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Glomus Tumour

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Updated Oct 202613 citations
Illustration: hand

What you're feeling

The pain from a glomus tumour is usually felt in one small spot, most often under the nail of a finger or in the soft part of the fingertip. It can be severe and sharp, and pressing on that exact point hurts intensely. Cold sets it off: reaching into the fridge or freezer, washing your hands in cool water, or stepping outside on a chilly morning can bring on a sudden wave of pain. Some people notice a small bluish or pink spot under the nail, or a ridge where the nail has changed shape.

The pain tends to flare without much warning. It can wake you at night when the bedclothes press on the finger, or when you knock the fingertip on a door handle or bench. Turning a key, buttoning a shirt, typing, or gripping a pen can all become uncomfortable because they press the tender spot. Over time many people start protecting the hand without realising it, avoiding tasks that put pressure on that finger.

This condition is often mistaken for something else, and the diagnosis can be delayed for years because the tumour is tiny and often cannot be seen. Some people are told they have a nerve or joint problem first, and a few are even treated for a psychiatric condition before the true cause is found. If your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand, see your GP or ask for a specialist review.

A glomus tumour is benign, which means it is not a cancer. It will not spread. But the pain it causes is real and can be debilitating, so it is worth naming early.

What's actually happening

Deep in your skin, especially in the fingertips and nail beds, sit tiny structures called glomus bodies. Each one is a small coil of blood vessel wrapped in special muscle cells. Its job is to control blood flow to the skin, which helps your body manage its temperature. When you get cold, these little structures open up or close down to adjust how much warm blood reaches the skin.

A glomus tumour is a benign overgrowth of these cells. It is not a cancer and it will not spread. The tumour is usually small, often less than a centimetre across, and it most often forms under the nail or in the soft pad of the fingertip. Some people have more than one.

The pain comes from where the tumour sits. Glomus bodies are packed close to nerve endings, and the tumour keeps that crowded, nerve-rich setting. So a lump only a few millimetres across can cause pain far bigger than its size. The nerves in and around the tumour react to pressure and to cold, which is why pressing the spot hurts so much and why cold water or chilly air can trigger a sudden flare. The tumour can also press on nearby nerves, adding to the ache.

Most glomus tumours appear in the fingers, under the nail being the common spot, but they can turn up elsewhere in the hand or forearm. They are more common in women and usually appear in middle age. They are also much more common in people with neurofibromatosis type 1, a condition that causes growths along nerves.

Because the tumour is so small and often cannot be seen, it is easy to miss. The diagnosis is often delayed, sometimes for years. That delay is not a sign that anything worse is going on. It reflects how tiny and well hidden these tumours are, and how much pain such a small thing can cause.

What we can do about it

Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. A clinic assessment, which includes your history, an examination, and imaging where needed, establishes the diagnosis.

For a glomus tumour, there is no tablet, cream or injection that makes it go away. Simple measures can take the edge off while you wait for assessment. Protecting the finger from knocks, keeping it warm in cold water and chilly weather, and wearing a splint to shield the tender spot may help you manage day to day. These steps ease the symptoms, but they do not remove the cause.

Because the pain comes from one pinpoint spot, the treatment that works is surgical removal of the whole tumour. We usually recommend surgery once the diagnosis is clear, because waiting rarely makes the problem settle on its own. Removing the tumour relieves the pain, and after complete removal the typical pain usually goes straight away. The operation itself has its own page, so we will not go into technique here.

If your finger becomes hot, red, swollen and painful, especially with a fever, go to the emergency department the same day. No GP referral is needed for that.

What to expect

Left alone, a glomus tumour does not usually settle. The pain tends to persist, and for many people it goes on for years before the cause is found. Some live with it for a long time while protecting the finger and avoiding cold. The longer it goes unnamed, the more it can wear you down, affecting your sleep, your work and how much you use your hand.

Once the tumour is removed completely, the outlook is different. The typical pain usually goes straight away. Recurrence after removal is uncommon. If pain does return months or years later, it is often a second small tumour in a new spot rather than the first one growing back, and occasionally there is more than one tumour from the start. Your surgeon will keep this in mind if symptoms come back.

