Bryan Colasacco, OMS 2027¹; Alyssa Cevetello, OMS 2027¹; Janae Rasmussen, DO^2
1Touro College of Osteopathic Medicine – Middletown
²Valley Consortium for Medical Education – Department of Orthopedic Surgery

DOI: http://doi.org/10.70709/rkempsw6k7v

Abstract

Morel-Lavallée lesions (MLLs) are internal degloving injuries caused by shearing forces that separate subcutaneous tissue from the underlying fascia, creating a space for blood and lymphatic fluid to accumulate. MLLs are commonly reported in the hip, thigh, and pelvis, but are much rarer in the upper extremity (UE). The low number of clinical cases and potential for misdiagnosis makes for unique diagnostic and management challenges. This study aimed to review the current literature of UE MLLs and summarize their pathophysiology, clinical presentation, diagnostic criteria, and key management. A literature review was conducted using PubMed and Google Scholar to identify case reports and systematic reviews describing MLLs. Relevant studies were analyzed for clinical relevance, diagnostic methods, treatment modalities, and patient outcomes. There have been under 20 cases of UE MLLs documented in the literature. The variable and sometimes delayed presentation is compounded by concurrent injuries. Common finds are a soft, fluctuant mass with ecchymosis, contour deformity, skin hypermobility, and decreased sensation. Ultrasound is a useful diagnostic tool but the gold standard is magnetic resonance imaging (MRI). Management of MLLs ranges from conservative measures and aspiration to open debridement and suction-assisted lipectomy. MLLs of the UE are uncommon but clinically significant, especially due to the likelihood for secondary complications. Advanced imaging, specifically MRI, is essential for timely and accurate diagnosis. Although the presentation of MLLs in the UE is similar to other parts of the body, quick recognition and individual treatment plans are essential for improved patient outcomes. 

Keywords: morel-lavallée lesion, soft tissue surgery, upper limb, internal degloving

Introduction
Morel-Lavallée lesions (MLLs), also known as closed degloving injuries, are characterized by the separation of subcutaneous tissues from the underlying fascia [1,2]. These injuries are typically seen after traumatic injury due to a shearing force, which results in underlying tissues, such as fascia and subcutaneous adipose tissue, to be pulled in one direction while superficial tissue is pulled in the other [3]. This tissue separation disrupts the microvasculature and lymphatic channels, leading to the accumulation of blood and lymphatic fluid in the resulting cavity [1]. Fluid accumulation between the skin and underlying tissue can lead to tissue ischemia, which can lead to skin necrosis [2]. MLLs can be easily missed as many traumatic injuries, such as fractures, result in soft tissue swelling, making it challenging to differentiate from true soft tissue internal degloving. Radiographic findings, such as increased fluid signals on magnetic resonance imaging (MRI), can be non-specific, especially in the setting of fractures or other soft tissue injuries. Differentiating between a hematoma and MLLs is another clinical challenge. Therefore, discerning MLLs requires a high-index of suspicion considering the mechanism of injury, physical examination, and radiographic findings [4]. Many MLLs are identified if the patient is taken to the operating room for another reason and the soft tissue disruptions are noted intraoperatively or after observation when swelling does not decrease as expected. MLLs can impact any region of the body from the extremities to the trunk with a propensity for the thigh and hip region, especially in the setting of orthopedic-related trauma [2]. As MLLs are a rare finding, their diagnosis can be missed or determined later in their progression, which can potentially lead to consequences such as infection or deformities [5,6]. A significant lapse in time between injury and diagnosis may require surgical treatment, such irrigation and debridement with drain placement, to repair tissue damage [2]. Early diagnosis may prevent unfavorable outcomes that can result from the injury, such as need for soft tissue reconstruction from skin necrosis.

Compared to MLLs of the thigh, hip, and pelvic regions, cases of MLLs in the upper extremity are less frequently documented [4,7-10]. It is imperative to investigate MLLs of the upper extremity as the risk of infection and other sequelae are less common and studied compared to other sites of MLLs [9]. This literature review summarizes current knowledge on MLLs in the upper extremity, focusing on their pathophysiology, clinical presentation, diagnostic approaches, and management strategies.

Methods
A comprehensive search was conducted by researchers using search engines such as “PubMed” and “Google Scholar.” Key words were searched such as “Morel-Lavallée lesions,” “upper extremity,” “degloving,” and “soft tissue shearing.” Articles used for this review dated from 2007 to 2025. The case report review section of this review was limited to upper extremity cases only and excluded papers that discuss areas other than the upper extremity.

