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© 2023 THE AUTHORS. ORTHOPAEDIC SURGERY PUBLISHED BY TIANJIN HOSPITAL AND JOHN WILEY & SONS AUSTRALIA, LTD.

REVIEW ARTICLE

The Morel-Lavallée Lesion: Review and Update

on Diagnosis and Management
Yun Yang, MD1 Ting-ting Tang, MMed2,3
1
Department of Orthopaedics, The Third People’s Hospital of Chengdu and 2Department of Orthopaedics, West China Hospital and 3School of
Nursing, West China Hospital, Sichuan University, Chengdu, China

Morel-Lavallée lesion is a closed soft tissue degloving injury usually associated with high-velocity trauma. It most com-
monly occurs in the thigh, hip, and pelvis. Because such lesions are prone to a missed or delayed diagnosis, it may
present a potential risk of infection at the fracture site once it progresses. Therefore, timely identification and manage-
ment of Morel-Lavallée lesion is crucial. Moreover, there are no relevant guidelines for the treatment of Morel-Lavallée
lesion. Based on the above facts, we reviewed the etiology, epidemiology, pathophysiology, clinical presentation, imag-
ing features, treatment, prognosis, and complications of Morel-Lavallée lesion with the aim of providing a comprehen-
sive overview of Morel-Lavallée lesion, increasing awareness of this injury among orthopaedic surgeons, and thus
providing a management algorithm that can be applied to this injury.
Key words: Closed Degloving Injury; Diagnosis; Management; Morel-Lavallée Lesion; Shearing Force

Introduction Because Morel-Lavallée lesion is often combined with

M orel-Lavallée lesion was first described by a French

physician named Maurice Morel-Lavallee in 1863 as a
closed traumatic soft-tissue degloving injury.1 The lesion is
multiple severe injuries, the severity of the multiple injuries
distracts the orthopaedic surgeon from Morel-Lavallée lesion.
Once the diagnosis of the lesion is delayed or missed, it can
characterized by the separation of the deep fascia from the lead to increasing difficulty in management and long-term
skin and superficial fascia when a shearing force is applied to morbidity. Therefore, aggressive and effective management
the soft tissue, creating a potential space in which the hemo- of Morel-Lavallée lesion can play a very significant role in
lymph eventually accumulates.2–4 the treatment of orthopaedic injuries.
As the lesion progresses, it subsequently triggers a chronic
inflammatory response with fibrous encapsulation forming a cys- Methods
tic lesion.3 Thus the acute phase shows fluctuating swelling at
the site of injury. The chronic phase presents as a cystic or con-
fined effusion in the soft tissue. Some literature refers to this
P ubMed was searched using the terms “Morel-Lavallée
lesion” or “closed degloving injury.” Non-English articles
were not included unless their translations were available.
chronic lesion as Morel-Lavallée seroma, post-traumatic soft tis- The references of the selected articles were also read to
sue cyst, post-traumatic extravasation, Morel-Lavallée effusion, or screen for additional valuable articles. A total of 68 articles
chronic expanding hematoma.5–7 This lesion is mainly caused by were included in this review (Figure 1).
high-energy violence, mostly in the pelvis and thigh.5 It may also
result from low-velocity crush injury, mostly in the thigh. It has Etiology
also been reported in the literature that this lesion is associated The most common causes of Morel-Lavallée lesion include
with some contact sports, such as football.8,9 The most common high-velocity trauma, crush injuries, and blunt trauma.10 It
mechanism of injury was a shearing blow on the playing surface, occurs most frequently in the greater trochanteric region,11
most commonly occurring in the knee.8 which is associated with the prominence of this region, the

Address for correspondence Yun Yang, Department of Orthopaedics, The Third People’s Hospital of Chengdu, Sichuan, China. Email:
[email protected]
Yun Yang and Ting-ting Tang contributed equally to this study.
Received 20 March 2023; accepted 19 June 2023

Orthopaedic Surgery 2023;15:2485–2491 • DOI: 10.1111/os.13826

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in
any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
 17577861, 2023, 10, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/os.13826 by Cochrane Mexico, Wiley Online Library on [11/02/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
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FIGURE 1 A flow diagram illustrating the process of including and excluding articles.

