أمراض العظام / علاج العظام في الاردن / افضل دكتور عظام في الاردن / افضل اخصائي عظام في الاردن / استشاري عظام/ افضل استشاري عظام في الاردن / عمليات تطويل العظام في الاردن / اطباء العظام في الاردن / دكتور عظام في الاردن / الاطباء في الاردن / خلع الورك / عمليات اليزاروف في الاردن /علاج الكسور / خلع الولادة / تركيب المفاصل الاصطناعيه للركبه والورك / افضل طبيب عظام اطفال في الاردن / استشاري اطفال عظام في الاردن / علاج خلع الكتف / علاج التواء الكاحل / مشاكل العظام والمفاصل /مستشار جراحة العظام والمفاصل والكسور / مستشار جراحة عظام الأطفال / علاج اصابات الركبة / اسباب آلام الركبة / علاج الاصابات الرياضية / مفصل الركبة / علاج مفصل الركبة / عمليات مفصل الركبة / صابونة الركبة / علاج الم صابونة الركبة / استشاري جراحة العمود الفقري في الاردن / جراحة العمود الفقري بالتداخل المحدود / عمليات الديسك أو الإنزلاق الغضروفي / علاج الديسك / عمليات الديسك / الم الظهر من الديسك / علاج الديسك في الاردن / اطباء الديسك في الاردن / اسباب الديسك / الم العمود الفقري / اسباب الانزلاق الغضروفي / اعراض الديسك / افضل اطباء الديسك في الاردن / افضل طبيب لعلاج الانزلاق الغضروفي في الاردن / تحرير عصب اليد / عمليات تحرير العصب / اعراض الديسك / خدران او تنميل اليد / خدران الرجل / خدران الساق / خدران الاطراف / تنميل الاطراف / تنميل اليد / رجوع الديسك البروفيسور فريح ابوحسان – استشاري جراحة العظام في الاردن

1. Digital and Extradigital Glomus Tumors At Jordan University Hospital
A Retrospective Review (1989 - 1999)
Shaher El-Hadidi, Freih Abu Hassan, Shukri Aghabi, Jamal Al-Masad,Faiez Daoud, .Mahmoud Abu-Khalaf,
Husam Al-Muhtaseb, Musleh Tarawneh.
Jordan Univeisrtl.Hosprtal &l4edicil Schoot.
ABSTRACT
Ten patients diagnosed to have glomus tumors were
located in various parts of the body, treated at Jordan
University Hospital between 1989- lgg9.
Five out of six digital tumours were diagnosed clinically
and confirmed by histological examination after surgical
excision.
Extradigital tumours were diagnosed only after surgical
excision and histological examination.
Most of our cases though presented late and in all cases
were subjected to complete surgical excision did
produced a pennenant relief of symptoms
Clinical diagnosis is suflicient in digital lesions but plain
X-rays can be added to exclude bony erosions.
KEYWORDS
Glomus, Digital, Pain, Triad, Tumour.
INTRODUCTION
Glomus tumours and uncommon benign hamartoma,
were first described clinically by wood in l8l 2,t and,
histologically described by Masson in 1924 and Popoff
in 1934.2 .
Masson described the origin of the tumour as
hyperplasia of the neuromyoarterial elements of the
glomus body.2
Glomus body is an arteriovenous shunt found in dermal-subdermal
junction which acts as a regulator of skin
circulation,''' and is frequently encountered in
subungual region, abscent in people below one year of
age and atrophied in elderly.a
Glomus tumour is present in up to 75% of the distal
phalan*,:': .but is expected to d found in any place of
the body3'5'll and muitiple lesions have been ors.tiued .5
It forms l-l}yo of all hand tumours,6,7,8 and are
commonly found in adult females up to 88%.8
Although it is a few mm in size 4 ,',','and usually less
than I cm in noh4 rarely more than 2cm,e it proiuces
severe 4 symptoms, pain, tenderness and cold
intolerance.
