Negative pressure therapy in a scenario of distal femur fracture with internal degloving injury
- Ravikumar Thoppanahalli Venkatesh ,
- Dev Anand Galagali and
- Aanchal Bhatia
- Orthopaedics, MS Ramaiah Medical College, Bangalore, India
- Correspondence to Dr Ravikumar Thoppanahalli Venkatesh; ortho1980@gmail.com
Abstract
Internal degloving injuries are commonly seen in the pelvis. Similar lesions in the distal femur are rare. They cause a separation between the subcutaneous layer and deep fascia, which results in blood, lymph, necrosed fat and fluid collection in the space. They result in infection and soft tissue complications. Treatment options include conservative management with compression dressings, percutaneous aspiration, mini-incision drainage and sclerodesis. Here we describe a case of closed internal circumferential degloving injury of the distal thigh with a distal femur fracture treated by an innovative technique involving negative pressure therapy, internal fixation of the fracture and secondary skin grafting.
Background
Closed internal degloving injuries are devastating injuries that are commonly missed. Also called Morel-Lavallee lesions, these refer to injuries where the skin and subcutaneous tissues are separated from the underlying fascia, leading to haematoma formation, fat necrosis and fluid just superficial to the fascia. These usually occur after high-velocity trauma in the pelvi-acetabular region and proximal thigh.1 Pre-patellar lesions and lesions around the knee have been described in athletes.2 A similar case involving an older adult has also been reported after a fall.3 Management of such injuries varies from case to case. There have been successful conservative therapy reports with elevation, elastic compression dressings, compression bandages and anti-oedema measures, but only in cases of intact, healthy skin and minimal fluid collection.2 4 Percutaneous aspiration is also done in cases where there is a larger amount of fluid accumulation or haematoma.2 Small incision drainage has also been described.3 Sclerodesis, fibrin glue use and quilting sutures are also done in a few cases.2 However, large internal degloving injuries causing necrosis of the tissues and skin in a setting of a fracture require greater attention and surgical management due to the presence of the fracture haematoma and the need for fracture fixation. This article presents a case of internal degloving injury of the distal thigh, with a distal femur fracture successfully treated with primary plating of the fracture with vacuum-assisted, negative pressure dressings and secondary skin grafting.
Case presentation
A man in his 40s presented to the emergency room with a history of road traffic accident 4 hours prior. He was hit and run over by a four-wheeler while crossing the road when he suffered a high-velocity grazing injury to his right thigh. On examination, he had a grazed abrasion on the lateral aspect (figure 1), with a large discoloured area of skin on the medial aspect of the right distal thigh (figure 2), deformity and a boggy swelling over the same area. Initial splinting with a Thomas splint was done, and plain radiographs were taken. However, the boggy swelling gradually increased with time, raising the suspicion of an internal degloving injury.
Grazed abrasion on lateral aspect of thigh.
Discoloured skin on the medial aspect of thigh.
Investigations
Plain radiographs revealed a spiral fracture at the level of the distal third of the right femur (figures 3 and 4). Blood investigations were all within normal limits.
Anteroposterior radiographs of femur and knee.
Lateral radiographs of femur and knee.
Treatment
About 8 hours post-injury, the patient was taken to the operating room after initial blood investigations, which were within normal limits. A lateral approach to the distal femur was taken. Though there was a grazed abrasion, the skin and subcutaneous tissue on the lateral aspect of thigh was found to be viable and no necrosis was seen. Hence, a decision to go ahead with internal fixation was taken, after the plastic surgery team concurred with the same. The fracture was reduced, and a lateral distal femur locking plate was used to fix the fracture (figure 5). Intraoperatively, there was a 360° degloving around the distal femur shaft, but muscles were contractile to touch and electrocautery. The necrosed muscle was debrided. The epidermal layer of the skin over the medial aspect of about 15×12 cm was found to be necrosed; hence, a decision was made not to conserve the same (figure 6). Thorough debridement of this layer led to a large area of tissue loss, which could not be primarily closed. The lateral incision was closed in layers, except for a 7 cm region on which the foam for vacuum dressing was applied. A drain tube was placed between the two compartments to prevent the collapse and discontinuity of the medial and lateral compartments for the negative pressure to act (figure 7). It was planned to remove at a later date. A negative pressure dressing (3M V.A.C. THERAPY) was applied on the lateral side and maintained for 5 days. Medial wound was managed by daily dressings. The drainage volume was about 400 mL on day 1 and decreased gradually to 50 mL on day 5. He was then taken up for a relook operation, where a debridement was done along with the reapplication of foam and vacuum therapy. After 3 days, the drain tube between the two compartments was removed, and the lateral incision was closed completely. Healthy granulation tissue amenable to skin grafting was seen on the medial side (figure 8). Split skin grafting from the contralateral thigh was performed.
Postoperative radiographs.
Necrosed adipose tissue on the medial aspect of thigh typical of an internal degloving injury.
Diagrammatic illustration (made by author Aanchal Bhatia) of the procedure done (cross-section of distal thigh). (A) The 360° degree internal degloving injury. (B) If the compartments were not connected, tissues would collapse and form a separate cavity on medial side. (C) Tube placed between the medial and lateral sides in the subcutaneous plane, to avoid tissue collapse.
