Hand CASE 50
CASE 50
The patient is a 51-year-old male construction worker who presents with pain in his proximal left palm and a superficial 1 × 1 cm ulcer along the radial aspect of his small finger tip. He reports that he has had pain in his hand for approximately 4 months, but has had the ulcer for only 3 weeks. He operates heavy machinery at work and often uses a jackhammer. On examination, the patient has a normal appearing, sensate hand with an ulcer of his small fingertip. There is no muscular wasting. He has normal range of motion in all fingers and his grip and pinch strength are normal.
Which of the following additional components of the physical examination is likely to be abnormal for this patient?
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Two-point discrimination in the median nerve distribution
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Scaphoid shift test
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Allen test
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Bunnell intrinsic tightness test
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Elbow compression test
Discussion
The correct answer is (C). The most appropriate test to evaluate the perfusion to the hand is the Allen test, first described in 1929 to evaluate the differential vascular inflow into the hand from the radial and the ulnar arteries. In this patient, this test would be the most appropriate to evaluate the perfusion to the hand. The other tests mentioned, while important components of a thorough upper extremity evaluation, would not likely reveal pathology in this case.
The patient undergoes additional imaging and is found to have thrombosis of the ulnar artery as it passes through Guyon’s canal. What is this condition called?
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Carpal tunnel syndrome
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Buerger’s disease
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Scleroderma
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Hypothenar hammer syndrome
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Raynaud disease
Discussion
The correct answer is (D). Hypothenar hammer syndrome is characterized by finger ischemia, caused by occlusion of palmar ulnar artery in a person repetitively striking objects with the hypothenar surface of the hand. This patient’s presentation is classic for hypothenar hammer syndrome. The other diagnoses, although part of the differential diagnosis, are less likely in this case.
Which of the following objective measures can determine the degree to which arterial inflow into the digits is affected and help guide the decision for treatment?
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Capillary refill in the digits
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Color of the digits
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Digital brachial index
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Systolic blood pressure
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Two-point discrimination in the digits
Discussion
The correct answer is (C). The digital brachial index is an objective measure of arterial inflow into each of the digits, and can guide the various treatment options. One study concluded that patients with digital brachial indices of less than 0.7 required reconstruction with a vein graft or primary arterial anastomosis, whereas those above this level warranted only vessel ligation. The remaining options, although important components of the hand examination, are less objective than the digital brachial index in this patient.
Which of the following are treatment options for this patient?
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Aspirin, calcium channel blockers, and/or systemic anticoagulation
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Resection and ligation of the affected ulnar artery segment
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Smoking cessation
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Reconstruction of the affected ulnar artery with vein graft
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All of the above
Discussion
The correct answer is (E). All of the listed treatment options may be helpful for this patient. Smoking cessation, independent of surgical intervention, may be helpful for this patient to prevent disease progression. The choice of ulnar artery ligation vs. reconstruction with a vein graft is surgeon- and patient-dependent; either option might be indicated in this scenario as described above. Adjunctive medications such as anti-platelet therapy (Aspirin), anticoagulation, and vasodilators such as calcium channel blockers may be helpful in cases of distal finger ischemia.
Objectives: Did you learn...?
Identify the indications for the use of the Allen’s test? Identify the indications for Digital Brachial Index?
Describe the pathoanatomy of Hypothenar Hammer Syndrome? Treat Hypothenar Hammer Syndrome?