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