Case 13 (2024): Hypothenar hammer syndrome after minor injury to the hand

Frederik Kloss; Vincent März; Frederik Schlottmann; Peter M. Vogt

Journal of Plastic, Breast & Reconstructive Surgery·Fagfællebedømte kirurgiske case-rapporter med åben adgangFagfællebedømt · Open access

Case 13 (2024): Hypothenar hammer syndrome after minor injury to the hand · JPBRS

Case-rapport

Case 13 (2024): Hypothenar hammer syndrome after minor injury to the hand

Frederik Kloss¹, Vincent März¹, Frederik Schlottmann¹, Peter M. Vogt¹

¹MH Hannover, Germany

Publiceret 15. april 2024122 visninger5 min læsning

Hypothenar hammer syndromevascular reconstructionulnar arteryvein graftmalperfusion syndrome hand

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Resumé

A 17 year old, male patient presented six weeks after a work-related, minor trauma to the left hand with an exertion related malperfusion syndrome of the fourth and fifth finger. Contemplating the clinical symptoms and initiated medical imaging the initial blunt crush injury with a drilling machine battery resulted in an aneurysmatic occlusion of the ulnary artery.

Vigtigste læringspunkter

Pearls

Start the procedure under blood arrest to optimize visualization. Hereby, one may obtain stasis in a first step to check for the course of superficial veins and wrap the upper extremity in a separate second step to minimize bleeding.
Remember and paint anatomic landmarks (Arteries, hamate, FCU) before surgery.

Pitfalls

Always restore the blood flow and check for patency before starting a vascular reconstruction.
Depending on the extent of the vascular damage, reconstruction may be limited if the superficial or deep palmar arch or its branches are involved.

Patient history

Examination

17 year old, right handed male patient in good physical condition and professional training for a roofer. Symmetric configuration of the soft tissue with a centimeter long scar in the hypothenar region of the left hand. No muscular atophy. Fist closure, finger extension and spreading of the long fingers is powerful on both sides. The Phalen-Test is negative and there is no Hofmann-Tinel sign over the carpal canal or ulnar nerve sulcus. Isolated examination of the flexor- and extensor-tendons and a regular 2-point discrimination of 6 mm on all long fingers reveal no evidence of a sensomotoric deficit. The peripheral blood flow shows an ungual recapillarization time of

Pre-operative considerations

We treat a young patient with the need of utmost functionality regarding his age, physical fitness, personal aspirations and occupational requirements as a roofer. Hence, there is a need of evaluating the actual patency of the ulnar artery and considering conservative, as well as minimally invasive and open surgical methods. Providing the most accuracy we initiated an angiography also providing the therapeutic option of performing a simultaneous angioplasty, according to the extent and level of stenosis.

Angiography: Reviewing the angiography the ulnary artery presents with a highgrade stenosis of the ulnary. Solely after warm-up of the left handy there was a minimal residual patency of the ulnar artery. While there was no prescence of the superficial palmar arch the profund palmar arch had a strong contrast filling. The arteries of the digitus IV and V on the other hand also presented with a reduced patency suggesting associated occlusions.
Plan: Open Surgery remains the only possibility for a sufficient restoration of arterial flow to the ulnary fingers and patient consent was obtained for an open exploration of the vascularity of the hand and possible reconstruction of the ulnar artery with a vein graft.
Patient Consent: The patient was given the information that the procedure may lead to an aggravation of symptoms and potential acral necrosis due to embolisms or ultimately the loss of fingers in case of a total and permanent occlusion.

Referencer

Schröttle A, Czihal M, Lottspeich C, Kuhlencordt P, Nowak D, Hoffmann U. Hypothenar hammer syndrome. Vasa. 2015 May;44(3):179-85. doi: 10.1024/0301-1526/a000427. PMID: 26098321.
Elhadhri S, Chaouch N, Boughanmi K, Zlitni M, Hentgen B, Fallouh A. Hypothenar hammer syndrome associated with rapidly evolving ulnar false aneurysm. J Med Vasc. 2022 Jul-Aug;47(3):153-156. doi: 10.1016/j.jdmv.2022.07.001. Epub 2022 Jul 28. PMID: 36055686.
Piessat C, De Almeida YK, Athlani L. Hypothenar hammer syndrome: outcomes after ulnar artery reconstruction with autologous vein graft. Hand Surg Rehabil. 2023 Jun;42(3):203-207. doi: 10.1016/j.hansur.2023.02.008. Epub 2023 Mar 7. PMID: 36893887.