Hypothenar Hammer Syndrome

Ovid: 5-Minute Sports Medicine Consult, The

Hypothenar Hammer Syndrome
Tarek Hadla
Holly J. Benjamin
Lesion of the superficial palmar arch of the ulnar artery in the hand mainly owing to repetitive compression or blunt trauma or even a single severe trauma over the hook of the hamate (1,2)
Traditionally regarded as a rare condition, though may be underdiagnosed
  • Etiology (1,2):
    • Trauma: By frequent use of the hand as a “hammer”
    • Vascular pathology: Thrombosis, abnormal anatomy, or aneurysm of the ulnar artery, prothrombotic factors
    • Work-related: Auto mechanics, metal workers, lathe operators, miners, machinists, butchers, bakers, carpenters, and brick layers
    • Sport-related: Golf, baseball catchers, heavy weight lifting, martial arts, mountain biking
  • Anatomy and pathophysiology: Hypothenar relates to the muscles of the 5th finger: AFO:
    • Abductor digiti minimi
    • Flexor digiti minimi
    • Opponens digiti minimi
  • The hand obtains its arterial supply through the ulnar and radial arteries. The ulnar artery and nerve pass through Guyon's canal next to the hamate bone before dividing into the superficial and deep palmar branches. Just distal to the canal, a short segment of the superficial branch that forms the origin of the superficial palmar arch is unprotected between the skin and the bone in the hypothenar area. Chronic trauma to this area can lead to pathology of the ulnar artery.
  • Types of hypothenar hammer syndrome (HHS): Arteriographic patterns of HHS:
    • Type 1: Stenosis of superficial palmar arch around the hook of the hamate
    • Type 2a: Occlusion of the superficial palmar arch around the hook of the hamate
    • Type 2b: Occlusion of superficial and deep palmar arches around the hook of the hamate
    • Type 3a: Occlusion of the ulnar artery at the proximal part of the wrist
    • Type 3b: Occlusion of the ulnar artery near the wrist
Symptoms (2,3):
  • Paresthesias in fingers with “pins and needles” sensation
  • Pain in fingers caused by cold or repetitive movements
  • Reynaud-like phenomenon that spares thumb
Physical Exam
  • Signs:
    • A hypothenar mass or callus
    • Tenderness of the hypothenar eminence
    • Raynaud phenomenon in the fingers and on the ulnar side of the hand (as above) (3)
    • Positive Allen test (see below)
    • Dependent rubor
    • Ulceration of fingertips or gangrene
  • P.319

  • Allen test: The Allen test is often used before cannulating the radial artery or in assessment of hand trauma. The technique is as follows:
    • Patient elevates the hand and makes a fist for 20 sec.
    • Firm pressure is held against both the radial and ulnar arteries.
    • The patient opens the hand, and it should blanche white.
    • The examiner releases compression of the ulnar but not radial artery.
    • A normal hand flushes within 5–7 sec.
    • If the hand remains white, there is abnormal circulation.
Diagnostic Tests & Interpretation
CBC and international normalization ratio (INR) if thrombosis is suspected
  • Doppler US
  • MR angiography (4)
  • CT angiography
  • Arteriography (“gold standard”)
Differential Diagnosis
  • Hand-arm vibration syndrome (5)
  • Raynaud phenomenon (3)
Ongoing Care
  • Complications: Gangrene of the fingers in severe cases, which may require surgery
  • Prognosis: Many patients improve with nonsurgical treatments (see above). Results of reconstructive surgery were variable, and recurrence was fairly common (2).
  • Prevention: Prevention should focus at improving work practices, sports modification, and avoiding use of the palm of the hand as a hammer to pound, push, or twist objects (2).
1. Ferris BL, Taylor LM, Oyama K, et al. Hypothenar hammer syndrome: proposed etiology. J Vasc Surg. 2000;31:104–113.
2. Jagenburg A, Goyen M, Hirschelmann R, et al. [Hypothenar hammer syndrome: causes, sequelae and diagnostic aspects] Rofo. 2000;172:295–300.
3. Pineda CJ, Weisman MH, Bookstein JJ, et al. Hypothenar hammer syndrome. Form of reversible Raynaud's phenomenon. Am J Med. 1985;79:561–570.
4. Van de Walle PM, Moll FL, De Smet AA. The hypothenar hammer syndrome: update and literature review. Acta Chir Belg. 1998;98:116–119.
5. Cooke RA. Hypothenar hammer syndrome: a discrete syndrome to be distinguished from hand-arm vibration syndrome. Occup Med (Lond). 2003;53:320–324.
6. Conn J, Bergan JJ, Bell JL. Hypothenar hammer syndrome: posttraumatic digital ischemia. Surgery. 1970;68:1122–1128.
7. Brodmann M, Stark G, Aschauer M, et al. Hypothenar hammer syndrome caused by posttraumatic aneurysm of the ulnar artery. Wien Klin Wochenschr. 2001;113:698–700.
  • 904.9 Injury to blood vessels of unspecified site
  • 923.20 Contusion of hand(s)

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