large relative surface area, the high mobility of the skin, and of vessels disrupted.2,3,8,10,19 In addition, the inflammatory and
the dense capillary network within the soft tissue of the metabolic products contained in such collections enhance cell
proximal thigh and gluteal region.12,13 Other less common permeability and further increase leakage.13 As the effusion
sites of involvement include gluteal region, scapular region, progresses, the blood is mostly reabsorbed and replaced by
lumbosacral region, abdominal area, calf/lower leg and serosanguinous fluid.20 When the lesion is not treated in the
head.14 This lesion has also been reported to occur in ath- acute phase, there is usually an inflammatory response
letes with direct-blow sports injuries to the knee8; It can followed by the formation of a peripheral fibrous capsule.5,20–22
occur rarely in abdominoplasty and liposuction.15 Morel-Lavallée lesion is closely associated with orthopae-
dic injuries because its presence may increase the risk of periop-
erative infection. Hak et al. reported a 46% incidence of
Epidemiology
positive bacterial cultures for Morel-Lavallée lesion (11 of
Morel-Lavallée lesion is often combined with some high-
24 cases), and the incidence was not dependent on the time
energy violence-induced fractures occurring simultaneously,
from injury to debridement.23 Suzuki et al. reported that the
such as proximal femoral, pelvic, and acetabular fractures. Let- presence of Morel-Lavallée lesion was an independent signifi-
ournel and Judet reported the incidence of such lesion in ace- cant risk factor for postoperative surgical site infection after pel-
tabular fractures to be about 8.3%.4,11,16 A large review found vic and acetabular surgery.24 Another study came to the
that the incidence was twice as high in males as in females,17
opposite result that the presence of Morel-Lavallée lesion did
which may be related to the predominance of males in poly-
not increase the risk of deep wound infection after pelvic
trauma. However, the lesion is often undiagnosed or delayed
and/or acetabular surgery.25 Therefore, prospective studies with
in diagnosis, so its true prevalence may be underestimated. larger sample sizes are needed to assess whether this lesion
increases the risk of perioperative infection in orthopaedic inju-
Pathophysiology ries. However, there is no denying that orthopaedic surgeons
Under the action of shearing force, the underlying fascial layers must consider this soft tissue lesion when dealing with frac-
and the superficial subcutaneous tissues move relative to each tures, especially when it interferes with the surgical approach.
other, which in turn creates a cavity in the pre-fascial
plane.2,10,18 As a result of the separation of these layers, trans-
aponeurotic capillaries and lymphatic vessels are Clinical Presentation
disrupted.3,6,11,18 These avulsed channels leak lymph and blood Morel-Lavallée lesion typically presents within hours to days
into the newly formed cavity.2,3,8,10,18,19 A collection of blood, after the inciting trauma; however, up to one-third of cases
lymph, and necrotic fat ensues. The rate at which this collec- present months to years later.11,23,26 Its clinical presentation
tion forms depends on the flow into the cavity and the number is related to a variety of factors, such as the degree and rate
 17577861, 2023, 10, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/os.13826 by Cochrane Mexico, Wiley Online Library on [11/02/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
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of intraluminal hemolymphatic accumulation, and the resonance imaging (MRI) is considered the preferred modal-
patient’s body habitus.13 This presentation varies widely, ity to describe the effusion and to determine the type and
from obvious edema, ecchymosis, or abrasions, to the chronicity of the lesion. It can define various parameters of
absence of any external signs. the lesion including size, shape, contents, and its chronicity.
Patients in the acute phase may present with pain, skin The chronicity and the contents of the lesion determine the
ecchymosis, and soft tissue swelling.13 Physical examination appearance of the lesion. One study found that if the lesion
suggests fluctuating lesion site (Video S1) or skin hyper- was acute, it presented heterogeneously and irregularly. In
mobility. Early diagnosis may not be recognized because dis- the case of chronic lesion, it appeared homogeneous and
coloration of the skin surface may be delayed for several smooth. The capsule was usually present and exhibited
days. Sometimes the accumulation of bleeding from the fibrous tissue with a hypointense ring of haemosiderin.3,10 In
lesion may be significant and the patients present with addition, the age of the blood within Morel-Lavallée lesion is
hypovolemic shock27 and in severe cases, secondary skin an important factor in determining its MRI presentation.21,32
compression necrosis may occur28 (Figure 2A, B). Patients In the acute to subacute phase, it shows high T2 signal and
may also experience decreased cutaneous sensation due to low T1 signal due to fluid/lymphatic accumulation. If there
shearing damage to the cutaneous nerves.29 Due to the high- are blood products in the effusion, MRI presentation may
energy nature of this injury, it often occurs in conjunction show heterogeneity. Over time, the hematoma aggregates
with certain fractures, such as proximal femoral, pelvic, and and deoxyhemoglobin is converted into methemoglobin,
acetabular fractures. The most common lesion is on the which shows hyperintensity on T1WI.21,22 Mellado and
greater trochanter of the femur. The lesion is usually unilat- Bercandino classified the lesion into six categories based on
eral or may be bilateral.3,6,23,30 Other areas such as the lum- its shape, MRI features, and the presence or absence of a
bar, prepatellar, scapular, buttock, and trunk have also been capsule.21 However, the framework does not provide guid-
reported.3,6,8 The common site of occurrence of Morel- ance on the treatment or potential outcome of each cate-
Lavallée lesion differs in adults and children. In adults, it gory.17 Shen et al. suggested classifying the lesion as acute or
occurs more often in the hip and thigh, whereas in children chronic based on the presence or absence of a capsule, which
it occurs more often in the knee and distal lower extremity.31 can help predict the best treatment strategy and expected
As time progresses, this lesion may also develop sec- potential outcome.17
ondary infection, manifesting as soft tissue cellulitis or local- Compared to MRI, ultrasound is of relatively limited
ized abscesses. Patients in the chronic phase present with value. It can support the clinical suspicion by confirming the
pain and tightness in the area of the lesion. Imaging suggests location of the lesion.3,6 It can also show the compressibility
a cyst or mass,4 which needs to be differentiated from other of the lesion and rule out the presence of flow by Doppler
soft tissue diagnoses, such as tumors. imaging.10 On ultrasound, Morel-Lavallée lesion mainly
appear as nonspecific fluid collections.33–37 In the acute and
Imaging Features subacute (<1 month) phase, the lesion has a heterogeneous
Imaging is an important adjunct used for diagnosis when appearance with irregular, lobulated margins, whereas in the
Morel-Lavallée lesion is suspected. Although radiographs chronic (>18 months) phase, it becomes homogeneous with
and ultrasound can show Morel-Lavallée lesion, magnetic smooth, flat, or fusiform margins.35 Because ultrasound is

