Degloving Research Articles

Diagnosis and Treatment of a Morel-Lavallee Lesion via Point-of-Care Ultrasound (POCUS)

Morel-Lavallee Lesion (MLL) is a rare diagnosis of a closed internal degloving injury that can occur with high energy trauma. The pain, soft tissue swelling, and ecchymosis that patients describe mimic many other emergent diagnoses to include compartment syndrome and fractures. The following case highlights the importance of the role of Emergency Medicine physicians using point-of-care ultrasound (POCUS) to recognize and treat a potentially life-threatening injury. Our patient was initially managed with a bedside needle aspiration with drainage of 25cc of serosanguinous fluid that resulted in immediate pain relief. Patient was then admitted for further Interventional Radiology drainage of 160cc of serosanguinous fluid by Interventional Radiology.

Morel–Lavallee Lesion of the Hip in Children: About a Case and Literature Review

ABSTRACT Morel–Lavallée lesion, also called closed degloving injury, is a rare clinical entity in routine pediatric surgical practice. We present a case of an 11-year-old girl presenting with a left hip lesion, treated with compression bandage, and the clinical outcome was favorable.

Computed tomographic features of Morel-Lavallée lesions in 3 cats.

To describe the CT features of Morel-Lavallée lesions (MLLs) and their association with trauma in cats. This study aimed to investigate whether MLL fluid in cats accumulates between the dermis and deep fascia near superficial trauma, exhibits a vertical attenuation gradient, and shows no or only mild contrast enhancement on CT images. 3 young cats: a 1-year-old neutered male domestic shorthair cat, a 2-year-old neutered male domestic shorthair cat, and a 3-year-old neutered female British Shorthair cat. The clinical presentation of the 3 cats in the study involved recurrent swelling and fluid accumulation affecting at least 1 pelvic limb following trauma. In all cases, there was a fluid-filled space deep to the skin and superficial subcutaneous layer but superficial to the deep fascial plane overlying the muscular component of the pelvic limbs. The MLL fluid had a vertical attenuation gradient and no or only mild contrast enhancement. Morel-Lavallée lesions are often initially overlooked, likely due to distraction by concomitant significant bone injuries, and can be mistaken for hematomas, seromas, subcutaneous edema, contusions, or cellulitis, leading to less aggressive treatment. If left untreated, MLLs present a significant risk of extensive skin necrosis compared to other types of subcutaneous swelling.

Multiple Free Flaps and Second Toe Transfer to Salvage Grasp Function in Bilateral Complete Degloved Hands

AbstractA 21-year-old male laborer sustained bilateral degloving injury of the hands with multiple digital amputations and devascularized digits. After X-rays, preliminary debridement was done, when digital amputations were completed, including index ray amputation on both sides. The next day, two anterolateral thigh (ALT) flaps and one second toe transfer were done to restore coverage in the palm and the web and reconstruct the lost thumb. This ensured both coverage and thumb length on the right side, but on the left side the procedure was terminated with flap transfer only. After 3 months, the other second toe was harvested with a dorsalis pedis flap for reconstruction of the left thumb, and a free gracilis flap was done for optimal donor site coverage in the donor left foot. Evaluation after 2 years showed functional hands with reasonable power grasp, pinch grip, and dexterity to manipulate small and large objects that permitted an independent living.

Indocyanine Green-Based Fluorescence Imaging to Guide Local Tissue Rearrangement of a Complex Morel-Lavallee Lesion About a Hip: A Technical Trick.

https://ota.org/education/ota-online-resources/video-library-procedures-techniques/icg-based-fluorescence-imaging.

Morel-Lavallee associated lymphedema treated with lymphovenous anastomosis: A case report

Morel-Lavallee Lesions lead to disruption of lymphatic anatomy that require early identification and may necessitate lymphatic reconstruction. We present the case of a 59-year-old male with lower extremity lymphedema resulting after a severe Morel-Lavallee lesion and treated using lymphovenous anastomoses. He was initially managed with multiple aspirations followed by repeat incision and drainage. At 10 months following his injury, he continued to have swelling of his upper thigh and developed a large festoon medially, with lower leg pitting edema. He was diagnosed with lymphedema via lymphoscintigraphy. His superficial lymphatic anatomy was visualized using indocyanine green (ICG) lymphography and showed diffuse dermal backflow across his thigh, with signs of altered lymphatic anatomy distally. We preformed two lymphovenous anastomoses at the level of his mid-thigh to bypass the lymphatic disruption and restore drainage to his lower leg. After rerouting lymphatic flow from the lower extremity, the patient had overall improvement of his symptoms and reduced swelling with continued therapy. At 5 months postoperatively, his volumetric lower extremity measurements showed a decrease by 314 mL and he began walking again in 20-minute intervals. Lymphedema may be an important consideration following severe Morel-Lavallee lesions. Using modern diagnostic and supermicrosurgical techniques, plastic surgeons can help treat this long-term morbidity.

