Hongsil Joo; Sang Gyo Seo; Sang-Yeul Lee; Kun-Yong Sung

doi:10.12671/jkfs.2016.29.4.265

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Case Report
Percutaneous Drainage and Sclerotherapy for Delayed Lumbar Morel-Lavalee Lesion: Two Case Reports: Hongsil Joo, M.D., Ph.D., Sang Gyo Seo, M.D., Sang-Yeul Lee, M.D., Ph.D., Kun-Yong Sung, M.D., Ph.D.; Journal of the Korean Fracture Society 2016;29(4):265-269.
DOI: https://doi.org/10.12671/jkfs.2016.29.4.265
Published online: October 20, 2016

Department of Plastic Surgery, Hanil General Hospital, Seoul, Korea.

^*Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.

^†Department of Plastic and Reconstructive Surgery, School of Medicine, Kangwon National University, Chuncheon, Korea.

Address reprint requests to: Kun-Yong Sung, M.D., Ph.D. Department of Plastic Surgery, Kangwon National University Hospital, 156 Baengnyeong-ro, Chuncheon 24289, Korea. Tel: 82-33-258-9494·Fax: 82-33-258-9437, ps@kangwon.ac.kr

• Received: June 4, 2016 • Revised: July 5, 2016 • Accepted: July 5, 2016

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Abstract
Case Reports
Discussion
NOTES
REFERENCES

Abstract

Closed internal degloving is a significant soft-tissue injury associated with a trauma that results in a tear of the subcutaneous tissue away from the underlying fascia. Although the diagnosis of Morel-Lavallee lesion (MLL) is routinely based on clinical and radiological examinations, in one-third of the cases, there is a possibility that clinicians may fail to diagnose MLL due to its inconsistent clinical manifestations. Additionally, it often involves initial skin bruising due to underlying soft-tissue injury. We present two cases of delayed MLL without a fracture treated using percutaneous drainage and sclerotherapy. Our cases demonstrated successful treatment with a minimally invasive percutaneous approach. The potential advantage of using a percutaneous technique is to preserve the subdermal arterial plexus, which is the only remaining blood supply to the skin in the area of the lesion. Maintaining this blood supply may result in healthier skin at the time of any open procedure.
Key words: Morel-Lavallee lesion, Lumbar, Sclerotherpy

Closed internal degloving is a significant soft-tissue injury associated with pelvic trauma in which the subcutaneous tissue is torn away from the underlying fascia. This closed internal degloving over the greater trochanter is a Morel-Lavallee lesion (MLL). In the mid-nineteenth century, Morel-Lavallee described this lesion as a traumatic detachment of skin from the subjacent layers. Hak et al.1) thought that the accumulated fluid consisted of a blood serum concentrate resulting from small vessel shear. The diagnosis of MLL is routinely based on clinical and radiological examinations. In one-third of cases, there is a possibility that clinicians may fail to diagnose MLL because of its inconsistent clinical manifestations, and it often involves initial skin bruising due to underlying soft-tissue injury.2) We present two cases of delayed lumbar MLL without a fracture treated by percutaneous drainage and sclerotherapy.

Case Reports

1. Case 1

A 41-year-old man presented to the emergency department (ER) with a lower back contusion after a traffic accident. On physical examination, he was afebrile with stable vital signs. On radiographic examination, there was no fracture sign so he was discharged from the hospital. One week later, he was admitted to neurosurgery. Swelling and pain had significantly increased over the past week. A pressure cloth was applied and physical therapy was started. Fifteen days later, his lower back pain had not disappeared. On ultrasonography and magnetic resonance imaging (MRI), a 15×8×2 cm fluid collection was shown (Fig. 1). Ultrasonography-guided incision and drainage were performed, and 37 ml of seroma was drained. The specimen culture was negative. Seven days later, the amounts of vacuum drainage decreased to 2 ml. An antibiotic (tigecycline 50 mg mixed saline 2 ml) was administered to wound, and the tigecycline (3rd generation tetracycline) is allowed to remain there for a few minutes, followed by vacuum drainage. The draining tube was removed. After 7 days, the drainage wound was healed, and swelling had disappeared. After 6 months, the patient had no further problems and no recurrence of MLL.

