Management of the

More l- Lavallée Le s i o n
Dustin Greenhill, MD*, Christopher Haydel, MD, Saqib Rehman, MD

KEYWORDS
 Closed degloving injury  Morel Lavallée lesion  Soft tissue injury  Hematoma  Sclerodesis

KEY POINTS
 Diagnosis of Morel-Lavallée lesions is often missed or delayed.
 The presence of a lesion over operative fractures increases the risk of postoperative infection.
 Advanced imaging may help determine the best methods of treatment.
 Treatment options include compression, aspiration, percutaneous or open surgical treatment, and
sclerotherapy. Additionally, postoperative management plays an equal role in treatment success.
 Specific treatment should be individualized for each patient based on a surgeon’s thorough under-
standing of Morel-Lavallée lesions.

INTRODUCTION not yet clearly established. In a series of approxi-

In 1863, a French physician named Maurice Morel-
Lavallée1 first described a unique posttraumatic
fluid collection that developed in a patient who
fell from a moving train. More than a century later,
while Letournel and Judet2 compiled their well-
known series of acetabular fractures, they also wit-
nessed the same characteristic lesions develop
over the greater trochanter and named them
Morel-Lavallée (ML) lesions. Such lesions have
been described by other terms in the literature,
such as ML effusion or hematoma, posttraumatic
pseudocyst, posttraumatic soft tissue cyst, closed
degloving injury, or chronic expanding hema-
toma.2,3 If a lesion occurs, it is almost always after
direct trauma to the pelvis, thigh, or knee. A hypo-
vascular suprafascial space develops in which
fluid easily accumulates. Posttraumatic hematoma
formation increases the risk of infection, and a
unique combination of physical properties inhibits
physiologic dead space closure.4
Such lesions are rare, and diagnosis is often de-
layed or missed. As a result, their natural history is
mately 1100 consecutive pelvic fractures, Tseng
and Tornetta5 reported that 19 (1.7%) patients
developed ML lesions. However, the actual inci-
dence is higher because lesions can occur without
an underlying fracture and a small portion likely
persist subclinically.6 Letournel and Judet2 pub-
lished an incidence of 8.3% after trauma to the
greater trochanter.2 Consequently, the true inci-
dence is unknown. The current body of available
literature consists entirely of case series com-
posed of heterogeneous groups of patients.
Therefore, no standard treatment algorithms exist.
This article helps physicians understand the
currently accepted surgical indications, tech-
niques, and controversies when managing pa-
tients with an ML lesion.
CAUSE
Individuals are at risk for developing an ML lesion
after sustaining a significant blow or sudden
shearing force to any area with strong underlying
fascia, most often around the pelvis or lower
orthopedic.theclinics.com

The authors have nothing to disclose.

Department of Orthopaedic Surgery & Sports Medicine, Temple University Hospital, 3401 North Broad Street,
Zone B 5th Floor, Philadelphia, PA 19140, USA
* Corresponding author.
E-mail address: dustin.greenhill2@tuhs.temple.edu

