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Fırat Üniversitesi Sağlık Bilimleri Tıp Dergisi | |||||
2013, Cilt 27, Sayı 2, Sayfa(lar) 101-103 | |||||
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Tehşisi Atlanmış, Beraberinde Kırık Bulunmayan Morel-Lavallee Lezyonunun Aşırı Kilolu Hastada Tedavisi: Olgu Sunumu | |||||
Deniz CANKAYA, Bülent OZKURT, Yalçın TABAK | |||||
Ankara Numune Eğitim ve Arastırma Hastanesi, Ortopedi ve Travmatoloji Kliniği Ankara, TÜRKİYE | |||||
Anahtar Kelimeler: Morel-Lavallee lezyonu, obez, kırık olmayan | |||||
Özet | |||||
Morel-Lavallee lezyonu, acil serviste sık görülmeyen bir vakadır. Pelvik veya asetabular kırığın
eşlik etmediği Morel-Lavallee lezyonu ise oldukça enderdir. Pelvik ve asetabular kırığın eşlik
etmediği, obez bir hastada görülen yanlış teşhis edilmiş Morel-Lavallee lezyonu vaka örneği
olarak sunulmuştur. |
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Giriş | |||||
Significant soft tissue injury associated with a pelvic trauma in which subcutaneous
tissue is torn away from underlying fascia, creating cavity filled with hematoma and
liquefield fat is termed as closed degloving injury1. Morel-Lavalle´e described this
lesion for the first time in the 1800s. Subsequently, Letournel and Judet used the term
of Morel-Lavalle´e Lesion (MLL) as closed degloving injuries over the region of the
greater trochanter as associated with pelvic and acetabular fractures2. However,
MLL may occur in the thigh without any fracture in occasional instance. The presence
of MLL initially may be missed in up to one third of cases and may be detected months
or years after trauma3. We report an obese patient with misdiagnosed MLL in the
thigh without any concomitant pelvic or acetebular fracture. |
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Olgu Sunusu | |||||
A 41-years-old obese male patient suffered pelvic and hip injuries in a motor
vehicle crash and was taken to the emergency department of the local hospital. He
had right hip and thigh tenderness without any ecchymosis initially. In his plain
radiographs, there was no pelvic ring and acetabular fractures. He was diagnosed as
simple soft tissue trauma and discharged from emergency department without any
additional medical intervention. Two days after trauma, a fluctuating swelling appeared
in his right thigh and percutaneous drainage with needle was done and compression
therapy was applied in the outpatient department. Within two months after trauma,
serial percutaneous drainages were done for five times and every aspiration made
lesion larger. No medication was prescribed to him during this period. He applied to our hospital after treatment of nonresponsive serial aspirations. His height was 167 cm and his weight was 102 kg. He was an obese patient with body mass index of 36.57 kg/m2. He had no medical history and was not diabetic. In his plain radiographs, there were no pelvic ring and acetabular fractures (Figure 1). A Morel-Lavalle´e lesion was noted in his right lateral thigh from gluteal region to middle of the thigh with large anteroposterior extension. Physical examination revealed fluctuant mass without an ecchymosis and laceration. Laboratory values were in normal range.
Under spinal anaesthesia and in supine position, surgical drainage was accomplished by making 3 cm incision over the posterior edge of the lesion. About 1200 mL fluid was drained and lesion was irrigated with 5000 mL saline solution. A suction drain was placed and elastic bandage was applied tightly. Treatment of routine antibiotic prophylaxis was given (intravenous cephazolin 1 g /8 hour). His intraoperative culture was reported positive with E.Coli. The suction drain was removed 2 weeks after surgery when the drainage was less than 50 ml in twenty-four hours period. Antibiotic treatment was given additional two weeks after removal of drain. Patient had no complaint in his control four weeks after surgical treatment (Figure 2). Three months after surgery, patient was discharged from regular follow-up without any complain and complication.
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Tartışma | |||||
Morel-Lavalle´e lesion is not a frequent lesion in
orthopaedic trauma and there is no firm consensus on
initial management and treatment methods in the
literature 2. Due to the fact that it is a not frequently
seen lesion and bruising which is the most obvious sign
generally takes several days to develop, many lesions
may be easily missed on initial evaluation and misdiagnosed as simple soft tissue trauma by the
emergency doctor4. Beside the infrequency of the
Morel-Lavalle´e lesion, our case is interesting and
important with its additional features leading to
misdiagnosis of this lesion. First of all, it is an uncommon
example of Morel-Lavalle´e lesions of thigh without any
pelvic and acetabular fracture resulting from a highenergy
trauma. Due to the traditional description of
Morel-Lavalle´e lesion and its very low frequency, pelvic
injuries without any concomitant fracture may lead to
misdiagnose the Morel-Lavalle´e lesion. We want to draw
attention to the importance of meticulous examination of
patient in terms of Morel-Lavalle´e lesion and danger of
ruling out the Morel-Lavalle´e lesion by only confirming
the absence of fracture after pelvic injury. In suspicious
cases, MRI is the reliable diagnostic imaging modality of
choice in the evaluation of Morel-Lavallee lesions and
correct preoperative MRI diagnosis of MLL can be useful
for treatment algorithm3. Secondly, this case does not only show the difficulty in recognizing this lesion in obese patients when there is no concomitant fracture, but also shows us how obesity may chance our treatment method in Morel-Lavalle´e lesion. Initial management and treatment of MLL are still debated. In our case, conservative treatment with serial aspiration was done in the local hospital and treatment choice caused enlargement of lesion. Although the study with five patients concluded that MLL could be treated conservatively5, patients in this study were not obese and missed during their initial application to the emergency department. ‘'Review article of the literature suggested that MLL was more amenable for conservative treatment when it was diagnosed earlier6.‘' As obese patients are more vulnerable to degloving injuries due to their longer course of subcutaneous tissue, conservative management may make Morel- Lavalle´e lesion worse in obese patients. The present case is suggested to avoid conservative treatment in obese patients. Regarding to the aggressive surgical approach, possible post-operative soft tissue problems must be mentioned especially in obese patients. Extension of the body mass index is directly related to increase in hospital lengths of stay and obese patients require longer period of treatment in case of multi-organ disorder7. Due to the possible local and systemic disorders mentioned above, we suggested to avoid extensive surgical approach in the present case. We applied drainage from small incision in the posterior edge of the lesion and patient recovered without any additional problem after three months. We recommend applying drainage from small incision instead of conservative management or aggressive surgical approach for late diagnosed MLL in obese patients. |
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Kaynaklar | |||||
1) Hak DJ, Olson SA, Matta JM. Diagnosis and management
of closed internal degloving injuries associated with pelvic
and acetabular fractures: the Morel-Lavalle´e lesion. J
Trauma 1997; 42:1046-1051.
2) Phillips TJ, Jeffcote B, Collopy D. Bilateral Morel-Lavallée
lesions after complex pelvic trauma: A case report. J
Trauma 2008; 65: 708-711.
3) Mellado JM, Bencardino JT. Morel-Lavallée lesion: Review
with emphasis on MR imaging. Magn Reson Imaging Clin
N Am 2005; 13: 775-782.
4) Tseng S, Tornetta P. Percutaneous management of Morel-
Lavallee lesions. J Bone Joint Surg Am 2006; 88: 92-96.
5) Harma A, Inan M, Ertem K. The Morel-Lavallée lesion: A
conservative approach to closed degloving injuries. [Article
in Turkish] Acta Orthop Traumatol Turc 2004; 38: 270-273.
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