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Hey Brit and Jestinm
I'm Jon Gelber, an EM attending in the community and at UCSF. I really enjoyed the piece, but believe it could have included 2 additional things, both of which I discussed in a paper I published in the Journal of Emergency Medicine in January of this year 2023, titled "Morel-Lavallée Lesion Diagnosed by Point-of-Care Ultrasound: A Case Report and Review of Treatment Strategies." (PMID 36642674). I contacted EMRAP and Swami asked me to comment here directly.
1) In my opinion, ULTRASOUND should be the FIRST modality for diagnosis. Far faster than MRI or even CT, ultrasound can make the diagnosis within seconds, and can be easily and accurately done by an EM physician. There are several key features I discuss with pictures and videos, including hypoechoic homogeneous free fluid in the fascial plane, easy compressibility, and tethered floating fat globules, all in the correct clinical context. This is a bedside diagnosis that we can and should make, without the need for first consulting trauma/ ortho/ radiology or obtaining cross sectional imaging.
2) While there are no formal societal guidelines for management, quite a bit of trauma research has focused on how to best manage these lesions, and I do think we have a good framework for approach. There is decent data to support the following approach: For small minimally symptomatic lesions <50cc, compressions and conservative management should be used. For smaller but symptomatic or persistent lesions, needle aspiration should be performed. For large lesions, open debridement is recommended by literature.
Thank you for the comments, and great case report! Jestin and I enjoyed reading it. Your paper raises several important considerations, particularly regarding US. We completely agree that it is a rapid means of diagnosis and can provide important information at the bedside.
We do want to caution the listeners, however, that US is often not definitive for this diagnosis and does not demonstrate the necessary test characteristics to definitely rule out the condition. More advanced imaging provides an understanding of the extent of the disease and assists with treatment planning. In the vast majority of cases, we will need to consult either our trauma or orthopedic specialist. Based on the current literature, and as you state in your case report, there are no comprehensive guidelines or society recommendations concerning definitive therapy, and in many institutions the treatment will be specialist dependent. Thus, involving the specialist early is a great idea in these patients.
Thanks again for the comments!Brit
What you do matters.