Recovery is usually straightforward in its broad shape: the severe pinpoint pain that brought you in is relieved once the tumour is out, and over the following weeks your finger settles as the tenderness fades and you trust the finger again. Hand therapy after surgery is with Ruby Doolan at Extend Rehabilitation. Ruby is a hand therapist who will guide your recovery and make any splint you need.

If your finger becomes hot, red, swollen and painful, especially with a fever, go to the emergency department the same day. No GP referral is needed for that.

When to see someone

See your GP or ask for a specialist review if you have severe pain in one small spot on a finger that will not settle, hurts intensely when pressed, or flares in the cold. The same applies if a bluish or pink spot under the nail comes with that pain, or if the pain has gone on for months or years without a clear cause. These symptoms are often mistaken for something else, and some people are even treated for a psychiatric condition first, so it is worth naming the possibility early. The longer the cause goes unnamed, the more the pain can wear you down and limit your hand. If the pain sits elsewhere, such as the forearm or palm, mention that too, because these tumours can turn up outside the fingers. If your finger becomes hot, red, swollen and painful, especially with a fever, go to the emergency department the same day. No GP referral is needed for that.

In more depth

Advanced reading: the deeper science (optional)

This section goes further than you need for your own treatment decisions. A glomus tumour is worth the extra reading because it is one of the few conditions in hand surgery where the usual problem is not treatment but recognition: the tumour is tiny, often invisible, and cured by its removal, yet people commonly live with it for years before anyone names it.

Years of pain from something a few millimetres across

A glomus body is a small coil of blood vessel wrapped in specialised muscle cells that helps control blood flow to the skin, and the fingertips and nail beds are packed with them. A glomus tumour is a benign overgrowth of these cells, usually under the nail or in the pulp of the fingertip. Because the cells sit around blood vessels and nerve endings, a lump only a few millimetres across can produce pain out of all proportion to its size.

The delay in diagnosis is the defining feature of the condition. In a UK series of 73 tumours, more than 90% of patients had the classic symptoms, yet 31% had first been given another diagnosis, and the average time from first symptoms to diagnosis was 6 years [1]. In a Singapore series of 31 cases the average was 44 months; nearly everyone had pain (96.8%), but a visible lump was present in fewer than half (48.4%) [2]. In a review of 138 cases at a large American centre, the clinical diagnosis and the laboratory diagnosis agreed in only 45.4%; the commonest alternatives were a lipoma, a cyst or a blood vessel lump [3].

Three bedside tests, and why they are combined

The classic triad is severe pain at one spot, exquisite tenderness there, and pain set off by cold. Three simple tests build on it.

  • The pin test (Love's test): pressing with the head of a pin finds the single point of tenderness and maps it.
  • The cold test: chilling the finger reproduces the pain.
  • Hildreth's test: a cuff on the upper arm briefly stops blood flow; the tenderness fades while the cuff is up and returns when it comes down.

In a study of 24 patients Hildreth's test was 92% sensitive and 91% specific [4]. In a series of 18 people with fingertip pain, the cold test identified every tumour correctly, while the pin and Hildreth's tests were each 78% accurate [5]. The numbers come from small series and do not agree exactly, which is why the tests are used together rather than relied on one at a time.

What an MRI can and cannot do

An MRI scan is very good at confirming a tumour that is there. In a study of 42 hands it was 90% sensitive with a positive predictive value of 97%, but its negative predictive value was only 20%: all four tumours it missed were confirmed at surgery, and each measured just 2 to 3 mm [6]. In a second series of 36 MRI scans, about one in three did not make the diagnosis, more often when the tumour was small, unusual under the microscope, in an unusual place, or not suspected by the person requesting the scan [7]. An X-ray adds a little: a long-standing tumour under the nail can leave a small dent in the bone, and tumours without one were more likely to be missed on MRI [7]. A normal scan therefore does not rule out a glomus tumour when the history and examination fit; the clinical findings come first.

