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Flashcards in Vascular occulsion Deck (36):

What is hypothenar hammer syndrome?

What is the incidence adn risk factors?


Post traumatic digital ischaemia by thrombosis of 

 ulna artery in Guyon's canal

Males 9:1 Females

40-60 yrs

usually dominant hand- ring or little finger, thumb spared

risks: vibration tools, sports- baseball catchers/ golfers



What is the pathology of hypothenar hammer syndrome?

single or repetitive blunt impact to hypothenar eminence -> ulna artery thrombosis or aneursym

Hook of hmate acts an avil for thrombosis


Describe the course of the ulna artery as it exits Guyon's canal?

It branches into 2 - Superifical and Deep branch

its relationship to the hook of hamate- over distal 2cm, the artery is directly anterior to the hook of the hamate, covered by palmaris brevis, subcutaneous tissue and skin


what are the symptoms and signs of hypothenar hammer syndrome?

What test could you do confirm diagnosis?


pain over hypothenar eminence and ring finger

cold senstivity



blanching, mottlying, ulceration

tenderness over hypothenar eminence

prominent callus

pulsatile mass if aneurysm present

Allen's test- positive if occulsion


What imaging is useful for diagnosis?

What is ths Differential diagnosis for this condition?

Doppler- first line

Angiogram Ct/MRI to confirm occulsion around hook of hamate

Raynaud's disease- where the thumb is involved not so in hypothenar Hammer syndrome


What is the treatment for Hypothenar hammer syndrome?

Non operative: lifestyle changes- smoking cessation, avoid recurrent trauma= 80% success

Operative= when ischaemis in multiple digits= >

Resection of thrombotic / aneurysmal segment +/- local sympathectomy


Raynaud's syndrome consists of 2 diseases, name them?

Raynaud's Disease

Raynaud's phenomenon


What is the difference between Raynaud's disease and phenomenon?

Phenomenon= vasospastic disease with a cause/ disease

Disease= vasospastic disease with no cause found


Can you describe the eipdemiology of raynaud's phenomena?

Describe its pathology and signs?

Women >40

Female predominence

Path: Periodic digital ischemia induced by cold temperature or sympathetic stimuli including pain or emotional stress

Signs- triphasic colour change- white- blue -red


white= due to vasospam

blue to venous statsis

red- rebound hyperaemia


What are the condiiton assocaited with Raynaud's phenenoma?

Connective tissue disorders-

Scleroderma (80-90%)

SLE (18%-26%)

Dermatomyositis (30%)

RA (10%)

CREST Syndrome= calcinosis, Raynaud's, Eosphaygeal dysmolitiy, scleroderma, telangectasia

Neurovascular Compression- thoracic oulet syndrome


Are studies helpful in raynaud's phenomenon?

What is the TX?

Yes often abnormal blood chemistry, microangiology, angiography

Tx Non operative : treat underyling disease

Lifestyle modifications



Are studies helpful in Raynaud's disease?

How is it tx?

No- normal biochem etc, normal allen's test, as no underlying diseae is causeative

Tx; Non operative

lifestyle changes, avoid cold temperature, cessation smoking

medication- ca channel blockers, dipyridamole (Persantine), 

Surgery- Sympathectomy if consx tx fail




What is Buerger's disease aka Thromboangitis obliterans?

A nonartherosclerotic, segmental inflammatory disease of   small and medium vessels of hands and feet

A image thumb

What is the epidemiology of Buerger's disease?

What are the risk factors?

Common in smokers

Typically effects patients <45 yrs

Males 3: 1 female


Smoking and chewinf tobacco


What is the pathology of Buerger's disease?

Inflammation and clotting of the small vessels of hand and feet

3 Phases

Acute- thrombus including neutophils occlud vessel lumen sparing wall.

Subacute- organisaiton of the thrombus

Chronic- inflammation subsides- organised thrombus and fibrosis remains



What is the prognosis of Buerger's disease?

94% who quit smoking avoid amputation
43% chance of amputation within 8 years if smoking is continued




What are the signs and symptoms of Buerger's disease?

Intermittent claudication of feet and hands

Numbness/ tingling in extremities

rets pain

Signs- ulceration,large erythermatous blood vessels, necrosis of digit tips

sensory findings 70% patients

Absent pulses

Positive allen's test


A image thumb

What investigations are useful for Buerger's disease?

Arteriography- see corkscrew vessels (pic)

A image thumb

What is the tx for Buerger's disease?

Non operative-

Smoking cessation

Symptomatic treatment- avoid cold, daily aspirin,gentle exercise

Smoking cessation is the only treatment known to reduce the chances of amputation


Sympathectomy- controversial- cut nerves in pain area

Amputation- if gangrene/non healing ulces/ refractory pain


What is this?

What is it characterised by?

Q image thumb


Extensive soft tissue damage associated with exposure to temperatures below freezing point


What is the pathology of frostbite?

Cellular- movement of water from intracellular to extracellular which leads to cell dehyration and cell death

Ice crystals form extracellularly when temp = 6-15 degrees Celsius

Sensory nerve defecit ouccurs around 10 degrees celsius


What is the prognosis of frostbite?

