A 20-year-old, otherwise healthy, male presented to the Emergency Department (ED) after falling on his back while playing basketball. The patient landed on his right buttock on the hardwood floor. On presentation to the ED, he denied back pain, numbness, and weakness but did notice progressive swelling in the area of the fall. He denied any other injuries and had no previous bleeding or bruising history. His medical history was unremarkable for bleeding disorders or anticoagulation. He denied previous issues with hematomas, subcutaneous fluid collections, or abscesses.
On physical exam, the patient was not in acute distress and showed equivalent and intact strength and sensation in all four extremities. There was no weakness, numbness, or tingling in the lower extremities. All distal pulses were equal and palpable. The patient had mild pain in the right gluteal region with impressive swelling in the area. There was no lumbar, sacral, or pelvic tenderness to palpation. Point of care ultrasound demonstrated an 8 x 2.8 cm2 fluid collection in the right gluteal region which was incorrectly thought to be located within the muscle belly. He was given an ice pack, instructed to use Tylenol, and given a referral to Orthopaedics. He was instructed to return to the ED if the pain worsened or if he developed fevers, chills, nausea, vomiting, or other symptoms and was discharged the same evening.
The patient returned to the ED four days later for worsening pain and swelling of his buttock. He was unable to tolerate running and had worsening pain upon walking. The patient was concerned for a possible abscess at the injured area as it had become increasingly tender to touch since his previous visit to the ED. The skin at the area was intact and the patient denied drainage. He did not present with any constitutional symptoms including fevers, chills, nausea, vomiting, abdominal pain, lightheadedness, dizziness, or syncope. Physical exam was positive for myalgia in the right upper gluteal region. A complete blood count (CBC) revealed mildly microcytic RBCs of 78.3 fL (normal = 79.9-99.0), decreased mean corpuscular hemoglobin of 26.5 fmol/cell (normal = 27.0-32.0), and a decreased monocyte percentage of 5.8 (normal = 6.0-13.0). White blood cell count was 6.3 x 103 cells/mL (normal = 4.0-10.0), hemoglobin was 13.7 gm/dL (normal = 13.5-17.0), RBC count was 5.17 x 103 cells/mL (normal = 4.40-5.70), platelet count was 228 x 103 cells/mL (normal = 150-400), platelet thromboplastin time (PTT) was 25.1 seconds (normal = 22.0-32.0), prothrombin time (PT) was 10.9 seconds (normal = 9.5-12.0), and International Normalized Ratio (INR) was 1.0.
A radiology-based musculoskeletal ultrasound was performed on the right upper gluteal region. The exam was notable for a large hypoechoic fluid collection deep to the subcutaneous tissue and superior to the gluteal musculature (Figures 1 and 2). The fluid collection had increased to 13 x 2 x 9 cm3. Internal echoes and fat globules were found within the hypoechoic fluid collection. These findings were suggestive of a Morell-Lavallee closed degloving lesion. Plastic Surgery was consulted and opted not to perform drainage of the lesion as there was no superficial skin breakdown. The patient was given a pressure dressing for the lesion and recommended to follow up with Plastic Surgery clinic for further management of the lesion.