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Occupational Medicine Advance Access originally published online on May 22, 2006
Occupational Medicine 2006 56(5):317-321; doi:10.1093/occmed/kql022
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© The Author 2006. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

Hand–arm vibration syndrome with concomitant arterial thrombosis in the hands

Aaron Thompson and Ron House

61 Queen Street East, 8th Floor, Toronto, Ontario M5B 1W8, Canada

Correspondence to: Aaron Thompson, 61 Queen Street East, 8th Floor, Toronto, Ontario M5B 1W8, Canada. e-mail: Aaron.thompson{at}utoronoto.ca


   Abstract
Top
 Abstract
Introduction
 Methods
 Discussion
 Conflicts of interest
 References
 
Background Hand–arm vibration syndrome (HAVS) refers to the vascular, neurological and musculoskeletal effects that may occur in workers with prolonged exposure to vibrating tools. Hypothenar hammer syndrome (HHS) is a lesion of the ulnar artery at the level of the hamate bone secondary to single or repeated episodes of trauma to the hypothenar eminence. The literature suggests that digital arterial thrombosis and HHS may be associated with the use of vibrating tools.

Aim This study will familiarize investigators with the range of vascular abnormalities seen in workers using vibrating tools, and highlight the importance of screening for arterial thrombosis in the hand when assessing hand–arm vibration-exposed patients.

Methods In the patients referred to our clinic for HAVS assessment, three were identified during the period 2001 to 2004 who had vascular occlusions in the hands in addition to HAVS. In addition to standardized HAVS vascular investigations, all three patients had arteriograms based on a significantly positive Allen's test.

Results All three cases had documented HAVS based on vascular testing. Arteriograms revealed a spectrum of severity of arterial thromboses from severe HHS, to occlusion limited to the digital arteries.

Conclusion Our study reports three cases of HAVS with concomitant HHS and/or digital artery thrombosis. These findings support previous reports of an association between HAVS and vascular thrombosis in the hands. Screening for arterial occlusive problems in the hands should be included in the HAVS work up.

Keywords      Allen's test; hand–arm vibration syndrome; hypothenar hammer syndrome; occupational


   Introduction
Top
 Abstract
 Introduction
Methods
 Discussion
 Conflicts of interest
 References
 
The neurological, vascular and musculoskeletal aspects of hand–arm vibration syndrome (HAVS) have been well described [1–3]. Of these effects, the best studied is cold-induced vasospasm or Raynaud's phenomenon. To a lesser degree, other vascular disturbances including occlusive arterial thrombosis are identified in the literature [3,4]. Attribution of occlusive arterial disease to occupational vibration exposure is complicated by the alternative, though not mutually exclusive, diagnosis of hypothenar hammer syndrome (HHS) [5].

HHS refers to abnormalities in the ulnar artery at the level of the hamate bone secondary to single or repeated episodes of trauma to the hypothenar eminence [6]. Abnormalities may include simple arterial spasm, stenosis and occlusion, thrombosis formation due to injury to the intima and aneurismal formation after damage to the media [6,7]. These abnormalities result in digital ischemia due to proximal stenosis/occlusion and distal intraluminal emboli [8]. Patients present with cold fingers, cold intolerance, painful dysesthesia, numbness, pain and trophic changes including ulcerations [9]. First described by von Rosen in 1934 [10], and later termed ‘hypothenar hammer syndrome’ by Conn et al. [6], HHS is usually attributed to the use of the hypothenar eminence as a hammer. There is evidence that vibration exposure alone may be associated with HHS [3–5,11]. Vibration exposure may also be associated with arterial thrombosis limited to the digital arteries [3–5].

Few epidemiological studies have looked at the incidence of HHS. Ferris et al. [12] found 21 cases of HHS in 1300 prospectively enrolled patients in a vascular surgery clinic, an incidence of 1.6%. Mehlhoff and Wood [13] reported the incidence of HHS as 1.7% in patients with Raynaud's phenomenon. Kaji et al. reported the incidence of HHS as 7.3% in a sample of 330 vibration-exposed workers [5]. Little determined the incidence to be 14% in a population of automotive mechanics who used their hand as a hammer more than once a day [14].

The aim of this paper is to report three cases of HAVS with concomitant HHS and/or digital artery thrombosis to increase awareness of the spectrum of vascular disease that can occur in workers using vibrating tools. Awareness that HAVS patients may also have HHS and/or digital artery thrombosis should facilitate referral of potentially treatable cases. We also suggest the need for inclusion of screening for hand arterial thrombosis in the HAVS work up. Education of workers not to use the heel of the hand as a hammer is also important.


   Methods
Top
 Abstract
 Introduction
 Methods
Discussion
 Conflicts of interest
 References
 
Patients having a history of vibration exposure and presenting with symptoms of cold intolerance consistent with HAVS are referred to our clinic for assessment. Three patients seen in our clinic for investigation of HAVS also had arteriograms based on a significantly positive Allen's test over the 3-year period spanning 2001 to 2004 (see Table 1). All three men had been employed in occupations requiring significant manual labour and exposure to vibrating tools. Assessments took place at St Michael's Hospital, Toronto, Ontario, Canada.


