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A high radial neuropathy by parosteal lipoma compression.

High radial neuropathy refers to radial nerve lesions above the elbow, and possible causes are “Saturday night palsy,” “Honeymooner’s palsy,” humeral fracture and/or its callus formation, the use of crutches, strenuous muscular effort of the triceps, a fibrous arc within the lateral head of the triceps, traumatic aneurysm of the radial collateral artery, a lipoma, and others. 1,2,5,7 This is a case report of a 57-year-old woman who had compression of the radial nerve at the triceps muscle level caused by a parosteal lipoma. CASE REPORT A 57-year-old right-handed female nursing assistant came to our service with sensory loss in the dorsum of the right hand associated with progressive weakness of extension of the wrist and fingers of several months’ duration. There was no associated pain. She denied any trauma or other diseases. On physical examination, swelling was observed on the medial side of the arm, close to the axilla, which was more evident when the arm was elevated. On palpation of the area, a large, nontender mass that was firm, immobile, not fixed to the skin, pulseless, and without increase of local temperature was observed. When questioned about this tumoral mass, the patient stated that she thought it was a simple accumulation of fat tissue, since she had gained weight over the past years. There was no alteration of the peripheral perfusion in the right upper limb. The elbow function was normal, as was the flexor strength of the wrist and fingers; however, there was a decrease in the extension strength of the wrist and metacarpophalangeal joints of the fingers and thumb (grade 4 of Lovett and Martin). 8 The sensibility on the dorsum of the hand was decreased, as was the brachioradialis reflex. A plain radiograph of the right arm showed a large circumscribed radiolucent mass extending from the axilla to mid arm, and ultrasonography of that mass was compatible with a lipoma or rhabdomyosarcoma. Magnetic resonance imaging was performed for better evaluation of the tumor and its relation with the neighboring structures. This examination showed an extensive lipomatous lesion in the triceps muscle that measured 12.0 6.0 4.0 cm and was highly suggestive of a well-differentiated lipoma. It extended from the quadrilateral space to the lateral portion of the origin of the medial head of the triceps, approaching the lateral intermuscular septum, displacing the radial nerve posteriorly and displacing the axillary and proximal brachial arteries (Figure). Electromyography was not requested because surgical resection of the lipoma to decompress the nerve was indicated. Surgery was performed with the patient under general anesthesia in the supine position maintaining the upper limb abducted. The surgical approach was medial and longitudinal over the mass. The tumor extended from the axillary fossa to the middle third of the humerus, involving the medial, posterior, and lateral heads of the triceps muscle, following the course of the radial nerve through the spiral groove. It was firmly adherent to the cortical bone, displacing the nerve posteriorly and compressing it. After isolation of the nerve, the tumor was marginally resected and the nerve released. The other structures were inspected and were normal. The remaining dead space was closed, and suture was accomplished by planes without drainage. An analysis of the tumor confirmed it to be a benign lipoma of 105 g, measuring 9 7 4 cm and without central necrosis. In the early postoperative period the radial nerve recovered its function. A physiotherapy program was started 2 weeks after surgery for scar mobilization, muscle strengthening, and functional rehabilitation. The patient recovered well, and 4 weeks after surgery she resumed her activities at work.