Management of the Morel-Lavallée Lesion

More Than a Bruise: Two Cases of Morel-Lavallée Lesions in Active Duty Soldiers

Soft tissue injuries are common in the military, generally producing simple hematomas without the need for intensive evaluation and management. In certain situations, a shearing effect between fascial planes whereby a disruption of the vasculature and lymphatic systems creates a "closed degloving injury" is more generally referred to as a Morel-Lavallée Lesion (MLL). With a consistent pool of blood, lymph, and pieces of soft tissue, an M7LL can cause significant poor cosmesis, chronic pain, and risk secondary infection if left undetected and untreated. Proper diagnosis can be made through the effective use of ultrasound and, if detected early enough, through conservative measures to include needle aspiration and compression sleeves. Prior cases describe chronic MLLs existing for extended periods of time, in some cases years, requiring operative intervention, and in some cases poor outcomes. We present two cases of active duty soldiers presenting with seemingly innocuous injuries found on closer evaluation to have MLL, treated in one case with needle aspiration and compression, in the other with operative management.

The Morel-Lavallée Lesion: Review and Update on Diagnosis and Management

Morel-Lavallée lesion is a closed soft tissue degloving injury usually associated with high-velocity trauma. It most commonly occurs in the thigh, hip, and pelvis. Because such lesions are prone to a missed or delayed diagnosis, it may present a potential risk of infection at the fracture site once it progresses. Therefore, timely identification and management of Morel-Lavallée lesion is crucial. Moreover, there are no relevant guidelines for the treatment of Morel-Lavallée lesion. Based on the above facts, we reviewed the etiology, epidemiology, pathophysiology, clinical presentation, imaging features, treatment, prognosis, and complications of Morel-Lavallée lesion with the aim of providing a comprehensive overview of Morel-Lavallée lesion, increasing awareness of this injury among orthopaedic surgeons, and thus providing a management algorithm that can be applied to this injury.

Outpatient Treatment of Refractory Morel-Lavallée Lesion Infection With Retention Sutures: A Case Report

We report the case of a 41-year-old man with a Morel-Lavallée lesion (MLL) that developed an infection. The patient was initially treated with intravenous antibiotics, but the infection persisted. He was then treated with outpatient cleansing and retention sutures, which resulted in successful wound healing. This case report demonstrates the efficacy of outpatient cleansing and retention sutures for the treatment of MLL infection. This treatment modality is less expensive than inpatient treatment, and it allows the patient to return to their normal activities sooner.

Traumatic Degloving Wounds Treated With Low Continuous Wall Suction Drainage: A Novel and Effective Technique to Prevent Recurrence

Soft tissue degloving wounds overlying fractures present a technical surgical challenge and have a high rate of recurrence. Despite several current treatment methods, there remains a need for improved therapies to address this complex issue. The purpose of this study was to introduce a novel technique for managing soft tissue degloving wounds in the setting of fractures requiring operative fixation. Eleven consecutive patients with soft tissue degloving wounds overlying operatively managed fractures were treated with our novel technique for "dead space" elimination in the peri-operative period. The technique entails placing Jackson Pratt drain(s) within the degloving wound during operative debridement and placing them to low continuous wall suction postoperatively. This patient series shows that the application of 40 to 60 mm Hg of negative pressure allows for thorough drainage of the hemolymphatic fluid collection and elimination of dead space, allowing the delaminated tissue layers to heal together and preventing recurrence. [Orthopedics. 2023;46(4):e257-e263.].

Lower Extremity Sandblast Injury: A Rarely Seen Injury Mechanism in the Civilian Population

Blast injuries are both complex and rare in the civilian population. This combination can often lead to missed opportunities for early, effective intervention. This is a case report of a 31-year-old male who suffered a lower extremity blast injury while using an industrial sandblaster. This blast injury presented as a closed degloving, or Morel-Lavallee lesion, which can easily be mistreated and lead to infection and further disability. Following assessment, identification, and confirmation of the Morel-Lavallee lesion via radiographic imaging, this patient underwent debridement surgery, wound vac therapy, and antibiotic treatment before being discharged home with no major physiologic or neurologic deficits. The purpose of this report is to highlight the importance of assessing for closed degloving injuries when presented with blast injury traumas in the civilian trauma setting, and outlines the process utilized for assessment and treatment.

Ten-year incidence and treatment outcomes of closed degloving injuries (Morel-Lavallee lesions) in a level 1 trauma centre

INTRODUCTION

Morel-Lavallée lesions (MLL), also referred to as closed degloving injuries, result from traumatic shearing forces with separation of the subcutaneous fat from the underlying fascia. The aim of this study was to determine the incidence and treatment of MLLs at a level 1 trauma centre.

METHODS

Single-centre retrospective cross-sectional study of consecutive patients with an imaging diagnosis of a Morel-Lavallee lesion from 1/1/2010-31/12/2019. Demographic data, mechanism of injury, volume of lesion, management and outcome data were collated.

