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rev bras ortop.2017;52(5):612–615

SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

w w w . r b o . o r g . b r

Case

Report

Giant

palmar

lipoma

an

unusual

cause

of

carpal

tunnel

syndrome

Gaizka

Ribeiro

,

Marta

Salgueiro,

Miguel

Andrade,

Victor

Santos

Fernandes

HospitaldeSantaMaria(CHLN),Servic¸odeCirurgiaPlástica,Lisboa,Portugal

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received14July2016

Accepted16August2016

Availableonline14August2017

Keywords:

Lipoma

Carpaltunnelsyndrome

Hand

Mediannerve

a

b

s

t

r

a

c

t

Lipomaisaquitecommontypeofsoft-tissuetumor,butitisrarelyfoundinthehand.Hand

lipomasaregenerallyasymptomatic;however,whentheybecometoolargeorwhenthey

arepresentinsomespecificlocation,theycancausesymptomsduetocompressionofthe

mediannerve.Thesetumorsmustbecorrectlycharacterizedpreoperativelywithimaging

examsandthepropermanagementisthecompleteremovalofthetumorandreleaseofthe

mediannerve.Theauthorspresentthecaseofafemalepatientwithcarpaltunnelsyndrome

duetocompressionofthemediannervebyagiantpalmarlipoma,successfullytreatedwith

tumorexcisionandnerverelease.

©2017SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora

Ltda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://

creativecommons.org/licenses/by-nc-nd/4.0/).

Lipoma

palmar

gigante

Uma

causa

pouco

usual

de

síndrome

do

túnel

cárpico

Palavras-chave:

Lipoma

Síndromedotúnelcarpal

Mão

Nervomediano

r

e

s

u

m

o

Olipoma é um tumor frequente dos tecidos moles, mas a sua localizac¸ão na mão é

rara.Oslipomas damão geralmentesãoassintomáticos; contudo,quandoapresentam

umgrandecrescimentoouemdeterminadas localizac¸ões,podemcausarsintomas

dev-idoàcompressãodonervomediano.Essestumoresdevemserdevidamentecaracterizados

pré-operatoriamentecomumexamedeimagemeseucorretotratamentobaseia-sena

suaexcisãocompletaeliberac¸ãodonervomediano.Apresentamosocasoclínicodeuma

pacientecomodiagnósticodesíndromedotúnelcarpalresultantedecompressãodonervo

medianoporumlipomapalmargigante,tratadacomsucessocomlipectomiae

descom-pressãonervosa.

©2017SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevierEditora

Ltda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http://

creativecommons.org/licenses/by-nc-nd/4.0/).

PaperdevelopedatHospitaldeSantaMaria(CHLN),Servic¸odeCirurgiaPlástica,Lisbon,Portugal.

Correspondingauthor.

E-mail:akziag@sapo.pt(G.Ribeiro).

http://dx.doi.org/10.1016/j.rboe.2017.08.001

2255-4971/©2017SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditoraLtda.Thisisanopenaccessarticle

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rev bras ortop.2017;52(5):612–615

613

Introduction

Lipomasareveryfrequentbenignsofttissuetumors,1–8 but

theirincidence inthe handis rare.1–6 Lipomasare

consid-eredgianttumorswhentheyare5cm2,3ormoreindiameter,

and they generally behave as asymptomatic tumefactions,

ofslowandprogressivegrowth5,8;however,sometimesthey

canleadtosymptomatologyduetocompressionofadjacent

structures.1–3,5,8,9 Peripheric nerve compression bylipomas

is very uncommon. Few cases of carpal tunnel syndrome

resultingfrom mediannerve compression byalipoma are

describedintheliterature.4,6Theanatomicparticularitiesof

thehandrequirespecialcareinthediagnosticandtherapeutic

approachtothesetumors.3Inthisarticlewedescribea

clini-calcaseofaseventy-year-oldfemalepatientwithadiagnosis

ofgiantpalmarlipomathatleadstocarpaltunnelsyndrome,

successfullytreatedwithalipectomyandreleaseofthe

ante-riorannularligamentofthecarpus.

Clinical

case

Aseventy-year-oldfemale,leucodermicpatient,wasreferred

toaplasticsurgeryconsultationbytheattendingphysician

dueto swelling on the palmar side ofthe left hand

(non-dominanthand),withprogressivegrowthoverthelastyear,

andcomplaintsofparesthesiaandpaininthefirstthree

fin-gersofthelefthand.Thepatientunderwentacomputedaxial

tomographyofthehandandwristrequiredbyherphysician,

whichrevealedaformationofadiposedensitywithsomefine

internalseptations,withwell-definedcontours,

intramuscu-larlocationwithextensiontothedeep spacesofthehand

andwithabout6.5cmofcross-sectionalaxisand6.5of

longi-tudinalaxis,findingssuggestingthediagnosisofgiantpalmar

lipoma(Fig.1)

Onexamination,thepatienthadapalpable,movablemass

atthelevelofthethenareminence,ofsoftandpainless

consis-tency(Fig.2).Thepercussionofthemasstriggeredcomplaints

ofparesthesiaofthefirstthreefingersofthelefthand

(posi-tiveTinel’ssign).Thepatienthadnomotorcomplaintsofthe

hand,withpreservationofstrengthanddigitalpincer

func-tion.Axillaryadenopathieswerenotpalpable.

