Hypothenar hammer syndrome: proposed etiology

Successful percutaneous management of hypothenar hammer syndrome with thrombosuction and catheter-directed intra-arterial thrombolysis

Hypothenar hammer syndrome (HHS) is a rare vascular disorder leading to ulnar artery thrombosis or aneurysm and causing acute or chronic limb ischemia. The optimal approaches to managing this condition lack a definitive consensus and are essentially empirical, typically necessitating conservative methods for symptomatic relief, with surgical intervention reserved for cases for which conservative measures prove inadequate or when acute limb ischemia ensues. Limited data are available on percutaneous management for this condition. We present the case of a 36-year-old male powerlifter who developed acute digital ischemia due to HHS in the left hand that was managed successfully through an innovative approach using antegrade left brachial artery access and combining percutaneous thrombosuction and intra-arterial thrombolysis. This comprehensive approach resulted in restoration of blood flow and resolution of acute limb ischemia. The patient was subsequently prescribed short-term anticoagulation therapy and remained symptom free at 3 months of follow-up. This innovative strategy challenges traditional surgical approaches in HHS management, underscoring the importance of using minimally invasive techniques as a promising alternative and highlighting potential avenues for further research.

Hypothenar hammer syndrome: outcomes after ulnar artery reconstruction with autologous vein graft

The most common surgical procedure for the treatment of hypothenar hammer syndrome (HHS) is resection of the pathological segment followed by arterial reconstruction using a venous bypass. Bypass thrombosis occurs in 30% of cases, with various clinical consequences, ranging from no symptoms to reappearance of the preoperative clinical symptoms. We reviewed 19 patients with HHS who underwent bypass graft, to assess clinical outcomes and graft patency, with a minimum follow-up of 12 months. Objective and subjective clinical evaluation and ultrasound exploration of the bypass were carried out. Clinical results were compared according to bypass patency. At a mean follow-up of 7 years, 47% of patients had complete resolution of symptoms; symptoms were improved in 42% of cases, and unchanged in 11%. Mean QuickDASH and CISS scores were 20.45/100 and 28/100, respectively. Bypass patency rate was 63%. Patients with patent bypass had shorter follow-up (5.7 vs 10.4 years; p = 0.037) and a better CISS score (20.3 vs 40.6; p = 0.038). There were no significant differences between groups for age (48.6 and 46.7 years; p = 0.899), bypass length (6.1 and 9.9 cm; p = 0.081) or QuickDASH score (12.1 and 34.7; p = 0.084). Arterial reconstruction gave good clinical results, with the best results in case of patent bypass. Level of evidence: IV.

Ultrasound of the Hook of Hamate Region: Pictorial Review

The hook of hamate is a complex anatomical region with many small but important structures. A sound knowledge of anatomy along with a systematic ultrasound technique can help delineate a variety of disorders. In this pictorial review, we discuss the ultrasound anatomy and the possible pathologies that can be encountered in this region.

Bilateral Hypothenar Hammer Syndrome Case Presentation and Literature Review

Hypothenar hammer syndrome is a rare cause of vascular insufficiency. Generally, patients report a history of repetitive trauma to the hypothenar region of the hand. Symptoms often consist of cold intolerance, pain, paleness, and paresthesia due to digital ischemia. The severity of these symptoms will depend on the extent of ulnar artery occlusion and the presence or absence of collaterals between this artery's superficial and deep branches. It is a rare clinical entity, which on multiple occasions requires a surgical approach. We present a 63-year-old man with bilateral Raynaud's phenomenon secondary to hypothenar hammer syndrome successfully treated by vascular repair surgery. In patients with Raynaud's phenomenon, it is important to know that there are reversible causes such as hypothenar hammer syndrome.

Snuff box radial artery aneurysm: A case report and literature review

INTRODUCTION AND IMPORTANCE

Distal radial artery aneurysms in the anatomical snuff box are rare.

CASE PRESENTATION

Herein, we present the case of a snuff box radial artery aneurysm in a female patient with a possible history of trauma and discuss the evaluation and management of snuff box radial artery aneurysms. The aneurysm in this case was resected without reconstruction because of a normal preoperative Allen test finding and intraoperative evidence of adequate hand perfusion after the aneurysm was excised. The patient subsequently recovered with proper hand function.

CLINICAL DISCUSSION

Radial artery aneurysms cases are rare; literature search by us and others have identified only 20 cases. For the detection and management of aneurysm, several high-end techniques may be employed; however, in this case, we employed non-invasive ultrasound method. The method is non-invasive and accurately delineates and localises an aneurysm, differentiates true arterial aneurysms from pseudoaneurysms, and identifies the presence of a mural thrombus. Further, the ultrasound assessments also help surgeons on requirement of radial artery reconstruction.

CONCLUSION

In this case report, an anatomical snuff box radial artery aneurysm was surgically excised without reconstruction. Physical examination and Doppler ultrasound findings were employed to assess the medical condition of the patient; patient's proper hand function was restored.

