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Percutaneous Management of Morel-Lavallee Lesions

Susan Tseng and Paul Tornetta, III J Bone Joint Surg Am. 88:92-96, 2006. doi:10.2106/JBJS.E.00021

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THE JOURNAL

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BONE

AND JOINT

SURGERY, INCORPORATED

Percutaneous Management of Morel-Lavallee Lesions

BY SUSAN TSENG, MD, AND PAUL TORNETTA III, MD
Investigation performed at Boston University Medical Center, Boston, Massachusetts

Background: Previous recommendations for treatment of Morel-Lavallee soft-tissue degloving lesions have included open dbridement with packing or delayed closure. The purpose of this study was to review the use of percutaneous drainage for the initial management of these lesions. Methods: Nineteen patients with a Morel-Lavallee lesion were managed with percutaneous drainage and dbridement of the lesion within three days after the injury. Drainage was usually completed through two 2-cm incisions: one over the distal aspect of the lesion and one over the most superior and posterior extent of the lesion. A plastic brush was used to dbride the injured fatty tissue, which was washed from the wound with pulsed lavage. A medium Hemovac drain was placed within the lesion and was removed when drainage was <30 mL over twenty-four hours. Results: Fifteen of the nineteen patients had surgery for an associated pelvic or acetabular fracture. Seven of the nine patients in whom a pelvic fracture was treated surgically had percutaneous fixation of the posterior part of the pelvic ring as well as treatment of the Morel-Lavallee lesion during the same operative setting. Fixation of the remaining two pelvic fractures and the six acetabular fractures was deferred until at least twenty-four hours after the drain was removed. Three of sixteen cultures of specimens taken from the wounds were positive. None of the patients with percutaneous fixation of the pelvis had wound complications. One wound required surgical exploration because of persistent drainage, but the culture was negative and the wound healed with no sequelae. No patient required dbridement of skin and, at a minimum of six months, no deep infection had occurred. Conclusions: Early percutaneous drainage with dbridement, irrigation, and suction drainage for the treatment of Morel-Lavallee lesions appears to be safe and effective. Percutaneous procedures for pelvic fixation were well tolerated by the small number of patients in this series, and open procedures appeared to be safe when performed in a delayed fashion. Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

orel-Lavallee lesions are associated with pelvic and acetabular fractures and occur most commonly after direct trauma to the region of the greater trochanter1. The lesion is a closed soft-tissue degloving injury, in which the skin and subcutaneous tissue are separated from the underlying fascia. This creates a space that fills with blood and, in some cases, necrotic fat2,3. Although the natural history of these injuries has not been fully elucidated, previous reports have documented their potential to be colonized with bacteria at the time of initial drainage, even though they are closed injuries1,2,4. For this reason, many authors prefer to perform an open dbridement and allow the wound to heal by secondary intention2,4-7. However, this method violates a region of skin that is already injured. The remaining vascular supply to the skin over the lesion, the subdermal plexus, is disrupted by open dbridement8. Thus, it may be desirable to carry out irrigation and dbridement with a less aggressive approachi.e., by utilizing limited incisions. Because the injury

is closed, it can be assumed that the colonization takes place some time after the hematoma is created, probably as a result of circulating bacteria that are present after major trauma9. The purpose of this study was to review the use of percutaneous drainage for the early management of Morel-Lavallee lesions in the greater trochanteric region. Materials and Methods ata pertaining to nineteen consecutive patients with an acute Morel-Lavallee closed soft-tissue degloving injury were reviewed retrospectively. Institutional review board approval was not required for the collection of patient data when this protocol was initiated, and a waiver from our institutional review board was obtained subsequently to review the data. The patients were admitted to a level-I trauma center between 1994 and 2004. (Approximately 1100 patients presented to that emergency room with pelvic and acetabular fractures during that ten-year period.) The average age of the nineteen

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THE JOUR NAL OF BONE & JOINT SURGER Y JBJS.ORG VO L U M E 88-A N U M B E R 1 J A N U A R Y 2006 PE R C U T A N E O U S M A N A G E M E N T M O R E L -L AV A L L E E L E S I O N S
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Fig. 1-A

A patient with a vertically unstable pelvic ring injury and an associated Morel-Lavallee lesion three days after injury.

