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Haemangioma of flexor digitorum profundus
Haemangioma of Flexor Digitorum Profundus--C. E. A. Holden HAEMANGIOMA
OF FLEXOR
DIGITORUM
PROFUNDUS
C. E. A. HOLDEN, London Haemangioma of skeletal muscle is a well recognised but uncommon tumour. This is one reason why it is rarely diagnosed correctly before operation. This paper describes a case of haemangioma of the flexor digitorum profundus muscle. HISTORY
M. D., a twenty-five year old-clerk, presented in June, 1970 with a history of pain and swelling in the left forearm. The swelling had been present for about four weeks with some discomfort, but he had paid it little attention apart from transferring his watch to the other arm. Three days before admission his pain had become suddenly more severe, the swelling had increased in size and he had become unable to straighten his fingers. ON EXAMINATION
The ulnar side of the distal half of the flexor aspect of the left forearm was the site of a poorly defined swelling, some ten centimetres long and seven centimetres broad. The swelling was firm in consistency and tender on deep palpation. There was no audible bruit over the mass. The overlying skin was normal. Extension of the fingers was limited to about half the normal range when the wrist was held in the neutral position. Full extension could be achieved by flexing the wrist maximally. Active flexion of the fingers was limited by pain in the forearm. Movements of the thumb were not affected. X-ray of the forearm confirmed the presence of a large soft tissue swelling and showed a small rounded opacity in the distal part of the tumour. 4rteriography (Fig. 1). The radial artery was normal. The interosseous artery was much larger than normal and supplied a large vascular mass in the distal half of the forearm. There were abnormal vessels within this mass and abnormal draining veins. The diagnosis of a sarcoma was suspected. Chest X - r a y was normal.
Fig. I. Arteriography demonstrates a large interosseous artery, supplying a large vascular mass.
42
Vol. 4
No. 1
1972
Haemangiorna of Flexor Digitorurn Profundus'--C. E. A. Holden OPERATION
Through a direct ventral approach the superficialis muscle was reflected leaving the median nerve attached to its deep surface. The muscle of flexor digitorum profundus was found to be almost completely replaced by an irregular mass of hard tumour which appeared to contain areas of recent haemorrhage. The ulnar nerve was not adherent to the mass and was retracted. The main vessels to the mass were ligated and divided. Proximally the line of section was through a fringe of normal muscle; distally the tendons were divided about two centimetres proximal to the carpal tunnel. On its deep aspect the mass was adherent to the periosteum of the radius and an area of periosteum one by three centimetres was removed with the tumour. The wound was closed with suction drainage. PROGRESS
The wound healed without complication. The patient was relieved of his pain and could move his wrist and fingers easily and completely apart from loss of active flexion in the distal interphalangeal joints of all the fingers. One year later there is no sign of recurrence of the tumour. He is able to manage his work adequately. He has difficulty in fastening buttons and tying his tie, though he can play the piano. He has declined any further operation. PATHOLOGY
Within the muscle was a well circumscribed mass of fibrous tissue with widely dilated blood vessels occluded by ante-mortem thrombus (Fig. 2). Section of the tumour showed many medium sized muscular arteries within vascular connective tissue. Some vessels were occluded by thrombus and in others organised thrombus had obliterated the lumen. There were focal areas of tissue resembling both cavernous and capillary haemangiomata (Fig. 3). There was atrophy of some fibres in the muscle immediately adjacent to the mass but no evidence of invasion. The appearances are those of vascular hamartoma.