Orthop Clin N Am 47 (2016) 115–125

http://dx.doi.org/10.1016/j.ocl.2015.08.012
0030-5898/16/$ – see front matter Ó 2016 Elsevier Inc. All rights reserved.
116 Greenhill et al
limb. Motor vehicle collisions tend to be respon-
sible for most of these lesions, and more than
50% are due to high-energy mechanisms.7,8 How-
ever, a low-energy mechanism does not rule out
the possibility. ML lesions have been reported to
occur after sports injuries or, very rarely, less vio-
lent mechanisms.9–11 The lower limb is involved
in greater than 60% of cases, with most involving
the greater trochanter.12 This area of the body is
predisposed given the increased mobility of soft
tissue, limited anterolateral perforator vessels to
the subdermal vascular plexus originating from
the lateral femoral circumflex vessels, subcutane-
ous nature of bone, and strength of the fascia lata
as it attaches to the iliotibial band.13–15 A substan-
tial number of these lesions will occur with under-
lying osseous fractures and injuries to other organ
systems.14 Female sex and a body mass index of
25 or greater are proposed risk factors, presum-
ably because of the increased fat in predisposed
regions.12,16 However, more recent studies have
brought these risk factors into question.8
PATHOGENESIS
As a result of violent shear, a thick layer of subcu-
taneous fat and skin is ripped from its underlying,
firmly secured fascia. During this process, lym-
phatic channels and perforating vessels from
underlying muscle are torn and release their con-
tents into the newly created cavity. The fluid
mixture now contains blood, fat, and necrotic
debris within a relatively hypovascular space that
is ill equipped to drain internally because of the
intact underlying fascia. As lesions progress
beyond the acute phase, blood is reabsorbed
and replaced by serosanguineous and lymphatic
fluid, which has low coagulation ability and high
molecular weight.17 A sustained inflammatory re-
action eventually leads to a cystic mass sur-
rounded by a fibrous capsule that forms as a
result of peripheral deposition of hemosiderin,
granulation tissue, and fibrin.3,18 Exact timing of
the aforementioned mechanisms is unknown, but
MRI classifications detecting lesions in various
phases suggest that lesions are altered with age.19
CLINICAL MANIFESTATIONS
A large swollen bruised area whereby a hematoma
develops in a delayed fashion should alert practi-
tioners to the possibility of a closed degloving
injury (Fig. 1). Clinical manifestations of ML lesions
include soft tissue swelling with or without ecchy-
mosis, skin contour asymmetry and hypermobility,
and soft fluctuance with minimal or absent tender-
ness. Lesions can occur anywhere but are most
Fig. 1. Clinical appearance of an ML lesion 7 days af-
ter the patient sustained a shearing force to the
greater trochanter while snowboarding. After the
initial injury, the patient resumed sporting activities
until a discolored, fluctuant area developed 4 days
later.
often located around the peritrochanteric or peri-
pelvic region. Skin will often have decreased
sensation and may appear dry, cracked, or discol-
ored in more chronic lesions (Fig. 2). Lesions may
not be apparent at the time of initial trauma. Either
they are masked by more serious injuries or it
takes some time for the hematoma to develop. Re-
ported delays to diagnosis occur in approximately
one-third of patients.12 Depending on the study,
the average time to diagnosis ranges between
3 days and 2 weeks.8,12,20 Patients have even pre-
sented complaining of chronic contour deformities
up to 13 years after injury.12 Because ML lesions
are a result of trauma, they can present at any
age. The youngest documented case was in a
child aged 28 months.21 Those caring for pediatric
trauma patients should be especially vigilant when
managing soft tissue wounds given the decreased
clarity with which children communicate their
symptoms.
IMAGING
Standard radiographs can confirm the presence of
a soft tissue mass without calcifications.22 They
can also be used to determine whether or not the
lesion has underlying fractures, which may signifi-
cantly affect further management.
Ultrasound is useful as both a diagnostic
and therapeutic modality. Neal and colleagues23
observed ultrasound characteristics in 21 ML le-
sions. Acute lesions are heterogeneous and lobular
with irregular margins. Lesions older than 8 months

