Management of Morel-Lavallee lesion of the knee: twenty-seven cases in the national football league

Mid-term prognosis of endoscopic debridement combined with percutaneous cutaneo-fascial suture for the treatment of Morel-Lavallée lesion: a minimum 3-year follow-up study

PURPOSE

Morel-Lavallée lesion (MLL) is a closed soft-tissue degloving injurie resulting from shear forces. With the advent of endoscopic technology and advancements in surgical techniques, innovative solutions are now available. However, there are few data on mid-term results after treatment of MLL, especially regarding arthroscopic method. The objective of this study is to evaluate the clinical outcomes of endoscopic debridement combined with percutaneous cutaneo-fascial suture in treating MLL.

METHODS

A single-center retrospective study was conducted at a university teaching hospital investigating patients who underwent arthroscopic management of Morel-Lavallée lesion between 2014 and 2020.Patient demographics, postoperative recovery time, peri- and postoperative complications were investigated. Mid-term follow up clinical and radiological examinations were performed.

RESULTS

The retrospective study included 38 patients aged between 11 and 90 years, with an average age of 50.9 ± 16.9 years. These patients waited an average of 36.6±23.5days to return to work after operation. The average time to follow-up was from 3 to 9 years, averaging 5.0 ± 1.8 years. At the end of follow-up, only one complication of superficial skin necrosis occurred, accounting for 2.6%. The imaging assessment at the final follow-up indicated improvement over the postoperative period for all 38patients.

CONCLUSION

In mid-term experience, endoscopic debridement combined with percutaneous cutaneo-fascial suture for MLL management is a safe and effective option.

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.

Prepatellar Morel-Lavallée Effusion Mimicking a Bursitis

Morel-Lavallée lesions are traumatic abnormalities characterized by the accumulation of hemolymphatic fluid collection following disruption of subcutaneous fat tissue from the underlying deep fascia. Here, we present the case of a 63-year-old woman with a prepatellar Morel-Lavallée lesion, an unusual location for this pathology initially misdiagnosed as prepatellar bursitis. An MRI was performed allowing the correction of the diagnosis, highlighting the essential role of imaging in confirming the diagnosis and ruling out differentials such as prepatellar bursitis or neoplastic origins. In our case, conservative treatment with compression alone was employed, since surgery is reserved for chronic or complicated cases. Our experience underscores the utility of MRI in accurately delineating the anatomical extent and characteristics of prepatellar Morel-Lavallée effusion (PMLE). This imaging modality serves as a critical tool in guiding appropriate management strategies, ensuring timely and effective treatment for patients presenting with this lesion.

Cervico-thoracic Morel-Lavallée lesion

Morel-Lavallée lesions (MLLs) result from high-energy trauma causing separation of subcutaneous tissue from the underlying tissue, most commonly in the gluteal region or thigh.We report the case of a woman in her 40s with a fluctuant collection of the cervico-thoracic region following trauma. Further imaging identified an MLL. An orthoplastic approach resulted in non-operative management with a spinal brace. Three months from initial injury, the lesion completely resolved. She was symptom free at final follow-up and discharged.We present the only recorded case of MLL developing in the cervico-thoracic region. Management posed difficultly as no literature currently exists. We demonstrated conservative management for cervico-thoracic MLL can be effective.We have described the first documented case of cervico-thoracic MLL. MLL is not exclusive to pelvic injuries and can develop in the cervico-thoracic region. We have shown conservative management is a viable treatment of atypical MLL.

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.

Recurrence of symptoms may indicate the presence of a Morel-Lavallée lesion of the knee: A case report and literature review

Case

An 81 year old male with four failed aspirations presented with recurrent knee swelling following irrigation and debridement, which suggested the presence of a Morel-Lavallée lesion (MLL). This diagnosis was intraoperatively confirmed by separation of the tissue layers forming a space with accumulated fluid. Treatment consisted of doxycycline sclerodesis and tight closure of the tissue layers. The patient had a satisfactory outcome at 4 months.

