Musculoskelet Surg DOI 10.1007/s12306-015-0374-z
ORIGINAL ARTICLE
Nail-preserving modified lateral subperiosteal approach for subungual glomus tumour: a novel surgical approach B. Garg1 • M. V. Machhindra1 • V. Tiwari1 • V. Shankar1 • P. Kotwal1
Received: 4 March 2015 / Accepted: 22 April 2015 Ó Istituto Ortopedico Rizzoli 2015
Abstract Purpose Glomus tumours are benign, vascular neoplasms arising from glomus body and are often found near the fingertips. Complete surgical excision of the tumour must be ensured to avoid its recurrence. Several surgical approaches for its excision have been described in the literature; however, most of the approaches are associated with nail deformity in the post-operative period or fail to offer a complete exposure of the tumour. We wish to share our experience with our described nail-preserving modified lateral subperiosteal approach, where on account of the distal curve over the pulp tip, we achieve a large flap yielding an excellent exposure of the tumour mass. Methods We retrospectively evaluated 30 patients with subungual glomus tumour who were operated using this approach at a mean follow-up of 35.33 months. All patients were assessed for relief in the pre-operative symptoms, nail deformity, recurrence or any other complications.
& B. Garg [email protected] M. V. Machhindra [email protected] V. Tiwari [email protected] V. Shankar [email protected] P. Kotwal [email protected] 1
Department of Orthopaedics, All India Institute of Medical Sciences, Aurobindo Marg, New Delhi 110029, India
Results All wounds healed well without any possible wound complications such as wound dehiscence, suture margin necrosis or infection. At the end of the follow-up, all patients were relieved of the pre-operative symptoms. There was no evidence of deformity of nail or fingertip. No patient had recurrence. All the operated fingers were functionally normal. Conclusions Nail-preserving modified lateral subperiosteal approach does not damage the nail bed or interosseous supports to the distal phalanx. It is a very simple, less time-consuming approach for the resection of subungual tumours, and we would like to recommend it to our fellow orthopaedic surgeons. Keywords Glomus tumour Excision Approach Lateral Nail Recurrence
Introduction Glomus tumour is a rare, small pea-shaped tumour which in fact is an abnormal enlargement of the normal glomus bodies found all over the body [1]. Although this tumour can be found anywhere on the body, most common site of its occurrence is distal phalanx, especially in the subungual region [2]. Complete surgical excision of the tumour is the recommended treatment to reduce the chance of recurrence [3]. In the literature, several surgical approaches have been described to excise the tumour; however, incidence of nail deformity is quite high with most of the surgical approaches [4–7]. Many approaches, namely lateral ungual [8], lateral subperiosteal [9], Keyser–Littler [9] and nail bed margin approach [10], have been described with several modifications to prevent this problem. Most of them
123
Musculoskelet Surg
are useful only for particular location of the tumour [4, 5, 7, 9]. Also some approaches need nail plate removal, leading to a longer healing time. We wish to present our experience of nail-preserving modified lateral subperiosteal approach which gives a good exposure of glomus tumour in any subungual region facilitating the complete excision.
Materials and methods We retrospectively evaluated 30 patients with subungual glomus tumour operated in our hospital from January 2006 to January 2014. Ethical clearance for this study was taken from our institute. All the patients were diagnosed clinicoradiologically to have glomus tumour. All the patients had undergone a complete radiological examination by anteroposterior and lateral radiographs of the involved finger and magnetic resonance imaging (MRI). MRI was done in every case to better delineate the anatomical details of the tumour such as size and location and to aid in doubtful diagnoses. The diagnosis of glomus tumour was confirmed on histopathological examination of excised lesion. Surgical technique
Fig. 1 Skin incision. A high lateral incision extended distally and curved around the pulp
All patients were operated under either a general anaesthesia or brachial plexus block. The upper limb is fully exsanguinated using Esmarch bandage and tourniquet. Care was taken to exclude the involved digit to minimise any chances of tumour dissemination. A small high lateral incision is given to the side nearer to the tumour. This incision was extended distally and curved around the pulp (Fig. 1). After subcutaneous dissection, the deep dissection was taken straight to the bone and was continued subperiosteally to the distal phalanx raising a dorsal flap of nail matrix, nail bed and nail plate in one single unit exposing the tumour (Fig. 2). The magnitude of elevation of dorsal flap depended upon the central or peripheral position of the tumour. The tumour was separated from the surrounding soft tissue with the help of microsurgical scissors, and whole of the tumour along with its capsule was resected. Any bony impression was curetted thoroughly. The flap was replaced and the incision closed intermittently with 3–0 monofilament sutures. A sterile dressing of dry gauze pieces was applied over the wound. All patients were discharged the same day. We confirmed the diagnosis of glomus tumour by histopathological examination of the tumour. Sutures were removed on 13th post-operative day. Patients were advised active range of motion exercises
Fig. 2 Dorsal flap. A single unit dorsal flap exposing the tumour
123
Musculoskelet Surg
after the second post-operative day and were allowed to resume their duties once the sutures are removed. Patients were followed up after every 1 month till 3 months and then every year with the mean follow-up of 35.33 months (8–66 months). At each follow-up, patients were asked for relief in the pre-operative symptoms, nail deformity, recurrence or any other complications.
