Case Report Journal of Orthopaedic Case Reports 2016 Sep-Oct: 6(4):73-76

A Rare Case of Morel-Lavallee Syndrome Complicating an

Anterior Dislocation of Hip Joint
Supreeth Nekkanti1, C Vijay1, Sujana Theja1, R Ravi Shankar1, Anubhav Verma1
What to Learn from this Article?
Morel-Lavellee Syndrome is an extremely rare complication of anterior hip dislocation and hence such patients
should be closely followed up as it manifests as a late complication.

Abstract
Introduction: Hip dislocations are serious injuries as hip joint is an extremely stable joint. It requires a significant amount of force to
produce such an injury. Anterior dislocations are uncommon. Potential complications of anterior hip dislocations are a neurovascular
injury to femoral vessels or acetabular fractures.
Case Report: We report a rare late complication of Morel-Lavallee syndrome occurring 3 weeks after an anterior dislocation of the
hip in a 43-year-old male. The patient presented to us with history.
Conclusion: Morel-Lavallee syndrome is a rare complication. However if diagnosed early can be successfully treated with minimal
burden to the patient. The authors recommend surgeons to have a high index of suspicion for this syndrome and a stringent follow-up
examination of the patient.
Keywords: Anterior hip dislocation, Morel-Lavallee syndrome, complication.

Introduction a four-wheeler hit him from behind. The patient felt a snap following
Anterior dislocations of the hip joint are unusual injuries. They are relatively which he was unable to stand up on his affected limb. Clinical examination
rare and constitute 10-15% of all dislocations [1, 2]. The strong anterior revealed that the limb was in external rotation and flexion. A hard mass
capsule and ligament of Bigelow make these injuries rare. Anterior dislocations was palpable on the anterior aspect of the groin. X-ray revealed an anterior
usually lead to fractures of the anterior acetabular wall or femoral head fractures dislocation of the hip (Fig. 1).
or neurovascular injuries of the femoral vessels. We report a rare case of Morel-
A closed reduction under general anesthesia was performed within 2 h of
Lavallee lesion complicating an anterior dislocation of the hip.
the accident. The patient was laid down in a supine position; the pelvis
was fixed by an orthopedic surgeon while another orthopedic surgeon
Case Report
performed a continuous axial extension of the right leg till the femoral head
A 43-year-old presented to the emergency department following a history was located distal the acetabulum, which was checked by fluoroscopy. At
of road traffic accident. He was apparently standing on the road when that moment, the hip was flexed and internal rotated. This procedure was

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Dr. Supreeth Nekkanti Dr. C Vijay Dr. Sujana Theja Dr. R Ravi Shankar Dr. Anubhav Verma

DOI: 1
Department of Orthopaedics, JSS Hospital, Mysore, Karnataka, India.
2250-0685.578

Address of Correspondence
Dr. Supreeth Nekkanti, No. 160, 11th Cross, 5th Main, 1st Stage, NGEF Layout, Nrupatunganagar, Nagarbhavi, Bengaluru - 560 072, Karnataka, India.
Phone: +91-9742551646.
E-mail: drsupreethn@gmail.com

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Journal of Orthopaedic Case Reports | pISSN 2250-0685 | eISSN 2321-3817 | Available on www.jocr.co.in | doi:10.13107/jocr.2250-0685.578
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followed by a snap sound. The reduction of the hip joint was confirmed
with C-arm (Fig. 2).

The limb was immobilized in a Thomas splint. The patient was kept
under observation for 48 h and discharged. The patient presented to
us after 3 weeks with severe pain over the anteromedial aspect of thigh.
There was a tense cystic swelling with ecchymosis over the medial side
of thigh (Fig. 3). Ultrasonography showed multiple hypoechoic masses
floating in a cystic cavity in the thigh. Aspiration using an 18 gauge needle
yielded around 120 ml of blood mixed with clots (Fig. 4a and b). After
aspiration, a compressive bandage was applied and antibiotics were
given. The patient improved and was asymptomatic. The patient was
taught pelvic bridging exercises to avoid bed sores, isometric adductor,
and gluteal, and hamstring strengthening exercises initially. The patient
was also encouraged ankle range of movement exercises initially. He was Figure 1: X-ray showing anterior dislocation of hip joint.
then made to perform quadriceps strengthening and range of movement
exercises of the knee joint. After 4 weeks, at the end of 6 weeks, the patient
was made to weight bear. The patient continued all his normal activities
by the end of 3rd month. The patient achieved full range of movements by
the end of 6 months.

