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Neuropathy of the ulnar nerve caused by an aneurysm of the ulnar artery at the wrist
Neuropathy of the ulnar nerve caused by an aneurysm of the ulnar artery at the wrist A case report and review of the literature
W.P. Vandertop*
and J.W. van ‘t Verlaat*
Introduction Summary Aneurysms of the ulnar artery at the wrist are very uncommon and may lead to serious impairment of ulnar nerve functions. Less frequently than the median nerve the ulnar nerve is entrapped at the wrist or palm. This may be explained by the quite different topographical situation of both nerves. Localization Ulnar nerve lesions within divided into three groups1-4:
the hand
can
A case is reported of neuropathy of the ulnar nerve caused by an aneurysm of the ulnar artery at the wrist. A review of the literature is
1
iiL;ords:
neuropathy.
aneurysm.
ulnar
be
Compression distally to the branching point of the superficial terminal branch and proximally to the point where the deep terminal branch divides into fibres coursing to the individual muscles of the hand. There is weakness of all ulnar nerve innervated hand muscles excluding the palmaris brevis muscle. There are no sensory disturbances. Compression of the most proximal part of the deep terminal branch, usually at the pisohamate tunnel. All the ulnar innervated hand muscles are affected, including the palmaris brevis muscle, without any sensory impairment. Compression of the nerve as it enters the hand. All ulnar innervated hand muscles are affected, but the sensory impairment is res-
tricted to the area cutaneous branch.
supplied
by the palmar
Aetiology Although ulnar neuropathy in the hand can arise apparently spontaneously, there is almost always a history of injury5-8. The list of lesions responsible for compression of the ulnar nerve at the hand and/or wrist is very extensiveg-“. Aneurysms may be either true or false. Either form of aneurysm may develop gradually and in due time compress an adjacent, previously normal nerve, and thus induce neural ischemia. In such instances the nerve becomes flattened and even eroded. The complaints caused by an entrapment neuropathy of the ulnar nerve in the hand will of course depend is involved. but
on which portion of the nerve mostly it is weakness of the
139
hand that attracts ,i\ pain’:!.
the patients
attentton
as ~,:ell
An S-shaped
incision
v.as made
.ttc)ng the
radial edge of the hvpothcnar em~r~c~~~c, IIL~:! the ulnar ncrvc. to reach the t’ore;.lrn;
Case report A 30-year-old
male
Caucasian
outpatient
by the Department
the
University
State
September
Hospital
was seen as an of Neurology of
l.Itrecht
of in
1983.
Seven weeks earlier he had cut his wrist, falling through a glass window. The laceration was sutured
in the emergency
ward after which the
patient was sent home. Two weeks before his first visit
superficial branch ot’ the ulnar nerve was stretched over the volar surface of the aneurysm. while the deep branch was displaced dorsally. Both branches of the ulnar nerve were severely compressed. An external neurolysis 01’ both
he started
complaining of a burning and numb sensation over the ulnar aspect of the right palm and the fourth and fifth fingers. There was no clear motor weakness. Sometimes paresthesia were present over the hypothenar eminence and both ulnar fingers. Analgetics did not help. Patient was a drugaddict using 80 mg methadon daily. Physical examination revealed a slight weakness only of the adductor pollicis muscle of the right hand, without any atrophy. A disturbed sensibility to pinprick was found over the hypothenar eminence and the ulnar aspect of the wrist of the right hand. The sign of Tine1 was positive at the wrist. An electromyographic study was refused by the patient. On November 4, he was seen again and referred to our department because of a progressive motor impairment of the ulnar innervated muscles, including the palmaris brevis muscle, as well as a slight atrophy. The sensibility deficit remained unchanged. The patient was hospitalized on November 26. There was a marked atrophy now of the hypothenar eminence, slight atrophy of the interossei muscles, marked weakness of the adductor pollicis, interossei, abductor digiti minimi, and third and fourth lumbrical muscles, causing the fourth and fifth fingers in an ‘en griffe’ position. Pinprick and cotton wool sensibility was very much disturbed over the hypothenar eminence, fifth finger and ulnar aspect of the fourth finger. Over the base of the hypothenar region a weak pulsating mass was palpable. Patient underwent operation on December 1. 1983. 140
After careful preparation this mass C~ppeareJ to be an aneurysm of the ulnar artcry. I hc
branches
was performed.
