Morel-Lavallee Lesion: A Case of Lower Extremity Internal Degloving Injury.

A 22-year-old female patient was seen in the emergency department with a two-week onset of progressively worsening pain and swelling to the medial aspect of her distal left femur. The patient was involved in an automobile versus pedestrian accident two months prior sustaining superficial swelling, tenderness, and bruising to the affected area. Radiographs revealed soft tissue swelling without osseous abnormalities. Examination of the distal femur region revealed a large, tender, ovoid area of fluctuance with a dark crusted lesion and surrounding erythema. Bedside ultrasonography revealed a large anechoic fluid collection in the deep subcutaneous plane with mobile internal echogenic debris which was suspicious for a Morel-Lavallee lesion. The patient underwent contrast enhanced CT of the affected lower extremity demonstrating a 8.7 cm x 4.1 cm x 11.1 cm fluid collection superficial to the deep fascia of the distal posteromedial left femur, confirming the diagnosis of a Morel-Lavallee lesion. A Morel-Lavallee lesion is a rare, post-traumatic degloving injury that results in the separation of the skin and subcutaneous tissues from the underlying fascial plane. The resultant disruption of the lymphatic vessels and underlying vasculature leads to progressively worsening hemolymph accumulation. If not recognized and treated in the acute or subacute period, complications can ensue. Complications of Morel-Lavallee include recurrence, infection, skin necrosis, neurovascular injury, as well as chronic pain. Treatment is based on the size of the lesion and ranges from conservative management and surveillance for small lesions to percutaneous drainage as well as debridement, sclerosing agents, and surgical fascial fenestration approaches for larger lesions. Additionally, the utilization of point-of-care ultrasonography can help in the early identification of this disease process. This is important as a delay in diagnosis and subsequent treatment of this disease state is associated with long-term complications.

Imperforate Hymen and Hematometrocolpos in a Female With Back Pain and Urinary Retention.

A 12-year-old female with primary amenorrhea presented to the emergency department with episodic low back pain, suprapubic discomfort, and acute urinary retention. A protruding purple mass was noted at the vaginal introitus consistent with an imperforate hymen. Point-of-care bedside transabdominal ultrasonography revealed a distended uterus containing hypoechoic material. The patient underwent formal pelvic ultrasonography, which revealed a markedly enlarged uterus containing a large number of blood products, thinned myometrium, and a distended vaginal canal consistent with hematometrocolpos secondary to imperforate hymen. Imperforate hymen is a rare congenital anomaly of the female urogenital tract, in which the hymen obstructs the vaginal opening causing a vaginal outlet obstruction. Vaginal outlet obstruction secondary to imperforate hymen may lead to retrograde menstruation with a collection of blood within the uterus and vagina, which is termed hematometrocolpos. Treatment is based on identifying and treating the underlying imperforate hymen with surgical approaches. The growing use of bedside ultrasonography allows the clinician to rapidly and accurately diagnose hematometrocolpos. The use of point-of-care bedside ultrasonography can serve as an essential tool as delayed diagnosis and treatment of this rare condition are associated with significant morbidity and lifelong infertility.

Atraumatic Gluteal Compartment Syndrome Presenting in a Young Female with Unilateral Lower Extremity Symptoms.

Gluteal compartment syndrome is a rare condition that often develops following immobilization either secondary to illicit drug and alcohol abuse or improper surgical positioning. A case of a 22-year-old female with left lower extremity pain, weakness, and numbness after prolonged stasis from a night of drug and alcohol use is presented. She also complained of left low back pain. Her initial neurologic examination was significant for decreased deep tendon reflexes, decreased motor strength, and decreased sensation in the left lower extremity. Severe pain in the affected region persisted despite several attempts at pain control utilizing multiple modalities. An emergent MRI of the lumbar spine revealed gluteal compartment syndrome. The patient ultimately underwent emergent fasciotomy with resultant improvement in neurologic symptoms. Because presenting symptoms are frequently nonspecific in initial stages, gluteal compartment syndrome is often misdiagnosed. This can lead to unnecessary morbidity and mortality. It is important to maintain a high index of suspicion for gluteal compartment syndrome because delay in diagnosis can lead to nerve palsy, acute kidney injury, sepsis, and/or death.