RESULTS

Sixty-six MLLs were identified in 63 patients (64% Male) with a median age of 49.5 years (19-94 years). Mechanism of injury were road traffic accidents in the majority (66%). Median injury severity score (ISS) was 17 (range 1-33). Patients on oral anti-coagulants had significantly larger lesions (181.9 cc v 445.5 cc, P = 0.044). The most common lesion location was the thigh (60.5%). Patients that underwent imaging within 72 h of injury had significantly larger lesions than those imaged more than 72 h after the inciting trauma (65 cc v 167 cc, P < 0.05). Management data were documented in 59% of lesions (39/66) in which 66.6% (n = 26) had invasive treatment. In the 31 patients where follow-up was available, 64.5% (n = 20) were persistent but decreasing in size. There was no significant difference in follow-up size for those who had invasive compared to conservative treatment (P = 0.3).

CONCLUSION

The diagnosis of MLL should be considered for soft-tissue swelling in the context of shearing trauma. A variety of management options have been employed, with good overall outcomes.

Morel-Lavallée Lesion of the Elbow Region ‎in a Young Male: Case Report and ‎Literature Review

The Morel-Lavallée lesion is a fluid collection resulting from the traumatic separation ‎of the ‎subcutaneous tissue from the underlying fascia. It frequently occurs over the trochanteric ‎region but ‎may also occur in the flank, lumbosacral region, and buttock. Morel-Lavallée lesions ‎in the upper limb are rarely reported in the literature.‎

In this report, we present a case of a 42-year-old male, not known to have ‎‎any medical ‎diseases, who suffered from a post-traumatic left elbow mass that had existed for seven months before his presentation to our clinic. It is worth reporting this case to increase the awareness of ‎this little-known pathology among orthopedic surgeons. In addition, most of the Morel-Lavallée ‎lesions mentioned in the literature are located in the lower limb.‎

Peripelvic Morel-Lavallée lesion following high-energy spine trauma: Case report and review of treatment options

The Morel-Lavallée lesion (MLL) is an internal degloving injury typically associated with high-energy trauma and is suspected to be underdiagnosed in a majority of cases. Here, we illustrate the typical clinical and radiological characteristics of an extensive peripelvic MLL in a 50-year-old patient presenting to our trauma outpatient clinic with peripelvic pain, bruising and swelling six weeks after severe spine trauma caused by a high-energy car accident. Using this case study as an example, current therapeutic approaches are discussed. Therapeutic decisions should be based on clinical symptoms, lesion size, severity, age and co-morbidities. Extensive, symptomatic and chronic lesions should be addressed with early débridement, irrigation and drainage in order to prevent complications like infection or soft tissue necrosis.

Morel-Lavallée lesion associated with atypical skin damage: a case report

A Morel-Lavallée lesion is a post-traumatic, soft tissue lesion that is little known and for which there is no standard treatment. This report describes the case of a 51-year-old man who presented with a large Morel-Lavallée lesion on the left calf that was not diagnosed on two visits to the emergency department. Given the deteriorating condition of the skin, we performed surgical drainage of the effusion because the skin was showing signs of major damage. Complications occurred following surgery, with cellulitis in the lower limb caused by Citrobacter Koseri, a gram-negative bacillus that is rarely implicated in soft tissue infections, and wound dehiscence. The purpose of our article is to present the difficulty involved in choosing the right treatment from among the many proposed in the literature, and to inform any practitioner working in an emergency setting about the existence of this often overlooked condition.

Practical Review of the Comprehensive Management of Morel-Lavallée Lesions

Morel-Lavallée lesions have been described in the literature since the mid-19th century, yet contemporary clinical management continues to be challenging and remains variable. These closed degloving injuries are usually seen in the setting of blunt trauma and are due to shearing forces, creating a space for the collection of hemolymphatic fluid. These fluid collections can be persistent despite conservative treatment attempts and can require staged surgical interventions.

Sclerotherapy as an alternative treatment for complex, refractory seromas

Traditional therapy for seromas often entails compression, aspiration, drainage, or surgical excision and re-closure; however, more complex, treatment-refractory seromas may require additional treatment. Sclerotherapy has been well documented in the treatment of simple pleural effusions, vascular malformations, lymphoceles and seromas. However, little evidence is available on the efficacy of sclerotherapy in complex, treatment-refractory seromas that develop post-operatively in patients with complex medical histories. We present a case series highlighting the use of sclerotherapy by interventional radiology as an alternative or adjunctive treatment method for chronic, high-volume post-operative seromas recalcitrant to multiple attempts of traditional treatment. At long-term follow-up, the seromas resolved after a maximum of four rounds of sclerotherapy with various combinations of known sclerosants. Highly complex cases of large, chronic seromas may be refractory to conservative modalities and re-closure. Sclerotherapy can be considered an alternative method or adjunctive treatment for chronic, recalcitrant post-operative seromas.

[Application of channel screw combined with skin-stretching technique in treatment of pelvic fracture with severe Morel-Lavallée lesion]

OBJECTIVE

To investigate the effectiveness of channel screw combined with skin-stretching technique in treatment of pelvic fracture with severe Morel-Lavallée lesion.