The aneurysm
was resected and the ulnar artery anastomosed end-to-end with interrupted 10-O silk sutures. Postoperatively the pain subsided promptly: the position ‘en griffe’ became gradually less marked; the motor function of the interossei and lumbricalis 1V and V muscles was slightly improved. The sensibility was still disturbed, but clearly improving. Six weeks after discharge from hospital he still complained of mild paresthesia in the fourth and tifth finger. The motor function of the interossei, lumbricalis IV and V and abductor digiti minimi muscles was drastically improved. The sensibility was still disturbed. but to a much lesser extent. A venous digital subtraction angiography to check the patency of the ulnar artery was refused by the patient. The pathologist’s report stated that the wall of the aneurysm consisted of a layer of fibrin closely attached to concentric structures. mainly composed of connective tissue. Scattered are structures resembling an elastic membrane. but special elastic-colouring could not confirm this conclusively. All in all this fits the description of a false aneurysm. Discussion It seems that Guatiani, in 1772, was the first to describe an aneurysm of the palmar arch. In 1930, Volkmann published a very extensive survey of the literature, yielding 67 cases of traumatic aneurysms of the palmar arch.‘” Many of those case reports are very incomplete but it seems that all were indeed aneurysms. Volkmann excluded several other cases from his series because they were not traumatic of origin. but e.g. syphilitic (Morestin 1905) and
spontaneous
(Griftiths
1897). However,
it is not
ulnar nerve motor and sensory
quite clear how many he discarded. in 1933. published a survey of the Middleton’l.
caused
literature
ulnar
yielding
70 cases. Besides the 67 cases
of Volkmann he seems to have included the case of Griffiths, Morestin and one described bv Reid in 1926. In 1934 Von RosenI case
of thrombosis
considered
was the first to publish of the
it an entity
ulnar
pathologically
artery.
findings
distinct
from the cases of traumatic aneurysm occurring in the same region, suggesting that injury to the intima resulted in thrombosis. while damage to the outer layers of the vessel caused an aneu-
It is remarkable that in a majority of the reported cases the clinical picture seems to be dominated by the presence of a tender, hypothenar mass combined with ulnar artery insufficiency, leading to Raynaud’s phenomenon”x-‘~O. Millender, Nalebuff, and KasdotPtstated that the presence of ulnar nerve motor palsy is an important diagnostic point. In none of their cases and in none of the cases they reviewed there had been any true ulnar nerve motor palsy. According to them the motor branch was protected from aneurysms of the ulnar artery, because of the anatomy of the ulnar nerve. In the case we report it was especially the
well
capable
the ulnar but branch.
of the
of
severely
nerve, not only the also the deep motor
surprising
to find that only in a
very small minority of the reported cases. mention is made of an associated ulnar nerve sensory and/or
motor
rysm of the ulnar
impairment
when
an aneu-
artery is found.
References
rysm. He regarded both conditions having a similar etiology and similar symptoms. However. if thrombosed. the diagnosis is more difficult and can be made only on surgical exploration. For the past decades several reports of single cases have appeared; some of aneurysms. some of thrombosis. Many authors have discussed true palmar aneurysmst”--“’ and thrombosis”7-5G as if unrelated. but the similarity of many of the reported cases is striking. It is highly likely however that some of the many previously published cases of thrombosis were in fact true aneurysms. The most recent review by Green”’ in 1973 shows that it is virtually impossible to quantify the amount of aneurysms of the palmar arteries due to the fact that it is almost impossible to distinguish between palmar aneurysm and thrombosis when reviewing previously published cass.
that
care. The
show that aneurysms
are
It is therefore
impairment
to seek medical
at surgery artery
compressing superficial branch.
a He
the patient
w. M’OOl~H41.1.
HA> Mhi:R Principle\
ofdiagnosis.
Saunder\
n.
Peripheral
London: W.B.
C‘
NI(.SI
II. Die Chirurgle der peripheren Georg I hicme Vcrlag. 1955: XX. HJ.
SFI)I)ON Maje$‘\
Peripheral
Stationery
nerve
Office
SI.%.&LA. Entrapment GW.
nerve Injuries.
Ed 2. Phiisdelphia.
Nerven.
tnjurieh.
London:
Her
1954: 222.
neuropathies.
In: Vinken
ed\. Handbook
of Cl’lnical Neurology. Publishing Co. 1970: X:303.
