Traumatic Ulnar Artery Aneurysm and the Hypothenar Hammer Syndrome
- Volume 5 - Issue 1 - Jan/Feb 2008
- Posted on: 9/5/08
- 0 Comments
- 12896 reads
Vance Sohn, MD, Zachary Arthurs, MD, Charles Andersen, MD
Hypothenar hammer syndrome (HHS) is a rare clinical entity with a symptom complex attributable to an ulnar artery aneurysm. These aneurysms are uncommon and have been linked with traumatic injuries to the hand. Although most commonly seen in workers who use the hypothenar eminence of their hands repetitively as a hammer, both acute penetrating and blunt traumas have been documented as sources of ulnar artery aneurysms. In this case report, we present a patient who presented with digital ischemia from a subsequently diagnosed ulnar artery aneurysm the day after moving large boulders with his hands.
A 45-year-old, non-smoking, previously healthy male presented with a three-day history of cyanotic, painful, and cold right fourth and fifth digits after a day of manual labor. He denied antecedent trauma or crush injuries to the digits. Conservative treatment of cold compresses and analgesia failed to resolve his symptoms, and the patient presented to the emergency department the following day. Incidentally, the patient was discovered to be in new onset, asymptomatic, atrial fibrillation. Physical examination of the right upper extremity revealed a readily palpable radial pulse, bounding ulnar pulse, and markedly diminished 4th and 5th digital pressures. An Allen’s test was consistent with a patent palmar arch with markedly diminished ulnar antegrade fill. An arteriogram demonstrated a normal caliber proximal ulnar artery with sluggish antegrade filling and complete obstruction of the distal artery (Figure 1). Catheter-directed thrombolysis with 4 mg of tPA (Activase; Genentech, San Francisco, California) was aborted after minimal resolution of the ulnar artery occlusion and the patient was then scheduled for surgical treatment. In light of the newly discovered dysrhythmia, an echocardiogram was also performed and revealed no evidence of mural thrombus that would account for a potential embolic source.
Intraoperatively, a longitudinal wrist incision extending to the middle of the palm, directly over the ulnar artery, was performed. A 6 mm ulnar artery aneurysm with extensive thrombus was discovered, and a cephalic vein interposition graft with resection of the ulnar artery aneurysm was performed (Figures 2 and 3). Completion duplex ultrasonography confirmed excellent triphasic signals at completion of the surgery. The patient was discharged on post-operative day 2 with resolution of his ischemia and pain. At 8-month follow up, the graft remained patent and the patient remained asymptomatic.
True aneurysms of the ulnar artery, first reported in 1934 by Van Rosen, continue to be the most reported site of arterial aneurysms of the upper extremity. Most commonly, they occur in the superficial portion of the artery overlying the hamate bone at the hypothenar eminence. In this area, the artery is only covered by skin, subcutaneous tissue, fibers of the palmaris brevis muscle, and a fibrous lamina derived from the superficial aspect of the transverse carpal retinaculum. Repetitive blunt trauma of the artery against the hook of the hamate can lead to aneurysmal degeneration, formation of intraluminal thrombus, and subsequent embolization to digital arteries. A history of repetitive trauma to this region prompted Conn et al1 to name this condition hypothenar hammer syndrome (HHS).
