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Musculoskeletal » Superficial

Glomus tumor under the nail of the thumb

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Author(s) :

Taco Geertsma, MD

Presentation 14 year old female patient with pain in the thumb during compression of the nail

Caption: Longitudinal image of the distal dorsal aspect of the right thumb

Description: There is a hypoechoic structure under the nail that has caused an erosion of the bony contour of the distal phalanx (arrows)

Caption: Longitudinal image of the distal dorsal aspect of the contralateral (left) thumb

Description: There is a normal distance between the nail and the distal phalanx. The bony contour (arrows) is normal

Caption: Longitudinal split image of the distal dorsal aspect of both thumbs for comparison

Description: The split image clearly shows the difference in the space between the nail and the distal phalanx and the difference in the bony contour of the left and right thumb

Caption: Longitudinal color doppler image of the right thumb

Description: Color doppler shows hypervascularity of the subungual lesion

Caption: Transverse color doppler image of the right tumb

Description: There is hypervascularity of the subungual lesion.Also the contour deformity of the dorsal aspect of the distal phalanx is claerly shown

Final Diagnosis Glomus tumor under the nail of the thumb

Discussion

A glomus tumor is a rare benign neoplasm that arises from the neuroarterial structure called a glomus body, which accounts for 1 % to 5 % of soft-tissue tumors in the hand. The normal glomus body is located in the stratum reticulare throughout the body, but is more concentrated in the digits. They are believed to function in thermal regulation. The normal glomus(glomus body) is an arteriovenous shunt that is composed ofan afferent arteriole, an anastomotic vessel (Sucquet-Hoyercanal), a collecting vein, and a capsular portion. Histologic analysisshows vascular channels surrounded by irregularly arranged cuboidal cells.Nerves are found and may account for the pain. The tumor issurrounded by a fibrose capsule. A glomus tumor may be considereda hamartoma rather than a true tumor. The tumor is mostcommonly found on the distal extremities (75% occur in the hand)in the nail bed and subcutaneous tissue, especially at the tipsof the first to fourth fingers

The average age at presentation is from 30 to 50 years of age, although they can occur at any age. Because the symptoms are not always specific and the physical examination is frequently normal, the time from the onset of symptoms to the correct diagnosis is usually long and sometimes several years.

The classical symptoms are temperature sensitivity and local tenderness. Sometimes there is pain during the night. However the symptoms vary. The smaller lesions are very difficult to detect during physical examination.

The radiological findings can be unremarkable. Larger lesions can cause bony erosions which can be detected on the lateral X ray of the finger.

Ultrasound has proved to be very sensitive for the detection of glomus tumors.

The ultrasound characteristics are:
-Thickening of the soft tissues between the distal phalanx and the nail
-Sometimes a circumscribed hypoechoic mass is present
-Bony erosion of the distal phalanx
-Hypervascularity of the subungual tissues compared to the normal side

MRI also has proved to be sensitive for the detection of glomus tumors, but ultrasound is much quicker and cheaper. De ultrasound findings are highly pathognomonic. However ultrasound is as always operator dependent
For more examples of glomus tumors and ultrasound see www.ultrasoundcases.info

Case References

Matsunaga A, Ochiai T, Abe I, Kawamura A, Muto R, Tomita Y, Ogawa M. Subungual glomus tumour: evaluation of ultrasound imaging in preoperative assessment. Eur J Dermatol. 2007 Jan-Feb;17(1):67-9.

Marchadier A, Cohen M, Legre R. Subungual glomus tumors of the fingers: ultrasound diagnosis Chir Main. 2006 Feb;25(1):16-21. Article in French.

Fornage BD. Glomus tumors in the fingers: diagnosis with US. Radiology. 1988 Apr;167(1):183-5.

Follow Up The patient was operated and the diagnosis was confirmed

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