Pathophysiology of Upper Extremity Morel-Lavallée lesions
The pathophysiology of Morel-Lavallée lesions (MLLs) in the upper extremity mirrors that of lesions in other anatomical locations. The primary factors are high-energy blunt force trauma or crush injuries [1,4]. Shearing forces cause the separation of the superficial subcutaneous tissues from the deeper fascial layers, creating a potential space for fluid accumulation [1,2]. This disruption of the vascular and lymphatic networks results in the accumulation of blood, lymphatic fluid, and necrotic fat within the created cavity [1,2]. The blood in the cavity is reabsorbed over time, leading to the infiltration of serosanguineous fluid. Ultimately, a fibrous pseudocapsule may form around the fluid collection, leading to a chronic lesion [1,6]. Without placement of a drain or other methods to decrease the potential space for fluid accumulation, this can create a nidus for infection and chronic inflammation. The upper extremity’s anatomy influences the primary locations of MLLs and clinical presentation of MLLs in this region [8]. The shoulder and elbow are the most frequently reported upper extremity regions for MLL cases, with some cases of the forearms as well [12,13]. The uniqueness primarily stems from the paucity of examples in published literature. Vanhegan et al. identified over 204 MLL cases, with over 30% in the hip region, 20% thigh, 18.6% pelvis, and 15.7% knee, but none in the upper extremity [14]. The limited vascular supply in certain areas of the upper extremity may contribute to a higher risk of complications, such as skin necrosis. An example of this are the distal portions of the superficial radial and posterior interosseous nerves, which are supplied partly by the septocutaneous arteries. The possibility of complications increases if a lesion is not promptly diagnosed and treated [8].

Clinical Presentation of Upper Extremity Morel-Lavallée lesions
The clinical presentation of upper extremity Morel-Lavallée lesions (MLLs) is variable and often depends on the mechanism of the injury [8,9]. The location of the lesion within the upper extremity – elbow, shoulder, or forearm – can also affect the specific symptoms experienced by the patient [8-10]. Pain, ranging from mild to severe discomfort, is a common symptom, which varies depending on the size and location of the lesion, and the presence of any associated injuries [8,9]. Diagnosis is often complicated by a delayed presentation that can occur weeks to months after the initial traumatic event [5]. A delayed diagnosis can be secondary to other injuries, like fractures in the location of the Morel-Lavallée lesion (MLL), which are also associated with soft tissue swelling and deformities. 

Acute lesions may present as a soft, fluctuant mass with ecchymosis, contour deformity, skin hypermobility, and decreased sensation [8,9]. In general, MLLs on their own do not cause systemic symptoms in the acute phase [13,15,16]. This can help differentiate from abscesses. Similarly, acute MLLs lack a pseudocapsule such as those seen in hematomas or contusions [17,18,12]. For chronic injuries, the initial signs of trauma, such as ecchymosis and swelling, may have resolved [9]. However, if a pseudocapsule does form, this can serve as a nidus of systemic illness [16,11]. Numerous comorbidities, such as diabetes mellitus, obesity, immunosuppression, and peripheral vascular disease, also increase the risk of developing complications post-MLL [6,12,18]. These conditions prevent proper wound healing, increase risk of infection, and may form seromas. Other factors to consider are patients with coagulopathies or those on anticoagulant therapies since these conditions predispose patients to the development of chronic lesions [6,12,18]. Lastly, patients with poor nutrition or limited mobility will also experience impaired lymphatic drainage and tissue repair [6,12,18]. These compounding factors pose a difficult clinical challenge for physicians. 

Diagnostic Approaches for Upper Extremity Morel-Lavallée lesions
Accurate and timely diagnosis of Morel-Lavallée lesions (MLLs) in the upper extremity is crucial to reduce risk of complications, such as superficial or deep tissue necrosis [5]. An initial diagnostic work-up should focus on obtaining a detailed history of the trauma with mechanism of injury, a thorough physical examination, x-rays or other baseline imaging, and palpation of the affected extremity. Imaging techniques play a critical role in assessing for a Morel-Lavallée lesion (MLL) and other associated injuries, as well as characterizing the extent and chronicity of a MLL [2, 4, 8, 9].

Ultrasound (US) is typically the initial imaging modality used in diagnosing MLLs due to its accessibility and non-invasive nature [5,6]. US can reveal a heterogeneous hypoechoic or anechoic lesion with internal septations and fat globules [5,6]. However, as the lesion progresses, more regular margins are often noted, which can demonstrate formation of a pseudocapsule [6]. The overlap in imaging findings between MLLs and other conditions, such as hematomas and bursitis, can make the differential diagnosis challenging [2, 5]. Additionally, it is important to consider obtaining x-rays in the setting of trauma with soft tissue swelling to ensure no fractures or other acute osseous abnormalities could be present.

