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Physiotherapy as a Cause of Hypothenar Hammer SyndromeCambridge Vascular Unit, Addenbrooke’s Hospital, Cambridge, UK E-mail: sadat.umar{at}gmail.com Dear Sir, A 46 year-old patient presented with pain in the right wrist of 8 months duration, particularly at night, and a palpable pulsation in the palmar aspect of the hand. She had no significant comorbidities but detailed history revealed the repetitive use of this hand for giving physiotherapy to her child, who suffered from Cystic Fibrosis. On examination, the hand was found to be warm, well perfused and with no signs of muscle wasting. Both ulnar and radial pulses were palpable with negative Allen’s tests. A pulsation was palpable in the right hypothenar eminence. Duplex scanning identified a small aneurysm. Arteriogram of the right arm confirmed the presence of a small aneurysm arising from one of the metacarpal arteries (Fig 1), consistent with a diagnosis of hypothenar hammer syndrome. The aneurysm was ligated surgically (Fig 2) with resolution of the symptoms postoperatively.
Hypothenar hammer syndrome was first described by Conn et al. (1970). This syndrome is an uncommon condition, reported to occur in manual workers, such as mechanics and carpenters, and in sportsmen (Muller et al., 1997). Underlying fibrodysplasia has also been implicated as an associated factor (Ferris et al., 2000). It results from repetitive trauma to the ulnar artery as it courses around the hook of the hamate bone. This usually leads to either stenosis or occlusion of the ulnar artery, although the presence of an aneurysm has also been reported. The clinical features include tenderness on compression and percussion of the hypothenar eminence, subcutaneous thickening and/or Raynaud’s phenomenon of the ulnar fingers (Cantero, 1987). Arteriography remains the gold standard for diagnosis. Patients suffering from hypothenar hammer syndrome have been managed conservatively. However, surgery has been undertaken to establish flow through a thrombosed ulnar artery by using an interposition graft, and to prevent rupture of an aneurysm by tying off the aneurysm or by coil embolisation, to block the feeding vessel to the aneurysm. This is the first reported case in which repetitive blunt trauma to the ulnar aspect of the hand as a result of giving physiotherapy to a patient with Cystic Fibrosis has resulted in this syndrome.
Cantero J (1987). Hypothenar hammer syndrome. A propos of 2 cases. Annales de Chirurgie de la Main, 6: 303–306.[CrossRef][Medline] [Order article via Infotrieve]Conn J, Bergan JJ, Bell JL (1970). Hypothenar hammer syndrome: post traumatic digital ischemia. Surgery, 68: 1122–1128.[Web of Science][Medline] [Order article via Infotrieve]Ferris BL, Taylor LM, Oyama K, McLafferty RB, Edwards JM et al (2000). Hypothenar hammer syndrome: proposed etiology. Journal of Vascular Surgery, 31: 104–113.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]Muller LP, Kreitner KF, Seidl C, Degreif J (1997). Traumatic thrombosis of the distal ulnar artery (hypothenar hammer syndrome) in a golf player with an accessory muscle loop around Guyon’s canal. Handchirurgie, Mikrochirurgie, Plastische Chirurgie, 29: 183–186.
Journal of Hand Surgery (European Volume), Vol. 32, No. 6,
715-716 (2007)
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