Dual Aneurysm Formation in an Occupationally Predisposed Male: Atypical Hypothenar Hammer Syndrome

Hypothenar hammer syndrome is typically described as a chronic repetitive injury to the ulnar artery at the level of hamulus of hamate and shows certain occupational predilection. Our case is an occupationally predisposed patient who had two aneurysm formations from the superficial palmar branch of ulnar artery and the digital branch, respectively, diagnosed and treated surgically. We call it an atypical hypothenar hammer syndrome as the arterial involvement was not typically at the level of hamate bone and only corresponded to the site of recurrent friction. This article also discusses the role of imaging and treatment options.

CT angiography and MRI of hand vascular lesions: technical considerations and spectrum of imaging findings

Vascular lesions of the hand are common and are distinct from vascular lesions elsewhere because of the terminal vascular network in this region, the frequent hand exposure to trauma and microtrauma, and the superficial location of the lesions. Vascular lesions in the hand may be secondary to local pathology, a proximal source of emboli, or systemic diseases with vascular compromise. In most cases, ischaemic conditions are investigated with Doppler ultrasonography. However, computed tomography angiography (CTA) or dynamic contrast-enhanced magnetic resonance angiography (MRA) is often necessary for treatment planning. MR imaging is frequently performed with MRA to distinguish between vascular malformations, vascular tumours, and perivascular tumours. Some vascular tumours preferentially affect the hand, such as pyogenic granulomas or spindle cell haemangiomas associated with Maffucci syndrome. Glomus tumours are the most frequent perivascular tumours of the hand. The purpose of this article is to describe the state-of-the-art acquisition protocols and illustrate the different patterns of vascular lesions and perivascular tumours of the hand.

Use of Arterial Grafts in Hypothenar Hammer Syndrome: Application of Perforator Flap Anatomy

Background

Hypothenar hammer syndrome (HHS) is traditionally treated with venous bypass grafting, but controversy has arisen as arterial grafts have become more available.

Methods

A retrospective review of all patients undergoing ulnar artery bypass grafting for HHS with an arterial graft from 2008 to 2017 was performed. We also review the literature for patency rates and discuss the scenarios that favor different graft choices.

Results

Six patients were included in our series. Five had primary surgery and 1 had revision surgery for HHS. Five arterial grafts were from the deep inferior epigastric artery and 1 was from the lateral circumflex femoral artery. The proximal anastomotic site was the ulnar artery for all: n = 6. The distal anastomosis site was the palmar arch and common digital artery (CDA) of the ring/small finger and CDA of the middle/ring finger: n = 3; the palmar arch and the CDA of the ring/small finger: n = 3. All patients were symptom-free at follow-up and had a patent ulnar artery on Allen's testing or angiogram.

Conclusion

Patency rates of arterial grafts for HHS appear to be excellent and this small series and may offer an alternative to traditional venous grafts and end-to-end arterial anastomoses. We suggest using arterial perforator grafts from free flap donor sites. These have well-described anatomy, are easily harvested, and carry minimal donor site morbidity. Lateral circumflex femoral artery graft is favored in patients requiring a single distal anastomosis, who have a ventral hernia, or who are obese. Deep inferior epigastric artery graft is preferred when multiple distal targets or versatile configurations are needed, in thin patients, or in female patients.

Prospective assessment of function and cold-intolerance following revascularization for hypothenar hammer syndrome

Ulnar artery revascularization in hypothenar hammer syndrome has repeatedly been shown to reduce ischaemic symptoms, however with varying graft patency percentages. This study prospectively assesses the effect of revascularization surgery with a vein graft using validated questionnaires in seven patients. The Disabilities of the Arm, Shoulder and Hand (DASH) and the Cold Intolerance Symptom Severity (CISS) questionnaires have been used to compare the preoperative and postoperative functionality and cold intolerance. All patients showed improvement in either functionality, or cold intolerance, or both from disabled to nearly normalized levels and resumed their occupation at final follow-up (mean of 28 months). Strikingly this was also the case in a patient with graft stenosis. Patients with the highest preoperative questionnaire scores showed most postoperative improvement. In conclusion, revascularization surgery seems to improve the symptomatology irrespective of graft patency. Questionnaires can be a valuable contribution to quantify and to follow the symptomatology in hypothenar hammer syndrome.

