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OJHAS: Vol. 5, Issue
1: (2006 Jan-Mar) |
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Giant Lipoma In The Hand - Report Of A Rare Case |
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Jagannath Kamath B
Associate Professor of Orthopaedics
Kasturba Medical
College, Mangalore, Karnataka, India
Ramachandra Kamath K
Assistant
Professor of Orthopaedics
Kasturba Medical
College, Mangalore, Karnataka, India
Praveen Bhardwaj
Assistant Professor of Orthopaedics
Kasturba Medical
College, Mangalore, Karnataka, India
Shridhar
Post graduate student of Orthopaedics
Kasturba Medical
College, Mangalore, Karnataka, India
Chetna Sharma
Post graduate student of Pathology
Kasturba Medical
College, Manipal, Karnataka, India.
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Address For Correspondence |
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Dr. B.
Jagannath Kamath
Jyothi Mansion, Opposite Prabhat
Theatre,
K. S. Rao Road, Mangalore - 575001, India.
E-mail:
bjkamath@satyam.net.in |
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Kamath BJ, Kamath RK, Bhardwaj P, Shridhar, Sharma C. A
Giant Lipoma In The Hand - Report Of A Rare Case.
Online J Health Allied Scs.2006;1:6 |
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Submitted: Apr 11,
2006; Suggested revision: Jun 8, 2006; Revised: Jun 15, 2006; Accepted: Jun 23, 2006; Published:
Jul 08, 2006 |
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| Abstract: |
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A
38 years old male patient presented with a large painless swelling in the right
palm with ultrasound
examination suggestive of fatty nature of the swelling MRI showing a well-circumscribed soft tissue swelling in
the deep palmar space. The giant tumor of 6.5 X 4 cm was excised and the patient
was symptom free two years following the surgery.
Key Words:
Lipoma; Giant tumor; Deep palmar space;
Surgical excision. |
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Lipoma is the
most common and most widely distributed tumor seen in the body. The
most common clinical presentation is a gradually increasing, soft and
resilient, non-tender mass. Upper limb is one of the favoured sites
for lipomas; Pack and Ariel reported 352 lipomas in 134 patients out
of which 94 were in upper limb.(1) But for some reason not known, lipomas
in the palm are very rare and when seen they are normally of a small
size. Barrile could find only one case of palmar lipoma in his 476 lipomas
of the upper extremity.(2) Only case reports and small series of this
entity have been described in the English literature.(3-10) These tumors
are rare and may be very deceptive in terms of their size. We herein
report a case of giant lipoma of deep palmar space. The approach to
such a rare problem has been described and the precautions while handling
such a case have been highlighted.
A
38 year old male patient presented with the complaints of swelling in the
right palm and difficulty in doing his daily activities since one and
half years. He was a computer operator by profession. He first noticed
the swelling on the thenar aspect of the palm one and half-years back,
which slowly increased in size for first six months and then remained
the same. He reported no pain in the palm or numbness in the fingers.
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On
examination a swelling measuring 4 X 3 cm was noticed on the right palm.
Proximal to distal, it extended from 4cm distal to the wrist flexion
crease to the proximal palmar crease. Medio-lateral extent was from
the hypothenar eminence to the radial margin of the hand, obliterating
the hollow of the palm [Figure 1]. On palpation the margins of
the swelling were not well defined. Swelling was non-tender, soft in
consistency and non-compressible. There was no local rise of temperature
or lymphadenopathy. The swelling was not fixed to the skin and overlying
skin was normal. The swelling was not fixed to the underlying structures.
There was no evidence of compressive neuropathy of the median nerve
or any vascular deficit. Based on the features in history and clinical
examination a diagnosis of lipoma or hemangioma was considered. |
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Figure 1: The Zig-Zag incision
used to excise the tumor. This incision allowed us the freedom of extending it and provided good exposure. It can be
noted that on clinical examination the swelling was mainly on the thenar
eminence only. |
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Blood
investigations were normal and x-ray showed a soft tissue swelling over the
thenar eminence [Figure 2 A]. Ultrasound of the swelling was done, which showed
the content of the tumor to be fat and helped to rule out hemangioma. MRI scan
[Figure 2 B] showed a well-circumscribed soft tissue swelling suggesting lipoma.
The extent of the tumor was clearly delineated by the MRI; it showed the lesion
to be larger than what was expected from the clinical examination and helped in
planning the incision and operation. It also revealed the relation of the tumor
to the important structures in the palm.
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Figure 2:(Top)
A: X-ray of the hand showing the soft tissue shadow in
the palmar region.
B: MRI showing the actual extent of the tumor and its relation with
the important structures in the region. |
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Figure 3:(Right)
A:
The excised tumor en masse.
B: Picture showing the dissected and preserved important neurovascular
structures. |
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The
patient was positioned supine under general anesthesia and a tourniquet
was applied over the arm. After adequate preparation and draping a zigzag
incision was made over the palm, extending from the flexion crease of
the wrist to the proximal palmar crease [Figure 1]. Careful dissection
was carried out, starting proximally before the swelling area. The carpal
tunnel was opened and all the important neurovascular structures and
tendons identified all along the course distally [Figure 3 B]. Median
nerve and its branches and digital vessels were identified and well
protected. Palmar arch was preserved. The tumor was carefully dissected
out and excised en masse [Figure 3 A]. The tumor measured 6.5
cm X 4cm [Figure 4]. Tourniquet was deflated and hemostasis achieved.
