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Case report: Hypothenar hammer syndrome with embolic occlusion of digital arteries
ClinicalRadiology (1988)39, 324-325
Case Report" Hypothenar Hammer Syndrome With Embolic Occlusion of Digital Arteries S C O T T J. S A V A D E R ,
BARBARA
L. S A V A D E R a n d G A R T H R. D R E W R Y
Department of Radiology, University of South Florida, College of Medicine, 12901 N. 30th Street, Box 17, Tampa, Florida 33612 Although the hand is highly vascular and subjected to frequent and often repeated trauma, only 52 cases of true aneurysms have been described up to 1982 (Martin and Manktelow, 1982). Of these cases, 60% involved the ulnar artery. These injuries have a distinct tendency to occur in workers who routinely use hammers and screwdrivers, thus it can be considered an occupational disease (Middleton, 1933). A single violent traumatic event is rarely the cause, but rather repeated minor trauma over several months or years appears to be the more c o m m o n history. A case with arteriographic demonstration of occlusion of the c o m m o n and proper digital arteries secondary to emboli originating from a traumatic true aneurysm of the ulnar artery is presented.
ischaemia if the radial a n d i n t e r o s s e o u s a r t e r i e s have c o m p r o m i s e d or a b s e n t flow. T h e p r i m a r y a e t i o l o g y of u l n a r artery a n e u r s y m s is t r a u m a t i c a n d c o r r e l a t e s i n t i m a t e l y with the r e g i o n a l a n a t o m y . A s the u l n a r artery e n t e r s the wrist, it passes superficial to the flexor r e t i n a c u l u m ( t r a n s v e r s e carpal l i g a m e n t ) a n d h a m a t e b o n e , lying just m e d i a l to the h o o k of the h a m a t e . A force applied to the h y p o t h e n a r e m i n e n c e will crush the
CASE REPORT A 26-year-old carpenter presented with a chief complaint that the right fourth and fifth fingers had been blue and intensety painful for one day, and cold and numb for 4 days. Past medical history was significant only in that he had smoked for some years. The patient originally denied any history of trauma, but later stated that 1 week prior to the onset of his symptoms, he had struck the arm of a wrench several times with his right hand while working on a car. He stated that be often did this to loosen nuts when working on auto transmissions. He experienced severe pain and tingling in the hypothenar eminence at the time but this later resolved, leaving a symptom-free interval of about 3 days. Physical examination showed cold, blanched right fourth and fifth digits with poor capillary refill distal to the proximal interphalangeal joints. Two point discrimination and radial and ulnar pulses were normal. Flexion and extension were limited due to pain. The proximal hypothenar eminence was tender on palpation. Plain radiographs of the hand were normal. Arteriography, performed via a direct brachial artery approach, demonstrated a 6 mm aneurysm of the distal ulnar artery. Embolic occlusion of multiple sites including the third and fourth common palmar digital arteries, the distal fourth and fifth proper digital arteries, and the medial proper digital artery of the third finger was noted (Fig. 1). Later arterial phase films clearly demonstrated delayed washout from the aneurysm (Fig. 2). At surgery a partially thrombosed true aneurysm of the ulnar artery was resected with end-to-end anastomosis performed. A continuous stellate block was administered for 5 days. The patient was discharged on the eighth post-operative day at which time the affected digits demonstrated normal capillary refill and improved range of motion. His pain was moderately improved. Two weeks after discharge, his range of motion had returned to normal but he was still experiencing moderate pain in the third digit.
DISCUSSION T h e first r e p o r t e d case of a n arterial a n e u r y s m involving the h a n d o c c u r r e d in a c o a c h m a n in R o m e d e s c r i b e d by G u a t t a n i in 1772 ( G i v e n et al., 1978). T h e u l n a r artery is the p r i n c i p a l b l o o d s u p p l y of the h a n d . I n t e r r u p t i o n of this vessel can result in severe digital Correspondence to: Scott J. Savader, MD.
Fig. 1 - A subtraction angiogram demonstrates the 6 mm aneurysm of the distal ulnar artery (thin arrow) and multiple embolic occlusions of palmar and proper digital arteries (two indicated by arrow heads).