A B

FIGURE 2 Image showing a female patient with a pelvic fracture combined with Morel-Lavallée lesion with secondary skin necrosis of the gluteal
region and right greater trochanter region. (A) Skin necrosis of both gluteal region was observed 3 days after the car accident, with the right side
being the most severe. At this time, negative pressure drainage was performed in the left greater trochanteric region. (B) The skin necrosis was
further aggravated 5 days after the injury, with clear boundaries.
 17577861, 2023, 10, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/os.13826 by Cochrane Mexico, Wiley Online Library on [11/02/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
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not specific, it should be differentiated from other types of be used as a pathway for the injection of sclerosing agents.
lesions such as tumors, hematomas, abscesses, and fat In chronic Morel-Lavallée lesions with well-developed
necrosis.11 pseudocapsules, the recurrence rate is also high after aspira-
Computed tomography (CT) can do little to improve tion and compression bandaging.17,40,45,46 Sometimes a com-
the differential diagnosis, except to confirm the presence of a bination of sclerosing agents is required to successfully
fluid collection.3,6 One study reported 25% of Morel-Lavallée eliminate the lesions.19
lesions were not mentioned in CT findings.38 Nevertheless,
in the emergent setting or when MRI is not readily available Sclerodesis
(e.g., multiple injuries), CT may be the first modality to eval- Sclerosing agents are widely used in persistent pericardial
uate these lesions. Contrast-enhanced CT may show extrava- effusion and malignant pleural effusion by closing the patho-
sation of blood in the closed space in the acute phase, or a logical cavity. Their main mechanism of action is to destroy
fluid collection with a lower density than simple hematoma the cells surrounding the lesion, inducing inflammation and
in the subacute phase.26,38 fibrosis, which in turn promotes the apposition of the cavity
walls and prevents the recurrence of fluid accumulation.47
Management For Morel-Lavallée lesions that have failed percutaneous
The treatment for Morel-Lavallée lesion is related to a variety aspiration, sclerosing agents are often used to close off dead
of factors, such as the lesion size, the stage, the severity, and cavities.8,14 The efficiency of sclerotherapy for Morel-Lavallée
the proximity to the surgical incision expected for a lesions has been reported to be 95.7%.17 The sclerosing
coexisting fracture. At present, there are no guidelines for agents that have been reported to be used include doxycy-
the management of Morel-Lavallée lesion. Although many cline, erythromycin, bleomycin, vancomycin, absolute etha-
studies have reported the efficacy of various treatment regi- nol, tetracycline, and talc.4,8,10,17,19,47–50 Singh et al.
mens, such as conservative treatment, percutaneous aspira- recommend talc as first-line treatment for acute lesions or
tion, sclerodesis, minimally invasive surgery, and open chronic lesions with a volume of up to 400 mL.4 Reported
surgery, the methods of the aforementioned studies lack complications include infection, mild post-procedural pain,
high-quality evidence due to the small number of cases tight sensation, and induration of the skin.8,19,50
included in the study, and more prospective cohort studies
with a large sample size are needed to confirm the reliability Minimally Invasive Surgery
of the findings. The ultimate goal of treating Morel-Lavallée lesion is to close
the dead space within the lesion.14,17 If the overlying skin is
Conservative Treatment viable, a variety of minimally invasive approaches can be
For the small, acute Morel-Lavallée lesion without a capsule, used to eliminate the dead space. The traditional method is
non-surgical treatment, such as compression bandaging irrigation and drainage through one or more limited small
alone, may be used.3,8,17 However, this approach carries a incisions.28,51 It has also been reported that progressive ten-
risk of recurrence and often requires further intervention.17 sion sutures, quilting, fibrin sealant, and low suction drains
When the lesion is chronic or large, or in an area that is not can successfully achieve the above goal.14,17,18,49,52–57 Kalaria
