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Morel-Lavallée Injuries

Posted Jan 31, 2017 Updated Apr 10, 2023
By James A. Spain MD , Matthew Rheinboldt MD , David Parrish MD , Eric Rinker MD
10 min read

Morel-Lavallée lesions are relatively rare closed degloving injuries caused by a shearing force resulting in separation of the dermis and the hypodermis from the subjacent deeper fascia. Although most commonly encountered lateral to the greater trochanter, these injuries may occur throughout the body in a variety of locations. Separation of the hypodermal tissue planes results in a complex serosanguinous fluid collection with areas of internal fat necrosis. The imaging appearance is variable and nonspecific, potentially mimicking superficial hemorrhagic bursitis, or cystic or necrotic primary soft tissue neoplasms. If not treated in the acute or early subacute setting, these collections are at risk of superinfection, overlying tissue necrosis, and continued expansion. In this article, we will review the pathophysiology, cross-sectional imaging features, and differential diagnostic considerations of Morel-Lavallée lesions as well as discuss management and treatment options.

Introduction

First described in 1863 by the French physician Maurice Morel-Lavallée as a posttraumatic fluid collection arising in the proximal thigh of a patient who had fallen from a moving train, Morel-Lavallée (ML) lesions are closed internal degloving injuries secondary to a tangential shearing force separating the subdermal fascial planes . The resultant hemolymphatic fluid collection has also been alternatively termed a posttraumatic soft tissue cyst or pseudocyst, ancient or chronic expanding hematoma, ML effusion, or extravasation . Delayed or slow progressive enlargement may obscure initial clinical detection, with up to one third of patients presenting months or years after the inciting injury . Motor vehicle collisions are the most commonly reported etiology, although ML lesions have been described following lower energy injury sustained during contact sports such as wrestling and football . The surrounding inflammatory reaction leads to the formation of a peripheral encapsulation, hindering resolution and facilitating slow enlargement due to hemolymphatic internal leakage . Most commonly, ML lesions form at the level of the greater trochanter and the proximal thigh, following pelvic trauma . Dependent on the internal age of the hemorrhage and proportions of lymphatic and hemorrhagic fluid, the imaging appearance is variable, potentially mimicking other soft tissue pathology including hemorrhagic bursitis or primary soft tissue neoplasm . In this article, we will review the pathophysiology underlying ML lesions, imaging features and classification schemes, differential diagnostic considerations, and management options.

Pathophysiology and Clinical Presentation

Following the initial traumatic event, most commonly a tangential shearing force to the pelvis or the lower extremity, there is a closed disruption of the dermal and subdermal tissue plane fat from the underlying superficial fascia . Motor vehicle accidents are the most common inciting event, with high-energy trauma responsible for more than 50% of injuries sustained; however, low-grade blunt force trauma including falls and sport-related injuries account for a significant minority of cases . Postoperative cases have also been reported involving the anterior abdominal wall following liposuction . The lower limb, most often at the level of the greater trochanter, is the most commonly involved region, with injuries at this level accounting for more than 60% of cases . Predisposing factors at this location include the superficial position of the femoral cortex, relative mobility of the subdermal soft tissues, limited arterial perforator arborization from the lateral femoral circumflex vasculature, and strength of the underlying tensor fascia lata . Reported secondary demographic risk factors include female gender and a body mass index of 25 or higher . In addition to the greater trochanter, other reported sites in decreasing incidence include the thigh, pelvis, knee, gluteal region, lumbosacral trunk, abdominal wall, distal lower extremity, and calvarium . Underlying concomitant fractures may be present in a minority of cases . Although rare, bilateral ML lesions have been reported . Pediatric cases are less common but do occur, with the youngest reported patient aged 28 months .

With the disruption of the subdermal capillaries and lymphatics, hemorrhage, lymphatic fluid, and locules of subdermal fat can accumulate in the suprafascial tissue plane. With temporal evolution, there is resorption of the hemorrhagic elements and increase of serosanguineous fluid. Progressive fibrous encapsulation prohibits resorption and allows slow continued expansion .

Clinical presentation of ML lesions is usually in close proximity to the inciting traumatic event, although up to one third of patients may present in a delayed fashion with gradual swelling months or years after the initial injury . Pain and swelling are the most frequent clinical complaints, with a compressible, fluctuant area typically detectable on physical examination . Clinical findings may mimic a regional contusion or even deep venous thrombosis . Cutaneous hypoesthesia or anesthesia may be observed owing to the disruption of the subdermal afferent nerves . Overlying secondary dermal changes include drying and cracking, discoloration, and less commonly frank necrosis .

