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      Morel-Lavallee Lesion Initially Diagnosed as Quadriceps Contusion: Ultrasound, MRI, and Importance of Early Intervention

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          Abstract

          Morel-Lavallee lesions (MLL) are rare, closed degloving injuries caused by trauma that delivers a shearing force to the soft tissue most commonly of the hip. If not treated in the acute and subacute setting these lesions are often complicated by re-accumulation of fluid, infection, or chronic pain. We present a unique case of a recurrent, massive medial knee/thigh MLL in which proper treatment was delayed due to initial diagnosis of a quadriceps contusion. We describe the ultrasound and magnetic resonance imaging findings of this patient and based on a review of recent literature propose that the initial management should have included early drainage/debridement, which likely could have prevented recurrence and significantly shortened the clinical course.

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          Most cited references13

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          The Mayo Clinic experience with Morel-Lavallée lesions: establishment of a practice management guideline.

          Although uncommon, Morel-Lavallée lesions (also called closed degloving injuries) are associated with considerable morbidity in trauma patients. There is lack of consensus regarding proper management of these lesions. Management options include nonoperative therapies, along with percutaneous and operative techniques. We sought to define the factors associated with failure of percutaneous aspiration to better identify patients requiring immediate operative management.
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            Management of Morel-Lavallee lesion of the knee: twenty-seven cases in the national football league.

            The Morel-Lavallee lesion is a closed degloving injury most commonly described in the region of the hip joint after blunt trauma. It also occurs in the knee as a result of shearing trauma during football and is a distinct lesion from prepatellar bursitis and quadriceps contusion. To review the authors' experience with Morel-Lavallee lesion of the knee in the elite contact athlete to construct a diagnostic and treatment algorithm. Case series; Level of evidence, 4. Twenty-seven knees in 24 players were identified from 1 National Football League team's annual injury database as having sustained a Morel-Lavallee lesion between 1993 and 2006. Their charts were retrospectively reviewed. The most common mechanism of injury was a shearing blow on the playing surface (81%). The most common motion deficit was active flexion (41%). The mean time for resolution of the fluid collection and achievement of full active flexion was 16.3 days. The mean number of practices missed was 1.5. The mean number of games missed was 0.1. Fourteen knees (52%) were treated successfully with compression wrap, cryotherapy, and motion exercises. Thirteen knees (48%) were treated with at least 1 aspiration, and 6 knees (22%) were treated with multiple aspirations for recurrent serosanguineous fluid collections. In 3 cases (11%), the Morel-Lavallee lesion was successfully treated with doxycycline sclerodesis after 3 aspirations failed to resolve the recurrent fluid collections; return to play was immediate thereafter in each case. In football, Morel-Lavallee lesion of the knee usually occurs from a shearing blow from the playing field. Diagnosis is confirmed when examination reveals a large suprapatellar area of palpable fluctuance. Elite athletes are typically able to return to practice and game play long before complete resolution of the lesion. Recurrent fluid collections can occur, necessitating aspiration in approximately half the cases for successful treatment. Recalcitrant fluid collections can be safely and expeditiously treated with doxycycline sclerodesis.
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              The Morel-Lavallée lesion: pathophysiology, clinical presentation, imaging features, and treatment options.

              Morel-Lavallée lesions are posttraumatic hemolymphatic collections related to shearing injury and disruption of interfascial planes between subcutaneous soft tissue and muscle. We review the pathophysiology of Morel-Lavallée lesions, clinical presentation, and potential sites of involvement. Magnetic resonance imaging (MRI) is the modality of choice for characterization. We present the MRI classification and highlight the key imaging features that distinguish the different types, focusing on the three most common: seroma, subacute hematoma, and chronic organizing hematoma. Potential mimics of Morel-Lavallée lesions, such as soft tissue sarcoma and hemorrhagic prepatellar bursitis, are compared and contrasted. Treatment options and a management algorithm are also briefly discussed.
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                Author and article information

                Journal
                West J Emerg Med
                West J Emerg Med
                WestJEM
                Western Journal of Emergency Medicine
                Department of Emergency Medicine, University of California, Irvine School of Medicine
                1936-900X
                1936-9018
                May 2015
                09 April 2015
                : 16
                : 3
                : 438-441
                Affiliations
                [* ]San Antonio Military Medical Center, Fort Sam Houston, Texas
                []San Antonio Military Medical Center, Department of Emergency Medicine, Fort Sam Houston, Texas
                []San Antonio Military Medical Center, Department of Radiology, Fort Sam Houston, Texas
                Author notes
                Address for Correspondence: Nicholas A. Weiss, DO, San Antonio Military Medical Center, 3551 Roger Brooke Dr., Transitional Year Internship, JBSA Fort Sam Houston, TX 78234. Email: naweiss86@ 123456gmail.com .
                Article
                wjem-16-438
                10.5811/westjem.2015.3.25148
                4427222
                25987925
                a27db2fe-ad94-47a4-846f-0a16f1dba29e
                Copyright © 2015 the authors.

                This is an Open Access article distributed under the terms of the Creative Commons Non-Commercial Attribution License, which permits its use in any digital medium, provided the original work is properly cited and not altered. For details, please refer to http://creativecommons.org/licenses/by-nc-nd/3.0/. Authors grant Western Journal of Emergency Medicine a nonexclusive license to publish the manuscript.

                History
                : 17 December 2014
                : 14 January 2015
                : 29 March 2015
                Categories
                Diagnostic Acumen
                Case Report

                Emergency medicine & Trauma
                Emergency medicine & Trauma

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