Fig. 2. The tumour shows a mass of fibrous tissue with widely dilated vessels containing ante-mortem thrombus. Fig. 3. Vascular hamartoma with focal areas of tissue resembling both cavernous and capillary haemangiomata. Vol. 4
No. 1
1972
43
Haemangiorna of Elexor Digitorum Profundus--C. E. A. Holden DISCUSSION
This case illustrates many of the features of the tumour and its situation is of interest. Jenkins and Delany (1932) reviewed 256 cases from the literature adding one of their own. In only twelve per cent was the correct diagnosis made before operation; the commonest diagnoses being lipoma, sarcoma and cold abscess. A valuable diagnostic feature was the presence of a phlebolith on plain X-ray film which they found in fifty per cent of cases. In no series have these tumours been recorded as metastasizing and recurrence (about six per cent) has usually been associated with incomplete removal. It is important to remove these tumours completely on the first occasion. If left untreated or incompletely excised they infiltrate local tissues to such an extent that any form of local surgical removal is impracticable and amputation may have to be considered (Scott, 1957). Residual disability after resection of these tumours depends on their site and occurs in about five per cent of cases. In the case reported here the operation required removal of all but a proximal fringe of the belly of flexor digitorum profundus. Had the benign nature of the turnout been appreciated at the time of operation the level of section through the tendons might have been made more proximally and each tendon could then have been attached to the appropriate superficial tendon. Jones (1953) described a similar case where the haemangioma involved only that part of the flexor digitorum profundus which supplied the index and middle fingers. The tumour was excised and the tendons of the index and middle fingers were sutured to the profundus tendons of the ring and little fingers. Normal function was restored. A reconstruction of this nature was not available in the present case. At this stage the function of the left hand could most easily be improved by fusion of the distal interphalangeal joints, at least of the index and middle finger in an appropriate degree o f flexion. ACKNOWLEDGEMENT
I am grateful to Dr. C. W. Elston for details of the pathology of the specimen.
REFERENCES
JENKINS, H. P., DELANEY, P A. (1932)Benign Angiomatous Tumours of Skeletal Muscles. Surgery, Gynecology and Obstetrics, 55, 464-480. JONES, K. G. (1953) Cavernous Hemangioma of Striated Muscles. Journal of Bone and Joint Surgery, 35A, 717-728. SCOTT, J. E. S. (1957) Haemangiomata in Skeletal Muscle. British Journal of Surgery, 44, 496-501. 44
Vol. 4
No. 1
1972
OF FLEXOR
DIGITORUM
PROFUNDUS
C. E. A. HOLDEN, London Haemangioma of skeletal muscle is a well recognised but uncommon tumour. This is one reason why it is rarely diagnosed correctly before operation. This paper describes a case of haemangioma of the flexor digitorum profundus muscle. HISTORY
M. D., a twenty-five year old-clerk, presented in June, 1970 with a history of pain and swelling in the left forearm. The swelling had been present for about four weeks with some discomfort, but he had paid it little attention apart from transferring his watch to the other arm. Three days before admission his pain had become suddenly more severe, the swelling had increased in size and he had become unable to straighten his fingers. ON EXAMINATION
The ulnar side of the distal half of the flexor aspect of the left forearm was the site of a poorly defined swelling, some ten centimetres long and seven centimetres broad. The swelling was firm in consistency and tender on deep palpation. There was no audible bruit over the mass. The overlying skin was normal. Extension of the fingers was limited to about half the normal range when the wrist was held in the neutral position. Full extension could be achieved by flexing the wrist maximally. Active flexion of the fingers was limited by pain in the forearm. Movements of the thumb were not affected. X-ray of the forearm confirmed the presence of a large soft tissue swelling and showed a small rounded opacity in the distal part of the tumour. 4rteriography (Fig. 1). The radial artery was normal. The interosseous artery was much larger than normal and supplied a large vascular mass in the distal half of the forearm. There were abnormal vessels within this mass and abnormal draining veins. The diagnosis of a sarcoma was suspected. Chest X - r a y was normal.
Fig. I. Arteriography demonstrates a large interosseous artery, supplying a large vascular mass.