Long-term Patient-Reported Outcomes After Surgery for Hypothenar Hammer Syndrome

Background: This study aims to describe the long-term patient-reported outcomes after surgery for hypothenar hammer syndrome (HTHS) and to identify factors associated with inferior outcomes. Methods: We retrospectively identified 27 patients who underwent surgical intervention for HTHS from 2002 to 2016. Fifteen patients (56%) completed outcome questionnaires: Quick Disabilities of the Arm, Shoulder, and Hand, Cold Intolerance Symptom Severity (CISS) survey, Patient-Reported Outcomes Measurement Information System Upper Extremity Computer Adaptive Test, and Patient-Reported Outcomes Measurement Information System Pain Interference Computer Adaptive Test. The median questionnaire follow-up was 7.2 years (interquartile range, 3.1-9.9). Outcomes were compared across different surgical techniques, and the influence of patient-related factors on outcomes was also evaluated. Results: Six (40%) patients experienced complete symptom resolution, 6 (40%) had improvement without complete resolution, 1 (7%) had resolution followed by recurrence, and 2 (13%) reported no improvement. The most common symptom after surgical intervention was cold intolerance. Questionnaire scores were similar across ligation, direct repair, and vein graft vascular reconstruction. Patients had better CISS scores if they had surgery on their nondominant hand (13.2 vs 38.6) and did not have a manual labor job (18.1 vs 40.5). Conclusions: Surgery for HTHS leads to moderate long-term improvement in patient-reported outcomes. Different surgical techniques yield similar symptomatic relief. Manual labor and surgery of the dominant hand are associated with worse CISS scores.

Hypothenar Hammer Syndrome in an Elderly Caucasian Female: A Case Report

Hypothenar hammer syndrome (HHS) is a vascular disorder characterized by ulnar artery thrombosis or aneurysmal formation. It is most commonly reported in middle-aged males who suffer from repetitive trauma to the palm secondary to occupational or recreational activities. Most cases of HHS can be managed conservatively; however, surgical management is typically indicated for persistent symptoms following conservative measures, imminent vascular compromise, those who fail conservative treatment, or those in imminent danger of rupture. Here we present the case of a right-handed 74-year-old female with HHS who presented with a three-week history of a mass in the hypothenar eminence of the left hand. Reportedly, the mass had appeared slowly and had no associated pain, ischemia of the distal hand, numbness, paresthesia, or changes in the overlying skin. She denied any history of a blunt or penetrating hand injury. The patient was treated surgically by removing a 2.0-cm thrombosed pseudoaneurysm of a collateral branch of the ulnar artery within the left hypothenar eminence. On follow-ups at 1, 2, and 12 weeks postoperatively, the patient's pain was found to be well-controlled. Her normal range of motion was restored, and her digits remained neurovascularly intact. This was an atypical presentation of HHS, and our review of the disorder emphasizes the importance of diagnostic reasoning in rare conditions with unusual presentations of HHS.

Diagnosis of hypothenar hammer syndrome in a patient with acute ulnar artery occlusion

A 56-year-old truck driver with a history of tobacco use presented with acute onset digital ischaemia in the ulnar distribution of his dominant hand, associated with severe pain. Occupational exposures included extensive manual labour and prolonged vibratory stimuli. Workup with Doppler and angiography confirmed the diagnosis of hypothenar hammer syndrome (HHS). After the failure of medical management, he underwent ulnar artery thrombectomy with reconstruction and arterial bypass grafting. His pain improved significantly postsurgically, and he was able to return to a normal routine. This case illustrates the classic presentation, examination, imaging findings and management options of HHS. HHS should be considered in patients with digital ischaemia and associated occupational exposures. Diagnosing the condition appropriately allows for optimal management, aiming at minimising symptoms and maximising quality of life.

Prevalence of Ulnar Artery Thrombosis in Orthopedic Surgeons

Ulnar artery thrombosis (UAT) occurs most commonly in athletes and manual laborers who repeatedly use their palm in high-impact activities. Anecdotal evidence has shown an increased prevalence of UAT in orthopedic surgeons, especially in joint arthroplasty surgeons, compared with the general population. This study sought to determine the prevalence of UAT among orthopedic surgeons and to identify risk factors for developing UAT. Eighty orthopedic surgeons and residents were included in the study. Participants completed a demographic questionnaire, and a timed Allen test was performed on each hand with the radial artery occluded. A reperfusion result greater than 6 seconds was considered abnormal. Participants with a positive Allen test and UAT-associated symptoms were deemed to have UAT. Statistical analysis was performed using the Fisher exact and Wilcox-on rank-sum tests. The prevalence of UAT was 11% (9 of 80) in the study population compared with 1.6% (21 of 1300) in the general population (P<.0001). For surgeons with 15 years or more of practice, the UAT rate was 24% (8 of 33) compared with 2% (1 of 47) for surgeons with less than 15 years of practice (P=.0030). The prevalence of UAT in adult reconstruction surgeons trended toward significance at 40% (2 of 5) compared with 9% (7 of 75) in the other subspecialties (P=.095). Orthopedic surgeons have an increased risk for developing UAT compared with the general population. The risk of UAT is significantly correlated with advancing years in clinical practice and may be associated with the number of arthroplasty cases performed. [Orthopedics. 2019; 42(5):e415-e422.].

