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Int J Surg Case Rep
Int J Surg Case Rep
International Journal of Surgery Case Reports
2210-2612
Elsevier

S2210-2612(24)01095-2
10.1016/j.ijscr.2024.110314
110314
Case Report
Trauma-induced dual-plane hemangioma in the hand: A case report
Yassin Amin M.
Mohamed Momen Momen.m.ibrahim@gmail.com
⁎
Department of Plastic Surgery, AlSororab Hospital, Khartoum, Sudan
⁎ Corresponding author. Momen.m.ibrahim@gmail.com
16 9 2024
10 2024
16 9 2024
123 11031415 8 2024
10 9 2024
14 9 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction and importance

Hemangioma is a neoplastic disorder of vascular structures that can manifest at any site of the body. It is a rare ailment in general, and the intramuscular type is particularly uncommon and accounts for approximately 1 % of all hemangiomas. The presentation of hand hemangioma differs from other sites due to the restricted space and compression of vital structures, which frequently manifests as pain and functional impairment alongside mass. In this article, we present a case of trauma-induced dual-plane hemangioma in the hand.

Case presentation

A 55-year-old right-handed individual, without any significant medical background, sought medical attention for a painful mass on his right hand that had developed over the past year. He indicated a history of blunt trauma to the hand, with the mass becoming apparent two months post-injury. With the growth of the mass, the severity of pain progressively escalates; however, there is no loss of function observed. The diagnosis was established through duplex ultrasonography, and the patient received surgical excision utilizing the WALANT technique. Intraoperatively, the hemangioma was identified in two planes: one beneath the skin over the thenar eminence and another within the adductor pollicis muscle. The follow-up period proceeded without any complications or recurrence of the condition.

Clinical discussion

Hand hemangiomas are relatively rare, and a history of trauma may lead to misdiagnosis as other conditions. There are various management strategies that are not suitable for hand hemangiomas. While surgical excision can alleviate symptoms, it carries the risk of increasing disability if muscle tissue is excised.

Conclusion

Trauma-induced dual-plane hemangioma in the hand is a phenomenal condition that has been successfully treated surgically. Despite the removal of a portion of the adductor pollicis, both functional and aesthetic satisfaction was achieved. Hence, it is advisable to employ surgical management for such a presentation.

Highlights

• Hand hemangioma presents with symptoms related to pressure, which may include discomfort and tingling sensations.

• Hand hemangioma manifests as a compressible mass located within the confined areas of the hand.

• Hemangiomas have the potential to appear in different planes at the same anatomical site.

• The surgical excision of a hand tumour can be effectively accomplished through the application of the WALANT technique.

Keywords

Hemangioma
Hand tumor
Hand surgery
Intramuscular hemangioma
Hand
Hand trauma
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pmc1 Introduction

Haemangioma is identified as a benign vascular tumor that showcases a broad spectrum of variations and can manifest in various soft tissue areas. The leading hypothesis regarding its development is based on congenital abnormalities, a view that has been recognized for many years. Musculoskeletal haemangioma are mainly found in the limbs, with a higher incidence in the lower limbs compared to the upper limbs, and they also occur in the torso.

The musculoskeletal haemangioma has similar characteristics to skeletal tumours, growing slowly and not causing any discomfort until it reaches a size that compresses adjacent structures. Consequently, most patients know the underlying condition and seek medical guidance. Interestingly, ultrasound can be used for diagnosis, although MRI is more reliable for assessment. It is always necessary to have histological confirmation. A large portion of haemangiomas have gone through a phase of regression, so there may not be a need for intervention. The intramuscular type is less than 1 % of all haemangiomas and tends to appear before the third decade of age [1].

Hand haemangioma is an uncommon condition that exhibits non-specific symptoms, rendering its diagnosis arduous. The treatment techniques employed for haemangiomas in other areas of the body may not prove efficacious for hand haemangiomas. Furthermore, the surgical excision of an intramuscular haemangioma in the hand may necessitate the sacrifice of the whole muscle and may result in hand impairment. Hence, a comprehensive assessment and a meticulously planned treatment plan are imperative for achieving optimal outcomes [2].