More than one tumour, and neurofibromatosis

Glomus tumours are not always single. In an early series of 28 patients, 7 (25%) had more than one, and 15% had their symptoms come back after surgery, which the authors put down to a second tumour missed at the first operation [8]. In a later series, all 5 recurrences among 12 patients appeared in new, separate places rather than where the first tumour had been removed [9]. Pain that returns months or years after a successful operation is therefore often a second tumour rather than regrowth.

People with neurofibromatosis type 1, a genetic condition that causes growths along nerves, are at much higher risk. In one study 6 of 21 people with a hand glomus tumour (29%) had neurofibromatosis, against none of 200 people with a wrist ganglion; the odds ratio was 168 [10]. A painful fingertip in someone with neurofibromatosis deserves a careful look for a glomus tumour.

What removal achieves

Complete removal cures the typical pain, usually at once. In a series of 53 people every one had relief by the day after surgery [11]. In a smaller French study that followed people for more than 10 years, the pain had gone in 91% [12]. Recurrence after removal is uncommon, at about 3 to 7% in the larger modern series [1] [13], and is covered in more detail on the operation page.

What this means for you

  • A small, very tender spot at the fingertip that hurts in the cold is worth naming early. The diagnosis is commonly missed for years.
  • The examination tests matter as much as the scan. A normal MRI does not rule out a small tumour when the story fits.
  • Removal is the only treatment that cures it, and the relief is usually immediate.
  • If the pain comes back later, it is often a second small tumour, and a repeat MRI is worth having.

Reviewed by AI synthesis (v2) — pending human review · 25 October 2026.

Want the clinical detail? Read the clinician version.

Talk to your treating clinician for advice specific to you.

For an appointment with the CQ Hand + Upper Limb team, ask your GP about a referral or visit www.cqupperlimb.com.

References for the advanced reading
  1. Jabir S, Rodrigo T, Petkar M, Iwuagwu F. Glomus tumours of the upper limb and hand. A clinicopathological review of cases over two decades. J Hand Surg Eur Vol. 2021;47(4):419-20.
  2. Lee WQ, Li Y, Yeo NEM. Glomus tumour: an institutional experience of 31 cases. J Orthop Surg Res. 2023;18(1):741.
  3. Mravic M, LaChaud G, Nguyen A, Scott MA, Dry SM, James AW. Clinical and histopathological diagnosis of glomus tumor: an institutional experience of 138 cases. Int J Surg Pathol. 2015;23(3):181-8.
  4. Giele H. Hildreth's Test is a Reliable Clinical Sign for the Diagnosis of Glomus Tumours. J Hand Surg Br. 2002;27(2):157-8.
  5. Bhaskaranand K, Navadgi BC. Glomus Tumour of the Hand. J Hand Surg Br. 2002;27(3):229-31.
  6. Al-Qattan MM, Al-Namla A, Al-Thunayan A, Al-Subhi F, El-Shayeb AF. Magnetic Resonance Imaging in the Diagnosis of Glomus Tumours of the Hand. J Hand Surg Br. 2005;30(5):535-40.
  7. Trehan SK, Athanasian EA, DiCarlo EF, Mintz DN, Daluiski A. Characteristics of Glomus Tumors in the Hand Not Diagnosed on Magnetic Resonance Imaging. J Hand Surg Am. 2015;40(3):542-5.
  8. Maxwell GP, Curtis RM, Wilgis ES. Multiple digital glomus tumors. J Hand Surg Am. 1979;4(4):363-7.
  9. Gandhi J, Yang SS, Hurd J. The Anatomic Location of Digital Glomus Tumor Recurrences. J Hand Surg Am. 2010;35(6):986-9.
  10. Harrison B, Moore AM, Calfee R, Sammer DM. The Association Between Glomus Tumors and Neurofibromatosis. J Hand Surg Am. 2013;38(8):1571-4.
  11. Madhar M, Bouslous J, Saidi H, Fikry T, Schuind F. Which approach is best for subungual glomus tumors? Transungual with microsurgical dissection of the nail bed or periungual? Chir Main. 2015;34(1):39-43.
  12. Faisan Smilevitch D, Chaput B, Grolleau J, Rongieres M, Mansat P. Improvement in quality of life after surgery for glomus tumors of the fingers. Chir Main. 2014;33(5):330-5.
  13. Kim YJ, Kim DH, Park JS, Baek JH, Kim KJ, Lee JH. Factors affecting surgical outcomes of digital glomus tumour: a multicentre study. J Hand Surg Eur Vol. 2018;43(6):652-8.
Evidence & references