Overview of arterial pathology related to repetitive trauma in athletes

BACKGROUND/OBJECTIVE

Sport-related vascular trauma is an important consequence of increased physical activity. Repetitive, high-intensity movements predispose athletes to vascular disease, including arterial pathology, by exerting increased pressure on neurovascular structures. This is an important source of morbidity in an otherwise young and healthy population. Arterial pathology associated with repetitive trauma is often misdiagnosed as musculoskeletal injury. This article increases awareness of sport-related arterial disease by reviewing the symptomatology, investigation, and treatment modalities of this pathology. In addition, prognostic outcomes specific to the athlete are discussed.

RESULTS

Arterial thoracic outlet syndrome and vascular quadrilateral space syndrome are associated with athletes involved in overhead throwing exercises. Sport-related arterial pathology of the lower limb include external iliac artery endofibrosis (EIAE), popliteal artery entrapment syndrome (PAES), and adductor canal syndrome. Vascular stress and kinking secondary to vessel tethering are important contributors to pathology in EIAE. Chronic exertional compartment syndrome must also be considered, presenting with clinical features similar to PAES. In addition, athletes are predisposed to blunt mechanical trauma. Hypothenar hammer syndrome is one such example, contributing to a high burden of morbidity in this population.

CONCLUSIONS

In arterial thoracic outlet syndrome and vascular quadrilateral space syndrome, surgery is advocated in symptomatic individuals, with postoperative outcomes favorable for the athlete. Acute limb ischemia may occur as a result of secondary thrombosis or embolization, often without preceding claudication. PAES and adductor canal syndrome are associated with functional entrapment in the athlete, secondary to muscular hypertrophy. Surgical exploration may be indicated. Poorer outcomes are noted when this process is associated with vascular reconstruction. Surgical treatment of EIAE follows failure of conservative management, with limited data available on postoperative prognosis. Investigations for all these conditions should be targeted based on clinical suspicion. A delay in diagnosis can have severe consequences on return to competition in these high-functioning individuals.

Hypothenar hammer syndrome: Case report and literature review

Hypothenar hammer syndrome is a rare but serious cause of digital ischemia and morbidity. Presented here is a case of a manual laborer who had symptoms of digital ischemia after acute hyperextension injury to the ring finger. Magnetic resonance imaging revealed thrombosed ulnar artery aneurysm. Etiology, presentation, and current treatments are reviewed.

Unusual case of hypotenar Hammer Syndrome and carpal tunnel syndrome association

BACKGROUND AND AIM OF THE WORK

Hypothenar Hammer Syndrome is a relatively rare disease process caused by repetitive stress or injury to the hypothenar eminence leading to chronic injury to the ulnar artery. Our study reports an unusual case.

METHODS

A 57 years old Plumber presented in April 2016 with a history of constant pain and recurrent paresthesia involving the fingers of the right hand for several months, over the previous 1 year, his hand had become more intolerant of exposure to cold temperatures. Angio-RNM and electromyography were performed and showed a severe double compression of ulnar and median nerve and an ulnar artery deformity without thrombosis. Surgery was performed under sedation and axillary anesthesia.

RESULTS

After surgery patient' symptoms immediately improved, and within a few months, his hand had normalized.

CONCLUSION

Hypothenar Hammer Syndrome is a rare disease process which manifests in certain occupations and activities that put undue stress on the hypothenar area. Furthermore, the carpal tunnel syndrome, a pressure damage of the median nerve, caused by repetitive manual tasks with flexion and extension of wrist has been added as well as hypothenar hammer syndrome which are vascular damages of hand caused by shock-type application of force.

Dropping the Hammer: An Uncommon Case of Right-Hand Pain in a Professional Hockey Player

A 26-year-old, right-handed male professional hockey player presented for a second opinion with dysesthesia of the tips of his right third, fourth, and fifth fingers after 2 previous incidents of hyperextension injuries to his right wrist while holding his hockey stick. Radiographs and computed tomography scans were negative for fracture. After magnetic resonance angiography and Doppler ultrasound imaging, the athlete was diagnosed with hypothenar hammer syndrome (HHS) with ulnar artery aneurysm and thrombosis. He underwent successful surgery with ligation and excision of the aneurysmal, thrombosed ulnar artery and was able to return to hockey 4 weeks after surgery. HHS is thought to be a rare posttraumatic digital ischemia from thrombosis and/or aneurysm of the ulnar artery and was traditionally considered an occupational injury but has been reported more frequently among athletes. There have only been 2 previous case reports of hockey players diagnosed with HHS, and in the previous 2 case reports, both involved repetitive trauma from the hockey stick, which resulted in thrombotic HHS. We present a case of a professional hockey player diagnosed with HHS also due to repetitive trauma from the hockey stick, but this time resulting in aneurysmal HHS with thromboembolism. This case report highlights the importance of keeping HHS in the differential diagnosis in athletes with pain, cold sensitivity, and paresthesia in their fingers with or without a clear history of repetitive trauma to the hypothenar eminence, as HHS is a condition with good outcomes after proper treatment.

