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Parosteal lipoma of the proximal radius: A report of five cases
Parosteal lipoma of the proximal radius: A report of five cases Parosteallipoma of the proximal radius is a benign, slow-growing tumor. It may cause compression of either the posterior interosseous or the superficial branch of the radial nerve. Surgical excision usually leads to complete recovery. Five cases of parosteal lipoma of the proximal radius are presented. X-ray films demonstrated a radiolucent mass in contact with the radius. Two patients had signs of posterior interosseous nerve compression, and two showed signs of superficial radial nerve compression. In one case the lipoma surrounded an exostosis arising from the proximal radius. The tumors were excised in four patients. The three patients with neurologic involvement recovered fully. One patient refused surgery, and posterior interosseous nerve paralysis developed. (J HAND SURG 1992;17A:I095-7.)
Cobi Lidor, MD, PhD, Moshe Lotem, MD, and Tom Hallel, MD, Kfar Saba, Israel
P
arosteal lipoma around the proximal radius was first reported as a distinct entity by Moon and Marmor I in 1964. It was described as a slow-growing, benign tumor that frequently caused compression of the posterior interosseous or the superficial branch of the radial nerve. This leads to various patterns of weak digital extension or paresthesias. 1-3 Moon and Marmor reviewed 18 cases of parosteal lipoma arising from the proximal radius and added two cases of their own. Since then four more cases were reported.i? the most recent in 1981. 5
Material and methods We present five additional cases of parosteal lipoma of the proximal radius (Table I). All patients were women and were seen over a period of 19 years. Two had involvement of the posterior interosseous nerve, and two had involvement of the superficial radial nerve. One did not demonstrate any nerve compression. The tumor was excised in four cases; this led to full recovery in the three cases with neurologic involvement. Patient FromtheDepartment of Orthopaedic Surgery, SapirMedical Center, Kfar Saba, and Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel. Received for publication Jan. 16, 1991; accepted in revised form March 25, 1992. No benefits in any form have been received Or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Cobi Lidor, MD, PhD, Department of Orthopaedic Surgery, Meir General Hospital, SapirMedical Center, KfarSaba 44281, Israel.
3, who refused surgery, had complete paralysis of the extensor muscles of the fingers and thumb within a period of 2 years. A detailed report of Case 5 follows. Case report A 40-year-old woman was admitted with pain in the proximal right forearm and numbness of the fingers of 8 months' duration. Four months before admission the patient noticed a mass in the right proximal forearm. Physical examination revealed a nontender mass of the anterolateral aspect of the proximal forearm. Plain x-ray (Fig. I, A) and computed tomographic (CT) examination (Fig. I, B) disclosed an exostosis arising from the anterolateral aspect of the proximal radius with a 40 x 35 X 40 mm radiolucent mass surrounding the proximal radius as well as the exostosis. At surgery the lipoma was found surrounding the proximal radius and adherent to the exostosis. The exostosis was cut at its base, and the lipoma and the exostosis were removed en bloc (Fig. 2). Histologic examination revealed mature, lobular, adipose tissue with a minimal amount of interlobular fibrous connective tissue. The exostosis showed mature cortical bone around a cancellous medulla with a thin cartilaginous cap. The exostosis had not been invaded by the lipoma. Eighteen months after the surgical procedure the patient had no complaints, and physical examination findings were normal.
Discussion Lipoma is a common benign tumor that is usually found subcutaneously." Lipomas are found less commonly in deep intermuscular, intramuscular, parosteal, or intraosseous structures, Parosteallipomas have been reported in relation to almost all the long bones and represent 0.3% of all lipomas," The periosteum itself
3/1138139 THE JOURNAL OF HAND SURGERY
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The Journal of HAND SURGERY
Litlor et al,
Fig. 1. X-ray film and CT scan of forearm. A, Anteroposterior film shows an exostosis on the lateral aspect of the radius and a radiolucent mass around it. B, CT image of the proximal forearm shows the exostosis arising from the lateral aspect of the radius. The lipoma, which is radiolucent, completely surrounds the proximal part of the radius .
Table I. Case studies of five female patients Case No.