Discussion

Anterior dislocations are extremely rare injuries. They constitute 10-15%

of all dislocations [1, 2]. About 75% of anterior dislocations occur in
males [1, 2]. Almost 35% of patients who suffer from anterior dislocations
are in their third decade of life [1, 2]. On the contrary, our patient was
43-year-old and in the fourth decade of life. The ratio of anterior to
posterior dislocations varies from 1:10 to 1:19 [1, 3, 4]. The rarity of these
injuries is due to the strong anterior capsule and the ligament of Bigelow.
Anterior dislocations are of two types, the superior iliac or pubic type and
the inferior obturator type. In our patient, it was of the obturator variety
of anterior dislocation. Figure 2: Check X-ray confirming reduction of hip joint.

The mechanism of injury in anterior dislocation of the hip is usually

one of the three types. One is due to dashboard injury when the thigh is
abducted. The second likely mode of injury is fall from a height. Finally
blow to the back, when the patient is squatting seems to be a relatively
more common mode of injury [1, 3, 4]. Our patient was hit from behind
by a four wheeler. We suspect that the limb probably was forced into
external rotation, abduction, and hyperextension at the hip joint at the
time of impact.

The sequence of events that occur following trauma are the neck of the
femur or the greater trochanter impinges on the rim of the acetabulum,
which in turn levers out the femoral head out of the acetabulum socket.
The femoral head usually pushes itself out through a tear in the anterior
capsule [1, 3]. Figure 3: Clinical photo showing ecchymosis over medial aspect of thigh.

The hip joint ideally should be reduced within 6 h of fall. The incidence
of avascular necrosis keeps increasing as time passes. The incidence required which may lead to trauma of the retinacular or circumflex vessels.
of avascular necrosis of the femoral head in an unreduced hip after 6 h This, in turn, leads to avascular necrosis. The recommendations are to
varies from 0 to 22% [1, 3]. Aware of these statistics, a successful attempt reduce the hip joint under general anesthesia.
was made to reduce the hip joint within 2 h of trauma under general
anesthesia. The usual complications after an anterior dislocation of the hip
include neurovascular injury of the femoral vessels [1, 5], femoral head
The authors do not recommend a reduction of the hip joint under the effect fracture [1, 6], and acetabulum fractures [1]. Our patient did not have
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of muscle relaxants, as more often than not the relaxation is not adequate any of the above-mentioned complications. Our patient developed Morel-
to successfully reduce the joint. Moreover, excessive manipulation is Lavallee syndrome 3 weeks after his accident. Morel-Lavelle lesion refers

Journal of Orthopaedic Case Reports | Volume 6 | Issue 4 | Sep - Oct 2016 | Page 73-76
 www.jocr.co.in

a b
Figure 4: (a and b) Ultrasound photograph showing 60-70 ml collection in the thigh.

to a cystic lesion secondary to blunt injury and especially in degloving The available treatment modalities depend on the timing of identification
injuries. The mechanism behind these injuries is when a tangential of a Morel-Lavelle lesion. If it is detected during the acute phase,
shearing force acts on the relatively mobile tissue, it gets torn away from percutaneous drainage, and compression may be sufficient. However
the underlying firm muscle fascia [7]. This creates a dead space between in later stages, surgical aspiration or excision of the fibrous capsule may
the two tissue planes which is filled with blood and/or lymph from the be warranted [7, 12, 13]. After surgery, it would be necessary to place
disrupted perforating vessels or capillaries [7, 8]. suction drain to drain out any remnant fluid from the cyst. The differential
diagnosis of a Morel-Lavelle lesion includes posttraumatic fat necrosis,
Morel-Lavelle lesions are more often encountered over the trochanteric coagulopathy-related hematoma, and posttraumatic early stage myositis
region or the proximal thigh; however, it has been reported in other ossificans [7, 12].
locations such as the lower lumbar region or the calf. Furthermore, they
have been associated with pelvicor acetabular fractures [7, 9]. In our
patient, during the course of the dislocation of the femoral head anteriorly, Conclusion
it induces a shearing force on the subcutaneous tissues which get dragged In conclusion, we presented a rare case of a Morel-Lavelle lesion
along with it. This results in the dead space as explained above. following anterior dislocation of the hip. Although rare, this particular
entity should be looked for as it may present as a late complication such
The key steps of the process have been identified; after the initial formation
as our case. MRI is the best imaging modality for characterizing Morel-
of the potential blood filled space, there is evolution of this hematoma
Lavelle lesions. Aspiration, compressive bandaging, and antibiotics are
with absorption of the blood, which is replaced by serosanguineous
sufficient if diagnosed early. The results are usually good. However,
fluid [7, 10]. The last step in this chain of events is the formation of a
surgical excision is the preferable treatment modality when the lesion
peripheral fibrous capsule secondary to an anti-inflammatory reaction.
is advanced.
The entrapment of fluid within the cyst may maintain a degree of chronic
inflammation that could cause the gradual enlargement of the lesion over
a long period.
Clinical Message
In our patient, we aspirated hematoma clots from the site of injury,
Anterior hip dislocations are rare. Atypical complications like
i.e.,  along the anteromedial aspect of thigh. The diagnosis was made
Morel-Lavallee syndrome after hip dislocations present an unusual
clinically by palpating an extremely tender area on the anteromedial aspect
challenge during the treatment of the patient. Early clinical
of thigh. The diagnosis was confirmed with ultrasonography.
diagnosis of this condition is critical. Aid of MRI must be sought
Most authors, however, agree that the imaging modality of choice is in case of doubt. Most cases respond well with almost immediate
magnetic resonance imaging (MRI). However, the findings of an MRI relief if diagnosed early and managed promptly. This reduces
significant physical and financial burden to the patient. A diagnosis
may vary significantly, based on the chronicity and internal contents of the
of Morel-Lavallee syndrome should be thought of as a potential
lesion. Despite the rarity of this lesion, MRI imaging has been used for the
late complication.
only so far available classification system [7, 11].