North-llolland
Stuttgart:
( 4\v1 F\ .II. Acute traumatic
aneurysm
PJ. Bruvn
Amsterdam:
of the palm. Am J
Surg 1974: 74: 98. MC LALIGHLIU(TV. Traumatic
aneurysm
artery. (‘aw 42x.
report. U.S. Naval Medival
5HORl
Occupational
1)~.
aneurysm
of
the
Bulletin
ulnar
1944: 42:
of the palmar
arch.
C,tw report. Lancet 194X: 217. /I ( KFKM,~NN
II.
Proctor SE. Traumatic
palmar aneurysm.
Am J Surg 1946: 72: 52. c 1II toKI) tumor\ “’ KOPPtl
KH. KFI
LY
4P.
Diagnosis
ofthe
hand. Clin. Orthop
I
IHOMPSOY
HP.
HP. Thomwn pathies.
WAL.
W.&l-L.
New
( . c I OllrlbR
\\ndrome
treatment
of
nerve.
York:
In: Kopell
entrapment Robert
E.
ncuroKrieger
Co. 1976: 120.
” MI hltvt HAI t,R M. Die Thiemc Verlag. 1961. I” l)t’I’ONl
Ulnar
eds. Peripheral
Huntington
Publi\hln~
and
1959: 13: 204.
Ulnarlsparesen. (;b.
PRth’OSr
Y et
Stuttgart:
Georg
al. Ulnar-tunnel
at the wriht. .I Bone and Joint Surg 1965: 47A:
77. I” \ OI KM~NN
I.
Uchcr
traumatlwhr
arterxlle
Aneurvsmen
dcr Hohlhandhogcn. Dtsch Zeitschr Chir 1930: 22?-151. ‘* MII)III F I ON 11s. Occupational aneurysm of the palmar arterlcs. Brtt J Surg 1933; 21: 215.
I”
RO\bU
\. LOI\;.
Etn Fall van Thromboae
I Ilnaris nach Einuirkung Stand
in der Arterla
van stumpfer Gewalt.
Acta Char
1981: 24: 207.
I” Ht ht 1.h 9
I I 4. (~AI.ASSI t POPPI M. Paralyis
nerve at the uri\t
with aneurysmal
artcry. Ycurochirurgia
of the ulnar
dilatation
of the ulnar
1981: 24: 207.
” FI 1%.t)o\ttt M. ( IIEAH H: Mvcotlc artt’rl. Med J Awl 1979: I :4h2.
aneurvsm
” tt KIN IX . wOOI~HALL H. Combined vascular injuries of warfare. Ann Surg 1944: 119: 41 I. I” i.\i(il’l M&U KM. Cl FMFNr’i
JM. HERMANN
of the ulnar and nerve
JR. Stab
wounds
and traumatic falw aneuryms in the extremities. J. lrauma l96Y: Y:77. ?‘I FRIIO\ cm. Lllnar artery aneur)&m on the hand. Magi 1 raumatol
Orth
141
I(. WORKMAN ct. Aneurysm of the ulnar arten due to blunt trauma to the hand. Missourt Med 1964; 61:927. :a GAGE M. Traumatic arterial aneurysm of the peropheral arteries, Am J Surg 1943: 59: 210. ‘:’ GAYLLS H, KUSHLICK AR. Ulnar artery XleUrySIllSof the hand. Surgery 1973; 73: 478. ?,r GEE H. Traumatic aneurysms of the ulnar artery. Med J Aust 1945; 1:395. “’ GOADBYHK.MCSWTNEYRR,ROBCC~. Mycoticaneurysm.St. Thomas Rep. 1949: 5:44. ” HELBIG B. STEIN H. Differential diagnosis of soft tissue tumors of the palm: cirsoid aneurysm of the ulnar artery. Handchirurgie 1981; 13: 305. L’7INOUE. TABIRA K. HIDAKA N et al. Ulnar nerve paralysis of the carpal tunnel due to traumatic aneurysm of the ulnar artery. Orthop Surg 1971; 22: 924. yx JESHRANI MK. Bilateral ulnar artery aneurysm in the palm Case report. East Afr Med J 1976; 53: 13. K, WOLFF ~w. Ulnar nerve aa KALISMAN M. LABORD compression secondary to ulnar artery false aneurysm at Guyon’s canal. J Hand Surg 1982; 7: 137. at’ KAPLAN EB. ZEIDE MS. Aneurysm of the ulnar artery. Case report. Bull Hosp Joint Dis 1972; 33: 197. ‘t’ KUSIER L VVN, ABT AB. Traumatic aneurysms of the ulnar artery. Arch Pathol Lab Med 1980; 104 75. a2 LOKEY H. PHELPS DB, BOSW~CK IA. Traumatic false aneurysm of the hand in hemophilia. J Trauma 1978; 18: 283. :t:t MARTIN AI;.Ulnar artery thrombosis in the palm. Case report. Clin Orthop 1960; 17: 373. .j4 MAYS ET. Traumatic aneurysm of the hand. Am Surg 1970: 36: 552. a: MILLING MA, KINMONTH MH. False aneurysms of the ulnar artery. Hand 1977: 9:57. a6 MOORE JB.ZooK EG.KINKEAD LR. Ulnaryartery aneurysm in osteogenesis imperfecta. Hand 1983; 15: 91. :j7 MUNKERJEA SK. Occupational true aneurysm of the ulnar artery in the palm Br J Surg 1971; 59: 934. 