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  		Table 1. Profiles of the case report patients

 
Each patient underwent standardized HAVS investigations as per our clinic's protocol. Medical history verified that all three men had been employed in occupations requiring exposure to vibrating tools. Testing on physical examination included grip strength, Phalen's test, Tinel's test and Allen's test. The Allen's test involves the patient making a tightly clenched fist so as to exsanguinate the vessels of the hand. The examiner then compresses the ulnar and radial arteries at the wrist and the patient is instructed to open the hand without hyperextending the wrist or fingers. To test the ulnar artery, the examiner then releases the ulnar artery and measures the capillary return time to the palm of the hand [15]. For the Allen's test, a cut-off of 6 s was used. Objective tests included digital thermometry, digital plethysmography, Doppler examination of the upper extremities, electromyography and current perception threshold studies. Blood work consisted of complete blood count, erythrocyte sedimentation rate, urinalysis, serum electrolytes, creatinine, urea, glucose, thyroid-stimulating hormone, uric acid, cryoglobulins, rheumatoid factor, antinuclear antibody and serum protein electrophoresis. The case reports describe those tests for which there were positive findings.

Case reports
Case 1—HAVS with concomitant HHS
A 38-year-old right-handed water well driller presented with a history of vibration exposure due to the use of grinding tools over a 13-year period. In addition to the hand transmitted vibration exposure, the worker also gave a history of using the hypothenar eminence of his right hand to forcefully bang the collar around drill pieces during disassembly of the drill. He presented with a 2-month history of rapidly progressive numbness, tingling, pain and blanching of the middle, ring and little fingers of the left hand. He was a smoker with a 20-pack year history. On examination, there was a tender palpable area over the right hypothenar eminence, splinter hemorrhages at the tips of the right middle, ring and little fingers and an early ulcer crater on the volar tip of the right little finger. Allen's test was positive for the right ulnar artery. Neurological examination was unremarkable. HAVS work up was positive for delayed rewarming during cold provocation digital thermometry. Digital plethysmography revealed severely dampened baseline right middle, ring and little finger waveforms and further dampening post cold stress (immersion in water of 10°C for 2 min) indicating diminished baseline circulation with further cold-induced vasospasm. An angiogram revealed tortuosity of the right ulnar artery in the region of the hook of the hamate. There was proximal ulnar artery thrombosis and occlusion of the medial and lateral digital arteries of the middle, ring and little fingers, as well as occlusion of the medial digital artery of the index finger. The superficial palmer arch was absent representing possible thrombus in the distribution of the ulnar artery (see Figure 1). Due to his rapidly progressive symptoms and the likely imminent loss of his fingers secondary to digital ischemia, he was treated by a plastic surgeon specializing in hand surgery. Surgery involved removal of the damaged artery and insertion of a venous graft from the right forearm. Follow-up assessment ~1 month after surgery revealed that he had good circulation to all fingers and overall normal hand function. He was advised to discontinue using his hand in a forceful hammering action, and instead to use a real hammer for the required tasks. The worker was counselled to protect his hands from cold exposure and to discontinue smoking. Prior to the surgery, he had been treated with a calcium channel-blocking agent for his vasospastic symptoms with minimal relief. This medication was discontinued after the surgery.


Figure 1
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  		Figure 1. Angiograms of the right hand of Case 1 demonstrating tortuosity of the ulnar artery at the level of the hamate and pisiform bone and minimal, irregular filling of the digital arteries of the middle, ring and little fingers. There is normal filling of the radial artery and deep palmer arch.

 
Case 2—HAVS with vibration-induced vascular injury presenting as HHS
A 32-year-old right-handed machinist who had worked in the automotive and construction industries was assessed for HAVS. He had been exposed to vibration through the use of impact guns and jackhammers over a 13-year period. He gave no history of repetitive blunt hand trauma. He presented with a 1.5-year history of cold-induced blanching, numbness and tingling of all his fingers with sparing of the thumbs. He had a 7.5-pack year history of smoking. Physical examination revealed hypothenar atrophy bilaterally with no trophic changes in the fingers. Allen's test was positive for the ulnar artery bilaterally with the delay in filling being more pronounced in the left hand. Testing was positive bilaterally on cold provocation digital thermometry and digital plethysmography. An angiogram showed left distal ulnar artery occlusion several centimetres proximal to the wrist joint along with occlusions in the digital arteries of the index, middle and ring fingers. Occlusions were deemed to be secondary to thrombosis or intraluminal emboli. The diffuse nature of the occlusions along with the small size of the vessels involved resulted in the patient not being considered a surgical candidate. He was counselled to avoid further exposure to vibration, to protect his hands from cold exposure and to discontinue smoking. He was treated with nitroglycerine and a calcium channel blocker with only mild abatement of his symptoms.

