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Year : 2021  |  Volume : 29  |  Issue : 3  |  Page : 190-192

A new utilization area of near-infrared fluorescence imaging: Hypothenar hammer syndrome

1 Department of Plastic Reconstructive and Aesthetic Surgery, Fatsa State Hospital, Ordu, Turkey
2 Department of Plastic Reconstructive and Aesthetic Surgery, Selcuk University, Konya, Turkey

Date of Submission13-Dec-2020
Date of Acceptance30-Mar-2021
Date of Web Publication29-Jul-2021

Correspondence Address:
Dr. Seyda Guray Evin
Hospital Street, Fatsa State Hospital, Fatsa, Ordu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjps.tjps_126_20

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Hypothenar hammer syndrome (HHS) is a rare traumatic vascular disease, which is characterized by pain and cold insensitivity in the areas fed by ulnar artery. Computerized tomography angiography (CTA) is the gold standard for the accurate diagnosis of it. Less invasive tests that are used to make decisions regarding the application of angiography, which is an invasive imaging method, have been reported in the literature. In this study, an indocyanine green-enhanced near-infrared fluorescence imaging system is used for the diagnosis of a patient with HHS who was not properly diagnosed with CTA. Although CTA is still considered as the gold standard for the diagnosis of upper extremity vascular insufficiencies, indocyanine green-enhanced fluorescence imaging, being an easily applicable and lacking of radiation exposure, should be considered first before CTA.

Keywords: Computerized tomography angiography, hammer, hypothenar, indocyanine green-enhanced, laser fluorescein angiography

How to cite this article:
Evin SG, Erkol EE, Sutcu M, Tosun Z. A new utilization area of near-infrared fluorescence imaging: Hypothenar hammer syndrome. Turk J Plast Surg 2021;29:190-2

How to cite this URL:
Evin SG, Erkol EE, Sutcu M, Tosun Z. A new utilization area of near-infrared fluorescence imaging: Hypothenar hammer syndrome. Turk J Plast Surg [serial online] 2021 [cited 2021 Sep 17];29:190-2. Available from: http://www.turkjplastsurg.org/text.asp?2021/29/3/190/322673

  Introduction Top

Hypothenar hammer syndrome (HHS) is a condition characterized by chronic ischemia of the hypothenar region. Computerized tomography angiography (CTA), which can give a detailed information about vascular anatomy, patency, and pathologies, is necessary for the definitive diagnosis of HHS.[1]

This study shows the use of an indocyanine green-enhanced This study shows the use of an indocyanine green-enhanced near-infrared (NIR) fluorescence imaging system SPY [Novadaq, Mississauga, ON, USA; Canada/LifeCell, Branchburg, NJ, USA] for the diagnosis of a patient who is suspected to have HHS who cannot be diagnosed with CTA.

  Case Report Top

A 32-year-old male presented with sudden pallor on his right hypothenar area and pain for 3 years. He has been a ceramic worker for the past several years and he used the hypothenar area of his right hand as a hammer. He had no known illness and a history of smoking. He did not have symptoms such as bruising, whitening, on the fingertips in cold weather, fever, or sweating that are suggestive of vasculitis or connective tissue diseases. Arterial examination was performed with an 8-MHz bidirectional hand Doppler (Dopplex; Huntleigh, Luton, UK), and both ulnar and radial arteries were evaluated as intact. We observed pallor on the hypothenar area, especially on 4th finger when the pressure of ulnar artery was released by means of Allen test [Figure 1]. The patient was suspected of HHS, and he was subjected to CTA. Although the ulnar artery and its branches, which nourish 4th and 5th finger, were audible on Doppler, the patency of ulnar artery was not visualized by CTA from the level of wrist [Figure 2]. These findings have not supported our examination. Thus, we decided to use an indocyanine green-enhanced NIR fluorescence imaging system to see the perfusion pattern of the affected hand.
Figure 1: Pallor area especially on the 4th finger is observing as the result of Allen's test

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Figure 2: The level at which the ulnar artery is interrupted is marked by the blue arrow in computerized tomography angiography

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Medial cubital vein catheterization was performed. 25 mg indocyanine green (Aurogreen®, Aurolab, Madurai, India) was diluted with 10cc 0.9% sterile saline, and 1.5 cc indocyanine green was injected, while both ulnar and radial arteries were occluding with finger pressure. Ulnar artery occlusion was removed when NIR fluorescein images were recorded. Circulatory insufficiency was observed at approximately 50% of 4th finger and 5th finger [Figure 3]. This finding was well correlated with the patient's first complaints and examination of evidence. This condition was evaluated to support of HHS.
Figure 3: Hypoperfused area on the 4th fingertip in the indocyanine green-enhanced fluorescence imaging system