Results A total of 32 glomus tumours were excised in 30 patients and were included in the study, out of which 19 were females and 11 were males. The average patient age was 31.13 years with (21–50 years). The average duration of symptoms till the diagnosis was 9 years with a range of 3–20 years. Left hand was involved in 17 cases, and right hand in 13 cases. Five lesions were observed in thumb, six in index finger, two in middle finger, 10 in ring finger and seven in little finger. Twenty-eight cases had solitary lesion. Two of the patients had two lesions: index finger and second toe in one patient and ring finger and great toe in another (Table 1).
Table 1 Demographic profile of the patients and tumour characteristics
All patients reported to have characteristic triad of ‘‘pinpoint tenderness, excruciating pain on touch and aggravation of symptoms on exposure to cold’’. Two patients gave the history of blunt injury to the involved finger, but one of them was not sure whether the injury occurred before the symptoms or after the symptoms. One male patient gave history of similar disease to his paternal uncle. There was no similar family history in rest of the patients. Four patients had hypertension, and two patients had diabetes mellitus. Rest of the patients had no significant co-morbidity. On clinical examination, no patient had nail deformity pre-operatively. A bluish or purple-red spot on the nail was observed in 13 patients. The Love’s test and cold sensitivity test were positive in all 30 patients, while the Hildreth test was found to be negative in two patients. Radiographs were inconclusive in 21 patients, while nine patients showed evidence of bony erosion on the distal phalanx (Fig. 3). MRI was done in all the cases which revealed a lesion of low signal intensity on T1-weighted images and high signal intensity on T2-weighted images in all patients (Fig. 4). The anatomical details and location were documented after the MRI examination of involved digit. In 18 cases, the tumour was in the peripheral subungual region. The
Feature
Number/value [n (%)]
Sex Male
11 (36.66)
Female
19 (63.33)
Mean age with range in years
31.13 (21–50)
Average duration of symptoms with range in years
9 (3–20)
History of trauma
2 (6.66)
Associated lesions at other site
2 (6.66)
Triad of pain, tenderness and cold sensitivity
30 (100)
Involved finger Thumb
5 (16.66)
Index finger
6 (20)
Middle finger
2 (6.66)
Ring finger
10 (33.33)
Little finger
7 (23.33)
Tests Love’s test Cold sensitivity test Hildreth test
30 (100) 30 (100) 28 (93.33)
Nail plate deformity
None
Bluish or purple spot on nail
13 (43.33)
Bony erosion on X-rays
9 (30)
Classic presentation on MRI
30 (100)
123
Musculoskelet Surg Fig. 3 Plain radiographs. Bony erosions on the distal phalanx
Fig. 4 Magnetic resonance images. High signal intensity of the tumour mass on T2weighted images
central subungual region and nail matrix were involved in seven and five patients, respectively. Post-operative outcome All wounds healed well without any possible wound complications such as wound dehiscence, suture margin necrosis or infection. All patients were evaluated after 1 month of the surgery. Four patients complained of tenderness over the scar which resolved over the time in next 3–4 weeks. At the end of the follow-up, all patients were relieved of the pre-
123
operative symptoms. The Love’s test and cold sensitivity test were negative in all of them. There was no evidence of deformity of nail or fingertip. No patient had recurrence. All the operated fingers were functionally normal.
