Soft-tissue case 42. Diagnosis

T deep palmar arterial arch on the arteriogram was absent (Fig. 4, white arrowhead [dashes indicate the normal position of the deep palmar arch]) with little contrast medium flowing distally beyond the intermediate phalanx of the middle and ring fingers (Fig. 5, arrowheads). On the basis of the patient’s unilateral symptoms, the history of repetitive trauma and the angiographic findings, a diagnosis of post-traumatic occlusion of the deep palmar arterial arch was made. The patient was treated with acetylsalicylic acid and nifedipine. Ipsilateral stellate ganglion blockade produced some amelioration of his symptoms. He was encouraged to hand over the arduous daily work tasks to his son, and his symptoms gradually subsided over the next 6 months with complete healing of the fingertip ulcer. Hypothenar hammer syndrome has mainly been reported in athletes who use their hands for catching and striking objects, and the diagnosis is used to describe symptoms associated with vasospasm or occlusion of the ulnar artery in the hand due to repetitive blunt trauma to the hypothenar eminence. Usually seen in men, the condition manifests as rest pain, cold intolerance and numbness of the affected hand. Patients may present with trophic skin changes and ulceration of the fingertips, as well as the development of a tender hypothenar mass. The severity of hand ischemia can be evaluated by digital photoplethysmography, but a definitive diagnosis is made by angiography to evaluate the patency of the palmar arterial arches. The deep palmar arch is an arterial arcade formed by the terminal branch of the radial artery (Fig. 4, thick white arrow) anastomosing with the deep branch of the ulnar artery (Fig. 4, thin white arrow). Unlike the superficial arch (Fig. 4, black arrowhead), the former is complete in 97% of patients. In the present case, a congenitally absent deep palmar arch is unlikely because of absent digital flow in the affected finger. Occlusion of the deep palmar arch is rare, but it can occur in workers whose hands are subjected to repeated blunt trauma or gripping, as this compresses the ulnar artery against the hook of hamate, triggering vasospasm. Continued trauma damages the arterial intima and with slowing of blood flow from vasospasm encourages platelet aggregation and thrombus formation. Distal embolization of the digital arteries exacerbates the ischemia. Chronic blunt trauma also causes thickening and fibrosis of the periadventitial tissues, thereby compressing Radiology for the Surgeon Chirurgie et radiologie