Transungual Approach Research Articles

Successful Subungual Glomus Tumor Removal: A Case Report and Future Guidance on Diagnosis and Treatment

Background: Glomus tumors are rare benign hamartomas of the glomus body that occur mostly – though not limited to - the distal phalanxes of the digits. This article provides a real-life example of successful rare disease identification and treatment. It also provides a guideline that may help serve as future guidance on diagnosis and treatment. Case: A 41-year-old male came to our hospital presenting with a chief complaint of episodes of throbbing pain, which occurred spontaneously on the left thumb for the past two years. The pain had worsened in the past two weeks. The patient was positive for Hildreth’s, Love’s pin, and cold sensitivity tests. The previous x-ray showed no abnormalities in the left thumb. MRI found a hyperdense subungual lesion in the dorsal interphalangeal joint of the left thumb. We then performed an excision using the transungual approach. Histopathological findings found a relatively well-circumscribed lesion of the glomus apparatus absent of abnormal mitosis and necrosis. Two months after the excision, the patient reported no symptoms of recurrency, nail deformity, or other adverse outcomes. Conclusion: Patients typically present a chief complaint of chronic paroxysmal throbbing nail pain that persists for years, increases following exposure to cold environments, and is disproportionately exacerbated with the slightest touch. Hildreth’s, Love’s Pin, and cold sensitivity tests are special examinations that elicit or suppress pain. As with most benign tumors, complete excision usually yields good results. Adequate knowledge about diagnostic methods will help patients achieve early intervention and cure.

From diagnosis to recovery – a detailed case report on a nail bed glomus tumor

Introduction and aim. Glomus tumors represent benign neoplastic proliferations of the glomus body, an integral thermoregulatory component within the cutaneous microvasculature. Although they can manifest at various anatomical sites, they are predominantly observed in the subungual region. The tumors present as painful, firm, purplish, solitary nodules of the extremities, especially in the nail bed. They may be solitary or multiple; solitary lesions are encapsulated and most commonly subungual, while multiple tumors are unencapsulated and rarely subungual. Description of the case. Here, we present a case of multiple glomus tumors of the right hand in an 18-year-old female who presented with complaints of painful bluish discoloration of the right little finger for six years and progressive asymptomatic nodules on the right index finger for six months. A clinical examination revealed acute tenderness in both fingers. Love’s pin test and Hildreth’s test were positive. Excision of all lesions was done and sent for histopathology, which confirmed the diagnosis. The patient was symptom-free immediately following surgery. No nail deformities were noticed, and there was no recurrence of symptoms after one year of follow-up. Conclusion. The transungual approach is a safe and effective minimally invasive surgical technique for the treatment of symptomatic nail bed glomus tumors. It offers high success rates, promising cosmetic outcomes, and minimal complications. However, careful patient selection and meticulous surgical technique are essential to avoid potential nail deformities.

Outcomes of the Transungual Approach in 56 Consecutive Digital Subungual Glomus Tumours.

Background: Glomus tumour is a painful small tumour of the glomus body commonly located under the nail bed. The aim of this study is to evaluate the correlation of clinical diagnosis with MRI findings, determine the prevalence of the tumour at different subungual locations and determine the differences in outcomes (if any) between a longitudinal and a transverse nail bed incision for excision of the tumour. Methods: This retrospective study of 56 subungual glomus tumour was conducted from May 2010 to December 2021. Data with regard to gender, age at presentation, digit involved, presenting symptoms, duration of symptoms, clinical signs, need for MRI, anatomical location, surgical approach (longitudinal versus transverse), histopathology result, period of follow-up and complications were recorded. Results: All 56 (100%) patients presented with classic triad of symptoms. The average duration of symptoms was 52.9 months (range: 3-204 months). Eleven (20%) tumours were in the sterile matrix, 38 (68%) at the junction of sterile and germinal matrix and 7 (12%) in the germinal matrix. The tumours were excised through the longitudinal incision in 31 (55.3%) patients and transverse incision in 25 (44.7%). One (1.8%) tumour was intraosseous that was diagnosed intraoperatively and excised successfully. Average follow-up was 35.4 months (range: 6-120 months). There was no difference in outcomes (pain or nail deformity) between the two incisions. One patient (1.8%) has persistent pain that was due to a missed satellite lesion in the same digit. This was excised later with resolution of symptoms. There were no recurrences and all patients were cured after excision of tumour. Conclusions: Diagnosis of glomus tumour is usually clinical, and most are located at junction of sterile and germinal matrix. Tumour can be excised either by longitudinal or transverse nail bed incisions without any change of treatment outcome. Level of Evidence: Level IV (Therapeutic).