Diagnosis usually done by the classic typical triad of
symptoms in most digital iesiorrr. t'o't'e r ^
Clinically: Tenderness almost present in all cases,
hypersensitivity to touch and cold in 630A, nail
deformity in 47% and blue-red discoloration spot in
430 .8
We rarely needed to proceed for further investigations
once the full picture encountered.
Few authors suggested to use X-rays to exclude bony
erosioD,6'8 ultrasound 2'e or MRI for localization and
diagnosis.6'7 '
In extradigital areas may present as a painful nodule
with long history of pain and tenderness in relation to
the soft tissue.4'lo'l I
Provocative tests have been suggested to increase the
pain, Love's test in 1944 by pressing the lesion with
pin head 4'8 using the or ethyl ChloriOe cold test.a
Grossly, the glomus tumour forms a capsulated nodule
of less than 5mm but a larger lesion have been
reported. e
Histologically it is formed by benign glomus cells
which are round or oval and are specialized
perivascular muscle cells wilh dense, granular
cytoplasm near a rich neural bed. 2'4
Local infiltrative tumours and sarcomatous lesions are
rare but have been reported. l'3' l I 't2't3
Complete surgical excision was found to be the most
effective method to eradicate infections in patients
symptoms.4'8'lo
Correspondence should be addressed to:
S.T.F.El-Hadidi, FRCS. (Ed.),
Jordan University, P.O. Box 13347-Amman, Jordan.
54
JORDAN MEDICAL JOURNAL, VOL.35, NO.(l), MAy 2001

2. DIGITAL AND EXT,.ADIGITAL GLOMUS TUMORS AT JUH. SH. EL-HADIDI ET AL.
We did a. retrospective review of l0 cases of such
tumours over a l0 year period encountered in the
General Surgery and the Orthopaedic Surgery
departments at the Jordan University Hospital.
PATIENTS AND METHODS
A total of 10 proven glomus tumours involving the
digital and .- extradigital soft tissues confirmed
histologically were retrospectively reviewed with a
mean follow-up of 5 years (6 months- 13 year). There
were 6 males and four females with a mean age of 42.1
years (range 20-60 years). Five tumours were located to
distal phalanx and one located to the volar pad of
proximal phalanx. Table l. While the remaining extra
digital tumours were located to the (forearffi, thigh,
hypothenars and natal cleft) as shown in tabl e 2.
Clinically, all the digital tumours had pain as initial
symptoms or more than 2 years, four of them had typical
triad of glomus tumour in the form of severe
pain/hypersensitivity to the touch and pressure with
marked tenderness and cold intolerance, especially in
winter. One patient has severe pain only and another had
a painful nodule. Five had a red-blue discoloration of
the nail at the site of the tumour. Nail deformity in
only 3 cases.
While extradigital tuinours were presented as a painful
nodule for more than the duration of one year and only
2 had the triad presentation of a glomus tumour.
(Table 2).
Inspite of the typical clinical triad in 6 of our cases, all
these cases were missed initially by physicians. The 4
digital cases with triad were clinically diagnosed by
orthopaedic and hand surgeons, the other 2 were
diagnosed after excision and histopathology.
The remaining 4 were typical presentation, one
suspected clinically and the other 3 diagnosed after
excision and histopathology.
Pre operatively three cases assessed radiologically,
two by plain x-ray and both showed bony erosion due
to pressure. ( Figure 3 ),
One patient assessed by an MRI scan and showed
bright lesions with the characteristics.
Of vascular origin in T2 image. Case No.: l, table I ,
figure ( I ).
Table 1. Demographic characteristics and symptoms of the digital lesions in the study group.
JORDAN MEDICAL JOURNAL, VOL. 35, NO.(l), MAY 2001
Case Age Sex Symptoms
duration
Site .Presenta
tion
Red - blue
discoloration
Nail
deformity
Size Location
I
53
years
Male 3 years Thumb Triad Positive Positive 0.5 x 0.5 cm Subungual
2-
54
years
Male 3 years Big toe Pain Positive Negative 0.4 x 0.4 cm Subungual
.,
J.
