Multimodality imaging review of ulnar nerve pathologies

The ulnar nerve is the second most commonly entrapped nerve after the median nerve. Although clinical evaluation and electrodiagnostic studies remain widely used for the evaluation of ulnar neuropathy, advancements in imaging have led to increased utilization of these newer / better imaging techniques in the overall management of ulnar neuropathy. Specifically, high-resolution ultrasonography of peripheral nerves as well as MRI has become quite useful in evaluating the ulnar nerve in order to better guide treatment. The caliber and fascicular pattern identified in the normal ulnar nerves are important distinguishing features from ulnar nerve pathology. The cubital tunnel within the elbow and Guyon's canal within the wrist are important sites to evaluate with respect to ulnar nerve compression. Both acute and chronic conditions resulting in deformity, trauma as well as inflammatory conditions may predispose certain patients to ulnar neuropathy. Granulomatous diseases as well as both neurogenic and non-neurogenic tumors can also potentially result in ulnar neuropathy. Tumors around the ulnar nerve can also lead to mass effect on the nerve, particularly in tight spaces like the aforementioned canals. Although high-resolution ultrasonography is a useful modality initially, particularly as it can be helpful for dynamic evaluation, MRI remains most reliable due to its higher resolution. Newer imaging techniques like sonoelastography and microneurography, as well as nerve-specific contrast agents, are currently being investigated for their usefulness and are not routinely being used currently.

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.

Saved by the SPY: Ulnar Artery Reconstruction With LCFA Graft for Hypothenar Hammer Syndrome

Introduction: Hypothenar Hammer syndrome refers to thrombosis/aneurysm of ulnar artery at Guyon's canal in wrist, with resultant arterial insufficiency in the ulnar artery distribution.1 Patients typically describe unilateral symptoms in the fourth and/or fifth fingers of the hand. Symptoms can range from asymptomatic to pain, pallor, paresthesia, weakness, cold intolerance, and eventually ulceration, necrosis, and gangrene of the distal digits.1 Treatment options range from conservative, lifestyle management, to medication, and ultimately to surgical intervention. In this case report, we outline the second successful lateral circumflex femoral artery (LCFA) graft reconstruction of the ulnar artery in the setting of Hypothenar Hammer Syndrome conducted by the senior author. However, during this procedure, the use of intraoperative intravenous (IV) injection of indocyanine green (ICG) dye (hereafter ICG) imaging helped identify an additional area of stenosis previously unseen on pre-operative MRA, therefore enabling us to perform a more adequate resection and repair. To our knowledge, the use of intraoperative ICG for Hypothenar Hammer Syndrome and/or ulnar artery reconstruction has not been documented in the literature.

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.

Mycotic Aneurysm of the Ulnar Artery Secondary to Bacillus Calmette-Guérin Therapy for Bladder Cancer: A Rare Presentation of Hypothenar Hammer Syndrome

Mycotic aneurysms, especially those of the upper extremity, are rarely reported in literature. These aneurysms are caused by bacterial endocarditis and, therefore, are more commonly seen in patients who are in an immunocompromised state, including those requiring bacillus Calmette-Guérin (BCG) therapy for bladder cancer. Owing to the inevitable rupture of mycotic aneurysms, the standard treatment is surgical repair with appropriate secondary antibiotics. We present a unique case of a mycotic ulnar artery aneurysm following BCG therapy and repetitive hand trauma in a patient with bladder cancer that was successfully repaired with microsurgical techniques and secondary antibiotics.

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.