Surgical treatment of benign subungual tumours—a systematic review and case series

**Background**: Proper surgical technique is critical in the excision of benign subungual tumours to ensure complete tumour removal and prevent nail deformities. A systematic literature review was performed to identify approaches to excision and their clinical outcome. We present a series of rare benign subungual tumours to highlight different approaches and their outcomes.**Methods**: A systematic review of English language literature was conducted using the PubMed database between 1 January 1962 and 31 December 2021 for studies describing surgical approaches to benign subungual tumours. Search terms include ‘glomus tumour’, ‘subungual exostosis’, ‘osteoid osteoma’, ‘fibro-osseous pseudotumour of the digit’, ‘enchondroma’ and ‘implantation dermoid tumour’. We performed a retrospective review of patient records from our institute from 2021–2022. Six patients with subungual tumours were selected.**Results**: Twenty-one studies (with a total of 228 participants) described various techniques for excision of benign subungual tumours. The majority of the studies (n = 18) described the transungual approach, which allows maximum tumour exposure but with risk of nail deformity postoperatively. Other approaches described include lateral subperiosteal (n = 3), periungual (n = 2), nail bed margin (n = 1) and fish mouth (n = 2). Outcomes were measured using the rate of postoperative nail deformity and rate of tumour recurrence. Our series of patients were treated with excision using the transungual (5 of 6) and periungual approach (1 of 6), with good results. **Conclusion**: The available literature demonstrates that the transungual approach is the most widely used technique for removal of subungual tumours. This technique provides excellent tumour exposure; however, it is associated with damage to the nail bed. Our case series suggests that risk of nail dystrophy can be minimised by meticulous nail bed repair.

Clinico-epidemiological profile and management outcome of subungual digital glomus tumor-Indian experience.

Glomus tumors are rare tumors arising from the mesenchymal smooth muscle cells of the glomus body. They are extremely painful tumors but because of their subungual location, remain mostly underdiagnosed. To characterize the demographic, clinical, onychoscopic, radiological features and management outcome of subungual glomus tumor. Material & methods- 15 patients with a total of 16 subungual glomus tumors were evaluated and their demographic data, history, clinical features, investigations, treatment, and follow-up were analyzed. Glomus tumors had a female preponderance (11/15) with thumb being the commonest site. All patients presented with intractable pain. Nail discoloration was observed in 11/16 (68.8%) lesions and nail plate deformity in 6/16 (37.5%) lesions. Common features on onychosocpy were pink glow and linear vascular structures. Doppler sonography and/or magnetic resonance imaging confirmed the diagnosis of glomus tumor in all the lesions. Surgical excision was done under local anesthesia using a trans-ungual approach and no recurrence was seen. High index of suspicion, meticulous clinical assessment along with radiological investigations can help in the early diagnosis. Complete surgical excision is the treatment of choice to prevent recurrence.

Digital Glomus Tumor: Bibliographic Review of the Studies Published over the Past 10 Years

AbstractGlomus tumors are a mostly benign neoplasm that constitutes less than 4% of upper-limb soft-tissue tumors. Its unspecific clinical presentation, added to its low frequency, leads to a late diagnosis.The objective of the present study is to update the clinical-paraclinical approach and the surgical technique used in the treatment.We carried out a literature review from 2014 to 2019 on digital glomus tumor in the hand in adult patients using the PubMed search engine.In most of the publications analyzed, the diagnosis was clinical, with a delay of 1 to 10 years. Plain radiography is the most requested study; of the 16 articles reporting its indication, only half evidenced compatible changes. Magnetic resonance imaging (MRI) was requested in 15 articles, presenting normal results in 3 of them. The treatment of choice was surgical excision using a transungual approach. Only 4 articles report recurrence after excision.Although there is diversity in the approach to these tumors, we conclude that the diagnosis is clinical, and the treatment surgical, and there is no consensus regarding the paraclinical indication. The information available comes mainly from case reports, publications that contribute to the generation of evidence for the clinical practice in rare diseases such as this one.

