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PATIENT STORY

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  • A 43-year-old man presented with no relevant past medical, family or social history except for 1 pack-a-day tobacco use.

  • Several-week history of right fourth- or fifth-digit coolness, pain, and ulceration of fourth digit.

  • No medications.

  • Patient's occupation was manual labor.

    His physical examination showed the following:

  • There were 2+ carotid, brachial, radial, femoral, popliteal, and pedal pulses. He did not have an ulnar pulse on the right side.

  • He had ischemia of his right fourth and fifth fingers, with decreased capillary refill, and there was a dry, and ischemic ulceration over the nail bed laterally on the fourth finger. No signs of infection were present.

  • A Doppler signal was present over the palmar arch until the radial artery was manually compressed.

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ETIOLOGY

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  • Repetitive use of the palm of the hand in activities that include pounding and pushing.

  • Anatomic site of injury to the ulnar artery is in the hypothenar eminence (Figure 19-1). The terminal branches of the ulnar artery arise in a groove that is bounded medially by the hamate bone.

  • As the distal ulnar artery lies superficially in the palm, it is covered for approximately 2 cm by only the skin, subcutaneous tissue, and the palmaris brevis muscle. Therefore, pounding and pushing of the hand causes the ulnar artery to hit the hamate bone repeatedly.

  • When this area is repeatedly traumatized, ulnar or digital spasm, aneurysms, occlusion, or a combination of these can result.

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FIGURE 19-1

Schematic showing the mechanism of ulnar artery injury (upper inset) in a patient with hypothenar hammer syndrome. The lower inset shows that the terminus of the ulnar artery is susceptible to injury because of its proximity to the hamate bone. (Modified from Eskandari MK. Occupational vascular problems. In: Cronenwett JL, Johnston KW, eds. Rutherford's Vascular Surgery. 7th ed. Philadelphia, PA: Saunders-Elsevier; 2010.)

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CLINICAL FINDINGS

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  • Intimal damage results in thrombotic occlusion. Damage to the media results in palmar aneurysms.

  • Fourth digit is most often involved.

  • Differentiated from Raynaud phenomenon by the lack of tricolor changes and sometimes absence of thumb involvement.

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DIAGNOSIS

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  • Suggested by history and physical examination.

  • Arteriography defines lesion, rules out other causes, and possibly can be therapeutic (Figures 19-2,19-3,19-4,19-5, and 19-6).

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FIGURE 19-2

Contrast injection into brachiocephalic artery revealing no stenosis in main brachiocephalic artery or proximal right common carotid or proximal right subclavian arteries.

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FIGURE 19-3

Normal right subclavian-axillary artery angiogram.

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FIGURE 19-4

Normal right brachial artery bifurcating into normal proximal radial and ulnar arteries.

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