Compression of the median nerve in the proximal forearm by a giant lipoma: A case report^[*]

Abstract

Background Compression of the median nerve by a tumour in the elbow and forearm region is rare. We present a case of neuropathy of the median nerve secondary to compression by giant lipoma in the proximal forearm.

Case presentation A 46-year-old man presented with a six month history of gradually worsening numbness and paresthesia on the palmar aspect of the left thumb and thenar eminence. Clinical examination reveals a hypoaesthesia in the median nerve area of the left index and thumb compared to the contralateral side. Electromyography showed prolonged sensory latency in the distribution of the median nerve corresponding to compression in the region of the pronator teres (pronator syndrome). Radiological investigations were initially reported as normal. Conservative treatment for one month did not result in any improvement. Surgical exploration was performed and a large intermuscular lipoma enveloped the median nerve was found. A complete excision of the tumour was performed. Postoperative revaluation the X-ray of the elbow was seen to demonstrate a well-circumscribed mass in the anterior aspect of the proximal forearm. At follow-up, 14 months after surgery, the patient noted complete return of the sensation and resolution of the paresthesia.

Conclusion In case of atypical findings or non frequent localization of nerve compression, clinically interpreted as an idiopathic compression, it is recommended to make a pre-operative complementary Ultrasound or MRI study.

^*This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

• References

• 1 Gross PT, Jones Jr HR. Proximal median neuropathies: electromyographic and clinical correlation. Muscle Nerve 1992; 15: 390-395 10.1002/mus.880150320 1313546
• 2 al-Qattan MM, Husband JB. Median nerve compression by the supracondylar process: a case report. J Hand Surg [Br] 1991; 16 (1) 101-103 2007799
• 3 Johnson RK, Spinner M, Shrewsbury MM. Median nerve entrapment syndrome in the proximal forearm. J Hand Surg [Am] 1979; 4: 48-51 759503
• 4 Dellon AL, Mackinnon SE. Musculoaponeurotic variations along the course of the median nerve in the proximal forearm. J Hand Surg [Br] 1987; 12 (3) 359-363 3437205
• 5 Jones NF, Ming NL. Persistent median artery as a cause of pronator syndrome. J Hand Surg [Am] 1988; 13: 728-32 3241046
• 6 Kutz JE, Singer R, Lindsay M. Chronic exertional compartment syndrome of the forearm: a case report. J Hand Surg [Am] 1985; 10 (2) 302-304 3980952
• 7 Foxworthy M, Kinninmonth AW. Median nerve compression in the proximal forearm as a complication of partial rupture of the distal biceps brachii tendon. J Hand Surg [Br] 1992; 17: 515-517 1479243
• 8 Nogueira A, Alcelay O, Pena C, Sarasua JG, Madrigal B. Synovial osteochondromatosis at the elbow producing ulnar and median nerve palsy. Case report and review of the literature. Chir Main 1999; 18: 108-114 10.1016/S0753-9053(99)80063-5 10855308
• 9 Leffert RD. Lipoma of the upper extremity. J Bone Joint Surg Am 1972; 54: 1262-1266 4652058
• 10 Cribb GL, Cool WP, Ford DJ, Mangham DC. Giant lipomatous tumors of the hand and forearm. J Hand Surg [Br] 2005; 30 (5) 509-512 15992974
• 11 Flores LP, Carneiro JZ. Peripheral nerve compression secondary to adjacent lipomas. Surg Neurol 2007; 67: 258-263 10.1016/j.surneu.2006.06.052 17320633
• 12 Babins DM, Lubahn JD. Palmar lipomas associated with compression of the median nerve. J Bone Joint Surg Am 1994; 76 (9) 1360-1362 8077265
• 13 Phalen GS, Kendrick JI, Rodriguez JM. Lipomas of the upper extremity. A series of fifteen tumours in the hand and six tumours causing nerve compression. Am J Surg 1971; 121: 298-306 10.1016/0002-9610(71)90208-X 4322966
• 14 Barber KW, Bianco Jr AJ, Soule ED, McCarty CS. Benign extraneural soft tissues tumours of the extremities causing compression of nerves. J Bone Joint Surg Am 1962; 44: 98-104
• 15 Bieber EJ, Moore JR, Weiland AJ. Lipomas compressing the radial nerve at the elbow. J Hand Surg [Am] 1986; 11 (4) 533-535 3722765
• 16 Fitzgerald A, Anderson W, Hooper G. Posterior interosseous nerve palsy due to parosteal lipoma. J Hand Surg [Br] 2002; 27: 535-537 12475510
• 17 Lidor C, Lotem M, Hallel T. Parosteal lipoma of the proximal radius: a report of 5 cases. J Hand Surg [Am] 1992; 17: 1095-1097 1430948
• 18 Nishida J, Shimamura T, Ehara S, Shiraishi H, Sato T, Abe M. Posterior interosseous nerve palsy caused by parosteal lipoma of proximal radius. Skeletal Radiol 1998; 27: 375-379 10.1007/s002560050401 9730328
• 19 Werner CO. Radial nerve paralysis and tumor. Clin Orthop Relat Res 1991; 268: 223-225 2060213
• 20 Bui-Mansfield LT, Williamson M, Wheeler DT, Johnstone F. Guyon’s canal lipoma causing ulnar neuropathy. AJR Am J Roentgenol 2002; 178: 1458 12034617
• 21 Galeano M, Colonna M, Risitano G. Ulnar tunnel syndrome secondary to lipoma of the hypothenar region. Ann Plast Surg 2001; 46: 83-84 10.1097/00000637-200101000-00020 11192045
• 22 Zahrawi F. Acute compression ulnar neuropathy at Guyon’s canal resulting from lipoma. J Hand Surg [Am] 1984; 9 (2) 238-240 6715832
• 23 Weinzweig N, Browne Jr EZ. Infraclavicular median nerve compression caused by a lipoma. Orthopedics 1988; 11: 1077-1078 3405907
• 24 Oster LH, Blair WF, Steyers CM. Large lipomas in the deep palmar space. J Hand Surg [Am] 1989; 14 (4) 700-704 10.1016/0363-5023(89)90193-7 2754203
• 25 Schmitz RL, Keeley JL. Lipomas of the hand. Surgery 1957; 42: 696-700 13467636
• 26 Sonoda H, Takasita M, Taira H, Higashi T, Tsumura H. Carpal tunnel syndrome and trigger wrist caused by a lipoma arising from flexor tenosynovium: a case report. J Hand Surg [Am] 2002; 27 (6) 1056-1558 10.1053/jhsu.2002.36522 12457357
• 27 Kremchek TE, Kremchek EJ. Carpal tunnel syndrome caused by flexor tendon sheath lipoma. Orthop Rev 1988; 17: 1083-1085 3205585
• 28 Higgs PH, Young VL, Schuster R, Weeks PM. Giant lipomas of the hand and forearm. South Med J 1993; 86: 887-890 10.1097/00007611-199308000-00008 8351548
• 29 Johnson CJ, Pynsent PB, Grimer RJ. Clinical features of soft tissue sarcomas. Ann R Coll Surg Engl 2001; 83: 203-205 11432141