34
years
Male 4 years Ring finger Triad Positive Positive 1.5 x 0.5 cm Subungual
4-
52
years
Female 2 years Thumb Triad Positive Negative 0.7 x0.7 cm Subungual
5-
20
years
Female 4 years Little
finger
Triad Positive Positive 1.5 x 0.5 cm Subungual
6-
60
years
(yr) in
all
Male 4 years
(yr)inall
Index
finger
Painful
nodule
Negative Negative 2xlcm Volar pad
of
proximal
phalanx
55

3. DIGITAL AND EXTRADIGI.I'AL GLOMUS TUMORS AT JUH. SH. EL.HADIDI ET AL.
Table 2. Demoeraphic characteristic and symptoms of the extradigital tumours.
Case Age Sex Symptom
duration
Site Presentation Size
I 3l yedrs Male I year Dorsum of
forearm
Painful nodule +
Triad
0.8 x 0.8 cm
2- 54 years Female I year Ant. thigh Painful nodule +
Triad
1.5 x 1.5 cm
3- 20 years Male 5 years Hypothenar area Pain I x0.6cm
4- 43 years
(yr) in all
Female' 2 years
(yr) in all
Natal cleft Painful nodule lxlcm
RESULTS
All patients with subungual lesions had surgical excision
through transungual approach with partial nail removal
is followed by nail bed reconstruction, the remaining
tumours needed local excision.
All tumours were found to be localized and capsulated'
without evidence of infiltrative or sarcomatous changes.
All patients were completely relieved of the syryptoms
after surgical intervention with no evidence of local
recuffence.
DISCUSSION
Glomus tumour is a benign lesion of the subungual area
in 59-7 5% of cases as reported by, take | & Graham et
al.5 however, in orlr study it is present in 84% of our 6
digital tumours which involves the subungual region, the
extra digital tumours can affect any paft of the body,
3's'lt on. of our cases did affect the natal cleft, (case No.
4 table 2) which have never been described in this
location before.
Middle aged women are usually affected in 8804,8 only
40% of our cases were females, the mean age of our
cases matches the literature.
Inspite of the classic triad of presentation more cases
were not diagnosed at the early presentation even
patients had u long history of symptoms up to l0 years,s
but in our cases the mean symptofft duration, ranged
between I -5 years.
It is a tradition that most of these cases are presented
to general physicians before they ask the advice of the
orthopaedic or the general surgeon. We have encoun-tered
the same problem in our cases, due to lack of
awareness of this uncommon tumour in general practice
which adds to the long duration suffering of the patients.
Clinical diagnosis can be made in most digital lesions
without the need of any further investigation.
Provocative tests has been suggested to enhance the
clinical picture, as Love's pin head pressure test a'8 and
the uppiiration of Ethyl chloride to the lesion,a but
sometimes a plain X-rays is needed to exclude bony
erosion in long standing lesion which was found in 2 of
our cases.
Few surgeons and radiologisls- used the ultrasound, or
Mzu to localize these lesions2'6'7'e but usually it will not
add too much to the diagnosis, one of our patients had
MRI and it did showed a bright vascular lesion which
did not add anything to the management.
MRI is an expensive investigation and rarely change the
surgical decision and only indicated when the clinical
piciure is uncl ear.6''
Ultrasound has been reported valuable in locali-zation2'
e but we did not use it in our cases, while
arteriography and bone scan is of doubtful value. 8
In digital lesions, we suggest to only to plain X-rays to
exclude bony erosion and no other investigations are
needed for tiny tumours.
In extradigital tumours, a high degree of suspicion is
needed if the triad symptoms are present but at the end,
histology after excision will be the rnost diagnostic.
Meticulous surgical excision is needed for this painf'ul
tumour to eradicate the patient agony, and all our
patients symptoms disappeared after excision.