METHODS

Between January 2017 and May 2020, 11 patients with pelvic fractures complicated with severe Morel-Lavallée lesions were treated with channel screw combined with skin-stretching technique. There were 8 males and 3 females, with an average age of 39.2 years (range, 28-58 years). Causes of injury included traffic accident in 9 cases and falling from hight in 2 cases. The time from injury to hospital admission ranged from 1 to 6 days (mean, 3.7 days). According to the Tile classification, the pelvic fractures were rated as type C1 in 7 cases, type C2 in 3 cases, and type C3 in 1 case. The sites of Morel-Lavallée lesions were buttocks in 8 cases, hips in 2 cases, and thigh in 1 case. There was 1 case of rectal injury, 1 case of splenic rupture, 3 cases of craniocerebral injury, 2 cases of chest injury, 4 cases of spinal fracture, and 6 cases of sacral nerve injury. X-ray films were performed to observe reduction and healing of fracture. The quality of fracture reduction was evaluated by Matta standard at 1 week after operation. Wound healing and complications were observed. Majeed scoring was used to evaluate hip function and Gibbons sacral nerve injury grading was used to evaluate neurological function recovery.

RESULTS

The patients underwent 4-7 operations, with an average of 5.8 operations. The time of first operation (pelvic fracture fixation, debridement, and skin distractor installation) was 115-275 minutes, with an average of 186.5 minutes. The amount of intraoperative blood loss was 30-80 mL, with an average of 45.5 mL. All patients were followed up 6-12 months, with an average of 8.3 months. The quality of fracture reduction according to the Matta standard was excellent in 7 cases, good in 2 cases, and fair in 2 cases, with an excellent and good rate of 81.8%. All fractures healed at 3-6 months after operation, with an average of 4.5 months. At last follow-up, the hip functions were excellent in 7 cases and good in 4 cases according to Majeed scoring, with an excellent and good rate of 100%. Among the 6 patients complicated with sacral nerve injury, the Gibbons sacral nerve injury grading reached gradeⅠ for 4 cases, gradeⅡ for 1 case, and grade Ⅲ for 1 case. The wounds of 9 cases were sutured directly after skin-stretching treatment for 25-32 days, with an average of 28 days. The dermal edge necrosis occurred in 1 case, and the defect was repaired by free skin grafting. The skin superficial dry necrosis of the wound occurred in 1 case, and healed by dressing change.

CONCLUSION

In the treatment of pelvic fracture complicated with severe Morel-Lavallée lesion, the channel screw and skin-stretching technique showed their own advantages, which can obtain early fracture fixation and good wound healing.

Huge scalp Morel-Lavallée lesion with eye involvement in a 3-year-old girl: a case report

Background

Morel-Lavallée lesions are posttraumatic, closed degloving injuries in which the skin and subcutaneous tissue are separated abruptly from superficial underlying fascia. This condition leads to an effusion containing hemolymph and necrotic fat. Magnetic resonance imaging, when available, is the modality of choice in the evaluation of Morel-Lavallée lesion. Early diagnosis and management is essential as any delay in diagnosis or missed lesion will lead to the effusion becoming infected or leading to extensive skin necrosis. We present a condition of a Morel-Lavallée lesion involving the scalp and complicated by conjunctival chemosis.

Case presentation

We report on a 3-year-old black African girl who presented a fluctuant swelling of entire scalp, extending to upper part of the face on the seventh day after a forehead trauma due to falling on a rock while playing. Skull x-ray revealed soft-tissue swelling, giving an impression of large fluid collection in the deep subcutaneous tissues with no bone fracture. A diagnosis of Morel-Lavallée lesion of the scalp complicated by conjunctival chemosis was made. The patient was managed with percutaneous drainage and compression bandage. The patient improved well and was subsequently discharged without any vision impairment. There was no recurrence of the lesion on follow-up.

Conclusions

The Morel-Lavallée lesion of the scalp complicated with conjunctival chemosis is a rare presentation of this condition. Prompt diagnosis and management are crucial for preventing complications. Image-guided diagnosis and treatment still remain a challenge in the setting of low-resource health facilities.

Morel-Lavallée Lesion of the knee after low-energy impact in a healthy non-athlete

BACKGROUND AND OBJECTIVE

Morel-Lavallée Lesion (MLL) of the knee is an uncommon cause of knee swelling usually due to high-energy impact or in patients on anticoagulation. MLL of the knee due to low-energy non-athletic associated trauma in patients without antithrombotic therapy is rare. Early diagnosis can be achieved using point-of-care ultrasound.

CASE REPORT

A 60-year-old female who was previously well was referred to our center for a persistently swollen left knee 2 months after a fall while on a flight of stairs. A point-of-care ultrasound identified a possible MLL of the knee. This was subsequently confirmed on magnetic resonance imaging (MRI). The lesion resolved with ultrasound-guided therapeutic aspiration.

CONCLUSION

MLL of the knee should be a differential diagnosis of traumatic knee swelling, even in low-energy trauma and in patients without bleeding diatheses. Ultrasound is a readily available and rapid modality that can aid both in the diagnosis and management of such lesions.

Morel-Lavallée lesions (internal degloving injuries) of the lower extremity in the pediatric and adolescent population

PURPOSE

To describe the largest case series of lower extremity traumatic internal degloving injury, i.e. Morel-Lavallée lesion (MLL) in the pediatric and adolescent population, its treatment and outcomes.

METHODS

Retrospective review of patients under 18 years who presented with MLL to a tertiary children's hospital. Demographic, clinical, radiographic, treatment and outcomes data were collected. Descriptive statistical analysis was conducted.