Conclusion

Resolution of Morel-Lavallée lesions requires prompt recognition and appropriate treatment. In the presence of a different diagnosis, recurrence of symptoms following treatment may indicate an MLL. Surgical treatment with doxycycline sclerodesis resulted in resolution of symptoms.

Musculoskeletal Injury in American Football: A Bibliometric Analysis of the Most Cited Articles

Background

Textbook knowledge and clinical dogma are often insufficient for effective evidence-based decision making when treating musculoskeletal injuries in American football players, given the variability in presentation and outcomes across different sports and different levels of competition. Key evidence can be drawn directly from high-quality published articles to make the appropriate decisions and recommendations for each athlete's unique situation.

Purpose

To identify and analyze the 50 most cited articles related to football-related musculoskeletal injury to provide an efficient tool in the arsenal of trainees, researchers, and evidence-based practitioners alike.

Study Design

Cross-sectional study.

Methods

The ISI Web of Science and SCOPUS databases were queried for articles pertaining to musculoskeletal injury in American football. For each of the top 50 most cited articles, bibliometric elements were evaluated: citation count and density, decade of publication, journal, country, multiple publications by the same first author or senior author, article content (topic, injury area), and level of evidence (LOE).

Results

The mean ± SD number of citations was 102.76 ± 37.11; the most cited article, with 227 citations, was "Syndesmotic Ankle Sprains" published in 1991 by Boytim et al. Several authors served as a first or senior author on >1 publication, including J.S. Torg (n = 6), J.P. Bradley (n = 4), and J.W. Powell (n = 4). The American Journal of Sports Medicine published the majority of the 50 most cited articles (n = 31). A total of 29 articles discussed lower extremity injuries, while only 4 discussed upper extremity injuries. The majority of the articles (n = 28) had an LOE of 4, with only 1 article having an LOE of 1. The articles with an LOE of 3 had the highest mean citation number (133.67 ± 55.23; F = 4.02; P = .05).

Conclusion

The results of this study highlight the need for more prospective research surrounding the management of football-related injury. The low overall number of articles on upper extremity injury (n = 4) also highlights an area for further research.

Diagnosis and Treatment of a Morel-Lavallée Lesion in the Lateral Knee With Point-of-Care Ultrasonography

A 14-year-old male presented to the sports medicine clinic for evaluation of right lateral knee pain for three weeks after he took a forceful blow to his right lateral knee during a football game. He reported swelling and bruising and increasing pain since then. Physical exam was significant for an area of fluctuance that was approximately 20 cm in length and 10 cm in width overlying the lateral right knee with associated ecchymosis and decreased sensation. The remainder of the exam was benign. Point-of-care ultrasound showed a large hypoechoic space overlying the lateral knee consistent with a Morel-Lavallée lesion (MLL). Twenty-six milliliters of serosanguinous fluid were aspirated from between the fascial planes, deep to subcutaneous fat but superficial to quadriceps muscles, under ultrasound guidance. The lesion was sclerosed with 1 cc 1% lidocaine without epinephrine and 4 cc dexamethasone 4 mg/mL, and the patient was given compression wrappings to wear for the next four weeks. MLLs are collections of fluid that occur between different planes of subcutaneous tissue following blunt force or shearing trauma. The general mechanism of injury is a closed degloving injury that occurs following damage to the potential space between layers of fascia, dermis, and subcutaneous fat. MLLs are relatively rare lesions and, when identified, are most frequently found in the proximal thigh and associated with serious underlying bony fractures. MLLs are uncommon and difficult to diagnose due to their nonspecific findings of fluctuance, pain, and bruising. This case is unique in its presentation of an isolated MLL in the lateral knee. Early diagnosis and intervention of these lesions prevent further sequelae.