Worsened with alcohol/ intoxication

Contat skin with ice/ metal

elevated wind chill factor


How does a patient present with frostbite?

Are any investigations helpful?

Development of blisters 6-24 hr post warming

superifical lesions= clear

Haemorrhagic- deeper= normal painless


Bone scan at 3rd day post injury can give idea on severity


How would you tx a patient with Frostbite?

Initial resuscitation with warm IV fluids

 Rewarming of the affected extremity 

 Wound care and topical antibiotics (prevent superficial infections)

Rewarming of body part

Perform in waterbath at a temperature of 40-44 degrees Celsius for 30 minutes.

This may require IV analgesia or even conscious sedation. Repetitive freeze-thaw cycles should be avoided

wound care

Topical aloe vera, extremity elevation and splinting white/clear blisters- require debridement

hemorrhagic blistersshould be drained, but left intact

IV tissue plasminogen activator if no evidence of blood flow.






















When would surgery be required in frostbite?

1) Circumferential frostbite-> Immediate surgical escharotomy

2) Surgical debridement +/- amputation - once demarcating is  complete - may take 1-3 months


What are the complications of frostbite in adults?

In children?


Cold intolerance

Vasopasic disease- Ca channel blockers or surgical sympathetectomy


Premature Growth plate closure

Joint laxity, short digits, degenerative disease- seen in patients >10 yrs with earlier disease.


What is Complex Regional pain syndrome aka Reflex Sympathetic Dystrophy?

When is this condition caused causalgia?

Sustained sympathetic activity in perpetuated reflex arc characterised by pain out of proportion to phsical examination findings


When a defined nerve is involved


What is the pathophysiology?

Trauma from an exageratted response to trauma- common poor outcome post crush injury ( foot)


Prolonged Immobilisation

Possible maligering



How can CRPS be prevented?

Vitamin C 500 mg daily is an effective prophylactic agent in distal radius fractures treated with conservative management- 

Vitamin C also has been shown to decrease the incidence of CRPS (type I) following foot and ankle surgery

Avoid tight dressings and immobilisation

Vitamin C is thought to reduce lipid peroxidation, scavenge free hydroxyl radicals, protect the capillary endothelium, and inhibit vascular permeability.

RCT by Zollinger in Lancet 1999- 115 adults with 119 fractures treated with conservative management. They found that RSD/CRPS occurred in four (7%) wrists in the vitamin C group (500mg daily for 50 days) and 14 (22%) in the placebo group.

2nd study by Zollinger in JBJS Br317 adult patients sustaining 328 distal radius fractures treated conservatively. They had allocated treatment groups to 200mg, 500mg, or 1500mg vitamin C dosages for 50 days. RSD/CRPS occurrence was 4.2% in the 200mg group, 1.8% in the 500mg group, and 1.7% in the 1500mg group and thus the 500mg dosage for 50 days was recommended at the conclusion of the study.

surgically - Cazanueve et al  belgium Acta orthop 2002- evaluated 195 patients who underwent open reduction internal fixation of a distal radius fracture. The first 100 did not receive vitamin C postoperatively. The next 95 patients received oral vitamin C for 45 days beginning the first day after surgery. The patients who received vitamin C had 5 times less incidence (2% vs. 10%) of reflex sympathetic dystrophy.



What is the classification system for CRPS?

Lankford and Evans ( bonnie lankford had red hair- red hands)

1) Acute 0-3 months, Pain, swelling, warmth, redness, decreased ROM, hyperhidrosis - picture- Normal xrays but positive 3 phase bone scan

2) Sub- Acute, 3-12mo, Worse pain, cyanosis, dry skin, stiffness, skin atrophy. xray= Osteopenia

3) Chronic >12 mo, Dimished pain, fibrosis, glossy skin, joint contractures. xray- Extreme osteopenia

A image thumb

What is the international study for pain classification of CRPS?

Type 1- CRPS without demonstrated nerve lesion=Most common

Type 2= CRPS with nerve damage


What are the cardinal signs of CRPS?

Exacerated Pain



Skin discolouration

A image thumb

What do you find on clinical examination of CRPS?

Trophic skin changes


vasomotor disturbance

Flamingo gait if knee involved


What investigations are useful in CRPS?

Xrays- define level of ostepenia

3 Phase bone scan

Phase 1 ( 2 mins)= arteriogram

Phase 2 (5-10mins) cellulitis/synovial inflammation

phase 3 ( 2-3rs) bone images

phase 4-  (24hrs) differentiates Osteomyelitis from adjacent cellulitis

RSD shows positive phase 3 not correlation to phase 1/2


What effects CRPS outcome?

Successful early diagnosis


What is the TX of CRPS?

Non operative:

Analgesia- refer to pain team early: NSAIDs, alpha blocking agents( phenozybenzamine), antidepressants, anticonvulsants,GABA agonists, Ca channel blockers. bisophonates for osteopenia.

Physical therapy- gentle stretchings ( type 1), tactile discrimination training, graded motor imagery,

Nerve stimulation- only for type 2 if one nerve effected can place on that nerve area

Chemical sympathectomy- when other consx tx fail


Sympathectomy- failed consx mx