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Anatomy & Pathophysiology

Osseous Skeleton

  • The skeleton of the hand and wrist consists of 27 bones, of which 19 are long bones [3].
  • The skeleton is divided into five rays, each ray making up a polyarticulated chain comprising the metacarpals and phalanges [3].
  • The base of each metacarpal articulates with the distal row of the carpus [3].
  • The carpus articulates with the skeleton of the forearm through its proximal row [3].
  • The radioulnocarpal articulation has two axes of movement, to which is added a third—pronation and supination from the forearm [3].
  • The wrist has three axes of movement, permitting the hand to be positioned in any spatial configuration and allowing it to be placed as needed for grasping [3].
  • The radial ray or first ray is the shortest and is made up of only three bones—a metacarpal and two phalanges [3].
  • The first ray continues the external column of the carpus formed by the scaphoid and trapezium [3].
  • The trapezium is clearly angled out in front of the carpal plane so that the first metacarpal makes an angle of about 45 degrees with the second metacarpal in the sagittal plane [3].
  • The thumb metacarpal is the shortest, and the index metacarpal is by far the longest [3].
  • The proximal and middle phalanges of the long and ring fingers are longer than those of the index finger [3].
  • The epiphyseal plates are located at the proximal ends of the phalanges and the first metacarpal, whereas they are located at the distal ends of the other metacarpals [3].
  • The hand presents a longitudinal and transverse concavity, giving it the shape of a cup with a palmar concavity when the thumb is placed next to the index finger [3].
  • The transverse axis of the palm, which corresponds to the metacarpophalangeal articulations, is not perpendicular to the longitudinal axis [3].
  • The transverse axis forms an acute angle of approximately 75 degrees with the longitudinal axis [3].

