Working Diagnosis:
Intramuscular Degloving Injury of the Rectus Femoris

Treatment:
The patient initially underwent conservative management, including compression, heat, pain control, and rehabilitation focused on range of motion and strengthening. Multiple aspiration attempts were unsuccessful due to rapid fluid reaccumulation. He subsequently underwent operative incision and drainage, during which 710 cc of hemolymphatic fluid and hematoma were evacuated. A Hemovac drain was placed, followed by compressive dressing application. After surgery, he resumed physical therapy and a supervised return-to-play progression.

Outcome:
The patient experienced progressive reduction in swelling and restoration of function. He completed a gradual return-to-play program under the supervision of his orthopedic surgeon and athletic trainer and returned to full baseball participation without recurrence or complications.

Author's Comments:
Intramuscular degloving injuries represent a severe, distinct variant of muscle trauma where shearing forces cause the muscle belly to detach from its central aponeurosis or surrounding fascial sheath, creating a persistent potential space. While classic Morel-Lavallee lesions occur in the subcutaneous-fascial interface, intramuscular degloving typically isolates within the muscle belly, most commonly the rectus femoris due to its complex bipennate architecture.
In this case, the high-velocity deceleration and shearing forces of a head-first slide precipitated the injury. This case underscores the necessity of maintaining a high index of suspicion for an intramuscular degloving injury when managing athletes with large, persistent post-traumatic thigh collections that fail conservative management. Recognizing this entity early can prevent the morbidity of repetitive, unsuccessful clinic aspirations, minimize the risk of secondary infection, and guide timely surgical intervention to expedite a safe return to sport.

Editor's Comments:
Intramuscular degloving injuries are rare and reported in the rectus femoris given its unique bipennate structure and bi-articular course. Diagnosis based on clinical history and appearance alone is challenging, as presentation can vary. However, MRI is the gold standard of imaging, with a classic “finger-in-a-glove” appearance on MRI.
Intramuscular degloving injury management depends on the degree of subdermal fluid collection, as larger collections can contribute to tissue necrosis. Beginning with rest, compression, and attempted needle aspiration are initial steps. If necessary, advancing to use of sclerosing agent (ie doxycycline) or surgical debridement is appropriate. If needle aspiration results in removal of 50 mLs or more, surgical debridement is indicated.

References:
Kassarjian A, Rodrigo RM, Santisteban JM. Intramuscular degloving injuries to the rectus femoris: findings at MRI. AJR Am J Roentgenol. 2014;202(5):W475-W480. doi:10.2214/AJR.13.10931.

Feger J, Intramuscular degloving injury. Reference article, Radiopaedia.org
https://doi.org/10.53347/rID-82386

Meller L, Oca MC, Wilson K, et al. Intramuscular degloving injury of the rectus femoris from kickball: a case report and review. Cureus. 2023;15(7):e42230. doi:10.7759/cureus.42230.

Return To The Case Studies List.