Fig. 2. Clinical appearance of a chronic ML lesion. This
16-year-old boy first presented as an outpatient with
a painless slow-growing mass 3 months after sustain-
ing a blow to his inner thigh on the handlebar of a
motocross bike.
are homogeneous and flat. Lesions greater than
18 months old have smooth margins. All lesions
were compressible and none had vascularity. All le-
sions were either hypoechoic or anechoic, and
there was no relationship between echogenicity
and age. This finding was presumed to be a result
of repeat hemorrhage or fatty remnants. However,
fat can appear as hyperechoic nodules.24
Computed tomography is often obtained in
trauma patients with ML lesions. Lesions are often
differentiated from hematomas by fluid-fluid levels
due to sedimentation of blood components.24
Lesions less than 1 month old will have irregular
margins (Fig. 3). More chronic lesions will be
homogenous and have smooth margins, and a
capsule may be appreciated.21 The average
Hounsfield unit for a hematoma is 75, whereas it
is 17 for an ML lesion.17
MRI is considered the preferred method of
imaging to determine lesion characteristics
and chronicity.18 Findings correlate with classic
hemorrhage and magnetic properties of blood
breakdown products. Within hours of injury,
oxygen-rich hemoglobin yields a homogeneous
collection that is hypointense on T1-weighted
(T1W) images and hyperintense on T2-weighted
Management of the Morel-Lavallée Lesion 117
(T2W) images. Days to weeks after injury, oxida-
tion of iron within heme to its ferric state results
in lesions appearing hyperintense on both T1W
and T2W images. In more chronic lesions, a pe-
ripheral capsule containing hemosiderin appears
hypointense on T1W and T2W images.25 Further-
more, fibrous septations and calcified fat nodules
may be present within the lesion (Fig. 4).
CLASSIFICATION
No standard classification system exists for ML le-
sions. Carlson and colleagues16 classified lesions
as acute (<3 weeks old) or chronic (>3 weeks
old). However, the choice of 3 weeks was arbitrary
and not consistent with the remaining available
literature. Multiple investigators have defined
acute versus chronic based on the presence or
absence of a capsule, and this method does
have limited ability to guide treatment.26,27 Mel-
lado and Bencardino19 created a classification
based on MRI appearance, which does help deter-
mine the age of the lesion but has not been used to
guide treatment.
DIFFERENTIAL DIAGNOSIS
An extensive list of differential diagnoses exists for
ML lesions, especially when they present as
chronic lesions with an unclear cause. MRI and
physical exam can be used to differentiate almost
all confounding diagnoses. Abscess, contusion, or
hematoma can be differentiated from ML lesions
based on tenderness, firmness, cutaneous sensa-
tion, and the condition of the overlying skin. Con-
tusions will have increased skin tension and less
fluctuance.9 In the knee, ML lesions have been
misdiagnosed as prepatellar bursitis for as long
as 7 months.28 Extension of fluctuance beyond
the anatomic boundaries of the prepatellar bursa
is the main distinguishing characteristics of ML le-
sions of the knee. Prepatellar bursae have been
shown to terminate before the midthigh proximally
and before the midcoronal plane medially and
laterally.9 Furthermore, ML lesions (as opposed
to prepatellar bursitis) do not respond to steroid
injections because they lack a synovial lining.3
ML lesions may also be easily mistaken for soft
tissue tumors, especially when they present in
the subacute to chronic phase as a painless
slow-growing mass. MRI can distinguish benign
lesions from sarcomas if contrast reveals internal
enhancement of the tumor.18
PRINCIPLES OF MANAGEMENT
There is currently no universally accepted treat-
ment algorithm for the management of ML lesions.
118 Greenhill et al

Fig. 3. Computed tomography

scan obtained during an initial
trauma evaluation identified an
acute ML lesion of the right
medial thigh. This patient also sus-
tained severe visceral injuries, a
closed acetabular fracture, and
an open tibia fracture.

However, the available literature does establish
the following guidelines. For acute lesions, some
form of treatment should be initiated as early as
possible. Benign neglect of an acute lesion may
predispose patients to develop a chronic hema-
toma without any reduction in dead space. Theo-
retically, this further compromises the blood
supply to the skin and increases the likelihood of
recurrence. Furthermore, hematoma formation in
polytrauma patients predisposes the wound to
bacterial colonization.29 In lesions overlying a
planned surgical approach to displaced fractures,
the potential for bacterial colonization justifies pro-
phylactic surgical debridement. Uncomplicated
subacute or chronic lesions should undergo imag-
ing in order to determine the extent and character-
istics of the lesion. Presence of a fibrous capsule
implies that the lesion will likely recur without sur-
gical intervention.
Absolute indications for surgical intervention
include deep infection, severe skin necrosis, or as-
sociation of a lesion with an open fracture. Relative
indications for surgical management include un-
successful nonsurgical treatment, symptomatic
lesions, and those overlying a planned surgical
approach for acute fixation of a closed fracture.
Conservative management options include
compression dressings and aspiration. Surgical
options include debridement of necrotic material
through either small percutaneous or large open
incisions. Large incisions were originally recom-
mended in order to adequately debride necrotic
components. They improve visualization and
allow intraoperative dead space closure at the
risk of further impairing subdermal vascularity.
Furthermore, they allow complete capsular
resection in more chronic lesions. More recently,
less invasive treatment has been described with
superior outcomes. The decision to perform
less invasive treatment depends on several fac-
tors to include lesion characteristics, approach
to underlying fractures, and need for capsular
resection. Adjuncts to surgical debridement
include sclerodesis and drain placement. Investi-
gators have used the aforementioned treatment
options in various combinations. A thorough
understanding of lesion pathophysiology and
specific lesion characteristics (such as acuity,
location, size, symptoms, and absence or pres-
ence of underlying operative fracture) will allow
surgeons to individualize treatment plans. Fig. 5
provides the authors’ recommended treatment