Discussion ‘‘Glomus’’ is a Latin word meaning a ‘‘ball’’ or ‘‘spherical mass’’. Glomus tumour is a benign, vascular spherical tumour arising from specialised cells found within the
Musculoskelet Surg
glomus bodies in the reticular dermis. Glomus body is a contractile neuromyoarterial structure consisting of afferent arteriole, anastomotic vessel known as Sucquet-Hoyer canal, primary collecting vein, intraglomerular reticulum and capsular portion [11]. They are present in the stratum reticularis of the dermis throughout the body, but are highly concentrated in the tips of the digits, especially under the nails [12, 13]. This fact explains most common subungual location for this tumour. The diagnosis of glomus tumour is usually evident from its classical triad of ‘‘pinpoint tenderness, severe pain to touch and cold sensitivity’’. To aid in the diagnosis, various clinical tests, namely Love’s pin test, Hildreth’s test and the cold sensitivity test, are used commonly [14]. Pre-operative imaging studies have been found to be of remarkable significance in case of doubtful diagnosis and also to elicit the anatomical details of the lesion. Radiographs can show cortical thinning or erosive changes in the adjacent bone in some of the cases [15–17]. Ultrasonography is capable of demonstrating the size, site and shape of the tumour, but is frequently influenced by the surgeon’s experience [15, 18]. MRI, however, is an excellent imaging modality for detecting the glomus tumour as small as 2 mm [6]. The glomus tumour in MRI is characteristically seen as a high-signal central dot surrounded by a zone of lower signal intensity. MRI can also be helpful in differentiating this tumour from its simulators such as neuroma, melanoma, pigmented nevus and haemangioma, as well as foreign bodies [19]. In our series, MRI confirmed the diagnosis in all cases. Complete surgical excision of the tumour is the only effective treatment, incomplete excision being the most important cause of recurrence [20]. In the literature, several surgical approaches have been described to excise the tumour. The standard traditional approach is direct transungual excision, which consists of cutting through the nail bed to reach the tumour. It affords good exposure to the central subungual tumours, but chances of longitudinal ridge or complete split nail deformity are high in the postoperative period [4, 5, 7]. Multiple modifications to this approach have been proposed to prevent these complications. Carroll and Berman proposed the use of a ‘‘lateral incision close to the edge of the nail’’ to approach subungual glomus tumours [8]. It was found to be useful only in case of tumours that are partially under the nail [9]. The Keyser–Littler approach is through a high mid-lateral incision below the lateral nail fold. Some authors believe that the lateral support to the nail matrix and the nail plate can be compromised in this approach owing to the retraction of the interosseous structures [6, 9]. In a lateral subperiosteal approach, the tumour mass in subungual region is directly
accessed without retracting the interosseous structures [9]. However, the degree of exposure is compromised [6]. In another approach known as modified periungual approach, a L-shaped incision is given over the periungual area and the tumour is exposed without splitting the nail bed, thus not needing nail bed repair [4]. According to some authors, this approach is suitable only for peripheral subungual tumours and there can be an inadequate visualisation in case of central subungual tumours with this approach [6]. In a recently described nail bed margin approach, the nail plate is removed completely to expose the tumour, and a curved incision is made near the side of the tumour along the nail bed margin [10]. Dissection is carried down to the distal phalanx, and a dorsal flap containing the nail bed and germinal matrix is raised to expose the tumour sufficiently. According to the authors, this approach can expose and completely excise tumours in any subungual region. But again, it needs the nail plate to be removed as in transungual approach. The recovery period includes the time till the nail plate reforms, needing the patients to come for multiple dressings and imposing them for a cosmetic disability till the normal nail plate reforms. The pain at each change in dressing adds to the discomfort to the patients. In our described nail-preserving modified lateral subperiosteal approach, the subungual region is directly accessed without any nail bed dissection or disrupting the interosseous supports of the distal phalanx. Recently, Muramatsu et al. [21] have also described a lateral subperiosteal approach for digital glomus tumours, but the number of cases was small. Moreover, they had residual tumour left in one case. We curve our lateral incision distally along the pulp of the finger. On account of the distal curve over the pulp tip, we achieve a flap large enough to reach the tumour without any struggle or overzealous retraction in the peripheral or central subungual region. The flap is replaced as it is after the resection of the tumour. Wound healed well in all patients without leaving a noticeable scar mark. Our study patients did not have any nail deformity or residual tumour left on further follow-up. Thus, the nail-preserving modified lateral subperiosteal approach is a very simple, less time-consuming approach for the resection of subungual tumours in any location. It provides a good exposure for the inspection of the tumour, and its complete excision without damaging the nail bed or interosseous supports to the distal phalanx. There is no chance of nail plate deformity as nail plate is not removed. This approach has proven to be a splendid approach for the excision of subungual glomus tumours in our practice, and we would like to recommend it to our fellow orthopaedic surgeons.