RESULTS

38 patients having MLL with mean age 14.6 years were classified into two groups: hip/thigh MLL (nine patients) and lower leg MLL (29). Most common cause of lower leg and hip/thigh MLL was sports injury (79.3%) and motor vehicle accident (MVA) (33%) respectively. Most implicated sports were football and baseball. Primary care physicians/pediatricians were the initial treating providers for 63% of patients. Imaging modality of choice was magnetic resonance imaging (MRI) for lower leg MLLs (72.4%) and ultrasonography (US) for hip/thigh MLL (66.7%). Twenty-five (65.8%) patients were treated with conservative management, 12 (31.6%) with minimally invasive methods and 1 (2.6%) needed surgical management. Average return to normal activities took 14.3 and 9.1 weeks for hip/thigh and lower leg MLL, respectively. Twenty-four patients with adequate documentation demonstrated lower extremity functional score (LEFS) and pain level of 74/80 (92.5%) and 0.7/10, respectively, at mean 12.5 months follow-up.

CONCLUSION

In contrast to adult injury literature, pediatric MLLs are more common in the leg/knee than hip/thigh region and caused mostly by sports injuries. Primary care physicians are the initial treating providers for the majority of the patients. Intervention is more often needed in the hip/thigh MLLs as opposed to non-operative management for lower leg injuries. This large case series on MLL in the pediatric population demonstrates differences in the management of hip and thigh lesions when compared to the management of the knee and leg lesions in the majority of these patients. Non-operative management in the majority of these lesions provided overall satisfactory outcomes.

Case Report: Stage VI Morel-Lavallée Lesion with a Large Challenging Defect

Morel-Lavallée lesion (MLL) is a closed degloving soft-tissue injury that results in the accumulation of a hemolymphatic fluid between the skin/superficial fascia and the deep fascia. This is a rare injury that may be challenging to diagnose, and necessitates early identification and treatment to achieve the best outcomes. We report the case of a 45-year-old male patient who was referred to our institution for large wound closure after undergoing debridement of a misdiagnosed MLL that became complicated by infection and sepsis. The patient was retrospectively diagnosed with a Stage VI MLL and had to undergo 4 operations with skin grafting and vacuum-assisted closure therapy playing an essential role in achieving tissue closure. This case was presented as a reminder of this rare diagnosis, and the importance of considering it when faced with a patient presenting with a relevant clinical picture post trauma. An early diagnosis is important because early intervention can prevent complications and lead to better outcomes. The misdiagnosis in the case of our patient and delayed treatment led to an aggressive debridement with a large wound that was challenging to close.

Partially avulsed anus in blunt traumatic perineal laceration: Case report

Blunt civilian perineal laceration with anorectal avulsion is rare and usually associated with severe pelvic trauma. The principles of management of these injuries consist of repair of the laceration (primarily or secondary), diversion of fecal stream, and presacral drainage of the wound. Unnecessary diversion of fecal stream may add complications and increases patient's morbidity. We report a case of severe blunt traumatic perineal laceration associated with partially avulsed anus which was managed without colostomy. The wound healed completely with preserved anal sphincter function. To our knowledge, no similar cases of anal avulsion were treated without diversion of the fecal stream in the English literature.

Morel-Lavallée lesion diagnosed 25 years after blunt trauma

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Morel-Lavallée lesions are rare injuries that can be difficult to diagnose acutely after trauma.

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It is important to distinguish it from other lesions on imaging.

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Open surgical excision is often required for large, chronic and recurrent lesions.

Introduction

Morel-Lavallée lesions are closed degloving injuries in which the skin and subcutaneous tissues separate from the underlying fascia secondary to a shearing force. These injuries are uncommon and can be misdiagnosed in acute settings. If treated incorrectly, they can recur, causing complications requiring multiple surgical interventions. Therefore, it is important to discuss the clinical presentation and imaging characteristics in order to improve their diagnosis and management.

Presentation of case

This is the case of a 44-year-old male patient with a Morel-Lavallée lesion of the left thigh that presented 25 years after trauma. He was successfully treated with open surgical excision. The patient underwent multiple surgical interventions before the lesion was accurately diagnosed and treated.

Discussion

Morel-Lavallée injuries can lead to chronic symptoms, such as pain and swelling, affecting the patient’s quality of life. Treatment options include minimally invasive procedures, such as compression bandages or percutaneous drainage. However, if diagnosed late, a fibrotic capsule can form, which may require surgical excision. Our patient was diagnosed more than 20 years after the trauma. Earlier noninvasive treatment options were unsuccessful.

Conclusion

The patient was treated with open surgical excision of the chronic lesion. There was no report of any recurrence up to 10 months after surgery. Such lesion treatments should be guided based on the chronicity of the injury and the patient’s symptoms. To the best of our knowledge, this is the first case with such delayed presentation.

Morel-Lavallée Lesion Following a Low-speed Injury: A Case Report

Introduction

Soft tissue injuries are a common presenting complaint seen in the emergency department following trauma. However, internal degloving injuries are not commonly seen by the emergency provider.

Case Report

A 57-year-old male presented with right lower extremity pain, bruising, and swelling after a low-speed bicycle accident five days prior. Physical examination revealed an edematous and ecchymotic right lower extremity extending from the mid-thigh distally. Computed tomography of the thigh demonstrated a hyperdense foci within the fluid collection suggesting internal hemorrhage and internal de-gloving suggestive of a Morel-Lavallée lesion.