Fig. 4. (A, B) Short tau inversion recovery sequence MRI depicting a chronic ML lesion measuring
8.2  6.8  3.2 cm with characteristic internal septations, calcified fat globules, and a fibrous capsule. (C) T2-
weighted fast spin echo sequence MRI depicting an ML lesion in the gluteal region in a patient who presented
3 years after initial injury with a painless contour deformity.

Fig. 5. Recommended treatment algorithm.
algorithm based on a thorough review of the
literature.
PREOPERATIVE PLANNING
Timing of definitive fixation for fractures with associ-
ated ML lesions is an important aspect of preopera-
tive planning. Both immediate and staged treatment
have been described with varied success. Investi-
gators uniformly agree that surgical debridement
before internal fixation is necessary to avoid postop-
erative hematoma.2,4 Additionally, the increased
prevalence of bacterial colonization in acute lesions
among trauma patients may indicate staged treat-
ment. In opposition, fractures that undergo delayed
open reduction are at risk for increased operative
time, blood loss, and difficulty obtaining anatomic
reduction. Whether or not to delay definitive fixation
should depend on the factors discussed earlier.
Also, external fixator pins through the lesion should
be avoided if possible.30 Hak and colleagues6
treated 15 pelvic fractures at the time of initial
debridement with concerning results, but this may
have resulted from incisions being left open to heal
by secondary intention. By contrast, Carlson and
colleagues16 emphasized strict dead space closure
during initial debridement while performing fracture
osteosynthesis directly through 6 lesions and had
no postoperative infections. These investigators
warned that any signs of clinical infection during
the index procedure should warrant staged treat-
ment. Tseng and Tornetta5 delayed definitive fixa-
tion until 24 hours after drain removal following
percutaneous debridement with excellent results.
Surgeons should use their best clinical judgment
when scheduling definitive fixation of underlying
fractures.
Management of the Morel-Lavallée Lesion 119
CONSERVATIVE TREATMENT
Nonoperative treatment methods mainly consist
of compression bandaging with or without fluid
aspiration. In general, investigators suggest that
small lesions are more amenable to conservative
treatment methods.28,31 Conservative manage-
ment was estimated by Shen and colleagues27 to
be successful less than 50% of the time, but this
statistic may actually be much higher or lower
depending on lesion characteristics. Compres-
sion bandaging is a well-documented, necessary
adjunct to both conservative and postsurgical
treatment in order to allow fibrous adhesions
within the preexisting lesion. As expected, its
efficacy may depend on lesion location. Among
13 lesions identified in a systematic review
that were treated conservatively, all those not
receiving compression failed conservative mea-
sures, whereas 62.5% of those receiving com-
pression healed successfully.27 Harma and
colleagues31 reported 5 acute lesions of which 4
healed with conservative management alone after
an average of 6.8  3.96 weeks. Those investiga-
tors did not mention the size of the lesions and only
aspirated one of them. Parra and colleagues7
treated 2 out of 3 large thigh lesions successfully
with compression alone. Multiple investigators
have attributed their treatment failures to inade-
quate compression bandaging.12,31
Risk of iatrogenic inoculation via simple aspi-
ration is also a common concern given the
increased prevalence of these closed lesions to
be culture positive. However, data from some of
the larger case series suggest that aspiration un-
der sterile conditions carries an acceptable risk
and should be performed when indicated. Among
120 Greenhill et al
the reported cases of sclerodesis, almost all
included patients had at least one aspiration
without developing infection.18,32 The 16 patients
reported by Bansal and colleagues33 averaged
3.4 aspirations before doxycycline sclerodesis
within at least a 6-month period and remained
free of infection. Zero of 13 uncomplicated knee
lesions averaged 2.7 aspiration attempts without
