Surgical Repair Using Cephalic Vein in a Crossfitter Patient with Hypothenar Hammer Syndrome

Hypothenar hammer syndrome (HHS) is a relatively rare entity but may occur more frequently than acknowledged. Current literature on the prevalence of this syndrome is limited, as it is often not reported. The prevalence of this condition is estimated at 14% in the population at risk. In contrast, the incidence of this condition in the patient who present with hand vascular problem was only 1.1 to 1.6%.[1]

Additionally, it has been reported to occur in athletes who experience repetitive trauma to the palm, and has been reported in baseball, karate, mountain biking, volleyball, golf, tennis, handball, softball, weight lifting, break dancing, hockey, and fire arm use,[2] with no report in CrossFit.

A 29-year-old man, nurse, presented to the emergency department with a pulsatile mass on the hypothenar eminence on the right hand, with no pain, paresis or paresthesia, with history of practice CrossFit for 1 and half years. The computed tomography angiography demonstrates an ulnar artery aneurysm with incomplete superficial palmar arch ([Fig. 1]), although Allen’s test was negative.

Fig. 1 Computed tomography angiography demonstrates an ulnar artery aneurysm.

The patient was taken to the operating room, the aneurysm was replaced by an inverted forearm cephalic vein interposition, using 9.0 polypropylene suture, under 3.5 power magnification.

Postoperatively, he had a “hot hand” with a palpable graft pulse in the palm. Complete healing occurred without further pain and was discharge 2 days later. On follow-up at 12 months, the hand remained asymptomatic with a palpable palmar pulse and the computed tomography angiography demonstrates full permeability ([Fig. 2]).

Fig. 2 Computed tomography angiography after 1 year of follow-up.

The pathogenesis of this syndrome relates closely to its anatomy. Guyon’s canal is triangular in shape, usually measures 4 cm in length and is located at the base of the ulnar side of the palm. The ulnar nerve and artery pass through Guyon’s canal before entering the hand. It is bordered laterally by the hook of the hamate and the transverse carpal ligament. Repetitive blunt trauma sustained to the ulnar aspect of the palm through frequent use of tools or habitual use of the heel of the hand as a hammer causes intimal damage of the ulnar artery within Guyon’s canal, resulting in thrombosis of the ulnar artery, leading to aneurysm formation.[3]

Doppler examination may be useful in HHS diagnosis. Recently, multidetector computed tomography angiography has been reported to detecting HHS lesions. Magnetic resonance angiography with three-dimensional acquisition may also be helpful. Angiography remains the gold standard test for accurately showing arterial damage consistent with HHS.[4]

For most patients, nonsurgical treatment will be sufficient, particularly in the setting of vasospasm with adequate collateral circulation. Conservative nonoperative care may include: (1) smoking cessation, (2) avoidance of further trauma (may require change of occupation), (3) padded protective gloves, (4) cold avoidance, (5) calcium channel blockers (nifedipine, diltiazem), (6) antiplatelet agents or anticoagulation, (7) local care of fingers with necrosis, and (8) pentoxifylline to reduce blood viscosity.

Often, decisions regarding surgical versus nonsurgical treatments are based on the acuteness of the symptoms and severity of the ischemia. Angiography may demonstrate more significant vascular damage, poor collateral circulation, and/or vasospasm. Surgical options in this setting include: (1) arterial ligation (assuming an intact radial/palmar arch), (2) resection of thrombosed arterial segment or aneurysm with end-to-end anastomosis, (3) resection and vascular reconstruction with vein or artery graft, using principally the saphenous vein, and (4) catheter-directed thrombolytic therapy in situations of acute occlusive thrombus.[5]

HHS has never been described to be associated with CrossFit. Similar to other HHS-associated activities, the mechanism is likely to be due to repetitive trauma into the hypothenar eminence. The use of inverted cephalic vein is a good vascular conduit for the reconstruction of the palmar arc.

Publication History

Article published online:
28 May 2020

• References

• 1 Orrapin S, Arworn S, Wisetborisut A. Unusual cases of hypothenar hammer syndrome. Ann Vasc Dis 2015; 8 (03) 262-264
• 2 Kreitner K-F, Düber C, Müller L-P, Degreif J. Hypothenar hammer syndrome caused by recreational sports activities and muscle anomaly in the wrist. Cardiovasc Intervent Radiol 1996; 19 (05) 356-359
• 3 Bauer NJ, Hardy SC. An unusual case of hypothenar hammer syndrome in the non-dominant hand. J Surg Case Rep 2014; 2014 (07) rju068-rju068
• 4 Marie I, Hervé F, Primard E, Cailleux N, Levesque H. Long-term follow-up of hypothenar hammer syndrome: a series of 47 patients. Medicine (Baltimore) 2007; 86 (06) 334-343
• 5 Ablett CT, Hackett LA. Hypothenar hammer syndrome: case reports and brief review. Clin Med Res 2008; 6 (01) 3-8