patients was twenty-eight years (range, twenty-three to fiftytwo years). Fourteen of the patients were male, and five were female. The diagnosis was made on the basis of physical findings consisting of a soft fluctuant area of variable ecchymosis over the greater trochanter with extension to the lateral aspect of the thigh or gluteal region (Figs. 1-A and 1-B). The surface area of the lesions averaged 30 12 cm and ranged from 15

10 cm to 40 15 cm. If there was any uncertainty about the diagnosis, usually because of obesity, a needle aspiration of the area was performed to confirm the presence of a hematoma. This was done in five patients. All patients were treated within three days after the injury, and none had a full-thickness skin lesion. Associated injuries included twelve pelvic fractures, seven acetabular fractures, one basicervical hip fracture, and

Fig. 1-B

A large fluctuant area is demonstrated by palpation.

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THE JOUR NAL OF BONE & JOINT SURGER Y JBJS.ORG VO L U M E 88-A N U M B E R 1 J A N U A R Y 2006 PE R C U T A N E O U S M A N A G E M E N T M O R E L -L AV A L L E E L E S I O N S
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Fig. 2

Incisions are made at the proximal and distal extents of the lesion.

two femoral shaft fractures. Systemic injuries included three pulmonary contusions, two head injuries, two splenic lacerations, one bladder rupture, and one liver laceration. All of the Morel-Lavallee lesions were managed with percutaneous drainage and dbridement within three days after the injury. Drainage was accomplished by making a 2-cm incision over the distal aspect of the lesion and a similar incision at the most superior and posterior extent of the injury. The extent of the lesion was determined by placement of a

suction tip through the lesion, from one extreme to the other (Fig. 2). In five patients, three incisions were used because of the extensive size of the cavity. Specimens of fluid from sixteen of the nineteen patients were sent for culture. After the hematoma was drained, a plastic brush (normally used for preparation of the femoral canal in hip replacements) was employed to percutaneously dbride the injured fatty tissue (Fig. 3). The dbrided tissue was washed from the wound with use of pulsed lavage that entered the injury cavity from the distal

Fig. 3

A plastic brush is used to percutaneously dbride necrotic fat from the wound.

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THE JOUR NAL OF BONE & JOINT SURGER Y JBJS.ORG VO L U M E 88-A N U M B E R 1 J A N U A R Y 2006 PE R C U T A N E O U S M A N A G E M E N T M O R E L -L AV A L L E E L E S I O N S
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incision and exited through the proximal gluteal incision, except in three patients in whom the irrigation was performed from proximal to distal because of improved flow in that direction. The lesion was irrigated until the fluid was completely clear. Although the amount of irrigation fluid was not specifically recorded, one 5-L bag of normal saline solution was generally used. A medium Hemovac drain was placed throughout the extent of the space, and the incisions were closed. Postoperatively, the drain was placed on wall suction and was removed when the drainage was <30 mL in a twenty-four-hour period. The duration of the closed drainage ranged from three to eight days. A cephalosporin was administered intravenously for twenty-four hours after the drain was removed. Results ifteen of the nineteen patients had surgery for an associated pelvic or acetabular fracture: nine of the twelve pelvic fractures and six of the seven acetabular fractures were fixed surgically. Percutaneous fixation of the posterior part of the pelvic ring was undertaken subsequent to the treatment of the MorelLavallee lesion but during the same operative setting in seven of the nine patients in whom a pelvic fracture was fixed. Fixation of the remaining two pelvic fractures and the six acetabular fractures was deferred until at least twenty-four hours after the drains were removed (five to fifteen days after dbridement). Three patients had positive cultures of specimens taken from the wound, and the antibiotic therapy for those patients was adjusted on the basis of the bacteriological findings. Three separate species, Staphylococcus aureus, Enterobacter, and Staphylococcus epidermidis, grew in the three cultures. Of the associated fractures in the patients with a positive culture, one was treated with percutaneous fixation; one, with open reduction and internal fixation; and one, nonoperatively. None of the patients who had percutaneous fixation of the pelvis had any wound complications or skin loss. Three patients had an operative incision that went directly through the lesion: two were treated with a Kocher-Langenbeck incision, and one was treated with a direct lateral approach to the hip. The other open procedures were performed through an anterior approach to the pelvis or an ilioinguinal approach to the acetabulum and did not violate the lesion. One patient with a both-column pelvic fracture and an associated hip fracture was treated through an ilioinguinal approach. The anterior column fracture was incomplete. Because specimens from the lesion on the outer aspect of the pelvis had been culture positive, the crest was not osteotomized, but the posterior column was reduced to the anterior column anatomically. At four years, this patient had no arthrosis, had returned to work, and was walking well although with occasional pain. Of the two fractures that were fixed through a Kocher-Langenbeck approach, one required a surgical exploration of the wound because of persistent drainage, on the tenth postoperative day. The culture of specimens obtained at that time was negative. The wound was closed after the exploration, and it healed with no sequelae. No patient required dbridement of skin, and, at a minimum of six months, no deep infection had occurred.

