Session IV - Pelvis

Percutaneous Management of Morel-Lavallee Lesions

Paul Tornetta, III, MD; Anne N. Normand, MD; Boston University Medical Center, Boston, Massachusetts, USA

Purpose: Morel-Lavallee lesions occur most commonly after direct trauma to the pelvic region and are associated with pelvic and acetabular fractures. Previous authors have recommended open debridement of these lesions with packing or delayed closure. The purpose of this study was to review the use of percutaneous drainage for the early management of these lesions.

Methods: Nineteen consecutive patients with Morel-Lavallee closed soft tissue degloving injuries were included. Associated injuries included 12 pelvic fractures, 7 acetabular fractures, 1 hip fracture, and 2 femoral shaft fractures. Systemic injuries included three pulmonary contusions, two head injuries, two splenic lacerations, one bladder rupture, and one liver laceration. All the Morel-Lavallee lesions were managed initially by percutaneous drainage within 3 days. Drainage was accomplished by using a 2-cm incision in the posterior gluteal region over the hematoma and a similar incision in the midline of the thigh determined to be over the extent of the injury by placement of a suction tip distally through the lesion from the proximal incision. After drainage of the hematoma, a plastic brush (normally used for preparation of the femoral canal in hip replacements) was used to percutaneously debride the injured fatty tissue, which was washed from the wound by using pulse lavage from the distal incision through the injured area and exiting the proximal gluteal incision. The lesion was irrigated until clear, a medium hemovac was placed, and the incisions were closed. The drain was removed when drainage was less than 30 cc in a 24-hour period. Cultures of the fluid were obtained from 16 of 19 patients.

Results: Of the 19 patients, 14 underwent surgery for their associated pelvic or acetabular fracture, including 9 of 12 pelvic fractures and 6 of 7 acetabular fractures. Percutaneous fixation of the posterior pelvic ring was undertaken at the same operative setting as the drainage in seven of nine pelvic fractures that were fixed. Fixation of the remaining two pelvic fractures and the six acetabular fractures (four ilioinguinal and two Kocher-Langenbeck) were deferred until at least 24 hours after the drains were pulled out; cephalosporin was used during this interval. None of the patients with percutaneous fixation of the pelvis developed any wound complications or skin loss. One patient with a both-column fracture and associated hip fracture was treated with surgical secondary congruence to avoid completion of an incomplete anterior column fracture because a culture from the lesion on the outer aspect of the pelvis had been positive. One patient fixed through a Kocher-Langenbeck approach required a surgical exploration of his wound because of persistent drainage, but the culture was negative and the wound was closed after exploration. No deep infections occurred, and no patient required debridement of skin. Only 3 of 16 cultures were positive (19%).

Conclusion: Early percutaneous drainage with debridement, irrigation, and suction drainage of Morel-Lavallee lesions is safe and effective. Percutaneous procedures for pelvic fixation are well tolerated, and open procedures appear to be safe when performed in a delayed fashion. By avoiding a wide and open debridement, the skin may be better able to resolve its injury because the blood supply is preserved. We recommend early percutaneous drainage of these lesions if the patient's condition is stable. None of the patients in this series developed an infection and none required debridement of skin; however, there were no patients in the series who had initial full-thickness skin lesions.