Degloving intramuscular injuries of the semimembranosus and adductor longus muscles in adolescent soccer players.

Degloving muscle injury was described for the rectus femoris where the inner bipennate component is dissociated from its superficial unipennate component. The semimembranosus muscle displays a distinctive dual morphology, featuring both unipennate and bipennate muscle fibers. Nevertheless, this specific tear pattern has not been previously documented. Conversely, the adductor longus muscle showcases an elongated intramuscular tendon segment, indicating a multipennate morphology. We present two separate cases of previous undescribed degloving injuries of the semimembranosus and the adductor longus in teenage soccer players with MRI and ultrasound diagnosis, ultrasound-guided hematoma aspiration, and recovery timelines for return-to-play.

Unmasking the face: A case report of soft-tissue reconstruction after degloving injury

Facial degloving injuries present a complex medical challenge, where the skin and underlying tissues detach from the muscles, fascia, and bones beneath. These injuries pose significant difficulties for surgeons, particularly when complicated by wound infection or tissue necrosis. This case report details the experience of a 26-year-old male patient with a history of trauma, who suffered a facial degloving injury requiring reconstructive soft-tissue surgery. It outlines the challenges encountered during both the surgical and post-operative phases in managing a patient with a full-thickness avulsed flap extending from the lower face to the suprahyoid area of the neck.

Negative pressure wound therapy: our experience of a polytrauma with degloving injury

Degloving injuries are uncommon serious conditions occurring in high-velocity traumas with high mortality and morbidity. The lack of standard guidelines for the diagnostic and therapeutic management of such injuries provides a challenge to the surgeon. We present a case of a 35-year-old male with an extensive degloving injury who underwent primary closure unsuccessfully. The necrotic area was debrided and negative pressure wound therapy was used for the management of the wound. The patient was managed with split skin grafting and post successful recovery on all fronts has been completely rehabilitated. Though primary suturing is always tried, the viability of the degloved skin remains questionable and might need extensive debridement. Negative Pressure Wound dressing is seen to be accelerating wound healing and improving the treatment outcome.

The Evolution of Hand Injuries at a State's Only Level I Trauma Center: A Look From the 1980s Through the Global Pandemic.

The purpose of this study is to evaluate any changes to hand trauma in the past three decades and through the COVID-19 pandemic. We hypothesized that improved consumer safety regulations, changes in access to care, and the impact of a global pandemic, among other variables, have significantly influenced the mechanisms and treatment of hand injuries between the 1980s, 2010s (pre-COVID-19), and 2020s (post-COVID-19). A retrospective single-center review was performed at the only level I trauma center in Mississippi, identifying all hand trauma consultations between 2012-2019 and 2020-2021, compared to aggregated data from 1989. Car accidents, gunshots, saw injuries, door injuries, and falls increased in 2012-2019 and 2020-2021 compared to 1989, whereas knife injuries, glass injuries, industrial injuries, and burns decreased. Crush injuries, de-gloving injuries, and lacerations with irregular edges were increased in recent cohorts, corresponding with increased amputations and tissue loss. Skin and subcutaneous injuries decreased in modern cohorts, corresponding with a decreased ability for primary skin repair and the need for more flaps. Additionally, while hospitalizations have increased, patients have improved follow-up. The nature of hand trauma has changed significantly over the past three decades. Increased numbers of cars and greater access to firearms might have led to increased rates of high-energy trauma, whereas burn and industrial injuries have decreased, potentially secondary to improved safety efforts. Despite increased overall hand trauma, time to treatment and follow-up have improved. Through this study, we can be more cognizant of the evolution of hand trauma in the modern era. This can allow improved access to care and further refine management to optimize functionality for hand injuries.

Morel-Lavallée Lesion: A Case Report

The Morel-Lavallée lesion (MLL) is an uncommon, traumatic internal degloving injury of the soft tissues and the fascia. The MLLs are often misdiagnosed or delayed in being diagnosed due to the severity of other injuries from an accident. Sonography and/or magnetic resonance imaging may be used to confirm the diagnosis. After the MLL is diagnosed, treatment options vary from conservative options to surgical methods depending on the chronicity of the lesion. The case study presented occurs in the most common site for the injury, the hip and pelvis.