Minimally Invasive Transungual Tumors Enucleation With Nail Preservation for Subungual Glomus Tumors

Glomus tumors are benign neurovascular neoplasms, most commonly located in the subungual region. These subcutaneous nodules are characterized by intense pain and temperature sensitivity. Although surgical excision is the curative treatment, permanent nail deformity and recurrence are not uncommon after conventional surgery. This study evaluated the long-term efficacy of a modified transungual approach with nail preservation for removing subungual glomus tumors. Thirty-nine patients with clinically diagnosed and histopathologically proven glomus tumors treated at a medical center over a 13-year period (2007-2019) were retrospectively evaluated. The 39 patients included 28 women and 11 men (ratio, 2.5:1), with a mean age of 48.9 years. Thirty-four tumors were located in the fingers and 5 in the toes. All patients returned to normal activity soon after the surgery. At a mean follow-up of 28.8 months, all were pain free or experienced minimal pain and were satisfied with treatment outcomes. One patient (2.6%) experienced recurrence. No nail deformity was observed. The transungual approach with nail plate preservation is a novel and effective method for removing subungual glomus tumors with reduced postoperative pain and rapid healing, while preserving or improving the configuration of the nail.

Glomus tumors of the upper extremity.

Glomus tumors are uncommon and painful benign perivascular neoplasms. They usually occur in the subungual region of phalanx, and present with a classic clinical triad of localized tenderness, cold hypersensitivity, and excruciating paroxysmal pain. The aim of this study was to review 45 cases of glomus tumor according to the clinical, radiological and therapeutic characteristics, and the clinical and functional outcomes of surgical treatment. A retrospective review was made of 45 glomus tumors of the upper extremity operated on between June 2005 and January 2019. Data were collected of demographic characteristics and the diagnostic, immunohistochemical, therapeutic and postoperative clinical findings. The patients comprised 69 % females and 31 % males with a median age of 41 years at the time of surgery. The most commonly affected anatomic location was the digits (87 %). Of the 39 cases with an affected digit, there was a predominance of the middle finger in 28 % and the peri-subungual area in 51 %. There was no recurrence or need for secondary surgical intervention in any patient in this study. The mean QuickDASH score was 1.47 at mean 66 months follow-up. Glomus tumor, which is usually seen in the middle finger of middle-aged women, presents with excruciating paroxysmal pain out of proportion to the tumor size. The long-term outcomes after surgical loupe-assisted surgery with a transungual approach were seen to be good, without local recurrence and an acceptable rate of postoperative nail dystrophy.

15240 Modified transungual approach with nail preservation for subungual glomus tumor: A 13-year evaluation and experience in a medical center in Taiwan

Background: Glomus tumors are benign neurovascular neoplasms, commonly in subungual region. The clinical presentation appears as intense pain, cold sensitivity, and severe tenderness of the involved digits or toes. The permanent nail deformity and recurrence is not uncommon after conventional surgery Objective: This study was designed to evaluate the long-term efficacy of the modified transungual approach with nail-preservation for removing subungual glomus tumors.

Outcome of transungual surgical approach with synthetic nail shield in the treatment of digital glomus tumors: A retrospective study

Glomus tumor is a benign neuromyoarterial tumor commonly found in the hand, particularly in the subungual region, that is removed only by surgery. Surgical excision leaves postoperative nail deformity and may cause a recurrence of subungual glomus tumors. A retrospective chart review was performed to assess the role of a synthetic nail shield in the prevention of postoperative nail deformity after transungual glomus tumor excision; the review was performed at a minimum of one year of follow-up of proven diagnosed 19 patients with digital glomus tumor between May 2011 and April 2016 in the orthopedic department in the university hospitals. All patients underwent surgical excision using transungual approach with a synthetic nail shield under digital nerve block anesthesia. Pain, cold intolerance, and complications were examined before and after surgery, and data were recorded. All patients had pain, tenderness, and cold intolerance, 12 patients (63.2%) had nail discoloration, and 3 patients (15.8%) had dystrophic changes. The tumors detached from surrounding tissues had an ovoid or round shape of 2–10 mm in size. Diagnosis was confirmed after pathological examination. In all patients, pain and cold sensitivity diminished. The mean follow-up period was 20.6 months, with no recurrences detected and improved nail appearance. No patient had postoperative nail deformity. Transungual approach followed by artificial coverage was an effective method for the treatment of glomus tumors without complications to the nail bed.