[Hypothenar hammer syndrome: A recurrent case report after surgery]

Hypothenar hammer syndrome is a rare entity secondary to ulnar artery damage in the wrist, affecting mainly those exposed to repeated hand-palm trauma. Surgery is discussed in case of severe symptoms, resistant to medical treatment, and/or when anatomical lesions with emboligenic potential are demonstrated in the radiological exams. In this case, resection of the pathological zone with revascularization by autologous vein graft is the best option. We report the case of a 60-year-old patient who had a recurrence of symptoms more than 10 years after the completion of a surgical treatment. There was an aneurysmal thrombosed vein graft with extensive thrombus extending from the ulnar artery upstream of the Guyon's canal to the superficial palmar arch. The digital revascularization was provided by the radial superficial palmar arch and the presence of a collateral vascular supply. This late complication was responsible for compression of the ulnar nerve in Guyon's canal. A new surgery was performed consisting of the resection of the thrombosed zone, including the vein graft, without vascular reconstruction given the good vascularization of all the fingers, and release of the ulnar nerve to the wrist. The operative follow-up was uneventful with the disappearance of pain and sensory-motor deficits. Good digital vascularization was confirmed by imaging at 3 months postoperatively; nerve recovery by electromyogram at 6 months with normal conduction.

Hypothenar hammer syndrome: A case of a late complication after surgery

Hypothenar hammer syndrome is a rare condition secondary to ulnar artery damage in Guyon's canal, affecting mainly those exposed to repeated palm trauma. Surgery is discussed in cases of severe symptoms that are resistant to conservative treatment, and/or when anatomical lesions with high embolism potential are discovered during imaging exams. Resection of the pathological zone with revascularization by autologous vein graft is the best option. We report the case of a 60-year-old patient who had a recurrence of symptoms more than 10 years after this type of surgical treatment was performed. There was an aneurysmal thrombosed vein graft with extensive thrombus from the ulnar artery upstream to Guyon's canal to the superficial palmar arch. Finger revascularization was provided by the superficial branch of the radial artery and the presence of a collateral vascular supply. This late complication was responsible for compression of the ulnar nerve in Guyon's canal. A new surgery was performed to resect the thrombosed zone, including the vein graft, without vascular reconstruction due to the good vascularization of all the fingers, and to release the ulnar nerve at the wrist. The postoperative course was uneventful with the disappearance of pain and sensory-motor deficits. Good finger vascularization was confirmed by imaging at 3 months postoperative; nerve conduction was normal at 6 months on electroneuromyography.

Aneurysms of the hand: Imaging and surgical technique

Hand aneurysms are a rare entity only described as case reports in the literature. The aim of our study was to describe a series of four cases and the surgical technique using an arterial bypass. We also wanted to define an algorithm for the imaging of this pathology. We have operated on four patients with hand aneurysms in the past decade or so. One patient had an aneurysm in the thumb proper palmar digital artery, one in the superficial palmar arch and the two others in the ulnar artery. All patients had an excision surgery with direct arterial bypass; no patient had a venous graft. All patients were seen a few years after the surgery and underwent an ultrasonography to check the anastomosis permeability. All anastomoses were permeable 2 to 8 years after surgery. Through a review of the literature we discuss the best algorithm for imaging a hand aneurysm. Direct arterial suture by proximal and distal mobilization allows for long-term permeability. If a graft is necessary, a graft of arterial origin should be preferred. The additional first-line examination is ultrasonography, followed by arteriography if acute ischemia is present; otherwise, CT angiography or MR angiography is performed.

Hypothenar Hammer Syndrome: Surgical Approach in Patients Presenting with Ulnar Artery Aneurysm

Hypothenar hammer syndrome is an uncommon condition but of high clinical importance due to ischemia-related complications. In this article, we discuss about our surgical approach to deal with hypothenar hammer syndrome patients suffering from ulnar artery aneurysm, which is surgical exploration and end-to-end anastomosis of the ulnar artery.

Management of Hypothenar Hammer Syndrome A Case Report

BACKGROUND Hypothenar hammer syndrome is a relatively rare disease process caused by repetitive stress or injury to the hypothenar eminence leading to chronic injury to the ulnar artery. This chronic stress (usually as a result of occupational or sport activities) may result in arterial constriction or thickening, which may lead to thrombosis or aneurysm formation. A review of current literature revealed that reports related to management of hypothenar hammer syndrome are limited. CASE REPORT A 33-year-old male without significant past medical history presented with left hand/digit pain, skin discoloration, and coolness of the hand/digits after a mechanical accident experienced 12 hours prior to presentation. Angiography confirmed reduced flow in the ulnar and radial artery with significant spasm of the ulnar artery. Treatment consisted of heparin, nitroglycerin, and papaverine with rapid resolution of symptoms. The patient was discharged on anticoagulation and a calcium channel blocker, with scheduled follow-up. CONCLUSIONS Hypothenar hammer syndrome is a rare disease process which manifests in certain occupations and activities that put undue stress on the hypothenar area. The use of angiography for definitive diagnosis and the use of anticoagulation and calcium channel blockers for treatment should continue to be studied to determine a standard treatment regimen.

