Answer

Closed internal degloving injury: The patient underwent CT of the pelvis, which
demonstrated evidence of a large, subcutaneous fluid collection extending from
the region of the lumbosacral spine along the right lateral buttock to the thigh
and down to the level of the femoral shaft (arrows, Images 2-3). The fluid
collection was not present on a previous CT scan obtained 2 weeks ago, the
time of the motor vehicle collision. The patient's pertinent laboratory studies are
a WBC count of 8.38 X 109/L, hematocrit of 0.363 (36.3%), platelet count of 953
X 109/L (953 X 103/ µL), and international normalized ratio (INR) of 1.0.

The patient underwent CT-guided aspiration of the fluid collection under local
anesthesia. An 8F catheter was used to aspirate 800 mL of dark red fluid (see
Image 4). Postaspiration CT images demonstrated near-complete resolution of
the fluid collection (see Image 5), and the catheter was removed. A pressure
dressing (elastic spica dressing) was applied. That is, an elastic bandage was
wrapped around the entire thigh by starting just proximal to the knee and moved
upward across the proximal thigh and buttock. It was wrapped around the waist
several times and then brought back over the thigh to compress the entire lower
back, buttock, and proximal thigh. The patient tolerated the procedure well and
was discharged home the following day. He was instructed to wear the
compression dressing as much as possible, and follow-up was scheduled. The
aspirated fluid was sent for bacterial culture and found to be negative.

Closed internal degloving is a clinically significant soft-tissue injury associated

with pelvic trauma in which the subcutaneous tissue is torn away from the
underlying fascia. This tearing creates a potential space that can fill with serous
fluid and/or hematoma due to the disruption of arteries perforating through the
fascia and a mixture of viable and necrotic fat. The condition commonly occurs
over the greater trochanter, but it can also occur anywhere over the trunk,
buttock, or thighs. When closed internal degloving occurs over the greater
trochanter, the condition is known as a Morel-Lavallee lesion. As mentioned,
this condition usually occurs in association with pelvic and acetabular fractures,
but it can also occur in the absence of fractures. Direct crush injury to the pelvis
or a high-speed motor vehicle crash is the common mechanism. The
importance of this soft-tissue injury may not be initially apparent, and some
patients present months after the initial event, complaining of soft-tissue
swelling or contour abnormalities that are not resolving.

The diagnosis is usually based on physical findings of a soft, fluctuant area over
the lesion and a loss of local sensation. Diagnostic aids may include
ultrasonography and CT imaging. Various methods or combinations of
techniques for treating degloved areas have been suggested. These include
application of compression dressings, fluid aspiration or liposuction, injection of
sclerosing agents, deep fascial fenestration, prolonged closed surgical
drainage, and open surgical debridement leaving the degloved area open for
closure by secondary intention. A PubMed literature search between 1975 and
2006 failed to reveal prospective comparisons of the different therapeutic
techniques. Our review of the available literature demonstrated variable
outcomes with the different therapeutic approaches, ranging from complete
resolution to the development of various complications, including infections and
skin necrosis or breakdown. Complications often require extensive therapy and
surgical management.

To determine the appropriate therapeutic modality, clinicians should carefully

assess closed internal degloving injuries while accounting for various
parameters, including the size and location of the lesion, the time since the
initial injury, and the patient's comorbidities and accompanying injuries and their
expected management. Close follow-up should be arranged to ensure complete
resolution of the injury and to diagnose posttherapeutic complications, such as
infection, fluid reaccumulation, and skin necrosis.

For more information on internal degloving, see the eMedicine articles Pelvic
Fractures (within the Orthopedic Surgery specialty) and Vascular and Solid
Organ Trauma - Interventional Radiology (within the Radiology specialty).

References
 Hak DJ, Olson SA, Matta JM: Diagnosis and management of closed
internal degloving injuries associated with pelvic and acetabular
fractures: the Morel-Lavallee lesion. J Trauma 1997 Jun;42(6):1046-51.
 Harma A, Inan M, Ertem K: The Morel-Lavallee lesion: a conservative
approach to closed degloving injuries. Acta Orthop Traumatol Turc
2004;38(4):270-3.
 Hudson DA: Missed closed degloving injuries: late presentation as a
contour deformity. Plast Reconstr Surg 1996 Aug;98(2):334-7.
 Hudson DA, Knottenbelt JD, Krige JE: Closed degloving injuries: results
following conservative surgery. Plast Reconstr Surg 1992 May;89(5):853-
5.

 Tsur A, Galin A, Kogan L, Loberant N: Morel-Lavallee syndrome after

crush injury. Harefuah 2006 Feb;145(2):111-3, 166.

BACKGROUND
A 35-year-old man presents to the emergency department complaining of sacral
and right hip pain. The pain is associated with increasing swelling in that region
over the last 3 days. The patient otherwise denies having any systemic
symptoms, such as fevers, chills, nausea, or vomiting. His medical history is
significant for a recent admission to the hospital after an accident with a motor
vehicle approximately 2 weeks ago. He was a pedestrian struck by a car,
sustaining multiple rib fractures and facial lacerations. He was discharged home
from the hospital 10 days ago and has been doing relatively well, with adequate
pain control for his rib fractures.

On physical examination, the patient's temperature is 37.2°C with a blood

pressure of 129/67 mm Hg and a heart rate of 89 beats per minute. His
respiratory rate is 20 breaths per minute, and his O 2 saturation is 95% on room
air. The patient is in no acute distress. Head, eyes, ears, nose, and throat
(HEENT) examination shows well-healing facial lacerations with intact sutures.
His chest is clear to auscultation on both sides, with normal cardiovascular and
abdominal findings. The lower extremities have normal sensation and 5/5
strength.

A visible fluid collection is observed in the proximal-lateral aspect of his right

thigh. The fluid seems to track up around the gluteus maximus muscle and to
the lumbosacral region, with slight crossing of the midline to the left (see Image
1). The fluid appears to be a free-flowing, low-viscosity collection with no
evidence of erythema or ecchymosis. No loculation is noted on palpation, and
the patient has no thickening or induration of the skin overlying and surrounding
the area.

What is your clinical diagnosis?

Hint
This fluid collection was not appreciated during the patient's previous admission
to the hospital.

Authors: Gil Z. Shlamovitz, MD,

UCLA/Olive View-UCLA
Emergency Medicine Residency,
UCLA Emergency Medicine
Center,
UCLA Medical Center,
David Geffen School of Medicine,
Los Angeles, Calif

Rick G. Kulkarni, MD,

Assistant Professor,
Yale School of Medicine,
Section of Emergency Medicine,
Department of Surgery, Attending
Physician,
Medical Director,
Department of Emergency
Services,
Yale-New Haven Hospital, Conn

eMedicine
Editor: Eugene Lin, MD,
Department of Radiology,
Virginia Mason Medical Center,
Seattle, Wash,
Assistant Clinical Professor of
Radiology,
University of Washington Medical
Center, Seattle, Wash