Case 3—HAVS with digital arterial thromboses
A 45-year-old assembly worker at an automotive plant was assessed for HAVS. He had been exposed to vibration over a 19-year period through the use of pneumatic and electric impact guns. He gave no history of repetitive blunt hand trauma. He presented with cold-provoked recurrent numbness, tingling and blanching of the middle and ring fingers from the tips of the fingers extending to the proximal interphalengeal joints of the left hand. He was a smoker with a 10-pack year history. Allen's test was positive for the left ulnar artery. Cold provocation digital thermometry revealed delayed rewarming of all digits of the left hand except for the thumb. Digital plethysmography was positive in the middle and ring fingers of the left hand. An arteriogram revealed local stenosis in the radial side digital arterial branches of the ring finger, short segment occlusions of both digital arterial branches of the middle finger and occlusion of the ulnar aspect palmer digital arterial branch of the index finger. The observed stenosis and occlusions were consistent with arterial thrombosis. No cardiac or proximal vascular sources were identified by echocardiogram, ultrasound and angiogram of the proximal vessels. Treatment required partial amputation of left middle finger following an episode of gangrene. Given that the vascular abnormalities were predominantly microvascular, he was not deemed to be a surgical candidate. The worker was counselled to avoid further exposure to vibration, to protect his hands from cold exposure and to discontinue smoking. A calcium channel blocker was given for treatment of HAVS symptoms.


   Discussion
Top
 Abstract
 Introduction
 Methods
 Discussion
Conflicts of interest
 References
 
HAVS and HHS present in a similar fashion, both producing symptoms due to reduced blood flow to the hands [16]. While vibration may play a role in the etiology of HHS, there remains a paucity of studies on the coexistence of HAVS and HHS. This may reflect a lack of awareness on the part of clinicians of the possibility of HHS in vibration-exposed patients. These reports demonstrate the potential for HAVS to present with concomitant HHS and/or digital artery occlusions.

Case 1 appears to be a classical case of HHS presenting in a patient initially referred for HAVS assessment, and found to have only mild cold-induced vasospasm. He had fairly rapid progression of symptoms and a clear history of using the affected hand like a hammer resulting in repeated forceful trauma. Angiography showed ulnar artery tortuosity and thrombosis with distal arterial occlusions, and surgical intervention was successful. Upon returning to work, he modified his job task by using a hammer instead of his hand. Case 2 illustrates ulnar and digital arterial thrombosis presenting like HHS in a vibration-exposed worker. This worker gave no history of using the hand for repeated blunt trauma, with the only apparent trauma being from vibrating tools. In Case 3, the pathological changes were more distal, involving digital arterial thromboses that were most prominent in the ulnar aspects of the palmer arterial branches without involvement of the ulnar artery. Again there was no history of using the hand for repeated blunt trauma.

The reported cases of thrombosis in workers with HAVS suggest the possibility that vibration may be contributing to the development of thrombi. The most likely area of thrombosis in workers using vibrating tools is in the ulnar artery in the region of the hamate, as resonance phenomena are transmitted to this area via the hamulus of the hamate and the pisiform bone [3]. This area is also predisposed as it is stressed when force is applied to a tool along the ulnocarpal axis. There are also reports in the literature of isolated digital vessel thrombi without ulnar involvement in vibration-exposed workers, as in our Case 3, suggesting a problem distinct from classical HHS [3–5]. This phenomenon might be attributed to activation of the coagulation cascade by vibration-induced shear stress damage to the vascular endothelium [17,18]. It is possible that more impulsive vibration in exposed workers might be important in the development of thrombi although the literature does not provide much insight in this regard. In cases involving younger men with a history of heavy smoking and bilateral diffuse small vessel involvement, Buerger's disease should also be considered.

The incidence of HHS in patients undergoing HAVS assessment is best estimated by the study conducted by Kaji et al. [5], who reported an incidence of 7.3% in vibration-exposed workers, as it is the only study that we are aware of that used vibration-exposed workers as the base population. This prevalence of HHS in vibration-exposed workers justifies inclusion of screening for HHS in the HAVS work up. HHS is a serious disease which can result in gangrene of the fingers if treatment is delayed [9,19] and early detection can reduce morbidity [19–23]. The Allen's test may be used as a screening tool [5, 24]. Jarvis et al. [24] reported the 5-s cut-off as having a sensitivity of 75.8% and a specificity of 81.7%, and the 6-s cut-off as having a sensitivity of 54.5% and specificity of 91.7%. The gold standard for subsequent investigation is arteriography. The colour coded duplex ultrasound and MR angiography are less invasive imaging methodologies which might also be used for subsequent assessment following a positive Allen's test [25–31].

These case reports illustrate the spectrum of occlusive vascular problems that can occur in workers exposed to vibrating tools and the potential for treatment. Assessments should review work practices and educate workers to not use the heel of the hand in a hammering action. Additional research is needed to determine the relationship between vascular occlusion in the hand and vibration exposure and those aspects of vibration exposure (such as the impulsivity) that may be associated with increased risk.


   Conflicts of interest
Top
 Abstract
 Introduction
 Methods
 Discussion
 Conflicts of interest
References
 
None declared.


   References
Top
 Abstract
 Introduction
 Methods
 Discussion
 Conflicts of interest
 References
 

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