2 Case presentation

A 55-year-old, right-handed African man working as a labourer, with no significant medical history. He presented with a prominent right-hand swelling at the palmar aspect. One year before the presentation, he sustained a minor blunt injury to the same hand. He denied any significant pain, wound, or functional limitations arising from period-related trauma. He noticed swelling two months later and described it as slowly growing in size until it became apparent. A slowly growing swelling becomes larger with daily activities, accompanied by numbness at the thumb and index finger. The movement of the hands has been unaffected since the onset of swelling. Clinical examination shows that the mass is located at the thenar eminence and extends to the first web space. The mass is soft and compressible, measuring 5*4 cm, with obvious dilated vessels subcutaneously (Fig. 1). The skin above the mass appeared to be normal without discoloration or ulceration. The movement and sensation of the fingers remained unaltered. An X-ray of the hand revealed no abnormal skeletal structure, while duplex/ultrasonography revealed an ill-defined hypoechoic mass without a detectable signal. A magnetic resonance imaging scan was unavailable.Fig. 1 Pre-operative: showing mass at 1st web space.

Fig. 1

In the operation room, a Wide-Awake Local Anaesthetia No Tourniquet was used, as well as magnification. An incision was made along the proximal palmar crease, approximately 10 cm, and subsequently, the dissection was extended throughout the subcutaneous tissue. The subcutaneous portion of the haemangioma extending over the thenar muscles was removed from the skin. The common digital nerves of the three lateral fingers are found to be enveloped by mass. After meticulous neurolysis, the remaining tumor was located deep within the first web space, and it was discovered that it was encircling the adductor pollicis muscle (Fig. 2). The oblique head of the adductor muscle was successfully dissected from the tumor, while the transverse head was found to be filled with mass. Additionally, multiple feeders were discovered around the origin of the muscle from the third metacarpal bone. After ligation of the main feeder vessels, excision of the transverse head adductor muscle was performed, followed by careful hemostasis (Fig. 3, Fig. 4). The drain was then applied, and the wound was closed in layers (Fig. 5). As the operation was executed using the WALAT technique, the patient was able to move his hand, and an intraoperative examination of dynamic hand movement revealed no deficiencies. The pathological evaluation of the mass confirms the diagnosis of hemangioma. The follow-up period transpired uneventfully, and the patients were content with their unrestricted return to daily activities (Fig. 6). This work is under SCARE guideline [3].Fig. 2 Intra-operative right hand hemangioma: A: showing intramuscular part, B: subcutaneous part.

Fig. 2

Fig. 3 Intra-operative: showing multiple feeders vessels.

Fig. 3

Fig. 4 Intra-operative: showing mass after excision.

Fig. 4

Fig. 5 Intra-operative: showing hand after excision of hemangioma.

Fig. 5

Fig. 6 A week post-operative follow up: showing dynamic hand movements.

Fig. 6

3 Discussion

The hand is a precious organ of the body and is considered the most functional tool for communication and conducting daily activities. The pathology of the hand has a profound impact on the productivity of an individual and his quality of life. A hand tumor is one of the conditions that bring patients to hand surgery units. Hemangioma of the upper extremities is considered a rare condition, and several reports have presented several unique presentations at different anatomical sites. It is common to have hemangioma at a young age, and theories link the development of it to congenital factors. However, reports indicate that it occurs in older age groups and is induced by other factors, such as trauma. Trauma induces various degrees of ischemia in local tissue, which promotes angiogenesis as part of the healing process. However, deviation from the normal pathway may be the reason why hemangioma can occur following trauma [4]. The uniqueness of our patient lies in his age, which contrasts with the usual presentation of hemangiomas typically seen in younger individuals. Furthermore, it is thought that trauma is the main factor contributing to the development of the mass.

Musculoskeletal hemangioma is a benign neoplasm, but it is still able to cause symptoms if it is enlarged to fill small spaces, such as the hand. The most prevalent presenting symptom is pain, evidently due to the direct pressure effect on adjacent structures. The severity of pain depends on the size of the mass and the space that becomes occupied, as well as the proximity of neurovascular bundles. Activity-induced pain is a distinctive feature of hemangioma, resulting from an increase in flow and consequently engorgement of pressure. Hand hemangioma may also cause contracture or restriction of movement, which may also lead to significant disability. Deep-located hemangioma may remain asymptomatic for a long period and go to the regression phase therefore will not recognized [1,5,6]. Our patient meets the criteria for hemangioma, which is characterized by increased activity, slowly growing mass, and enlargement due to positioning dependency.