Discussion

The Morel-Lavallée lesion is a post-traumatic soft tissue injury that occurs as a result of shearing forces that create a potential space for the collection of blood, lymph, and fat. First described in 1853 by French physician Maurice Morel-Lavallée, this internal degloving injury can serve as a nidus of infection if not treated appropriately. Magnetic resonance imaging has become the diagnostic modality of choice due to its high resolution of soft tissue injuries. Treatment has been focused on either conservative management or surgical debridement after consultation with a surgeon.

Conclusion

The emergency physician should consider Morel-Lavallée lesions in patients with a traumatic hematoma formation to avoid complications that come from delayed diagnosis.

Morel Lavallée Lesion - A case report and review of literature

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Morel Lavallée Lesion is an elusive diagnosis & can cause a life-threatening state.

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Diagnosis of Morel Lavallée Lesion is clinical, but aided by several modalities.

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There are several treatment options for Morel Lavallée Lesion.

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Morel Lavallée Lesion should be treated when diagnosed.

Introduction

Morel-Lavallée lesion (MLL) is an uncommon entity, by which shearing forces result in a closed degloving lesion. This can result in an infected hematoma and lead to a life-threatening situation.

Presentation of case

We present a case of a 59-year-old patient who presented to our emergency department. This patient had a crushing injury, and later was found to have an infected MLL. The patient was treated with surgical drainage, and 2 split thickness skin grafts. The patient fully healed.

Discussion

We review the current literature regarding MLL and diagnostic tools in order to accurately and rapidly diagnose this often-missed entity. Special emphasis is given to the treatment of MLL, with the current knowledge as reflected in the literature.

Conclusions

It is important for caregivers to know the diagnostic steps and pitfalls of this elusive diagnosis in order to diagnose and treat MLL quickly, before it turns into a life-threatening state for the patient.

Acute Traumatic Arterial Occlusions Combined with Massive Morel-Lavallée Lesions Treated by Percutaneous Angioplasty, Multiple Debridements and Skin Grafts

Morel-Lavallée lesions (MLL) create pre-fascial space by shearing the subcutaneous tissues away from the underlying fascia, in a patient with trauma. Necrosis of the overlying skin can develop over a wide area of the lesion. The lesion might be contaminated by the surgical site due to careless intrusion when treating the combined arteriopathy. A 70-year-old woman presented with avulsion of the skin over the right foot and bilateral leg pain following a car accident. Computed tomography showed bilateral popliteal artery occlusion with large hematoma on both legs. Percutaneous angioplasty was performed with successful restoration of the flow. However, the skin color changes over time. Necrosis of the skin occurred over a wide area of the right leg. Extensive debridement was performed, and the defect was covered with a skin graft. MLLs can occur in patients with multiple traumas, multiple vascular injuries, and complex skeletal injury. Vascular surgeons treating multiple traumas should be aware of the diagnostic and management options for MLL. It should be diagnosed early because it can be difficult to manage once the overlying skin develops necrosis.

Management of chronic seromas: A novel surgical approach with the use of vacuum assisted closure therapy

Postoperative seroma is a common complication of many surgical procedures in which anatomical dead space has been created. A particular case of lesion in which seroma occurs is the Morel-Lavallée lesion (MLL), which is an uncommon closed soft-tissue degloving injury that develops after high-energy trauma or crush injury where shearing forces separate the subcutaneous tissue from the underlying fascia. The diagnostic evaluation begins with an adequate history and physical examination, followed by instrumental research with ultrasonography, computed tomography, and magnetic resonance imaging. Postoperative seromas and MLLs share a similar pathology and natural evolution as both injuries, once chronic, develop a pseudobursa; thus, the authors think that the same treatment algorithm may be suitable for both the lesions. Several strategies for the treatment of post-surgical and post-traumatic seromas have been described in the literature, ranging from conservative measures for acute and small injuries to surgical management and sclerotherapy for chronic and large ones. Despite some seromas resolving with conventional management, lesion recurrence is a matter of concern. The authors present their experience in the treatment of both post-surgical and post-traumatic chronic seromas not responsive to conservative treatments by surgical drainage of the seroma, capsulectomy, and application of vacuum-assisted closure therapy to allow granulation tissue formation, dead spaces obliteration, and wound healing. Primary wound closure with closed suction drain placement and an elastic compression bandaging are finally performed. From 2014 to 2019, a total of 15 patients (9 females and 6 males) were treated for recurrent chronic seromas with the proposed surgical approach. Five cases were MLLs, while 10 cases were postoperative seromas. The patients were between 33 and 79 years old, and they were followed up at 4 weeks and 3 and 6 months after surgery. All 15 patients with chronic seromas not responsive to conservative treatment showed a complete resolution of the lesions with the proposed treatment approach with no evidence of lesion recurrence, proving its effectiveness.

