1 Introduction

Lipoma is a slow-growing, benign fat tumour that forms soft, lobulated masses enclosed by a thin, fibrous capsule. They may develop at any location throughout the body-skin or splanchnic. However, in the hands, lipomas are rather rare. The clinical presentation of such lipomas ranges from being completely asymptomatic to causing debilitating symptoms. The symptoms are correlated to their location and size.^1a,1b Giant lipomas are defined to be greater than 5 cm.² Due to their size, they may compress the surrounding neuromuscular bundle causing sensory-motor symptoms, namely pain, paraesthesia, and difficult movements.^1a,1b

2 Case report clinical history

An otherwise healthy old age female with no known co-morbidity, presented to the orthopaedic outpatient with complaints of swelling on her right palm in the first web space, deteriorating pincer grasp and digital paraesthesia (see Fig. 1). She first noticed the swelling in the center of her palm, which gradually increased in size over the period of one year. On clinical examination, a soft, non-tender, fluctuant mass, with the normal overlying skin, was palpated over the thenar region. The slippage sign was elucidated. Lipoma of the first web space was suspected, and the case was investigated accordingly.

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Fig. 1 Pre-operative image showing swelling over thenar area extending to first web space.

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Laboratory reports did not characterise anything abnormal. The MRI of the right hand reported a superficial subcutaneous lipoma of the first interdigital space (see Figs. 2–4). Based on the clinical, and radiological data, the diagnosis of ‘Superficial subcutaneous lipoma of first interdigital web space of the right hand’ was made. As per protocols, the patient was taken up for elective excision of the lipoma.

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Fig. 2 MRI reporting ascertaining the size and location of the lipoma.

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Fig. 3 MRI imaging in transverse view. Lipoma is marked within red circle. (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.)

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Fig. 4 MRI imaging in coronal view. Lipoma is marked within the red circle. (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.)

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3 Operative procedure

Under antiseptic control, the operative site was draped and marked. After ensuring adequate preparation of the site, marginal resection of the lipoma was performed under the axillary block by tourniquet-controlled hemostasis. A palmar incision was given. An encapsulated yellowish mass was identified and delineated as such. The identified lesion was separated from the palmar fascia overlying it (see Fig. 5). The digital cutaneous branch of the median nerve was identified and preserved during the procedure (see Figs. 6 and 7). Skin was sutured, tourniquet was released, and the antiseptic compressive dressing was applied to the incision site.

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Fig. 5 Lipoma in situ along with the cutaneous nerve.

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Fig. 6 Digital cutaneous branch of the median nerve identified and preserved.

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Fig. 7 Excised lipoma in its capsule.

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4 Post-operative course

During the postoperative period, the due course of antibiotics and regular dressings were done. Sutures were removed and the patient was discharged on day 12. Physiotherapy was advised. Histopathology confirmed the lesion to be lipoma. The patient noted improvement in her troublesome symptoms. No complaint of any restriction in the finger movements or any sensory loss was reported. No fresh complaints were registered on the subsequent visits.

Figs. 8 and 9 - Patient notes post-operative improvement in mobility.

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Fig. 8 Image showing the post-operative scar.

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Fig. 9 Image showing movement of thumb.

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5 Discussion

Lipoma is generally defined to be a slow-growing, benign adipose cell tumour which forms a soft, and lobulated mass enclosed by a thin but fibrous capsule. Since lipomas are mesenchymal tumours in origin, their locations are diverse. Considering their locations, they are cutaneous, sub-cutaneous, inter-muscular, intra-muscular or splanchnic. Owning to their fluctuant property, their margins resemble the tissue space they occupy. Thus, the presence of the lack of tissue fascia explains the varied shapes and sizes of lipomas described in the literature.

Despite the apparent abundance of adipose tissue in the palm, lipomas at this location are anything but common. Lipoma directs itself with the anatomical contours of the surrounding tissue¹ and hence — subcutaneous tissues give rise to superficial lipomas. The typical presentation of a palmar lipoma is a painless swelling in the hand. It can, however, also cause sensorimotor symptoms due to compression of nearby nerves. Paraesthesia and reduced range of motion often cause the patients to seek medical intervention. The palpatory hallmarks of a lipoma are the same, irrespective of the location i.e. a soft, fluctuant, lobulated, mass with freely mobile overlying skin. A characteristic “slippage sign” may be elicited by gently sliding the fingers off the edge of the tumour. Laboratory investigations are often inconclusive when diagnosing a lipoma. MRI is described as the recommended preoperative investigation in various clinical studies.³

Benign lipomas are excised with a complete removal of their capsule. Recurrence may occur if the excision is incomplete. Otherwise, their outcome and prognosis are usually excellent.

6 Conclusion

Unlike lipomas at other anatomical locations, lipomas of the hand and wrist are often at the bottom of the differentials. Only a handful of case reports of palmar lipoma are present in literature.⁴ They often compress the surrounding nerves and produce significant sensorimotor symptoms. Patients often undergo unnecessary testing and treatments for carpal tunnel, without any relief. This report reiterates that clinical suspicion supersedes most, if not all the modalities. The consideration of lipoma among the differentials of the tumours of the hand and wrist is imperative. Although symptoms are curable with a seemingly simple procedure, a quicker diagnosis is the need of the hour.

Consent

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008. Informed consent was obtained from the patient for publication of this case report and any accompanying images.

Declarations competing interests

The authors declare that they have no competing interests.

Funding

NA.

Consent

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008. Informed consent was obtained from the patient for publication of this case report and any accompanying images.

Ethics

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008.

Funding

NA - This study has been solely been based for the purpose of research. The author does not expect any kind of financial gain from this study whether directly or indirectly.

CRediT authorship contribution statement

Aarush Paul: First case was reported to him. Assisted the surgery as well, collected all the relevant information from literature. Maninder Singh: Assisted the surgery in this case. Satnam Singh: Chief operating surgeon in this case.