Abraham M,
Arnold C. Fracture Blisters. West J Emerg Med.
2011;12(1):131-133.

9. Halawi MJ. Fracture Blisters After Primary Total
Knee Arthroplasty. Am J Orthop.
2015;44(8):E291-E293.

CONCLUSION