3x NADE s. Tardy paralysis of the ulnar nerve due to traumatic false aneurysm of the ulnar artery. Case report. Injury 1972; 3: 196. .$a R~BIo FA. GUINN GA, MIN Kw et al. Mirror image aneurysms of the ulnar artery in the palm. Vast Surg 1976? IO: 195. do SHAPIRA L,RUBINSTEIN ZJ,JACOBET. Traumaticaneurysm of the ulnar artery in the palm. Harefuah 1978: 95: 263. " FOWLER
142
" SMI IH JW. 1 rue nneur)i\mh
ot trdumauc orlg”’ in the p,mIi Am J Surg 1962; 104: 7. ‘:! SPITILLIA.JANES JM. Aneurvsms of the ulnar ,tt-tcr\. C‘asc report. Staff meetings of the Mayo Clinic 1957: 32; 295. rziSUSLKO B. Traumatic aneurv\m of the ulnar ,trrcry. Wtati Lek 1974: 27: 1899. _ ” 1 HI0 R I.F&e aneurysm of the ulnar artery after surger\ employing a tourniquet. Am J Surg 1972: 123:604. ” lHORRI-.NS 5. IRIPPEI. OH. BtRGAN JJ. Arteriosclerotic aneurysms of the hand. Arch Surg 1966: 92:937. “’ VRA( EVI(' I). Aneurysm of the ulnar artery tn the hypothenar region. Acta Chir lugosl 1976: 23:329. ‘r c OSTIGAN DG. RILEY JM. coy FE. Thrombotibrosts of the ulnar artery in the palm. J Bone Joint Surg 1959: 41A: 702. ” GOKEN ML. Palmar intramural thrombosis tn the ulnar arter\/. California Med 1958; 89:424. ” JACKSON JP. Traumatic thrombosis of the ulnar arterv in the palm. J Bone Joint Surg 1954; 36 B: 438. “’ KI.EINERT JE. VOLIANTIS GJ. Thrombosis of the palmar arterial arch and its tributaries: Etiology and newer concepts in treatment. J Trauma 1965: 5: 447. :,’ LAWRENCE RR, WILSON IN. Ulnar artery thrombosis in the palm. Case report. Plast Reconstr Surg 1965: 36: 604. 52 MARTIN AF. Ulnar artery thrombosis in the palm. Case report. Clin Orthop 1960; 17: 373. ‘.t PAABY H, S~AOIL F. Thrombosis of the ulnar artery. Acta Orthop Stand 1968: 39: 336. 5” TREVASKIS AE, MARCKX KM. P~NNIYI AM et a]. Thrombosis of the ulnar artery in the hand. Case report. Plast Reconstructr Surg 1964: 33:73. ” ZWIZIC;J.KK. PoscH JL et al. Thrombosis of the ulnar artery following blunt trauma to the hand. J Bone Joint Surg 1969: 5lA:I 191. ‘,7 GREEN Dp. True and false traumatic aneurysms in the hand. J Bone Joint Surg 1973; 55A: 120. iti BERFAN JJ.BONN J.TRIPPEL OH. Severe ischemia of the hand. Ann Surg 1971: 173: 301. ,jy MAY JW.GROSSMANN JA,coSTAS B. Cyanotic painful index and long fingers associated with an asymptomatic ulnar artery aneurysm. Case report. J Hand Surg 1982; 7: 622. li” (~.AKOLJ.TORDOIR JHM, BUTH J.Arteriele stoornissen in de hand blJ gebruik van de hypothenar als hamer. Ned Tijdschr Geneeskd 198 I : 125: 1444-50. “’ MILI.ENDER LH, NALEBUPI EA. KASDON E. Aneurysms and thrombosis of the ulnar artery in the hand. .&ch Surg 1972; 105: 686.