Novel Use of a Closed Liposuction System: Treatment of an Acute Morel-Lavallée Lesion of the Upper Extremity

Morel-Lavallée lesions (MLL) are closed post-traumatic soft tissue shear injuries that occur between fascial planes and may result in tissue loss. Current treatment options for MLL include percutaneous drainage and open irrigation and debridement. A few cases of suction-assisted lipectomy (SAL) have been described for subacute and chronic MLL of the lower extremity. We present the first case report of using a closed SAL system to treat an acute MLL of the upper extremity. A 78-year-old female with right forearm MLL presented after blunt force trauma while on apixaban. After inpatient monitoring and anticoagulant drug clearance, a closed system SAL was performed to evacuate the hematoma and prevent ischemia of overlying soft tissues. Treatment outcomes were measured by clinical exam and CT imaging. Pre-operative diagnostic CT scan demonstrated a 4.8 x 6.6 x 13 cm fluid collection between fascial layers of the right forearm. SAL resulted in the evacuation of 300 cc of coagulated blood. Post-operative CT imaging of the right upper extremity did not show any measurable fluid collection. Clinical exam demonstrated resolution of swelling and soft tissue compromise. The patient reported significant pain reduction, resumed her anticoagulation, and was discharged home. There were no notable complications at her three month post-operative visit. Consideration of a constant low-pressure SAL system can successfully treat MLL in the acute period. This system is relatively minimally invasive, results in faster healing times compared to open debridement, and still results in effective hematoma evacuation.

A minimally invasive incision and loop drainage technique for the treatment of lower limb Morel-Lavallée lesions: Nose ring drainage technique

Morel-Lavallée lesions (MLLs) are shearing injuries resulting in separation of the skin and subcutaneous tissue from the underlying fascia. They are closed internal degloving injuries. Classical sites of the lesions are around the greater trochanter, pelvis, thigh, knee joint, and on the head, in decreasing order of frequency. This injury is often delayed or misdiagnosed when patients present with soft tissue injury alone or when more obvious injuries distract from its presence in polytrauma patients. There is currently no universally accepted treatment for these lesions. Conservative management often fails and requires surgical intervention. The purpose of this manuscript is to show that nose ring drainage, a minimally invasive incision and loop drainage technique for the treatment of lower limb Morel-Lavallée lesions, is effective and economical.

Medico-legal considerations for Morel-Lavallée lesions

The Morel-Lavallée lesion is an infrequent traumatic lesion that the forensic physician may need to evaluate during examination of a victim. Using a review of the literature and an illustrative case, the objective of this paper is to discuss the medico-legal issues (accountability, functional recovery and healing times, and aftermath) associated with Morel-Lavallée lesions. We describe the case of a 24-year-old motorcycle driver who was hit by a car. Clinically, the right lumbar region had a large 16 × 15 cm ecchymosis with subcutaneous fluid swelling found by palpation. A body scan revealed a Morel-Lavallée lesion among other lesions. On day 7, its thickness was decreased by half. Morel-Lavallée lesions are specifically induced by shearing force with moderate-to-high kinetics in an anatomical area with an underlying fascia. The associated functional disability is globally moderate, but a large lesion or recurrences can extend the time needed to recover. Apart from some exceptions, care without any delay in diagnosis and treatment allows evolution of the lesion without functional consequences, but these lesions are frequently unnoticed in the initial phase.

Morel-Lavallée Lesion in the Sacrococcygeal Area with Associated Coccygeal Fracture

A Morel-Lavallée lesion is a posttraumatic, closed internal degloving injury caused by shearing force abruptly separating the skin and superficial fascia from the deep fascia and creating a potential space. Blood, lymphatic fluid, and debris collect and fill the space. The most commonly affected sites are the thigh, knee, hip, and pelvic area, but the lesion can occur anywhere in the body. Among various treatments, surgical procedure is a good option if the lesion is chronic and a thick peripheral capsule has developed. We report an uncommon case of a chronic Morel-Lavallée lesion in the sacrococcygeal area, a rarely reported location, with an associated coccygeal fracture and dislocation.

A Morel-Lavallée lesion of the proximal calf in a young trauma patient: A case report

RATIONALE

The Morel-Lavallée lesion (MLL) is a closed degloving injury developing when shear force acts between the muscle fascia and the subcutaneous layer. MLLs develop principally in the trochanteric area or the pelvis; lesions in the proximal calf are rare. Acute lesions can be treated conservatively, but chronic lesions are best treated surgically because of a high rate of recurrence. To the best of our knowledge, this is a rare case of successful treatment of an MLL in the proximal calf associated with tibio-fibular shaft fracture.

PATIENT CONCERNS

A 14-year-old male visited our emergency room after having been hit by a car. He exhibited direct trauma to the right lower leg and a distal tibio-fibular shaft fracture without an open wound. He underwent surgery to treat the fracture, which was immobilized with splint for 2 weeks post-operatively. At the 3-month follow-up, he complained of a painless, mobile, soft tissue mass in the posteromedial aspect of the proximal calf. Blood circulation was normal and we found no neurological abnormality in the distal region of the lower leg.

DIAGNOSIS

A plain radiograph of the right lower leg revealed a proximal, round, radiopaque soft tissue lesion. Ultrasonography revealed a homogeneous, hypoechoic fluid collection. Magnetic resonance imaging revealed fluid of homogeneous signal intensity between the subcutaneous layer and the underlying fascia of the gastrocnemius muscle.

INTERVENTIONS

Percutaneous drainage and intralesional steroid injection were performed on several occasions, but the lesion recurred every time. After 5 aspirations, we scheduled surgery. We radically excised the mass and sutured the superficial to the deep fascia to prevent shearing at the surgical plane.

