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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 2  |  Issue : 1  |  Page : 7-9

Subungual glomus tumor in hand and treatment: A report of three cases


Department of Orthopedics, Sriram Chandra Bhanja Medical College, Cuttack, Odisha, India

Date of Web Publication23-Mar-2018

Correspondence Address:
Dr. Tapas Kumar Panigrahi
Department of Orthopedics, Sriram Chandra Bhanja Medical College, Cuttack, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/oji.oji_6_18

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  Abstract 


Hand pain is a common presenting symptom in orthopedic, but digital pain due to glomus tumor is a rare entity. It is a benign vascular neoplasm arising from glomus body with subungual space of nail plate of the hand being the common location. Bluish- or pinkish-red discoloration of the nail plate with classical triad of localized tenderness, severe pain, and cold sensitivity are the common presentations of the glomus tumor. Treatment is purely surgical, i.e., complete surgical excision with dramatic results. We report three cases of subungual glomus tumor in the hand, and all the cases underwent complete excision of the tumor followed by complete relief of the symptoms.

Keywords: Digital pain, glomus tumor, split nail bed graft and transungual excision


How to cite this article:
Maharaj RC, Kumar J, Nanda SK, Panigrahi TK. Subungual glomus tumor in hand and treatment: A report of three cases. Oncol J India 2018;2:7-9

How to cite this URL:
Maharaj RC, Kumar J, Nanda SK, Panigrahi TK. Subungual glomus tumor in hand and treatment: A report of three cases. Oncol J India [serial online] 2018 [cited 2018 Nov 16];2:7-9. Available from: http://www.ojionline.org/text.asp?2018/2/1/7/228327




  Introduction Top


Glomus tumor is a rare benign tumor of the neuromyoarterial structure called glomus body which is responsible for thermoregulation of the body.[1] Although glomus tumor can be found at any location on the body, distal phalanx of the fingers, particularly subungual region, is the most common site.[2] Glomus tumor constitutes 1%–5% of all the soft-tissue tumor of the hand with a female predominance. About 50%–90% of the glomus tumors of the hand are subungual in location followed by the nail matrix, nail bed, and pulp of a finger.[3],[4] The majority of the patients are presenting in the middle age group. Typical time from onset of symptoms to diagnosis of symptoms varies from 6 months to 10 years.[5],[6]


  Case Report Top


Three cases of glomus tumor of the subungual region were reported with the demographic profile and treatment details.

Case 1

A 60-year-old male presented with pain in the nail plate of index finger of the right hand for 6 years with severe cold intolerance and deformed nail. He had been operated 2 years ago for the above mentioned complaints suspecting as a case of ganglion. However, the symptom was persisting. On local examination, there was a well-defined swelling at the base of nail bed of the right index finger with deformed nail and longitudinal ridge [Figure 1]a. The patient had pinpoint tenderness (Love's test positive), and pain shoots up with cold. X-ray of the right index finger showed no abnormality.
Figure 1: (a) Swelling at the base of nail bed of the right index finger, (b) the mass was excised from the nail bed, (c) spit thickness nail bed graft from germinal matrix of ipsilateral great toe, and (d) repair of nail bed

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The patient was planned for transungual excision and biopsy. The nail plate was elevated, and the mass that invades more than half of the germinal matrix was excised [Figure 1]b, but the defect could not be closed primarily. The gap was repaired with split-thickness nail bed graft from germinal matrix of ipsilateral great toe with 6-0 catgut [Figure 1]c. The repair was covered with trimmed nail plate with multiple holes with a “figure-of-8” stay suture [Figure 1]d. Microscopic examination of the operated specimen came out to be features of glomus tumor. After surgery, the patient followed up every month for the first 6 months without recurrence of the disease. New nail with thick texture without any deformity appeared at 3 months.

Case 2

A 27-year-old-female complained of severe shooting pain in the left middle finger below the nail plate for 3 years that aggravated with pressure, and there is no specific history of cold intolerance. Physical examination of the left middle finger showed no swelling, no discoloration, or visible deformity of the nail. The patient showed localized tenderness over the radial aspect of base of middle fingernail [Figure 2]a. The pinpoint tenderness (Love's test positive) was present. X-ray of the left hand showed punched out osteolytic lesion over the distal phalanx of the left middle finger [Figure 2]b. Magnetic resonance imaging (MRI) showed 3 mm × 3 mm vascular mass underneath the nail bed with a possible radiological diagnosis of glomus tumor.
Figure 2: (a) Area of localized tenderness of the left middle figure, (b) punched out osteolytic lesion over the distal phalanx of the left middle finger on X-ray, (c) nail plate and nail bed elevated, (d) the mass was excised, (e) repair of nail bed, and (f) presence of sheets of uniform small round cells without nuclear atypia with intervening small vascular spaces on microscopic examination (H and E, ×100)

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The patient was planned for a transungual excision and biopsy. Nail plate was elevated from the nail bed. A longitudinal spilt was found on the nail bed. Through this spilt nail bed was elevated from either side and the underneath mass was excised [Figure 2]c and [Figure 2]d. Nail bed repaired with 5-0 chromic catgut and nail plate trimmed and reposed over the repair side with a stay suture over the nail plate [Figure 2]e. Microscopic examination of the excised specimen came out to be glomus tumor [Figure 2]f. A new nail reappeared during the 3rd month of the surgery, and there was no residual pain or nail deformity during 8 months of follow-up.

