Replies to BK Blisters
Don McGovern
Description
Collection
Title:
Replies to BK Blisters
Creator:
Don McGovern
Date:
11/3/2008
Text:
Below is the original post followed by the many replies. I have made a few replies in italics for clarity to the list.
Thank you all so much for your assistance. Hopefully, in the near future I can report a satisfactory result.
Don McGovern, CPO
Original Question:
I have been working with a gentleman who has undergone a transtibial (and
fibular) amputation secondary to diabetes within the last 6 months. He is
in his late 50s. The residual limb was healed enough for preprosthetic care
within a month. Thus far we have attempted two RRDs, a variety of shrinkers
(Juzo/ Compresso Grip) lined or unlined with Xstatic socks, and the last
item we tried for want of ideas - a Medipro silicone liner. All of the
above were d/ced due to blistering of the residuum after about 24-36 hours.
The blisters are usually between 2 to 4 cm in diameter, and mostly on the
distal end, though not over bony areas. The blisters form, pop, drain, and
heal. Even a 5ply sock alone had the same reaction. The residuum is well
healed otherwise, good length, good shape. The person would do quite well
if the blister phenomenon would cease. Any suggestions would be
appreciated.
Replies:
Seems to me that you are getting circumferential compression without adequate distal pressure. My suggestion would be to apply a compression stump bandage elset. If applied properly you will get distal pressure that is even to the circumferential pressure and the blisters should cease. Bandage to be removed and reapplied every 4 hours. Of the things you have tried all will not give adequate distal pressure. In most cases they are fine but in this case I think you have to bandage.
regards
--------------------------------------
Wow.
As I always tell folks, the fluid causing the edema will follow the path of least resistance especially when compression is applied.
With that, does he have a latex allergy? No - we have stayed away from latex since the Compressogrip - even that says it is latex free -DM.
Is he being compliant (truly) w/not leaving his residuum hang dependent? This is Questionable, but he is just as compliant without any coverings, but only gets blisters with any type of covering even a simple sock - DM.
Are there heart issues &/or a change in his meds? Not that his doctor knows of - DM
My 1st 2 thoughts were:
He is not keeping the limb up OR he is having an allergic Rxn to the subQ sutures. He only gets the blisters after wearing something, whether compression is present or not.
Way out there is: a work w/a lady who has a skin condition called bullous pemphigoid- this causes blister-like eruptions anywhere on the body @ anytime. Hers seemed exacerbated w/stress. Used an Ossur TF loner on her w/o Rxn...happily surprised.
Good Luck & Post findings.
-------------------------------------------
Don, my experience is that time will resolve this problem. I am assuming that the little water blisters are being caused by the surface circulation dead ending at the incision line. I do recommend that the patient massage the residual limb at the incision line as well as towel pulls and light towel rubbing across incision line. This gives the paitent something positive to do and may even help while the circulation improves and the blisters self resolve. Good luck.
---------------------------------------------
I am the Clinical Director for OPGA. In my previous life before being a prosthetist (pre 1988) I was a practicing Orthopaedic Physician Assistant. I routinely saw what you described from those days up to and including today's care that I provide to diabetic amputees. It sounds like you are describing fracture blisters. Most are filled with serous, rarely blood. These are not from friction.
I am in Iowa. Female prosthetists DO NOT tell farmers to leave their leg off because of a blister they cannot even feel due to their neuropathy. So I got real practical fast.
Leave blister intact until they spontaneously burst. This will prevent local epithelials from contaminating wound. Leave the roof alone until it is obviously sloughing off. Have your attending order a small amount of Silvadene. I have been successful with the use of a small amount of Silvadene and very critical to apply a Telfa like non-stick pad overtop. This is for when the leg is on and off. Decreases the co-efficient of friction as well. Make sure it is at least a 3x3. 2x2 migrates too much. Well fit socket with weight-bearing secures its position. If it moves around too much, decrease the amount of Silvadene. I have used this technique on transtibials only. It is peculiar, but I have never had an AK with this. Perhaps it is because the vessel diameters are larger and deeper.