Magnetic resonance imaging (MRI) is considered the gold standard for definitive diagnosis and characterization of MLLs [2,4]. MRI provides superior soft-tissue contrast and multiplanar imaging capabilities, enabling detailed visualization of the lesion’s internal structure and relationship to surrounding anatomical structures [2]. MRI can reveal a fluid collection with varying signal intensities that can help elucidate the acute versus chronic nature of a fluid collection [5,6]. Acute lesions may show heterogeneous signal intensity, whereas chronic lesions often appear encapsulated with internal septations and fat globules [5,6]. The presence of fluid-fluid levels on MRI may suggest an infected lesion [6]. Furthermore, MRI can help rule out other diagnoses, such as tumors or abscesses [2]. In general, contrast is not a hard requirement for diagnosis of MLLs since T1-weighted sequences are sufficient for identification and characterization [19,20]. Contrast may be used if a patient presents with a new soft tissue mass, area of fluctuance or infection, or there is uncertainty of the diagnosis, especially without a source of trauma [7,19,20]. It is important to consider prompt MRI with and without contrast to assess for tumors like sarcomas, which can present insidiously. The correlation between US and MRI findings can significantly aid in the diagnostic process [5].

Management of Upper Extremity Morel-Lavallée lesions
Management strategies for upper extremity Morel-Lavallée lesions (MLLs) vary depending on the lesion’s size, acute or chronic state, and the presence of complications (i.e. infection) [1,4]. Failure to treat the lesion can predispose the patient to infections, recurrence, and skin or other soft tissue breakdown as blood supply may be impaired [6]. Several algorithms have been proposed to guide treatment decisions [1,4].

Conservative management, such as compression bandaging, nonsteroidal anti-inflammatory drugs (NSAIDs), and observation, may be appropriate for small, asymptomatic acute lesions [2, 10]. However, this approach is generally not recommended for larger or chronic lesions [4]. Acute lesions are defined as those identified within 3 days of trauma or presentation and chronic lesions as those present for more than 30 days after the initial injury [17]. Lesions are categorized as small (<100 cm³) or large (≥100 cm³) based on the volume measured on imaging [21]. Percutaneous aspiration may be considered for smaller lesions, but it carries a high risk of recurrence if significant fluid volumes (>50 mL) is aspirated [7]. Therefore, percutaneous drainage should ideally be combined with sclerodesis to reduce the likelihood of recurrence [1,4]

Sclerodesis is well reported in the literature as a viable means to prevent Morel-Lavallée lesion (MLL) recurrence [22,23]. The lesion is aspirated then a compound is injected into the site. Sclerotherapy, using agents like doxycycline, ethanol, or talc, is an effective minimally invasive technique for lesions up to 400 mL [1,4]. However, contour deformities have been reported as a potential complication of sclerotherapy. If necessary, surgical measures, such as liposuction, may be taken to amend these deformities [1,11,24].

Surgical intervention, involving open debridement and excision of the pseudocapsule, is often necessary for chronic lesions, large lesions, lesions with infection, or those that fail to respond to conservative or minimally invasive treatments [1,4,9]. Surgical management aims to remove the necrotic tissue, remove fluid collections, and achieve complete lesion resolution [9,11]. It is important to consider obtaining intraoperative biopsies and sending the lesion to pathology to ensure there is no underlying malignancy or other pathology. Surgical debridement, while serving as an effective treatment, can result in damage to vascular supply, such as the subdermal vascular plexus, to surrounding tissue in the area of the lesion [11,12,18]. A closed suction-assisted lipectomy (SAL) system has also been successfully used for the treatment of acute MLLs in the upper extremity [8]. This minimally invasive technique effectively evacuates the hematoma while minimizing tissue trauma, preserving the subdermal plexus, and reducing healing time compared to open debridement [8].

The choice of management strategy should be individualized based on the specific characteristics of the lesion, the patient’s clinical presentation, and the surgeon’s expertise [7]. Early diagnosis and prompt intervention are crucial to prevent complications such as infection, skin necrosis, and the need for more extensive surgical procedures like soft tissue reconstruction [9, 11].

Rare Occurrence in the Upper Extremity: A Review of Case Reports
The rarity of Morel-Lavallée lesions (MLLs) in the upper extremity is consistently highlighted across multiple previous studies [8-10]. The few case reports on this specific presentation underscore this observation, and provide valuable insights into identifying and managing these lesions within the upper extremity.