Skin was closed over a drain and compression dressing applied.
Histopathological examination of the tumor stated it as lipoma with
no neural element and with no evidence of any malignant transformation.
Drain was removed on second day and sutures on the 10th day.
Post operative period was uneventful. Gentle mobilization exercises
of the hand were started at the end of the second week and patient was
back to daily routine by the end of four weeks. He had excellent hand
function without any deficits [Figure 5]. At two years follow up there
was no evidence of any recurrence, patient continued to have normal
hand function and was happy with the results.
Figure 4:(Top)
Tumor
measured about 6.5 cm X 4 cm.
Figure 5:(Right)
Pictures
showing the good hand function four weeks post-operatively. |
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Although there
is a good amount of fat in the palm region, the commonest tumor of the
body that arises in the fat, that is lipoma, is only rarely seen at
this location. Many authors have highlighted the rarity of this lesion
in the palm although there is no apparent reason for it.(3-10) Lipomas
in the hand were classified by Mason (11) in 1937 as superficial and
deep palmar lipomas; the deeper ones are less common than the superficial
ones.(10) Lipoma in the hand typically presents as painless swelling
and usually attains a large size by the time patient seeks medical attention.
Deep palmar lipomas have been reported to result in compressive neuropathy
of the median nerve; some authors have observed grasping difficulties
and decrease in the digital flexion and deviation of the fingers.(3,
8-10,12)
Oster emphasized
on the peripheral location of these tumors in the palm because of the
thick palmar fascia in the center.(3) In our case also the swelling
was more over the thenar eminence [Figure2]. The thick palmar fascia
further deceives the surgeon about the size of tumor. It may be hard
to guess the size of these tumors thinking of the limited space available
under the deep palmar space. Although on clinical examination the size
of the swelling was only about 4 X 3 cm [Figure 2], the size of the
tumor excised in our case was 6.5 X 4 cm [Figure 4], which accounts
to a real giant lipoma of the palmar space. The association of median
nerve compression appears quite possible and has been reported by many
authors. In our patient there were no features suggestive of median
nerve compression.
The tumors
lie in close approximation with the important neurovascular structures
and tendons, which makes the surgery very demanding. A surgeon trained
in hand surgery should preferably do the surgery. The surgeon should
anticipate the large size of the tumor and plan the incision accordingly
[Figure 2]. The important neurovascular structures should be identified
carefully and protected. The distorted anatomy because of the large
tumors further adds to the woes of the surgeon. It is advisable to start
the dissection and identification of all the structures proximally before
the swelling and the proceed distally tracing and preserving all the
important structures carefully [Figure 3B], MRI scan is an excellent
investigation for preoperative planning as it tells the details about
the extent of the tumor, also the homogeneous intensity of MRI indicates
that the lesion is benign [Figure 1B].
Marginal excision
is usually curative and chances of recurrence are minimal. Johnson et
al advised that any soft tissue tumor lump, which is greater than 5cm,
should be considered as malignant until proved otherwise.(13) In our
case the size of the tumor was much more than 5 cm but histopathology
revealed no evidence of any malignant changes.
Deep palmar
lipomas are rare. They can be deceptively large and extensive. MRI scan
is very helpful in planning surgery as it clearly shows the extent of
the tumor and its relation with important structures. The surgical incision
planned, should allow for proximal and distal extension of the incision.
Vital structures should be identified and preserved proximally and followed
distally. With careful surgical technique the complications can be prevented.
Marginal excision of these tumors is curative.
- Phalen GS, Kendrick
JL, Rodriguez JM. Lipoma of the upper extremity: A series of fifteen
tumors in the hand and wrist and six tumors causing nerve compression.
Am J Surg. 1971;121:298-306.
- Barrile NM. Gran
lipoma palmar subaponeurotico. Presna Med Argent. 1958;45:318-320.
- Oster LH, William
FB, Curtis MS. Large lipomas in the deep palmar space. J Hand Surg.
1989;14A:700-704.
- Cribb GL, Cool WP,
Ford DJ et al. Giant lipomatous tumors of the hand and forearm. J Hand Surg. 2005;30B:509-512.
- Schmitz RL, Kelley
JL. Lipoma of the hand. Surgery 1957;42:696-700.
- McEnery ET, Schmitz
RL, Nelson PA. Palmar lipoma: Report of a case. AMA Arch Surg. 1959;699-700.
- Hueston JT. Massive
lipoma of the hand. Aust NZ J Surg. 1965;34:19-21.
- Booher RJ. Lipoblastic
tumors of the hands and feet: Review of literature and report of thirty-three
cases. J Bone Joint Surg. 1965;47A:727-40.
- Paarlberg D, Linscheid
RL, Soule EH. Lipoma of the hand. Mayo Clin Proc. 1972;47:121-124.
- Leffert RD. Lipomas
of the upper extremity. J Bone Joint Surg. 1972;54A:1262-1266.
- Mason ML. Tumors
of hand. Surg Gynec Obstet. 1937;64:129-135.
- Brand MG, Gelberman
RH. Lipoma of the flexor digitorum superficialis causing triggering
at the carpal canal and median nerve compression. J Hand Surg. 1988;13A:342-44.
- Johnson CJ, Pynsent
PB, Grimer RJ. Clinical features of soft tissue sarcomas. Ann Roy Coll Surg Eng. 2001;83:203-205.
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