42
Vol. 4
No. 1
1972
Haemangiorna of Flexor Digitorurn Profundus'--C. E. A. Holden OPERATION
Through a direct ventral approach the superficialis muscle was reflected leaving the median nerve attached to its deep surface. The muscle of flexor digitorum profundus was found to be almost completely replaced by an irregular mass of hard tumour which appeared to contain areas of recent haemorrhage. The ulnar nerve was not adherent to the mass and was retracted. The main vessels to the mass were ligated and divided. Proximally the line of section was through a fringe of normal muscle; distally the tendons were divided about two centimetres proximal to the carpal tunnel. On its deep aspect the mass was adherent to the periosteum of the radius and an area of periosteum one by three centimetres was removed with the tumour. The wound was closed with suction drainage. PROGRESS
The wound healed without complication. The patient was relieved of his pain and could move his wrist and fingers easily and completely apart from loss of active flexion in the distal interphalangeal joints of all the fingers. One year later there is no sign of recurrence of the tumour. He is able to manage his work adequately. He has difficulty in fastening buttons and tying his tie, though he can play the piano. He has declined any further operation. PATHOLOGY
Within the muscle was a well circumscribed mass of fibrous tissue with widely dilated blood vessels occluded by ante-mortem thrombus (Fig. 2). Section of the tumour showed many medium sized muscular arteries within vascular connective tissue. Some vessels were occluded by thrombus and in others organised thrombus had obliterated the lumen. There were focal areas of tissue resembling both cavernous and capillary haemangiomata (Fig. 3). There was atrophy of some fibres in the muscle immediately adjacent to the mass but no evidence of invasion. The appearances are those of vascular hamartoma.
Fig. 2. The tumour shows a mass of fibrous tissue with widely dilated vessels containing ante-mortem thrombus. Fig. 3. Vascular hamartoma with focal areas of tissue resembling both cavernous and capillary haemangiomata. Vol. 4
No. 1
1972
43
Haemangiorna of Elexor Digitorum Profundus--C. E. A. Holden DISCUSSION
This case illustrates many of the features of the tumour and its situation is of interest. Jenkins and Delany (1932) reviewed 256 cases from the literature adding one of their own. In only twelve per cent was the correct diagnosis made before operation; the commonest diagnoses being lipoma, sarcoma and cold abscess. A valuable diagnostic feature was the presence of a phlebolith on plain X-ray film which they found in fifty per cent of cases. In no series have these tumours been recorded as metastasizing and recurrence (about six per cent) has usually been associated with incomplete removal. It is important to remove these tumours completely on the first occasion. If left untreated or incompletely excised they infiltrate local tissues to such an extent that any form of local surgical removal is impracticable and amputation may have to be considered (Scott, 1957). Residual disability after resection of these tumours depends on their site and occurs in about five per cent of cases. In the case reported here the operation required removal of all but a proximal fringe of the belly of flexor digitorum profundus. Had the benign nature of the turnout been appreciated at the time of operation the level of section through the tendons might have been made more proximally and each tendon could then have been attached to the appropriate superficial tendon. Jones (1953) described a similar case where the haemangioma involved only that part of the flexor digitorum profundus which supplied the index and middle fingers. The tumour was excised and the tendons of the index and middle fingers were sutured to the profundus tendons of the ring and little fingers. Normal function was restored. A reconstruction of this nature was not available in the present case. At this stage the function of the left hand could most easily be improved by fusion of the distal interphalangeal joints, at least of the index and middle finger in an appropriate degree o f flexion. ACKNOWLEDGEMENT
I am grateful to Dr. C. W. Elston for details of the pathology of the specimen.
REFERENCES
JENKINS, H. P., DELANEY, P A. (1932)Benign Angiomatous Tumours of Skeletal Muscles. Surgery, Gynecology and Obstetrics, 55, 464-480. JONES, K. G. (1953) Cavernous Hemangioma of Striated Muscles. Journal of Bone and Joint Surgery, 35A, 717-728. SCOTT, J. E. S. (1957) Haemangiomata in Skeletal Muscle. British Journal of Surgery, 44, 496-501. 44
Vol. 4
No. 1
1972