All posts by The Trauma Pro

Complications

What Is: A Morel-Lavallee Lesion? Part 2

In my previous post, I reviewed some of the basics of Morrel-Lavallee lesions. In this one, I’ll discuss a very recently published paper that explores early versus late management.

Although these lesions are relatively common after unprotected blunt trauma (e.g., motorcycle crashes), there has not been a lot of definitive literature published. The Morrel-Lavallee study group published this study, which was coordinated at the University of California, Irvine. It was a multicenter, prospective, observational study involving 15 trauma centers.

The study included any adult patient undergoing surgical management of the lesion, with no exclusions during the study. Surgical management included percutaneous or open drainage, wound excision and debridement, vacuum-assisted closure, or any other operative procedures. The primary outcome was hospital length of stay, and secondary outcomes included wound-related and other complications (cellulitis, deep wound infection, skin necrosis, organized hematoma, etc.), stratified by time to injury treatment. Early treatment was defined as occurring within 48 hours of admission, and late management as occurring after 48 hours.

Here are the factoids:

  • There were 230 patients with this diagnosis seen over a 3-year period; 150 underwent surgical intervention and were included in the study.
  • Demographics, BMI, ISS, and comorbidities were similar in both groups.
  • Two-thirds underwent early operative intervention, and one-third late.
  • The number of surgical procedures (5 vs. 4) and wound complications (20% vs. 24%) were similar across both groups (early vs. late).
  • ICU length of stay in the early treatment group was significantly shorter (2 vs. 5 days); hospital length of stay was also shorter (12 vs. 20 days) but did not quite achieve significance (p=0.06). 

Bottom line: This relatively large study showed little difference in wound complications, but shorter ICU and hospital lengths of stay if Morrel-Lavallee lesions are treated within 48 hours of arrival. Although this length-of-stay difference could reflect disparities in lesion location or other injuries sustained, the authors attempted to control for this. They showed that injury severity scores were similar across groups. Trauma professionals should begin treatment as soon as practical after admission to reap the benefits of a shorter hospital stay and potentially lower costs to the patient. 

Reference: Early vs Late Surgical Intervention for Morel-Lavallée Injuries: A Pacific Coast Surgical Association Prospective Multicenter Study. J Am Coll Surg. 2026 Sep 1;243(3):651-659. doi: 10.1097/XCS.0000000000001918. Epub 2026 Aug 14. PMID: 42599047.

General

What Is: A Morel-Lavallee Lesion? Part 1

Anyone who takes care of blunt trauma has seen the Morel-Lavallee lesion (M-L). Here’s an obvious one because it’s acute:

The M-L lesion is essentially a closed degloving injury in which the skin remains intact. The subcutaneous tissue is sheared off of the underlying fascia, and typically blood accumulates in the potential space that is created. This picture shows a less acute lesion; the bruising and ecchymosis on the surface have resolved. Note the collection on the lateral thigh:

These injuries may take a very long time to resolve and may leave some residual deformity. The definitive management has never been very clear: needle drainage vs incision, timing, compression wraps, etc.

The Mayo Clinic reviewed their 8-year experience with 87 of these lesions to try to shed some light on proper management. They treated their patients in four different ways: needle drainage, incision and drainage, compression wraps, and debridement with vacuum drainage devices. Here are the factoids from their study:

  • Motor vehicle crash was the most common etiology for this lesion, which makes sense due to the energy needed to shear the tissues
  • The most common locations were thigh, hip, and flank
  • The incidence of pre-existing conditions that might influence outcome (diabetes, obesity, smoking history, use of anticoagulants) did not seem to influence outcomes
  • Lesion location did not change the recurrence rate (even over joints)
  • Aspiration suffered the highest recurrence rate (56%) vs only 15-19% in the other groups
  • Aspiration of more than 50cc of fluid was more common in lesions that recurred (83%) vs those that did not (33%)

Their experience led them to develop the following practice guideline:

An incision and drainage procedure is not necessarily straightforward. Many of these wounds develop a pseudo-capsule if they are long-standing. Closure of the dead space can be challenging and may require quilting sutures or use of fibrin glue in addition to low suction drains. Some surgeons use sclerosing agents, either alone or in addition to the adjuncts listed above.

Bottom line: The Morel-Lavallee lesion can be challenging to treat. Although this study has limited numbers, it provides guidance to suggest a consistent way of managing it. 

In my next post, I’ll review a brand new multicenter study that provides some additional information on this troublesome wound.

Reference: The Mayo Clinic experience with Morel-Lavallee lesions: establishment of a practice management guideline. J Trauma 76(2):493-497, 2014.

