Chronic excruciating forearm pain in a child with intra-neural hemangioma: A challenging case report

Cavernous hemangioma is a rare form of hemangioma. It usually arises in the central nervous system, but the tumor has also been reported in the liver, retina and skin with a lower prevalence. Its occurrence into the peripheral nerves has only been reported a few times. Herein, we report an extremely rare case of intra-neural hemangioma in the ulnar nerve and discuss the complications we faced following surgery.

We present a 6-year-old boy with history of severe progressive left forearm pain in the last two years. Imaging studies revealed a soft tissue mass and histopathological exam was in favor of a cavernous hemangioma. Patient underwent surgery to excise the tumor. Despite temporary response, he began to experience excruciating pain shortly after surgery which caused him to adopt bizarre postures.

In the more common form of nerve involvement in a hemangioma, the nerve is displaced and surrounded by the tumor. However, in cases with intra-neural involvement, the nerve would have to be sacrificed. This case report brings some rare but important characteristics of a hemangioma in to attention, such as the intra-neural location, possibility of recurrence and aggravating pain with bizarre positions as a result.

In cases of intra-neural hemangioma, there is a chance that the patient experiences recurrence and/or excruciating pain following surgery. The orthopedic surgeon should be prepared for the possibility of nerve transfer, repeat surgeries and the need for prolonged palliative pain suppression modalities in the approach to intra-neural hemangioma.