123
Musculoskelet Surg Conflict of interest of interest.
The authors declare that they have no conflict
Ethical standard All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent Informed consent was obtained from all individual participants included in the study.
References 1. Tomak Y, Akcay I, Debak N, Eroglu L (2003) Subungual glomus tumors of the hand: diagnosis and treatment of 14 cases. Scand J Plast Reconstr Surg Hand Surg 37:121–124 2. Al-Qattan MM, Al-Namla A, Al-Thunayan A et al (2005) Magnetic resonance imaging in the diagnosis of glomus tumours of the hand. J Hand Surg Br 30:535–540 3. Kim DH (1999) Glomus tumor of the finger-tip and MRI appearance. Iowa Orthop J 19:136–138 4. Fong ST, Lam YL, So YC (2007) A modified periungual approach for treatment of subungual glomus tumour. Hand Surg 12:217–221 5. Roan TL, Chen CK, Horng SY, Hsieh JH et al (2011) Surgical technique innovation for the excision of subungual glomus tumors. Dermatol Surg 37:259–262 6. Samaniego E, Crespo A, Sanz A (2009) Key diagnostic features and treatment of subungual glomus tumor. Actas Dermosifiliogr 100:875–882 7. Song M, Ko HC, Kwon KS, Kim MB (2009) Surgical treatment of subungual glomus tumor: a unique and simple method. Dermatol Surg 35:786–791 8. Carroll RE, Berman AT (1972) Glomus tumors of the hand: a review of the literature and a report on twenty-eight cases. J Bone Joint Surg Am 54:691
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9. Vasisht B, Watson HK, Joseph E, Lionelli GT (2004) Digital glomus tumors: a 29-year experience with a lateral subperiosteal approach. Plast Reconstr Surg 114:1486–1489 10. Wang PJ, Zhang Y, Zhao JJ (2013) Treatment of subungual glomus tumors using the nail bed margin approach. Dermatol Surg 39(11):1689–1694 11. Drape JL, Idy-Peretti I, Goettmann S et al (1995) Subungual glomus tumors: evaluation with MR imaging. Radiology 195:507–515 12. Sorene ED, Goodwin DR (2001) Magnetic resonance imaging of a tiny glomus tumour of the fingertip: a case report. Scand J Plast Reconstr Surg Hand Surg 35:429–431 13. Theumann NH, Goettmann S, Le Viet D et al (2002) Recurrent glomus tumors of fingertips: MR imaging evaluation. Radiology 223:143–151 14. Netscher DT, Aburto J, Koepplinger M (2012) Subungual glomus tumor. J Hand Surg Am 37:821–823 15. Chen SH, Chen YL, Cheng MH et al (2003) The use of ultrasonography in pre-operative localization of digital glomus tumours. Plast Reconstr Surg 112:115–119 16. Kale SS, Rao VK, Bentz ML (2006) Glomus tumour of the index finger. J Craniofac Surg 17:801–804 17. Lin YC, Hsiao PF, Wu YH et al (2010) Recurrent digital glomus tumor: analysis of 75 cases. Dermatol Surg 36:1396–1400 18. Ham KW, Yun IS, Tark KC (2013) Glomus Tumors: symptom variations and magnetic resonance imaging for diagnosis. Arch Plast Surg 40:392–396 19. Nazerani S, Motamedi MH, Keramati MR (2010) Diagnosis and management of glomus tumors of the hand. Tech Hand Up Extrem Surg 14:8–13 20. Rohrich R, Hochstein L, Millwee R (1994) Subungual glomus tumors: an algorithmic approach. Ann Plast Surg 33:300–304 21. Muramatsu K, Ihara K, Hashimoto T, Tominaga Y, Taguchi T (2014) Subungual glomus tumours: diagnosis and microsurgical excision through a lateral subperiosteal approach. J Plast Reconstr Aesthet Surg 67(3):373–376
ORIGINAL ARTICLE
Nail-preserving modified lateral subperiosteal approach for subungual glomus tumour: a novel surgical approach B. Garg1 • M. V. Machhindra1 • V. Tiwari1 • V. Shankar1 • P. Kotwal1
Received: 4 March 2015 / Accepted: 22 April 2015 Ó Istituto Ortopedico Rizzoli 2015
Abstract Purpose Glomus tumours are benign, vascular neoplasms arising from glomus body and are often found near the fingertips. Complete surgical excision of the tumour must be ensured to avoid its recurrence. Several surgical approaches for its excision have been described in the literature; however, most of the approaches are associated with nail deformity in the post-operative period or fail to offer a complete exposure of the tumour. We wish to share our experience with our described nail-preserving modified lateral subperiosteal approach, where on account of the distal curve over the pulp tip, we achieve a large flap yielding an excellent exposure of the tumour mass. Methods We retrospectively evaluated 30 patients with subungual glomus tumour who were operated using this approach at a mean follow-up of 35.33 months. All patients were assessed for relief in the pre-operative symptoms, nail deformity, recurrence or any other complications.
