Diagnosis of hypothenar hammer syndrome in a patient with acute ulnar artery occlusion.

A 56-year-old truck driver with a history of tobacco use presented with acute onset digital ischaemia in the ulnar distribution of his dominant hand, associated with severe pain. Occupational exposures included extensive manual labour and prolonged vibratory stimuli. Workup with Doppler and angiography confirmed the diagnosis of hypothenar hammer syndrome (HHS). After the failure of medical management, he underwent ulnar artery thrombectomy with reconstruction and arterial bypass grafting. His pain improved significantly postsurgically, and he was able to return to a normal routine. This case illustrates the classic presentation, examination, imaging findings and management options of HHS. HHS should be considered in patients with digital ischaemia and associated occupational exposures. Diagnosing the condition appropriately allows for optimal management, aiming at minimising symptoms and maximising quality of life.

International consensus criteria for diagnosing and staging hand-arm vibration syndrome.

PURPOSE: In the 30 years since the Stockholm Workshop Scale (SWS) was published, the scientific literature on hand-arm vibration syndrome (HAVS) has grown and experience has been gained in its practical application. This research was undertaken to develop an up-to-date evidence-based classification for HAVS by seeking consensus between experts in the field. METHODS: Seven occupational physicians who are clinically active and have had work published on HAVS in the last 10 years were asked to independently take part in a three-round iterative Delphi process. Consensus was taken when 5/7 (72%) agreed with a particular statement. Experts were asked to provide evidence from the literature or data from their own research to support their views. RESULTS: Consensus was achieved for most of the questions that were used to develop an updated staging system for HAVS. The vascular and neurological components from the SWS are retained, but ambiguous descriptors and tests without adequately developed methodology such as tactile discrimination, or discriminating power such as grip strength, are not included in the new staging system. A blanching score taken from photographs of the hands during vasospastic episodes is recommended in place of self-recall and frequency of attacks to stage vascular HAVS. Methods with the best evidence base are described for assessing sensory perception and dexterity. CONCLUSIONS: A new classification has been developed with three stages for the clinical classification of vascular and neurological HAVS based on international consensus. We recommend it replaces the SWS for clinical and research purposes.

Nailfold capillary morphological characteristics of hand-arm vibration syndrome: a cross-sectional study.

OBJECTIVE: The purpose of this study was to investigate the characteristics of nailfold capillaroscopy associated with hand-arm vibration syndrome (HAVS). METHODS: In total, 113 male gold miners were recruited: 35 workers who were chronically exposed to vibration and developed vibration-induced white finger were defined as the HAVS group, 39 workers who were exposed to vibration but did not have HAVS were classified as the vibration-exposed controls (VEC) group, and 39 workers without vibration exposure were categorised as the non-VEC (NVEC) group. Video capillaroscopy was used to capture images of the 2nd, 3rd and 4th fingers of both hands. The following nailfold capillary characteristics were included: number of capillaries/mm, avascular areas, haemorrhages and enlarged capillaries. The experiments were carried out in the same winter. All characteristics were evaluated under blinded conditions. RESULTS: Significant differences in all morphological characteristics existed between the groups (p<0.05). Avascular areas in the HAVS, VEC and NVEC groups appeared in 74.3%, 43.6% and 25.0% of participants, respectively. A higher percentage of participants had haemorrhages in the HAVS group (65.7%) compared with the other groups (VEC: 7.7% and NVEC: 7.5%). The number of capillaries/mm, input limb width, output limb width, apical width, and ratio of output limb and input limb all had more than 70% sensitivity or specificity of their cut-off value. CONCLUSIONS: Nailfold capillary characteristics, especially the number of capillaries/mm, avascular areas, haemorrhages, output limb width, input limb width and apical width alterations, revealed significant associations with HAVS.

[Carpal canal ultrasound examination in patients with mild hand-arm vibration disease].

