Reconstruction of the Superficial Palmar Arch Using the Subscapular Arterial System (original) (raw)

2019, Plastic and Reconstructive Surgery - Global Open

BACKGROUND Hypothenar hammer syndrome (HHS) involves repetitive blunt trauma or vibrational forces to the ulnar aspect of the hand, causing injury to the ulnar artery and potentially leading to thrombosis and distal ischemia. 1 Signs and symptoms of hypoperfusion or ischemia to the ulnar digits may include pain, coolness, and pallor. 2 Neuropathy of the adjacent ulnar nerve may occur. 3 Conservative measures are appropriate for most cases and may include activity modification, smoking cessation, cold avoidance, and/or calcium channel blockers. 2,4 Operative management is indicated when nonoperative management fails, or if critical ischemia is present. Reconstruction of the ulnar artery with venous and arterial interposition grafts has been described. 4-9 Venous donor sites include the greater saphenous vein, dorsal venous arch of the foot, or flexor aspect of the arm but have high thrombosis rates. 6,7,9 Previously described arterial donor sites include the descending branch of the lateral femoral circumflex artery, the deep inferior epigastric artery, or the serratus branch of the thoracodorsal artery. 4,8,9 We present a case of acute HHS that resulted in a large, complex arterial defect in the hand after resection of thrombosed arterial segments. Successful treatment utilized an interposition graft from the subscapular arterial system, which included multiple branches to reconstruct the arterial defect with 1 contiguous graft. CASE REPORT A 53-year-old right-hand-dominant carpenter presented with a 2-week history of right-sided intermittent median and ulnar nerve paresthesias and ulnar-sided hand pain. His symptoms worsened acutely with the development of bluish discoloration and exquisite pain to the tip of the fourth digit. History revealed frequent repetitive trauma to the hypothenar eminence when he used the ulnar aspect of his hand "like a hammer" to forcefully turn a large wrench. Medical history included well-controlled type 2 diabetes with no history of smoking, cardioembolic disease, or coagulopathy. The pulp of the fourth digit was cool to touch with a bluish hue, decreased capillary refill, and pain to