Definition
Morel-Lavallée lesion (MLL) was first described in 1853 [1] [2]. It is a closed soft tissue degloving injury [1][3][4][5][6], usually following blunt trauma[1][2][3][5]. In more recent literature, it may also be called Morel-Lavallée seroma or posttraumatic soft effusion Tissue cyst or posttraumatic extravasation [2].
Epidemiology and aetiology
These injuries are uncommon [2], and there is no consensus on male-to-female ratios. One source reports a 2:1 ratio [2], while another reports a 1:1 ratio [7].
These injuries occur after blunt trauma due to:
- Motor vehicle accidents[1][2][8][6][9]
- Falls[1][6][9]
- Sport-related injuries[1] [2][6][9]
MLL can also be iatrogenic, such as after abdominal liposuction or mammoplasty [1][2][6]
Pathophysiology
MLL occurs due to shear forces separating the skin and subcutaneous tissue from the deep fascia, resulting in a potential space [1][2][4][5][8][10][11]. Lymphatic and vascular damage leads to blood and lymph[1][3][4][8][10] and necrotic fat[1][3][8][12] in Potential space leading to hematoma or seroma [10]. Over time, the blood will begin to be reabsorbed, leaving serum blood surrounded by a layer of hemosiderin [2]. Inflammation is then induced by the hemosiderin layer leading to the fibrous capsule [2] [11]. This fibrous sac prevents more fluid Reabsorption triggers chronic MLL [3].
MLL is usually associated with pelvic or acetabular fractures but can also occur without fractures[9].
Secondary risk factors for MLL include female sex and BMI over 25 [1].
Clinical Presentation
MLL occurs most frequently in the greater trochanter (>60% of cases)[1][3][5][6][8][11] proximal femur[1][2][5] hip[2][3 ][5] knees[3][5][6][11] and in rare cases lumbar region[2][3][6][11]. It can also occur in the scapula [2][6]. Delayed visits (months or years) can occur up to ⅓ patients[1][8]. The most common signs and symptoms include:
- Compressible fluctuating swelling zones [1][2][5][8][9]. Fluctuating swelling is an important clinical feature [9].
- Pain[1][2][4][8]
- Stiffness[5][9]
- Skin anesthesia or hypothesia may be present[1][2][4][8].
- Ecchymosis may be present[9]
- Abrasions may be present[9]
- Secondary skin changes e.g. discoloration frank necrosis withering/cracking[1][9].
Complications
The necrotic tissue associated with MLL is susceptible to infection[3] and in the event of infection may cause
- Cellulitis[3]
- Abscess[3]
- Osteomyelitis[3]
- Compression necrosis of the underlying tissue[9].
Classification
Mellado and Bencardino proposed MRI classification and identified 6 types of MLLs based on MRI-appearing chronic lesions and histological characteristics [2][7][8][9]. The 6 types include the following:
Types I to III are the most common types with Type I being acute type II sub-acute and III chronic[8].
A more basic acute vs chronic classification was proposed by Shen et al (2013)[2]. The lesion is considered chronic once a capsule is present[2].
Diagnosis and Imaging
Physical examination and imaging should be diagnosed based on the patient’s history[11].
Ultrasound MRI and CT scan can be used to diagnose MLL[7][8][9]. In ultrasound the fluid volume is in front of the tissue but behind the hypodermis[9]. MRI is especially important in the diagnosis of MLL [7][9][11] and helps in the differential diagnosis[11].
MLLs frequently disappear (up to one-third of cases)[11] and untreated lesions can lead to complications such as infection[4][9] and chronic scarring[11]. Early diagnosis is very important to prevent infection and capsule progression (chronic ulcers)[12].
Differential diagnosis
- Haematoma[4][5][7][11]
- Seroma[11]
- Malignant smooth muscle [4][5][7][11].
- Bursitis[5][7][11]
- Abscess[5]
Physiotherapy management
Although physical therapy cannot directly cure MLL it can help improve functions and reduce pain[9]. There is no specific exercise plan as the exercise plan will depend on the requirements of the patient e.g. range-of-motion development gait reinstruction or strengthening. The exercises used depend on the severity of the lesion including the medical/surgical treatment and the amount of bed rest the patient received. A study (2022) of a patient with hip MLL showed that exercise significantly improved joint range of motion strength in cardiovascular/pulmonary functional and operational autonomy[9]. Another study (2021) found physical therapy to be important to achieve optimal functional outcomes after surgery or conservative treatment[13].
Medical management
Compression bandaging can be performed in acute and chronic cases [2][7][9][11] with or without sclerotherapy[11][12]. However effective packaging is not always available in some areas e.g. greater trochanter[2].
Existing evidence suggests that surgical treatment results in shorter healing times compared to compression bandaging alone[2]. While some MLLs resolve spontaneously[4] others have symptoms that can persist for decades and affect quality of life in untreated cases[11].
