Multistage surgical management of severe left thigh degloving injury and right thigh morel-lavallée lesion in an eight-year-old child: A case report

Rachel Dorairaj1*, Shalini H S2, Vijayakumari. D3

1Nursing Supervisor, Kauvery Hospital, Electronic city, Bengaluru

2CNO, Kauvery Hospital, Electronic city, Bengaluru

3Nurse Educator, Kauvery Hospital , Electronic city, Bengaluru

*Correspondence

Introduction

Degloving injuries are severe soft-tissue injuries caused by shearing forces that separate the skin and subcutaneous tissue from the underlying fascia. These injuries may result in extensive tissue damage, compromised blood supply, and subsequent skin necrosis. A Morel-Lavallée lesion is a form of closed degloving injury in which the skin and subcutaneous tissues separate from the underlying deep fascia, creating a potential space that accumulates blood, lymphatic fluid, and tissue debris. The management of extensive degloving injuries in pediatric patients presents significant challenges, particularly when both lower limbs are involved. Successful treatment often requires a staged surgical approach incorporating hematoma evacuation, wound debridement, Negative Pressure Wound Therapy (NPWT), dermal substitutes, and skin grafting. This case describes the multidisciplinary management of an eight-year-old boy with extensive left thigh degloving injury and a large right thigh Morel-Lavallée lesion following a road traffic accident. The patient underwent six surgical procedures over approximately three weeks, demonstrating the importance of coordinated surgical intervention, specialized nursing care, and progressive wound reconstruction.

Case Presentation

An eight-year-old male patient, weighing 36 kg, presented to the Emergency Department of Kauvery Hospital, Bengaluru, on 13 September 2026, following a road traffic accident involving a two-wheeler on 12 September 2026.

The patient had initially received medical care at another healthcare facility, where stabilization measures were undertaken and a surgical drain was placed. At presentation, he complained of progressive swelling of the right thigh, associated with intermittent pain and a reported history of fever.

On examination, the patient was conscious, alert, and oriented.

Initial Vital Signs

ParametersPatient Values
Pulse Rate117 Beats/min
Blood Pressure90/70 mmof Hg
Respiratory Rate20 Breaths / min
Oxygen Saturation98% on Room Air
TemperatureAfebrile

Systematic examination revealed normal bilateral breath sounds, normal heart sounds (S1 and S2), and a soft, non-tender abdomen.

Local examination revealed two significant injuries:

  • Left Thigh: An extensive open degloving injury involving the thigh and groin region, with a large soft-tissue defect and areas of devitalized, necrotic skin.
  • Right Thigh: Marked swelling over the lateral and posterior thigh, associated with an extensive hematoma collection consistent with a Morel-Lavallée lesion.
  • Considering the extent of bilateral soft-tissue trauma, a multidisciplinary surgical management plan was initiated.

Investigations

  • Arterial Doppler Ultrasonography: Colour Doppler assessment of both lower limbs demonstrated normal arterial blood flow, with no evidence of major arterial compromise.
  • Soft-Tissue Ultrasonography: Ultrasonography demonstrated diffuse subcutaneous and intramuscular edema involving both anterior thigh regions. No large residual localized fluid collection was identified at the time of examination.
  • Pre-anaesthetic Assessment: The patient underwent pre-operative evaluation and was classified as ASA Physical Status II-E for emergency surgical management.

The recorded pre-operative observations were:

ParametersPatient Values
Pulse Rate72 Beats/ min
Blood Pressure100/60 mm of Hg
Respiratory Rate20 Breaths/ min
Oxygen Saturation98% on Room air
TemperatureAfebrile
Airway AssessmentMallampati Class I, with adequate mouth opening and temporomandibular joint mobility.

Pre-operative Nursing Care

Pre-operative nursing care focused on patient stabilization, infection prevention, preparation for repeated surgical interventions, and psychological support.

