Hypothenar hammer syndrome successfully managed with intravenous prostaglandin E1 and heparin and with correction of the thrombogenic risk profile. A case report

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

Hypothenar hammer syndrome is an underdiagnosed disorder that classically has been associated with repetitive occupational trauma. However, a substantial portion of cases can arise from recreational activities or a single acute event. A 15-year-old drummer presented with a 6-month history of a bulge over the hypothenar eminence of his left palm. An angiogram showed a 1.5 x 2.0 cm pseudoaneurysm arising from the ulnar artery just distal to the deep palmar branch and extending into the proximal portion of the superficial palmar arch. The aneurysm was resected and reconstructed with a primary end-to-end anastomosis. The symptoms of hypothenar hammer syndrome are variable and can be related to poor inflow, distal spasm, or emboli. Careful history and physical examination with consideration of anatomical relationships will reveal the diagnosis. Recommendations for further diagnostic testing and specific treatment strategy vary owing to increased understanding of this syndrome combined with a paucity of controlled studies. Clinical aspects and management of this case are discussed in light of the current literature.

Combined Thenar and Hypothenar Hammer Syndromes and Raynaud's Phenomenon Successfully Treated with Iloprost

Thenar and hypothenar hammer syndromes are uncommon conditions characterised by digital ischemia of the hand as a result of repetitive trauma at level of the thenar and/or hypothenar eminence and damage to the radial and/or ulnar arteries, respectively. The symptoms are related to the mechanism of the trauma and a Raynaud's phenomenon can be predominant for a long time. The angiography is the “gold standard” imaging technique which allows to confirm the diagnosis. Therapeutic strategy depends on the type of the lesion and severity of symptoms and includes pharmacological (antithrombotic and thrombolytic drugs) and surgical treatments. The authors present a case of a 53-year-old man, carpenter by profession, with combined thenar and hypothenar hammer syndromes and Raynaud's phenomenon, successfully treated with a short course of intravenous infusion of iloprost.

Therapeutic management of hypothenar hammer syndrome causing ulnar nerve entrapment

Introduction. The hypothenar hammer syndrome is a rare traumatic vascular disease of the hand. Method and Materials. We report the case of a 43-years-old man with a painful tumefaction of the left hypothenar region. The ulnar artery appeared thrombosed clinically and radiologically. The patient underwent surgery to resolve the ulnar nerve compression and revascularise the artery. Results. The symptoms disappeared immediately after surgery. The arterial flow was reestablished. Postoperatively on day 20, a new thrombosis of the ulnar artery occurred. Conclusion. Hypothenar hammer syndrome is caused by repetitive trauma to the heel of the hand. The alterations of the vessel due to its chronic inflammation caused an acute compression of the ulnar nerve at the Guyon's canal and, in our case, do not allow a permanent revascularisation of the ulnar artery.