& B. Garg [email protected] M. V. Machhindra [email protected] V. Tiwari [email protected] V. Shankar [email protected] P. Kotwal [email protected] 1
Department of Orthopaedics, All India Institute of Medical Sciences, Aurobindo Marg, New Delhi 110029, India
Results All wounds healed well without any possible wound complications such as wound dehiscence, suture margin necrosis or infection. At the end of the follow-up, all patients were relieved of the pre-operative symptoms. There was no evidence of deformity of nail or fingertip. No patient had recurrence. All the operated fingers were functionally normal. Conclusions Nail-preserving modified lateral subperiosteal approach does not damage the nail bed or interosseous supports to the distal phalanx. It is a very simple, less time-consuming approach for the resection of subungual tumours, and we would like to recommend it to our fellow orthopaedic surgeons. Keywords Glomus tumour Excision Approach Lateral Nail Recurrence
Introduction Glomus tumour is a rare, small pea-shaped tumour which in fact is an abnormal enlargement of the normal glomus bodies found all over the body [1]. Although this tumour can be found anywhere on the body, most common site of its occurrence is distal phalanx, especially in the subungual region [2]. Complete surgical excision of the tumour is the recommended treatment to reduce the chance of recurrence [3]. In the literature, several surgical approaches have been described to excise the tumour; however, incidence of nail deformity is quite high with most of the surgical approaches [4–7]. Many approaches, namely lateral ungual [8], lateral subperiosteal [9], Keyser–Littler [9] and nail bed margin approach [10], have been described with several modifications to prevent this problem. Most of them
123
Musculoskelet Surg
are useful only for particular location of the tumour [4, 5, 7, 9]. Also some approaches need nail plate removal, leading to a longer healing time. We wish to present our experience of nail-preserving modified lateral subperiosteal approach which gives a good exposure of glomus tumour in any subungual region facilitating the complete excision.
Materials and methods We retrospectively evaluated 30 patients with subungual glomus tumour operated in our hospital from January 2006 to January 2014. Ethical clearance for this study was taken from our institute. All the patients were diagnosed clinicoradiologically to have glomus tumour. All the patients had undergone a complete radiological examination by anteroposterior and lateral radiographs of the involved finger and magnetic resonance imaging (MRI). MRI was done in every case to better delineate the anatomical details of the tumour such as size and location and to aid in doubtful diagnoses. The diagnosis of glomus tumour was confirmed on histopathological examination of excised lesion. Surgical technique
Fig. 1 Skin incision. A high lateral incision extended distally and curved around the pulp
All patients were operated under either a general anaesthesia or brachial plexus block. The upper limb is fully exsanguinated using Esmarch bandage and tourniquet. Care was taken to exclude the involved digit to minimise any chances of tumour dissemination. A small high lateral incision is given to the side nearer to the tumour. This incision was extended distally and curved around the pulp (Fig. 1). After subcutaneous dissection, the deep dissection was taken straight to the bone and was continued subperiosteally to the distal phalanx raising a dorsal flap of nail matrix, nail bed and nail plate in one single unit exposing the tumour (Fig. 2). The magnitude of elevation of dorsal flap depended upon the central or peripheral position of the tumour. The tumour was separated from the surrounding soft tissue with the help of microsurgical scissors, and whole of the tumour along with its capsule was resected. Any bony impression was curetted thoroughly. The flap was replaced and the incision closed intermittently with 3–0 monofilament sutures. A sterile dressing of dry gauze pieces was applied over the wound. All patients were discharged the same day. We confirmed the diagnosis of glomus tumour by histopathological examination of the tumour. Sutures were removed on 13th post-operative day. Patients were advised active range of motion exercises
Fig. 2 Dorsal flap. A single unit dorsal flap exposing the tumour
123
Musculoskelet Surg
after the second post-operative day and were allowed to resume their duties once the sutures are removed. Patients were followed up after every 1 month till 3 months and then every year with the mean follow-up of 35.33 months (8–66 months). At each follow-up, patients were asked for relief in the pre-operative symptoms, nail deformity, recurrence or any other complications.
