Fibrolipomatous Hamartoma (FLH) of Median Nerve: A Rare Case Report and Review

Decompression and collagen wrapping of a fibrolipomatous hamartoma of the median nerve: a new approach for a rare and difficult problem

Fibrolipomatous hamartoma is a rare benign slow growing fibrofatty tumor of peripheral nerves of unknown etiology. Clinical presentation may mimic carpal tunnel syndrome when involving the median nerve. We present a case of FLH of the median nerve in a 59-year-old female treated with decompression and collagen nerve wrapping.

Fibrolipomatous Hamartoma Over the Left Forearm and Palm

Introduction

Fibrolipomatous hamartomas are rare congenital benign tumors that can affect the nerves. The symptoms arise due to compression and may require surgical excision.

Case Report

A man in his mid-20s suffered swelling over the volar aspect of the left forearm and hand for 4 months. He was symptomatic. A soft, non-tender swelling of size 6 × 4 cm was present over the flexor aspect of the left forearm and palm, with features suggestive of median nerve compression. Magnetic resonance imaging and electromyography were performed. Decompression of the carpal tunnel was performed with debulking of fibrofatty elements and fine dissection of the neural elements.

Conclusion

This case report demonstrates a rare fibrolipomatous hamartoma encompassing the median nerve, which required surgical excision.

Fibrolipomatous hamartoma of the median nerve in a child with carpal tunnel syndrome: imaging findings and literature review

Fibrolipomatous hamartoma of the median nerve is an uncommon benign tumour of the childhood, which usually manifests in adolescents or adulthood with signs of compressive neuropathy at wrist. Symptomatic tumour is unusual in children below 5 years age and can be underdiagnosed. Magnetic resonance imaging provides pathognomonic features for the diagnosis, obviating the need for biopsy. Although standard ultrasonography is frequently the first-line imaging approach in the evaluation of soft-tissue masses, sonographic findings of this lesion are less frequently reported and have to be kept in mind by radiologist. We report the unusual case of carpal tunnel syndrome secondary to fibrolipomatous hamartoma of the median nerve in a 4-year-old child successfully treated with surgical carpal tunnel release.

Fibrolipomatous hamartoma of the median nerve: a case report and literature review

Fibrolipomatous hamartoma (FLH) of the nerve, also known as lipomatosis of the nerve, neurofibrillary lipomatous lesion, or intraneural li-poma, is a rare benign soft tissue tumor which mainly occurs in the nerves of the upper limb, especially in the median nerve.In April 2021, a 30-year-old male patient was secondly admitted to our hospital and underwent his third surgery, due to the recurrence of a mass and pain in the right palm, noticeable swelling and numbness of the right index and ring fingers, and limited flexion and extension activities of the right ring finger. He first visited our hospital in December 2017 due to a mass and pain in the right palm and swelling and numbness of the right index and ring fingers. When the clinician asked for the patient medical history, his parents stated that his right middle finger was swol-len after birth. When the patient was ten years old; he was diagnosed with “mac-rodactyly” at the local county hospital, not in our hospital, and subsequently, the middle finger was amputated at the metacarpophalangeal joint level at the local county hospital. The postoperative pathological examination was not per-formed at that time, which was the first surgery the patient received.FLH is clinically rare, and its exact epidemiology and etiology are poorly understood. FLH is highly suspected in cases where a painless mass is present in the wrist, combined with macrodactyly. Magnetic resonance imaging and pathological examination are helpful in clarifying the diagnosis. Although FLH is a benign tumor, an individual treatment plan is the best choice according to the severity of the patient’s symptoms. Therefore, further exploration and understanding of this disease by clinicians radiologists, and pathologists is necessary.

Post Ambulatory Swollen Hands (POTASH): An Autobiographical Case Report

Post ambulatory swollen hands (POTASH) is a rarely described etiology for hand swelling; to the best of my knowledge, it has only been reported in the medical literature a decade ago in a prospective study evaluating its development in walkers who were either dog owners (who walked or did not walk their dogs) in comparison to non-dog owners. In addition to swelling after initiating ambulation by participating in an activity such as hiking, running, or walking, there are also several other causes of swollen hands; a positive fist sign has only been described in a limited number of conditions observed in individuals with hand swelling. A fist is created when there is clenching of the fingers and the fingertips are in direct contact with the palm of the hand with the thumb lying on top of the fingers between the proximal and distal interphalangeal joints. A positive fist sign is demonstrated by the inability to clench the fingers tightly into a fist; indeed, it is a common--yet not frequently reported--manifestation observed in individuals with a swollen hand. In contrast, a negative fist sign occurs when the patient can form a fist of tightly clenched fingers. The author, a 62-year-old physician and long-distance runner since high school, developed recurrent episodes of POTASH beginning five years ago. He noticed asymptomatic, bilateral, and symmetric swelling of his dorsal and palmar hands--with a positive fist sign--beginning after approximately one hour of running; the degree of swelling was proportional to the duration of time he ran. His hand swelling would completely resolve spontaneously--and his fist sign would be negative--within two hours after he stopped running. Recommendations for hikers and walkers to potentially eliminate or limit the degree of POTASH have been suggested; for dog owners who walked their dog, POTASH was less likely to occur if they regularly walked the dog. Several etiologies for POTASH have been proposed; however, the definitive pathogenesis for hand swelling related to either hiking, running, or walking remains to be determined. Therefore, research to gain additional insight and possibly establish the cause of ambulatory-associated swollen hands is warranted.

Fibrolipomatous Hamartoma of Median Nerve - A Diagnostic Challenge

INTRODUCTION

Fibrolipomatous hamartoma (FLH) is an uncommon slow-growing tumor of benign etiology, which predominantly affects the median nerve.

CASE REPORT

We report the case study of a 17-year-old male patient, who presented with complaints of a gradually increasing localized swelling over the volar aspect of left hand for 1 year. A contrast-enhanced Magnetic resonance (MR) scan of the left hand was performed which demonstrated characteristic findings. The patient was treated surgically and post-excision histopathological examination confirmed the diagnosis.

CONCLUSION

The characteristic MR imaging features of coaxial cable-like appearance on axial section or spaghetti shaped enlarged nerve fascicles and fibrous tissue is confirmatory for a definitive diagnosis of FLH, which alleviates the need for any unnecessary biopsy.