Working Diagnosis:
Hip/thigh contusion
Morel-Lavellee Lesion

Treatment:
Treatment of compression, and cryotherapy was immediately initiated consisting of continuous compression with a hip Spica compression wrap along with cold compression 4 to 6 times per day for 30mins. Case Photo #6 , Case Photo #7 Physical therapy was continued with a focus on manual therapy with range of motion and light, low impact stationary bike minimizing shearing forces. The patient was able to maintain full functional activity during treatment. There were no complications identified during treatment.

Outcome:
After 3 weeks of treatment Case Photo #8 , Case Photo #9 , the patient showed overall clinical improvement. His greater trochanteric circumference measurements had decreased from 101 cm to 98 cm. He returned to cycling on an indoor trainer utilizing a power meter to titrate wattage output as tolerated and advanced to outdoor cycling once he was back to baseline power output without significant symptoms.

Author's Comments:
Treatment of MLL currently consists of noninvasive management with compression or invasive managements of percutaneous aspiration, sclerotherapy, or surgical interventions. Noninvasive management of acute MLL is an effective approach when intervention occurs prior to the development of a fibrous capsule or with smaller lesions. Noninvasive management involves placing a compression banding over the affected area with rest, elevation and periodic use of ice with a healing time of 2-11 weeks. Noninvasive management without compression banding resulted in a high incidence of cases requiring subsequent surgery. Once a fibrous capsule has developed around the lesion, surgical intervention is the only recommended treatment for resolution of the lesion. Some have recommended invasive management of all large lesions. Large lesions defined as those containing greater than 50ml can be more frequently found in the pelvis, flank and thigh. Previously, large lesions which were not treated surgically were more likely to have a recollection or encapsulation of the lesion.
Ultrasound provides an accessible modality for early evaluation of MLL allowing for earlier intervention with noninvasive management. This earlier identification and management can precede development of a fibrous capsule to mitigate necessity for surgical intervention and the complications it can entail. On ultrasound, MLL appears as nonspecific fluid collections with heterogeneous or homogeneous echogenicity depending on the chronicity of the lesion. Acute lesions are typically heterogeneous in appearance with irregular margins and lobular shape. Chronic lesions are typically homogenous with smooth margins and a flat or fusiform shape. Echogenicity of the fluid collections has no relationship with the age of the lesions.
This case supports the effectiveness of noninvasive management as an initial treatment in the setting of acute MLL. Ultrasound provides a quick, easily accessible modality to identify these lesions following a traumatic event involving shearing forces. Given early identification and intervention, favorable outcomes can be achieved with noninvasive management without necessitating procedural intervention and the risks it involves. More research is necessary on the effectiveness of using ultrasound for early identification of MLL and subsequent intervention with noninvasive management given the appropriate ultrasound findings for an acute lesion.

Editor's Comments:
This case represents an example of the potential complications associated with a cycling injury. It shows the possible complications from a contusion to the lower extremity. Morel Lavallee lesions have the potential to be difficult to treat and need surgical intervention. This case represents an injury that was able to be treated conservatively. It also shows the typical course of conservative treatment.

References:
Management of the Morel-Lavallee Lesion.
Greenhill D, Haydel C, Rehman S.
Orthop Clin North Am. 2016 Jan;47(1):115-25.

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