The diagnosis of intramuscular hemangiomas is a challenging task, and a significant proportion of patients are incorrectly diagnosed, resulting in a delay in the identification of the disorder. X-rays can exclude skeletal diseases, however, they are not informative in the case of hemangioma, whereas duplex ultrasonography may provide clues about the condition, but it is operator-dependent. In ultrasound, it was perceived as an ill-defined or well-defined hypoechoic mass with multiple spaces within it, and Doppler detected no signal or a weak signal. The capability of MRI to delineate soft tissue masses renders it an indispensable diagnostic tool, as it is capable of distinguishing the texture of the mass [7,8]. Upon history and clinical examination, we were able to establish a diagnosis in our patient, but ultrasound provided further details. Regrettably, Magnetic Resonance Imaging (MRI) was not available. However, if it is available, it will furnish additional details regarding the extension and the current state of the surrounding structures.

The management of hemangiomas is a significant topic, and numerous methods have been described for various types at various sites. However, there is no superiority of one technique over another, and the management plan must fit the patient's condition. Embolization of the major blood vessels that supply the hemangiomas is one of the most common methods of treatment, reducing the risk of bleeding during surgery and the likelihood of recurrence. Despite its efficacy, this approach fails to apply to the hand due to its vulnerability to ischemia and the numerous supplying vessels. A complete resection with wide margins is considered a curative option, and the remission rate is low. However, the surgery carries a risk of anesthesia, bleeding, injuries to neurovascular structures, or the sacrifice of muscle. Notwithstanding all of these adverse effects, surgery offers the longest duration of symptoms-free period and the lowest rate of recurrence among all other treatment options [1,2,9,10,11]. Surgery proved to be the most appropriate approach to address the complaints of our patients, while simultaneously providing an excisional biopsy for a precise diagnosis. It can be challenging to perform a wide resection in the hand due to the potential impact on the mechanisms of the hand. However, it can be accomplished without any functional deficits.

General anesthesia was traditionally employed for hand surgeries, and certain surgeons still hold a preference for this traditional approach. However, recently, wide-awake local anesthesia without a tourniquet has gained popularity, and most hand procedures have become achievable with this method. Providing anesthesia with minimal resources, less toxic anesthetic medication, and less post-operative need for analgesia were some of the fancy features of this technique. Furthermore, it safeguards motor control, enabling surgeons to evaluate hand movement during surgery, thereby adjusting surgical procedures to achieve the ideal outcome [[12], [13], [14]]. In our instance, the implementation of the WALANT technique offers remarkable hand analgesia, thereby enhancing the satisfaction of both patients and surgeons and alleviating the complications associated with general and regional anesthesia.

The scarcity of published literature on hand hemangiomas, coupled with their diverse clinical presentations, complicates accurate diagnosis, often leading to misdiagnosis. Furthermore, the absence of MRI facilities in our hospital exacerbates the challenges associated with surgical intervention, as it prevents the visualization of anatomical variations and the involvement of adjacent structures that imaging could reveal. These factors represent significant limitations in our study. Therefore, careful and precise patient management, along with a well-structured treatment plan, emerged as the most critical aspects of our approach.

4 Conclusion

Trauma-induced dual-plane hemangioma in the hand is an exceptional condition that has been treated effectively with surgery. Despite the removal of a portion of the adductor pollicis, both functional and aesthetic outcomes were satisfactory. As a result, surgical management is recommended for this type of presentation, given that other treatment options are not relevant for hand pathologies.

Ethical approval

Patient confidentiality maintained and data collected after full explanation of research project and aim of it, then written informed consent was obtained for publication including photos and this adherent to Alsrorab hospital ethical committee, Khartoum, Sudan. 12/4/2024.

Funding

None.

Author contribution

Conceived and designed the analysis

Amin Yassin, Momen Mohamed

Contributed data or analysis tools

Amin Yassin, Momen Mohamed

Performed the analysis

Amin Yassin, Momen Mohamed

Wrote the paper

Momen Mohamed

Guarantor

Dr. Momen Mahmoud Ibrahim Mohamed

Tel No: +249 (0) 917500516

Email: Momen.m.ibrahim@gmail.com

Research registration number

No trial or experiment involved human subjects.

Consent

Written consent was obtained by patient to be part of this job and provide permission for publication includes photography. A copy of consent available but written in Arabic to allow patient to understand purpose of study.

Conflict of interest statement

No conflict of interest.
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