Glomus tumors of the nail bed: topographic anatomy and an algorithmic approach based on the topography.

Glomus tumors are rare vascular pathologies characterized by a triad of symptoms: tenderness, pain and cold intolerance. In the hand they are highly concentrated under the nail bed. In this retrospective study, we aimed to present a topographic map of the location of glomus tumors in the nail bed and a map-based surgical approach algorithm to the subungual glomus tumors. We prepared a nail bed map with 6 zones and named these zones as ulnar distal, ulnar proximal, central distal, central proximal, radial distal and radial proximal. With respect to the tumor location and the used surgical approach we retrospectively evaluated the intraoperative photos and the hospital records of patients who were operated between 2008-2019 and had the pathological diagnosis of glomus tumor. The examination records of the postoperative first year were evaluated for each patient retrospectively. A descriptive statistical analysis was performed. In addition we analyzed the described surgical approaches to excise a glomus tumor in the nail bed. The described approaches and the approaches used by us were matched with the localisation of the tumors in this study developing an algorithm for the surgical approach depending on the localisation of the nail bed glomus tumor. Finally 44 patients had inclusion criteria. The distribution of the glomus tumor was as follows: 2 were on ulnar distal (4.5 %), 9 on ulnar proximal (20.5 %), 1 on central distal (2.3 %), 18 on central proximal (40.9 %), 4 on radial distal (9.1 %) and 10 were on the radial proximal zones (22.7 %). 4 lateral approaches, 1 nail sparing and 39 transungual approaches were performed. We had one recurrence in a male patient operated by transungual approach. Glomus tumors are mostly located on the central proximal part of the nail bed. Our glomus map and the algorithm we described might be helpful for the selection of the surgical approach for the glomus tumor.

Glomus tumor of hand: A rarity treated by transungual approach

Introduction: Glomus tumor is a benign and rare vascular tumor arising from the glomus body, commonly found in the hand particularly in subungal region. These tumors present usually as bluish discolouration of nail plate with classical triad of excruciating pain, localized tenderness and sensitivity to cold. It’s etiology remains unknown but several hypothesis explain the excruciating pain. Different clinical test including Love’s pin test, Hildreth’s test and trans-illumination test are often helpful in diagnosis. MRI (Magnetic Resonance Imaging) is an excellent imaging modality in the diagnosis of these lesions. Diagnosis of tumor is delayed because of subtle clinical signs and also surgeons often miss advising MRI to patients due to its high cost. There are two main approaches for excision of glomus tumor-transungual and periungual. Selection of approach depends upon surgeon’s choice and anatomical location of the tumor. Complete surgical excision of the tumor reduces chance of recurrence. The aim of this study is to review the time from onset of symptoms to the diagnosis, management of problem and recurrence retrospectively. Material and methods: This study was done retrospectively between May 2017 to May 2019 at tertiary care center of eastern India. All patients with histopathologic ally confirmed subungual glomus tumor of distal phalanx of hand were included in this study. Patients with Reynolds disease were excluded from this study. MRI was done preoperatively and histopathological analysis of the excised specimen was done postoperatively to confirm the diagnosis. Patients were followed-up after every 3 month for 1 year to see any complication and recurrence. Results: It was found that the patients had clinical symptoms for an average of 2.3 years. All patients were women with mean age of 34.2 years. Out of 5 patients, 2 patients developed nail deformity. Recurrence was not found till last follow-up period. All patients were returned to their normal routine work and regained their full function of the hand.