Negative pressure therapy in a scenario of distal femur fracture with internal degloving injury

Internal degloving injuries are commonly seen in the pelvis. Similar lesions in the distal femur are rare. They cause a separation between the subcutaneous layer and deep fascia, which results in blood, lymph, necrosed fat and fluid collection in the space. They result in infection and soft tissue complications. Treatment options include conservative management with compression dressings, percutaneous aspiration, mini-incision drainage and sclerodesis. Here we describe a case of closed internal circumferential degloving injury of the distal thigh with a distal femur fracture treated by an innovative technique involving negative pressure therapy, internal fixation of the fracture and secondary skin grafting.

Morel-Lavallee lesions. Size matters? Treatment and time of disability

INTRODUCTION

Degloving soft-tissue injuries are serious and potentially devastating medical conditions where an early recognition is a crucial step for a favorable outcome. One of the most important types is Morel-Lavallée lesions (MLL); a significant soft-tissue injury associated with pelvic trauma (30%) and thigh (20%), located over the greater trochanter.

MATERIAL AND METHODS

In this retrospective study we selected adult patients diagnosed with MLL between 2010 and 2019 at our trauma center. We then identified 9 cases and followed them up for a minimum of two years. CT scans were performed to measure the size of the degloved zone.

RESULTS

we did not found direct relationship between greater dimensions of MLL injury and the need for an increase of days to return to work. We rather identified an association between bigger dimensions of MLL injury and higher energy trauma. These patients waited an average of 133 days to return to work after being injured; which is a longer period compared to non-op patients.

DISCUSSION

MLL lesions generally take several days to develop and many may be missed on initial evaluation. Once identified, compression dressings should be applied, especially when diagnosed acutely. Early identification would lead to early operative debridement. Also, drainage should be performed, since the pathophysiology of the injury will result in the failure of observation or simple aspiration.

CONCLUSION

MLL diagnosis and treatment must be identified as early as possible. We didn't find a correlation between MLL size and the treatment performed. In our study all patients returned to their jobs and normal life. Patients following conservative treatment take longer time to recover and could require more patient's implication, but -at least- would avoid possible surgical complications.

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.

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.

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.

Post-traumatic Late Presentation of Morel-Lavallée: Case Report and Review of Literature

Introduction

Morel–Lavallée (MLL) is an uncommon entity that is missed by many physicians, it is the result of a shearing force that leads to degloving of the subcutaneous fat from the underlying deep fascia.

Case Report

We present a case of a 15-year-old male patient who presented 3 months after the initial crush injury with a large MLL lesion at the lateral aspect of the right proximal thigh. He was treated with incision and drainage with compressive dressing and a negative pressure drain.

Conclusion

Diagnosis of MLL is usually clinical and can be aided with radiological tools like MRI that is the gold standard of imaging in this lesion. Several treatment options are available, ranging from conservative treatment with compressive bandages to percutaneous drainage, injection of sclerotic agents, and surgical treatment with incision, drainage, and debridement. Diagnosis and treatment should be familiar to all caregivers to prevent further complications that could be life or organ-threatening.

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.

Endoscopic Resection of Chronic Morel-Lavallée Lesion of the Knee

The Morel-Lavallée lesion is a closed internal soft-tissue degloving injury. About 15.7% of Morel-Lavallée lesions occur in the knee region. Morel-Lavallée lesions are considered chronic when the lesion contains a capsule. The capsule prevents resorption of the fluid content, and the lesion will recur when using conservative treatment alone. Surgical debridement with resection of the capsule is a more definitive treatment option, but it may induce wound complications. In this Technical Note, the technical details of endoscopic resection of chronic Morel-Lavallée lesion of the knee are discussed. This minimally invasive technique has the advantage of better cosmetic results and fewer wound complications.

Morel-Lavallée Lesion of the Knee in the Young Athlete: About 2 Cases After Sports Trauma

BACKGROUND

Differential diagnosis of soft tissue swelling on exposed body parts in the young athlete is large and mostly includes benign self-limiting conditions, once underlying lesion to the bone, the cartilage, and the ligaments is excluded. Morel-Lavallée lesion represents a rare soft tissue injury requiring prompt intervention to ensure favorable outcome.

