Figure 1
Digital subtraction angiogram (DSA) of proximal left upper extremity
Hand arteriogram for chronic pain and numbness
SectionInterventional radiology
Case TypeClinical Cases
AuthorsSampson Kyere, Bertrand Janne d'Othée
Connected authors
67 years, male
Clinical History
67-year-old man with chronic pain and numbness in hand (ulnar side). No motor deficit, no ischaemia/ulcer, no pulsatile mass.
Imaging Findings
Slow flow in ulnar artery relative to flow speed in radial artery, already seen at forearm level.
Non-opacification (occlusion) of distal portion of ulnar artery at carpal level.
Distal refilling of the superficial palmar arch via small collaterals.
Delayed or incomplete filling of 3rd through 5th digit arteries.
Non-opacification (occlusion) of distal portion of ulnar artery at carpal level.
Distal refilling of the superficial palmar arch via small collaterals.
Delayed or incomplete filling of 3rd through 5th digit arteries.
Discussion
Hypothenar hammer syndrome is characterized by occlusion or aneurysm of the distal ulnar artery or superficial palmar arch. Aetiology is due to blunt trauma to the hypothenar eminence resulting in compression of the segment of the ulnar artery within Guyon canal against the hook of hamate [1]. Distal emboli to the digital arteries are not uncommon leading to ischaemia involving the 3rd through 5th digits [2]. Patients will have an occupational exposure history of repetitive palmar trauma (e.g., carpenter, mechanic, racket sports, repetitive use of vibratory tools, hammer or jackhammer; martial arts). Smoking is likely a risk factor. The most common symptom is pain; however cold intolerance mimicking Raynaud’s syndrome, paresthesias from involvement of the ulnar nerve and finger discoloration or ulceration can also be seen [1].
Conventional angiography of the wrist and digits is the gold standard for diagnosis with added selective views of the subclavian, axillary and brachial arteries to exclude a proximal lesion [3]. Imaging features include focal ulnar artery aneurysm, occlusion at the level of the hamate bone, distal emboli, or delayed filling of the proximal ulnar artery due to distal occlusion as seen in this case. Thrombosis may extend into the palmar arch. Characteristic corkscrew elongation of the ulnar artery may be present marked by alternating areas of stenosis and ectasia [2].
Presentation is often too late for endovascular recanalization. As such, patients are usually treated conservatively with occupational exposure reduction, smoking cessation and calcium channel blockers [2]. Surgical venous grafting or segmental excision and end-to-end anastomosis is reserved for refractory cases where symptoms progress or persist [4].
Conventional angiography of the wrist and digits is the gold standard for diagnosis with added selective views of the subclavian, axillary and brachial arteries to exclude a proximal lesion [3]. Imaging features include focal ulnar artery aneurysm, occlusion at the level of the hamate bone, distal emboli, or delayed filling of the proximal ulnar artery due to distal occlusion as seen in this case. Thrombosis may extend into the palmar arch. Characteristic corkscrew elongation of the ulnar artery may be present marked by alternating areas of stenosis and ectasia [2].
Presentation is often too late for endovascular recanalization. As such, patients are usually treated conservatively with occupational exposure reduction, smoking cessation and calcium channel blockers [2]. Surgical venous grafting or segmental excision and end-to-end anastomosis is reserved for refractory cases where symptoms progress or persist [4].
Differential Diagnosis List
Hypothenar hammer syndrome; occluded distal ulnar artery.
Arterial thromboembolism
Septic endocarditis
Buerger\'s disease
Raynaud\'s syndrome
Final Diagnosis
Hypothenar hammer syndrome; occluded distal ulnar artery.
References
[1] Blum AG, Zabel JP, Kohlmann R, Batch T, Barbara K, Zhu X, Dautel G, Dap F. (2006) Pathologic conditions of the hypothenar eminence: evaluation with multidetector CT and MR imaging. RadioGraphics 26(4):1021-44. (PMID: 16844930)
[2] Ablett CT, Hackett LA. (2008) Hypothenar hammer syndrome: case reports and brief review. Clin Med Res 6(1):3–8. (PMID: 18591371)
[3] Vayssairat M, Debure C, Cormier JM, Bruneval P, Laurian C, Juillet Y. (1987) Hypothenar hammer syndrome: seventeen cases with long-term follow-up. J Vasc Surg 5(6):838-43. (PMID: 3586181)
[4] Taylor LM Jr. (2003) Hypothenar hammer syndrome. J Vasc Surg 37(3):697. (PMID: 12618716)
Case information
| URL: | https://www.eurorad.org/case/11818 |
| DOI: | 10.1594/EURORAD/CASE.11818 |
| ISSN: | 1563-4086 |
Figure 2
Hand arteriograms from brachial, radial and ulnar arterial injections
Figure 3
Left brachial artery injection, DSA imaging at forearm level
DSA of the forearm shows delayed filling of the ulnar artery relative to the flow speed seen in the radial artery.
Digital subtraction angiogram (DSA) of proximal left upper extremity
Global aortogram shows no proximal lesion in the left subclavian and axillary arteries.
Dept. of Radiology, Beth Israel Deaconess Medical Center, Boston, MA, USA.
Dept. of Radiology, Beth Israel Deaconess Medical Center, Boston, MA, USA.
Selective arteriogram of left subclavian artery shows no arterial lesion in left axillary or brachial arteries.
Dept. of Radiology, Beth Israel Deaconess Medical Center, Boston, MA, USA.
Dept. of Radiology, Beth Israel Deaconess Medical Center, Boston, MA, USA.
Hand arteriograms from brachial, radial and ulnar arterial injections
Brachial injection shows occlusion of the distal ulnar artery at the carpal level, with collaterals. Progression of the contrast column to the 4th and 5th fingers is slow relative to the other fingers.
Dept. of Radiology, Beth Israel Deaconess Medical Center, Boston, MA, USA.
Dept. of Radiology, Beth Israel Deaconess Medical Center, Boston, MA, USA.
Contrast injection in the radial artery.
Dept. of Radiology, Beth Israel Deaconess Medical Center, Boston, MA, USA.
Dept. of Radiology, Beth Israel Deaconess Medical Center, Boston, MA, USA.
Contrast injection in the ulnar artery.
Dept. of Radiology, Beth Israel Deaconess Medical Center, Boston, MA, USA.
Dept. of Radiology, Beth Israel Deaconess Medical Center, Boston, MA, USA.
Left brachial artery injection, DSA imaging at forearm level
DSA of the forearm shows delayed filling of the ulnar artery relative to the flow speed seen in the radial artery.
Dept. of Radiology, Beth Israel Deaconess Medical Center, Boston, MA, USA.
Dept. of Radiology, Beth Israel Deaconess Medical Center, Boston, MA, USA.