Musculature

  • Extrinsic muscles have their origin outside of the hand and their insertion on the hand or carpus, whereas intrinsic muscles have both origin and insertion within the hand [2].
  • Extrinsic muscles are either flexors or extensors, and intrinsic muscles contribute to both digital flexion and extension [2].
  • The extrinsic extensors run through six different fibroosseous retinacular compartments at the wrist level [2].
  • The first (most radial) compartment contains the abductor pollicis longus and the extensor pollicis brevis [2].
  • The abductor pollicis longus has multiple slips that insert at the base of the thumb metacarpal and radially abducts the thumb [2].
  • The extensor pollicis brevis inserts on the dorsum of the proximal aspect of the proximal phalanx of the thumb and actively extends the metacarpophalangeal joint of the thumb [2].
  • The second extensor compartment contains the extensor carpi radialis longus and the extensor carpi radialis brevis [2].
  • The extensor carpi radialis longus inserts on the index metacarpal, dorsiflexes and radially deviates the wrist [2].
  • The extensor carpi radialis brevis inserts into the base of the middle metacarpal, providing balanced wrist dorsiflexion [2].
  • The third compartment contains the extensor pollicis longus, which runs longitudinally down the forearm through the third compartment and turns abruptly radialward about Lister tubercle [2].
  • The extensor pollicis longus provides forceful extension of the thumb interphalangeal joint [2].
  • The oblique course of the extensor pollicis longus tendon provides a substantial adduction component to the pull of the extensor pollicis longus [2].
  • The fourth extensor compartment contains the extensor indicis proprius lying deep to the four tendons of the extensor digitorum communis [2].
  • The fifth compartment contains the extensor digiti quinti [2].
  • The principal bony insertion of the extrinsic digital extensors is on the dorsal proximal aspect of the middle phalanx [2].
  • Metacarpophalangeal joint extension is provided by extrinsic extensor force transmitted through the sagittal bands [2].
  • Distal interphalangeal joint extension is achieved through the conjoined lateral bands that are composed of tendinous slips from the extrinsic and intrinsic tendons [2].
  • The extensor indicis proprius inserts on the index finger ulnar to the extensor digitorum communis [2].
  • The extensor digitorum communis inserts on the index, middle, ring, and, in some cases, little fingers [2].
  • The extensor digiti quinti tendon inserts on the little finger ulnar to the extensor digitorum communis insertion [2].
  • The extensor carpi ulnaris tendon runs through the sixth compartment and inserts at the base of the little finger metacarpal [2].
  • The extensor carpi ulnaris provides wrist extension and ulnar deviation [2].
  • The extensor digitorum communis tendons of the middle, ring, and little fingers are tethered together by juncturae tendinum over the dorsum of the hand proximal to the metacarpophalangeal joint [2].
  • The extensor indicis proprius tendon may be recognized at the wrist level as possessing the most distal muscle belly of any of the digital extensor tendons [2].
  • The digital extensor tendons are stabilized over the mid-line of the metacarpophalangeal joint by their attachment to sagittal band fibers [2].
  • The sagittal band fibers insert onto the volar proximal phalanx and onto the lateral borders of the volar plate [2].
  • The sagittal band fibers form a sling that allows proximal extrinsic extensor tension to be transmitted to the proximal phalanx, permitting metacarpophalangeal joint extension without a tendinous insertion onto the proximal phalanx [2].
  • By holding the extrinsic extensor tendon balanced over the prominence of the metacarpal head, the sagittal bands normally keep the extrinsic extensor as far as possible away from the center of rotation of the metacarpophalangeal joint, thereby giving it the greatest mechanical efficiency [2].
  • With rupture or attenuation of the sagittal band fibers, the extrinsic extensor tendon can sublux to the ulnar side of the metacarpal head causing ulnar deviation of the finger [2].
  • The extrinsic finger flexors are the flexor digitorum profundus and the flexor digitorum superficialis [2].
  • The flexor digitorum profundus inserts on the proximal volar aspect of the distal phalanx, flexing the distal interphalangeal joint as well as the proximal interphalangeal and metacarpophalangeal joints [2].
  • The flexor digitorum superficialis acts as a flexor of the proximal interphalangeal and metacarpophalangeal joints [2].
  • There are seven interosseous muscles, four dorsal and three volar [6].
  • The dorsal interossei are abductors [6].
  • Because the anatomic axis of the hand coincides with the axis of the third metacarpal, the dorsal interossei lie to the radial side of the index and middle fingers and the ulnar side of the middle and ring fingers [6].
  • The little finger is abducted by the abductor digiti quinti [6].
  • The volar interossei are adductors and lie to the ulnar side of the index finger and the radial side of the ring and little fingers [6].
  • The middle finger has two dorsal interossei (abductors) and no volar interossei (adductors) because the central axis of the hand lies within it [6].
  • Each dorsal interosseous muscle, with the exception of the third, has two muscle heads [6].
  • The superficial head of the dorsal interosseous muscle arises most dorsally from the shaft of the contiguous metacarpals and is inserted deeply by a medial tendon onto the lateral tubercle of the base of the proximal phalanx [6].
  • The superficial head abducts and weakly flexes the proximal phalanx [6].
  • The superficial head has no direct effect on the middle or distal phalanges [6].
  • The deep head of each dorsal interosseous muscle forms a lateral tendon, or lateral band, at the level of the MP joint [6].
  • The deep head flexes and weakly abducts the proximal phalanx while extending the middle and distal phalanges [6].
