What is the management of closed internal degloving?

Management of Closed Internal Degloving Injuries

Early surgical debridement is the recommended treatment for closed internal degloving injuries to reduce the risk of infection and complications. 1

Understanding Closed Internal Degloving Injuries

Closed internal degloving injuries, also known as Morel-Lavallée lesions, occur when subcutaneous tissue is torn away from underlying fascia, creating a cavity filled with hematoma and liquefied fat. These injuries:

• Commonly occur over the greater trochanter but may also affect the flank, buttock, and lumbodorsal regions 1, 2
• Result from high-energy trauma, particularly motor vehicle accidents 3
• Can be easily missed during initial assessment in multiply injured patients 4
• Present with a soft fluctuant area and often decreased cutaneous sensation 2

Diagnostic Approach

• Physical examination: Look for soft fluctuant swelling, decreased cutaneous sensation, and local contusion
• Imaging: Ultrasound examination is the primary diagnostic tool 2
• MRI: Helpful for identifying fluid intensity lesions in the subdermal and dermal layers 3

Management Algorithm

Initial Management

1. Early surgical debridement - Either before or at the time of fracture fixation if associated with pelvic/acetabular fractures 1
2. Drainage of the degloved area - Through small incisions followed by compression bandaging 4
3. Leave wound open - Avoid primary closure to prevent deep soft-tissue infections 1

Specific Treatment Options

For Small to Moderate Lesions:

• Drainage through small incisions
• Compression bandaging
• Serial wound assessment

For Extensive Lesions:

• Thorough surgical debridement
• Consider Negative Pressure Wound Therapy (NPWT)
  • Use continuous pressure settings of 50-80 mmHg 5
  • Always use a non-adherent interface layer to protect exposed tissues 5
  • Maintain effective fluid removal while preventing tissue damage 5

For Recurrent Collections:

• Repeat surgical debridement
• Consider NPWT with specialized foam-based dressing kits 5
• Avoid repeated closed drainage alone, as this has high recurrence rates 1

Important Considerations

• Infection risk: Cultures from closed internal degloving injuries are positive in up to 46% of cases 1
• Antibiotics: Consider broad-spectrum antibiotic coverage, especially in contaminated wounds 6
• Delayed necrosis: May occur in extensive degloving where effective compression cannot be applied 4
• Recurrence: High recurrence rates with closed serial drainage alone 1
• Mortality: Higher in closed degloving injuries (19.4%) compared to open degloving injuries (6.3%) 7

Pitfalls and Caveats

1. Missed diagnosis: Up to one-third of closed degloving injuries are missed at initial assessment 4
2. Expanding hematoma: Can further compromise skin vascularity if not promptly drained 1
3. Primary closure: Avoid primary closure over suction drains as this can lead to chronic deep soft-tissue infections 1
4. Inadequate debridement: Increases risk of infection and tissue necrosis
5. Underestimation: Closed degloving injuries are often underestimated, particularly in multiply injured patients 7

Follow-up

• Close monitoring for signs of infection or skin necrosis
• Serial debridement may be necessary for optimal wound healing
• Consider skin grafting if delayed necrosis occurs

By following this management approach, the risk of complications such as infection, skin necrosis, and chronic fluid collections can be minimized, improving patient outcomes in these challenging injuries.