Glomus Tumour of the Hand

• Frequency: 1 to 5 percent of all hand tumours
• Age: peak in the third to fifth decades, but reported at any age
• Sex: female predominance (approximately 2-3 to 1)
• Location: 75 to 80 percent subungual; remainder in pulp, volar finger, palm
• Multiple lesions: approximately 10 percent, often familial (glomuvenous malformation)

• Disabling pain: paroxysmal, triggered by cold and pressure
• Diagnostic delay: average 7 years from symptom onset
• Functional loss: avoidance of typing, writing, tool use, cold weather
• Psychological impact: chronic undiagnosed pain, anxiety, sleep disturbance
• Cost: multiple GP and specialist visits, unnecessary imaging and treatment

Pain: dense unmyelinated C-fibre innervation of the lesion

Cold sensitivity: thermoregulatory origin of the parent cell; vascular channels constrict in cold

Pinpoint tenderness: small (1-5 mm) discrete, encapsulated, superficial nodule

Hildreth relief: exsanguination empties the vascular channels and removes pressure on nerve fibres

Tumour is tiny (1-5 mm) and often invisible on inspection

Plain X-ray is frequently normal in early disease

Symptoms are episodic - patients are well between attacks

Misdiagnosis is common: neuroma, Raynaud, arthritis, CRPS, psychiatric pain

Average 7 years from first symptom to correct diagnosis in published series

• Pain pattern: episodic, paroxysmal, sharp or burning
• Triggers: cold exposure, light pressure, dependency
• Localisation: patient points to a single fingertip or subungual spot
• Duration: average 7 years from symptom onset to diagnosis
• Prior diagnoses: neuroma, Raynaud, arthritis, CRPS, psychiatric pain

• Inspect: subungual blue-red spot, nail ridging, onycholysis
• Palpate: small, well-defined, exquisitely tender nodule
• Love test: tip of a paper clip or pencil - disproportionate pain
• Hildreth test: tourniquet exsanguination - pain abolished
• Cold test: ice cube on the digit reproduces pain (less specific)

• Hand tumours: glomus tumours account for 1 to 5 percent of all hand tumours worldwide
• Subungual predilection: 75-80 percent of glomus tumours in the hand are subungual, with a female predominance
• Diagnostic delay: average 7 years from symptom onset to correct diagnosis, regardless of healthcare system
• Familial forms: autosomal dominant inheritance with mutations in the glomulin gene; more common in some populations

• High-resource: MRI with dedicated finger coil is the standard pre-operative localiser; Littler approach or transungual with nail bed repair under loupe magnification
• Limited-resource: clinical diagnosis (triad plus Love and Hildreth tests) with or without plain X-ray is acceptable; transungual excision is inexpensive and effective
• Universal principle: accurate pre-operative localisation (clinical, MRI or both) and complete marginal excision are the keys to cure
• Histology: essential in all healthcare settings - melanoma must be excluded

The transungual approach (with partial or total nail avulsion) gives direct midline access but carries a higher risk of nail dystrophy. The Littler lateral subungual approach preserves the nail plate and is associated with less dystrophy, but offers more limited exposure. There is no high-quality comparative trial; choice is dictated by lesion location and surgeon preference.

The classic triad plus positive Love and Hildreth tests is highly specific, and some surgeons proceed to surgery without MRI. However, MRI detects occult satellite lesions and guides the approach. In recurrent cases, MRI is mandatory. The balance between cost and added value remains debated.

Multifocal disease carries a higher risk of recurrence. There is no consensus on the timing of excision of asymptomatic lesions, the value of genetic testing, or surveillance protocols. Selective excision of symptomatic lesions, with genetic counselling, is the current pragmatic approach.

A small number of patients have persistent pain despite complete excision and benign histology. Causes include digital nerve neuroma, scar neuroma, complex regional pain syndrome, or a missed satellite. MDT discussion, diagnostic nerve block, and pain-clinic input are useful; further surgery without a clear target is rarely helpful.