References
1. Bonilla-Yoon I, Masih S, Patel DB, White EA, Levine BD, Chow K, 4. Amihood S. Anterior dislocation of the hip. Injury
et al. A rare case of open anterior hip dislocation. J Surg Case Rep 1975;7(2):107-110.
2013;2013(1):1-4. 5. Schwartz DL, Haller JA Jr. Open anterior hip dislocation with femoral
2. Whitehouse GH. Radiological aspects of posterior dislocation of vessel transection in a child. J Trauma 1974;14(12):1054-1059.
the hip. Clin Radiol 1978;29(4):431-441. 6. Jacob JR, Rao JP, Ciccarelli C. Traumatic dislocation and fracture
75 3. Sahin V, Karakas ES, Aksu S, Atlihan D, Turk CY, Halici M. dislocation of the hip. A long-term follow-up study. Clin Orthop
Traumatic dislocation and fracture-dislocation of the hip: A long- Relat Res 1987;214:249-263.
term follow-up study. J Trauma 2003;54(3):520-529. 7. Kontis E, Vezakis A, Psychogiou V, Kalogeropoulos P, Polydorou

Journal of Orthopaedic Case Reports | Volume 6 | Issue 4 | Sep - Oct 2016 | Page 73-76
 www.jocr.co.in
A, Fragulidis G. Morel-lavallée lesion: Report of a case of unknown 2014;127(7):1351-1356.
mechanism. Case Rep Surg 2015;2015:947450. 11. Mellado JM, Bencardino JT. Morel-lavallée lesion: Review with
8. Bonilla-Yoon I, Masih S, Patel DB, White EA, Levine BD, emphasis on MR imaging. Magn Reson Imaging Clin N Am
Chow K, et al. The morel-lavallée lesion: Pathophysiology, clinical 2005;13(4):775-782.
presentation, imaging features, and treatment options. Emerg 12. Nair AV, Nazar PK, Sekhar R, Ramachandran PV, Moorthy S. Morel-
Radiol 2014;21(1):35-43. lavelle lesion: A closed degloving injury that requires real attention.
9. Hak DJ, Olson SA, Matta JM. Diagnosis and management Indian J Radiol Imaging 2014;24(3):288-290.
of closed internal degloving injuries associated with pelvic 13. Nickerson TP, Zielinski MD, Jenkins DH, Schiller HJ. The mayo
and acetabular fractures: The morel-lavallée lesion. J Trauma clinic experience with morel-lavallée lesions: Establishment of
1997;42(6):1046-1051. a practice management guideline. J Trauma Acute Care Surg
10. Li H, Zhang F, Lei G. Morel-lavallee lesion Chin Med J (Engl) 2014;76(2):493-497.

How to Cite this Article

Conflict of Interest: Nil
Source of Support: None Nekkanti S, Vijay C, Theja C, Shankar RR, Verma A. A Rare
Case of Morel-Lavallee Syndrome Complicating an Anterior
Dislocation of Hip Joint. Journal of Orthopaedic Case Reports
2016 Sep-Oct;6(4):73-76.

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Journal of Orthopaedic Case Reports | Volume 6 | Issue 4 | Sep - Oct 2016 | Page 73-76