Equipment

Use Of The Surgical Robot In Trauma Surgery

The practice of medicine steadily advances, and trauma surgery is no exception. For centuries, operative management of trauma has entailed open procedures. Laparoscopic equipment was developed about 100 years ago, and a short procedure described as “coelioscopy” was the first reported case used to identify hemoperitoneum in 1925. Occasional case reports surfaced over the following decades until a series of 37  laparoscopic trauma cases was reported in 1976. This is thought to be the first modern description of minimally invasive surgery in acute trauma.

Beginning in the 1990s, many advances were made in developing laparoscopic cautery, staplers, and suturing devices, and this field then began to advance rapidly. Although some authors aggressively tried to find ways to use laparoscopy in trauma, it was generally thought to be unacceptable. However, it was gradually accepted for quick inspections of the peritoneal cavity when the likelihood of injury was low and the patient was stable. It has now advanced to the point where it is regularly used in stable patients with injuries that can be easily and safely addressed laparoscopically.

But what about the robot? Using this device raises complexity to a new level and requires special training, setup, techs, and equipment not usually found in the trauma OR. But if it’s available, someone will eventually think about using it.

A few case reports and small series have been published over the years describing the use of the robot in trauma surgery. But finally, this year, two series were published that begin to give us a glimpse into its usefulness. The first is a descriptive database study, and the other is a systematic review that helps us understand its pros and cons.

The trauma group at Massachusetts General Hospital in Boston published the database study and reviewed the American College of Surgeons TQIP database over a 4-year period.

Here are the factoids:

  • Of over 4 million trauma records in the database, 1.4M (35%) underwent surgical procedures. Of these, 210 were robotic (0.015%, or 7.5 per 100,000 procedures).
  • Only 3 of the 210 underwent an exploratory procedure. The others delayed management involving the lung (17%), spine (14%), and diaphragm (4%).
  • Interestingly, more cases were performed in Level II and III trauma centers and non-teaching hospitals than in their academic counterparts

Overall, this study shows that robotic surgery was exceedingly rare and generally restricted to subacute interventions.

A group at King George’s Medical University in India performed the systematic review. They searched the world literature for all papers involving adult patients undergoing robotic surgery for emergency general surgery or visceral trauma. Each group was examined separately. Their primary outcomes included conversion to open surgery, technical success, and timing of the procedure. Secondary outcomes included time in the OR, length of hospital stay, postoperative morbidity, and cost outcomes.

Here are the factoids:

  • Only 14 studies involved visceral trauma and were almost exclusively case reports, case series, and observational studies.
  • The robotic procedures were nearly universally performed once the patients were hemodynamically stable and during the semi-acute phase of care.
  • Median intervention time was 76 hours after arrival.
  • Typical procedures performed involve the diaphragm, thoracic structures, the pancreas, and pelvic reconstruction.
  • There was a high rate of successful procedure completion, but no data on operative duration.

Bottom line: The use of the surgical robot is highly complex. It requires availability (not in use by others) and access to a specific OR, rapid arrival of specialized technicians, staff familiarity with the device, and patient setup. This obviously takes time, and quite a bit of it. And since 2 a.m. seems to be the trauma witching hour, it takes even longer to assemble the help necessary to pull it off at that hour. Many major trauma patients are literally bleeding to death and don’t have that time. 

Should use of the robot be considered during the initial trauma operation? Simple answer. No. The initial operation to control bleeding and contamination should nearly always involve an open procedure. Time is of the essence, and your patient doesn’t have much of it. However, once the surgeon has the “lay of the land,” future procedures may be planned using the robot to address anatomic areas that are challenging in the open situation. 

If the patient is not bleeding to death and is stable enough for extensive evaluation using CT and other appropriate modalities, then the robot may be considered for these technically challenging cases. In most cases, it should not be considered for routine procedures since it adds an additional level of OR time and expense not seen in classic trauma surgical procedures. And it should only be performed once the patient is fully resuscitated and stable. 

References:

  1. Dock the Robot for the Injured Patient: Patterns and Trends of Robotic Surgery Use in Trauma Patients. Journal of the American College of Surgeons, 242(6), 1530–1536. https://doi.org/10.1097/XCS.0000000000001726
  2. Robotic Surgery in Acute Care: A Systematic Review of Its Role in Visceral Trauma and Emergency General Surgery. Cureus. 2026 Jun 16;18(6):e110954. doi: 10.7759/cureus.110954. PMID: 42465151; PMCID: PMC13375391.
Performance Improvement

The Importance Of Hip Fracture Fixation Within 24 Hours

One metric in the TQIP program that most U.S. trauma centers subscribe to measures time to hip fracture fixation. Why is this important? When someone (usually an older adult) falls and breaks their hip, their mobility immediately drops to a much more sedentary level. We know this has an immediate impact on pulmonary function and increases pulmonary risk from simple things like atelectasis to more critical issues like pneumonia.