Hypothenar hammer syndrome: long-term follow-up after ulnar artery reconstruction with the lateral circumflex femoral artery

In symptomatic patients with hypothenar hammer syndrome, the occluded part of the ulnar artery can be reconstructed with an autologous graft. Venous grafts are used frequently, but they are known for their low patency rate. Arterial grafts show better patency rates than venous grafts in coronary bypass surgery. We performed 11 ulnar artery reconstructions with the descending branch of the lateral circumflex femoral artery and compared these with previously performed venous reconstructions. All patients with an arterial graft reconstruction had a patent graft at a mean follow-up of 63 months. In addition, nine out of 11 patients reported improvement in their symptoms. The patency rate of venous reconstructions in hypothenar hammer syndrome is significantly lower. Arterial grafting for hypothenar hammer syndrome has superior patency compared with venous grafting; we recommend it as the surgical treatment of choice for symptomatic hypothenar hammer syndrome.

LEVEL OF EVIDENCE

4.

Repetitive Blunt Trauma and Arterial Injury in the Hand

INTRODUCTION/PURPOSE

Arterial injury in the hand is most often due to repetitive blunt trauma. Although not always associated with significant impairment, it may cause serious ischemic damage or considerable disability. As a cause of digital ischemia, the frequency of this disorder is widely under appreciated. This study reviews the clinical and angiographic features of this condition.

MATERIALS/METHODS

An extensive literature review combined with the authors experience with arterial injury in the hand due to repetitive blunt hand trauma is summarized with emphasis on mechanisms of injury and pathologic changes to explain the angiographic findings and clinical presentations.

RESULTS

Angiographic findings are related to severity of injury and underlying changes in the arterial wall. The clinical presentation varies from asymptomatic to digital necrosis and gangrene, related to severity of arterial injury, collateral circulation, and the highly variable arterial anatomy in the hand.

CONCLUSION

Early recognition is important because compared to many other causes of digital ischemia in the upper extremities, traumatic arterial injury is frequently readily treatable. Angiographic findings and clinical presentation are often characteristic. The diagnosis should not be based on a clear history of repetitive hand trauma since the patient may be unaware of this occurrence.

Proximal ulnar artery aneurysm following a Bentall procedure for type A aortic dissection

Non-traumatic or infective peripheral aneurysms of the upper extremities are rare. We report a case of an aneurysm involving the left proximal ulnar artery leading to upper limb ischemia in a patient following a Bentall procedure for a type A dissection.

Recurrent Hypothenar Hammer Syndrome: A Case Report

Hypothenar hammer syndrome (HHS) is a rare cause of digital ischemia and pain caused from repetitive trauma to the palm. Often related to occupational practices, thrombosis and embolization can occur. Treatment is often surgical and involves excision with or without reconstruction. We describe a 55 year-old, male pipe fitter previously diagnosed and treated for HHS with excision and repair using a reversed interpositional vein graft in the mid-1980's. He continued to work in the profession, which he regularly used his palm as a hammer and returned approximately 30 years later with recurrent symptoms of cold intolerance and pain. Angiography confirmed occlusion of the ulnar artery with emboli present distally. The patient was again treated with excision and reconstruction. HHS is an uncommon cause of digital ischemia. Its recurrence is even more rare. To our knowledge, this is the first described case of diagnosed and treated recurrent HHS.

Occupation-Related Vascular Disorders of the Upper Extremity

Hypothenar hammer (HH) syndrome and vibration-induced white finger (VWF) syndrome are the main occupation-related vascular diseases of the upper extremity. The clinical presentation is similar to that of Raynaud’s phenomenon. The characteristic history will lead to the appropriate diagnosis being confirmed by angiographic features in HH and by functional tests in VWF. While in HH the underlying cause, which is mostly thought to be an aneurysm of the ulnar artery, might be cured surgically, in VWF only medical treatment offers relief from the symptoms. The knowledge of these entities is necessary to suspect such disorders so that further exposure to risk factors like repetitive hypothenar trauma or work with vibrating hand-held tools can be avoided, which is of great importance for the overall prognosis of these patients.

Surgical Management of Hypothenar and Thenar Hammer Syndromes: A Retrospective Study of 31 Instances in 28 Patients

This retrospective study assessed the results of treatment of 29 cases of hypothenar hammer syndrome and two cases of thenar hammer syndrome. Three hands were symptom free, 15 were improved, 11 were unchanged and two were worse at a mean follow-up of 43 (range 4–60) months. Follow-up colour-coded Duplex sonography of revascularizations ( n = 27) revealed 13 patent, five occluded and one partially thrombosed grafts, seven grafts with aneurysmal dilatations and one coiled graft. Colour-coded Duplex sonography results after venous interposition graft combined with endoscopic thoracic sympathectomy were no better than venous interposition graft alone. All three arterial interposition grafts and two end-to-end-reconstructions were patent. The Duplex outcomes of the revascularizations did not correspond well with the clinical outcomes. Endoscopic thoracic sympathectomy was associated with a high rate of inconvenient side effects.