  • Initial Assessment: Recorded vital signs, assessed pain, and monitored the patient’s general condition following admission.
  • Intravenous Access and Fluid Management: Established and maintained intravenous access and administered prescribed IV fluids.
  • Wound and Drain Assessment: Assessed bilateral thigh wounds and monitored the surgical drain placed at the referring hospital, maintaining aseptic precautions.
  • Neurovascular Monitoring: Observed lower-limb circulation and assessed for changes in colour, warmth, distal perfusion, and sensation.
  • Pre-operative Fasting: Maintained nil per oral (NPO) status according to the surgical and anaesthesia team’s instructions.
  • Surgical Preparation: Verified patient identification, assisted with surgical-site preparation, and coordinated pre-operative investigations and prescribed medications.
  • Consent Verification: Supported verification of informed consent from the patient’s parent or legal guardian before operative procedures.
  • Infection Prevention: Maintained appropriate wound hygiene and aseptic practices during preparation.
  • Psychological Support: Provided age-appropriate reassurance and emotional support to the child and caregivers throughout the pre-operative period.

Surgical Management / Procedure

Given the severity of the bilateral thigh injuries, the patient underwent six staged surgical procedures under general anaesthesia between 14 and 30 September 2026.

Surgical Timeline

DateSurgical Procedure
14 September 2026Right thigh hematoma evacuation
16 September 2026Bilateral wound debridement, MatriDerm application, and VAC dressing
18 September 2026Repeat debridement, dermal matrix application, and bilateral VAC dressing
22 September 2026Bilateral wound reassessment, debridement, and VAC dressing
26 September 2026Left thigh split-thickness skin grafting and right thigh secondary suturing
30 September 2026Graft assessment, dressing change, and surgical staple removal

Stage 1: Right Thigh Hematoma Evacuation — 14 September 2026

The first surgical intervention was performed by the CTVS team under general anaesthesia. Intraoperative examination revealed a large Morel-Lavallée cavity containing approximately 900 mL of blood and soft clot in the posterolateral region of the right thigh. A surgical incision was made over the affected area, and the hematoma was evacuated. The cavity was thoroughly irrigated, and hemostasis was achieved. A 16F Romovac suction drain was placed to facilitate drainage, followed by wound closure and sterile dressing.

Stage 2: Bilateral Thigh Debridement and VAC Application — 16 September 2026

The second procedure focused on wound cleaning, removal of damaged tissue, and preparation for reconstruction. Surgical debridement and irrigation were performed on the bilateral thigh wounds. A collagen–elastin dermal matrix (MatriDerm) was applied over the raw wound area of the left thigh. Additional surgical drains were placed as required in the right thigh cavity. Vacuum-Assisted Closure (VAC) dressings were applied to both thighs to support wound management and reduce accumulation of fluid within the affected tissues.

Stage 3: Repeat Debridement and Dermal Matrix Application — 18 September 2026

  • A further surgical exploration was performed to reassess tissue viability and manage residual necrotic tissue.
  • Right Thigh: The extensive Morel-Lavallée cavity extended from the region of the anterior superior iliac spine toward the lower third of the thigh. Residual hematoma and devitalized tissue were removed, and suction drains were repositioned.
  • Left Thigh: Necrotic skin within the degloved groin and thigh region was excised. The wound was irrigated, and MatriDerm was applied to the exposed wound bed.
  • Bilateral VAC dressings were reapplied following completion of wound preparation.

Stage 4: Bilateral Wound Debridement and VAC Dressing — 22 September 2026

During the fourth procedure, both thigh wounds demonstrated improvement. The left thigh exhibited healthy granulation tissue over the raw surface. The right thigh showed a healthy wound bed, with a small area of approximately 2 mm of skin-margin necrosis. Wound irrigation and further debridement were performed as required. Four suction drains were removed, while the remaining drains were repositioned and secured. Fresh VAC dressings were applied to both thighs.

