Clínica y Tratamiento de la Morel Lavallée

Morel Lavallée Clinic and Treatment

Morel Lavallée Clinic And Treatment. A 36-year-old male patient reported pain in his right knee for 1 year associated with playing basketball, which improved after physiotherapeutic treatment.
However, he had recently worsened, accompanied by a slightly painful bulging in the popliteal fossa, which limited flexion of the same knee. He reported a history of trauma to the posterior region of both knees, when performing exercises on a circus trapeze two months ago, an unusual practice.
At the time, he felt local discomfort for a few days, which improved spontaneously and did not seek medical attention. He had a history of Os Good Schlatter Disease in both knees during adolescence and had been asymptomatic for several years (Figure 1).
In the MRI, carried out a year ago, to investigate the onset of pain, the presence of a popliteal cyst and patellar chondromalacia were detected, defined as the supposed cause of the pain, after sports (Figures 2-5).
Figura 1: Ressonância magnética realizada um ano antes da queixa atual. Imagem axial ponderada em T1, com supressão de gordura, evidenciando lesão cística na região posterior do joelho direito.
Figure 1: Magnetic resonance imaging performed one year before the current complaint. Axial T1-weighted image, with fat suppression, showing a cystic lesion in the posterior region of the right knee.
Figura 2: Ressonância magnética realizada um ano antes da queixa atual. Imagem coronal, ponderada em T1, evidenciando lesão de baixo sinal na região posterior do joelho direito.
Figure 2: Magnetic resonance imaging performed one year before the current complaint. Coronal image, T1-weighted, showing a low-signal lesion in the posterior region of the right knee.
Figura 3: Ressonância magnética realizada um ano antes da queixa atual. Imagem coronal ponderada em T1, com supressão de gordura, evidenciando lesão de alto sinal na região posterior do joelho direito.
Figure 3: Magnetic resonance imaging performed one year before the current complaint. T1-weighted coronal image, with fat suppression, showing a high-signal lesion in the posterior region of the right knee.
Figura 4: Ressonância magnética realizada um ano antes da queixa atual. Imagem sagital, ponderada em T1, evidenciando lesão de baixo sinal na região posterior do joelho direito.
Figure 4: Magnetic resonance imaging performed one year before the current complaint. Sagittal, T1-weighted image, showing a low-signal lesion in the posterior region of the right knee.
Figura 5: Ressonância magnética realizada um ano antes da queixa atual. Imagem sagital, ponderada em T1, com supressão de gordura, evidenciando lesão de alto sinal na região posterior do joelho direito.
Figure 5: Magnetic resonance imaging performed one year before the current complaint. Sagittal image, T1-weighted, with fat suppression, showing a high-signal lesion in the posterior region of the right knee.
Figura 6: Radiografias do joelho direito de frente, evidenciando sequela antiga de doença de Os Good Schlatter, sem outras alterações relevantes ósseas ou de tecidos moles
Figure 6: Radiographs of the right knee from the front, showing old sequelae of Os Good Schlatter disease, without other relevant bone or soft tissue changes
Figura 7: Radiografia do joelho direito de perfil, evidenciando sequela antiga de Doença de Os Good Schlatter, sem outras alterações relevantes ósseas ou de tecidos moles.
Figure 7: Radiograph of the right knee in profile, showing old sequelae of Os Good Schlatter Disease, without other relevant bone or soft tissue changes.
He sought medical attention, worried about the posterior bulging of his right knee, which bothered him a lot when he flexed his knee. He took x-rays and no changes were observed (Figures 6 and 7).
Subsequently, a new resonance was performed, in which a soft tissue tumor was detected in the popliteal fossa, and he was advised to see an orthopedic oncologist for a biopsy and probable resection (Figures 8 to 15).
Figura 8: Ressonância magnética atual evidenciando imagem coronal, ponderada em T1, com lesão de baixo sinal.
Figure 8: Current magnetic resonance imaging showing coronal image, T1-weighted, with low signal intensity lesion.
Figura 9: Ressonância magnética atual evidenciando imagem coronal, ponderada em T2, com lesão de alto sinal.
Figure 9: Current magnetic resonance imaging showing coronal image, T2-weighted, with high signal intensity lesion.
Figura 10: Ressonância magnética atual evidenciando imagem axial ponderada em T1, com supressão de gordura, com lesão de alto sinal, entre o plano celular subcutâneo e a fáscia muscular.
Figure 10: Current magnetic resonance imaging showing an axial T1-weighted image, with fat suppression, with a high-signal lesion, between the subcutaneous cellular plane and the muscular fascia.
