Case Report

Closed internal degloving injury with conservative treatment

Abstract

In the emergency department, we frequently manage patients with multiple contusions and bruise over the trunk without severe injuries. Emergency department discharge is a common option for these patients, and we may neglect the existence of closed internal degloving injury, which is a soft tissue injury with pelvic trauma, combining the subcutaneous tissue torn away from the underlying fascia followed by a cavity being filled with hematoma and liquefied fat created in the next few days (Harefuah 2006;145:111-3:66, J Trauma 1997;42:1046). We report the unusual occurrence of this entity in an 18-year-old man. He encountered a scooter accident and experienced a few days of hospitalization because of thoracispinal (T10 and T11) process fracture. He was discharged, but a fluctuating mass developed at the lumbar area 10 days later. The comprehensive survey excluded the cerebrospinal fluid leakage associated with spinal fracture, and internal degloving injury was diagnosed. percutaneous drainage with compressive bondage was aggressively used. Even though the treatment course was time consuming, the lesion eventually disappeared 10 months after his First visit.

An 18-year-old man presented to the emergency department (ED) complaining of a protruded and fluctuating mass over the lumbar area. The mass was associated with increasing swelling in that region over the previous 2 days. The patient otherwise denied having any systemic symptoms, such as fevers, chills, nausea, or vomiting. His medical history was significant for a recent admission to the hospital after an accident with a motor vehicle approximately 10 days before. He had been riding his motorcycle and fell off, sustaining back contusions with the suspicion of T10 and T11 spinal process bone disruption. He was discharged from the hospital 2 days after this first admittance and had been doing relatively well, with adequate pain control for T-Spinal fractures. A visible fluid collection was observed in the proximal-lateral aspect of his right and left thighs. The fluid seemed to track up around the gluteus maximus muscle and to the lumbosacral region, with slight crossing of the midline to the left (Fig. 1). The aspirated fluid appeared to be a free-flowing low-viscosity collection.

Laboratory tests disclosed no infective process or cerebrosp- inal fluid content. No loculation was noted on palpation, and the patient had no thickening or induration of the skin overlying and surrounding the area.

The patient underwent computed tomography of the pelvis, which demonstrated evidence of a large subcuta- neous 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 (Fig. 2). The fluid collection was not present on a previous computed tomography scan obtained 2 weeks earlier, at the time of the motor vehicle collision. External drainage was per- formed with placement of a subcutaneous catheter. bed rest and limited torso movement were encouraged. An abdom- inal compressive bondage with focal strength over the lesion was also applied.

The fluid collection disappeared 2 weeks later, and he was discharged without infection or necrosis of the skin. He received regular following up at our outpatient clinic, and the mass recurred with more limited extent compared with his initial episode. Frequent echo-guided aspiration procedures and compressive dressing coverage were performed. The fluctuating mass gradually decreased in size at each visit. After 10 months of drainage, the fluid collection was totally resolved (Fig. 3).

Fig. 1 The fluid tracks up around the Gluteus maximus muscle and to the lumbosacral region (small arrow), with slight crossing of the midline to both sides (long arrow).

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254.e6 Case Report

When closed internal degloving occurs over the greater trochanter, it is known as a Morel-Lavallee lesion. A PubMed literature search did not find consensus about how to treat this kind of injury because there are still no prospective comparisons of the different therapeutic techniques.

The management of degloving injuries of the pelvis remains one of the most troublesome clinical problems in trauma dehiscence [1]. High incidence of deep bone and soft tissue infections causing serious disability is the major concern in these patients. Choice of closed or extensive open approach, timing of debridement, modality of pelvic fixation, as well as the type of soft tissue reconstruction have all been critical to prevent such morbidity [2,3].

Various methods have been suggested for the treatment of these degloved areas, including aspiration, injection of sclerosing agents such as tetracycline, deep fascial fenestra- tion, compression dressings, and prolonged closed surgical drainage [3,4].

Most articles suggest surgical management. However, Tsur et al [5] treated 2 of their patients successfully by puncture drainage and pressure therapy, although their initial treatment of external drainage failed. In our patient’s case, echo-guided percutaneous aspiration had been performed in an outpatient setting several times within his follow-up period. The application of compressive bondage to minimize the potential space was also used. His fluctuating mass decreased in size at each visit. After 10 months of treatment, the patient completely recovered from his condition. The fracture of the bone with extravasation of blood may have been the cause of hematoma accumulation. However, not all patients need fixation of the bone and debridement of the wound, so 2 different types of closed internal degloving injury should be distinguished: one needing surgery and debridement, and the other not. The patient who has no major

Fig. 2 Computed tomography of the pelvis shows the sub- cutaneous fluid collection (short arrow) 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, and a fracture is also found (long arrow).

Fig. 3 After 10 months of drainage, the fluid accumulation was totally resolved.

bone fracture or Skin necrosis may be treated with drainage instead of debridement.

In the ED, more attention should be paid to the patient with bruising as to whether we may omit this kind of soft tissue injury. Early application of compression devices over injured sites when pelvic or lumbar trauma occurs may reduce the incidence of closed internal degloving injury. Furthermore, even if the entity occurs, aggressive and frequent external drainage is effective in the patient without major bone fracture and tissue necrosis.

Hsing-Lin Lin MD Wei-Che Lee MD Liang-Chi Kuo MD Chao-Wen Chen MD Department of Trauma

Kaohsiung Medical university hospital Kaohsiung Medical University Kaohsiung 807, Taiwan

E-mail address: [email protected] doi:10.1016/j.ajem.2007.05.006

References

1. Sarlak AY, Buluc L, Alc T, et al. Degloving injury of pelvis treated by internal fixation and omental flap reconstruction. J Trauma 2006;61:749-51.
2. 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;42:1046-51.
3. Hudson DA, Knottenbelt JD, Krige JE. Closed degloving injuries: results following conservative surgery. Plast Reconstr Surg 1992;89: 853-5.
4. Kottmeier SA, Wilson SC, Born CT, et al. Surgical management of soft tissue lesions associated with pelvic ring injury. Clin Orthop Relat Res 1996:46-53.
5. Tsur A, Galin A, Kogan L, et al. Morel-Lavallee syndrome after Crush injury. Harefuah 2006;145:111-3, 66.