OUTCOMES

No complication or recurrence was noted at the 1-year follow-up.

LESSON

An MLL in the proximal calf is an uncommon post-traumatic lesion and care must be taken to avoid misdiagnosis. If an MLL is suspected after imaging studies and physical examination, it is important to determine whether the lesion is acute or chronic and to plan treatment accordingly. Appropriate treatment should be given to patients to improve outcomes.

Morel-Lavallée lesion in a 12-month-old child: A case report and literature review

INTRODUCTION

The Morel-Lavallée lesion is an infrequently described, post-traumatic closed de-gloving wound that results from separation of the skin and subcutaneous tissues from the underlying deep fascia as a result of shearing forces that tear perforating vessels and lymphatics. This condition is rare in children and to our knowledge it represents the youngest case of Morel-Lavallée lesion yet reported.

PRESENTATION OF CASE

We report on a twelve-month-old girl who presented after a motor vehicle accident with a tender fluctuant mass of the back and buttocks. Computed tomography revealed a large but discrete fluid collection between the subcutaneous fat and the deep fascial planes, extending from the posterior thoracic paraspinal soft tissues to the right gluteal region. A diagnosis of Morel-Lavallée lesion was made. This patient was managed with serial ultrasound-guided percutaneous drainage and compression bandages. The patient did well and was subsequently discharged. There was no recurrence of the lesion on follow-up.

DISCUSSION

The Morel-Lavallée lesion is a rare consequence of abrupt high impact trauma. There is no accepted management approach and a variety of conservative as well as surgical options exist. Goals of management include drainage, debridement and meticulous dead space management to prevent recurrence.

CONCLUSION

The Morel-Lavallée lesion is a rare finding in children involved in high impact trauma and prompt intervention is crucial to prevent complications. Image-guided drainage is a rational management approach with excellent outcomes.

A Rare Presentation of a Morel-Lavallee Lesion of the Lower Leg Successfully Treated With Ultrasound-Guided Aspiration

A Morel-Lavallee lesion (MLL) is a relatively rare condition that is caused by a traumatic shearing force. This force leads to a closed degloving injury of the subcutaneous tissue and fascia that creates a potential space that can fill with lymph, blood, and necrotic fat. The MLLs are traditionally seen after high impact trauma and typically located at the greater trochanter and pelvis, although recent reports have found them to be located at the knee, thigh, and lower leg. The MLLs typically present as swelling at the site of injury, which can be difficult to differentiate from several other diagnoses. This case report discusses an MLL in the lower extremity that occurred during a rugby game. A lack of familiarity with MLLs often leads to delayed diagnosis and treatment. The diagnosis was eventually made with an magnetic resonance imaging, and the lesion was successfully treated with ultrasound-guided aspiration and compression. The athlete was able to return to play without recurrence of the lesion.

Morel-Lavallée lesions: a phenomenon in cats? Case report and review of the literature

Case summary

A 3-year-old male neutered domestic shorthair cat sustained a severe sacrococcygeal luxation post-motor vehicle trauma. Six days post-trauma, a fluid-filled swelling was noticed over the caudoventral abdomen and inguinal regions. Needle aspiration, closed suction drain placement and debridement with subcutaneous tacking were all attempted but failed to resolve the continued accumulation of serosanguinous lymphocyte-rich fluid in the subcutaneous pocket. Clinical resolution was ultimately achieved after surgical debridement and omentalisation of the lesion.

Relevance and novel information

Morel-Lavallée lesions are post-trauma closed soft tissue degloving injuries described infrequently in people. The avulsion of subcutaneous tissue from deep muscle fascia results in the accumulation of haemolymph and necrotic fat, which can persist for several days to months after the inciting incident. In people, they are commonly seen in the proximal thigh. This article proposes the existence of Morel-Lavallée lesions in cats.

Mountain Biking Injuries

With the increasing popularity of mountain biking, also known as off-road cycling, and the riders pushing the sport into extremes, there has been a corresponding increase in injury. Almost two thirds of acute injuries involve the upper extremities, and a similar proportion of overuse injuries affect the lower extremities. Mountain biking appears to be a high-risk sport for severe spine injuries. New trends of injury patterns are observed with popularity of mountain bike trail parks and freeride cycling. Using protective gear, improving technical proficiency, and physical fitness may somewhat decrease the risk of injuries. Simple modifications in bicycle-rider interface areas and with the bicycle (bike fit) also may decrease some overuse injuries. Bike fit provides the clinician with postural correction during the sport. In this review, we also discuss the importance of race-day management strategies and monitoring the injury trends.

