J Ultrasound DOI 10.1007/s40477-015-0157-2
LETTER TO THE EDITOR
Morel-Lavalle´e lesion of the knee in a soccer player Remigio Depaoli • Elena Canepari • Chandra Bortolotto • Guja Ferrozzi
Received: 3 December 2014 / Accepted: 30 December 2014 Ó Societa` Italiana di Ultrasonologia in Medicina e Biologia (SIUMB) 2015
First described in 1853 [1], the Morel-Lavalle´e lesion is a closed, post-traumatic, soft tissue degloving injury [1–3], characterized by an accumulation of blood, lymph, and other breakdown products between the subcutaneous tissue and underlying fascia [4] (Fig. 1). It is due to shearing stress with disruption of perforating blood vessels and the creation of potential spaces. Morel-Lavalle´e is most commonly associated with pelvic and acetabular fractures, but it may also occur at various locations [4]; the lesion has been reported occurring over the flank, buttock, lumbar spine, scapula, knee, and elsewhere. Clinical presentation of the lesion is pain, swelling, and stiffness at the site of injury. Upon examination, there is an area of tissue swelling that is soft to palpation [4]. Radiological investigations, especially ultrasound imaging and magnetic resonance imaging, are highly valued in the traumatic pathology of soft tissue [5] and so for the diagnosis of this condition [6]. The sonographic appearance is characterized by acute lesions that tend to be heterogeneous and lobular, with irregular margins. The chronic lesions are anechoic with well-defined margins, separating the subcutaneous tissue from the underlying fascia [7, 8].
Additionally, the magnetic resonance imaging appearance depends on the age and amount of blood, fat, and lymph [9]. The differential diagnosis is with muscle and soft tissue hematomas and with bursitis [10], more rarely with neoplasms. There is a lack of consensus regarding the management of these lesions, including non-operative therapies and operative techniques [11–13]. An 18-year-old male presented with left medial knee pain and swelling, 26 days following an injury occurred while playing soccer. Clinical examination showed a fluctuant swelling on the medial aspect of the right knee, without any surrounding cutaneous laceration or edema. Ultrasound of the medial aspect of the right knee, using a linear transducer at 18 MHz (Fig. 1), showed a
R. Depaoli Radiology Unit, Moncucco Hospital, Lugano, Switzerland E. Canepari C. Bortolotto (&) Institute of Radiology, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy e-mail: [email protected] G. Ferrozzi Department of Radiology, Guglielmo da Saliceto Hospital, Piacenza, Italy
Fig. 1 Morel-Lavalle´e lesion. Morel-Lavalle´e lesion is a posttraumatic injury characterized by an accumulation of fluid (arrows) between subcutaneous tissue and underlying fascia
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J Ultrasound
longitudinal homogenous fluid lesion, located between the subcutaneous tissue and muscle (Morel-Lavalle´e lesion) (Fig. 2). Magnetic resonance imaging of the lesion (Fig. 3)
Fig. 2 Morel-Lavalle´e lesion. Extended field-of-view sonograms a, b shows a fusiform homogeneous anechoic fluid collection (arrows) with smooth margins, located between subcutaneous tissue and muscle
subcutaneous tissue and the underlying muscle. A conservative approach to treatment was preferred. After 3 months of simple resting of the knee, no significant effusion could be appreciated on sonographic examination. The patient is currently asymptomatic. Morel-Lavalle´e lesions [1] are rare but should be suspected in high inertia trauma of the knee, commonly developing secondarily to blunt trauma separation of subcutaneous tissue from the underlying fascia. The diagnosis remains primarily a clinical diagnosis [2], but there is a wide range of differential diagnoses, including hematomas, abscesses, bursitis, fat necrosis, and neoplasms; particularly, the clinical presentation of a posttraumatic hematoma and an acute Morel-Lavalle´e lesion are similar. Ultrasound and MRI must be used to confirm the diagnosis [2, 4] and for the differential diagnosis. The sonographic and magnetic resonance imaging characteristics of Morel-Lavalle´e lesions are variable: lesions less than 1 month of age tend to be heterogeneous and irregularly marginated. When they evolve, they became more regularly marginated and homogeneous, but only the anatomic features are typical: a fluid lesion, located between subcutaneous tissue and muscle [6, 8]. The Morel-Lavalle´e lesion has a specific anatomic location and pathophysiological process that make it more prone to complications and chronicity. No clear best management is known, but the options can be narrowed based on location, age, and size of the lesion [2].
Fig. 3 Morel-Lavalle´e lesion. Axial and sagittal proton density fat suppressed images confirm the presence of fluid collection (arrows) with smooth margins, located between subcutaneous tissue and muscle
confirmed, on the medial aspect of the right knee, the presence of a homogenous collection of fluid, between the
123
Conflict of interest interest to disclose.
All authors confirm that they have no conflict of
J Ultrasound Ethical standard All human and animal studies have been approved by the appropriate ethics committee and have therefore been performed in accordance with the ethical standards laid down in the Helsinki Declaration of 1975 and its late amendments.