ULNAR HAMMER SYNDROME
325
changes. Ischaemia is usually due to vasospasm and arterial insufficiency. Ischaemia may rarely occur secondary to embolic occlusion of arteries distal to the aneurysm as illustrated by the angiograms of our patient. Neurological changes may be present if the aneurysm is in contact with or impinges on the adjacent ulnar nerve. Although the clinical suspicion for this type of injury may be high, based on the history and physical examination, arteriography is required for diagnosis. Arteriography allows evaluation of the exact size and location of the aneurysm, possible damage to other vessels of the hand, distal arterial occlusion secondary to emboli or vasospasm, and collateral circulation. In cases with equivocal history of recent trauma, arteriography can rule out possible primary arterial pathology such as Buerger's disease. Surgical resection is the treatment of choice for symptomatic arterial aneurysms (Kleinert e t a / . , 1973; Gaylis and Kushlick, 1973; Martin and Manktelow, 1982; Bayle et al., 1983). Resection produces a local sympathectomy and removes the source of embolisation. In a study by Given et al. (1978), 89% of those undergoing resection and graft reconstruction had excellent results with 11% unimproved compared with 60% improved and 40% unimproved in those undergoing aneurysmal resection and vessel ligation. This case exemplifies the classic hypothenar hammer syndrome and the role of arteriography in the diagnosis and the evaluation of possible complications such as peripheral emboli. We postulate that initially, repeated low-grade trauma led to the aneurysm, and more severe trauma 1 week before admission caused thrombosis of the aneurysm and focal pain, with symptomatic emboli occurring a few days later. The mechanism of injury and the regional anatomy correlate exceptionally well. An appreciation of this relationship is vital in the diagnosis of hypothenar hammer syndrome. REFERENCES
Fig. 2 - A late arterial phase film clearly demonstrates delayed washout from the aneurysm (thin arrow).
ulnar artery against the unyielding hook of the hamate (Martin and Manktelow, 1982). The majority of palmar true aneurysms are caused by repeated trauma to this segment of the artery. False aneurysms are usually due to penetrating wounds and tend to occur more distally. Symptoms occur secondary to irritation of the hypothenar eminence by the aneurysm and distal ischaemic
Bayle, E, Tran, K, Benslamia, B, Dufilho, A & Drouard, F (1983). Ulnar artery aneurysm of the hand. InternationaISurgery, 68,215217. Gaylis, H & Kushlick, AR (1973). Ulnar artery aneurysms of the hand. Surgery, 73, 378--480. Given, KS, Puckett, CL & Kleinert, HE (1978). Ulnar artery thrombosis. Plastic and Reconstrive Surgery, 61. 504-411. Kleinert, HE, Burget, GC, Morgan,.IA, Kutz, JE & Alasoy, E (1973). Aneurysms of the hand. Archives of Surgery, 106, 554-557. Martin, RD & Manktelow, RT (1982). Management of ulnar artery aneurysm in the hand: a case report. Canadian Journal of Surgery, 25, 97-99. Middleton, DS (1933). Occupational aneurysm of the palmar arteries. British Journal of Surgery, 21,215.
Case Report" Hypothenar Hammer Syndrome With Embolic Occlusion of Digital Arteries S C O T T J. S A V A D E R ,
BARBARA
L. S A V A D E R a n d G A R T H R. D R E W R Y
Department of Radiology, University of South Florida, College of Medicine, 12901 N. 30th Street, Box 17, Tampa, Florida 33612 Although the hand is highly vascular and subjected to frequent and often repeated trauma, only 52 cases of true aneurysms have been described up to 1982 (Martin and Manktelow, 1982). Of these cases, 60% involved the ulnar artery. These injuries have a distinct tendency to occur in workers who routinely use hammers and screwdrivers, thus it can be considered an occupational disease (Middleton, 1933). A single violent traumatic event is rarely the cause, but rather repeated minor trauma over several months or years appears to be the more c o m m o n history. A case with arteriographic demonstration of occlusion of the c o m m o n and proper digital arteries secondary to emboli originating from a traumatic true aneurysm of the ulnar artery is presented.
ischaemia if the radial a n d i n t e r o s s e o u s a r t e r i e s have c o m p r o m i s e d or a b s e n t flow. T h e p r i m a r y a e t i o l o g y of u l n a r artery a n e u r s y m s is t r a u m a t i c a n d c o r r e l a t e s i n t i m a t e l y with the r e g i o n a l a n a t o m y . A s the u l n a r artery e n t e r s the wrist, it passes superficial to the flexor r e t i n a c u l u m ( t r a n s v e r s e carpal l i g a m e n t ) a n d h a m a t e b o n e , lying just m e d i a l to the h o o k of the h a m a t e . A force applied to the h y p o t h e n a r e m i n e n c e will crush the
CASE REPORT A 26-year-old carpenter presented with a chief complaint that the right fourth and fifth fingers had been blue and intensety painful for one day, and cold and numb for 4 days. Past medical history was significant only in that he had smoked for some years. The patient originally denied any history of trauma, but later stated that 1 week prior to the onset of his symptoms, he had struck the arm of a wrench several times with his right hand while working on a car. He stated that be often did this to loosen nuts when working on auto transmissions. He experienced severe pain and tingling in the hypothenar eminence at the time but this later resolved, leaving a symptom-free interval of about 3 days. Physical examination showed cold, blanched right fourth and fifth digits with poor capillary refill distal to the proximal interphalangeal joints. Two point discrimination and radial and ulnar pulses were normal. Flexion and extension were limited due to pain. The proximal hypothenar eminence was tender on palpation. Plain radiographs of the hand were normal. Arteriography, performed via a direct brachial artery approach, demonstrated a 6 mm aneurysm of the distal ulnar artery. Embolic occlusion of multiple sites including the third and fourth common palmar digital arteries, the distal fourth and fifth proper digital arteries, and the medial proper digital artery of the third finger was noted (Fig. 1). Later arterial phase films clearly demonstrated delayed washout from the aneurysm (Fig. 2). At surgery a partially thrombosed true aneurysm of the ulnar artery was resected with end-to-end anastomosis performed. A continuous stellate block was administered for 5 days. The patient was discharged on the eighth post-operative day at which time the affected digits demonstrated normal capillary refill and improved range of motion. His pain was moderately improved. Two weeks after discharge, his range of motion had returned to normal but he was still experiencing moderate pain in the third digit.
