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Clinical case: Glomus tumor of the hand misdiagnosed as carpal tunnel syndrome: want to learn more about it?

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Clinical case: Glomus tumor of the hand misdiagnosed as carpal tunnel syndrome

In this article, we describe a case of a man who complains of stabbing pain in his right palm, together with the presence of a tender nodule. His diagnosis is a tumor, but which type exactly? Stick around to find out what types of tumors grow in places like the palms. You will also learn how the diagnosis was reached, the clinical presentation, and relevant anatomy.

Key facts
Carpal tunnel syndrome It occurs when the median nerve is compressed as it travels through the carpal tunnel, resulting in nerve damage and muscle atrophy. The main causes include swollen tendon synovial sheaths or osteo-ligamentous changes. 
Thenar eminence It is the fleshy muscular area at the base of the thumb on the volar surface of the hand, consisting of the abductor pollicis brevis, flexor pollicis brevis, and the opponens pollicis muscles.
Specific tests 'Rule in a disease' - high true positive and low false positive rates
Sensitive tests 'Rule out a disease' - high true negative and low false negative rates

After reviewing this case you should be able to describe the following:

  • What is meant by carpal tunnel syndrome, what causes the condition and how it is treated? Why, in this case, carpal tunnel syndrome could be confused with a tumor in the thenar eminence?
  • What is meant by the thenar eminence, and what vessels and nerves supply the thenar eminence?
  • What is meant by specificity versus sensitivity?

This article is based on a case report published in the Journal "Case Reports in Surgery" in 2015, by Caroline C. Jadlowiec, Beata E. Lobel, Namita Akolkar, Michael D. Bourque, Thomas J. Devers, and David W. McFadden.

Case description

History

The patient was a 55-year-old-male with complaints of a stabbing pain in his right palm. He described the pain as a sharp shooting pain that was present while working or handling objects. A neurologist had examined him previously, diagnosed carpal tunnel syndrome and started the patient on medication and physiotherapy, although nerve conduction studies done for the median nerve were normal.

Physical examination

The patient’s symptoms failed to subside and thus he was referred to an orthopedic surgeon. On examination, the right hand appeared normal. There was no discoloration or evidence of any abnormal swelling. However, there was a focal point of extreme tenderness in his right thenar eminence and exposure to cold also caused extreme pain. A small very tender nodule was identified on deep palpation of the thenar eminence.

Imaging and management

An ultrasound scan showed a highly vascularized solitary nodule of about 1 x 1 cm (Figure 1). A provisional diagnosis of hemangioma was made.  A 2 cm incision was made over the nodule. Blunt dissection revealed a reddish blue nodule of approximately 1 x 1 x 1 cm in size, which was extirpated (Figure 2).

Figure 1. Glomus tumor of the finger. This is not from the patient in the current case but demonstrates the appearance of a glomus tumor on ultrasound. Courtesy of Wikidocs (http://www.wikidoc.org/index.php/Glomus_tumor_ultrasound)

Histopathology and final diagnosis

Histopathological analysis showed the nodule to contain multiple blood vessels that were surrounded by tumor cells with dense abundant cytoplasm and multiple nucleoli, indicative of a glomangioma (glomus body tumor) rather than a hemangioma.

Anatomical and surgical considerations

Glomus bodies are plentiful in the fingers and toes. They shunt blood away from the skin surface when exposed to cold temperature, reducing heat loss, but also the converse, which is to allow maximum heat flow to the skin in warm weather to facilitate body cooling. The glomus body is well innervated by sympathetic fibers and stimulation leads to near complete vasoconstriction of cutaneous vessels. The glomus bodies in the skin and elsewhere are atypical in that their “endothelial cells” are found in multiple layers of cells called myoepithelioid cells. The typical age at presentation of a patient with a glomus body tumor is 30-50 years of age, although the condition can occur at any age. Women are affected more than men. In the case described here, the patient was a male aged 55 years, which is unusual.

The patient with a glomus tumor seeks medical attention early because of the pain, but the mass is often too small to be identified on physical examination. However, a series of clinical tests that show severe pain upon probing, temperature sensitivity, and point tenderness have high specificity and sensitivity for the condition. The pain experienced by the patients on blunt probing is described as being similar to being struck by a hammer. Ultrasonography was done to determine the extent of the tumor. It indicated a solid, homogeneous, hypoechoic, hypervascular well-demarcated nodule of about one cm in size. The only treatment that has been advocated for a glomus nodule is complete surgical excision. Histopathology revealed the diagnosis of this tumor. The patient experienced complete pain relief with no recurrence (up to 18 months after surgery).

Figure 2. A. Intraoperative photograph showing nodule in thenar eminence. B. Removed nodule.

Glomus bodies are innervated by the sympathetic nervous system. The sympathetic innervation of the hand is derived from the upper thoracic part of the thoracolumbar outflow through the stellate ganglion and the brachial plexus. The postganglionic sympathetic fibers eventually join the median and ulnar nerves to reach the fingertips (see Reynaud’s case for more details on the sympathetic innervation of the upper limb).

Clinical case: Glomus tumor of the hand misdiagnosed as carpal tunnel syndrome: want to learn more about it?

Our engaging videos, interactive quizzes, in-depth articles and HD atlas are here to get you top results faster.

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“I would honestly say that Kenhub cut my study time in half.” – Read more. Kim Bengochea Kim Bengochea, Regis University, Denver

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