Stump socks, gel liners, shrinkers have all been used over this telfa pad technique, whichever you prefer. You must stress the importance of non-contamination of the Silvadene jar to whoever is providing the care to prevent cross contamination. In skiers, Tib/fib fractures could take upwards of 9 months to a year if severe enough. Since amputation is the epitome of a fracture, this is not unheard of but not that common either. The internal pressure of the amount of fluid is simply pushing it out the pores. Your patient's timeline is right on with this.
I must also tell you of a second technique I learned from the patient. He believed in a liquid called Ginsing Violet. Comes in this little bottle like Iodine/Merthiolate. It is purple! It is a drying agent for wound healing he used in this childhood pre-antibiotic days. It was amazing how it worked for him. He lived with his fracture blisters for over a year. OTC at most pharmacies.
I hope this was helpful for some great brainstorming. Would love to hear back if this does work and what you ended up using. I am always searching for treatments to improve the quality of care we provide. Good luck to you and your patient. Have a great week.
-------------------------------------------
I don't think that is a blister. It sounds like a fluid filled bursa the usually happens when someone is on a poorly fitting socket for awhile. Wait until it goes down and heals and then fit him. It make take awhile. Sometimes they can be drained but that may not be a good idea consdiering his diabetes.
------------------------------------------
IVE USED LINER LINERS FOR SOME OF MY PATIENTS
----------------------------------------
Sounds like edema rather than a reaction to materials. How does the limb
volume compare with the sound limb at comparable levels?
Perhaps all of the previous attempts have actually caused fluid to stagnate
in the residuum. I would try wrapping with attention to proper technique
using an elastic bandage to encourage fluid to move proximal into
circulation. This was attempted - 24-36 hours blisters appearred on the distal area again - DM
----------------------------------------
I had a patient that was exactly as described. He ended up having MRSA....... Be careful..
-----------------------------------------
I'm guessing that this person has a significantly large residual limb which is quite bulbous. I've had similar issues and unfortunately it comes down to the circulatory system's inability to absorb the excess edema. When putting any form of compression therapy the result is the fluid escaping at the point of least resistance which may be the dermis especially along the suture line. Actually the limb is just about a perfect shape and size, the person is not over weight - DM.
The only treatment I'm aware of would be intensive use of a diuretic to help siphon off the excess fluid.
------------------------------------------
Thank you all so much for your assistance. Hopefully, in the near future I can report a satisfactory result.
Don McGovern, CPO
Original Question:
I have been working with a gentleman who has undergone a transtibial (and
fibular) amputation secondary to diabetes within the last 6 months. He is
in his late 50s. The residual limb was healed enough for preprosthetic care
within a month. Thus far we have attempted two RRDs, a variety of shrinkers
(Juzo/ Compresso Grip) lined or unlined with Xstatic socks, and the last
item we tried for want of ideas - a Medipro silicone liner. All of the
above were d/ced due to blistering of the residuum after about 24-36 hours.
The blisters are usually between 2 to 4 cm in diameter, and mostly on the
distal end, though not over bony areas. The blisters form, pop, drain, and
heal. Even a 5ply sock alone had the same reaction. The residuum is well
healed otherwise, good length, good shape. The person would do quite well
if the blister phenomenon would cease. Any suggestions would be
appreciated.
Replies:
Seems to me that you are getting circumferential compression without adequate distal pressure. My suggestion would be to apply a compression stump bandage elset. If applied properly you will get distal pressure that is even to the circumferential pressure and the blisters should cease. Bandage to be removed and reapplied every 4 hours. Of the things you have tried all will not give adequate distal pressure. In most cases they are fine but in this case I think you have to bandage.
regards
--------------------------------------
Wow.
As I always tell folks, the fluid causing the edema will follow the path of least resistance especially when compression is applied.
With that, does he have a latex allergy? No - we have stayed away from latex since the Compressogrip - even that says it is latex free -DM.
Is he being compliant (truly) w/not leaving his residuum hang dependent? This is Questionable, but he is just as compliant without any coverings, but only gets blisters with any type of covering even a simple sock - DM.
Are there heart issues &/or a change in his meds? Not that his doctor knows of - DM
My 1st 2 thoughts were:
He is not keeping the limb up OR he is having an allergic Rxn to the subQ sutures. He only gets the blisters after wearing something, whether compression is present or not.