Imaging Features

In the setting of trauma, radiography may often be the first imaging modality employed. Besides evaluating for osseous integrity, there is minimal contribution to the final diagnosis other than potential delineation of regional swelling and exclusion of associated soft tissue calcification .

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Figure 1, Transverse grayscale sonographic image demonstrates a predominantly anechoic fluid collection in the subdermal region, overlying the greater trochanter ( blue arrow ). An internal area of echogenicity is seen with partial distal acoustic shadowing, corresponding to a sheared area of subdermal fat within the hemolymphatic fluid collection ( red arrow ). (Color version of figure is available online.)

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Figure 2, Coronal reformatted image from a contrast-enhanced multidetector computed tomography examination through the left hip demonstrates an ovoid loculated fluid collection in the subdermal tissue planes overlying the greater trochanter. Nonspecific peripheral capsular enhancement is seen. Although a chronic hematoma or inflammatory collection would be a consideration, the presence of internal foci of low attenuation, isodense to the adjacent subcutaneous fat, supports the diagnosis of a chronic Morel-Lavallée shearing injury in this patient status post remote injury. Although these examples were obtained from different patients, the internal lipomatous foci as seen above ( blue arrow ) would correspond to the echogenic intracapsular nodular focus seen previously in Figure 1 . (Color version of figure is available online.)

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Figure 3, Coronal STIR image at the level of the right hip demonstrates an elliptiform subdermal fluid collection ( red star ) overlying the tensor fascia lata with homogeneous internal high T2 signal in this patient status post remote blunt trauma and persistent swelling. A faint low T2 signal capsule is suggested ( blue arrow ). Internal signal heterogeneity at the level of the proximal femoral head and neck is incidentally observed compatible with prior intramedullary screw fixation. Although the location and traumatic history support the diagnosis of a Morel-Lavallée lesion, the appearance is nonspecific, potentially mimicking a chronic seroma or myxoma. STIR, short tau inversion recovery. (Color version of figure is available online.)

Figure 4, (a) Coronal PD image at the level of the distal right lower extremity demonstrates an elliptiform fluid collection in the subdermal soft tissues. A low signal intensity rim is observed compatible with hemosiderin deposition and fibrous encapsulation ( blue arrow ). Internally, there is a focal area of rounded nodularity isointense to that of subdermal fat ( red arrow ). (b) Coronal T2 fat-saturated image at the same level as (a) demonstrates progressive loss of signal intensity at site of previously seen hyperintense internal nodule ( blue arrow ) compatible with a sheared island of subdermal fat, supporting the diagnosis of a Morel-Lavallée lesion. PD, proton density. (Color version of figure is available online.)

Figure 5, A coronal fat-suppressed T1-weighted FSE image, obtained following administration of gadolinium, demonstrates peripheral capsular enhancement at the site of a chronic subdermal fluid collection overlying the tensor fascia lata in this patient status post prior blunt injury. The appearance is nonspecific, with diagnostic considerations including chronic hematoma or seroma, or primary soft tissue myxoid neoplasm. FSE, fast spin echo.

Figure 6, (a) Coronal T1-weighted image obtained at the level of the left hip in this patient with a history of prior blunt trauma and persistent swelling demonstrates a longitudinally extensive fluid collection in the subdermal soft tissues overlying the tensor fascia lata. Islands of internal fat globules are observed, compatible with a prior Morel-Lavallée shearing injury ( blue arrow ). (b) Coronal STIR image through the same lesion demonstrates low signal intensity at the site of previously seen internal foci in Figure 4a , persistently isointense to that of subdermal soft tissues, and compatible with sheared globules of subdermal fat in conjunction with a Morel-Lavallée lesion ( blue arrow ). STIR, short tau inversion recovery. (Color version of figure is available online.)

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Differential Diagnostic Considerations

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Figure 7, Sagittal FSE T2-weighted fat-suppressed image through the central knee demonstrates a longitudinally extensive T2 hyperintense subdermal fluid collection in the prepatellar region ( blue arrow ). Although the appearance superficially mimics that of prepatellar bursitis, extension superiorly over the myotendinous quadriceps junction is observed ( red arrow ), beyond the expected physiologic bursal confines, compatible with a Morel-Lavallée lesion in this patient status post prior blunt trauma. A faint peripheral capsule is observed with minimal areas of internal low T2 signal inferiorly corresponding to fibrinous stranding ( green arrow ). FSE, fast spin echo. (Color version of figure is available online.)

