Hypothenar hammer

syndrome

Christian Dumontier, MD, PhD

Clinique les eaux Claires, Guadeloupe
 Historical
• Von Rosen (1934) described thrombosis of the ulnar
artery secondary to blunt trauma of the hand in a
23-year-old factory worker who was successfully
treated with excision of the thrombosed artery.
• Named Hypothenar Hammer Syndrome by Conn
et al. as it is classically seen in workers who
repeatedly use the hypothenar eminence as a
substitute for a hammer.
Von Rosen S. Ein fal von thrombose in der arteria ulnaris nach einwirkung von stumpfer gewald. Acta
Chir Scand 1934;73:500–6.
Conn J Jr, Bergan JJ, Bell JL. Hypothenar hammer syndrome: posttraumatic digital ischemia. Surgery
1970;68(6):1122–8.
 Incidence
• 1,6% to 14% in manual laborers
• Also reported in athletes (golf, badminton, squash,
mountain biking, weightlifting, martial arts, base- ball,
basketball, football, hockey, and tennis)
• Either a single or multiple repetitive traumas to the
hand at the hypothenar eminence.
• However rare: less than 2% of over 1,300 cases of
hand ischemia
•
 Pathophysiology
• Damage of the medial wall of the artery, leading
to UA thrombosis, occlusion, distal embolization
(extending into the superficial palmar arch and
digital arteries), and aneurysmal degeneration
and expansion of the wall.
• In a series of 47 patients: occlusion were present
in 60%, aneurysmal dilation in 40%, and distal
digital embolic occlusions in 57%.

• It is a true aneurysms. False or pseudoaneurysms

result from penetrating trauma to the UA and
the intima is breached and bleeding occurs
external to the artery, forming a hematoma.
•
From: Malgras. J Mal Vasc 2014

Marie I, Herve F, Primard E, et al. Long-term follow-up of hypothenar hammer syndrome: a series of 47
patients. Medicine (Baltimore) 2007;86(6):334–43.
Clinical presentation
• Young males, smokers (?)
• Dominant hand (53%–93%).
• Unilateral hand and digit ischemia symptoms
• Pain, numbness, tingling, cold intolerance,
weakness in ulnar nerve distribution
• Acute or chronic episodes
 Clinical examination
• Hand and ulnar digits
• Pallor, cyanosis, splinter
hemorrhages, ulcerations,
and/or wounds
(according to the severity)
• A pulsatile mass may be
found
 Diagnostic tools

• Allen test (usually positive but sensitivity 55%,

specificity 92%)
• Hand-held pencil Doppler is useful to determine
the site of occlusion of the UA and presence of
distal blood flow in the digits.
 Diagnostic tools (2)
• Pulse volume recording (PVR) measures
the volume of arterial blood flow
(circulation)
• Digital brachial index (DBI) quantifies
abnormal perfusion to the hand and
digits by comparing digital blood pressure
with the contralateral brachial level blood
pressure (normal range is 0.75 to 0.97.
When < 0.7, perfusion is inadequate)
• Doppler ultrasonography can
demonstrate flow abnormalities, deficient
UA flow, wall irregularity, echogenic
intraluminal thrombus, and aneurysm
 Diagnostic tools (3)
• Computed tomographic angiography (fast acquisition time
and a lower dose of radiation exposure than conventional
arteriography)
• Magnetic resonance angiography (contrast dye is less
nephrotoxic than CTA contrast dye but highly susceptible
to movement artifact and contraindicated in patients with
metallic implants and claustrophobia)
• Costs differential in 2004 were US flow duplex at $450,
CTA at $1140, MRA at $2500, and conventional
angiography costing $3900.
 Conventional
angiography
• The gold standard