Results A total of 32 glomus tumours were excised in 30 patients and were included in the study, out of which 19 were females and 11 were males. The average patient age was 31.13 years with (21–50 years). The average duration of symptoms till the diagnosis was 9 years with a range of 3–20 years. Left hand was involved in 17 cases, and right hand in 13 cases. Five lesions were observed in thumb, six in index finger, two in middle finger, 10 in ring finger and seven in little finger. Twenty-eight cases had solitary lesion. Two of the patients had two lesions: index finger and second toe in one patient and ring finger and great toe in another (Table 1).
Table 1 Demographic profile of the patients and tumour characteristics
All patients reported to have characteristic triad of ‘‘pinpoint tenderness, excruciating pain on touch and aggravation of symptoms on exposure to cold’’. Two patients gave the history of blunt injury to the involved finger, but one of them was not sure whether the injury occurred before the symptoms or after the symptoms. One male patient gave history of similar disease to his paternal uncle. There was no similar family history in rest of the patients. Four patients had hypertension, and two patients had diabetes mellitus. Rest of the patients had no significant co-morbidity. On clinical examination, no patient had nail deformity pre-operatively. A bluish or purple-red spot on the nail was observed in 13 patients. The Love’s test and cold sensitivity test were positive in all 30 patients, while the Hildreth test was found to be negative in two patients. Radiographs were inconclusive in 21 patients, while nine patients showed evidence of bony erosion on the distal phalanx (Fig. 3). MRI was done in all the cases which revealed a lesion of low signal intensity on T1-weighted images and high signal intensity on T2-weighted images in all patients (Fig. 4). The anatomical details and location were documented after the MRI examination of involved digit. In 18 cases, the tumour was in the peripheral subungual region. The
Feature
Number/value [n (%)]
Sex Male
11 (36.66)
Female
19 (63.33)
Mean age with range in years
31.13 (21–50)
Average duration of symptoms with range in years
9 (3–20)
History of trauma
2 (6.66)
Associated lesions at other site
2 (6.66)
Triad of pain, tenderness and cold sensitivity
30 (100)
Involved finger Thumb
5 (16.66)
Index finger
6 (20)
Middle finger
2 (6.66)
Ring finger
10 (33.33)
Little finger
7 (23.33)
Tests Love’s test Cold sensitivity test Hildreth test
30 (100) 30 (100) 28 (93.33)
Nail plate deformity
None
Bluish or purple spot on nail
13 (43.33)
Bony erosion on X-rays
9 (30)
Classic presentation on MRI
30 (100)
123
Musculoskelet Surg Fig. 3 Plain radiographs. Bony erosions on the distal phalanx
Fig. 4 Magnetic resonance images. High signal intensity of the tumour mass on T2weighted images
central subungual region and nail matrix were involved in seven and five patients, respectively. Post-operative outcome All wounds healed well without any possible wound complications such as wound dehiscence, suture margin necrosis or infection. All patients were evaluated after 1 month of the surgery. Four patients complained of tenderness over the scar which resolved over the time in next 3–4 weeks. At the end of the follow-up, all patients were relieved of the pre-
123
operative symptoms. The Love’s test and cold sensitivity test were negative in all of them. There was no evidence of deformity of nail or fingertip. No patient had recurrence. All the operated fingers were functionally normal.
