Macrodystrophia lipomatosa (MDL) is a rare, congenital, non-hereditary disorder characterized by localized gigantism of the fingers or toes, resulting from the overgrowth of mesenchymal tissues, particularly fibroadipose tissue. The pathophysiology remains debated, with theories involving humoral, vascular, neurological mechanisms, and recent studies suggesting potential links to the PIK3CA gene. MDL lacks established diagnostic criteria and management guidelines, with treatment strategies ranging from conservative monitoring to surgical intervention. A 31-year-old female with a history of progressive enlargement of the right second toe, present since age 2, was referred for chronic pain and functional impairments. Imaging revealed multiple exostoses and soft tissue swelling. Core and open biopsies confirmed the diagnosis of MDL, showing adipose and connective tissue. Based on these findings, a second ray amputation was performed. Postoperatively, the patient showed significant improvement, with complete wound healing and a reduction in pain and functional limitations. MDL is most commonly observed in males and affects the hands and feet, with unilateral involvement often seen. Imaging modalities play a crucial role in diagnosis. Histopathological examination reveals excessive adipose tissue. The progressive nature of MDL often leads to recurrence, requiring repeated surgical interventions. The second ray amputation performed in this case resulted in improved function and pain relief, as evidenced by favorable VAS and FAOS scores. This case highlights the importance of early diagnosis and individualized treatment for MDL. While surgical intervention can improve outcomes, further research is needed to establish standardized management protocols for this rare condition.

Macrodystrophia lipomatosa is a rare form of nonhereditary congenital localized gigantism involving upper and lower limbs and is characterized by overgrowth of all the mesenchymal elements predominantly fibro-adipose component, in the distribution of a particular nerve, usually median nerve. It usually presents with progressive painless overgrowth of the involved limb, toe, or digit and is associated with macrodactyly. It might cause limitation of the movement of the involved part. Imaging has an important role in diagnosing this condition and differentiating it from malignant mimics. Imaging findings include hypertrophy of the mesenchymal elements of the involved digits and/or limbs predominantly fibro adipose component with associated overgrowth of the phalanges. In this case report, we present a case of unilateral involvement of index finger and thumb with associated macrodactyly.