Healthy granulation tissue amenable to skin grafting.
Outcome and follow-up
The surgical site healed, and the graft was well taken up by the recipient site in 2 weeks (figure 9). The patient was mobilised non-weight-bearing for 2 months after the last procedure and gradually progressed to full weight-bearing over the next month, along with knee range of motion and strengthening exercises for the quadriceps and hamstrings. His knee range of motion at the end of 6 months was 0°–120°, and he was comfortable ambulating in the community with no complications. Seven-month follow-up radiographs are shown in figure 10. Range of motion of hip and knee at 7 months is shown in video 1. There were no draining sinuses or skin breaks at the end of 7 months.
Clean surgical site and good skin cover 2 weeks after skin grafting.
Seven-month follow-up radiographs showing good callus formation and adequate healing at fracture site.
Discussion
Internal degloving injuries are commonly found in the pelvis and sacral areas, extending to the proximal thigh. They are called Morel-Lavallee lesions and were first described by French physician Maurice Morel-Lavallée in 1853. Shearing forces cause a separation of the subcutaneous layer from the underlying fascia, creating a pocket for collecting blood, fat and lymph. This leads to necrosis and infection if not treated early.1 A similar lesion in the distal third of the thigh is rare and is reported scarcely in literature.3 5 These lesions are commonly diagnosed clinically or by MRI. Conservative management is advocated in most cases with compression bandages.4 5 Percutaneous aspiration or mini-incision drainage is also approved.3 5 Sclerodesis is the injection of material like doxycycline, absolute ethanol and talc into the lesion, which destroys surrounding cells, inducing fibrosis and closure of the cavity. Use of fibrin glue and quilting sutures has also been described. These are usually used in chronic injuries that do not respond to primary aspiration and drainage.6
This patient had a large lesion of about 15×12 cm and was acutely expanding in a setting of a fracture of the distal femur. Necrosis of the skin over the swelling had begun on presentation. This poses a risk of widespread infection and increased necrosis. Hence, thorough debridement of the entire lesion was done. The fracture was then fixed with an open reduction and locking compression plate fixation. Closed reduction techniques were not used as there was a definite need to open the fracture site to address the soft tissue component. Internal fixation with a plate was considered over a retrograde femoral nail as a single incision could be used for the fixation as well as the evacuation of seroma and the minimal healthy skin and soft tissue around the knee would not be compromised with fresh incisions. Also, the incision for the entry would form a connection between the impending unhealthy soft tissue and the healthy parts of the knee joint. The stability provided by a plate in a scenario of a long spiral fracture is higher than that given by a nail. Use of an external fixator and the eventual morbidity of a second procedure for a definitive fixation was completely avoided by the use of negative pressure therapy to address the Morel-Lavallee lesion. A drainage tube connecting the medial and lateral subcutaneous compartments placed along with negative pressure therapy only on the lateral side helped in reducing the surgical time, morbidity and the financial burden of a second vacuum-assisted draining site on the medial aspect.
Very few cases of an internal degloving injury treated with vacuum-assisted dressings have been reported.7 8 However, all of them are in the lumbar and pelvic areas and none affecting the distal third of the thigh in a 360° manner. This makes the management of this case unique. Split skin grafting was done after treatment with negative pressure therapy. The successful management of this case shows that such therapy can be used for extensive closed degloving lesions, which have significant chances of infection and necrosis. The lesion, in this case, was all around the distal femur shaft.
The only concern which we experienced was the time to skin grafting (about 8 days) and the risk of exposure of implant if soft tissue coverage was inadequate. However, we did not face any untoward complications due to communication of medial and lateral subcutaneous areas with the negative pressure therapy, making open reduction and internal fixation with plating of the distal femur fracture safe with this form of soft tissue management.
Learning points
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Internal degloving injuries are frequently missed or misdiagnosed. They are most commonly seen in the pelvi-acetabular area, and those around the distal femur are rare.
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They result from a high-velocity accident causing shearing forces that delaminate the fascia and the subcutaneous tissue.
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Such injuries at the distal thigh treated by negative pressure therapy were not reported in the literature earlier. This mode of management in a fracture setting is unique and thriving in this case, and we believe that placing a drain tube between the medial and the lateral compartments helped heal on both sides.
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Superficial abrasions and discolouration may not be an indicator for the use of external fixation in such injuries. Viability of the skin and subcutaneous tissue at surgical site is important for successful internal fixation and incision healing in trauma with extensive soft tissue damage.
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However, a larger number of cases and comparison of functional results with conservative methods, aspiration, drainage and sclerodesis are required for a better assessment of the results of vacuum therapy in internal degloving injuries.
Ethics statements
Patient consent for publication
Footnotes
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Contributors RTV was the chief operating and treating surgeon of the patient. DAG and AB played a major role in the preoperative, postoperative care and follow-up of the patient. RTV, DAG and AB performed the literature search, drafted and revised the case report.
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Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
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Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.
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Competing interests None declared.
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Provenance and peer review Not commissioned; externally peer reviewed.
- © BMJ Publishing Group Limited 2023. No commercial re-use. See rights and permissions. Published by BMJ.
References
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