Hypothenar hammer syndrome: A case and brief review

Abstract

A 51-year-old, right-handed, Caucasian, male factory mechanic with an underlying history of active tobacco abuse, hypertension and hyperlipidemia, awoke with severe, throbbing, left hand pain. His hand felt 'ice-cold'; 'like someone pulled my fingernails out'. He denied previous trauma of the involved upper limb or hand. He denied similar past symptomatology. Home medications included zolpidem, simvastatin, losartan, celecoxib, amitriptyline and diltiazem. His work activities were physically demanding, involving heavy use of his hands. He described a history of frequently using his left hand for pounding during previous employment as a farmer. For the previous 6 years, he had been employed as a factory mechanic, requiring less overall use of the left hand as a hammer, though he did still use this technique. Pounding activities using the right hand were much less frequent.He sought initial evaluation in the emergency department where Raynaud's phenomenon was suspected and a trial of cilostazol started. Symptoms, however, progressed to dusky, cyanotic-appearing 2nd, 3rd, 4th, and, to a lesser extent, 5th digits ( Figure 1) with worsening pain and hypersensitivity. Early signs of tissue loss were noted at the tip of the long finger (Figure 2 AbstractHypothenar hammer syndrome is an uncommon cause of upper-extremity ischemia that is often overlooked in the absence of a thorough occupational and recreational history. Importantly, it is a reversible cause of hand ischemia that, if missed, can lead to significant morbidity and even amputation. The occupational ramifications and quality of life of those affected can be significant. Its relative rarity, set against the ubiquitous use of the hand as a 'hammer' is noteworthy. Several other causes of hand ischemia can present similarly; therefore, consideration of other etiologies must be thoroughly investigated. Key distinguishing clinical features, in addition to a detailed occupational and recreational history, may include characteristic sparing of the thumb, the absence of a hyperemic phase in 'Raynaud's phenomenon', and a positive Allen's sign. Both non-invasive and invasive diagnostic studies, including bilateral upper-limb segmental pulse volume recordings (PVR), arterial duplex examination, and upper-extremity angiography, are complementary to a thorough history and physical examination. Optimal management strategies are not well defined because of its rarity and resultant lack of quality, evidence-based data. Though most cases can be successfully managed non-operatively, micrographic arterial reconstruction may be limb saving in severe or recalcitrant cases. Newer, experimental strategies including selective sympathetic blockage using botulinum toxin A have been reported in a few recalcitrant cases. The brief case description illustrates the typical presentation and potential treatment strategies employed in a difficult case. A review of relevant literature is also presented.

Hypothenar hammer syndrome: a case series and literature review

“…[1] Timely diagnosis of HHS is important for minimizing potential complications. [5] There is no consensus concerning the diagnosis and treatment of HHS. In addition, the diagnostic algorithm is complex because of the disease's rarity and wide range of symptoms.…”

“…In addition, the diagnostic algorithm is complex because of the disease's rarity and wide range of symptoms. [5,6] In most patients, recovery and symptom relief may be achieved via conservative treatment. Conservative treatment approaches include calcium antagonists and type A botulinum toxin, beta-blockers, cilostazol, nifedipine, antithrombotic agents, and thermal therapies.…”

“…[1] Of note, ischemia associated with HHS is reversible. [5] In those with occupations that necessitate regular use of hammers, repeated trauma to the hypothenar muscles may damage the superficial arch branch of the ulnar artery. [6] Digital emboli from an ulnar artery thrombosis may cause ischemia or necrosis in the fingers.…”

Critical ischemia of the fingers in an auto mechanic as a result of occupational exposure

“…Neurological symptoms (pain, paresthesia, numbness) occur as a result of concomitant ulnar nerve injury. In the hand, the ulnar nerve runs segmentally together with the ulnar artery in the ulnar eminence created by the hamulus of the hamate bone, pisiform bone, and transverse carpal ligament, which form the anatomical Guyon's canal [7][8][9]. The natural course of the disease is usually similar.…”

“…The association between nicotine addiction and the pathogenesis of HHS is still unclear; however, smoking cessation is a necessity. In the absence of necrosis, a conservative therapy using low molecular weight heparin, antiplatelet agents, thrombolytic agents, and vasoactive agents (prostaglandin E1, sulodexide, pentoxifylline, bencyclane) is sufficient [7,13,14]. Surgical approach consists of thrombectomy or, if necessary, reconstructive treatment (arterial autograft, autologous venous bypass) [15,16], and is reserved for cases of critical ischemia with the presence of severe pain and advanced regressive changes in the affected fingers.…”