Multilocular True Ulnar Artery Aneurysm in a Pediatric Patient

Ulnar artery aneurysms are an exceedingly rare entity in the pediatric population and have no consistent etiologic mechanism. We present the case of a 15-year-old male with a multilocular ulnar artery aneurysm in the setting of no antecedent history of trauma, no identifiable connective tissue disorders, and no other apparent etiological factors. Furthermore, the patient's arterial palmar arch system was absent. The aneurysm was resected, and arterial reconstruction was successfully performed via open surgical approach with cephalic vein interposition graft. We believe this treatment modality should be considered as the primary approach in all of these pediatric cases in consideration of the possible pitfalls of less comprehensive measures.

Upper Extremity Runoff: Pearls and Pitfalls in Computed Tomography Angiography and Magnetic Resonance Angiography

Upper extremity vasculature can be affected by various traumatic and nontraumatic pathologies; however, the evaluation of these arteries can be challenging for the radiologists as well as for the clinicians. After an accurate history and clinical examination, imaging plays a vital role in the diagnosis and treatment planning of these patients. Depending on the urgency and the indication, upper extremity arteries may be evaluated by ultrasonography with color Doppler, computed tomography (CT), magnetic resonance imaging (MRI), or digital subtraction angiography. This review article discusses relevant imaging anatomy of the upper extremity arteries, presents CT and MRI protocols, briefly describes the state-of-the-art CT and MRI of various pathologies affecting the upper extremity arteries, and summarizes the important pearls needed for busy practicing radiologist.

Unusual Cases of Hypothenar Hammer Syndrome

OBJECTIVE

Hypothenar hammer syndrome (HHS) is a rare occupational disease. The risk group of HHS is patient whose dominate hand used as a hammer. Our study report unusually cases in Chiang Mai University Hospital.

RESULT

19 year-old basketball player had right ulnar artery aneurysm for two months. After operation, his symptom was relieved and returned to play basketball again. 65 year-old housekeeper had non-dominated hand ulnar artery aneurysm for two years. After operation she still had hand claudication due to poor run-off vessel.

CONCLUSION

HHS is previously state in risk group. But from our report there was a risk in different occupation.

Point-of-care Ultrasound to Identify Distal Ulnar Artery Thrombosis: Case of Hypothenar Hammer Syndrome

Hypothenar hammer syndrome (HHS) is a rare condition of distal ulnar artery injury and thrombosis secondary to repetitive blunt trauma to the hypothenar area. We present a case of HHS for which point-of-care ultrasound (POCUS) was used as the initial means of imaging, prompting management and disposition without further imaging studies ordered in the emergency department (ED). This case demonstrates the utility of POCUS to aid the Emergency Physician in the diagnosis and management of patients with extremity vascular issues in the ED, and details a rarely seen clinical entity in the ED.

Hypothenar hammer syndrome: long-term results of vascular reconstruction

PURPOSE

To evaluate long-term patency rates and related outcomes after vascular reconstruction of hypothenar hammer syndrome and identify patient- or treatment-related factors that may contribute to differences in outcome.

METHODS

We used color flow ultrasound to determine the patency of 18 vein graft reconstructions of the ulnar artery at the wrist in 16 patients. Validated questionnaires evaluated patients' functional disability with the Disabilities of the Arm, Shoulder, and Hand score, pain with the visual analog scale, and cold intolerance with the Cold Intolerance Symptom Severity survey. Patient demographics, clinical data, and surgical factors were analyzed for association with graft failure. Patients were asked to grade the result of treatment on a scale of 0 to 10.

RESULTS

Of 18 grafts, 14 (78%) were occluded at a mean of 118 months postoperatively. Patients with patent grafts had significantly less disability related to cold intolerance according to the Cold Intolerance Symptom Severity survey in addition to significantly less pain on the visual analog scale. There was no statistical difference in Disabilities of the Arm, Shoulder, and Hand scores between patients with patent or occluded grafts. Patients graded the result significantly higher in patent reconstructions.

CONCLUSIONS

We noted a higher incidence of graft occlusion than previously reported at a mean follow-up of 9.8 years, which represents a long-duration follow-up study of surgical treatment of hypothenar hammer syndrome. Despite a high percentage of occlusion, overall, patients remained satisfied with low functional disability and all would recommend surgical reconstruction. This study suggests that improved outcomes may result from patent grafts in the long term.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Vascular injuries in the upper extremity in athletes

Repetitive, high-stress, or high-impact arm motions can cause upper extremity arterial injuries. The increased functional range of the upper extremity causes increased stresses on the vascular structures. Muscle hypertrophy and fatigue-induced joint translation may incite impingement on critical neurovasculature and can cause vascular damage. A thorough evaluation is essential to establish the diagnosis in a timely fashion as presentation mimics more common musculoskeletal injuries. Conservative treatment includes equipment modification, motion analysis and adjustment, as well as equipment enhancement to limit exposure to blunt trauma or impingement. Surgical options include ligation, primary end-to-end anastomosis for small defects, and grafting.

