Radiating Upper Limb Pain Due to a Large Subcutaneous Lipoma: Fascial Sono-Palpation

Dear Editor, Lipomas are benign, slow-growing soft tissue tumors that are usually located in the subcutaneous tissues—and seldom in/among muscles. Like other soft tissue mass lesions, ultrasound (US) imaging can undoubtedly be used for their initial evaluation. They display a fusiform echostructure; that is, they are homogenously hyperechoic and sometimes have a micronodular appearance due to internal very fine septations. “Atypical” features—for example, large size, permeative margins, heterogeneous echostructure, presence of nodules with variable appearances or thick septations— can also be seen. Power Doppler imaging is almost always negative [1][AQ5]. In this report, we describe the role of sono-palpation of the fasciae to reproduce a radiating upper limb pain due to a large subcutaneous lipoma. A 55-year-old woman presented with radiating right upper limb pain each time she kept a particular posture during her job in the laboratory. She reported that the pain had begun three years before, immediately after having lifted some weights. Rest and anti-inflammatory drugs had partially improved her complaints, and since then, she went on suffering pain sometimes in the arm and sometimes in the forearm. Additionally, she also described that the pain had often turned into cramping and tingling sensations in the median, radial, and ulnar nerve innervated regions interchangeably. Her medical history was unremarkable except for hypercholesterolemia and gastritis. Current physical examination showed arm disfiguration, enhanced by isometric (Figure 1A–C) triceps brachii contractions, due to a nodule in the middle and lateral part of her right arm. Musculoskeletal examination was otherwise normal. Further, substantial neurological examination of the upper limb was negative for any cervical radiculopathy and brachial plexus or peripheral nerve entrapments. Figure 1 Clinical and ultrasound examination. Arm disfiguration enhanced by isometric contraction with a nodule in the middle part of the right arm. A) Lateral view. B) Posterior view. C) Medial view. D) The lipoma is seen to be wrapped between the two layers of the superficial fascia[AQ11].