Hypothenar hammer syndrome: Case report
A 47-year-old engine mechanic presented to orthopedic hand surgery, 3 weeks after initial injury where his left ring finger was caught in a set of keys, resulting in traumatic hyperextension. The patient heard a “pop” and felt immediate pain over the palm, with continued pain and swelling for 2 days. Numbness and coldness of the ring finger set in approximately 10 days after initial injury. A day later, the patient's little finger had also started to become cold to the touch. At work, the patient performed an infrared image of the left hand using a Forward-Looking Infrared camera, which is commonly used by mechanics to detect abnormal heat build-up in engine compartments, which showed decreased surface temperature of the ring finger relative to the other digits of the left hand.

The numbness resolved, but the coldness and pain persisted so the patient presented to the emergency department where physical exam revealed a cooler left ring finger tip compared to other digits. Radiographs of the left hand excluded acute osseous injury. There was a history of remote fracture of the right hand 2 years prior, but no injuries to the left hand. Given the concern for vascular injury the patient was referred to orthopedic hand surgery. On clinic review, the patient's left ring and small fingers were cooler to the touch, with normal color, but with slight delay in capillary refill. There was normal sensation and strength. A tender mass was noted on the ulnar aspect of the hook of the hamate. Allen's test suggested compromise of the ulnar arterial supply to the hand. The patient underwent MR Angiogram (MRA) of the left hand, given concern for HHS. This showed a 2.3 cm ulnar artery aneurysm with thrombus at the level of the hook of the hamate extending from the pisiform to the metacarpal base.

The patient was subsequently scheduled for aneurysm excision and ulnar artery bypass grafting. However, his symptoms significantly improved without medication or other treatment before surgery, and so he opted for continued nonoperative management. At the time of submission for publication, the patient has been asymptomatic for 8 months and decided not to pursue any follow-up unless his symptoms returned.

Source: Radiology case report

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