Discussion orel-Lavallee lesions are uncommon but major softtissue injuries. Because the bruising, which may be the most obvious sign of the lesion, generally takes several days to develop, many lesions may be missed on initial evaluation. Hudson et al. reported a delay in diagnosis for one-third of the patients in their series5. Hak et al. reviewed the diagnostic methods, which include close inspection for soft fluctuance and skin hypermobility as well as needle aspiration in some cases4. Lesions also may be visible on computed tomography scans10. To our knowledge, all authors have agreed that, once the injury is identified, the hematoma must be evacuated and any necrotic tissue must be removed as neglected lesions can become infected, complicating management1,2,4-7,11. However, the method by which this is performed is controversial. Less invasive surgery was recommended by Hudson et al., but only six lesions in their series were in the area of the pelvis and none of them were associated with a major fracture5. Open dbridement is recommended for cases that are diagnosed later1,2,4-7,11. In the study by Hak et al., in which the average time from the injury to the dbridement was 13.1 days, 46% of the lesions were culture positive at the time of the initial dbridement. However, to our knowledge, there has been no specific information on lesions treated as early as those in our series. As the skin over a Morel-Lavallee injury is intact, the infection must come from circulating bacteria; therefore, some time must pass before the lesion becomes colonized. Accordingly, it would seem that, if the diagnosis is made early, there is less time for colonization to occur and there may be a lower rate of infected lesions. In our series, Morel-Lavallee lesions diagnosed within three days after the injury were treated with the percutaneous technique. The lesion was completely evacuated through incisions at its proximal and distal extents. It is important that the entire lesion be dbrided and thoroughly washed with pulsed lavage. We think that wound closure over a drain, which is attached to wall suction until the drainage is minimal, is also an important step. 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. Most of the patients in this series required reduction and fixation of the fracture. However, only three operative incisionstwo Kocher-Langenbeck incisions and one direct lateral approach to the hipwent directly through the lesion. The other open procedures were performed through an anterior approach to the pelvis or an ilioinguinal approach to the acetabulum. One of the three patients with an incision through the lesion had continued serous drainage that required an exploration and removal of additional necrotic fat, but specimens from the wound were negative on culture and the wound healed without additional problems. None of the fractures that were fixed percutaneously were associated with infectious complications, and none of the patients sustained skin loss.

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THE JOUR NAL OF BONE & JOINT SURGER Y JBJS.ORG VO L U M E 88-A N U M B E R 1 J A N U A R Y 2006 PE R C U T A N E O U S M A N A G E M E N T M O R E L -L AV A L L E E L E S I O N S
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We believe that early percutaneous drainage with dbridement, irrigation, and suction drainage is a safe and effective method of treatment of Morel-Lavallee lesions. Percutaneous procedures for pelvic fixation in the same operative setting can be well tolerated, and open procedures appeared to be safe when performed in a delayed fashion. Thus, we recommend percutaneous drainage of these lesions within the first three days after injury if the patients condition is stable.

850 Harrison Avenue, Dowling 2 North, Boston, MA 02118. E-mail address for P. Tornetta: ptornetta@pol.net. E-mail address for S. Tseng: stseng@bu.edu The authors did not receive grants or outside funding in support of their research for or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Susan Tseng, MD Paul Tornetta III, MD Department of Orthopaedic Surgery, Boston University Medical Center,

doi:10.2106/JBJS.E.00021

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