any subsequent infections.9 In a series of 87 le-
sions whereby 25 underwent simple aspiration,
there was one infection in the aspiration group.8
This finding was not statistically different than
the nonoperative and operative group infection
rates. One case report describes the clinical
course of a patient who underwent 10 aspirations
over a 7-month period without developing infec-
tion.28 Another case report describes a patient
who underwent multiple repeated aspirations for
10 months without developing infection.34
SURGICAL TREATMENT: TECHNIQUES AND
OUTCOMES
Open Debridement
In 1976, Ronceray26 described the first formal
open surgical technique aimed at preventing
lesion recurrence whereby aponeurotic fenestra-
tions were created deep to the lesion in order to
allow internal drainage and healing. This method
was primarily applied to abdominal lesions, and
the results with respect to injured extremities are
not reported. Coulibaly and colleagues35 reported
success rates with this method as low as 40%.
Currently described open treatment includes a
longitudinal incision across the lesion along a
palpable midpoint, removal of necrotic fat, irriga-
tion and debridement of the deep fascial layer (us-
ing a plastic brush or electrocautery scratch pad)
to encourage revascularization, and dead space
closure by sealing healthy fat to fascia with an
absorbable suture. If the lesion is chronic and a
capsule is present, complete removal of the
fibrous capsular tissue should be performed
(Fig. 6). Additionally, a sclerosing agent may be
added at the surgeon’s discretion. Outcomes after
open treatment have been reported with variable
results.
In a landmark article, Hak and colleagues6
emphasized the challenges of managing an ML
lesion over a fractured pelvis. In hopes of prevent-
ing hematoma formation over a planned surgical
approach, closed degloving lesions in 24 hospital-
ized polytrauma patients were treated with open
surgical debridement before or during internal fix-
ation of pelvic fractures. The duration between
injury and initial debridement averaged 13.1 days
(range 2–60 days). Fascia was closed but the
Fig. 6. Specimens obtained during open capsular
resection of a chronic ML lesion. The pathology report
confirmed fragments of nodular, benign adipose tis-
sue with necrosis, fibrin, and chronic inflammation.
degloved portion was left open to drain and heal
by secondary intention. Intraoperative fluid from
11 lesions (46%) yielded positive cultures,
although patients did not necessarily exhibit
symptoms of infection. Culture results did not
correlate with the time between injury and surgical
debridement. All wounds eventually healed, but
the postoperative course for some patients was
alarming. Three patients developed deep bone in-
fections; 2 patients required split-thickness skin
grafting; one patient developed a chronic soft tis-
sue infection that needed a posterior thigh flap; 2
patients underwent elective cosmetic surgery after
their wounds healed.
The aforementioned outcomes led to subse-
quent modifications of open surgical technique
to encourage meticulous dead space closure by
sealing healthy fat to fascia with an absorbable su-
ture.16,36 If minimal fat remains after debridement,
a nonabsorbable suture can be used to join the
skin and fascia. Carlson and colleagues16 reported
zero postoperative infections in their series of 24
lesions treated with open debridement and dead
space closure.
It is presumed that circulating bacteria in poly-
trauma patients predisposed acute lesions to
have positive cultures. Most patients in the series
reported by Hak and colleagues6 had significant
injuries to include 4 open pelvic fractures,
numerous visceral organ injuries, and injuries to
the peripheral and central nervous system. Of
note, only 2 of 9 lesions in this series cultured after
2 weeks had positive cultures. Therefore, clini-
cians should interpret the aforementioned results
with respect to the acuity of the lesion and the
trauma patient population that was studied. The
likelihood of bacterial colonization in an isolated
closed wound may not be as high as that of
acutely injured patients with polytrauma. Carlson