  • At the level of the middle of the proximal phalanx, transverse fibers arch dorsally from each lateral band to join each other over the dorsum of the finger, flexing the proximal phalanx [6].
  • More distally, oblique fibers (spiral fibers) from the lateral bands sweep over the distal third of the proximal phalanx to insert onto the lateral tubercles at the base of the middle phalanx [6].
  • The oblique fibers extend the middle phalanx (PIP joint) [6].
  • More distally, the lateral bands are joined by the lateral slips of the extensor tendon to form the conjoined lateral band [6].
  • The two conjoined lateral bands to each finger unite at the distal third of the middle phalanx to form the terminal tendon [6].
  • The terminal tendon inserts at the base of the distal phalanx to extend it [6].
  • The flexor digiti quinti brevis is structurally and functionally similar to the deep head of the dorsal interossei, forming the ulnar lateral band of the little finger [6].
  • The three volar interossei arise from adjacent surfaces of contiguous metacarpal shafts [6].
  • Unlike the dorsal interossei, each volar interosseous muscle has only one muscle head and none of them insert onto the proximal phalanx [6].
  • The volar interossei form the ulnar lateral band of the index finger and the radial lateral band of the ring and little fingers [6].
  • As with the lateral bands of the dorsal interossei, transverse fibers arch over the dorsum of the proximal phalanx and join those of the opposite lateral band to flex the proximal phalanx [6].
  • All lateral bands are joined by the lateral slips of the extensor tendon to form a conjoined lateral band and finally a terminal tendon that extends to the distal phalanx [6].
  • Of the hypothenar muscles, the abductor digiti quinti and flexor digiti quinti brevis are similar in both structure and function to the superficial and deep heads of the dorsal interossei, respectively, and arise from the fifth metacarpal [6].
  • The abductor inserts onto the ulnar lateral tubercle at the base of the proximal phalanx of the little finger [6].
  • The flexor digiti quinti forms the ulnar lateral band [6].
  • A third muscle, the opponens digiti quinti, lies deepest [6].
  • The opponens digiti quinti arises from the pisohamate ligament and the hook of the hamate and inserts onto the ulnar side of the diaphysis of the fifth metacarpal, which it flexes and supinates [6].
  • The extrinsic flexors of the finger consist of the flexor digitorum profundus and the flexor digitorum superficialis [13].
  • The flexor digitorum profundus originates from the proximal ulna and the interosseous membrane [13].
  • In the forearm, the flexor digitorum profundus divides into two muscle groups: the most radial component supplying the index finger and the ulnar component supplying the middle, ring, and little fingers [13].
  • The flexor digitorum profundus and the flexor pollicis longus muscles form the deep compartment of the volar forearm [13].
  • As the flexor digitorum profundus and flexor pollicis longus tendons travel through the carpal tunnel, they occupy the floor of the carpal tunnel [13].
  • The tenosynovial sheath of the flexor pollicis longus is continuous with the radial bursa [13].
  • The tenosynovial sheath to the little finger is continuous with the ulnar digital bursa [13].
  • In some patients, these two bursae communicate, allowing a so-called horseshoe abscess to spread between the thumb and little finger if infection occurs in the flexor tendon sheath of either one of these digits [13].
  • The lumbricals originate from the radial side of the index, middle, ring, and little fingers in the palm [13].
  • The profundus tendon passes through the bifurcation of the flexor digitorum superficialis before inserting into the proximal palmar base of the distal phalanx [13].
  • The innervation of the flexor digitorum profundus of the index and middle fingers is through the anterior interosseous branch of the median nerve [13].
  • The profundus of the ring and little fingers is innervated by the ulnar nerve [13].
  • The flexor digitorum profundus provides digital flexion at both the proximal and distal interphalangeal joints [13].
  • The flexor digitorum superficialis has two heads: The radial head originates from the proximal shaft of the radius, and the humeral ulnar head originates from the medial humeral epicondyle and coronoid process of the ulna [13].
  • Each digit has a corresponding independent superficialis muscle [13].
  • As the superficialis tendons pass through the carpal tunnel, the tendons of the middle and ring fingers are more superficial and central than those of the index and little fingers [13].
  • In the proximal aspect of the finger, the flexor digitorum superficialis tendon bifurcates around the flexor digitorum profundus at the beginning of the A2 pulley [13].
  • The flexor digitorum superficialis tendon slips then reunite distally at the Camper chiasm, with approximately half of the fibers staying on the ipsilateral side and half crossing to the contralateral side of the finger [13].
  • The tendon then inserts via radial and ulnar slips into the proximal metaphysis of the middle phalanx [13].
  • The entire flexor digitorum superficialis muscle receives innervation from the median nerve [13].
  • The primary function of the superficialis is digital flexion at the proximal interphalangeal joint [13].
  • The flexor pollicis longus originates from two heads: The radial head takes origin from the proximal radius and interosseous membrane, and an accessory head originates from the coronoid process of the ulna and from the medial epicondyle of the humerus [13].
  • In the palm, the flexor pollicis longus tendon transverses between the abductor pollicis brevis and the flexor pollicis brevis [13].
  • The flexor pollicis longus inserts into the proximal base of the thumb distal phalanx and is innervated by the anterior interosseous branch of the median nerve [13].
  • The flexor pollicis longus flexes both the interphalangeal and metacarpophalangeal joints of the thumb [13].

