Poor Outcome of Bilateral Lower Extremity Morel-Lavallee Lesions: A Case Report

Abstract

The Morel-Lavallee lesion was first described in 1853 by the French physician, Maurice Morel-Lavallee. It is characterized by the separation of subcutaneous fat from the underlying fascia that is caused by a tangential, shearing force and often results in seroma or hematoma of the newly formed space. It is an uncommon sequela of posttraumatic closed degloving injury, often a pedestrian-motor vehicle collision, and is often underdiagnosed because the initial symptoms may consist of tenderness and ecchymosis, mimicking contusion. During the acute resuscitation phase of a polytrauma, this occult injury can be missed. Patients commonly present after the injury in the outpatient setting with complaints of a contour deformity or unresolving mass.We present the case of a woman who sustained bilateral Morel-Lavallee lesions of the lower extremities after being dragged by a bus. Case ReportA 77-year-old female with no significant past medical history presented to our Level I trauma center with tenderness and open wounds on both lower extremities after being caught in the doors of a bus and dragged for several hundred feet. She sustained a 5-cm wound on the left lateral ankle and a 3-cm wound on the lateral side of the dorsum of the left foot. There was significant edema bilaterally distal to the mid-lower extremities, over which the skin was paler and cooler; however, she was neurovascularly intact. She suffered bilateral fibular, bilateral medial malleolar, and multiple toe fractures bilaterally. She was admitted to the trauma service and underwent washout of her wounds and fixation of the fractures with orthopedic surgery. On hospital day 5, during fixation of the right lower extremity, skin necrosis was noted over both lower extremities. While awaiting further demarcation, skin necrosis developed on the left lower extremity as well. The patient required serial debridements managed by vacuum-assisted closure (VAC) dressings followed by splitthickness skin grafts. She was discharged to subacute rehabilitation on hospital day 52 in stable condition.The patient returned to the emergency room 38 days after discharge with open wounds of the split-thickness skin grafts. She had developed pressure ulcers on the grafts while at rehabilitation. The patient was admitted and underwent debridement of both legs. The extremities were debrided down to the bone, then packed and splinted with intent to offload the heels and prevent pressure ulcers. She underwent daily dressing changes and local wound care and was discharged to rehabilitation in stable condition. However, the Keywords ► Morel-Lavallee lesion ► internal degloving injury ► skin necrosis ► skin graft ► amputation ► trauma AbstractThe Morel-Lavallee lesion is a closed, internal degloving injury that results when a strong, shearing force is applied parallel to the plane of injury, as is common in vehicular trauma. It is an underdiagnosed entity that is often missed during the initial trauma workup as symptoms can be subtle. There are few reports of lesions occurring below th...