Vascular trauma of the hand - a systematic review

Hypothenar or thenar hammer syndrome (HHS) and hand-arm vibration syndrome (HAVS) are diseases caused by acute or chronic trauma to the upper extremities. Since both diseases are generally related to occupation and are recognised as occupational diseases in most countries, vascular physicians need to be able to distinguish between the two entities and differentiate them from other diagnoses. A total of 867 articles were identified as part of an Internet search on PubMed and in non-listed occupational journals. For the analysis we included 119 entries on HHS as well as 101 papers on HAVS. A professional history and a job analysis were key components when surveying the patient's medical history. The Doppler-Allen test, duplex sonography and optical acral pulse oscillometry were suitable for finding an objective basis for the clinical tests. In the case of HHS, digital subtraction angiography was used to confirm the diagnosis and plan treatment. Radiological tomographic techniques provided very limited information distal to the wrist. The vascular component of HAVS proved to be strongly dependent on temperature and had to be differentiated from the various other causes of secondary Raynaud's phenomenon. The disease was medicated with anticoagulants and vasoactive substances. If these were not effective, a bypass was performed in addition to various endovascular interventions, especially in the case of HHS. Despite the relatively large number of people exposed, trauma-induced circulatory disorders of the hands can be observed in a comparatively small number of cases. For the diagnosis of HHS, the morphological detection of vascular lesions through imaging is essential since the disorder can be accompanied by critical limb ischaemia, which may require bypass surgery. In the case of HAVS, vascular and sensoneurological pathologies must be objectified through provocation tests. The main therapeutic approach to HAVS is preventing exposure.

Hypothenar hammer syndrome in an office worker

Hypothenar hammer syndrome (HHS) is an uncommon cause of unilateral Raynaud's phenomenon, splinter haemorrhages and hypothenar weakness. The typical patient is a male blue-collar worker who uses their hypothenar eminence to hammer objects as part of their work. The distal ulnar artery beyond Guyon's canal is superficial and vulnerable to blunt trauma. CTA and MRA are common initial investigations and can suggest the diagnosis. DSA is the gold standard imaging modality and offers therapeutic opportunities. Management is controversial, but unless there is critical digital ischaemia, conservative treatment is first line.

Vascular hand-arm vibration syndrome--magnetic resonance angiography

The diagnosis of vascular hand-arm vibration syndrome (HAVS) requires consistent symptoms, photographic evidence of digital blanching and sufficient exposure to hand-transmitted vibration (HTV; A(8) > 2.5 m/s2). There is no reliable quantitative investigation for distinguishing HAVS from other causes of Raynaud's phenomenon and from normal individuals. Hypothenar and thenar hammer syndromes produce similar symptoms to HAVS but are difficult to diagnose clinically and may be confused with HAVS. Magnetic resonance angiography (MRA) is a safe and minimally invasive method of visualizing blood vessels. Three cases of vascular HAVS are described in which MRA revealed occlusions of the ulnar, radial and superficial palmar arteries. It is proposed that HTV was the cause of these occlusions, rather than blows to the hand unrelated to vibration, the assumed mechanism for the hammer syndromes. All three cases were advised not to expose their hands to HTV despite one of them being at Stockholm vascular stage 2 (early). MRA should be the investigation of choice for stage 2 vascular HAVS or vascular HAVS with unusual features or for a suspected hammer syndrome. The technique is however technically challenging and best done in specialist centres in collaboration with an occupational physician familiar with the examination of HAVS cases. Staging for HAVS should be developed to include anatomical arterial abnormalities as well as symptoms and signs of blanching. Workers with only one artery supplying a hand, or with only one palmar arch, may be at increased risk of progression and therefore should not be exposed to HTV irrespective of their Stockholm stage.

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.

Acute Arterial Thrombosis of the Hand

Arterial thrombosis of the hand occurs infrequently but may result in considerable morbidity and compromise of hand function. The hand surgeon may be called upon to direct management in cases of acute arterial thrombosis of the hand and should have an understanding of the available diagnostic tools and treatment modalities. This article discusses the vascular anatomy of the hand and clinical manifestations of arterial thrombosis. Differences between isolated thrombosis and diffuse intravascular injury are detailed, and treatment options for these conditions are described. Appropriate care often requires coordination with interventional radiologists or vascular surgeons. Outcomes after treatment of arterial thrombosis of the hand are variable, and prognosis may be related to whether isolated thrombosis or diffuse intravascular injury is present.

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.

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.

Hypothenar hammer syndrome: case reports and brief review

Patients with hand and finger pain regularly present to primary care practices. Although a well-known clinical entity to specialists, hypothenar hammer syndrome is an uncommon vascular overuse syndrome that may not be familiar to primary care practices. It is caused by trauma to the palmar portion of the ulnar artery, usually as a result of occupational or sports activities which involve repetitively striking objects with the heel of the hand. In this report we describe two representative cases as well as discuss clinical features, pathogenesis, diagnosis, imaging and management.