Stage 5: Split-Thickness Skin Grafting and Secondary Suturing — 26 September 2026

  • Following progressive wound-bed preparation, definitive reconstruction was undertaken.
  • Left Thigh: The wound demonstrated a healthy, well-vascularized granulation bed suitable for skin grafting.
  • A split-thickness skin graft (SSG) was harvested from the right thigh donor site and transferred to the left thigh wound. The graft was secured using surgical staples.
  • Right Thigh: The previously extensive cavity had reduced significantly, with healthy surrounding granulation tissue.
  • The remaining suction drains were removed, and secondary suturing of the right thigh wound was performed.
  • VAC dressings were applied over the grafted and surgically closed areas.

Stage 6: Graft Assessment and Staple Removal — 30 September 2026

The final documented procedure involved removal of the VAC dressings, wound inspection, and removal of surgical staples under general anaesthesia. Assessment revealed excellent graft adherence over the left thigh and groin region. The right thigh secondary suture line appeared healthy, without documented wound discharge, infection, or dehiscence. The surgical staples were removed, graft edges were trimmed as required, and protective non-adherent dressings were applied.

Post-operative Course

The patient received continued multidisciplinary care throughout the staged reconstructive treatment. Post-operative management included regular clinical assessments, vital-sign monitoring, wound evaluation, drain management, pain control, and nutritional support.

Medical Management

The documented medication regimen included:

  • Antibiotics: Intravenous amoxicillin-clavulanate, piperacillin-tazobactam, and metronidazole during the treatment course.
  • Analgesia: Paracetamol and tramadol, with other prescribed oral analgesic and anti-inflammatory medications.
  • Gastro protection: Pantoprazole and lansoprazole as prescribed.
  • Supportive Treatment: Antiemetic therapy and other medications according to the treating team’s assessment.

Oral intake was resumed and advanced to an age-appropriate diet under pediatric supervision. During the subsequent recovery period, the patient demonstrated progressive wound improvement, satisfactory pain control, and stable clinical observations. Following the final procedure, graft assessment was satisfactory, and the patient progressed toward assisted mobilization and discharge planning.

Post-operative Nursing Care

Specialized postoperative nursing care played an important role in supporting wound healing, monitoring for complications, and promoting recovery following repeated surgical interventions.

  • Vital Signs and Clinical Monitoring: Monitored blood pressure, pulse, respiratory rate, oxygen saturation, and general condition following each surgical procedure.
  • Pain Management: Assessed pain using age-appropriate paediatric pain scales, administered prescribed analgesics, and evaluated the patient’s response.
  • VAC Dressing Management: Monitored negative pressure wound therapy systems for seal integrity, drainage accumulation, and effective functioning according to prescribed settings.
  • Drain Care: Observed Romovac drains for patency and drainage characteristics, recorded output, and maintained aseptic precautions during drain care.
  • Infection Prevention: Followed aseptic techniques during wound assessments, dressing changes, and drain manipulation. Monitored for fever, abnormal wound discharge, increasing redness, or other signs of infection.
  • Skin Graft Monitoring: Assessed graft appearance and adherence during authorized dressing reviews, observing for discoloration, fluid accumulation, graft displacement, or other concerns.
  • Neurovascular Assessment: Monitored bilateral lower-limb circulation, skin temperature, colour, distal perfusion, and sensation.
  • Medication Administration: Administered prescribed antibiotics, analgesics, and supportive medications, monitoring the patient’s tolerance and clinical response.
  • Positioning and Mobilization: Assisted with safe positioning and gradual mobilization according to the surgical team’s instructions, protecting the graft and donor sites.
  • Compression and Edema Management: Assisted with prescribed crepe bandaging and monitored swelling while ensuring dressings did not compromise circulation.
  • Nutritional Support: Supported adequate oral intake and hydration following recovery from anaesthesia, in coordination with the paediatric team.
  • Family Education: Educated caregivers regarding wound hygiene, dressing care, medication adherence, activity precautions, and warning signs requiring medical review.

