Hypothenar Hammer Syndrome Caused by Playing Tennis

Eur J Vasc Endovasc Surg 11, 240-242 (1996)

CASE REPORT

Takashi Nakamura, Jun-ichi Kambayashi, Tomio Kawasaki and Takafumi Hirao

Department of Surgery II, Osaka University Medical School, 2-2 Yamadaoka, Suita, Osaka, 565 Japan.

Introduction of the fifth digital artery. (Fig. 2a). The aneurysm (10 x 8 mm) was resected, followed by end-to-end Ulnar artery aneurysm following repeated hand reconstruction. The resected specimen was submitted injury has been recognised since the 18th centur~ for pathological examination and the presence of an although the cumulative number of the reported case outer degraded media indicated that the specimen is very low. 1 In most reported cases, the condition has was a true aneurysm. There were no postoperative been mainly observed in the dominant hand of male complications and the digital ischaemic symptoms manual laborers. 2 We report the case of a woman with completely disappeared. Postoperative angiography an ulnar artery aneurysm probably caused by playing confirmed good patency of the distal ulnar artery (Fig. tennis. The ulnar aneurysm was successfully treated 2b) The patient has remained asymptomatic for 6 by aneurysmectomy. months since discharge.

Case Report Discussion

A 55-year-old female office worker, was admitted with Although injuries to the hands are very common in an enlarging pulsatile mass located over the dominant the athletic or occupational setting, arterial aneurysm right hypothenar eminence of 5 months duration. She of the hand has rarely been reported. 1 The first had been aware of a small lump for 13 years, but it remained asymptomatic except for occasional tender- ness and coldness and numbness on the fifth finger. She denied any history of trauma but stated that she had played tennis every week for about 15 years. She always held the tennis racket at the end against the hypothenar eminence (Fig. 1). On physical examination, there was a pulsatile 14 × 14 mm mass over the hypothenar eminence. All peripheral pulses and capil- lary filling were normal, and the results of Allen's test were negative. Serological and haematological tests were normal, without clinical evidence of autoim- mune disease. Arteriograph~ performed through a direct brachial artery puncture, revealed a fusiform aneurysm of the distal ulnar artery and the occlusion

Please address all correspondence to: Takashi Nakamura, Depart- ment of Surgery II, Osaka University Medical School, 2-2 Yama- Fig. 1. This picture illustrates the unusual way of holding the racket daoka, Suita, Osaka, 565 Japan. in this patient.

(a) ',,, , .::,!,. ..: :..

F 'i

,0.... . ,:.' . ~"

p~ 7 l (b) ),I I

Fig. 2. (a) Preoperative arteriogram illustrating the irregular lumen characteristically identified in patent distal ulnar artery aneurysms. Note a poorly developed superficial palmar arch, and an embolisation of the fifth digital artery. (b) Postoperative arteriogram taken thirteenth day after the repair of the aneurysm.

Eur J Vasc Endovasc Surg Vol 11, February 1996 242 T. Nakamura et al reported case of an arterial aneurysm involving the Before considering surgerN it is necessary to assess hand occurred in a coachman in Rome and was the patency of the palmar arch (Allen's test). Doppler described by Guattani in 1772.3 The superficial ulnar mapping, a noninvasive technique of visualising artery distal to the hamate bone just as it leaves vascular anatomN is recommended for preoperative Guyon's canal is most susceptible to trauma, leading assessment of ulnar artery. Patients with normal to arterial wall injury and possible aneurysm forma- results on noninvasive studies may not need more tion. 4 Similar vulnerable conditions exist for a short invasive diagnostic procedures, such as angiography. segment of the superficial branch of the radial artery The appropriate treatment for lesions of the ulnar at the base of the thenar eminence, a much less artery varies with according to the signs and symp- frequent site for traumatic damage to this vessel. 5 toms. Surgery was indicated in this case because of the Patients with ulnar artery aneurysms frequently have rapidly increasing size of the mass, which could have a history of repeated blunt hypothenar trauma, as is lead to complications such as rupture, distal embolism commonly seen in carpenters and mechanics who use and nerve damage. In view of the poor supply to the this portion of their hand as a hammer. Therefore, 5th finger and insufficient palmar arch, revascularisa- ulnar artery aneurysms usually occur in the dominant tion was performed. Meticulous mobilization of the hand of male manual labourers. 2 In some cases, an ulnar artery was required to accomplish end-to-end isolated traumatic event such as stabbing and crush- anastomosis. ing injuries to the palm can result in damage to the whole of the vessel wall and cause false aneurysms.6 In the present case, the patient was a female office worker and we postulate that repeated low-grade References trauma, caused by holding a tennis racket in an 1 AULICINO PL, DuPuY TE, HUTTON PMJ. True palmar aneur- unusual manner led to aneurysm formation. ysms -- A case report and literature reviews. J Hand Surg 1982; 7: Clinicall~ an ulnar artery aneurysm manifests as a 613-616. mass located at the hypothenar eminence. If the mass 2 WIGLIS EFS. Vascular injuries and diseases of the upper limb. Boston: Little, Brown and Compan}~ 1983: 49-67. is large, pulsatile, and has a palpable thrill, it is easy to 3 GUATTANI C. De externis aneurysmatibus manuchirurgica meth- diagnose. However, if the mass is not pulsatile due to odece peretractandis. Rome, 1772. thrombus and mimics acute infection, it is prone to be 4 KLEINERT HE, BURGET GC, MORGAN JA. Aneurysms of the hand. Arch Surg 1973; 106: 554-557. misdiagnosed.7 Neurological changes may develop if 5 SMITH JW. True aneurysms of traumatic origin in the palm. Am ] the aneurysm is in contact with or impinges on the Surg 1962; 104: 7-13. adjacent ulnar nerve. The clinical syndrome, including 6 GREENDP. True and false traumatic aneurysms in the hand. f Bone Joint Surg 1973; 55A: 120. hand ischaemia with repetitive blunt hypothenar 7 KaY PR, ABRAHAM IS, DAVIES RA, VERTPIELD H. Ulnar artery trauma has been identified and was labeled "hypoth- aneurysms after injury mimicking acute infection in the hand. enar hammer syndrome" by Conn et aI. 8 In our case, Injury 1988; 19: 402-404. 8 CONN Jr BERGANJJ, BELL JL. Hypothenar hammer syndrome: post occasional digital ischaemia was seen and arteriog- traumatic digital ischemia. Surgery 1970; 68: 1122-1128. raphy demonstrated occlusion of the fifth digital artery presumably due to emboli. Accepted 26 October 1994

Eur J Vasc Endovasc Surg Vol 11, February 1996