and colleagues16 included details for 13 of 14
closed degloving injuries of which zero were clini-
cally infected before initial debridement. Further-
more, Bansal and colleagues33 cultured fluid
from 16 chronic lesions after excluding those
with prior surgery or underlying fractures. None
of their lesions produced positive cultures.
Limited Incision
Concerns about infection risk and flap survival
following open treatment led to the description of
minimally invasive techniques as the current gold
standard for appropriate lesions. The first mention
in the English literature that specifically addressed
treatment of closed degloving injuries via a
limited incision occurred in 1991. Hudson12 re-
ported 16 patients who underwent irrigation and
debridement through a small incision, appropri-
ately sized to allow evacuation of necrotic prod-
ucts. If displaced fat created a contour deformity,
the incision was extended across the entire lesion.
All lesions healed successfully except one exten-
sive gluteal lesion over a fractured pelvis in which
compression could not be maintained. No lesions
within their series occurred over a displaced
fracture.
In order to address the treatment of acute le-
sions over displaced pelvic fractures, Tseng and
Tornetta5 described a new technique using small
percutaneous incisions. They reported encour-
aging results among a series of 19 consecutive pa-
tients. Their technique included irrigation and
drainage of hematoma through two small 2-cm in-
cisions (one each at the proximal and distal extent
of the lesion). The proximal incision was placed
posterosuperiorly to ensure the entire cavity was
influenced. A plastic brush was used to debride
necrotic fat before the lesion was again irrigated
with pulse lavage until exiting fluid was clear.
Finally, a suction drain was left within the lesion un-
til output was less than 30 mL per day. Intravenous
antibiotics were discontinued 24 hours after drain
removal.
All lesions were debrided within 3 days of injury,
and drain removal took place between 3 and
8 days after debridement. The injury profile of
these polytrauma patients was similar to that of
the series reported by Hak and colleagues.6 How-
ever, only 3 of 16 (19%) of patients had positive
fluid cultures at the time of initial debridement.
Fifteen patients underwent surgical fixation of
displaced pelvic or acetabular fractures. Percuta-
neous fixation of the posterior pelvic ring was per-
formed immediately following initial debridement
(during the same procedure) in 7 patients. One of
these patients had a positive fluid culture but no
Management of the Morel-Lavallée Lesion 121
sequelae. Open reduction and internal fixation in
the remaining 8 patients was delayed until 24 hours
after drain removal. Three open reductions were
performed directly through the lesion without in-
fectious complications.
Subsequent investigators have reproduced
similar satisfactory results after percutaneous
debridement. Zhong and colleagues20 performed
the procedure described by Tseng and Tornetta5
on 8 lesions after an average time to diagnosis of
11.9 days. Lesions healed in an average time of
3.25 weeks after debridement without recurrence
or infection, although 2 patients required skin
grafting for associated flap necrosis. Additionally,
Matava and colleagues37 performed the afore-
mentioned procedure on an extensive peritro-
chanteric lesion whereby 500 mL of fluid was
aspirated. The patient returned to playing profes-
sional football without recurrence 22 days after
debridement.
Sclerodesis
Introduction of various sclerosing agents into more
chronic lesions has been successfully described
as an adjunct to percutaneous surgical treatment.
A systematic review reports a success rate for
percutaneous sclerodesis of chronic lesions to
be 95.7%.27 Once inside the lesion, sclerosing
agents activate an inflammatory cascade that en-
courages scar formation and fusion of subdermal
membranes. Especially in the presence of a
chronic or recurring lesion, sclerodesis potentially
avoids the need for a more extensive and painful
surgical incision wide enough to allow capsular
resection and dead space closure. If necessary,
sclerodesis can be repeated and does not inter-
fere with future surgical options.
The concept of injecting a sclerosing agent into
an ML lesion was derived from its application in
malignant pleural effusions, whereby talc and
doxycycline are commonly used.38 In 2006, Luria
and colleagues17 were the first to use sclerodesis
in 4 ML lesions that failed prior aspiration. After
defining the cavity with contrast fluid under fluoro-
scopic guidance, they evacuated all contents and
instilled 5 g of sterile talc diluted in 50 mL sterile
saline, removed the mixture after 5 minutes, and
left a drain in until the output was less than
30 mL per day. Three patients had drains removed
after 1 week and enjoyed an uncomplicated
postprocedural course. One patient with a nonop-
erative pelvic fracture and bilateral lesions devel-
oped subsequent infection treated with only
antibiotics and simple drainage.
In 2013, Bansal and colleagues33 reported their
