Summary A Morel-Lavallee Lesion (MLL) is a closed traumatic soft tissue degloving injury characterized by separation of the dermis from the underlying fascia due to a shearing force. Diagnosis requires high a index of suspicion with presence of an area of ecchymosis, swelling, fluctuance and skin hypermobility in the polytrauma patient with underlying fractures. Treatment is generally operative irrigation and debridement for most lesions given the proximity to planned surgical incisions and increased risk of infection. Epidemiology Incidence present in up to 8% of acetabulum fractures Anatomic location most often along proximal lateral thigh, in the peritrochanteric region to a lesser extent gluteal, lumbosacral, and abdominal areas due to hypermobility of skin in these regions Risk factors high-energy, shearing trauma Etiology Pathophysiology divided into 4 stages: shearing forces to soft-tissue envelope lead to separation of the dermis from the underlying fascia injured lymphatics and vasculature from the injured subdermal plexus produce these components are then replaced by serosanguinous fluid as the lesion enlarges finally, if left untreated during the acute stage, local inflammation leads to pseudocapsule formation and lesion maturation as the body attempts to sequester the space bacterial colonization of the fluid occurs in up to 46% of lesions Associated conditions orthopaedic conditions pelvic and acetabular fractures proximal femur fractures Anatomy Anatomy of soft tissues (order of layers from superifical to deep) epidermis dermis subcutaneous fat MLL develops deep to subctuaneous fat and superfical to deep fascia deep fascia muscle Presentation History there should be high clinical suspician for a MLL in a polytrauma patient with a high-energy mechanism Symptoms often minimally symptomatic or marginalized due to underlying distracting injuries or patient body habitus up to 33% of lesions are missed at the time of index evaluation chronic lesions may lead to cosmetic issues Physical exam inspection ecchymosis, swelling, fluctuance and skin hypermobility skin discoloration may not be apparent until several days later neurovascular key indicator is paresthesias of overlying skin Imaging Radiographs indications evaluate underlying proximal femur, acetabulum or pelvis fractures findings may show soft tissue swelling CT indications CT of the area of interest often obtained due to high-energy nature of the injury, underlying fracture, or abdominal/pelvic injury findings used to measure size of lesion to determine management soft tissue windows will show slice of fluid within fascial plane Ultrasound indications can be used to localize lesion for percutaneous treatment findings hypoechoic space superficial to fascial layer MRI indications generally not required for diagnosis but will best demonstrate extent of the lesion findings average size reported to be 30 x 12 cm fluid-filled space is often identifiable on T1- and T2-weighted MRI sequences. login to view 2 more bullets Treatment Nonoperative compressive therapy indications login to view 1 more bullet outcomes login to view 1 more bullet percutaneous drainage with drain placement indications login to view 1 more bullet outcomes login to view 1 more bullet Operative Single-incision irrigation and debridement (I&D) relative indications login to view 2 more bullets outcomes login to view 2 more bullets Dual-incision I&D relative indications login to view 2 more bullets outcomes login to view 1 more bullet Open debridement with resection of the fibrous capsule relative indication login to view 1 more bullet outcomes login to view 1 more bullet Techniques Compressive therapy technique most common modalities are ace wraps, compression bandages, bike shorts (for proximal thigh lesions) Percutaneous drainage with drain placement technique use ultrasound to localize lesion then make 1-2 cm incision overlying leison insert a suction tip into the lesion to remove hemorrhagic fluid irrigate with normal saline Single incision I&D approach incision centered over MLL technique aggressive debridement of cavity performed with scrub brush, Cobb and/or other instruments placement of a drain exiting away from lesion (consider using 15 Fr or larger drain) login to view 1 more bullet primary closure of lesion versus delayed closure login to view 3 more bullets Dual-incision I&D approach incision over most proximal aspect of lesion counter incision over most distal aspect of lesion technique similar to single incision for rest of treatment EXCEPT login to view 3 more bullets Complications Recurrence incidence most common complication login to view 1 more bullet risk factors inadequate debridement, larger lesions treatment repeat I&D and placement of drain use of VAC and secondary healing (requires delayed skin graft) use of sclerotherapy with talc or other sclerosing compound Pseudocyst formation risk factors chronic, untreated MLL treatment open debridement with resection of the fibrous capsule Skin necrosis risk factors delay in treatment, loss of epidermal blood supply due to inciting event or several repeat I&Ds of large MLL lesions treatment skin grafting Peri-operative infection risk factors presence of a MLL has been cited as an independent risk factor for postoperative surgical site infection following pelvic and acetabular surgery Prognosis MLL cited as an independent significant risk factor for postoperative surgical site infection following pelvic and acetabular surgery Overall prognosis varies with lesion chronicity and size improved prognosis with smaller, acute lesions and discontiguous with surgical incisions