Age (yr)
I
40
2
53
3 4 5
72 55 40
Duration of symptoms Presenting symptoms
Complete extensor paralysis Painful growing tumor with paresthesia of ring finger Complete extensor paralysis Slow-growing mass Painful growing tumor with paresthes ia of fingers
contains no fat cells. Therefore it seems that parosteal lipoma develops from structures adjacent to it. R Compression of the ulnar, radial, median, peroneal, and sciatic nerves has been reported. 9 Parosteal lipoma of the proximal radius is a distinct entity . 1 This benign, slow-growing, usually painless tumor may compress the posterior interosseous nerve , leading to various patterns of paresis or paralysis . The superficial branch of the radial nerve may also be involved, causing paresthesia. Approximately half the previously reported cases of parosteal lipoma of the proximal radius'? and four of the cases reported here
(mo)
Treatment
Result
10
Excision Excision
Complete recovery Complete recovery
24 3 8
Excision Excision
Complete recovery Complete recovery
4
had neurologic involvement. Two thirds of the reported cases occurred in women, !? as did all five of our cases (Table I). Plain x-ray films revealed radiolucent masses in the proximal forearm in all cases . In none of our cases did the radius develop bony changes. In Case 5 the lipoma surrounded the proximal radius and what seemed 10 be a solitary osteocartilaginous exostosis. This bony projection had a cortical shell with a cancellous medulla and a cartilaginous cap. The occurrence of a parosteal lipoma surrounding an osteocartilaginous exostosis has not been reported previously. In our opinion, the exostosis was not invaded by the lipoma.
Parosteal lipoma ofproximal radius
covery in cases in which the nerve is already compressed by the tumor.
REFERENCES
Fig. 2. X-ray film showing lipoma and exostosis after removal in one piece from the base of the exostosis. Note the intimate contact between the exostos is and the lipoma.
Surgical exploration and excision of parosteallipoma of the proximal radius is recommended. This should prevent involvement of the posterior interosseous and I or superficial radial nerves and ensure optimal re-
1. Moon N, Marmor L. Parosteal lipoma of the proximal part of the radius. 1 Bone loint Surg 1964;468:608-14. 2. Berry IB, Moiel RH. Parosteallipoma producing paralysis of the deep radial nerve. South Med 1 1973;66:1298-300. 3. Kurland KZ, Kennard lW. Parosteallipoma arising from the proximal radius: a case report . Clin Orthop 1965;41:140-4. 4. Capener N. The vulnerability of the posterior interosseous nerve of the forearm: a case report and an anatomical study. 1 Bone Joint Surg 1966;48B:770-3. 5. Savarese A, D'Onofrio G. A ease of parosteal lipoma of the neck of the radius . Chir Organi Mov 1981;67:711-4. 6. Leffert R. Lipomas of the upper extremity. J Bone Joint Surg 1972;54A:1262-6. 7. Fleming Rl, Alpert M, Garcia A. Parosteallipoma. AIR 1962;87:1075-84. 8. Albright lA, Brand RA . The scientific basis of orthopaedics . New York: Appleton-Century-Crofts, 1979. 9. Barber KW lr, 8ianco AJ, Soule EH, MacCarty CS. Benign extraneural soft-tissue tumors of the extremities causing compression of nerves. 1 Bone Joint Surg 1962;44A:98-104.
Efficacy of immobilization following aspiration of carpal and digital ganglions In a prospective study 69 carpal and digital ganglions were aspirated, multiply punctured, and digitally ruptured. Fifty percent of the wrists and digits were immobilized for 3 weeks and 50% were mobilized early. Follow-up was 1 year. Immobilization in our study did not significantly improve the results of treatment. During the course of the study, 51 % of all ganglions did not recur. The outcome was successful in 52% of the wrists and digits that were immobilized and in 50% of those that were not. Forty-six percent of the dorsal carpal ganglions did not recur. Treatment was successful in 48 % of dorsal carpal ganglions in which the wrists were immobilized and in 45% of those that were not. Similar percentages were found for palmar and digital ganglions. From our results, we conclude that immobilization does not significantly improve the successful treatment of ganglions over perforation and aspiration alone. (J HAND SURG 1992j17A: 1097-9.)
Joshua Korman , MD, Robert Pearl , MD , and Vincent R. Hentz, MD, Santa Clara and Stanford, Calif. From the Division of Plastic Surgery, Kaiser Hospital. Santa Clara. Calif., and the Division of Hand Surgery. Stanford University Medical Center, Stanford , Ca lif.
