Clinical image description

A 55-year-old female with a painful, solitary subcutaneous nodule in the subungual area of her right thumb was admitted. A strip of onycholysis was identified on distal part of the nail of the thumb, but no discoloration in the nail was found (Figure 1A). The pain was caused by pressure, and occurred as cold intolerance. For diagnosis, she underwent a simple ice cube test and pain was induced. Simple X-ray test showed mild bone erosion. Ultrasonography was additionally performed and revealed about 4.6 x 5.1 x 9.5 mm size circumscribed homogenous hypoechoic nodule in the subungual region, with focal bone erosion in the dorsal cortex of the distal phalanx of right thumb. Prominent blood flow was observed on the Doppler image.

Operation was performed under a digital nerve block with 2.5 × magnifying loupes, and a tourniquet was applied. The specific location of the tumor was outlined again before the anesthesia because the position might be confused after anesthesia. A typical transungual approach was employed. A periosteal elevator was inserted between the fingernail and nail bed. The nail was avulsed, with care not to damage the nail bed. Then the fingernail was raised from the bed and nail fold, exposing the nail bed where the tumor was present (Figure 1B). A relatively well-defined tumor was seen (Figure 1C). The nail bed was incised longitudinally, and the tumor was carefully detached and removed completely (Figure 1D). The primary suture was made using Vicryl 7-0 absorbable suture, and the nail plate was repositioned after being closed with blue nylon 4-0. The patient reported immediate relief of pain after the surgery. The wound healed without any complications, and the nail plate grew back normally. Histopathology confirmed the diagnosis of a glomus tumor. Transungual excision is a safe and effective treatment option for subungual glomus tumors [1,2]. Early diagnosis and prompt intervention can prevent long-term morbidity and improve patient outcomes.

Figure 1: Intraoperative images of surgical excision of subungual glomus tumor. (A) A strip of onycholysis was present on the thumbnail, distal from the area which is suspicious for a glomus tumor lesion. (B) Nail bed exposure with partial color change above suspicious glomus tumor after nail elevation. (C) Exposed capsule of subungual glomus tumor after longitudinal incision on the nail bed. (D) Completely extirpated glomus tumor without rupture or spillage.

Declarations

Acknowledgement: None

Disclosure: None of the following authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article.

Conflict of interest statement: All of the authors confirm that there is no conflict of interest.

References

1. Netscher DT, Aburto J, Koepplinger M. Subungual glomus tumor. J Hand Surg Am. 2012; 37: 821-823. Quiz 824.
2. Grover C, Jayasree P, Kaliyadan F. Clinical and onychoscopic characteristics of subungual glomus tumor: A cross-sectional study. Int J Dermatol. 2021; 60: 693-702.