Glomus tumour: A review of clinical presentation and treatment

Glomus tumors are perivascular hamartomas originating from glomus apparatus which are rare in occurrence and have a higher predilection for the subungual region of the hand. We retrospectively analyzed the management and outcome of patients with subungual glomus tumor treated over a period of 5 years from January 2013 to December 2018. Clinical evaluation included Love's test, Hildreth's test, and cold sensitivity tests. X-ray and MRI were done for all patients. Transungual approach was used in the treatment of all the patients. Total of seven cases were included in the study (6 females and 1 male). Mean age was 30.4 years with a range from 21 to 42 years. Average duration of complaints was 1.6 years ranging 1-3 years. Bone involvement was detected only in one case. Average size of the lesion was 2.7 mm ranging from 1.8 to 4 mm. Post operatively there was no nail deformity except in one patient.

Surgical Resection of Occult Subungual Glomus Tumors: Cold Sensitivity and Sonographic Findings.

We surgically treated subungual masses that were suspected glomus tumors, although definitive clinical and radiological findings were lacking. We report the outcomes of a retrospective case series. Of 42 patients treated by surgical resection between March 1996 and December 2015, 7 who met our inclusion/exclusion criteria were evaluated. At least 1 symptom of the typical triad (temperature sensitivity, severe pain, and localized tenderness) was absent, and computed tomography (CT) and magnetic resonance imaging (MRI) findings were normal. After ultrasonographic evaluation, we resected the masses using a transungual approach or a nail-preserving method. After pathological confirmation of the diagnosis, we followed all patients for at least 2 years to evaluate tumor recurrence and nail deformity. In 5 patients, cold sensitivity was the only symptom; no physical finding was suggestive of a glomus tumor. Tenderness was evidenced by the 2 patients who lacked cold sensitivity. None of the 7 patients exhibited CT or MRI abnormalities, but small acoustic shadows were evident in 4 patients, and blood-rich nodules were noted in 2 patients. The mean diameter of the 7 tumors was 2.1 mm, and pathological examination revealed typical glomus bodies. No major surgery-associated complication developed during follow-up. The final mean visual analog scale score (assessing pain) improved to 0.3 from the mean preoperative value of 3.6. Small glomus tumors exhibit few traditional symptoms and signs and no definitive radiological CT/MRI finding. However, cold sensitivity alone is a powerful surgical indication, and occasionally, ultrasonographic findings are useful even in the absence of CT/MRI findings.

Clinical analysis of surgical treatment for subungual glomus tumor

Objective To explore the clinical efficacy of surgical treatment for subungual glomus tumor. Methods From February 2006 to July 2015, 35 patients with subungual glomus tumor were performed surgical treatment. Transungual approach was used in 29 patients and Lateral Subperiosteal approach was used in 4 patients under the microscope. 2 cases of glomus tumor were located at the depth of the finger, and the finger pulp incision was adopted. The pain, recurrence and nail deformity of the fingers were evaluated before and 6 months after the operation. Results After 6 months of follow-up, 34 cases (97.0%) relieved of subjective pain, and 3 cases (8.6%) recurred after operation. 10 cases (28.5%) performed by Transungual occurred nail deformities, but no cases occurred by Lateral Subperiosteal and abdominal incision. Conclusion Surgical treatment of subungual glomus tumor has significant improvement in pain and low recurrence rate. The occurrence of nail deformity may be related to the surgical methods. Key words: Glomus tumor; Pain; Recurrence; Nail deformity

Sub-ungual Glomus Tumor: Study of 20 Cases

Glomus tumors are benign hamartoma of glomus body. It accounts 1-5% of all soft tissue tumors of hand. They can cause recurrent episodes of intense lancinating pain and disability. Patients often undergo undiagnosed or misdiagnosed for many years because the tumors are small. Twenty patients were operated during the period of 2010 to 2015. Most of the cases were selected on the basis of clinical diagnosis. The help of magnetic resonance imaging was taken in suspicious cases. The only treatment of glomus tumor is total surgical excision. In this study surgical excision were performed by direct trans-ungual approach. All patients showed dramatic relief of pain after surgical excision. Early diagnosis and surgical excision decreases patient's sufferings from severe pain and disability. Eagerness in early diagnosis and surgical excision can reduce long period of sufferings.Faridpur Med. Coll. J. Jul 2017;12(2): 64-67

Surgical treatment of subungual glomus tumors: Experience with lateral subperiosteal and transungual approaches