results after using doxycycline as a sclerosing
122 Greenhill et al
agent in 16 chronic lesions. All lesions were pre-
sent more than 6 months and failed prior interven-
tion. They inserted 21-gauge needles into the
proximal and distal extent of the lesion, drained
all fluid from the cavity, instilled 500 mg of doxycy-
cline powder (obtained from 100-mg capsules and
mixed with 25 mL of saline solution), had the pa-
tients maneuver themselves once every 10 minutes
for 1 hour, aspirated the mixture, then applied
a compression dressing for 4 weeks. No drains
were used. The average volume aspirated was
387 mL (range 150–700 mL). All lesions resolved
without recurrence in an average time of 5 weeks
and were followed for more than 2 years. Subse-
quent investigators have also described their use
of doxycycline for recurrent lesions with similar
success.9
Other sclerosing agents proposed for use
include alcohol, bleomycin, and tetracycline. Pe-
naud and colleagues32 described 5 chronic lesions
treated with pure ethanol, all of which had confir-
mation of a capsule via MRI. Postprocedural imag-
ing 6 months later confirmed complete absence of
a capsule in 4 patients and a small asymptomatic
cavity in one patient. Bleomycin has been used in
malignant pleural and pericardial effusions but is
less popular because of higher costs.39 The low
postoperative infection rates after sclerodesis
have been anecdotally attributed to the antibacte-
rial effects of sclerosing agents.
POSTOPERATIVE CARE
Drains are almost universally described as part of
all surgical procedures. In general, surgeons leave
them in until the output is less than 30 mL per day.
Postoperative drains were generally removed
within 1 week for acute lesions and up to several
weeks for more chronic lesions.5,6,16,17,20 Com-
pression is also of utmost importance, and investi-
gators have directly blamed its absence for
treatment failure.33 For patients with acute lesions
managed as inpatients, antibiotics were also used
until 24 hours after drain removal.5,16
COMPLICATIONS
Postoperative Infection
Treating displaced fractures through ML lesions
at the time of initial debridement may increase
the risk of infection. The study by Hak and col-
leagues,6 whereby 46% of closed lesions were
culture positive during initial debridement, made
the orthopedic community distressingly aware of
the potential disaster that might exist within these
lesions. Fifteen of 24 patients underwent open
reduction and internal fixation at the time of initial
debridement, after which the skin was left to heal
by secondary intention. Three patients subse-
quently developed deep bone infections, and
several others had wound complications. There
is further concerning evidence that acute ML le-
sions harbor infectious potential if opened. In a se-
ries of 20 patients with vertically unstable sacral
fractures, 2 of 5 patients with ML lesions became
infected postoperatively. However, none of the
15 patients without an ML lesion developed a
postoperative infection.40 In a case series of 4 pa-
tients with spinopelvic dissociation and lesions
overlying the approach used for internal fixation,
2 patients developed postoperative infections
and one patient developed skin necrosis that
led to infection and extensive soft tissue
reconstruction.41
Most literature highlights the potential risk of
bacterial colonization within planned surgical inci-
sions for underlying displaced fractures. However,
this risk is not to be confused with that of nonoper-
ative or surgically decompressed lesions. In the
series of 19 patients by Tseng and Tornetta,5 inter-
nal fixation was delayed until 24 hours after percu-
taneous debridement and no patients developed
postoperative infections. In 2007, Carlson and col-
leagues16 highlighted 6 fractures treated directly
through ML lesions after thorough debridement
and meticulous dead space closure with no sub-
sequent infections. When sclerodesis is used, the
infection risk seems to be low. Doxycycline scle-
rodesis in 16 patients and alcohol sclerodesis in
5 patients did not result in any postoperative infec-
tions.32,33 Talc sclerodesis in 5 lesions led to one
postoperative infection.17 Conservative manage-
ment via aspiration and compression dressings
in 4 patients by Harma and colleagues31 led to
one sacral ulcer that became infected. In a sys-
tematic review by Shen and colleagues,27 almost
all postoperative infections were managed with
antibiotics alone. In summary, surgeons should
not allow the risk of bacterial colonization in
trauma patients to prohibit appropriately staged
surgical debridement when necessary.
Recurrence
Lesion recurrence is a primary concern when treat-
ing ML lesions. It is thought to occur because of the
decreased capability of lesions to evacuate fluid
combined, the persistent introduction of blood
and lymph, and squamous cells within a more
chronic lesion’s serosal lining.17 Persistent fluid
collection is a cosmetic and symptomatic nuisance
for patients; allows time for a pseudocapsule to
develop, thus, making definitive treatment more
detailed; and places the overlying soft tissue at