JORDAN MEDICAL JOURNAL, VOL. 35, NO.(l ), MAY 200 I
56

4. t
DIGITAL AND EXTRADIGITAL GLOMUS TUMORS AT JUH. SH. EL-HADIDI ET AL
Transungual approach with reconstruction of the nail
bed is considered to be the safest8 to avoid local
reculTence, aS no reculTence was seen in our cases.
In extradigital lesions, usually the local excision is
sufficient to cure the patient's symptoms.
Figure l. MRI scan T2 image showing the glomus
at the base of distal phalanx Ap view.
Figure 2.Same Case lateral view T2 image.
Figure 3. Plain A.p X-ray of both thumbs shows erosion of the
taft on the left one.
Figure 4. Lateral view iri plain X-ray.
The same case in figure 3.
CONCLUSION
Glomus tumours are of uncommon pathologY,
usually missed at initial presentation in spite of the
classic picture specially in digital lesions, we need to
raise awareness of physicians to this pathology
which produces a lot of suffering to the patient.
Surgical excision offers a pennanent relief of
symptoms.
Contrary to other series, most of our patients were
males.
REFERENCES
Lumely J.S.P, Stansfeld A.G. Infiltrating
Glomus Tumour of lower limb. BMJ
1972;1,484-5.
Fornage B. Glomus Tumours in the finger:
Diagnosis with US, RadiologY,
1 98 8;167: 1 83-5.
Gould E.W., Manivel J.C., Saaredra J.A.,
Monforle H., Locally infiltrative glomus ' tumour and glomangiosarcoma. Cancer;
65:3 10- I 8.
1.
2.
3.
57
JORDAN MEDICAL JOURNAL, VOL. 35, NO.(l), MAY 2001

5. . DIGITAL AND EXTRADIGITAL GLOMUS TUMORS AT JUI{. SH. EL-HADIDI ET AL
4. Takei T.R., Nalebuff E.A.,: Extradigital
giomus tumour; J. Hand surg. 1995-
208:3:409-12.
5. Graham 8., Wotff T.W.: Synchronus
subungual glomus tumour in adjacent digital. J
Hand sug. 19.92, l7B: 576-6.
6. Jablon, M. Horowits, A. and Bernstein, D.A.:
.lylagnetic Resonance imaging of a glomus
tumour of the finger tip. Journal of Hans
surgery 1990, I 5A:3L507-509.
7. Hou. S.M., Shin T.T-F Lin M.C. MRI of an
obscure glomus tumour in the finger tip. J.
Hand Surg, l88:482-93. :
8. van Geertruyden, J. Lorea P, Goldschmidt,
D., cle fontaine, S. Shuind, F. Kinnen, L.
LedouX,'P. Moermans, JP. Glomus. tumours.of
the hand, a retrospective study of 15 cases.
Journal of hand surgery 1996;2l B:25 7 -260.
9. Ogino. T., Ohnishi N., Ultrasonography
of a subungual glomus tumour. J. Hand
Surg 1993, I 88 : 7 46-47 .
l0. Smith K.A. Mackinnon, S.E. Macaul*y,
R.J.E}' & Mailis A. Glomus tumour
originating in the, radial nerve. A case
report J. Hand Surg. 1992; 17 A:4:665-
) 667
I l. Hayes M.M.M., Van der Westhuizen
N., Holden G.P. Aggressive Glomus
Tumour of the nasal region. Arch
pathol. Lab. Med, 1993, Vol. 117,649-
52.
12. Wetherington R.W., Lyle W.G.,
Sangueza O.P. Malignant Glomus
turnour of the thumb. A case report. J.
Hand Surg. 1997; 22-A: 1098- lI0Z.
13, Aiba M., Hirayama A., Kuramochi SH.
Glomangiosarcoma in a glomus
tumour. Cancer. 1988,61 :1467 -7 |
58
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