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| IMAGE QUIZ ARCHIVE | ||||||
| Image Quiz | ||
| Persistent Pain in the Ring Finger1 continued |
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| Answer: Glomus tumor | ||
 Fig. 3 | Histological analysis revealed a lesion composed of round cells with pale cytoplasm and small round nuclei, around vascular channels (hematoxylin and eosin, ×10). For larger view, click on image | |
| Discussion | ||
| The glomus tumor is an encapsulated hamartoma arising from one of the subcutaneous glomi that control blood flow. Proliferation of angiomatous tissue causes pressure on the nerve endings, which could explain the exquisite pain reported by the patient. Multiple glomus tumors, also known as glomangiomas, usually have an autosomal dominant pattern of inheritance. They often present at birth or appear during childhood1 and are asymptomatic. | ||
| Glomus tumor is a rare and debilitating lesion of unknown etiology that constitutes <2% of all hand tumors2. This tumor predominantly affects middle-aged women and is more often located in the distal phalanx and in the subungual region in 75% of cases1,2. | ||
| Discrete pain, tenderness, and temperature sensitivity are the classic triad of symptoms that point to a diagnosis of glomus tumor. In one series, purple discoloration of the nail was noted in 43% of the subungual lesions3. Other clinical features included nail deformity and a palpable nodule in the pulp of the finger. Love described a test consisting of the application of discrete pressure, with the head of a straight pin, to elicit tenderness and localize the tumor4. | ||
| Plain radiographs may show a bony erosion with a sclerotic border or scalloping in the distal phalanx in the cases in which the tumor has invaded the bone1. Ultrasonography may reveal a well-circumscribed hypoechoic lesion between the nail and the distal phalanx5. Bone scanning shows increased uptake in the affected area but is nonspecific. Magnetic resonance imaging and magnetic resonance angiography provide information useful for a definitive diagnosis and precise localization of the tumor6. | ||
| The lesion is treated with surgical excision, using either a transungual approach7 or a lateral approach8. The transungual approach provides the best exposure for subungual lesions and results in fewer cosmetic complications3. If the tumor is small, the nail bed can be closed primarily whereas a large tumor necessitates nail-bed grafting, which carries the risk of donor-site morbidity. | ||
| Local invasion of the capsule around the tumor, which has been reported in 1% to 2% of cases, may lead to inadequate excision and local recurrence9. | ||
| Because the classical signs of glomus tumor are absent in the early stages, any persistent pain in the distal phalanx and/or nail bed warrants consideration of a diagnosis of glomus tumor. | ||
| References | ||
| 1. Novice FM, Collison DW, Esterly NB.
Handbook of genetic skin disorders. Philadelphia: WB Saunders,1994. p
497-8. 2. Rettig AC, Strickland JW. Glomus tumor of the digits. J Hand Surg [Am]. 1977;2:261-5. 3. Van Geertruyden J, Lorea P, Goldschmidt D, De Fontaine S, Schuind F, Kinnen L, Ledoux P, Moermans JP. Glomus tumours of the hand. A retrospective study of 51 cases. J Hand Surg [Br]. 1996;21:257-60. 4. Love JG. Glomus tumors: diagnosis and treatment. Mayo Clin Proc. 1944; 19:113-6. 5. Ogino T, Ohnishi N. Ultrasonography of a subungual glomus tumour. J Hand Surg [Br]. 1993;18:746-6. 6. Boudghene FP, Gouny P, Tassart M, Callard P, Le Breton C, Vayssairat M. Subungual glomus tumor: combined use of MRI and three-dimensional contrast MR angiography. J Magn Reson Imaging. 1998;8:1326-8. 7. Carroll RE, Berman AT. Glomus tumors of the hand: review of the literature and report on twenty-eight cases. J Bone Joint Surg Am. 1972;54:691-703. 8. Gandon F, Legaillard P, Brueton R, Le Viet D, Foucher G. Forty-eight glomus tumours of the hand. Retrospective study and four-year follow-up. Chir Main Memb Super. 1992;11:401-5. 9. Holzberg M. Glomus tumor of the nail. A 'red herring' clarified by magnetic resonance imaging. Arch Dermatol. 1992;128:160-2. | ||
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