CASES

A 10-year-old boy presented with 2-week-old swelling of the medial side of the knee without recent traumatic event. Unawareness of Morel-Lavallée lesion in the differential diagnosis led to delayed diagnosis and treatment. A 16-year-old boy came to our pediatric tertiary care center with a similar presentation and history. Timely intervention allowed for favorable outcome and early return to play.

CONCLUSIONS

Morel-Lavallée lesion is a rare entity in the pediatric population, although underreporting due to unfamiliarity with the diagnosis is highly probable. Raising awareness among professionals in charge of young athletes should allow for better reporting as well as for elaboration of a standardized treatment plan, including rapid intervention and early return to play.

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.

Percutaneous Debridement of and Fibrin Glue Injection Into a Pretibial Morel-Lavallée Lesion: A Case Report and Literature Review

ABSTRACT

The Morel-Lavallée lesion (MLL) is a posttraumatic close degloving injury, which is often underdiagnosed at first. Patients with MLLs usually present with tender and enlarging soft tissue swelling with fluctuation, decreased skin sensation, ecchymosis, or even skin necrosis hours to days after the inciting injury. The lesion can lead to intractable morbidity if it remains untreated. There is no consensus regarding the treatment for MLL at present. Here, we report an MLL in the pretibial region of a 43-year-old woman who experienced a low-energy contusion in a motorbike accident. The pretibial lesion was diagnosed using sonography and fine-needle aspiration. We successfully treated the patient by performing percutaneous debridement via a small incision and injections of fibrin after conservative treatment failed. The method we herein propose achieved the goal of open surgical debridement, providing faster recovery and a high degree of patient comfort. We reviewed the available pertinent literature and propose our own treatment protocol with the aim to establish common therapies ofMLL.

Arthroscopic treatment for Morel-Lavallée lesion of the thigh: A case report and literature review

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We present a case of Morel-Lavallée Lesion (MLL) of the thigh.

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The MLL was treated with arthroscopic procedure because of comorbidity.

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Negative pressure wound therapy was added to prevent recurrence.

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In case of MLL with comorbidity, the arthroscopic treatment is a reasonable method.

Introduction

Morel-Lavallée lesion (MLL) is a posttraumatic closed degloving soft tissue injury, in which the subcutaneous tissues are separated from the underlying fascia. Surgical treatment is recommended if conservative management fails. The conventional surgical treatment for the lesion is surgical drainage and debridement.

Presentation of case

A 51-year-old male patient presented with swelling of the right thigh incurred during a traffic accident. The lesion was diagnosed with MLL. The MLL was successfully treated with a minimally invasive arthroscopic treatment after failure of conservative treatment. The arthroscopic treatment was chosen because of the patient’s comorbidity that posed a risk of surgical wound complications. In addition, negative pressure wound therapy (NPWT) was performed postoperatively to ensure healing and to prevent recurrence of the lesion. The patient was successfully treated and the healing of the lesion was also confirmed with MRI.

Discussion

In a patient with a risk of wound complications due to a comorbidity, this minimally invasive arthroscopic treatment is useful. In addition, NPWT was used to ensure healing and to prevent recurrence. Although the use of NPWT combined with endoscopic treatment has not been reported, additional NPWT reported in this case may be helpful to ensure healing.

Conclusion

In case of MLL with a risk of surgical complications, the arthroscopic treatment is a reasonable method and achieves the goal of an open surgical debridement without increased morbidity.

Morel-Lavallée lesion as an unusual cause of hemorrhagic shock: Case report and review of literature

Introduction

Morel-Lavallée syndrome (MLS) is considered as a rare entity and hemorrhagic shock as a complication is uncommon.