Random pattern sub-clavicular flap in digital degloving injuries: an alternative in the reconstructive ladder

Degloving soft tissue detachment injuries occur when the skin and subcutaneous tissue detach from the underlying structures, affecting the skin coverage. The hand is usually the most frequent affected site. In digital lesions, the best results are obtained by revascularization; nevertheless, this procedure is challenging for the surgeon. Random pattern flaps represent an effective alternative for the treatment of these devastating lesions. We present two clinical cases with digital degloving injury from the proximal phalanx. Both cases required reconstructive surgery in 2 stages, using a successful random pattern sub-clavicular flap. This article aims to share the results of using this method as another reconstructive option with good results. After an average follow-up of 8 months in both cases, adequate skin coverage and functionality of the finger treated with the described flap was observed. Patient A presents a finger with proper healing and functionality. Patient B at 10 months, presents a thumb with adequate length for clamping and opposition. Sub-clavicular flap is an excellent reconstructive alternative for digital degloving injuries where revascularization is unattainable, providing good skin coverage and functionality and being a reproducible outpatient procedure.

More Than a Bruise: Two Cases ofMorel-Lavallée Lesions inActive 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.

A Rare Case of Morel-Lavallée Lesion of the Left Thigh

Morel-Lavallée lesion (MLL) is a closed degloving soft tissue injury that occurs when there is abrupt separation of skin and subcutaneous tissue from the underlying fascia. It usually develops following high-velocity trauma and crush injuries. This is a case report of a young female who had a fall and presented with a large swelling in her left thigh and was diagnosed to have a MLL. She underwent drainage of the collection; the wound was left open and allowed to heal by secondary intention.

Repair of Fingertip Degloving Injuries Using the Extended Reverse Second Dorsal Metacarpal Artery Flap.

This study aimed to introduce modified reverse second dorsal metacarpal artery flap (MRSDMAF) transfer for the treatment of fingertip degloving injuries. From January of 2004 to March of 2020, 31 patients with fingertip degloving injuries underwent MRSDMAF transfer. The mean defect and flap size were 4.5 × 1.6 cm and 4.7 × 1.7 cm, respectively. Nerve repair was performed in 18 fingers. Flap sensation, function restoration of the reconstructed fingers, and donor-site morbidity were assessed. For comparison, we reviewed a cohort of 45 patients undergoing modified cross-finger flap (MCFF) transfer. Complete flap survival was achieved in 28 fingers, and partial distal flap necrosis was noted in 3 fingers. After a mean of 24 months, the static 2-point discrimination was 8.6 ± 1.0 mm and 7.2 ± 0.8 mm in the MRSDMAF and MCFF groups, with a significant difference ( P < 0.0001). Sensory restoration of the MRSDMAF group was inferior to that of the MCFF group. In addition, the MRSDMAF group presented a higher incidence of fingertip pain ( P = 0.019) and suboptimal appearance of the reconstructed finger ( P = 0.036). On the donor site, the MRSDMAF group presented a lower incidence of scar pain ( P = 0.030) and better appearance ( P = 0.025). MRSDMAF transfer is an alternative treatment for fingertip degloving injuries, especially when MCFF transfer is not feasible. Therapeutic, III.

Morel–Lavallee lesions and number of surgeries for associated injuries predict surgical site infection risk following pelvic ring injury osteosynthesis

We examined the incidence and causative factors of surgical site infection (SSI) following osteosynthesis for pelvic ring injury by reviewing the data of 97 consecutive patients with pelvic ring injuries treated between 2014 and 2019. Osteosyntheses, including internal or external skeletal fixation with plates or screws, were performed based on fracture type and patient’s condition. Fractures were treated surgically, with a 36 months minimum follow-up period. Eight (8.2%) patients experienced SSI. The most common causative pathogen was Staphylococcus aureus. Patients with SSI had significantly worse functional outcomes at 3, 6, 12, 24, and 36 months than those without. For patients with SSI, the average Merle d’Aubigné and Majeed scores at 3, 6, 12, 24, and 36 months after injury were 2.4, 4.1, 8.0, 11.0, and 11.3, and 25.5, 32.1, 47.9, 61.9, and 63.3, respectively. Patients with SSI had a higher likelihood of undergoing staged operations (50.0 vs. 13.5%, p = 0.02), more surgeries for associated injuries (6.3% vs. 2.5%, p = 0.04), higher likelihood of Morel–Lavallee lesions (50.0% vs. 5.6%, p = 0.002), higher incidence of diversional colostomy (37.5% vs. 9.0%, p = 0.05), and longer intensive care unit stay (11.1 vs. 3.9 days, p = 0.001) than those without. The contributing factors for SSI were Morel–Lavallee lesions (odds ratio [OR] 4.55, 95% confidence interval [95% CI] 3.34–50.0) and other surgeries for associated injuries (OR 2.37, 95% CI 1.07–5.28). Patients with SSI after osteosynthesis for pelvic ring injuries may have worse short-term functional outcomes.