Anelectromyographyofthewristwasdone,which

identi-fiedaspectsconsistentwithmarkedleftmediannervelesion.

Fig.2–Swellingofthethenareminence.

Withthediagnosisobtained,surgicaltreatmentwas

pro-posed to the patient. In a supine position, under brachial

plexus anesthesia and controlled ischemia of the upper

limbwithapneumatictourniquet,tumorexcisionwas

per-formed. Through apalmar incision, thepalmar fascia was

opened and the tumorwas dissected and excised (Fig. 3).

Themediannerveanditsbranchesweredulyidentifiedand

preserved(Fig.4).Theanteriorannularcarpalligamentwas

sectioned.Afterrevisionofthehemostasis,theincisionwas

closedinasingleplanewithnon-absorbablesuturesunder

passive drainage. The procedure lasted for about 2h and

therewerenocomplications.Thepatientwasdischargedon

the same dayand wasfollowedup atanoutpatientclinic.

Theanatomopathologicalresultconfirmedthe diagnosisof

lipoma.

Afterfive months,there wasreversionofcomplaintsof

paresthesiaand painofthe firstthree fingersofthehand.

Duringthisperiod,noclinicalsignsoftumorrecurrencewere

identified,andtherewasgoodwoundhealing(Fig.5).

Discussion

Lipomas are the most frequent tumors in the human

body1–8;however,theirlocationinthehandisrare,1–6which

is a challenge in terms of a diagnostic and therapeutic

approach.3

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614

rev bras ortop.2017;52(5):612–615

Fig.3–Intraoperativephotoofpalmarlipoma.

Fig.4–Intraoperativephotowherethemediannerveand

branchescanbeseen.

Fig.5–Postoperativephotoafterfivemonths.

Handlipomahasahigherincidenceinindividualsbetween

50 and 60 years and is generally asymptomatic, revealing

itselfasamobileandpainless massofprogressivegrowth.

Sometimes, when it becomes massive or in certain

loca-tions, it can cause symptoms resulting from nervous

compression.1–4,6,8,9Intramuscularorsubfascialgiantlipomas

ofthehand(>5cmofdiameter)canbethecauseofcarpal

tun-nelsyndrome;therearefewcasesdescribedintheliterature.6

Whencarpaltunnelsyndromesecondarytogiantlipoma

is suspected, hand imaging (ideally a computed axial

tomography or magnetic resonance imaging) is essential,

allowingabettercharacterizationofthesizeandlocationof

thetumor,aswellasitsrelationwiththeneighboringvascular

andnervestructures.1–4,6,8,9Theseexamsarealsoimportant

toestablishthedifferentialdiagnosiswithmalignanttumors,

becausethesehandtumorsofmorethan5cmofdiameterare

highlysuggestiveofmalignancy.2,3,6,7Awristelectromyogram

isequallyindispensablefordocumentingthenervelesion.3,6

Thetreatmentofthesepatientsinvolvestumorexcision

andmediannervereleaseinthecarpaltunnel.Amonoblock

excision ofthelipomashouldbeideallydone, withcareful

dissectionthatallowstheidentificationandpreservationofall

vascularandnervestructuresadjacenttothetumor,toreduce

theriskofiatrogenicinjury.1,3,6,8,9

Although hand lipomas are rare, they should not be

neglectedasapossiblecaseofmediannervecompressionin

thecarpaltunnel.Itscorrecttreatmentreliesontheadequate

tumortopographiccharacterization,onasurgicalapproach

that preserves the anatomic structuresinvolved, and on a

completeexcision,reducingtheriskofrecurrence.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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1.MohanL,SemoesJ.Thenarintramuscularlipoma:anunusual

case.InternetJSurg.2007;17:1–3.Availablefrom:

http://print.ispub.com/api/0/ispub-article/9785.

2.YildiranG,AkdagO,KarameseM,SelimogluM,TosunZ.Giant lipomasofthehand.HandMicrosurg.2015;4(1):8–11.

3.FazilleauF,WilliamsT,RichouJ,SauleauV,NenD.Median

nervecompressionincarpaltunnelcausedbyagiantlipoma.

CaseRepOrthop.2014;2014:1–5.Availablefrom:

http://www.hindawi.com/journals/crior/2014/654934/. 4.AzwaN,ShalimarA,JamariS.Apalmarlipomawithmedian

andulnarnervecompressivesymptoms.MalaysOrthopJ. 2007;1:33–5.

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rev bras ortop.2017;52(5):612–615

615

6.SbaiMA,BenzartiS,MsekH,BoussenM,KhorbiA.Carpal tunnelsyndromecausedbylipoma:acasereport.PanAfrMed J.2015;22:51.

7.MoralesC,LópezJ,GargolloC,JiménezY.Handlipoma, surgicalenclinicallynaunderstimatedtumor.CirPlást Iberolatinoam.2011;37:349–53.

8.NadarMM,BartoliCR,KasdanML.Lipomasofthehand:a reviewand13patientcaseseries.Eplasty.2010;10:e66.

Imagem

Fig. 1 – Preoperative hand axial computed tomography.
Fig. 3 – Intraoperative photo of palmar lipoma.

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