Presentation of case

We report the case of a 56-year- old man who presented to the emergency department after a road traffic accident. Initially, the patient was hemodynamically unstable (heart rate 160 beats/min and blood pressure 65/30). Physical examination revealed multiple lacerations on his back and a gradually expanding large subcutaneous hematoma on the left flank extending to the hip and left leg. Fluid resuscitation was rapidly initiated. After stabilizing his hemodynamic status, a full-body computed tomography was performed revealing, apart from a small unilateral pneumothorax and a stable pelvis fracture, an extensive Morel-Lavallée lesion in the lumbar region extending to the hip and both legs. The patient was then transferred to a surgical intensive care unit for further resuscitation and surgical drainage of the collection followed by continuous suction was performed. Even though rare, Hemorrhagic shock is one of the threatening complications of Morel-Lavallée lesions and should be kept in mind by every traumatologist and emergency doctor.

Conclusion

We report a case about a rare complication of MLS which is hemorrhagic shock in order to highlight the importance of making the diagnosis, which can be unrecognized, and initiate an adequate treatment on time.

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.

Slow-growing buttock mass after failure of incorporation of autologous fat transfer for gluteal augmentation: ultrasound and MRI features

Gluteal augmentation procedures are gaining popularity and encompass a variety of surgical techniques and methods of graft preparation. While surgical history remains essential for diagnosis, the radiologist must avoid pitfalls and rely on imaging features to recognize both the expected appearance and complications of gluteal augmentation procedures. We report a case of a slowly growing buttock mass after gluteal augmentation with autologous fat transfer 1 year after surgery. The potential diagnostic imaging pitfalls and characteristics on ultrasound and contrast-enhanced MRI are discussed. Multiplicity of fat-containing lesions depicted on large field-of-view images and granulated appearance of the intralesional fat on MRI should allow the radiologist to recognize the appearance of failed fat graft incorporation that can present as a slowly growing encapsulated collection with layered fat and fluid contents.

Retrosacral Morel-Lavallée lesion: resolution with ultrasound-guided drainage and sclerotherapy

Morel-Lavallée lesions are chronic seromas due to closed degloving injuries, resulting from blunt trauma. They most commonly occur over the greater trochanteric, gluteal and flank regions. We present a case of retrosacral Morel-Lavallée lesion. Initial ultrasound demonstrated a fluid collection lying between the subcutaneous fat and the underlying fascia superficial to the sacrum. Following repeated ultrasound-guided aspirations, further recurrence of a superficial pre-sacral seroma was confirmed with MRI. Ultrasound-guided aspiration was performed and 100 mg of injectable doxycycline was instilled into the lesion. 4 months after sclerotherapy, the patient was asymptomatic, and follow-up MRI demonstrated no residual fluid collection or complication. This case demonstrates the value of using MRI in conjunction with ultrasound to characterize Morel-Lavallée lesions in an atypical site and in confirming response to treatment, in addition to the use of sclerotherapy for treatment of a lesion refractory to repeated aspiration.

Squamous Cell Carcinoma Arising from a Morel-Lavallée Lesion: A Case Report

CASE

A 72-year-old man presented 20 years after a Morel-Lavallée (ML) lesion with pain and drainage. Biopsies of the lesion and lymph nodes were positive for squamous cell carcinoma (SCC). There was no cutaneous involvement or distant metastasis. After chemotherapy and radiation, he underwent resection of the lesion and lymph nodes with flap closure. Two months postoperatively, he unfortunately developed malignant pleural effusions, hypercalcemia, and kidney injury and was eventually transferred to hospice care and died.

CONCLUSION

This is the first report of SCC arising from a ML lesion. Chronic ML lesions should be treated aggressively and monitored for transformation into malignancy, even without cutaneous involvement.

Surgical Treatment of a Chronic Morel-Lavallée Lesion: A Case Report

Introduction

Morel-Lavallée lesions (MLLs) are a post-traumatic degloving injury which the superficial fascia and skin are separated from the deep fascia through shearing forces. This process leads to the development of a potential space in which blood products and necrotic material can collect, potentially resulting in abscesses, cellulitis, or osteomyelitis. Most of these cases occur at the greater trochanter, gluteal musculature, proximal femur, and around the knee. However, there have been few reports of MLLs occurring in the lumbar region. In this report, we seek to present our experience with a case of a lumbar MLL and outline the diagnostic and operative management utilized.

