Case 13 (2024): Hypothenar hammer syndrome after minor injury to the hand
Frederik Kloss1, Vincent März1, Frederik Schlottmann1, Peter M. Vogt (MD1, Professor)1
- 1MH Hannover, Germany
Abstract
A 17 year old, male patient presented six weeks after a work-related, minor trauma to the left hand with an exertion related malperfusion syndrome of the fourth and fifth finger. Contemplating the clinical symptoms and initiated medical imaging the initial blunt crush injury with a drilling machine battery resulted in an aneurysmatic occlusion of the ulnary artery.
BeforeAfterA 17 year old, male patient presented six weeks after a work-related, minor trauma to the left hand with an exertion related malperfusion syndrome of the fourth and fifth finger. Contemplating the clinical symptoms and initiated medical imaging the initial blunt crush injury with a drilling machine battery resulted in an aneurysmatic occlusion of the ulnary artery.
Preoperative Allen Test demonstrates a malperfusion of the fingers.
- The bloodflow via the radial artery is manually suppressed
- The fingertips especially acral regions remain pale
The pressure on the radial artery is released and the perfusion of the fingers restored.
- The acral regions immediately assume a reddish tone.
The y-shaped Millesi approach is chosen to gain optimal exposure of the palm with the possibility of extending the preparation to the fingers. Furthermore it may be combined with the classical ulnary approach to the loge de guyon.
- Ending in the commissure of the digitus IV/V, one may individually address either finger without risking skin perfusion.
- Shifting the classical Millesi approach slightly ulnary gives one the possibility to easily access the loge de guyon.
- Curved incisions along the palmar creases and over the rascetta provide a more natural scar appearance and reduce the risks of evolving contractures.
The ulnar artery is identified after a cutting through the fascia at the distal forearm. The flexor carpi ulnaris muscle provides as anatomic landmark as the ulnar artery is situated right medial to it. The preparation is extended to the palm and the palmar aponeurosis as well as the short palmar muscles are opened to gain access to the superficial palmar arch.
5
Restore the blood flow and check for the patency of the ulnar artery.
- The ulnar artery presents stiff and thrombosed along a distance of 3 cm. Proper visualization of the actual extent of vascular damage may only be achieved under sufficient perfusion.
- Use patency tests such as the double occlusion or milking test to check for minor blood flow in the ulnar artery.
Place vascular clips before and after the excision margins and use microscissors to obtain straight and smooth edges when excising the vessel.
- Measure the vascular segment in vivo as it shrinks after excision.
Obtain a vein graft from the distal forearm and use standard microsurgery techniques to place the vein in a reversed direction as an interposition graft.
- Suture sizes of 8-0 to 10-0 have proven to be appropriate depending on the respective blood vessels.
- Check for patency and bleeding.
Perform sonographic examinations of the patient in regular follow-up consultations and check for patency of the vascular reconstruction in addition to clincal examinations and the reported subjective symptoms.
- Only initiate an angiography if a patent blood flow remains elusive with non-invasive imaging (e.g. ultrasound, MRI, CT).
- Start the procedure under blood arrest to optimize visualization. Hereby, one may obtain stasis in a first step to check for the course of superficial veins and wrap the upper extremity in a separate second step to minimize bleeding.
- Remember and paint anatomic landmarks (Arteries, hamate, FCU) before surgery.
How to cite this article
Frederik Kloss, Vincent März, Frederik Schlottmann, Peter M. Vogt (MD, Professor). Case 13 (2024): Hypothenar hammer syndrome after minor injury to the hand. Journal of Plastic, Breast & Reconstructive Surgery. 2024.
Open access. © 2024 The Author(s). Published by the Journal of Plastic, Breast & Reconstructive Surgery. Copyright to this case is shared between the author(s) and the journal; authors may reuse their own case for education, presentations and social media.
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