A case report by Patel et al. details the successful use of a closed suction-assisted lipectomy (SAL) system for treating an acute Morel-Lavallée lesion (MLL) in the upper extremity of a 78-year-old female patient [8]. The authors demonstrate the effectiveness of this minimally invasive approach in evacuating a significant hematoma, resulting in improved clinical outcomes without complications. This case highlights the potential of SAL as an effective treatment option for acute upper extremity MLLs, particularly in patients who may be at higher risk for complications from open surgical procedures [8].

Cochran and Hanna presented a case of a chronic MLL in the upper extremity of a 58-year-old male following a motor vehicle accident [9]. The patient presented with a soft tissue mass in the arm [9]. Diagnosis of an MLL was able to be made after proper history taking uncovered prior trauma [9]. Their report emphasizes the importance of early diagnosis to prevent infection, which is notably higher in untreated cases, and highlights the importance of obtaining a thorough history to reach this diagnosis [9]. Surgical management involving excision of the pseudocapsule and careful closure resulted in successful healing without recurrence. This case underscores the effectiveness of surgical intervention for chronic lesions in the upper extremity [9].

Sulaiman et al. described a case of a 42-year-old male with a post-traumatic elbow mass diagnosed as an MLL [10]. The report revealed an unremarkable physical exam as well as blood tests including CBC and inflammatory markers returning as within normal limits [10]. The authors proceeded to discuss that they resorted to a magnetic resonance imaging (MRI) for diagnosis after an ultrasound (US) was performed [10]. Their report highlights the diagnostic challenges associated with MLLs in the upper extremity, emphasizing the importance of MRI for accurate diagnosis and characterization [10].

Gross et al. presented one of the earliest reported cases of an MLL in the elbow. This report emphasized the importance of US and MRI in diagnosing these lesions and that radiographs provide nonspecific findings [5]. Their study provides valuable imaging characteristics of MLLs in the elbow. US revealed increased echogenicity of lobules with areas of complex lower echogenicity. Unenhanced MRI demonstrated a T2 hyperintense collection of numerous fat globules overlying the deep fascia [5].

Abdul Halim et al. reported a case of an MLL in the upper extremity of a 32-year-old male following a high-energy motor vehicle accident [24]. Upon admission, the authors were suspicious of an internal degloving injury [24]. They discussed US findings of a fluid collection with notes of septations and echogenic debris [24]. Their case report illustrates the clinical and radiological features of MLL in the upper limb, detailing the diagnostic process and treatment [24].

These individual case reports, while limited in number, collectively emphasize the unique challenges associated with diagnosing and managing MLLs in the upper extremity. The variability in presentation, the need for advanced imaging techniques, and the potential for complications highlight the importance of increased awareness among clinicians.

Research Gaps and Future Directions
Despite the growing recognition of Morel-Lavallée lesions (MLLs) in the upper extremity, research gaps remain. Further studies are needed to establish standardized diagnostic criteria and treatment guidelines specific to the upper extremity [4,7]. More research is needed to determine the optimal management strategies for different types of upper extremity MLLs, considering factors such as lesion size, chronicity, and the presence of complications [1,4]. Large-scale prospective studies are needed to evaluate the effectiveness and safety of different treatment modalities, including minimally-invasive techniques, such as suction-assisted lipectomy (SAL), and to compare outcomes with open surgical procedures [8]. Research is needed to investigate the long-term outcomes of Morel-Lavallée lesion (MLL) treatment in the upper extremity, including functional recovery, cosmetic results, and the incidence of recurrence [8, 9]. Finally, studies focusing on the specific pathophysiological mechanisms underlying MLL formation in the upper extremity, considering the unique anatomical features of this region, are warranted [8].

Conclusion
Morel-Lavallée lesions (MLLs) in the upper extremity, although rare, represent a significant clinical challenge. The similarity in presentation to other injury types makes MLLs difficult to diagnose. Ecchymosis, swelling, and pain do little to narrow down a physician’s differential. The need for advanced imaging techniques and the potential for complications necessitate increased awareness among healthcare professionals in timely diagnosis.. While the management strategies for MLLs in the upper extremity largely mirror those used for lesions in other locations, the segmental and poorly overlapping vascular areas of tissue and nerves require prompt treatment decisions. Further research is crucial to establish standardized diagnostic criteria, treatment guidelines, and a comprehensive understanding of the long-term outcomes associated with MLLs in this anatomical location. The available literature, while limited, highlights the importance of early diagnosis, individualized treatment plans, and the potential for minimally invasive techniques to improve patient outcomes.

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