W.P. Vandertop*
and J.W. van ‘t Verlaat*
Introduction Summary Aneurysms of the ulnar artery at the wrist are very uncommon and may lead to serious impairment of ulnar nerve functions. Less frequently than the median nerve the ulnar nerve is entrapped at the wrist or palm. This may be explained by the quite different topographical situation of both nerves. Localization Ulnar nerve lesions within divided into three groups1-4:
the hand
can
A case is reported of neuropathy of the ulnar nerve caused by an aneurysm of the ulnar artery at the wrist. A review of the literature is
1
iiL;ords:
neuropathy.
aneurysm.
ulnar
be
Compression distally to the branching point of the superficial terminal branch and proximally to the point where the deep terminal branch divides into fibres coursing to the individual muscles of the hand. There is weakness of all ulnar nerve innervated hand muscles excluding the palmaris brevis muscle. There are no sensory disturbances. Compression of the most proximal part of the deep terminal branch, usually at the pisohamate tunnel. All the ulnar innervated hand muscles are affected, including the palmaris brevis muscle, without any sensory impairment. Compression of the nerve as it enters the hand. All ulnar innervated hand muscles are affected, but the sensory impairment is res-
tricted to the area cutaneous branch.
supplied
by the palmar
Aetiology Although ulnar neuropathy in the hand can arise apparently spontaneously, there is almost always a history of injury5-8. The list of lesions responsible for compression of the ulnar nerve at the hand and/or wrist is very extensiveg-“. Aneurysms may be either true or false. Either form of aneurysm may develop gradually and in due time compress an adjacent, previously normal nerve, and thus induce neural ischemia. In such instances the nerve becomes flattened and even eroded. The complaints caused by an entrapment neuropathy of the ulnar nerve in the hand will of course depend is involved. but
on which portion of the nerve mostly it is weakness of the
139
hand that attracts ,i\ pain’:!.
the patients
attentton
as ~,:ell
An S-shaped
incision
v.as made
.ttc)ng the
radial edge of the hvpothcnar em~r~c~~~c, IIL~:! the ulnar ncrvc. to reach the t’ore;.lrn;
Case report A 30-year-old
male
Caucasian
outpatient
by the Department
the
University
State
September
Hospital
was seen as an of Neurology of
l.Itrecht
of in
1983.
Seven weeks earlier he had cut his wrist, falling through a glass window. The laceration was sutured
in the emergency
ward after which the
patient was sent home. Two weeks before his first visit
superficial branch ot’ the ulnar nerve was stretched over the volar surface of the aneurysm. while the deep branch was displaced dorsally. Both branches of the ulnar nerve were severely compressed. An external neurolysis 01’ both
he started
complaining of a burning and numb sensation over the ulnar aspect of the right palm and the fourth and fifth fingers. There was no clear motor weakness. Sometimes paresthesia were present over the hypothenar eminence and both ulnar fingers. Analgetics did not help. Patient was a drugaddict using 80 mg methadon daily. Physical examination revealed a slight weakness only of the adductor pollicis muscle of the right hand, without any atrophy. A disturbed sensibility to pinprick was found over the hypothenar eminence and the ulnar aspect of the wrist of the right hand. The sign of Tine1 was positive at the wrist. An electromyographic study was refused by the patient. On November 4, he was seen again and referred to our department because of a progressive motor impairment of the ulnar innervated muscles, including the palmaris brevis muscle, as well as a slight atrophy. The sensibility deficit remained unchanged. The patient was hospitalized on November 26. There was a marked atrophy now of the hypothenar eminence, slight atrophy of the interossei muscles, marked weakness of the adductor pollicis, interossei, abductor digiti minimi, and third and fourth lumbrical muscles, causing the fourth and fifth fingers in an ‘en griffe’ position. Pinprick and cotton wool sensibility was very much disturbed over the hypothenar eminence, fifth finger and ulnar aspect of the fourth finger. Over the base of the hypothenar region a weak pulsating mass was palpable. Patient underwent operation on December 1. 1983. 140
After careful preparation this mass C~ppeareJ to be an aneurysm of the ulnar artcry. I hc
branches
was performed.