References 1. Morel-Lavalle´e M (1863) Decollements traumatiques de la peau et des couches sousjacentes. Arch Gen Med 1:20–38, 172–200, 300–332 2. Turner CJ, Van Lancker H (2014) A prepatellar Morel-Lavalle´e lesion in a pedestrian vs automobile collision. Am J Emerg Med 32(1):109. doi:10.1016/j.ajem.2013.08.023 e3-4 3. Bianchi S, Martinoli C (2007) Ultrasound of the musculoskeletal system. Springer, Berlin, pp 677–678 4. Goodman BS, Smith MT, Mallempati S, Nuthakki P (2013) A comparison of ultrasound and magnetic resonance imaging findings of a Morel-Lavalle´e lesion of the knee. PM R 5(1): 70–73 5. Draghi F, Bianchi S, Gervasio A, Fachinetti C, Gaignot C, De Gautard R (2006) L’ecografia nella valutazione della patologia traumatica del polso e della mano. J Ultrasound 9(3):218–226
6. van Gennip S, van Bokhoven SC, van den Eede E (2012 ) Pain at the knee: the Morel-Lavalle´e lesion, a case series. Clin J Sport Med 22(2):163–166 7. Robinson P, Farrant JM, Bourke G, Merchant W, McKie S, Horgan KJ (2008) Ultrasound and MRI findings in appendicular and truncal fat necrosis. Skeletal Radiol 37(3):217–224 8. Neal C, Jacobson JA, Brandon C, Kalume-Brigido M, Morag Y, Girish G (2008) Sonography of Morel-Lavallee lesions. J Ultrasound Med 27(7):1077–1081 9. Borrero CG, Maxwell N, Kavanagh E (2008) MRI findings of prepatellar Morel-Lavalle´e effusions. Skeletal Radiol 37(5):451–455 10. Draghi F, Danesino GM, Coscia D, Precerutti M, Pagani C (2008) Overload syndromes of the knee in adolescents: sonographic findings. J Ultrasound 11(4):151–157 11. Nair AV, Nazar P, Sekhar R, Ramachandran P, Moorthy S (2014) Morel-Lavalle´e lesion: a closed degloving injury that requires real attention. Indian J Radiol Imaging 24(3):288–290 12. Nickerson TP, Zielinski MD, Jenkins DH, Schiller HJ (2014) The Mayo clinic experience with Morel-Lavalle´e lesions: establishment of a practice management guideline. J Trauma Acute Care Surg 76(2):493–497 13. Draghi F, Robotti G, Jacob D, Bianchi S (2010) Interventional musculoskeletal ultrasonography: precautions and contraindications. J Ultrasound 13(3):126–133
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LETTER TO THE EDITOR
Morel-Lavalle´e lesion of the knee in a soccer player Remigio Depaoli • Elena Canepari • Chandra Bortolotto • Guja Ferrozzi
Received: 3 December 2014 / Accepted: 30 December 2014 Ó Societa` Italiana di Ultrasonologia in Medicina e Biologia (SIUMB) 2015
First described in 1853 [1], the Morel-Lavalle´e lesion is a closed, post-traumatic, soft tissue degloving injury [1–3], characterized by an accumulation of blood, lymph, and other breakdown products between the subcutaneous tissue and underlying fascia [4] (Fig. 1). It is due to shearing stress with disruption of perforating blood vessels and the creation of potential spaces. Morel-Lavalle´e is most commonly associated with pelvic and acetabular fractures, but it may also occur at various locations [4]; the lesion has been reported occurring over the flank, buttock, lumbar spine, scapula, knee, and elsewhere. Clinical presentation of the lesion is pain, swelling, and stiffness at the site of injury. Upon examination, there is an area of tissue swelling that is soft to palpation [4]. Radiological investigations, especially ultrasound imaging and magnetic resonance imaging, are highly valued in the traumatic pathology of soft tissue [5] and so for the diagnosis of this condition [6]. The sonographic appearance is characterized by acute lesions that tend to be heterogeneous and lobular, with irregular margins. The chronic lesions are anechoic with well-defined margins, separating the subcutaneous tissue from the underlying fascia [7, 8].