Case Report

A 48-year-old female presented to our clinic with complaints of persistent low back and swelling 1 month after sustaining a fall from stand resulting in an L5 transverse process fracture. The patient was treated non-operatively but continued to have swelling noted to the lower back. A computed tomography scan demonstrated a large subcutaneous fluid collection measuring 15 cm×16 cm×7 cm centralized over the lower lumbar region. We elected to proceed with operative evacuation of the fluid collection. A 2 cm midline incision over the proximal aspect of the fluid collection was made and approximately 900 ml of serosanguinous fluid was evacuated. The cavity was then irrigated with a normal saline 0.9%/betadine solution and a wound vacuum-assisted closure (VAC) sponge was placed. The post-operative course was unremarkable and the wound VAC was discontinued at the first post-operative visit. The surgical incision went on to heal uneventfully with no signs of infection or fluid reaccumulation.

Conclusion

Although MLLs are rare, clinicians should maintain a high clinical suspicion in patients presenting after blunt trauma injuries with persistent pain, and fluid collections noted on advanced imaging. Conservative management can be initiated if discovered acutely, but if left untreated may require surgical intervention and evacuation of fluid as described in this case.

Two Cases of Morel-Lavallée Lesion Which Resulted in a Wide Skin Necrosis from a Small Laceration

Morel-Lavallée lesion (MLL) is a degloving injury in soft tissues caused by shear force accompanying trauma. Even if it is a small lacrimal wound at the initial visit, there is a range of skin necrosis which is not suitable for it. As a cause of the injury, a shearing force was applied over a wide range, and penetrating blood vessel damage to the skin occurred, resulting in skin necrosis. Attention is required.

Percutaneous Quilting Technique for the Treatment of Morel-Lavallée Lesion

OBJECTIVE

This study looks at the outcome of percutaneous quilting technique for the treatment of closed degloving injuries or Morel-Lavallée lesions (MLL).

DESIGN

Prospective single-centre nonrandomized case series.

PARTICIPANTS

Patients with MLL visiting our hospital between January 2012 and May 2018.

METHOD

The method involves percutaneous single-stage suturing of skin and deep fascia with heavy, non-absorbable, non-braided sutures starting from periphery to centre.

OUTCOME MEASURES

Resolution of the lesion.

RESULTS

Twenty-two patients with MLL treated, which included 18 males and 4 females with an average age of 22 (range 16-52). Lesions varied in length from 12 to 60 cm. The average time gap from the injury to drainage of the lesion was 7 days (range 2-60 days). We followed these cases weekly for 4 weeks and then once a month until 6 months and then at the end of the year. All 22 cases healed uneventfully.

CONCLUSION

Percutaneous drainage along with suturing of the skin and subcutaneous tissue to deep fascia prevents the discordant movement and obliterates the dead space-aiding apposition of the layers. This is a simple and effective procedure with low recurrence rates that addresses the primary pathology of MLL.

LEVEL OF EVIDENCE

Therapeutic level IV.

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.

A Systematic Review of the Orthopaedic Literature Involving National Football League Players

Background

Orthopaedic injuries of National Football League (NFL) players can have a deleterious effect on their health, with minimal to no high-level evidence on the management of these injuries.

Purpose

To summarize all data published between January 1980 and March 2018 on orthopaedic injuries experienced by NFL candidates and professional players in the NFL.

Study Design

Systematic review; Level of evidence, 4.

Methods

A literature search of studies examining orthopaedic injuries in the NFL was performed through the PubMed, Embase, and CINAHL databases. The review included studies of orthopaedic injuries in college football recruits attending the NFL Combine as well as professional NFL players. Excluded were studies of nonorthopaedic injuries, such as concussions, traumatic brain injury, facial injuries, and vascular injuries, as well as case reports.