Case 3

A 26-year-old female presented with severe pain beneath the nail of right-hand ring finger, with cold intolerance for the past 5 years. On the local examination, there was no visible swelling [Figure 3]a; point tenderness was positive with cold sensitive and purple discoloration at the lunula. X-ray of the right hand was normal.
Figure 3: (a) No visible swelling, (b) purple discoloration of the mass after the nail bed elevation, (c and d) tumor excision, (e) repair of the nail bed, and (f) presence of uniform small round cells arranged around small vessels in a collar-like pattern on microscopic examination (H and E, ×100)

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The patient was planned for transungual excision with biopsy. Nail plate was elevated and nail bed showed purple discoloration at germinal matrix [Figure 3]b. Through the transungual approach, tumor was excised [Figure 3]c and [Figure 3]d. Nail bed repaired with 5-0 catgut and nail plate reposed with “figure-of-8” suture [Figure 3]e. Microscopic examination of the excised specimen revealed features of glomus tumor [Figure 3]f. New nail appeared after 3 months of surgery without any deformity. The patient was without any recurrence of the disease during the last follow-up at 12 months.


  Discussion Top


Majority of glomus tumors present with a small, slightly raised, bluish or pinkish red, painful nodule. However, glomus tumor of subungual location can elevate, deform, and discolor the nail. The patient with typical clinical finding of localized tenderness, severe pain, and cold sensitivity highly suggests the diagnosis of glomus tumor.[2] Two out of three cases in the present report were presenting with such classical triads and one case did not present with cold intolerance. Majority of the patients have a history of aggravation of symptoms in cold weather and on contacting with cold objects or cold water in hands. Approximately 26%–50% of the subungual lesions are visible through the nail plate as a bluish discoloration and nail deformity or ridging can occur as seen in one out of three present cases.[3] However, the present case with deformed nail is a recurrence one.

Instead of classical presentation, delayed diagnosis is common in glomus tumor possibly due to the variations in presenting symptoms, its rarity, and lack of suspicion during examination of the patient with impalpable glomus tumor. The patients are easily misdiagnosed with neuropathic complaints, arthritis, or neuralgia undergoing unsuitable treatment.[7]

There are three useful tests that help in diagnosis of such type of tumors such as Love's pin test, Hildreth's test, and cold-sensitivity test. In Love's pin test, the area containing the glomus tumor would be exquisitely painful upon applying pressure with a pinhead. Hildreth's test is considered to be positive if withdrawal of pain from the affected area is noted by the patient on applying a tourniquet along the arm to induce a transient ischemia, and the pain will suddenly return on removing the tourniquet. In cold-sensitivity test, the patient will feel increased pain in the affected area upon application of cold water or an ice cube to the affected area.[8]

Preoperative imaging studies are necessary in doubtful cases upon clinical findings. Radiographs are typically normal most of the time; sometimes, long-standing cases show cortical thinning or bony erosion.[1],[3],[4] In our case reports, one case had punched out lesion in X-ray and rest two cases were having normal X-ray. MRI is the excellent imaging modality for glomus tumor and can detect the tumor as small as 2 mm, but seldom used may be due to higher cost, nonavailability. A high signal central dot surrounded by a zone of lower signal intensity is the characteristic feature of glomus tumor on MRI.[2],[8]

Complete surgical excision is the modality of treatment and for histopathological diagnosis. Direct transungual excision is the standard approach of surgery for subungual glomus tumor.[5] Two approaches are described transungual and periungual approaches.[3],[6] Transungual approaches are the classical approach, and postoperative nail deformity may be seen in 3.3% to 26.3% cases. Periungual or paraungual approaches are specifically applied for pulp lesions and lesions partially under the nail.[3] We perform transungual approach in all the three cases as it allows clear visualization of the tumor resulting complete excision of tumor without any postoperative nail deformity.

Recurrence may occur after excision of the tumor with the rate of 4%–50% due to skin-colored tumors, incomplete excision of the tumor, presence of a second tumor which was not diagnosed previously, and development of a new lesion at or near the excision site.[2] The first case of the present reports was presenting with a recurrent glomus tumor which might be due to incorrect diagnosis and thus incomplete excision.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Shin DK, Kim MS, Kim SW, Kim SH. A painful glomus tumor on the pulp of the distal phalanx. J Korean Neurosurg Soc 2010;48:185-7.  Back to cited text no. 1
[PUBMED]    
2.
Morey VM, Garg B, Kotwal PP. Glomus tumours of the hand: Review of literature. J Clin Orthop Trauma 2016;7:286-91.  Back to cited text no. 2
[PUBMED]    
3.
Jawalkar H, Maryada VR, Brahmajoshyula V, Kotha GK. Subungual glomus tumors of the hand: Treated by transungual excision. Indian J Orthop 2015;49:403-7.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Lin YC, Hsiao PF, Wu YH, Sun FJ, Scher RK. Recurrent digital glomus tumor: Analysis of 75 cases. Dermatol Surg 2010;36:1396-400.  Back to cited text no. 4
    
5.
Thakur BK, Verma S, Jitani A. Subungual glomus tumour excision with transungual approach with partial proximal nail avulsion. J Cutan Aesthet Surg 2016;9:207-9.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Muramatsu K, Ihara K, Hashimoto T, Tominaga Y, Taguchi T. Subungual glomus tumours: Diagnosis and microsurgical excision through a lateral subperiosteal approach. J Plast Reconstr Aesthet Surg 2014;67:373-6.  Back to cited text no. 6
    
7.
Lee W, Kwon SB, Cho SH, Eo SR, Kwon C. Glomus tumor of the hand. Arch Plast Surg 2015;42:295-301.  Back to cited text no. 7
    
8.
Netscher DT, Aburto J, Koepplinger M. Subungual glomus tumor. J Hand Surg Am 2012;37:821-3.  Back to cited text no. 8
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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