Additionally, the magnetic resonance imaging appearance depends on the age and amount of blood, fat, and lymph [9]. The differential diagnosis is with muscle and soft tissue hematomas and with bursitis [10], more rarely with neoplasms. There is a lack of consensus regarding the management of these lesions, including non-operative therapies and operative techniques [11–13]. An 18-year-old male presented with left medial knee pain and swelling, 26 days following an injury occurred while playing soccer. Clinical examination showed a fluctuant swelling on the medial aspect of the right knee, without any surrounding cutaneous laceration or edema. Ultrasound of the medial aspect of the right knee, using a linear transducer at 18 MHz (Fig. 1), showed a
R. Depaoli Radiology Unit, Moncucco Hospital, Lugano, Switzerland E. Canepari C. Bortolotto (&) Institute of Radiology, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy e-mail: [email protected] G. Ferrozzi Department of Radiology, Guglielmo da Saliceto Hospital, Piacenza, Italy
Fig. 1 Morel-Lavalle´e lesion. Morel-Lavalle´e lesion is a posttraumatic injury characterized by an accumulation of fluid (arrows) between subcutaneous tissue and underlying fascia
123
J Ultrasound
longitudinal homogenous fluid lesion, located between the subcutaneous tissue and muscle (Morel-Lavalle´e lesion) (Fig. 2). Magnetic resonance imaging of the lesion (Fig. 3)
Fig. 2 Morel-Lavalle´e lesion. Extended field-of-view sonograms a, b shows a fusiform homogeneous anechoic fluid collection (arrows) with smooth margins, located between subcutaneous tissue and muscle
subcutaneous tissue and the underlying muscle. A conservative approach to treatment was preferred. After 3 months of simple resting of the knee, no significant effusion could be appreciated on sonographic examination. The patient is currently asymptomatic. Morel-Lavalle´e lesions [1] are rare but should be suspected in high inertia trauma of the knee, commonly developing secondarily to blunt trauma separation of subcutaneous tissue from the underlying fascia. The diagnosis remains primarily a clinical diagnosis [2], but there is a wide range of differential diagnoses, including hematomas, abscesses, bursitis, fat necrosis, and neoplasms; particularly, the clinical presentation of a posttraumatic hematoma and an acute Morel-Lavalle´e lesion are similar. Ultrasound and MRI must be used to confirm the diagnosis [2, 4] and for the differential diagnosis. The sonographic and magnetic resonance imaging characteristics of Morel-Lavalle´e lesions are variable: lesions less than 1 month of age tend to be heterogeneous and irregularly marginated. When they evolve, they became more regularly marginated and homogeneous, but only the anatomic features are typical: a fluid lesion, located between subcutaneous tissue and muscle [6, 8]. The Morel-Lavalle´e lesion has a specific anatomic location and pathophysiological process that make it more prone to complications and chronicity. No clear best management is known, but the options can be narrowed based on location, age, and size of the lesion [2].
Fig. 3 Morel-Lavalle´e lesion. Axial and sagittal proton density fat suppressed images confirm the presence of fluid collection (arrows) with smooth margins, located between subcutaneous tissue and muscle
confirmed, on the medial aspect of the right knee, the presence of a homogenous collection of fluid, between the
123
Conflict of interest interest to disclose.
All authors confirm that they have no conflict of
J Ultrasound Ethical standard All human and animal studies have been approved by the appropriate ethics committee and have therefore been performed in accordance with the ethical standards laid down in the Helsinki Declaration of 1975 and its late amendments.
References 1. Morel-Lavalle´e M (1863) Decollements traumatiques de la peau et des couches sousjacentes. Arch Gen Med 1:20–38, 172–200, 300–332 2. Turner CJ, Van Lancker H (2014) A prepatellar Morel-Lavalle´e lesion in a pedestrian vs automobile collision. Am J Emerg Med 32(1):109. doi:10.1016/j.ajem.2013.08.023 e3-4 3. Bianchi S, Martinoli C (2007) Ultrasound of the musculoskeletal system. Springer, Berlin, pp 677–678 4. Goodman BS, Smith MT, Mallempati S, Nuthakki P (2013) A comparison of ultrasound and magnetic resonance imaging findings of a Morel-Lavalle´e lesion of the knee. PM R 5(1): 70–73 5. Draghi F, Bianchi S, Gervasio A, Fachinetti C, Gaignot C, De Gautard R (2006) L’ecografia nella valutazione della patologia traumatica del polso e della mano. J Ultrasound 9(3):218–226
6. van Gennip S, van Bokhoven SC, van den Eede E (2012 ) Pain at the knee: the Morel-Lavalle´e lesion, a case series. Clin J Sport Med 22(2):163–166 7. Robinson P, Farrant JM, Bourke G, Merchant W, McKie S, Horgan KJ (2008) Ultrasound and MRI findings in appendicular and truncal fat necrosis. Skeletal Radiol 37(3):217–224 8. Neal C, Jacobson JA, Brandon C, Kalume-Brigido M, Morag Y, Girish G (2008) Sonography of Morel-Lavallee lesions. J Ultrasound Med 27(7):1077–1081 9. Borrero CG, Maxwell N, Kavanagh E (2008) MRI findings of prepatellar Morel-Lavalle´e effusions. Skeletal Radiol 37(5):451–455 10. Draghi F, Danesino GM, Coscia D, Precerutti M, Pagani C (2008) Overload syndromes of the knee in adolescents: sonographic findings. J Ultrasound 11(4):151–157 11. Nair AV, Nazar P, Sekhar R, Ramachandran P, Moorthy S (2014) Morel-Lavalle´e lesion: a closed degloving injury that requires real attention. Indian J Radiol Imaging 24(3):288–290 12. Nickerson TP, Zielinski MD, Jenkins DH, Schiller HJ (2014) The Mayo clinic experience with Morel-Lavalle´e lesions: establishment of a practice management guideline. J Trauma Acute Care Surg 76(2):493–497 13. Draghi F, Robotti G, Jacob D, Bianchi S (2010) Interventional musculoskeletal ultrasonography: precautions and contraindications. J Ultrasound 13(3):126–133
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