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  Discussion Top

HHS occurs as a result of repetitive blunt trauma to hypothenar eminence. Initial symptoms are hand pain, discoloration and sensorial changes, pulsatile mass on the hypothenar region, and ulceration or necrosis on fingers and later finger amputations. Before the diagnosis of HHS, Raynoud's, scleroderma, Buerger's disease, systemic lupus erythematosus, rheumatoid arthritis, and thoracic outlet syndrome should be considered.[2],[3] History of repetitive blunt hand or wrist traumas, male dominance, asymmetric distribution, ulceration on areas nourished by ulnar artery branches, and decrease of ulnar artery pulse support the diagnosis of HHS.

In our patient, Allen test was positive, and we suspected ulnar artery stenosis or occlusion. However, Allen test is positive for 22% of the normal patients, and hence its accuracy is not reliable. In this situation, thermography, cold stress test, digital pulse volume, and Doppler color pencil mapping recording can enable us to come close to the decision of performing CTA for HHS.[4] Doppler imaging, digital plethysmography, CTA, or magnetic resonance angiography can provide the exact diagnosis.

CTA is accepted as the gold standard for the diagnosis of HHS.[5] However, CTA has some disadvantages such as it requires a radiologist and also advance preparation. Furthermore, patients who undergo CTA are exposed to significant radiation. In addition, CTA has some adverse effects such as renal failure or allergic reactions due to contrast material.[5],[6] In addition, contrast material may cause vasoconstriction of arteries that make difficult to detect pathology of ulnar artery.[7] Positive findings to support the HHS with indocyanine green-enhanced NIR fluorescence imaging would protect the patient from the risks related to CTA.

Main purpose of indocyanine green-enhanced NIR fluorescence imaging is to demonstrate the blood supply of some areas, normal and pathological circulation, and ischemia and lymphatic pathways.[8] In addition, it has previously been used successfully in the evaluation of peripheral arterial occlusive disease and ischemia of the upper extremity caused by HHS, embolism, atherosclerosis, arteriovenous fistula, arteritis, etc.[9],[10] It is considered to be one of the best promising methods for the diagnosis. Comparative studies with large sample groups will be effective in ensuring that this method is included in routine clinical practice.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.


Elsevier language editing provided language help during the research.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Abdel-Gawad EA, Bonatti H, Housseini AM, Maged IM, Morgan RF, Hagspiel KD. Hypothenar hammer syndrome in a computer programmer: CTA diagnosis and surgical and endovascular treatment. Vasc Endovascular Surg 2009;43:509-12.  Back to cited text no. 1
Swanson KE, Bartholomew JR, Paulson R. Hypothenar hammer syndrome: A case and brief review. Vasc Med 2012;17:108-15.  Back to cited text no. 2
Yuen JC, Wright E, Johnson LA, Culp WC. Hypothenar hammer syndrome: An update with algorithms for diagnosis and treatment. Ann Plast Surg 2011;67:429-38.  Back to cited text no. 3
Ablett CT, Hackett LA. Hypothenar hammer syndrome: Case reports and brief review. Clin Med Res 2008;6:3-8.  Back to cited text no. 4
Hinson JS, Ehmann MR, Fine DM, Fishman EK, Toerper MF, Rothman RE, et al. Risk of acute kidney injury after intravenous contrast media administration. Ann Emerg Med 2017;69:577-86.e4.  Back to cited text no. 5
Leow KS, Wu YW, Tan CH. Renal-related adverse effects of intravenous contrast media in computed tomography. Singapore Med J 2015;56:186-93.  Back to cited text no. 6
DiBenedetto MR, Nappi JF, Ruff ME, Lubbers LM. Doppler mapping in hypothenar syndrome: An alternative to angiography. J Hand Surg Am 1989;14:244-6.  Back to cited text no. 7
Tashiro K, Yamashita S, Koshima I, Miyamoto S. Visualization of accessory lymphatic pathways in secondary upper extremity lymphedema using indocyanine green lymphography. Ann Plast Surg 2017;79:393-6.  Back to cited text no. 8
Brooks D. Perfusion assessment with the SPY system after arterial venous reversal for upper extremity ischemia. Plast Reconstr Surg Glob Open 2014;2:e185.  Back to cited text no. 9
Neumann J, Schmaderer C, Finsterer S, Zimmermann A, Steubl D, Helfen A, et al. Noninvasive quantitative assessment of microcirculatory disorders of the upper extremities with 2D fluorescence optical imaging. Clin Hemorheol Microcirc 2018;70:69-81.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3]


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