2. Case 2

A 14-year-old man presented to the ER with a lower back contusion following a traffic accident. On physical examination, he had mild swelling and tenderness of his back. Initial radiographs showed no fracture of the spine and pelvic regions. Since the patient had severe pain, an MRI was performed, which demonstrated a small air collection (3×4×0.5 cm) superficial to the back muscle on the left, extending across the midline to the right side (Fig. 2A). After 1 month of physical therapy, his lower back pain became severe, and the swelling had increased. MRI was repeated, which demonstrated a large fluid collection (10×10×1 cm) superficial to the back muscle on the left side (Fig. 2B). An MLL was radiologically diagnosed. The patient was hospitalized for drainage and sclerotherapy. A percutaneous drain via a 12-French catheter was placed by sonography, which immediately drained 50 ml of serous fluid. Over the following 3 days, the vacuum drain removed 40 ml of serous fluid. The specimen culture was negative. Four days later, the amount of vacuum drainage decreased to 2 ml. An antibiotic (tigecycline 50 mg mixed saline 2 ml) was administered to wound, and the tigecycline (3rd generation tetracycline) is allowed to remain there for a few minutes, followed by vacuum drainage. The draining tube was removed, and 7 days after, the drainage wound healed, and the swelling had disappeared. After 6 months, the patient had no further problems and no recurrence of MLL.

None of the patients who had percutaneous drainage of the lesion had any wound complications or skin loss. The specimen cultures were negative. The wounds were closed after vacuum drainage, and they healed without sequelae. Neither patient required debridement of the skin, and at a minimum of 6 months, no deep infection occurred.

Discussion

Closed degloving injuries are an uncommon clinical condition. The mechanisms that cause MLL are violent, direct, and tangentially applied forces to the superficial integument over unyielding aponeurotic fascia.3) The initial injury represents a shearing of subcutaneous tissues away from the underlying fascia. The disrupted capillaries may continuously drain into the perifascial plane, filling up the virtual cavity with blood, lymph, and debris. A subsequent inflammatory reaction may lead to peripheral capsule formation, which may account for the self-perpetuation and occasional slow growth of the process.1) Predisposed detachable zones include the lumbodorsal fascia, gluteal region, and anteroexternal and iliotibial tract regions of the thigh.3) The clinical features of MLL vary depending on the amount of blood and lymphatic fluid collected at the site of injury and the time elapsed since the injury. Patients usually have complaints of pain, swelling, and stiffness. On clinical examination, patients often have a soft fluctuant area of contour deformity with or without skin discoloration, and skin sensation is frequently decreased.

Closed internal degloving injuries may occur in association with pelvic and acetabular fractures or in the absence of fractures.4) MLL can be diagnosed based on imaging studies of the suspected sites and physical examination. On ultrasonography, it is characterized by hyperechoic (blood-predominant) or echoic (lymph-predominant) fluid collection, depending on the age of the lesion and its predominant content. Acute and subacute lesions <1 month old show a heterogeneous appearance with irregular margins and a lobular shape. Additionally, chronic lesions (>18 months old) show a homogenous appearance with smooth margins and a flat or fusiform shape.5) On MRI scans, however, the lesions are better visualized with soft-tissue contrast enhancement. Therefore, MRI is a better choice of imaging modality than computed tomography for diagnosing MLL.5)

In the literature, the management of lesions varies for closed internal degloving injuries. In the acute traumatic setting, Hak et al.1) suggested thorough surgical debridement to prevent infection.4) Other methods that have been described include aspiration with or without pressure therapy, injection of a sclerosing agent, and prolonged closed surgical drainage.4 6) There is controversy whether drainage in the acute setting should be percutaneous or open.1 4) Percutaneous drainage can be used to manage larger acute lesions that cannot resolved with a single application of compression bandages. It can also be attempted with sclerotherapy as first-line therapy in patients with chronic lesions.7 8) Sclerotherapy is performed by injecting a sclerosant into the dead space. The sclerosant is allowed to remain there for a few minutes, followed by percutaneous drainage. Sclerotherapy can be used as first-line therapy in patients with acute lesions that are refractory to compression bandages and in those with chronic lesions.9) In patients with chronic lesions, percutaneous drainage may result in recurrent postoperative hematoma or secondary infection. Therefore, it is essential to combine percutaneous drainage with sclerotherapy. MLLs that are not diagnosed early enough or those that are refractory to treatment require open surgery.3) The presence of a well-defined capsule is an indication for open surgery over conservative therapy.4) It has been reported that primary closure of the degloved area results in a high incidence of complications, including reaccumulation of hematoma, wound breakdown, and infection.10)

In conclusion, our cases demonstrated successful treatment with a minimally invasive percutaneous approach. The potential advantage of using a percutaneous technique is preservation of the subdermal arterial plexus, which is the only remaining blood supply to the skin in the area of the lesion. Maintaining this blood supply may result in healthier skin at the time of any open procedure.