Outcome & Follow-Up

Following six staged procedures, the patient demonstrated favourable early postoperative recovery. The left thigh skin graft showed excellent adherence during the final operative assessment, while the right thigh wound demonstrated satisfactory healing following secondary closure. The patient was discharged on 3 October 2026, after approximately 20 days of hospitalization. At discharge, he was clinically stable, afebrile, and able to mobilize with assistance.

Discharge Advice

  • Continue wound care and dressing management according to surgical instructions.
  • Maintain prescribed compression bandaging of the lower limbs.
  • Follow the recommended positioning and gradual ambulation plan.
  • Continue prescribed oral medications, including amoxicillin–clavulanate, paracetamol, and lansoprazole, for the documented short course.
  • Monitor for fever, wound discharge, increasing swelling, wound separation, or new lower-limb symptoms.
  • Attend the scheduled Plastic Surgery follow-up appointment.

Discussion

Extensive degloving injuries in paediatric patient’s present complex challenges because of substantial tissue damage, disruption of vascular supply, and the potential for wound necrosis and infection. In the present case, the child sustained two distinct but related injury patterns: an extensive open degloving injury involving the left thigh and groin, and a large, closed degloving injury of the right thigh consistent with a Morel-Lavallée lesion. The evacuation of approximately 900 mL of hematoma from the right thigh highlighted the severity of the underlying soft-tissue disruption.

Importance of Staged Surgical Management

The treatment strategy combined early hematoma evacuation with serial wound debridement, drainage, negative pressure wound therapy, dermal matrix application, and subsequent split-thickness skin grafting. Repeated wound assessment allowed the surgical team to remove nonviable tissue and reassess wound-bed suitability before definitive reconstruction.

Role of Advanced Wound Management

The use of VAC therapy formed an important component of the staged treatment plan. Negative pressure wound therapy can assist in managing wound exudate, reducing dead space, and preparing complex wounds for delayed closure or grafting. The collagen–elastin dermal matrix (MatriDerm) provided a scaffold for dermal reconstruction over the left thigh defect. Following wound-bed improvement, the patient underwent split-thickness skin grafting, with excellent graft adherence documented during subsequent surgical assessment.

Importance of Specialized Nursing Care

This case also emphasizes the contribution of perioperative nursing care in complex paediatric reconstruction. Repeated surgical interventions required coordinated monitoring of vital signs, wound condition, drain output, VAC systems, pain, nutritional intake, and functional recovery. Careful wound surveillance, aseptic dressing management, and caregiver education supported the continuity of treatment throughout hospitalization and during discharge preparation.

Multidisciplinary Approach

Collaboration between Plastic Surgery, Cardiovascular and Thoracic Surgery, Paediatrics, and the nursing team enabled coordinated management of the patient’s extensive bilateral injuries. The favourable early outcome demonstrates the feasibility of a staged reconstructive approach in severe paediatric soft-tissue trauma. Longer-term follow-up would be required to assess scar development, joint mobility, and durable functional recovery.

Conclusion

This case demonstrates the successful early management of severe bilateral thigh soft-tissue trauma in an eight-year-old child using a structured, multistage surgical approach. The combination of large-volume hematoma evacuation, repeated wound debridement, negative pressure wound therapy, collagen–elastin dermal matrix application, and split-thickness skin grafting achieved satisfactory wound coverage and facilitated recovery. The case particularly highlights the importance of specialized perioperative nursing care, including infection prevention, VAC and drain management, skin graft surveillance, pain assessment, rehabilitation support, and caregiver education. A coordinated multidisciplinary approach, supported by consistent nursing care, contributed to a favourable early clinical outcome and discharge following extensive surgical reconstruction.

Nightingale Journals

Kauvery Hospital
Find Doctor
Book Appointment