Discussion ‘‘Glomus’’ is a Latin word meaning a ‘‘ball’’ or ‘‘spherical mass’’. Glomus tumour is a benign, vascular spherical tumour arising from specialised cells found within the
Musculoskelet Surg
glomus bodies in the reticular dermis. Glomus body is a contractile neuromyoarterial structure consisting of afferent arteriole, anastomotic vessel known as Sucquet-Hoyer canal, primary collecting vein, intraglomerular reticulum and capsular portion [11]. They are present in the stratum reticularis of the dermis throughout the body, but are highly concentrated in the tips of the digits, especially under the nails [12, 13]. This fact explains most common subungual location for this tumour. The diagnosis of glomus tumour is usually evident from its classical triad of ‘‘pinpoint tenderness, severe pain to touch and cold sensitivity’’. To aid in the diagnosis, various clinical tests, namely Love’s pin test, Hildreth’s test and the cold sensitivity test, are used commonly [14]. Pre-operative imaging studies have been found to be of remarkable significance in case of doubtful diagnosis and also to elicit the anatomical details of the lesion. Radiographs can show cortical thinning or erosive changes in the adjacent bone in some of the cases [15–17]. Ultrasonography is capable of demonstrating the size, site and shape of the tumour, but is frequently influenced by the surgeon’s experience [15, 18]. MRI, however, is an excellent imaging modality for detecting the glomus tumour as small as 2 mm [6]. The glomus tumour in MRI is characteristically seen as a high-signal central dot surrounded by a zone of lower signal intensity. MRI can also be helpful in differentiating this tumour from its simulators such as neuroma, melanoma, pigmented nevus and haemangioma, as well as foreign bodies [19]. In our series, MRI confirmed the diagnosis in all cases. Complete surgical excision of the tumour is the only effective treatment, incomplete excision being the most important cause of recurrence [20]. In the literature, several surgical approaches have been described to excise the tumour. The standard traditional approach is direct transungual excision, which consists of cutting through the nail bed to reach the tumour. It affords good exposure to the central subungual tumours, but chances of longitudinal ridge or complete split nail deformity are high in the postoperative period [4, 5, 7]. Multiple modifications to this approach have been proposed to prevent these complications. Carroll and Berman proposed the use of a ‘‘lateral incision close to the edge of the nail’’ to approach subungual glomus tumours [8]. It was found to be useful only in case of tumours that are partially under the nail [9]. The Keyser–Littler approach is through a high mid-lateral incision below the lateral nail fold. Some authors believe that the lateral support to the nail matrix and the nail plate can be compromised in this approach owing to the retraction of the interosseous structures [6, 9]. In a lateral subperiosteal approach, the tumour mass in subungual region is directly
accessed without retracting the interosseous structures [9]. However, the degree of exposure is compromised [6]. In another approach known as modified periungual approach, a L-shaped incision is given over the periungual area and the tumour is exposed without splitting the nail bed, thus not needing nail bed repair [4]. According to some authors, this approach is suitable only for peripheral subungual tumours and there can be an inadequate visualisation in case of central subungual tumours with this approach [6]. In a recently described nail bed margin approach, the nail plate is removed completely to expose the tumour, and a curved incision is made near the side of the tumour along the nail bed margin [10]. Dissection is carried down to the distal phalanx, and a dorsal flap containing the nail bed and germinal matrix is raised to expose the tumour sufficiently. According to the authors, this approach can expose and completely excise tumours in any subungual region. But again, it needs the nail plate to be removed as in transungual approach. The recovery period includes the time till the nail plate reforms, needing the patients to come for multiple dressings and imposing them for a cosmetic disability till the normal nail plate reforms. The pain at each change in dressing adds to the discomfort to the patients. In our described nail-preserving modified lateral subperiosteal approach, the subungual region is directly accessed without any nail bed dissection or disrupting the interosseous supports of the distal phalanx. Recently, Muramatsu et al. [21] have also described a lateral subperiosteal approach for digital glomus tumours, but the number of cases was small. Moreover, they had residual tumour left in one case. We curve our lateral incision distally along the pulp of the finger. On account of the distal curve over the pulp tip, we achieve a flap large enough to reach the tumour without any struggle or overzealous retraction in the peripheral or central subungual region. The flap is replaced as it is after the resection of the tumour. Wound healed well in all patients without leaving a noticeable scar mark. Our study patients did not have any nail deformity or residual tumour left on further follow-up. Thus, the nail-preserving modified lateral subperiosteal approach is a very simple, less time-consuming approach for the resection of subungual tumours in any location. It provides a good exposure for the inspection of the tumour, and its complete excision without damaging the nail bed or interosseous supports to the distal phalanx. There is no chance of nail plate deformity as nail plate is not removed. This approach has proven to be a splendid approach for the excision of subungual glomus tumours in our practice, and we would like to recommend it to our fellow orthopaedic surgeons.