Tendon Sheaths and Pulleys

  • As the flexor tendons pass distal to the metacarpal neck, they enter the fibroosseous tunnel, or digital flexor sheath [13].
  • The fibroosseous tunnel extends distally to the proximal aspect of the distal phalanx [13].
  • The tendinous sheath consists of annular pulleys, which provide mechanical stability, and cruciate pulleys, which provide flexibility [13].
  • The first, third, and fifth annular pulleys (A1, A3, and A5) are located over the metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints, respectively [13].
  • The second and fourth pulleys (A2 and A4) are situated over the middle portion of the proximal and middle phalanges [13].
  • The A2 and A4 pulleys are the most essential in maintaining the mechanical advantage of the flexor tendons [13].
  • The tenosynovium that lines the fibroosseous tunnel supplies both nutrition and lubrication to the poorly vascularized flexor tendons [13].
  • Proximal to the sheath, the tendons are well vascularized by the peritenon [13].
  • Within the sheath, tendon vascularity is supplied via the vincula system: the vinculum longus and brevis [13].

Soft Tissue and Fascia

  • The superficial palmar fascia lies in a coronal plane beneath the palmar subcutaneous tissue [16].
  • It covers a triangular area of the central palm, the proximal corner facing directly proximal [16].
  • The palmaris longus tendon, when present, terminates in continuity with the fibers of this proximal corner [16].
  • From this common point, four central bands of fascia extend distally toward each of the fingers [16].
  • There is no central band for the thumb [16].
  • Confluent proximally, the central bands separate and diverge just distal to the transverse retinacular ligament, each following the underlying ray [16].
  • At the distal palmar cre

Investigations

  • Clinical evaluation of the hand and wrist requires combining patient history with a careful physical examination to pinpoint or narrow the scope of possible pathologic processes [1].
  • Diagnostic tests such as imaging and serum laboratory studies are useful in determining pathology but can be expensive, time consuming, and often nonspecific [1].
  • A careful physical examination is essential to direct care and future testing if indicated [1].
  • An 8-MHz Doppler tone assessment may be used to identify superficially displaced neurovascular bundles when Dupuytren cords lie beneath soft fleshy prominences [19].
  • False-negatives are possible with 8-MHz Doppler tone assessment for identifying neurovascular bundles [19].
  • Doppler imaging is a promising improvement over handheld Doppler assessment but higher resolution imaging technology is needed [19].
  • MR assessment of Dupuytren’s disease is hindered by the resolution of current equipment, orientation issues due to multiplanar deformities of the fingers, and lack of intraoperative availability [19].
  • MRI is probably most useful in identifying additional pathology such as flexor tendon bowstringing [19].
  • MRI may be helpful in providing a quantitative noninvasive measure of cellularity of affected areas, which is an index of biologic activity [19].

References

[1] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Anatomy, Evaluation, Clinical Examination, and Imaging > Evaluation and Clinical Examination: Current Concepts.

[2] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 9Hand Surgery > Image DISORDERS OF THE MUSCULATURE OF THE HAND.

[3] Exam Of The Hand Wrist 2Ed. 1.1 SKELETON OF THE HAND > The osseous skeleton.

[6] Green S Operative Hand Surgery. Interosseous and Hypothenar Muscles.

[13] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 9Hand Surgery > FLEXOR TENDON INJURY.

[16] Green S Operative Hand Surgery. PERTINENT ANATOMY.

[19] Dupuytren S Disease And Related Hyperproliferative Disorders. 54. The Future of Dupuytren’s Research and Treatment > 54.4 Mechanical Measurements and Procedures > 54.4.4 Imaging.

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