suitable for compression bandaging, such as above the et al. successfully applied liposuction cannulas to destroy the
greater trochanter, non-surgical treatment is rarely cavity of the lesion.58 Li et al. successfully applied a mini-
effective.17 mally invasive incision in combination with loop drainage
technique to treat Morel-Lavallée lesion of the lower extrem-
Percutaneous Aspiration ity and named this technique as nose ring drainage
In the management of Morel-Lavallée lesions, percutaneous technique.59
aspiration has proven to be effective in the eradication of Video-assisted endoscopic debridement is another rela-
dead space. It is indicated for some small lesions. It is some- tively minimally invasive technique.60–62 It has the advantage
times used as an adjunct in combination with compression of removing the lesion under direct visualization and reduc-
bandaging.39 However, the recurrence rate of these lesions ing the risk of nerve and vascular injury.61 Liu et al. managed
was high with percutaneous aspiration alone.8,17,40 Com- Morel-Lavallée lesion by endoscopic debridement combined
pared to open surgery, this approach was more prone to with percutaneous cutaneo-fascial suturing.61 This approach
recurrence, especially for the lesions larger than 50 mL in helped to close the dead space directly and reduce the recur-
volume.40 Therefore, percutaneous aspiration alone is often rence rate. This endoscopic debridement technique is
inappropriate for large lesions that are expected to require expected to replace open surgery and may be suitable for
multiple aspirations. those patients who require rapid recovery.
Aspiration is usually performed under ultrasound or
CT guidance.39,41–44 Depending on the size of the lesion, one Open Surgery
or several drainage tubes may be placed to continuously In the acute phase, if overlying skin is necrotic, complete
drain the fluid from the lesion. The drainage tubes can be removal of the necrotic tissue is often required13 (Figure 3).
connected to the negative pressure drainage system or can In cases of massive soft tissue defects, skin grafts or flap
 17577861, 2023, 10, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/os.13826 by Cochrane Mexico, Wiley Online Library on [11/02/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
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aspiration of more than 50 mL of fluid from Morel-Lavallée

lesion was more likely to recur and recommended surgical
treatment for this type of lesion.40

Complications
Complications of Morel-Lavallée lesion are often the result
of delayed recognition or incorrect diagnosis. The most com-
mon complications are skin necrosis and secondary infec-
tion. If this lesion is not treated promptly or improperly, it
can cause pressure necrosis of overlying skin,3,6,17 which ulti-
mately leaves underlying fractures exposed. Infection is the
main problem in such lesion and it complicates the manage-
ment of the lesion. Bacteria enter the lesion unintentionally
through soft tissue trauma, hematologic seeding, or handling
of the lesion.4,14,17,23,49 Published data on whether bacterial
colonization of the lesion occurs is inconclusive. Some stud-
ies found a high rate of positive infection in this lesion,17,23
which was in contrast to several smaller case series that
reported negative fluid cultures in all cases after aspiration.19
The current consensus among pelvic surgeons is that there is
a high risk of deep infection if the approach to fracture fixa-
tion traverses the lesion. Therefore, culture-directed antibi-
otic therapy remains necessary.
Recurrence is common after initial treatment of Morel-
Lavallée lesion. Published recurrence rates range from 0% to
75%.17,19,40 Due to the variability of published data, it is diffi-
cult to determine the true recurrence rates.
Contour deformity is a complication after chemical
sclerotherapy. Bansal et al. suggested that the occurrence of
FIGURE 3 Intraoperative photograph showing formal open debridement this complication was associated with collapse of dead space
of the Morel-Lavallée lesion that involved the patient’s bilateral gluteal and alteration of fibrous and fatty tissue within the cavity.
region and right greater trochanteric region. Therefore, patients should be fully informed of this possible
risk when using sclerotherapy for such lesions.19