The aneurysm
was resected and the ulnar artery anastomosed end-to-end with interrupted 10-O silk sutures. Postoperatively the pain subsided promptly: the position ‘en griffe’ became gradually less marked; the motor function of the interossei and lumbricalis 1V and V muscles was slightly improved. The sensibility was still disturbed, but clearly improving. Six weeks after discharge from hospital he still complained of mild paresthesia in the fourth and tifth finger. The motor function of the interossei, lumbricalis IV and V and abductor digiti minimi muscles was drastically improved. The sensibility was still disturbed. but to a much lesser extent. A venous digital subtraction angiography to check the patency of the ulnar artery was refused by the patient. The pathologist’s report stated that the wall of the aneurysm consisted of a layer of fibrin closely attached to concentric structures. mainly composed of connective tissue. Scattered are structures resembling an elastic membrane. but special elastic-colouring could not confirm this conclusively. All in all this fits the description of a false aneurysm. Discussion It seems that Guatiani, in 1772, was the first to describe an aneurysm of the palmar arch. In 1930, Volkmann published a very extensive survey of the literature, yielding 67 cases of traumatic aneurysms of the palmar arch.‘” Many of those case reports are very incomplete but it seems that all were indeed aneurysms. Volkmann excluded several other cases from his series because they were not traumatic of origin. but e.g. syphilitic (Morestin 1905) and
spontaneous
(Griftiths
1897). However,
it is not
ulnar nerve motor and sensory
quite clear how many he discarded. in 1933. published a survey of the Middleton’l.
caused
literature
ulnar
yielding
70 cases. Besides the 67 cases
of Volkmann he seems to have included the case of Griffiths, Morestin and one described bv Reid in 1926. In 1934 Von RosenI case
of thrombosis
considered
was the first to publish of the
it an entity
ulnar
pathologically
artery.
findings
distinct
from the cases of traumatic aneurysm occurring in the same region, suggesting that injury to the intima resulted in thrombosis. while damage to the outer layers of the vessel caused an aneu-
It is remarkable that in a majority of the reported cases the clinical picture seems to be dominated by the presence of a tender, hypothenar mass combined with ulnar artery insufficiency, leading to Raynaud’s phenomenon”x-‘~O. Millender, Nalebuff, and KasdotPtstated that the presence of ulnar nerve motor palsy is an important diagnostic point. In none of their cases and in none of the cases they reviewed there had been any true ulnar nerve motor palsy. According to them the motor branch was protected from aneurysms of the ulnar artery, because of the anatomy of the ulnar nerve. In the case we report it was especially the
well
capable
the ulnar but branch.
of the
of
severely
nerve, not only the also the deep motor
surprising
to find that only in a
very small minority of the reported cases. mention is made of an associated ulnar nerve sensory and/or
motor
rysm of the ulnar
impairment
when
an aneu-
artery is found.
References
rysm. He regarded both conditions having a similar etiology and similar symptoms. However. if thrombosed. the diagnosis is more difficult and can be made only on surgical exploration. For the past decades several reports of single cases have appeared; some of aneurysms. some of thrombosis. Many authors have discussed true palmar aneurysmst”--“’ and thrombosis”7-5G as if unrelated. but the similarity of many of the reported cases is striking. It is highly likely however that some of the many previously published cases of thrombosis were in fact true aneurysms. The most recent review by Green”’ in 1973 shows that it is virtually impossible to quantify the amount of aneurysms of the palmar arteries due to the fact that it is almost impossible to distinguish between palmar aneurysm and thrombosis when reviewing previously published cass.
that
care. The
show that aneurysms
are
It is therefore
impairment
to seek medical
at surgery artery
compressing superficial branch.
a He
the patient
w. M’OOl~H41.1.
HA> Mhi:R Principle\
ofdiagnosis.
Saunder\
n.
Peripheral
London: W.B.
C‘
NI(.SI
II. Die Chirurgle der peripheren Georg I hicme Vcrlag. 1955: XX. HJ.
SFI)I)ON Maje$‘\
Peripheral
Stationery
nerve
Office
SI.%.&LA. Entrapment GW.
nerve Injuries.
Ed 2. Phiisdelphia.
Nerven.
tnjurieh.
London:
Her
1954: 222.
neuropathies.
In: Vinken
ed\. Handbook
of Cl’lnical Neurology. Publishing Co. 1970: X:303.
North-llolland
Stuttgart:
( 4\v1 F\ .II. Acute traumatic
aneurysm
PJ. Bruvn
Amsterdam:
of the palm. Am J
Surg 1974: 74: 98. MC LALIGHLIU(TV. Traumatic
aneurysm
artery. (‘aw 42x.
report. U.S. Naval Medival
5HORl
Occupational
1)~.
aneurysm
of
the
Bulletin
ulnar
1944: 42:
of the palmar
arch.