Background: Nail bed deformity and tumor recurrence are the major complications of subungual glomus tumor surgery. Therefore, alternative methods to approach glomus tumors in the hand have been proposed in order to avoid further nail bed injury after surgical treatment. Methods: In this study, we report a series of 32 patients with glomus tumors in the subungual region of the hand, treated surgically with two different types of incisions. The clinical efficacy and safety of the surgical treatment of glomus tumors performed by the lateral subperiosteal or the transungual approaches were analyzed. Results: In transungual approach since the nail plate is extracted and the nail bed is incised, there is a high risk of postoperative nail deformity and late recovery. However, in lateral subperiosteal approach since only the skin lateral to the nail is incised without extracting nail plate and incising nail bed, the nail bed injury does not occur. Conclusion: As a result, early recovery occurs and postoperative nail deformity is unaccepted. The main advantages of lateral subperiosteal approach are reducing postoperative nail deformity and early recovery. However, not every glomus tumor is suitable for lateral subperiosteal approach. In peripherally located tumors, the lateral subperiosteal approach provides quick recovery of the cosmetic appearance and less deformation of the nail.

Subungual Glomus Tumour Excision with Transungual Approach with Partial Proximal Nail Avulsion.

Subungual Glomus Tumour Excision with Transungual Approach with Partial Proximal Nail Avulsion.

Subungual glomus tumors of the hand: Treated by transungual excision.

Background:Glomus tumors are benign hamartomas arising from the glomus body, mostly occurring in the subungual region of the digits. A triad of excruciating pain, localized tenderness and cold sensitivity is the key to diagnosing these tumors. Two surgical approaches are described in the literature for excision of subungual glomus tumors-transungual and periungual. We reviewed retrospectively the results of subungual glomus tumors of the hand treated by transungual excision.Materials and Methods:Twelve patients (9 females and 3 males) with histopathologically confirmed subungual glomus tumors of the hand were treated by transungual excision at our institute. The mean age of the patients was 40.5 years (range 28–63 years). All patients presented with pain in the nail bed and cold sensitivity. A bluish-brown discoloration was present in 6 patients. Love's pin test was positive in all and Hildreth's test was positive in 8 patients. The mean duration of followup was 38 months (range 8–72 months).Results:All patients had complete pain relief. There was no new nail deformity and no recurrence till last followup. One patient had deformity of the nail preoperatively due to previous surgery, which persisted after excision of the tumor. All of them returned to their preoperative occupation and regained full function of the hand.Conclusions:The transungual approach provides good access to the entire lesion and facilitates complete excision. Contrary to reported literature, we did not find the development of any new nail deformity with this approach.

Glomus tumor of the hand.

BackgroundGlomus tumors were first described by Wood in 1812 as painful subcutaneous tubercles. It is an uncommon benign neoplasm involving the glomus body, an apparatus that involves in thermoregulation of cutaneous microvasculature. Glomus tumor constitutes 1%-5% of all hand tumors. It usually occurs at the subungual region and more commonly in aged women. Its classical clinical triad consists of pain, tenderness and temperature intolerance, especially cold sensitivity. This study reviews 15 cases of glomus tumor which were analyzed according to its anatomic location, surgical approach and histologic findings.MethodsFifteen patients with subungual glomus tumors of the hand operated on between January 2006 and March 2013, were retrospectively reviewed. Patients were evaluated preoperatively with standard physical examination including ice cube test and Love's test. Diagnostic imaging consisted of ultrasonography, computed tomography, and magnetic resonance imaging. All procedures were performed with tourniquet control under local anesthesia. Eleven patients underwent excision using the transungual approach, 3 patients using the volar approach and 1 patient using the lateral subperiosteal approach.ResultsTotal of 15 cases were reviewed. 11 tumors were located in the nail bed, 3 in the volar pulp and 1 in the radial aspect of the finger tip. After complete excision, patients remained asymptomatic in the immediate postoperative period. In the long term follow up, patients exhibited excellent cosmetic results with no recurrence.ConclusionsAccurate diagnosis should be made by physical, radiologic and pathologic examinations. Preoperative localization and complete extirpation is essential in preventing recurrence and subsequent nail deformity.