Figure 8, (a) Sagittal T1 image at the level of the right knee midline demonstrates a high signal intensity elliptiform fluid collection in the prepatellar soft tissues overlying the patella and the patellar tendon ( blue arrow ). Internal areas of low signal serpiginous stranding are observed ( red arrow ). (b) Fat-suppressed sagittal PD-weighted image at the same level re-demonstrates a complex subdermal fluid collection overlying the patellar tendon with internal serpiginous areas of low signal intensity ( red arrow ). Absence of fat suppression supports serosanguineous or proteinaceous nature. No corresponding increased signal was seen on T1 images in the areas of internal debris to suggest sheared lipoid tissue. Imaging characteristics, as well as the characteristic location corresponding to the infrapatellar superficial bursa and absence of prior traumatic history, support the diagnosis of hemorrhagic bursitis. PD, proton density. (Color version of figure is available online.)

Figure 9, (a) Axial fat-saturated T2-weighted FSE image at the level of the right hip demonstrates an ovoid area of increased signal intensity abutting the superficial aspect of the tensor fascia lata and quadriceps musculature ( blue arrow ). Close inspection demonstrates the lesion to be deep to the muscular fascia, atypical for the subdermal location of a Morel-Lavallée shear injury. (b) Axial post-contrasted T1-weighted fat-saturated image of the same lesion at the level of the anterior proximal right thigh demonstrates the lesion to be solid with diffuse, heterogeneous internal enhancement. Myxoid liposarcoma was found at surgical resection. Myxomas, hemangiopericytomas, synovial sarcomas, and myxoid liposarcomas can demonstrate relatively indolent smooth margination, and high T2 signal, potentially mimicking a Morel-Lavallée lesion. Close inspection for a Morel-Lavallee lesion's wholly subdermal location and thin, smooth capsular enhancement can aid in discrimination. FSE, fast spin echo. (Color version of figure is available online.)

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Management

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Conclusion

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References

  • 1. Morel-Lavallée M.: Decollement traumatiques de la peau et des couches sousjacentes. Arch Gen Med 1863; 1: pp. 20-38. 172-200, 300-332

  • 2. Parra J., Fernandez M., Encinas B., et. al.: Morel-Lavallée effusions in the thigh. Skeletal Radiol 1997; 26: pp. 239-241.

  • 3. Kalaci A., Karazincir S., Yanat A.: Long-standing Morel-Lavallée lesion of the thigh simulating a neoplasm. Clin Imaging 2007; 31: pp. 287-291.

  • 4. Hudson D., Knottenbelt J., Krige J.: Closed degloving injuries: results following conservative surgery. Plast Reconstr Surg 1992; 89: pp. 853-855.

  • 5. Tejwani S., Cohen S., Bradley J.: Management of Morel-Lavallee lesion of the knee—twenty seven cases in the national football league. Am J Sports Med 2007; 35: pp. 1162-1167.

  • 6. Northam M., Gaskin C.: Presumed prepatellar fibrosis in collegiate wrestlers: imaging findings and clinical correlation. Skeletal Radiol 2015; 44: pp. 271-277.

  • 7. Hak D., Olson S., Matta J.: Diagnosis and management of closed internal degloving injuries associated with pelvic and acetabular fractures: the Morel-Lavallée lesion. J Trauma 1997; 42: pp. 1046-1051.

  • 8. Bonilla-Yoon I., Masih S., Patel D., et. al.: The Morel-Lavallée lesion: pathophysiology, clinical presentation, imaging features and treatment options. Emerg Radiol 2014; 21: pp. 35-43.

  • 9. Mellado J., Bencardino J.: Morel-Lavallée lesions: review with an emphasis on MR imaging. Magn Reson Imaging Clin N Am 2007; 13: pp. 775-782.

  • 10. Donahue F., Turkel D., Mnaymneh W., et. al.: Hemorrhagic prepatellar bursitis. Skeletal Radiol 1996; 25: pp. 298-301.

  • 11. Nickerson T., Zielinski M., Jenkins D., et. al.: The Mayo Clinic experience with Morel-Lavallée lesions: establishment of a practice management guideline. J Trauma Acute Care Surg 2014; 76: pp. 493-497.

  • 12. Scarenelo A., Davanco R.: Pseudocyst formation after abdominal liposuction—extravasations of Morel-Lavallée on MR images. Br J Plast Surg 2005; 58: pp. 849-851.

  • 13. Hudson D.: Missed closed degloving injuries: late presentation as a contour deformity. Plast Reconstr Surg 1996; 98: pp. 334-337.

  • 14. Kottmeier S., Wilson S., Born C., et. al.: Surgical management of soft tissue lesions associated with pelvic ring injury. Clin Orthop Relat Res 1996; 329: pp. 46-53.

  • 15. Dawre S., Lamba S., Sreekar H., et. al.: The Morel-Lavallee lesion: a review and a proposed algorithmic approach. Eur J Plast Surg 2012; 35: pp. 489-494.