Upon receiving the patient, we detailed the anamnesis, which highlighted the real importance of the trauma that occurred 2 months ago, on a circus trapeze, which limited his activities due to pain, but he did not seek medical attention at the time, as he was on vacation. On physical examination, we noticed a tense bulging, but elastic fiber in the right popliteal fossa, which was painful only on pressure and not on palpation. No neurological changes, no regional lymph node enlargement which, when in flexion, worsened the pain.
Figura 11: Ressonância magnética atual evidenciando imagem coronal ponderada em T1, com lesão de baixo sinal entre o plano celular subcutâneo e a fáscia muscular.
Figure 11: Current magnetic resonance imaging showing a coronal T1-weighted image, with a low-signal lesion between the subcutaneous cellular plane and the muscular fascia.
Figura 12: Rm coronal em T2.
Figure 12: Coronal MRI on T2.
Figura 13: Ressonância magnética atual evidenciando imagem coronal ponderada em T1, com supressão de gordura, com lesão de alto sinal entre o plano celular subcutâneo e a fáscia muscular.
Figure 13: Current magnetic resonance imaging showing a T1-weighted coronal image, with fat suppression, with a high-signal lesion between the subcutaneous cellular plane and the muscular fascia.
Figura 14: Ressonância magnética atual evidenciando imagem sagital ponderada em T1 contrastada e com supressão de gordura. Lesão de baixo sinal, com realce periférico do contraste, bem delimitado e homogêneo, de baixo sinal, no interior da lesão. A lesão está dissecando o plano entre o tecido celular subcutâneo e a fáscia muscular.
Figure 14: Current magnetic resonance imaging showing contrasted sagittal T1-weighted image with fat suppression. Low signal lesion, with peripheral contrast enhancement, well delimited and homogeneous, low signal, within the lesion. The lesion is dissecting the plane between the subcutaneous cellular tissue and the muscular fascia.
When calmly analyzing the images, we observed an image with low signal when T1-weighted and high signal when T2-weighted, which may initially suggest a lesion with liquid content. To differentiate from solid lesions, which are therefore more likely to be malignant, we must interpret the contrast images. In this patient’s case, the contrast accumulated only on the periphery of the lesion, strengthening the hypothesis of only liquid content, that is, without internal vascularization that would allow the contrast to spread within the lesion. We could now postulate the hypotheses of a cyst or an organized hematoma. However, some solid tumors can mimic this pattern of contrast enhancement, such as myxomas and some neural tumors.
Figura 15: Ressonância magnética atual evidenciando imagem axial ponderada em T1 contrastada e com supressão de gordura. Vemos lesão de baixo sinal com realce periférico do contraste, bem delimitado e homogeneamente de baixo sinal no interior da lesão. A lesão esta dissecando o plano entre o tecido celular subcutâneo e a fascia muscular
Figure 15: Current MRI showing axial T1-weighted image with contrast and fat suppression. We see a low-signal lesion with peripheral contrast enhancement, well-defined and homogeneously low-signal within the lesion. The lesion is dissecting the plane between the subcutaneous cellular tissue and the muscular fascia
Figura 16: Punção da lesão, no consultório, evidenciando conteúdo hemático.
Figure 16: Puncture of the lesion, in the office, showing hematic content.
Figura 17: Conteúdo da aspiração da lesão, evidenciando aspecto soro-hemorrágico.
Figure 17: Content of the aspiration of the lesion, showing a serohemorrhagic appearance.
Another important fact is that the lesion is superficial. The majority of malignant tumor lesions are found deep within the muscular fascia, further reducing the probability of being a malignant neoplasm, but approximately 1% of superficial tumor lesions are malignant, so this hypothesis cannot be completely ruled out.
The third characteristic that must be highlighted in the images of this case is that in addition to being superficial, this lesion is located exactly between the muscular plane and the subcutaneous fat plane. Very clearly it can be seen that the lesion is dissecting the two planes and assuming a half-moon shape, suggestive of liquid under external pressure that shapes the convexity of the external surface of the muscular plane and the internal surface of the fatty plane. Solid lesions can present different shapes, but they tend to be more rounded and well-defined.
Given the characteristics of the images, clinical history and physical examination, the diagnostic hypothesis of an organized traumatic hematoma, dissecting the tissue planes, Morel-Lavallée injury, was postulated. It was decided to puncture the hematoma in an office environment with asepsis and local anesthesia to relieve symptoms.
The patient remained with a Neoprene tensor around the knee for 4 days after the puncture to prevent the hematoma from re-forming and after 2 weeks he reported complete improvement in the condition.

Author: Prof. Dr. Pedro Péricles Ribeiro Baptista

 Orthopedic Oncosurgery at the Dr. Arnaldo Vieira de Carvalho Cancer Institute

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