Given this fairly reliable correlation, it seems reasonable that restoring mobility to baseline quickly would be important. But as we have learned, just because something seems reasonable or logical doesn’t mean that it really is. Where is the evidence?

A paper first presented at the American Association for the Surgery of Trauma meeting in 2020 provided some excellent insight into this question. It was a prospective, multicenter study that included 85 US trauma centers over a 3-year period. The study included elderly patients aged 65 to 100 with an intertrochanteric hip fracture (IHF). Only patients with an isolated hip fracture were included; the presence of any other injury excluded them.

All hospitals were part of a single healthcare system that had implemented a system-wide practice guideline for managing hip fractures before the study began. The primary outcome studied was inpatient mortality. Secondary outcomes included complication rates, individual complications, and hospital length of stay.

Here are the factoids:

  • Over 24,000 patients were enrolled in the study and were divided into four hospital cohorts:
    • No IHF guideline
    • Individual hospital IHF guideline
    • Partial adoption of the system IHF guideline
    • Full adoption of the system guideline
  • Overall mortality was 1.7% across all trauma centers and levels and was not impacted by the volume of repairs performed by a center
  • Hospitals that used their own guideline or the system guideline had the lowest mortality (1.2%); Those using a partial guideline did not show any significant improvement (1.8%)
  • Hospitals that used their own guideline or the system guideline saw improvement in their TQIP report, whereas the others did not.
  • There were no differences in length of stay or complications across the cohorts
  • The majority of patients (70%) did not require any preoperative clearance via medical consultation or additional testing
  • The majority of patients who were deemed at moderate to high preoperative risk were still able to have their operations within 24 hours

Bottom line: Obviously, this is not a randomized controlled trial, which would be very difficult to perform with the high enrollments achieved here. But the solid design and large numbers give us important information about the association between early fixation and mortality. It shows that adherence to a practice guideline, either developed by the health system or the hospital, is associated with a significant reduction in hospital mortality.

This study demonstrates the huge importance of crafting a well-designed practice guideline that respects the resources available at the hospital. It also shows that only a minority of these patients require consultation or testing for more complex medical clearance, so the main barriers are the availability of the operating room and the orthopedic surgeon. 

There will always be a certain number of these patients who will undergo their repair after 24 hours. This is unavoidable because some patients will come in at a time of day when the 24-hour clock runs out in the middle of the night. For most hospitals, it is not feasible to staff an OR and have an orthopedic surgeon immediately available in the middle of the night. We should all learn from this paper and strive to implement such a guideline and pay close attention to the details so that we can expedite hip fracture fixation as much as humanly possible. 

Reference: A multicenter study on definitive surgery for isolated hip fracture within 24 hours. J Trauma Acute Care Surg. 2021 Jan 1;90(1):113-121. doi: 10.1097/TA.0000000000002951. PMID: 33003017.

How to

How To: Secure An Endotracheal Tube To… Nothing!

Several decades ago, I took care of a patient who posed an interesting challenge. He had been involved in an industrial explosion and had sustained severe trauma to his face. Although he was able to speak and breathe, he had a moderate amount of bleeding and was having some trouble keeping his airway clear.

Everyone frets about getting an airway in patients who have severe facial trauma. However, I find it’s usually easier because the bones and soft tissue move out of your way. Or are already gone. As long as you can keep ahead of the bleeding to see your landmarks, things will go fine.

In this case, the intubation was easy. The epiglottis was visible while standing above the patient’s head, so a laryngoscope was practically unnecessary! But now, how do we secure the tube so it won’t fall out? Sure, there are tube-tamer type securing devices available, but what if they are not available to you? Or this happened in the field? Or their face was missing or falling off? Or it was in the 1980s, and it hadn’t been invented, like this case?

The answer is: create your own “skin” to secure the tube. Take a Kerlix-type stretchable gauze roll and wrap it tightly around their face and their head if needed. Remember, they are already sedated and can breathe through the tube. This also serves to further slow any bleeding from soft tissue. Once you have “mummified” the head with the gauze roll, tape the tube in place like you normally would, using the surface of the gauze as the “skin.”

Be generous with the tape, because the tube is your patient’s life-line. Now it’s time for the surgeons to surgically stabilize this airway, usually by converting to a tracheostomy.