Results

A total of 147 articles met the inclusion criteria and were divided into 11 topics based on anatomic site: general (16%), spine (13%), shoulder (13%), elbow (3%), hand and wrist (3%), trunk (0.7%), hip and pelvis (7%), thigh (3%), knee (24%), ankle (5%), and foot (12%). Of these studies, 74% were of level 4 evidence. Most studies obtained data from the NFL Combine database (26%), by searching the internet (24%), and via the NFL Injury Surveillance System (22%). Studies using internet search methods to identify injuries consistently found fewer participants than studies using the NFL Injury Surveillance System.

Conclusion

This systematic review provides National Collegiate Athletic Association and NFL team physicians with a single source of the most current literature regarding orthopaedic injuries in NFL players. Most research was published on knee, spine, shoulder, and foot injuries and consisted of level 4 evidence. A substantial portion of the published literature was based on data obtained from internet searches and may not accurately represent the NFL population.

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.

Morel-Lavellée lesions: MRI characteristics in the pediatric patient

BACKGROUND

A closed degloving injury is often referred to as a Morel-Lavellée lesion regardless of location despite traditionally being associated with the hip in adults. It results from a shearing injury that separates the subcutaneous layers from the fascia with fluid filling a potential space.

OBJECTIVE

While the most common location and cause have been described in adults, there is limited literature in pediatric patients. We have seen pediatric Morel-Lavellée lesions commonly occurring at the knee after sports. We set out to describe the magnetic resonance imaging (MRI) characteristics.

MATERIALS AND METHODS

A retrospective analysis was performed. All patients with trauma to the pelvis and lower extremities with a subcutaneous fluid collection seen on MRI were evaluated. Age, gender, mechanism of injury, time interval to imaging, and treatment were recorded. The collections were evaluated for location, size, shape and signal characteristics including the presence of fat, blood and septations.

RESULTS

Twenty-one patients ages 7 to 17 years old had findings of degloving injury on MRI. The most common etiology was sports related (18/21, 85.7%). The anterior knee was most often affected (18/21, 85.7%). Lesions were ovoid and centered over the medial retinaculum (8/18, 44.4%) or lateral retinaculum (7/18, 38.9%). A capsule was weakly associated with later presentation (P=0.12).

CONCLUSION

Pediatric Morel-Lavellée lesions commonly occur in a location not classically described, the anterior knee, and often after sports injury. Commonly, the collections are ovoid and always located at the subcutaneous fat/fascial interface. Recognition of specific imaging characteristics in a common location after sports injury allows for early identification. While most patients recover with conservative management, some need additional intervention with aspiration or debridement.

Imaging of hip and thigh muscle injury: a pictorial review

Muscle injuries of the hip and thigh are a highly relevant issue in competitive sports imaging. The gold standard in diagnostic imaging of muscle injuries is magnetic resonance imaging (MRI). Radiologists need to be familiar with typical MRI findings in order to accurately detect and classify muscle injuries. Proper interpretation of the findings is crucial, especially in elite athletes. In soccer players, muscle injuries of the hip and thigh are the most common reason for missing a game.The present pictorial review deals with the diagnostic assessment, especially MRI, of muscle injuries of the hip and thigh. Typical MR findings in muscle injuries include edema, hematoma, and tendinous avulsion as well as partial or complete muscle tear. To estimate the time to return to play, a grading into three groups-muscle strain, partial tear, complete tear-has traditionally been used. Taking into account the most recent literature, there are other prognostic factors such as the longitudinal length of a tear, the tendon's intramuscular component, or persisting edema.