Long-term follow-up of hypothenar hammer syndrome: a series of 47 patients

Hypothenar hammer syndrome (HHS) is an uncommon form of secondary Raynaud phenomenon, occurring mainly in subjects who use the hypothenar part of the hand as a hammer; the hook of the hamate strikes the superficial palmar branch of the ulnar artery in the Guyon space, leading to occlusion and/or aneurysm of the ulnar artery. In patients with HHS, such injuries of the palmar ulnar artery may lead to severe vascular insufficiency in the hand with occlusion of digital artery. To date, only a few series have analyzed the long-term outcome of patients with HHS. This prompted us to conduct the current retrospective study to 1) evaluate the prevalence of HHS in patients with Raynaud phenomenon and 2) assess the short-term and long-term outcome in patients with HHS. From 1990 to 2006, 4148 consecutive patients were referred to the Department of Internal Medicine at the University of Rouen medical center for evaluation of Raynaud phenomenon using nailfold capillaroscopy. HHS was diagnosed in 47 of these 4148 patients (1.13% of cases).Forty-three patients (91.5%) had occupational exposure to repetitive palmar trauma. The more common occupations were factory worker (21.3%), mason (12.8%), carpenter (10.6%), and metal worker (10.6%); the mean duration of occupational exposure to repetitive palmar trauma at HHS diagnosis was 21 years. One patient (2.1%) had recreational exposure (aikido training) to repetitive trauma of the palmar ulnar artery, and 3 other patients (6.4%) developed HHS related to a single direct injury to the hypothenar area. Clinical manifestations were more often unilateral (87.2%) involving the dominant hand (93%). HHS complications included digital ischemic symptoms (ischemia: n = 21, necrosis: n = 20) and irritation of the sensory branch of the ulnar nerve (n = 11). In HHS patients, angiography demonstrated occlusion of the ulnar artery in the area of the Guyon space (59.6%), aneurysm of the ulnar artery in the area of the Guyon space (40.4%), and embolic multiple occlusions of the digital arteries (57.4%). All patients were advised to change their occupational exposure. They were given vasodilators, including calcium channel blocker (n = 37) and buflomedil (n = 12); 36 patients (76.6%) also received oral platelet aggregation inhibitors. Twenty-one patients with digital ischemia/necrosis were further given hemodilution therapy to reduce the hematocrit level to 35%. In 3 patients with HHS-related digital necrosis who exhibited partial improvement with vasodilators, prostacyclin analog therapy (a 5-day regimen of intravenous prostacyclin analog) was instituted, resulting in complete healing of digital ulcer in these 3 patients. Other conservative treatment options included controlling risk factors (smoking cessation, low-lipid diet, therapy for arterial hypertension) and careful local wound care of fingers in the 20 patients with digital necrosis. Only 2 patients, exhibiting digital necrosis and multiple digital artery occlusions, with nonthrombotic ulnar artery aneurysm underwent reconstructive surgery, that is, resection of the aneurysm with end-to-end anastomosis of the ulnar artery. The median length of follow-up in patients with HHS was 15.9 months. Thirteen patients (27.7%) exhibited clinical recurrences of HHS; the median time of HHS recurrence onset was 11 months. Outcome of HHS relapse was favorable with conservative measures in all cases. Awareness of HHS is required to increase suspicion of the disorder so that further exposure to risk factors like repetitive hypothenar trauma can be avoided for these patients; this is of great importance for their overall prognosis. We found favorable outcomes in most patients after conservative measures were initiated; therefore we suggest that surgery may be undertaken in the subgroup of patients who exhibit partial improvement while receiving conservative therapy. Finally, because we observed recurrence of HHS in 27.7% of patients, we note that HHS patients require close follow-up, including both regular and systematic physical vascular examination.

Hypothenar Hammer Syndrome: Rare or Underdiagnosed?

Hypothenar hammer Syndrome (HHS) is a condition characterised by digital ischaemia as a result of repetitive trauma to the hypothenar eminence of the hand. It occurs in people who repeatedly use the palm of the hand as a hammer to push, grind or twist objects. It is a curable and a preventable cause of upper digital ischemia. In this report we present a case of HHS and discuss the causes and pathogenesis of this syndrome. We review the incidence, clinical characteristics, differential diagnosis, investigation and treatment.

["Progressive" hypothenar hammer syndrome Indication for operative treatment]

Hypothenar hammer syndrome (HHS) is ischemia of the distal ulnar artery caused by injury to the ulnar part of the palmar arch. This disease often involves workers who frequently use the hypothenar part of the hand as a hammer. The aneurysmatic form of HHS represents an indication for operative treatment; the thrombotic form is treated mainly conservatively. In our opinion, the symptomatic thrombotic form represents an indication for operation if symptoms persist during conservative therapy, particularly if symptoms progress. In fresh embolic occlusions, regional thrombolysis is usually successful. We present here the symptomatic treatment and course in two patients with complaints increasing during conservative therapy. The patients reported progressive Raynaud's phenomenon of the fingers. Angiography confirmed corkscrew-like aneurysmatic configuration of the distal ulnar artery and subsequent embolization of digital arteries. In both cases, we removed the source of the embolism with resection of the involved arterial segment and anastomosis with autologous vein grafts.

Reversible ischaemia after raising a radial forearm flap with ulceration of three fingers in a cigarette smoker

The radial forearm flap is a standard method for the reconstruction of intraoral defects of soft tissues. We report the case of a middle-aged man who developed ischaemia in three fingers after a fasciocutaneous radial flap had been raised. The preoperative Allen test to diagnose occlusion of radial or ulnar artery was satisfactory. Soon after the operation the patient resumed smoking and four weeks later he developed ulcers on the thumb, index, and middle fingers. Only after he had stopped smoking and been given acetylsalicylic acid and heparin did blood flow and capillary hemoglobin oxygenation increase. As a result, his radial fingers recovered completely.