Glomus Tumour and Common Hand Tumours
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Direct answer
A glomus tumour is a benign neoplasm of the glomus body, a neurovascular structure in the nail bed, and it classically causes severe pain that is sensitive to cold and to pressure. Love's pinpoint tenderness and Hildreth's relief of pain with a tourniquet support the diagnosis. Surgical excision, usually through a sub-ungual approach, is curative.
What you must remember
- Origin: the glomus body, a modified arteriovenous shunt (the Sucquet-Hoyer canal) in the dermis, found most densely in the nail bed.
- Commonest site: the subungual region of a finger, and the tumour is often a small, blue-red spot under the nail.
- Classic triad: paroxysmal pain, exquisite point tenderness and cold sensitivity.
- Love's sign: pinpoint tenderness that localises the tumour, which a fine probe can often reproduce under the nail.
- Hildreth's sign: relief of pain when a tourniquet is applied proximally, which indicates a vascular lesion.
- Ganglion: a cystic swelling arising from a joint or tendon sheath, most often on the dorsum of the wrist, usually painless or mildly aching.
- Giant cell tumour of tendon sheath: a benign, nodular synovial lesion around flexor tendons in the hand, the second most common hand tumour after ganglion.
A pathway for a painful lesion in the hand
A painful nodule in the hand has a short differential, and the examiner's question is usually which history or test separates the lesions. The steps below follow the order in which a clinician narrows the diagnosis.
- Take the pain pattern: a glomus causes paroxysmal pain triggered by cold and pressure, whereas a ganglion usually aches without the same trigger.
- Localise the point: the tumour is found by pinpoint tenderness under or beside the nail, which is Love's sign.
- Apply the tourniquet test: pain relief with proximal ischaemia, which is Hildreth's sign, favours a glomus over a neuroma.
- Palpate the swelling: a ganglion is a firm, cystic and often mobile swelling, most often on the dorsal wrist.
- Image the lesion: MRI defines a glomus as a small, well-defined lesion, while ultrasound helps distinguish a ganglion from a soft tissue mass.
- Decide the treatment: excise a glomus through a sub-ungual approach, and treat a ganglion by aspiration or excision, with excision carrying the lower recurrence.
Where the exam tries to catch you
Hand tumour questions reward the clinical sign and the right treatment rather than the pathology alone.
- Trap: aspirating a symptomatic dorsal wrist ganglion and expecting it to stay away. Correct: aspiration has a higher recurrence rate than excision, which is often preferred for symptomatic ganglia.
- Trap: treating the Hildreth sign as diagnostic on its own. Correct: it supports a vascular lesion, but the triad, the point tenderness and imaging are needed to confirm a glomus.
- Trap: calling giant cell tumour of tendon sheath malignant because it is a tumour. Correct: it is benign and usually treated by complete excision, with recurrence the main concern.
Frequently asked questions
Which clinical sign localises a glomus tumour under the nail?
Love's sign, which is pinpoint tenderness at the site of the tumour, localises a glomus tumour under the nail. A fine probe or the tip of a pen can often reproduce the pain. Localisation like this allows a targeted sub-ungual excision.
What is the Hildreth sign in a glomus tumour?
Hildreth's sign is relief of pain when a tourniquet is applied proximal to the lesion, which stops blood flow through the glomus. It indicates that the pain is generated by a vascular lesion. The sign supports, but does not alone confirm, the diagnosis of glomus tumour.
How is a dorsal wrist ganglion treated?
A dorsal wrist ganglion is treated by observation if it is painless, or by aspiration or excision if it is symptomatic. Excision carries a lower recurrence rate than aspiration. The choice depends on symptoms, size and the patient's preference.
Is giant cell tumour of tendon sheath a malignant tumour?
Giant cell tumour of tendon sheath is a benign, nodular synovial lesion, usually found around the flexor tendons of the fingers. It can recur after excision, and metastasis is exceptionally rare. Complete surgical excision remains the standard treatment.