No benefits in any fonn have been rece ived or will be received from a commercial party related directly or ind irectly to the subject of this article.
Received for publication Sept. 16, 1991; accepted in revised form Jan . 9, 1992.
Reprint requests: Joshua Korman, MD , Div ision of Plastic and Reconstructive Surgery, Kaiser Perrnancnte Medical Center, 900 Kiely Blvd., Santa Clara, CA 95051.
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Cobi Lidor, MD, PhD, Moshe Lotem, MD, and Tom Hallel, MD, Kfar Saba, Israel
P
arosteal lipoma around the proximal radius was first reported as a distinct entity by Moon and Marmor I in 1964. It was described as a slow-growing, benign tumor that frequently caused compression of the posterior interosseous or the superficial branch of the radial nerve. This leads to various patterns of weak digital extension or paresthesias. 1-3 Moon and Marmor reviewed 18 cases of parosteal lipoma arising from the proximal radius and added two cases of their own. Since then four more cases were reported.i? the most recent in 1981. 5
Material and methods We present five additional cases of parosteal lipoma of the proximal radius (Table I). All patients were women and were seen over a period of 19 years. Two had involvement of the posterior interosseous nerve, and two had involvement of the superficial radial nerve. One did not demonstrate any nerve compression. The tumor was excised in four cases; this led to full recovery in the three cases with neurologic involvement. Patient FromtheDepartment of Orthopaedic Surgery, SapirMedical Center, Kfar Saba, and Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel. Received for publication Jan. 16, 1991; accepted in revised form March 25, 1992. No benefits in any form have been received Or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Cobi Lidor, MD, PhD, Department of Orthopaedic Surgery, Meir General Hospital, SapirMedical Center, KfarSaba 44281, Israel.
3, who refused surgery, had complete paralysis of the extensor muscles of the fingers and thumb within a period of 2 years. A detailed report of Case 5 follows. Case report A 40-year-old woman was admitted with pain in the proximal right forearm and numbness of the fingers of 8 months' duration. Four months before admission the patient noticed a mass in the right proximal forearm. Physical examination revealed a nontender mass of the anterolateral aspect of the proximal forearm. Plain x-ray (Fig. I, A) and computed tomographic (CT) examination (Fig. I, B) disclosed an exostosis arising from the anterolateral aspect of the proximal radius with a 40 x 35 X 40 mm radiolucent mass surrounding the proximal radius as well as the exostosis. At surgery the lipoma was found surrounding the proximal radius and adherent to the exostosis. The exostosis was cut at its base, and the lipoma and the exostosis were removed en bloc (Fig. 2). Histologic examination revealed mature, lobular, adipose tissue with a minimal amount of interlobular fibrous connective tissue. The exostosis showed mature cortical bone around a cancellous medulla with a thin cartilaginous cap. The exostosis had not been invaded by the lipoma. Eighteen months after the surgical procedure the patient had no complaints, and physical examination findings were normal.
Discussion Lipoma is a common benign tumor that is usually found subcutaneously." Lipomas are found less commonly in deep intermuscular, intramuscular, parosteal, or intraosseous structures, Parosteallipomas have been reported in relation to almost all the long bones and represent 0.3% of all lipomas," The periosteum itself
3/1138139 THE JOURNAL OF HAND SURGERY
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1096
The Journal of HAND SURGERY
Litlor et al,
Fig. 1. X-ray film and CT scan of forearm. A, Anteroposterior film shows an exostosis on the lateral aspect of the radius and a radiolucent mass around it. B, CT image of the proximal forearm shows the exostosis arising from the lateral aspect of the radius. The lipoma, which is radiolucent, completely surrounds the proximal part of the radius .
Table I. Case studies of five female patients Case No.