  • 16. Vanhegan I., Dala-Ali B., Verhelst L., et. al.: The Morel-Lavallée lesion as a rare differential diagnosis for recalcitrant bursitis of the knee: case report and literature review. Case Rep Orthop 2012; pp. 593193.

  • 17. Phillips T., Jeffcote B., Collopy D.: Bilateral Morel-Lavallée lesions after complex pelvic trauma: a case report. J Trauma 2008; 65: pp. 708-711.

  • 18. Rha E., Kim D., Kwon H., et. al.: Morel-Lavallee lesion in children. World J Emerg Surg 2013; 8: pp. 60.

  • 19. Choudhary A., Methratta S.: Morel-Lavallée lesion of the thigh: characteristic findings on US. Pediatr Radiol 2010; 40: pp. S49.

  • 20. Mellado J., Perez del Palomar L., Diaz L., et. al.: Long-standing Morel-Lavallée lesions of the trochanteric region and proximal thigh: MRI features in five patients. AJR Am J Roentgenol 2004; 182: pp. 1289-1294.

  • 21. Fornecker C., Griffon C., Knauer V., et. al.: [Morel-Lavallée syndrome, an unusual differential diagnosis for deep venous thrombosis]. J Mal Vasc 2006; 31: pp. 98-100.

  • 22. Weiss N., Johnson J., Anderson S.: Morel-Lavallee lesion initially diagnosed as quadriceps contusion: ultrasound, MRI and importance of early intervention. West J Emerg Med 2015; 16: pp. 438-441.

  • 23. Tsur A., Galin A., Kogan L., et. al.: [Morel-Lavallee syndrome after crush injury]. Harefuah 2006; 145: pp. 111-113.

  • 24. Greenhill D., Haydel C., Rehman S.: Management of the Morel-Lavallée lesion. Orthop Clin North Am 2016; 47: pp. 115-125.

  • 25. Neal C., Jacobson J., Brandon C., et. al.: Sonography of Morel-Lavallee lesions. J Ultrasound Med 2008; 27: pp. 1077-1081.

  • 26. Mukherjee K., Perrin S., Hughes P.: Morel-Lavallee lesion in an adolescent with ultrasound and MRI correlation. Skeletal Radiol 2007; 36: pp. 43-45.

  • 27. Tresley J., Saraf-Levi E., Sklar E.: Sacral Morel-Lavallée lesion: a not-so-rare diagnosis. Neuroradiol J 2014; 27: pp. 755-758.

  • 28. Cheong S., Wong B.: Clinics in diagnostic imaging (164). Morel-Lavallée lesion. Singapore Med J 2016; 57: pp. 45-50.

  • 29. Shen C., Peng J., Chen X.: Efficacy of treatment in peri-pelvic Morel-Lavallee lesion: a systematic review of the literature. Arch Orthop Trauma Surg 2013; 5: pp. 635-640.

  • 30. Medverd J., Ngo A., Bhargava P.: An unusual cause of persistent subcutaneous fluid collection. Br J Radiol 2011; 84: pp. 864-866.

  • 31. Borrero C., Maxell N., Kavanagh E.: MRI findings of prepatellar Morel-Lavallée effusions. Skeletal Radiol 2008; 37: pp. 451-455.

  • 32. Tsai T., Evans H., Donnelly L., et. al.: Fat necrosis after trauma: a benign cause of palpable lumps in children. AJR Am J Roentgenol 1997; 169: pp. 1623-1626.

  • 33. Moriarty J., Borrero C., Kavanagh E.: A rare cause of calf swelling—the Morel-Lavallee lesion. Ir J Med Sci 2011; 180: pp. 265-268.

  • 34. Kumar S., Hasan R., Kadavigere R., et. al.: Morel-Lavallee lesion (MLL) mimicking a soft tissue neoplasm. J Clin Diagn Res 2015; 9: pp. 1-2.

  • 35. Luria S., Yaakov A., Yoram W., et. al.: Talc sclerodesis of persistent Morel-Lavallée lesions (posttraumatic pseudocysts): case report of four patients. J Orthop Trauma 2006; pp. 435-438.

  • 36. Bansal A., Bhatia N., Singh A., et. al.: Doxycycline sclerodesis is a treatment option for persistent Morel-Lavallée lesions. Injury 2013; 44: pp. 66-69.

  • 37. Penaud A., Quignon R., Danin A., et. al.: Alcohol sclerodesis: an innovative treatment for chronic Morel-Lavallée lesions. J Plast Reconstr Aesthet Surg 2011; 64: pp. e262-e264.

Academic Radiology, Volume 24, Issue 2
Journals General Radiology
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