Options for revascularization: artery versus vein: technical considerations

Vascular grafts, as either interpositional conduits or bypass grafts, can be used for revascularization procedures in the upper extremity. Vein grafts are more readily available and can be easier to harvest. Arterial grafts may provide superior patency rates compared with vein grafts. Arterial grafts can be located and harvested with consistent and reliable anatomy throughout the body.

Current options for treatment of hypothenar hammer syndrome

Hypothenar hammer syndrome is a rare vascular condition resulting from injury to the ulnar artery at the level of Guyon canal. The ulnar artery at the wrist is the most common site of arterial aneurysms of the upper extremity and is particularly prone to injury. Signs and symptoms include a palpable mass, distal digital embolization to long, ring, or small fingers, pain, cyanosis, pallor, coolness, and recurrent episodes of vasospasm. Modalities for diagnosis, evaluation, and surgical planning include duplex study, contrast arteriography, and computerized tomographic angiography (CTA). Management includes medical, nonoperative, or operative treatments. Appropriate treatment options are reviewed.

An unusual case of hypothenar hammer syndrome in the non-dominant hand

A 60-year-old male patient was referred to the vascular clinic with a 2-week history of a 1.5 cm pulsatile tender swelling in the left hypothenar eminence. He worked as a gas fitter and sustained this swelling following an injury at work. Interestingly, unlike many cases reported, his left, non-dominant hand was only used passively while his dominant right hand was using the hammer. Duplex ultrasonography confirmed the presence of a true aneurysm of the left ulnar artery, measuring 11 mm in diameter, as it approached the palmar arch. The ulnar nerve was revealed to be ectatic and tortuous and was found to cork-screw in the palm. The aneurysm was removed surgically and histological specimens revealed an intraluminal organizing thrombus. The literature reveals that, in a true aneurysm, it is rare to present with symptoms of this syndrome in the non-dominant, passive hand.

[False traumatic aneurysm of the ulnar artery in a teenager]

Most aneurysms of hand arteries are traumatic. It is a generally rare unrecognized pathology. Complications are serious (embolism and thromboses of interdigital arteries). Two main causes can be recalled: acute trauma, with development of a false aneurysm; repeated microtrauma (hand hammer syndrome), with occurrence of an arterial dysplasic aneurysm. The diagnosis is based on the presence of a pulsatile mass, with finger dysesthesia, unilateral Raynaud's phenomenon. It is confirmed by duplex Doppler. Arteriography is necessary but can be replaced by an angio-MR. We report a case of false traumatic aneurysm of the ulnar artery in a teenager. This case illustrates this rare condition and opens discussion on therapeutic options.

Hypothenar hammer syndrome and basilic bypass

We report a case of hypothenar hammer syndrome. The case presents necessary diagnostic measures and discusses the etiology of this syndrome. Additionally, the case reviews treatments, which culminated in the eventual use of ulnar artery bypass with autogenous basilica vein to treat and resolve the ischemic fingers of the patient.

CT angiography of the upper extremity arterial system: Part 2- Clinical applications beyond trauma patients

OBJECTIVE

CT angiography using modern MDCT scanners has evolved into a highly accurate noninvasive diagnostic tool for the evaluation of patients with pathologic abnormalities of the upper extremity arterial system.

CONCLUSION

Here we focus on the use of this modality in patients with nontraumatic vascular pathologic abnormalities.

Hypothenar hammer syndrome: a multicenter case-control study

BACKGROUND

The rarely diagnosed hypothenar hammer syndrome (HHS) is due to vascular damage to the distal part of the ulnar artery probably caused by acute or repetitive blunt trauma to the hypothenar region. To date, mainly case reports have been published, while epidemiological data are almost absent.

AIM

To identify potential risk factors for HHS.

METHOD

An interview-based multicenter case-control study of 71 patients with HHS and 105 matched controls was conducted with standardized questions regarding disease specific variables, occupation, exposure of the hands to different types of trauma in occupational and leisure context. Medical data were verified from individual medical records.

RESULTS

Multivariable logistic regression analysis revealed that using the hand as a hammer on a daily basis (adjusted odds ratio [aOR] 17.04, 95% CI 5.51-52.67) daily pressure to the palm of the hand (aOR 4.96, 95% CI 1.39-17.71), and daily exposure to vibrating tools (aOR 3.41, 95% CI 1.03-11.31) were significant risk factors for HHS.

CONCLUSIONS

This investigation represents one of the largest groups of patients with HHS described so far. Work-related repeated blunt trauma to the palm of the hand significantly increases the risk of HHS.