C,tw report. Lancet 194X: 217. /I ( KFKM,~NN
II.
Proctor SE. Traumatic
palmar aneurysm.
Am J Surg 1946: 72: 52. c 1II toKI) tumor\ “’ KOPPtl
KH. KFI
LY
4P.
Diagnosis
ofthe
hand. Clin. Orthop
I
IHOMPSOY
HP.
HP. Thomwn pathies.
WAL.
W.&l-L.
New
( . c I OllrlbR
\\ndrome
treatment
of
nerve.
York:
In: Kopell
entrapment Robert
E.
ncuroKrieger
Co. 1976: 120.
” MI hltvt HAI t,R M. Die Thiemc Verlag. 1961. I” l)t’I’ONl
Ulnar
eds. Peripheral
Huntington
Publi\hln~
and
1959: 13: 204.
Ulnarlsparesen. (;b.
PRth’OSr
Y et
Stuttgart:
Georg
al. Ulnar-tunnel
at the wriht. .I Bone and Joint Surg 1965: 47A:
77. I” \ OI KM~NN
I.
Uchcr
traumatlwhr
arterxlle
Aneurvsmen
dcr Hohlhandhogcn. Dtsch Zeitschr Chir 1930: 22?-151. ‘* MII)III F I ON 11s. Occupational aneurysm of the palmar arterlcs. Brtt J Surg 1933; 21: 215.
I”
RO\bU
\. LOI\;.
Etn Fall van Thromboae
I Ilnaris nach Einuirkung Stand
in der Arterla
van stumpfer Gewalt.
Acta Char
1981: 24: 207.
I” Ht ht 1.h 9
I I 4. (~AI.ASSI t POPPI M. Paralyis
nerve at the uri\t
with aneurysmal
artcry. Ycurochirurgia
of the ulnar
dilatation
of the ulnar
1981: 24: 207.
” FI 1%.t)o\ttt M. ( IIEAH H: Mvcotlc artt’rl. Med J Awl 1979: I :4h2.
aneurvsm
” tt KIN IX . wOOI~HALL H. Combined vascular injuries of warfare. Ann Surg 1944: 119: 41 I. I” i.\i(il’l M&U KM. Cl FMFNr’i
JM. HERMANN
of the ulnar and nerve
JR. Stab
wounds
and traumatic falw aneuryms in the extremities. J. lrauma l96Y: Y:77. ?‘I FRIIO\ cm. Lllnar artery aneur)&m on the hand. Magi 1 raumatol
Orth
141
I(. WORKMAN ct. Aneurysm of the ulnar arten due to blunt trauma to the hand. Missourt Med 1964; 61:927. :a GAGE M. Traumatic arterial aneurysm of the peropheral arteries, Am J Surg 1943: 59: 210. ‘:’ GAYLLS H, KUSHLICK AR. Ulnar artery XleUrySIllSof the hand. Surgery 1973; 73: 478. ?,r GEE H. Traumatic aneurysms of the ulnar artery. Med J Aust 1945; 1:395. “’ GOADBYHK.MCSWTNEYRR,ROBCC~. Mycoticaneurysm.St. Thomas Rep. 1949: 5:44. ” HELBIG B. STEIN H. Differential diagnosis of soft tissue tumors of the palm: cirsoid aneurysm of the ulnar artery. Handchirurgie 1981; 13: 305. L’7INOUE. TABIRA K. HIDAKA N et al. Ulnar nerve paralysis of the carpal tunnel due to traumatic aneurysm of the ulnar artery. Orthop Surg 1971; 22: 924. yx JESHRANI MK. Bilateral ulnar artery aneurysm in the palm Case report. East Afr Med J 1976; 53: 13. K, WOLFF ~w. Ulnar nerve aa KALISMAN M. LABORD compression secondary to ulnar artery false aneurysm at Guyon’s canal. J Hand Surg 1982; 7: 137. at’ KAPLAN EB. ZEIDE MS. Aneurysm of the ulnar artery. Case report. Bull Hosp Joint Dis 1972; 33: 197. ‘t’ KUSIER L VVN, ABT AB. Traumatic aneurysms of the ulnar artery. Arch Pathol Lab Med 1980; 104 75. a2 LOKEY H. PHELPS DB, BOSW~CK IA. Traumatic false aneurysm of the hand in hemophilia. J Trauma 1978; 18: 283. :t:t MARTIN AI;.Ulnar artery thrombosis in the palm. Case report. Clin Orthop 1960; 17: 373. .j4 MAYS ET. Traumatic aneurysm of the hand. Am Surg 1970: 36: 552. a: MILLING MA, KINMONTH MH. False aneurysms of the ulnar artery. Hand 1977: 9:57. a6 MOORE JB.ZooK EG.KINKEAD LR. Ulnaryartery aneurysm in osteogenesis imperfecta. Hand 1983; 15: 91. :j7 MUNKERJEA SK. Occupational true aneurysm of the ulnar artery in the palm Br J Surg 1971; 59: 934. 