The differential diagnosis of MLL includes other posttraumatic injuries such as fat necrosis or coagulopathy-related hematoma. As the MLL can clinically and radiographically simulate a malignant tumor, careful evaluation of a history of trauma can be very useful in making the correct diagnosis. Its diagnosis and treatment are often delayed because it involves internal degloving without surface penetration. Once the lesion is identified, the hematoma and dead space should be removed. Also, necrotic material should be debrided, as neglected lesions may become infected.4) There are no established cases of MLL with specific treatment regimens, thus clinicians decide the treatment method according to the nature of the lesion.

This study was supported by 2016 Research Grant from Kangwon National University.

None.

REFERENCES

1. Hak DJ, Olson SA, Matta JM. Diagnosis and management of closed internal degloving injuries associated with pelvic and acetabular fractures: the Morel-Lavallee lesion. J Trauma, 1997;42:1046-1051.
2. Shen C, Peng JP, Chen XD. Efficacy of treatment in peri-pelvic Morel-Lavallee lesion: a systematic review of the literature. Arch Orthop Trauma Surg, 2013;133:635-640.
3. Kottmeier SA, Wilson SC, Born CT, Hanks GA, Iannacone WM, DeLong WG. Surgical management of soft tissue lesions associated with pelvic ring injury. Clin Orthop Relat Res, 1996;(329):46-53.
4. Hudson DA, Knottenbelt JD, Krige JE. Closed degloving injuries: results following conservative surgery. Plast Reconstr Surg, 1992;89:853-855.
5. Mukherjee K, Perrin SM, Hughes PM. Morel-Lavallee lesion in an adolescent with ultrasound and MRI correlation. Skeletal Radiol, 2007;36:Suppl 1. S43-S45.
6. Letts RM. Degloving injuries in children. J Pediatr Orthop, 1986;6:193-197.
7. Moran DE, Napier NA, Kavanagh EC. Lumbar Morel-Lavallée effusion. Spine J, 2012;12:1165-1166.
8. Tseng S, Tornetta P 3rd. Percutaneous management of Morel-Lavallee lesions. J Bone Joint Surg Am, 2006;88:92-96.
9. Bansal A, Bhatia N, Singh A, Singh AK. Doxycycline sclerodesis as a treatment option for persistent Morel-Lavallée lesions. Injury, 2013;44:66-69.
10. Anakwenze OA, Trivedi V, Goodman AM, Ganley TJ. Concealed degloving injury (the Morel-Lavallée lesion) in childhood sports: a case report. J Bone Joint Surg Am, 2011;93:e148.

Fig. 1

On both ultrasonography (white arrow) (A) and magnetic resonance imaging (black arrow) (B), a 15×8×2 cm sized fluid collection is shown.

Fig. 2

(A) Magnetic resonance imaging demonstrating a small air collection (3×4×0.5 cm, white arrow), superficial to the back muscle on the left, extending across the midline to the right side. (B) After 1 month of physical therapy, magnetic resonance imaging was repeated, showing a large fluid collection (10×10×1 cm, black arrow) superficial to the back muscle on the left.

Figure & Data

REFERENCES

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Surgical Treatment of a Delayed Diagnosed Morel-Lavallee lesion: A Case Report
Choong Hyeon Kim, Woo Young Choi, Kyung Min Son, Ji Seon Cheon
Journal of Wound Management and Research.2017; 13(2): 62. CrossRef

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Percutaneous Drainage and Sclerotherapy for Delayed Lumbar Morel-Lavalee Lesion: Two Case Reports

J Korean Fract Soc. 2016;29(4):265-269. Published online October 31, 2016

DOI: https://doi.org/10.12671/jkfs.2016.29.4.265

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Percutaneous Drainage and Sclerotherapy for Delayed Lumbar Morel-Lavalee Lesion: Two Case Reports

Fig. 1 On both ultrasonography (white arrow) (A) and magnetic resonance imaging (black arrow) (B), a 15×8×2 cm sized fluid collection is shown.

Fig. 2 (A) Magnetic resonance imaging demonstrating a small air collection (3×4×0.5 cm, white arrow), superficial to the back muscle on the left, extending across the midline to the right side. (B) After 1 month of physical therapy, magnetic resonance imaging was repeated, showing a large fluid collection (10×10×1 cm, black arrow) superficial to the back muscle on the left.

Fig. 1

Fig. 2

Percutaneous Drainage and Sclerotherapy for Delayed Lumbar Morel-Lavalee Lesion: Two Case Reports