Age (yr)
I
40
2
53
3 4 5
72 55 40
Duration of symptoms Presenting symptoms
Complete extensor paralysis Painful growing tumor with paresthesia of ring finger Complete extensor paralysis Slow-growing mass Painful growing tumor with paresthes ia of fingers
contains no fat cells. Therefore it seems that parosteal lipoma develops from structures adjacent to it. R Compression of the ulnar, radial, median, peroneal, and sciatic nerves has been reported. 9 Parosteal lipoma of the proximal radius is a distinct entity . 1 This benign, slow-growing, usually painless tumor may compress the posterior interosseous nerve , leading to various patterns of paresis or paralysis . The superficial branch of the radial nerve may also be involved, causing paresthesia. Approximately half the previously reported cases of parosteal lipoma of the proximal radius'? and four of the cases reported here
(mo)
Treatment
Result
10
Excision Excision
Complete recovery Complete recovery
24 3 8
Excision Excision
Complete recovery Complete recovery
4
had neurologic involvement. Two thirds of the reported cases occurred in women, !? as did all five of our cases (Table I). Plain x-ray films revealed radiolucent masses in the proximal forearm in all cases . In none of our cases did the radius develop bony changes. In Case 5 the lipoma surrounded the proximal radius and what seemed 10 be a solitary osteocartilaginous exostosis. This bony projection had a cortical shell with a cancellous medulla and a cartilaginous cap. The occurrence of a parosteal lipoma surrounding an osteocartilaginous exostosis has not been reported previously. In our opinion, the exostosis was not invaded by the lipoma.
Parosteal lipoma ofproximal radius
covery in cases in which the nerve is already compressed by the tumor.
REFERENCES
Fig. 2. X-ray film showing lipoma and exostosis after removal in one piece from the base of the exostosis. Note the intimate contact between the exostos is and the lipoma.
Surgical exploration and excision of parosteallipoma of the proximal radius is recommended. This should prevent involvement of the posterior interosseous and I or superficial radial nerves and ensure optimal re-
1. Moon N, Marmor L. Parosteal lipoma of the proximal part of the radius. 1 Bone loint Surg 1964;468:608-14. 2. Berry IB, Moiel RH. Parosteallipoma producing paralysis of the deep radial nerve. South Med 1 1973;66:1298-300. 3. Kurland KZ, Kennard lW. Parosteallipoma arising from the proximal radius: a case report . Clin Orthop 1965;41:140-4. 4. Capener N. The vulnerability of the posterior interosseous nerve of the forearm: a case report and an anatomical study. 1 Bone Joint Surg 1966;48B:770-3. 5. Savarese A, D'Onofrio G. A ease of parosteal lipoma of the neck of the radius . Chir Organi Mov 1981;67:711-4. 6. Leffert R. Lipomas of the upper extremity. J Bone Joint Surg 1972;54A:1262-6. 7. Fleming Rl, Alpert M, Garcia A. Parosteallipoma. AIR 1962;87:1075-84. 8. Albright lA, Brand RA . The scientific basis of orthopaedics . New York: Appleton-Century-Crofts, 1979. 9. Barber KW lr, 8ianco AJ, Soule EH, MacCarty CS. Benign extraneural soft-tissue tumors of the extremities causing compression of nerves. 1 Bone Joint Surg 1962;44A:98-104.
Efficacy of immobilization following aspiration of carpal and digital ganglions In a prospective study 69 carpal and digital ganglions were aspirated, multiply punctured, and digitally ruptured. Fifty percent of the wrists and digits were immobilized for 3 weeks and 50% were mobilized early. Follow-up was 1 year. Immobilization in our study did not significantly improve the results of treatment. During the course of the study, 51 % of all ganglions did not recur. The outcome was successful in 52% of the wrists and digits that were immobilized and in 50% of those that were not. Forty-six percent of the dorsal carpal ganglions did not recur. Treatment was successful in 48 % of dorsal carpal ganglions in which the wrists were immobilized and in 45% of those that were not. Similar percentages were found for palmar and digital ganglions. From our results, we conclude that immobilization does not significantly improve the successful treatment of ganglions over perforation and aspiration alone. (J HAND SURG 1992j17A: 1097-9.)
Joshua Korman , MD, Robert Pearl , MD , and Vincent R. Hentz, MD, Santa Clara and Stanford, Calif. From the Division of Plastic Surgery, Kaiser Hospital. Santa Clara. Calif., and the Division of Hand Surgery. Stanford University Medical Center, Stanford , Ca lif.
No benefits in any fonn have been rece ived or will be received from a commercial party related directly or ind irectly to the subject of this article.
Received for publication Sept. 16, 1991; accepted in revised form Jan . 9, 1992.
Reprint requests: Joshua Korman, MD , Div ision of Plastic and Reconstructive Surgery, Kaiser Perrnancnte Medical Center, 900 Kiely Blvd., Santa Clara, CA 95051.
3/1/36377
THE JOURNAL OF HAND SURGERY
1097