Objective: To investigate the clinical value of ultrasound examination of carpal canal structure in patients with mild hand-arm vibration disease. Methods: A total of 29 patients (58 wrists) with mild hand-arm vibration disease who were treated in Shenzhen Prevention and Treatment Center for Occupational Diseases from May to December, 2015 were enrolled as observation group, and 20 healthy volunteers (40 wrists) were enrolled as the control group. Color Doppler ultrasound was used to observe the morphology and echo of the median nerve in the carpal canal and 9 muscle tendons and transverse carpal ligament. The thickness of transverse carpal ligament and diameter of the median nerve at the level of the hamulus of hamate bone were measured, as well as the cross-sectional area of the median nerve at the level of pisiform bone. Results: In the 29 patients with hand-arm vibration disease patients in the observation group, 8 experienced entrapment of the median nerve in the carpal canal, among whom 5 had entrapment in both wrists; there were 13 wrists (23%) with nerve entrapment and 45 wrists (77%) without nerve entrapment. Compared with the control group, the patients with hand-arm vibration disease and nerve entrapment in the observation group showed significant thickening of the transverse carpal ligament at the level of the hamulus of hamate bone and a significant increase in the cross-sectional area of the median nerve at the level of pisiform bone (P<0.05) , while there were no significant differences in the thickness of transverse carpal ligament at the level of the hamulus of hamate bone and the cross-sectional area of the median nerve at the level of pisiform bone (t=-9.397 and -4.385, both P>0.05) . Conclusion: Ultrasound examination can clearly show the radiological changes of carpal canal contents in patients with mild hand-arm vibration disease and has a certain diagnostic value in nerve damage in patients with hand-arm vibration disease.

Vascular hand-arm vibration syndrome--magnetic resonance angiography.

The diagnosis of vascular hand-arm vibration syndrome (HAVS) requires consistent symptoms, photographic evidence of digital blanching and sufficient exposure to hand-transmitted vibration (HTV; A(8) > 2.5 m/s2). There is no reliable quantitative investigation for distinguishing HAVS from other causes of Raynaud's phenomenon and from normal individuals. Hypothenar and thenar hammer syndromes produce similar symptoms to HAVS but are difficult to diagnose clinically and may be confused with HAVS. Magnetic resonance angiography (MRA) is a safe and minimally invasive method of visualizing blood vessels. Three cases of vascular HAVS are described in which MRA revealed occlusions of the ulnar, radial and superficial palmar arteries. It is proposed that HTV was the cause of these occlusions, rather than blows to the hand unrelated to vibration, the assumed mechanism for the hammer syndromes. All three cases were advised not to expose their hands to HTV despite one of them being at Stockholm vascular stage 2 (early). MRA should be the investigation of choice for stage 2 vascular HAVS or vascular HAVS with unusual features or for a suspected hammer syndrome. The technique is however technically challenging and best done in specialist centres in collaboration with an occupational physician familiar with the examination of HAVS cases. Staging for HAVS should be developed to include anatomical arterial abnormalities as well as symptoms and signs of blanching. Workers with only one artery supplying a hand, or with only one palmar arch, may be at increased risk of progression and therefore should not be exposed to HTV irrespective of their Stockholm stage.

Associations of work activities requiring pinch or hand grip or exposure to hand-arm vibration with finger and wrist osteoarthritis: a meta-analysis.

OBJECTIVE: We systematically reviewed the epidemiologic evidence linking finger and wrist osteoarthritis (OA) with work activities requiring pinch or hand grip or exposure to hand-arm vibration (HAV). METHODS: PubMed and Embase databases were searched up to June 2013. We selected studies assessing the associations of radiographic diagnosed finger and/or wrist joint OA with work activities involving pinch or hand grip or exposure to HAV. We used specific criteria to evaluate completeness of reporting, potential confounding, and bias. Pooled odds ratios (OR) were computed using random-effects meta-analyses. RESULTS: Of the 19 studies included, 17 were cross-sectional, 1 was a prospective cohort, and 1 a case-control study. The meta-analyses of studies that controlled their estimates for at least age and gender showed the associations of pinch grip work with proximal interphalangeal joint [OR 1.56, 95% confidence interval (95% CI) 1.09-2.23] and the first carpometacarpal joint OA (OR 2.10, 95% CI 1.06-4.17), but not with distal interphalangeal, metacarpalphalangeal, or wrist joints OA. Hand grip work and exposure to HAV were not associated with any finger or wrist OA. CONCLUSION: Epidemiological studies provide limited evidence that pinch grip may increase the risk of wrist or finger OA, but causal relation cannot be resolved because of cross-sectional designs and inadequate characterization of biomechanical strain to the hand and wrist.

[On efficiency of local xidiphone in treating osteoporotic changes in hands of vibration disease patients].

The authors demonstrated that local electrophoresis of xidiphone for osteoporotic changes in hands of vibration disease patients results in preservation of bone mineral density. Treatment courses should occur 2-3-4 times annually.