3x NADE s. Tardy paralysis of the ulnar nerve due to traumatic false aneurysm of the ulnar artery. Case report. Injury 1972; 3: 196. .$a R~BIo FA. GUINN GA, MIN Kw et al. Mirror image aneurysms of the ulnar artery in the palm. Vast Surg 1976? IO: 195. do SHAPIRA L,RUBINSTEIN ZJ,JACOBET. Traumaticaneurysm of the ulnar artery in the palm. Harefuah 1978: 95: 263. " FOWLER
142
" SMI IH JW. 1 rue nneur)i\mh
ot trdumauc orlg”’ in the p,mIi Am J Surg 1962; 104: 7. ‘:! SPITILLIA.JANES JM. Aneurvsms of the ulnar ,tt-tcr\. C‘asc report. Staff meetings of the Mayo Clinic 1957: 32; 295. rziSUSLKO B. Traumatic aneurv\m of the ulnar ,trrcry. Wtati Lek 1974: 27: 1899. _ ” 1 HI0 R I.F&e aneurysm of the ulnar artery after surger\ employing a tourniquet. Am J Surg 1972: 123:604. ” lHORRI-.NS 5. IRIPPEI. OH. BtRGAN JJ. Arteriosclerotic aneurysms of the hand. Arch Surg 1966: 92:937. “’ VRA( EVI(' I). Aneurysm of the ulnar artery tn the hypothenar region. Acta Chir lugosl 1976: 23:329. ‘r c OSTIGAN DG. RILEY JM. coy FE. Thrombotibrosts of the ulnar artery in the palm. J Bone Joint Surg 1959: 41A: 702. ” GOKEN ML. Palmar intramural thrombosis tn the ulnar arter\/. California Med 1958; 89:424. ” JACKSON JP. Traumatic thrombosis of the ulnar arterv in the palm. J Bone Joint Surg 1954; 36 B: 438. “’ KI.EINERT JE. VOLIANTIS GJ. Thrombosis of the palmar arterial arch and its tributaries: Etiology and newer concepts in treatment. J Trauma 1965: 5: 447. :,’ LAWRENCE RR, WILSON IN. Ulnar artery thrombosis in the palm. Case report. Plast Reconstr Surg 1965: 36: 604. 52 MARTIN AF. Ulnar artery thrombosis in the palm. Case report. Clin Orthop 1960; 17: 373. ‘.t PAABY H, S~AOIL F. Thrombosis of the ulnar artery. Acta Orthop Stand 1968: 39: 336. 5” TREVASKIS AE, MARCKX KM. P~NNIYI AM et a]. Thrombosis of the ulnar artery in the hand. Case report. Plast Reconstructr Surg 1964: 33:73. ” ZWIZIC;J.KK. PoscH JL et al. Thrombosis of the ulnar artery following blunt trauma to the hand. J Bone Joint Surg 1969: 5lA:I 191. ‘,7 GREEN Dp. True and false traumatic aneurysms in the hand. J Bone Joint Surg 1973; 55A: 120. iti BERFAN JJ.BONN J.TRIPPEL OH. Severe ischemia of the hand. Ann Surg 1971: 173: 301. ,jy MAY JW.GROSSMANN JA,coSTAS B. Cyanotic painful index and long fingers associated with an asymptomatic ulnar artery aneurysm. Case report. J Hand Surg 1982; 7: 622. li” (~.AKOLJ.TORDOIR JHM, BUTH J.Arteriele stoornissen in de hand blJ gebruik van de hypothenar als hamer. Ned Tijdschr Geneeskd 198 I : 125: 1444-50. “’ MILI.ENDER LH, NALEBUPI EA. KASDON E. Aneurysms and thrombosis of the ulnar artery in the hand. .&ch Surg 1972; 105: 686.