DISCUSSION T h e first r e p o r t e d case of a n arterial a n e u r y s m involving the h a n d o c c u r r e d in a c o a c h m a n in R o m e d e s c r i b e d by G u a t t a n i in 1772 ( G i v e n et al., 1978). T h e u l n a r artery is the p r i n c i p a l b l o o d s u p p l y of the h a n d . I n t e r r u p t i o n of this vessel can result in severe digital Correspondence to: Scott J. Savader, MD.
Fig. 1 - A subtraction angiogram demonstrates the 6 mm aneurysm of the distal ulnar artery (thin arrow) and multiple embolic occlusions of palmar and proper digital arteries (two indicated by arrow heads).
ULNAR HAMMER SYNDROME
325
changes. Ischaemia is usually due to vasospasm and arterial insufficiency. Ischaemia may rarely occur secondary to embolic occlusion of arteries distal to the aneurysm as illustrated by the angiograms of our patient. Neurological changes may be present if the aneurysm is in contact with or impinges on the adjacent ulnar nerve. Although the clinical suspicion for this type of injury may be high, based on the history and physical examination, arteriography is required for diagnosis. Arteriography allows evaluation of the exact size and location of the aneurysm, possible damage to other vessels of the hand, distal arterial occlusion secondary to emboli or vasospasm, and collateral circulation. In cases with equivocal history of recent trauma, arteriography can rule out possible primary arterial pathology such as Buerger's disease. Surgical resection is the treatment of choice for symptomatic arterial aneurysms (Kleinert e t a / . , 1973; Gaylis and Kushlick, 1973; Martin and Manktelow, 1982; Bayle et al., 1983). Resection produces a local sympathectomy and removes the source of embolisation. In a study by Given et al. (1978), 89% of those undergoing resection and graft reconstruction had excellent results with 11% unimproved compared with 60% improved and 40% unimproved in those undergoing aneurysmal resection and vessel ligation. This case exemplifies the classic hypothenar hammer syndrome and the role of arteriography in the diagnosis and the evaluation of possible complications such as peripheral emboli. We postulate that initially, repeated low-grade trauma led to the aneurysm, and more severe trauma 1 week before admission caused thrombosis of the aneurysm and focal pain, with symptomatic emboli occurring a few days later. The mechanism of injury and the regional anatomy correlate exceptionally well. An appreciation of this relationship is vital in the diagnosis of hypothenar hammer syndrome. REFERENCES
Fig. 2 - A late arterial phase film clearly demonstrates delayed washout from the aneurysm (thin arrow).
ulnar artery against the unyielding hook of the hamate (Martin and Manktelow, 1982). The majority of palmar true aneurysms are caused by repeated trauma to this segment of the artery. False aneurysms are usually due to penetrating wounds and tend to occur more distally. Symptoms occur secondary to irritation of the hypothenar eminence by the aneurysm and distal ischaemic
Bayle, E, Tran, K, Benslamia, B, Dufilho, A & Drouard, F (1983). Ulnar artery aneurysm of the hand. InternationaISurgery, 68,215217. Gaylis, H & Kushlick, AR (1973). Ulnar artery aneurysms of the hand. Surgery, 73, 378--480. Given, KS, Puckett, CL & Kleinert, HE (1978). Ulnar artery thrombosis. Plastic and Reconstrive Surgery, 61. 504-411. Kleinert, HE, Burget, GC, Morgan,.IA, Kutz, JE & Alasoy, E (1973). Aneurysms of the hand. Archives of Surgery, 106, 554-557. Martin, RD & Manktelow, RT (1982). Management of ulnar artery aneurysm in the hand: a case report. Canadian Journal of Surgery, 25, 97-99. Middleton, DS (1933). Occupational aneurysm of the palmar arteries. British Journal of Surgery, 21,215.