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The hypothenar hammer syndrome (HHS) is an occupational disorder of the arterial vessels in the hand.'`5 We present two patients with an unusual variant of this condition which is difficult to differentiate from industrial white finger. Case 1A 48 year old man presented with a seven month history of coldness, pain, numbness, and poor healing in the middle, ring, and little fingers of his right hand. These symptoms were exacerbated by exposure to cold and a small ulcer had recently developed at the tip of his right middle finger. He was a manual worker with a 20 year history ofusing his right hand as a hammer. He was not diabetic but smoked 40 cigarettes a day. He was not taking medication when seen but for one year previously had been taking propranolol and carbimazole for thyrotoxicosis.Examination showed that the affected fingers were colder than the corresponding fingers on the left hand and a small ulcer was present at the tip ofthe blanched right middle finger. Results of the remainder of the cardiovascular and general examination were normal, in particular no bruits were heard. All routine screening investigations for arm ischaemia were normal and in view of the presence of undiagnosed, unilateral, digital ischaemia, an arch aortogram was performed. This showed a local aneurysmal dilatation of the ulnar artery in the palm, with poor filling of the digital vessels especially those to the middle and ring fingers (figure). In view of the poor blood supply to the fingers and the presence of an ulcer it was decided to perform a cervical sympathectomy. After operation, the ulcer on the middle finger healed and at seven years follow up the patient is well with no symptoms from his right hand but with a small puckered scar at the tip of his right middle finger.