A 43-year-old man presented with no relevant past medical, family or social history except for 1 pack-a-day tobacco use.

Several-week history of right fourth- or fifth-digit coolness, pain, and ulceration of fourth digit.

No medications.

Patient’s occupation was manual labor.

His physical examination showed the following:

There were 2+ carotid, brachial, radial, femoral, popliteal, and pedal pulses. He did not have an ulnar pulse on the right side.

He had ischemia of his right fourth and fifth fingers, with decreased capillary refill, and there was a dry, and ischemic ulceration over the nail bed laterally on the fourth finger. No signs of infection were present.

A Doppler signal was present over the palmar arch until the radial artery was manually compressed.

Repetitive use of the palm of the hand in activities that include pounding and pushing.

Anatomic site of injury to the ulnar artery is in the hypothenar eminence (Figure 19-1). The terminal branches of the ulnar artery arise in a groove that is bounded medially by the hamate bone.

As the distal ulnar artery lies superficially in the palm, it is covered for approximately 2 cm by only the skin, subcutaneous tissue, and the palmaris brevis muscle. Therefore, pounding and pushing of the hand causes the ulnar artery to hit the hamate bone repeatedly.

When this area is repeatedly traumatized, ulnar or digital spasm, aneurysms, occlusion, or a combination of these can result.

Intimal damage results in thrombotic occlusion. Damage to the media results in palmar aneurysms.

Fourth digit is most often involved.

Differentiated from Raynaud phenomenon by the lack of tricolor changes and sometimes absence of thumb involvement.