Surgical management
Surgical management is indicated if conservative chemotherapy fails[11][14]; where untreated chronic wounds have developed a fibrous capsule due to ongoing inflammation[11]; where the diagnosis is unclear[14] or where there is a secondary infection[14]. Surgical treatment options include:
- Aspiration[2][4][7][9]
- Sclerotherapy alone in lesions up to 400ml[2]. Sclerodesis with Doxycycline is the most common[2][14] but other agents such as erythromycin vancomycin and tetracycline are also used[2]. Most of these sclerodesis-inducing agents cause fibrosis while causing cell damage[2].
References
- ↑ Jump up to:1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 Diviti S, Gupta N, Hooda K, Sharma K, Lo L. Morel-Lavallee lesions-review of pathophysiology, clinical findings, imaging findings and management. Journal of clinical and diagnostic research: JCDR. 2017 Apr;11(4):TE01.
- ↑ Jump up to:2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 2.15 2.16 2.17 2.18 2.19 2.20 2.21 2.22 2.23 2.24 2.25 2.26 2.27 2.28 2.29 Singh R, Rymer B, Youssef B, Lim J. The Morel-Lavallée lesion and its management: a review of the literature. Journal of orthopaedics. 2018 Dec 1;15(4):917-21.
- ↑ Jump up to:3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 3.12 Zairi F, Wang Z, Shedid D, Boubez G, Sunna T. Lumbar Morel-Lavallée lesion: case report and review of the literature. Orthopaedics & Traumatology: Surgery & Research. 2016 Jun 1;102(4):525-7.
- ↑ Jump up to:4.0 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9 LaTulip S, Rao RR, Sielaff A, Theyyunni N, Burkhardt J. Ultrasound utility in the diagnosis of a Morel-Lavallée lesion. Case Reports in Emergency Medicine. 2017 Feb 1;2017.
- ↑ Jump up to:5.00 5.01 5.02 5.03 5.04 5.05 5.06 5.07 5.08 5.09 5.10 5.11 5.12 Depaoli R, Canepari E, Bortolotto C, Ferrozzi G. Morel-Lavallée lesion of the knee in a soccer player. Journal of ultrasound. 2015 Mar;18(1):87-9.
- ↑ Jump up to:6.0 6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8 Mettu R, Surath HV, Chayam HR, Surath A. Chronic Morel-Lavallée lesion: a novel minimally invasive method of treatment. Wounds. 2016 Nov 1;28(11):404-7.
- ↑ Jump up to:7.00 7.01 7.02 7.03 7.04 7.05 7.06 7.07 7.08 7.09 7.10 Christian D, Leland HA, Osias W, Eberlin S, Howell L. Delayed presentation of a chronic Morel-Lavallee lesion. Journal of Radiology Case Reports. 2016 Jul;10(7):30.
- ↑ Jump up to:8.00 8.01 8.02 8.03 8.04 8.05 8.06 8.07 8.08 8.09 8.10 8.11 De Coninck T, Vanhoenacker F, Verstraete K. Imaging features of Morel-Lavallée lesions. Journal of the Belgian Society of Radiology. 2017;101(Suppl 2).
- ↑ Jump up to:9.00 9.01 9.02 9.03 9.04 9.05 9.06 9.07 9.08 9.09 9.10 9.11 9.12 9.13 9.14 9.15 9.16 9.17 9.18 9.19 9.20 Badjate DM, Jain D, Phansopkar P, Wadhokar OC. A Physical Therapy Rehabilitative Approach in Improving Activities of Daily Living in a Patient With Morel-Lavallée Syndrome: A Case Report. Cureus. 2022 Sep 24;14(9).
- ↑ Jump up to:10.0 10.1 10.2 Weiss NA, Johnson JJ, Anderson SB. Morel-lavallee lesion initially diagnosed as quadriceps contusion: ultrasound, MRI, and importance of early intervention. Western Journal of Emergency Medicine. 2015 May;16(3):438.
- ↑ Jump up to:11.00 11.01 11.02 11.03 11.04 11.05 11.06 11.07 11.08 11.09 11.10 11.11 11.12 11.13 11.14 11.15 11.16 11.17 11.18 11.19 Cruz N, Jiménez R. Morel-Lavallée lesion diagnosed 25 years after blunt trauma. International Journal of Surgery Case Reports. 2021 Apr 1;81:105733.
- ↑ Jump up to:12.0 12.1 12.2 12.3 Cochran GK, Hanna KH. Morel-Lavallee lesion in the upper extremity. Hand. 2017 Jan;12(1):NP10-3.
- ↑ Agrawal U, Tiwari V. Morel Lavallee Lesion.
- ↑ Jump up to:14.0 14.1 14.2 14.3 14.4 14.5 Dawre S, Lamba S, Gupta S, Gupta AK. The Morel-Lavallee lesion: a review and a proposed algorithmic approach. European Journal of Plastic Surgery. 2012 Jul;35(7):489-94.