risk for ulceration and subsequent infection.
Methods used to prevent recurrence aim to
enhance fluid drainage and close dead space.
Recurrence rates are different with regard to con-
servative versus operative management. Actual
rates of lesion recurrence are unknown. A recent
systematic review reports that open treatment ex-
hibited a 4.2% rate of recurrence, whereas less
invasive drainage yielded a recurrence rate of
17.4%; but those figures had no statistically signif-
icant difference.27
Given the widely heterogeneous lesion character-
istics within the available literature, it is difficult to
determine which lesions have the highest risk of
recurrence. The most obvious risk factor for recur-
rence is the presence of a fibrous capsule. After sim-
ple aspiration of an encapsulated lesion, fluid
collections are almost guaranteed to recur without
capsular resection or sclerodesis. Lesion location
has also been suggested as a risk factor for recur-
rence, as compression bandaging around the hip
or buttock region is more difficult to maintain than
around the knee and distal thigh.33 Surgical tech-
nique similarly affects recurrence rates. For
example, among the 24 patients reported by Carlson
and colleagues16 in which meticulous dead space
closure was a main priority, zero lesions recurred.
Lesion size may be a risk factor for recurrence af-
ter conservative treatment, and some investigators
even modify their surgical indications based on this
belief. However, establishing a numerical cutoff
value to differentiate small from large lesions is
controversial. Ronceray26 suggested in 1976 that
small lesions are more amenable to conservative
treatment, whereas operative management should
be considered for larger lesions. Nonetheless, he
did not define what constitutes a small versus large
lesion. Nickerson and colleagues8 retrospectively
reviewed their treatment of 87 lesions and recom-
mended that aspirating more than 50 mL indicates
operative intervention because of a statistically
higher risk of recurrence. Several statistical flaws
confound their conclusion. First, the aspiration
group in this study consisted of 25 patients with
significantly larger lesions (P 5 .006) and longer
diagnostic delays (P 5 .001) than the operatively
treated group. Secondly, aspirated lesions were
not categorized by location. This point is important
because subsequent compression therapy in
certain locations, such as the gluteal folds, is
more difficult to maintain. Lastly, 75% of the lesions
that recurred after aspiration were a result of high-
energy trauma. These confounders suggest that
other factors may have been responsible for the
increased rate of recurrence noted in lesions
whereby an initial aspiration yielded greater than
50 mL of fluid. Tejwani and colleagues9 reported
Management of the Morel-Lavallée Lesion 123
good results after 27 knee lesions were treated
with nonoperative measures. Their reported aspi-
rated quantities were relatively low compared
with other studies, averaging between 46 and
77 mL (range 12–300 mL).
Skin Necrosis
Soft tissue compromise remains a concern before
and after operative management. Limited blood
supply to the skin during hematoma formation,
combined with increased mechanical friction and
shear, predispose these lesions to ulceration and
subsequent skin necrosis or infection. Operative
intervention with larger incisions may place the
skin at more risk for necrosis than less invasive
techniques.5 Skin necrosis should be subse-
quently managed with further debridement and
skin grafting or soft tissue flaps as necessary.
Contour Deformity
Displacement of fat during the initial injury often
leads to asymptomatic, asymmetric, and nonfluc-
tuant displacement of the skin when compared
with the contralateral extremity.3 This displacement
is primarily a cosmetic concern. Slight skin hyper-
mobility may also be present. By contrast, sclerod-
esis of chronic lesions leads to skin immobility in a
subset of patients that is only symptomatic during
persistent high-level athletic activity.9,33
SUMMARY
ML lesions represent a serious soft tissue injury,
although their diagnosis is often missed or delayed.
These lesions are known to be associated with high
rates of recurrence, skin necrosis, and infection. In
the case of underlying pelvic fractures, lesions have
the ability to create treacherous outcomes after
open treatment of underlying displaced fractures.
Clinicians should remain suspicious when manag-
ing patients after shearing injuries or direct blows
to the greater trochanter. Early recognition and
optimal management can save patients from unde-
sirable morbidity and consequent need for more
complex surgical management.
ACKNOWLEDGMENTS
We wish to thank Dr. Alison Gattuso, St. Christo-
pher’s Hospital for Children, Philadelphia, PA for
her contributions to this article.
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