Volume VII, Number 1 | April 2023

Every Painful Lesion in the Upper Extremity is Not A Neuroma: An Algorithmic Approach for Diagnosing Painful Benign Forearm Lesions

1Bartholomew A, 2Bamberger B
1Ohio University, Athens, OH, United States; 2Orthopedic Associates of Southwest Ohio, Dayton, OH, United States of America

Painful forearm masses are one of the most common complaints for an upper extremity surgeon to treat. Patients usually have dealt with their forearm pain for years, have been evaluated or treated without resolution, and often have concerns for something more sinister. The forearm is a frequent location for many painful soft tissue tumors, most of which are benign lesions. Glomus tumors are among the less common soft tissue tumors; however, it is important for the upper extremity surgeon to be familiar with and regularly consider this entity. Glomus tumors are small, benign, neurovascular tumors that account for only 1-2% of soft tissue tumors and can be exquisitely painful and temperature-sensitive. Classic teaching would suggest that these tumors are found subungually. Extradigital manifestations in the forearm can present with atypical symptoms and are often misdiagnosed as neuromas due to their less common location. In practice, we have recently seen several painful upper-extremity lesions ultimately identified with surgical pathology as glomus tumors. This raises the question: are extradigital glomus tumors in the forearm truly rare and are we missing/misdiagnosing them more than we think? Although historically considered a relatively uncommon soft tissue tumor, there may be an opportunity to reconsider glomus tumors in your initial differential for painful upper extremities soft tissue lesions. We propose a new approach to the diagnosis of glomus tumors and other painful benign lesions of the upper extremity.

Literature Review of typical and atypical etiologies of painful benign masses of the forearm. Creation of algorithmic diagnostic approaches.

After a thorough review of the literature, we have compiled a list of painful benign tumors that have presented in the forearm. We have constructed an algorithm to serve as a guide for differential diagnoses to consider, including common tumors and rarities alike. Primary diagnoses included neuromas, schwannomas, glomus tumors, angiolipomas, fibromas, and ganglion cysts.

It is true that some painful soft tissue tumors of the forearm are much more common than others. Glomus tumors in the forearm may present as painful soft tissue lesions, but as they are historically considered rare, they are frequently not considered in the initial differential diagnoses and subsequently are misdiagnosed. With the overlap of symptomatology between extradigital glomus tumors and other common painful forearm lesions, glomus tumors should be in your initial differential. The diagnosis of a glomus tumor can be accomplished by conducting an inclusive history and physical exam, including appropriate imaging. Definitive treatment and diagnosis for many of these tumors is an excisional biopsy; however, preoperative planning, establishing postoperative expectations, and overall quality of patient care depends upon a thoughtful and comprehensive initial differential.

The Journal of the American Osteopathic Academy of Orthopedics

Steven J. Heithoff, DO, FAOAO

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