Hypothenar hammer syndrome has frequently been reported in athletes who use their hand for catching and striking objects, as well as in manual laborers whose hands are subjected to repetitive trauma.2–5 Usually seen in men, this syndrome manifests with a wide variety of symptoms related to the degree of vascular compromise. While thrombosis of the ulnar artery aneurysm may lead to occlusion, chronic digital embolization is a more common presentation.6 Affected individuals complain primarily of symptoms related to vascular insufficiency, including ulceration, cold intolerance, numbness, coolness, cyanosis, paresthesia, and sometimes, a hypothenar mass. Finger discoloration or pain, however, is the predominant symptom.6 The differential diagnosis of a patient presenting with this symptom complex can be broadly divided into vascular or neurogenic causes and can almost always be elucidated based on a focused history and physical examination alone. Potential vascular etiologies include Buerger’s disease, autoimmune diseases, ulnar artery anomalies, vasculitis, and Raynaud’s phenomenon. Potential neurogenic causes include ulnar tunnel syndrome, carpal tunnel syndrome, thoracic outlet syndrome, lower trunk brachial plexopathy, and C8/T1 radiculopathy. One author routinely recommends a wide battery of tests, including complete blood count, erythrocyte sedimentation rate, multichemistry panel, antinuclear antibody, serum protein electrophoresis, rheumatoid factor, cold agglutinin assay, and hepatitis serology.7 Ultimately, diagnosis can be confirmed with multiple modalities, although angiography remains the “gold standard.” Angiography cannot only establish the diagnosis, but can also aid in developing an interventional surgical strategy.4,8 Some have recommended interrogation of both upper extremities for precise definition of baseline anatomy.6 With continued technologic improvements, the role of computed tomographic angiography (CT-A) and endovascular therapy in the diagnosis and treatment of this rare disease entity remains to be determined.
1. Conn J, Jr., Bergan JJ, Bell JL. Hypothenar hammer syndrome: Posttraumatic digital ischemia. Surgery 1970; 68:1122–1128.
2. Applegate KE, Spiegel PK. Ulnar artery occlusion in mountain bikers. J Sports Med Phys Fitness 1995;35:232–234.
3. Birrer M, Baumgartner I. Images in clinical medicine. Work-related vascular injuries of the hand-hypothenar hammer syndrome. N Engl J Med 2002;347:339.
4. Galati G, Cosenza UM, Sammartino F, et al. True aneurysm of the ulnar artery in a soccer goalkeeper: A case report and surgical considerations. Am J Sports Med 2003;31:457–458.
5. Pineda CJ, Weisman MH, Bookstein JJ, et al. Hypothenar hammer syndrome. Form of reversible Raynaud's phenomenon. Am J Med 1985;79:561–570.
6. Dalman RL. Upper extremity arterial bypass distal to the wrist. Ann Vasc Surg 1997;11:550–557.
7. Dalman RL. Hypothenar Hammer Syndrome. In Ernst CB, Stanley JC (eds): Current Therapy in Vascular Surgery. St Louis: Mosby International, 2001: pp. 195–198.
8. Ferris BL, Taylor LM, Jr., Oyama K et al. Hypothenar hammer syndrome: Proposed etiology. J Vasc Surg 2000; 31:104–113.
9. Lawhorne TW, Jr., Sanders RA. Ulnar artery aneurysm complicated by distal embolization: Management with regional thrombolysis and resection. J Vasc Surg 1986;3:663–665.
10. Rothkopf DM, Bryan DJ, Cuadros CL, et al. Surgical management of ulnar artery aneurysms. J Hand Surg [Am] 1990;15:891–897.
11. De MD, Fritsche E, Rigoni G, et al. Hypothenar hammer syndrome. Retrospective study of nine cases. J Hand Surg [Br] 1999;24:731–734.
12. Dethmers RS, Houpt P. Surgical management of hypothenar and thenar hammer syndromes: A retrospective study of 31 instances in 28 patients. J Hand Surg [Br] 2005;30:419–423.
13. Harris EJ Jr, Taylor LM Jr, Edwards JM, et al. Surgical treatment of distal ulnar artery aneurysm. Am J Surg 1990;159:527–530.
14. Mehlhoff TL, Wood MB. Ulnar artery thrombosis and the role of interposition vein grafting: Patency with microsurgical technique. J Hand Surg [Am] 1991;16:274–278.
15. Nehler MR, Dalman RL, Harris EJ, et al. Upper extremity arterial bypass distal to the wrist. J Vasc Surg 1992;16:633–640.
16. Smith HE, Dirks M, Patterson RB. Hypothenar hammer syndrome: Distal ulnar artery reconstruction with autologous inferior epigastric artery. J Vasc Surg 2004;40:1238–1242.