Novel Treatment of Prepatellar Bursitis

A 31-yr-old soldier presented with an 8-mo history of right prepatellar bursitis with 1-mo history of pain and loss of range of motion. His symptoms did not respond to activity modification, compression, nonsteroidal anti-inflammatory agents, or repeated aspirations with fenestration. After thorough discussion, the soldier and his provider reviewed the literature and found a single case report of intrabursal sclerotherapy in two patients with recalcitrant prepatellar bursitis. After informed consent, the patient wished to proceed with the scelerotherapy. Utilizing ultrasound guidance, the bursal sac was aspirated then injected with the scerlosing agent polidocanol. The patient had a much slower reaccumulation of swelling and at the two week follow-up the procedure was repeated. The patient has had no reaccumulation of the fluid as of 10 mo post-procedure and has resumed all his normal activities with no symptom limitation. This case demonstrates that sclerotherapy has utility in the management of recurrent non-septic prepatellar bursitis.

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.

The Morel-Lavallée lesion and its management: A review of the literature

Background

Morel-Lavallée lesions can occur in polytrauma patients. Post-operative seroma is more frequently encountered, holds many pathological similarities with MLLs and continues to challenge plastic surgeons. We aimed to provide a comprehensive overview of MLLs to increase awareness of optimum treatment options amongst plastic surgery teams, and to provide a management algorithm that may also be applied to post-operative seromas.

Methods

PubMed, Google Scholar and the Cochrane Library were searched using the terms "Morel-Lavallée", "management" and "treatment", which yielded 52 results. One reviewer screened titles and abstracts for relevance. Seventeen full text articles were retrieved. Review of reference lists provided a further three articles for inclusion.

Findings

Morel-Lavallée lesions (MLLs) represent closed injuries with internal degloving of superficial soft tissues from fascial layers. Main causes of MLLs include high-energy, blunt force trauma or crush injuries. They are commonly found overlying the greater trochanter. MLLs should be actively looked for when treating patients with pelvic trauma. MRI is the investigation of choice. Currently no guidelines for the management of MLLs exist. Compression bandaging, percutaneous aspiration, sclerodesis and mass resection have all been utilised.

Conclusions

Our algorithm recommends avoidance of conservative management. For chronic lesions, percutaneous aspiration should not be used in isolation. Sclerodesis using doxycycline is appropriate for lesions up to 400 ml, where evidence suggests high degrees of efficacy. Larger lesions should be treated with open surgery. Quilting sutures, curettage and low suction drains are useful adjuncts. We hypothesise this algorithm would also be effective for post-operative seromas.

A Novel Surgical Technique for treatment of Morel-Lavallée Lesion: Endoscopic debridement combined with percutaneous cutaneo-fascial suture

Morel-Lavallée lesions are rare, closed degloving soft tissue injuries in which the skin and subcutaneous tissues are traumatic separated from the underlying fascia. There is lack of consensus regarding optimal management of these lesions. After failure of conservative management, operative intervention is imperative. The purpose of this manuscript is to describe a minimally invasive endoscopic method for treatment of Morel-Lavallée Lesions, which achieves the goal of an open surgical debridement.

The anterior knee: normal variants, common pathologies, and diagnostic pitfalls on MRI

The anterior aspect of the knee is host to an array of normal variants and potential pathology. These normal anatomic variants are often encountered and may mimic pathologies, leading to unnecessary work-up and treatments. On the other hand, there are several subtle abnormalities that may be easily overlooked or mistaken for variants or other injuries or diseases. Recognition of these diagnostic challenges is essential for radiologists to make an accurate diagnosis. This article reviews normal anatomical variants of ligaments, tendons, bones, and other important structures of the anterior knee, focusing on magnetic resonance imaging features. Commonly encountered injuries and abnormalities of the anterior knee and their diagnostic pitfalls are also discussed, highlighting findings on magnetic resonance imaging.

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.

Morel-Lavallee injury a case study

Morel-Lavallee lesions are post-traumatic, soft-tissue degloving injuries commonly misdiagnosed as hematomas or ruptured bursa. The clinician needs to be aware of this injury, in order to provide appropriate patient care and treatment. If not treated early, risks include superinfection, continued expansion, overlying tissue necrosis, and suboptimal patient outcomes.