Way out there is: a work w/a lady who has a skin condition called bullous pemphigoid- this causes blister-like eruptions anywhere on the body @ anytime. Hers seemed exacerbated w/stress. Used an Ossur TF loner on her w/o Rxn...happily surprised.
Good Luck & Post findings.
-------------------------------------------
Don, my experience is that time will resolve this problem. I am assuming that the little water blisters are being caused by the surface circulation dead ending at the incision line. I do recommend that the patient massage the residual limb at the incision line as well as towel pulls and light towel rubbing across incision line. This gives the paitent something positive to do and may even help while the circulation improves and the blisters self resolve. Good luck.
---------------------------------------------
I am the Clinical Director for OPGA. In my previous life before being a prosthetist (pre 1988) I was a practicing Orthopaedic Physician Assistant. I routinely saw what you described from those days up to and including today's care that I provide to diabetic amputees. It sounds like you are describing fracture blisters. Most are filled with serous, rarely blood. These are not from friction.
I am in Iowa. Female prosthetists DO NOT tell farmers to leave their leg off because of a blister they cannot even feel due to their neuropathy. So I got real practical fast.
Leave blister intact until they spontaneously burst. This will prevent local epithelials from contaminating wound. Leave the roof alone until it is obviously sloughing off. Have your attending order a small amount of Silvadene. I have been successful with the use of a small amount of Silvadene and very critical to apply a Telfa like non-stick pad overtop. This is for when the leg is on and off. Decreases the co-efficient of friction as well. Make sure it is at least a 3x3. 2x2 migrates too much. Well fit socket with weight-bearing secures its position. If it moves around too much, decrease the amount of Silvadene. I have used this technique on transtibials only. It is peculiar, but I have never had an AK with this. Perhaps it is because the vessel diameters are larger and deeper.
Stump socks, gel liners, shrinkers have all been used over this telfa pad technique, whichever you prefer. You must stress the importance of non-contamination of the Silvadene jar to whoever is providing the care to prevent cross contamination. In skiers, Tib/fib fractures could take upwards of 9 months to a year if severe enough. Since amputation is the epitome of a fracture, this is not unheard of but not that common either. The internal pressure of the amount of fluid is simply pushing it out the pores. Your patient's timeline is right on with this.
I must also tell you of a second technique I learned from the patient. He believed in a liquid called Ginsing Violet. Comes in this little bottle like Iodine/Merthiolate. It is purple! It is a drying agent for wound healing he used in this childhood pre-antibiotic days. It was amazing how it worked for him. He lived with his fracture blisters for over a year. OTC at most pharmacies.
I hope this was helpful for some great brainstorming. Would love to hear back if this does work and what you ended up using. I am always searching for treatments to improve the quality of care we provide. Good luck to you and your patient. Have a great week.
-------------------------------------------
I don't think that is a blister. It sounds like a fluid filled bursa the usually happens when someone is on a poorly fitting socket for awhile. Wait until it goes down and heals and then fit him. It make take awhile. Sometimes they can be drained but that may not be a good idea consdiering his diabetes.
------------------------------------------
IVE USED LINER LINERS FOR SOME OF MY PATIENTS
----------------------------------------
Sounds like edema rather than a reaction to materials. How does the limb
volume compare with the sound limb at comparable levels?
Perhaps all of the previous attempts have actually caused fluid to stagnate
in the residuum. I would try wrapping with attention to proper technique
using an elastic bandage to encourage fluid to move proximal into
circulation. This was attempted - 24-36 hours blisters appearred on the distal area again - DM
----------------------------------------
I had a patient that was exactly as described. He ended up having MRSA....... Be careful..
-----------------------------------------
I'm guessing that this person has a significantly large residual limb which is quite bulbous. I've had similar issues and unfortunately it comes down to the circulatory system's inability to absorb the excess edema. When putting any form of compression therapy the result is the fluid escaping at the point of least resistance which may be the dermis especially along the suture line. Actually the limb is just about a perfect shape and size, the person is not over weight - DM.
The only treatment I'm aware of would be intensive use of a diuretic to help siphon off the excess fluid.
------------------------------------------
Citation
Don McGovern, “Replies to BK Blisters,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 23, 2024, https://library.drfop.org/items/show/229828.
