Orthopedic Surgery for Glomus Tumor Treatment & Management

Updated: Apr 29, 2020
  • Author: Seema N Varma, MD; Chief Editor: Harris Gellman, MD  more...
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Treatment

Approach Considerations

Surgical excision of the tumor is the mainstay of treatment. Indications for surgical excision include local symptoms of pain and temperature sensitivity that are bothersome to the patient or that interfere with daily activities. Lesions associated with nail deformities may have to be excised for cosmetic purposes.

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Medical Therapy

Although surgical excision is the only definitive treatment, pain relief should be provided until the procedure is performed. To destroy the tumor, therapeutic alternatives to surgical excision include sclerotherapy with sodium tetradecyl sulfate or laser treatment with an argon, carbon dioxide, or neodymium:yttrium-aluminum-garnet (Nd:YAG) laser. [25, 35, 36, 37]  In one study, intralesional injections of hypertonic sodium chloride solution given in four sessions over 6 months were found to be effective. [38]

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Surgical Therapy

Complete surgical excision provides definitive treatment. For multiple glomus tumors, excision may be difficult because the tumors may be poorly circumscribed. Excision should be limited to symptomatic lesions. [25, 39, 40]

Because excision is a minimally invasive procedure, no specific preoperative workup is indicated if the diagnosis is clinically evident. The most crucial and challenging preoperative detail is exact localization of the glomus tumor. Magnetic resonance imaging (MRI) may be helpful in this regard. [28]

In lesions on the trunk or an extremity, careful localization and marking are essential for complete and successful excision. The use of methylene blue just before surgery can be helpful.

Because multiple tumors occur in 25% of cases, careful clinical examination and, possibly, radiographic investigation should be conducted to look for additional tumors.

Lesions in the nail bed are exposed after the nail is removed. A longitudinal incision is made in the sterile matrix, and the matrix is elevated on either side to expose the lesion. The entire flap, including the nail plate, nail bed, and periosteum, should be elevated to excise the circumscribed lesion on the undersurface of the flap or in the bone. Proximal lesions at the level of the germinal matrix should be exposed with a dorsolateral incision made at the junction with the glabrous skin. The flap is then replaced; it can be held with nylon sutures.

Complete excision with removal of the entire capsule should be ensured to prevent recurrences.

Pain relief is usually achieved immediately after surgical excision. If symptoms persist after 3 months or recur, exploration should be repeated. Persistence may be due to incomplete excision or multiple lesions, which affect 25% of patients. The incidence of recurrent symptoms is about 15%.

Garg et al described good results with a nail-preserving modified lateral subperiosteal approach to subungual glomus tumors in 30 patients. [41] At follow-up, all patients experienced relief of their preoperative symptoms, and all of the treated fingers had normal function. None of the patients showed evidence of nail or fingertip deformity or experienced tumor recurrence.

A subungual approach in which the nail bed is raised with the underlying periosteum as a proximally based flap in a distal-to-proximal direction has been described.

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Complications

Incomplete excision of the tumor capsule may cause symptoms to persist.

If the tumor extends into the germinal matrix of the nail bed, it may affect nail growth.

Lu et al reported a case of rupture of a subungual glomus tumor and subsequent finger infection. [42]

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