transfers may be required.63–68 In chronic lesions, conven- Prognosis

tional means, such as compression bandaging, aspiration, Morel-Lavallée lesion is related to a variety of factors, such
and/or injection of sclerosing agents, are prone to recurrence as the size of the lesion, the presence of complications, the
after treatment due to the presence of pseudocapsule.46 Open stage of the lesion (acute or chronic), and treatment modal-
surgery is therefore indicated for Morel-Lavallée lesions that ity. If the lesion is small and acute, it can sometimes heal
are large, prone to recurrence, or with heavy overlying soft spontaneously without operation. The larger acute lesion can
tissue compromise. not only cause skin necrosis and secondary infection, but
Early surgical debridement can remove the media of also affect surgical timing and approach for underlying frac-
bacterial colonization, such as effusion and necrotic tissue. tures. When the lesion is chronic, the pseudocapsule pre-
However, open surgery may damage the only remaining sub- vents reabsorption of the contents and may lead to
dermal vascular plexus of superficial tissue, leading to tissue undesirable sequelae.71
necrosis. For lesions with heavy overlying tissue necrosis or This review provides a comprehensive overview of the
the presence of infection, negative pressure wound therapy pathophysiology, clinical features, diagnostic and therapeutic
can be used as an initial treatment for staged surgery. This advances of Morel-Lavallée lesion to provide clinicians with
treatment reduces the dead space, decreases infection, and a reference for better treatment of the lesion. Nevertheless,
promotes vascular ingrowth in the wound.40,65,68–70 Shen the review has some limitations, such as some low-quality
et al. retrospectively analyzed 21 articles detailing 153 patients studies, small patient groups, and heterogeneity of the study
with peri-pelvic Morel-Lavallée lesion and concluded that population. In addition, there is no further inductive analysis
surgical treatment was superior to conservative treatment.17 of the various treatment methods. Future studies should
A retrospective study found that the overall recurrence rate focus on prospective randomized controlled studies with
was lower in the surgical group than in the percutaneous large sample sizes to better determine the therapeutic effects
aspiration group and non-surgical group. In addition, of different treatments.
 17577861, 2023, 10, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/os.13826 by Cochrane Mexico, Wiley Online Library on [11/02/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
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Conclusion Author Contributions

Morel-Lavallée lesion is a closed soft tissue degloving injury
caused by high-energy violence, usually associated with
underlying fractures of the pelvis, acetabulum, or proximal
Y un Yang and Ting-ting Tang wrote the draft of the
manuscript. Yun Yang and Ting-ting Tang were major
contributors to study design and revision, and Yun Yang
femur. Early identification of the lesion is critical as it may critically reviewed and revised the manuscript for important
constitute an independent risk factor for surgical site infec- intellectual content. Yun Yang and Ting-ting Tang was
tion. Clinical manifestations include soft tissue swelling, involved in collecting data and design of the study. All
bruise/ecchymosis, fluctuating swelling, and compressibility. authors approved the final manuscript and agree to be
Diagnosis is usually determined by an adequate history- accountable for all aspects of the work.
taking and a thorough physical examination. However, imag-
ing including ultrasound, CT scan, and MRI can provide Conflict of Interest Statement
detailed information about the lesion. Therapeutic decisions
should be based on clinical symptoms, lesion size, stage,
location, severity, infection, and proximity to the expected
T he authors declare that they have no conflict of interest.

Ethical Review Committee Statement

E
surgical site. The core of treatment is the elimination of dead ach author certifies that his or her institution approved
space and minimization of hematologic destruction of the the human protocol for this investigation, that all inves-
lesion. The management options include conservative treat- tigations were conducted in conformity with ethical princi-
ment, percutaneous aspiration, sclerodesis, minimally invasive ples of research.
surgery, and open debridement. Among them, minimally
invasive surgery shows a greater therapeutic prospect due to Informed Consent Statement

W
its unique advantages. Orthopaedic surgeons should be fully ritten informed consent was obtained from the patient
aware of the advantages and disadvantages of various treat- for the case images in this review.
ments to reduce related complications. At the same time,
communication and cooperation with other disciplines, such
Supporting Information
as plastic surgery, wound care, and rehabilitation, may help
Additional Supporting Information may be found in the
improve the prognosis of patients.
online version of this article on the publisher’s web-site:
Acknowledgment Video S1. Obvious fluctuation sensation was observed on

W e would like to thank Jia-yue Yang for providing inspi-

ration and motivation for this article.
Morel-Lavallée lesion on physical examination due to large
amount of effusion.

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