123
Musculoskelet Surg Conflict of interest of interest.
The authors declare that they have no conflict
Ethical standard All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent Informed consent was obtained from all individual participants included in the study.
References 1. Tomak Y, Akcay I, Debak N, Eroglu L (2003) Subungual glomus tumors of the hand: diagnosis and treatment of 14 cases. Scand J Plast Reconstr Surg Hand Surg 37:121–124 2. Al-Qattan MM, Al-Namla A, Al-Thunayan A et al (2005) Magnetic resonance imaging in the diagnosis of glomus tumours of the hand. J Hand Surg Br 30:535–540 3. Kim DH (1999) Glomus tumor of the finger-tip and MRI appearance. Iowa Orthop J 19:136–138 4. Fong ST, Lam YL, So YC (2007) A modified periungual approach for treatment of subungual glomus tumour. Hand Surg 12:217–221 5. Roan TL, Chen CK, Horng SY, Hsieh JH et al (2011) Surgical technique innovation for the excision of subungual glomus tumors. Dermatol Surg 37:259–262 6. Samaniego E, Crespo A, Sanz A (2009) Key diagnostic features and treatment of subungual glomus tumor. Actas Dermosifiliogr 100:875–882 7. Song M, Ko HC, Kwon KS, Kim MB (2009) Surgical treatment of subungual glomus tumor: a unique and simple method. Dermatol Surg 35:786–791 8. Carroll RE, Berman AT (1972) Glomus tumors of the hand: a review of the literature and a report on twenty-eight cases. J Bone Joint Surg Am 54:691
123
9. Vasisht B, Watson HK, Joseph E, Lionelli GT (2004) Digital glomus tumors: a 29-year experience with a lateral subperiosteal approach. Plast Reconstr Surg 114:1486–1489 10. Wang PJ, Zhang Y, Zhao JJ (2013) Treatment of subungual glomus tumors using the nail bed margin approach. Dermatol Surg 39(11):1689–1694 11. Drape JL, Idy-Peretti I, Goettmann S et al (1995) Subungual glomus tumors: evaluation with MR imaging. Radiology 195:507–515 12. Sorene ED, Goodwin DR (2001) Magnetic resonance imaging of a tiny glomus tumour of the fingertip: a case report. Scand J Plast Reconstr Surg Hand Surg 35:429–431 13. Theumann NH, Goettmann S, Le Viet D et al (2002) Recurrent glomus tumors of fingertips: MR imaging evaluation. Radiology 223:143–151 14. Netscher DT, Aburto J, Koepplinger M (2012) Subungual glomus tumor. J Hand Surg Am 37:821–823 15. Chen SH, Chen YL, Cheng MH et al (2003) The use of ultrasonography in pre-operative localization of digital glomus tumours. Plast Reconstr Surg 112:115–119 16. Kale SS, Rao VK, Bentz ML (2006) Glomus tumour of the index finger. J Craniofac Surg 17:801–804 17. Lin YC, Hsiao PF, Wu YH et al (2010) Recurrent digital glomus tumor: analysis of 75 cases. Dermatol Surg 36:1396–1400 18. Ham KW, Yun IS, Tark KC (2013) Glomus Tumors: symptom variations and magnetic resonance imaging for diagnosis. Arch Plast Surg 40:392–396 19. Nazerani S, Motamedi MH, Keramati MR (2010) Diagnosis and management of glomus tumors of the hand. Tech Hand Up Extrem Surg 14:8–13 20. Rohrich R, Hochstein L, Millwee R (1994) Subungual glomus tumors: an algorithmic approach. Ann Plast Surg 33:300–304 21. Muramatsu K, Ihara K, Hashimoto T, Tominaga Y, Taguchi T (2014) Subungual glomus tumours: diagnosis and microsurgical excision through a lateral subperiosteal approach. J Plast Reconstr Aesthet Surg 67(3):373–376