• May show tortuosity of the UA with

alternating stenosis and ectasia;
aneurysm formation ; occlusion of
the UA

• Requires arterial access

• Risks include bleeding, hematoma,

thrombosis, pseudoaneurysm,
allergy to contrast medium, renal
toxicity from contrast, and a dose of
4 times more radiation than CTA.
 Treatment
• Goals: restoration of blood flow to the ischemic
digits and prevention of further thrombotic or
embolic sequelae.
• Vary with patient age, occupation, medical
comorbidities, and vascular disease.
• Treatment options depends of the extent of disease
at presentation.
 Medical/conservative
treatment
• Can be the only treatment
• Usually associated with surgical treatment
• Includes activity modification, smoking cessation, pain control,
• Calcium channel blockers, alpha-blockers, beta-blockers, and steroids can
be used.
• Intravenous and oral vasodilators, including prostaglandins and
prostacyclin, have been used to decrease sympathetic tone and vasospasm.
• In patients with evidence of thrombosis and embolic disease,
anticoagulation (warfarin or low- molecular-weight heparin), and platelet
aggregation inhibitors have been effective (clopidogrel and aspirin)
 Thrombolysis
• Per-cutaneous: Intra- arterial thrombolytics t(recombinant
tissue plasminogen activator or urokinase)
• Success is limited if ischemic symptoms are severe or have
persisted for more than 2 weeks.
• Success rates are 55% to 75%, with a 30% complication
rate.
• Can be utilized as preoperative therapy to decrease the
amount of thrombosis before reconstruction of the artery,
which improves success rates of 77% to 100%.
•
 Surgical treatment
• Sympathectomy (Botox 100U),
• Exploration with ligation of diseased segment
(Leriche’s sympathectomy), to prevent embolic events
• Exploration with excision and primary repair (rarely
possible due to extension of the thrombosis)
• Exploration with revascularization procedure (by-
pass or intercalary grafts).
 Ligation of diseased
fragment ?

• Made possible by the fact that most patients have a radial

artery dominance.

• Of 120 normal subjects, 57% of radial arteries provided

dominant flow to three or more digits, the ulnar artery and
superficial arch supplied three or more digits in 21.5% of
hands, and flow from the radial and ulnar vessels was equal
in 21.5% of extremities.

Kleinert JM, Fleming SG, Abel CS, et al: Radial and ulnar artery dominance in normal digits, J Hand
Surg [Am] 14:504-508, 1989.
Clinical case of a superficial radial vein graft (8 cm) for a Hypothenar Hammer
Syndrome (From Dumas et al. Chir Main 2010)
 Outcomes
From: Malgras. J Mal Vasc 2014

• 47 patients treated conservatively with a 27.7%

recurrence rate (Marie)
• Venous grafts patency is 77% to 88%
• In systematic review : higher patency rate and clinical
efficacy with arterial conduits at 3-year follow-up
(Masden)
Marie I, Herve F, Primard E, et al. Long-term follow-up of hypothenar hammer syndrome: a series
of 47 patients. Medicine (Baltimore) 2007;86(6):334–43.
Masden DL, Seruya M, Higgins JP. A systematic review of the outcomes of distal upper extremity
bypass surgery with arterial and venous conduits. J Hand Surg Am 2012;37(11):2362–7.
 Outcomes Mayo clinic
series (endress et al.)
• Over a series of 53 patients treated with vein grafts
• 51 males, mean age 45,9 years
• 16 were reviewed with a FU of 10 years - all were
satisfied
• 78% of the vein grafts were occluded (most
occlusion appearing late > 3 years)
• Patients with vein graft patency tend to do better
 Literature review on
vein grafts
References n FU (y) Patency

Ferris, J Vasc Surg 2000 19 2 84 %

De Monaco, JHSB 1999 7 1-10 100 %

Lifchez, PRS 2009 14 4,5 55 %

Dethmers, JHSB2005 24 3,5 45 %

 Conclusion

• Rare injury
• Revascularisation should be considered in younger,
active individuals and in patients with severe
symptoms
 Recent References

• Hui-Chou HG, McClinton MA. Current Options

for Treatment of Hypothenar Hammer
Syndrome. Hand Clin 31 (2015) 53–62.
• Endress RD, Johnson CH, Bishop AT, Shin AY.
Hypothenar Hammer Syndrome: Long-Term
Results of Vascular Reconstruction. J Hand Surg
Am. 2015;40(4):660-665.