Don't Forget the Abdominal Wall: Imaging Spectrum of Abdominal Wall Injuries after Nonpenetrating Trauma

Abdominal wall injuries occur in nearly one of 10 patients coming to the emergency department after nonpenetrating trauma. Injuries range from minor, such as abdominal wall contusion, to severe, such as abdominal wall rupture with evisceration of abdominal contents. Examples of specific injuries that can be detected at cross-sectional imaging include abdominal muscle strain, tear, or hematoma, including rectus sheath hematoma (RSH); traumatic abdominal wall hernia (TAWH); and Morel-Lavallée lesion (MLL) (closed degloving injury). These injuries are often overlooked clinically because of (a) a lack of findings at physical examination or (b) distraction by more-severe associated injuries. However, these injuries are important to detect because they are highly associated with potentially grave visceral and vascular injuries, such as aortic injury, and because their detection can lead to the diagnosis of these more clinically important grave traumatic injuries. Failure to make a timely diagnosis can result in delayed complications, such as bowel hernia with potential for obstruction or strangulation, or misdiagnosis of an abdominal wall neoplasm. Groin injuries, such as athletic pubalgia, and inferior costochondral injuries should also be considered in patients with abdominal pain after nonpenetrating trauma, because these conditions may manifest with referred abdominal pain and are often included within the field of view at cross-sectional abdominal imaging. Radiologists must recognize and report acute abdominal wall injuries and their associated intra-abdominal pathologic conditions to allow appropriate and timely treatment. ^© RSNA, 2017.

Utilization of Liposuction for Delayed Morel-Lavallée Lesion: A Case Report and Review

Morel-Lavallée lesions are irregularly occurring and often overlooked results of traumatic injuries, resulting in potential long-term encapsulation of fluid between soft-tissue layers. The objective in this review was to discuss the delayed presentation of a Morel-Lavallée lesion and operative utility of liposuction in the patient's treatment and review literature with particular focus on diagnosis and therapeutic interventions. The reviewed case demonstrates the presentation and successful therapy of a young female presenting with a MLL and contour deformity.

Endoscopic surgical management of a large Morel-Lavallée lesion

The Morel-Lavallée lesion is a closed degloving injury that usually occurs following high-energy trauma. We present a case demonstrating endoscopic management of this lesion. A 44-year-old man fell from scaffolding. Initial assessment demonstrated no significant injury. An ultrasound scan 2 days post injury revealed a large fluid collection along the lateral right thigh. This subsequently became infected and did not respond to antibiotic therapy.Due to the extent of the lesion, we were reluctant to perform a traditional open drainage. An endoscopic probe was inserted at the proximal and distal poles of the lesion and the wound debrided.This resulted in a rapid improvement in symptoms and a complete resolution of the lesion at 1 year postsurgery, with no wound-associated morbidity.This is only the second description of endoscopic debridement of a large, acute Morel-Lavallée lesion, with an excellent outcome.

Can a Morel-Lavallée lesion be misdiagnosed as a mass like lesion?

The Morel-Lavallée lesion (MLL) is a post-traumatic closed soft tissue degloving injury. Common complaints of MLL patients are a haematoma or fluid collection on the trunk or the lower extremity. However, the authors introduce unique cases of MLL that present an atypical appearance. The fluid collection was not apparent, and the capsule formation was not detected on preoperative image study. The main complaint of patients was the uncomfortable mass-like lesion that was regarded as a simple benign lump. The purpose of this case study is to introduce the atypical cases of MLL and to help other physicians make accurate diagnosis based on trial and error of our cases.

Morel-Lavallée Injuries: A Multimodality Approach to Imaging Characteristics

Morel-Lavallée lesions are relatively rare closed degloving injuries caused by a shearing force resulting in separation of the dermis and the hypodermis from the subjacent deeper fascia. Although most commonly encountered lateral to the greater trochanter, these injuries may occur throughout the body in a variety of locations. Separation of the hypodermal tissue planes results in a complex serosanguinous fluid collection with areas of internal fat necrosis. The imaging appearance is variable and nonspecific, potentially mimicking superficial hemorrhagic bursitis, or cystic or necrotic primary soft tissue neoplasms. If not treated in the acute or early subacute setting, these collections are at risk of superinfection, overlying tissue necrosis, and continued expansion. In this article, we will review the pathophysiology, cross-sectional imaging features, and differential diagnostic considerations of Morel-Lavallée lesions as well as discuss management and treatment options.

Rare presentation of Brodie's abscess in the acromion process and the value of the penumbra sign

A 17-year-old male patient presented with a swelling on his right shoulder 1 week after a fall. MRI revealed a superficial fluid collection of the acromion and trapezius muscle, with slight enhancement of the wall. The swelling burst open spontaneously after failed conservative therapy and was treated with surgical drainage and antibiotics. Tissue cultures showed a Staphylococcus aureus 1 year later, he presented with local red discolouration and a recurrent painful swelling that fluctuated at palpation. Radiographs showed a lytic lesion of the acromion process. MRI showed a sinus in the lytic cavity and a penumbra sign, which helped to identify this extremely rare occurrence of Brodie's abscess in the acromion process that was breaking through to the subcutaneous fat. The abscess was treated successfully with surgical drainage and intravenous antibiotics. In retrospect, the first MRI showed a small cortical indentation, with slight oedema of the acromion process.

Endoscopic debridement and fibrin glue injection of a chronic Morel-Lavallée lesion of the knee in a professional soccer player: A case report and literature review

A Morel-Lavallée lesion is a post-traumatic closed degloving injury of soft tissue. The lesion is due to a shearing trauma with separation of subcutaneous tissue from underlying fascia. When conservative treatment fails, surgical treatment is imperative. Commonly, open drainage and debridement is performed. This case report describes a Morel-Lavallée lesion of the knee in a professional soccer player who was successfully treated with endoscopic debridement and fibrin glue injection after failure of conservative management. This method achieves the goal of an open surgical debridement without exposing patients to an increased morbidity.