Avulsive degloving soft tissue injury of the lower face in a child: A case report

Facial degloving injuries occur when the skin and subcutaneous tissues separate from the underlying muscles, fascia and bones. These injuries frequently pose a reconstructive challenge for surgeons, especially when complications such as wound infection or necrosis of the avulsed flap are present. The challenges in the operative management and post operative care of a case of facial degloving injury with full thickness avulsed flap involving lower face extending in to the supra hyoid region of the neck is presented in this case report. Treatment of such facial wounds in children requires a well co-ordinated team approach between the maxillofacial surgeon, anesthesiologist and paediatrician to deliver optimum aesthetic and functional results. Keywords: Avulsion, Degloving, Maxillofacial injuries, Soft tissue facial injuries

High degree degloving injury of the lower limb A case report and literature review

Degloving injuries occur when shearing forces act parallel to the tissues, resulting in displacement of superficial layers and separation of the skin and subcutaneous tissue from deep structures, such as muscular fascia and muscles [1]. These types of injuries are considered severe, with high morbidity and mortality rates [2], due to the increased risk of infections, thermal dysregulation, and fluid loss [3]. The severity of a degloving injury depends on factors such as the mechanism of injury, patient comorbidities, anatomical region, and type of injury (open or closed) [4]. Such injuries must be treated as a life-threatening emergency.

MOREL-LAVALLÉE LESION INDUCED BY DYNAMIC HIP SCREW (DHS) CUT OUT: A CASE REPORT AND LITERATURE REVIEW

A Morel-Lavallee lesion (MLL) is a benign cystic lesion that occurs due to injury to the soft-tissue envelope's perforating vascular and lymphatic systems, resulting in a distinctive hemolymphatic fluid accumulation between the tissue layers. The MLL has the potential to make a significant impact on the treatment of orthopaedic injuries.A 79-year-old male patient community ambulatory with assisting aid (cane) known case of Diabetes mellitus, hypertension, bronchial asthma and ischemic heart disease. He was brought to the Emergency, complaining of right hip discomfort and burning sensation for the last 5 days with no history of recent trauma at all. Patient had history of right trochanteric femur fracture 3 years ago, treated with DHS in a privet service. Clinical and Radiological assessment showed that the patient mostly has acute MLL due to lag screw cut out. We offered the patient the surgical intervention, but he refused despite explaining the risks of complications if not treated and preferred to receive the conservative treatment. Compression therapy management explained to him including biker's shorts (instructed to be worn full-time a day) and regular follow up in clinic. Symptom's improvement was reported by the patient in the subsequent visits.In the polytrauma patient, a delayed diagnosis of these lesions is conceivable due to the presence of more visible injuries. It's located over the greater trochanter more commonly, but sometimes in other areas such as the lower lumbar region, the thigh, or the calf. Incorrect or delayed diagnosis and care can have unfavorable outcomes such as infection, pseudocyst development, and cosmetologically deformity. Magnetic resonance imaging (MRI) and ultrasound will aid in MLL diagnosis. However, the effectiveness of MLL therapy remains debatable.We strongly believe that the MLL caused due to tangential shear forces applied to the soft tissue leads to accumulation of the blood and/or lymph between the subcutaneous and overlying fascia and it often misdiagnosed due to other distracting injuries. Nontheless, in our case we reported MLL occur due to internal pressure on the fascia caused by cut out of DHS lag screw.

Morel-Lavallée lesion: An uncommon internal degloving injury in trauma patients

Introduction Morel-Lavallée (ML) lesion is an uncommon closed internal degloving soft tissue injury seen in patients with blunt trauma. As it often takes days to weeks after trauma to develop, it may go undiagnosed and can be missed in up to 44% of the cases. Methodology A comprehensive literature search was performed using various databases till August 2022. Twenty-eight articles related to the pathophysiology, clinical presentation, diagnosis, treatment or complications of ML lesions were included and summarized in this review. Discussion Shearing forces lead to separation of the skin and subcutaneous tissues from the fascia superficial to underlying muscles, and collection of fluid in this space leads to development of a palpable fluctuant swelling. The most common etiologies were motor vehicle crashes, falls and contact sports. It usually forms adjacent to a bony protuberance. Common symptoms include pain and swelling over the injured area, either presenting acutely after the trauma, or developing few days to weeks after the injury. It is often misdiagnosed as muscle contusion or hematoma, abscess or neoplasm. Use of bedside ultrasound and computed tomography (CT) can aid in its identification, but magnetic resonance imaging (MRI) is the imaging modality of choice. Depending on the size and severity of the lesion, as well as presence or absence of a capsule, definitive management can be conservative or surgical. Conclusion ML lesion is often undiagnosed during initial presentation of a trauma patient, and emergency physicians and trauma surgeons should be aware of the possibility of occurrence of this injury. MRI is the imaging modality of choice, and the presence or absence of a capsule is an important imaging finding that guides appropriate therapy. Early diagnosis and management will help prevent long-term morbidity and complications in these patients.