Skeletal Radiol (2009) 38:929–932

DOI 10.1007/s00256-009-0715-9

CASE REPORT

Ultrasound and magnetic resonance angiography features

of post-traumatic ulnar artery pseudoaneurysm: a case
report and review of the literature
David Coll Gimenez & Oscar Valencoso Gilabert &
Joan Gimenez Ruiz & Carles Yanguas Muns &
Josep Badal Alter & M. Dolors Rosines Cubells

Received: 20 April 2009 / Accepted: 29 April 2009 / Published online: 20 May 2009
# ISS 2009

Abstract Ulnar artery pseudoaneurysms are very uncom- Introduction

mon. The least common etiological mechanism is a single
direct trauma. It is important to identify these lesions, which
may have important clinical complications such as distal
thrombosis with digital ischemia or gangrene. This report
describes the features of sonography and magnetic resonance
angiography of a histologically confirmed ulnar artery
pseudoaneurysm.
Keywords Ulnar artery . Sonography . Magnetic resonance
angiography . Wrist . Hypothenar hammer syndrome
Ulnar artery pseudoaneurysm is a rare entity with few
reports in the surgical literature. Although most ulnar artery
pseudoaneurysms are caused by chronic repetitive trauma, a
single, acute, traumatic, injury to an artery can also lead to
pseudoaneurysm formation. Pseudoaneurysms may be
erroneously diagnosed as soft-tissue tumors, based on
clinical and imaging findings. Awareness of the specific
imaging features of ulnar artery pseudoaneurysms may
improve the accuracy of the radiologic diagnosis, advance
the preoperative work-up, and prevent possible clinical
complications.

Case report
D. Coll Gimenez (*) : O. Valencoso Gilabert : C. Yanguas Muns
Department of Radiology, A 22-year-old man, professor of martial arts, came to the
Fundació Althaia. Xarxa Assistencial de Manresa,
emergency department with a 1-month history of a
C/ Joan Soler s/n 08243 Manresa,
Barcelona, Spain painful mass in the ulnar region of the right hypothenar
e-mail: estherdegeadavidcoll@yahoo.es eminence. The mass had appeared after he had delivered
a blow with his hand. Over the 3 days prior to his
J. Gimenez Ruiz
emergency visit, the mass had increased in size and he
Department of Radiology, Institut Mèdic per la Imatge,
C/ Caputxins 16 08243 Manresa, had developed paresthesias in the ring and little fingers
Barcelona, Spain of the right hand.
Physical examination revealed a pulsating soft mass in
J. Badal Alter
the hypothenar eminence of the right hand, and a positive
Department of Pathology,
Fundació Althaia. Xarxa Assistencial de Manresa, Tinel’s sign towards the cubital region. Gray scale and color
Barcelona, Spain Doppler ultrasound showed a cystic saccular formation
arising from the adjacent ulnar artery at the hook of the
M. D. Rosines Cubells
hamate bone, with internal turbulent flow (Fig. 1). Mag-
Department of Orthopaedic Surgery,
Fundació Althaia. Xarxa Assistencial de Manresa, netic resonance angiography was performed on a 1.5 T
Barcelona, Spain Siemens Simphony Maestro Class Quantum machine
930 Skeletal Radiol (2009) 38:929–932

a (Siemens Medical Systems, Erlangen, Germany) using a

large, circular, polarized, flex coil with the following
imaging parameters: axial and coronal T1-weighted sequen-
ces (TR/TE 327/14 ms ); axial and coronal T2-weighted
sequences (TR/TE range 3,000–3,142/29–92 ms); three-
* dimensional (3-D) gradient echo-sequences with matrix size
512 pixels×512 pixels; field of view 184 mm×159 mm ;
* partition thickness 1.6 mm; TR/TE 6,4/2.34 ms. After a
care-bolus test, the patient was given 15 ml of contrast
material, gadopentate dimeglumine (Magnevist, Schering,
Germany), injected at a rate of 4 ml/s. A thrombus in an
ulnar artery pseudoaneurysm was demonstrated, with
inflammatory peripheral wall enhancement (Fig. 2a, b).
b Maximum intensity projection reconstructions were made
and demonstrated correct flow, with no thrombosis in the
distal finger arteries from the superficial arterial arch
supplied by the radial artery (Fig. 2c).

* Initial conservative treatment failed. Although the

Fig. 1 a Longitudinal sonographic image shows the ulnar artery
pseudoaneurysm (white arrows) at the hook of the hamate bone
(arrowhead) and its proximal and distal communication with the ulnar
artery (white asterisks). b Longitudinal color Doppler sonographic
image shows turbulent flow (asterisk) within the pseudoaneurysm
pseudoaneurysm had decreased in size and was no longer
pulsating, the paresthesias did not resolve and the patient
experienced episodes of bluish discoloration of the ring and
little fingers. Because it was thought that the aneurysm had
undergone thrombosis, surgical excision was performed.
The lesion was seen to have a central thrombus on
macroscopic examination, and histology showed disruption
of the internal elastic lamina, confirming the diagnosis of
pseudoaneurysm of the right ulnar artery.

a b c

* *

Fig. 2 a Coronal T1-weighted image shows areas of high and low
signal intensity in the ulnar pseudoaneurysm, suggestive of thrombus
(white asterisk). b Coronal T1-weighted image with fat saturation
following intravenous administration of contrast agent demonstrates a
thrombus in the pseudoaneurysm (white asterisk) with inflammatory
peripheral wall enhancement (white arrow). c Maximum intensity
projection reconstructions were made and demonstrated correct flow,
with no thrombosis in the distal finger arteries from the superficial
arterial arch supplied by the radial artery (white arrow)
Skeletal Radiol (2009) 38:929–932
Discussion
Vascular lesions in the hypothenar eminence are very
uncommon [1]. The most frequently encountered vascular
soft-tissue abnormality is a hemangioma [1]. Pseudoaneur-
ysms of the ulnar artery are extremely rare. A 10-year
review by the Baltimore Hand Center, involving 30 upper
extremity aneurysms, revealed four radial and two ulnar
pseudoaneurysms of the wrist [2]. A 10-year review by the
Department of Surgery of Massachusetts General Hospital,
involving ten ulnar aneurysms of the wrist, revealed two
pseudoaneurysms and two thromboses [3]. Although most
ulnar artery pseudoaneurysms are caused by chronic
repetitive trauma, a single acute trauma with direct arterial
injury can also lead to formation of the lesion [2, 4, 5].
Anderson et al. compiled a list of 19 cases of ulnar artery
pseudoaneurysms from three countries over an 18-year
period [6]. Only one of these was due to a single traumatic
event.
Pseudoaneurysms are usually caused by perforation of
an artery, with hematoma formation between the arterial
wall and surrounding parenchyma. Flowing arterial blood
creates a cavity that remains in continuity with the normal
vessel [4, 7]. Histologically, there is an absence of internal
elastic lamina, and only adventitia is present. Ulnar artery
pseudoaneurysm is typically located in Guyon’s canal and
ranges in size from 3 mm to 27 mm, with a mean size of
10.5 mm. Hypothenar hammer syndrome is the term
applied to the signs and symptoms associated with ischemia
of the hands and fingers, resulting from blunt repetitive
injury to the ulnar artery and superficial volar arch by
compression against the hook of hamate. This syndrome
was first described by Conn et al. in 1870 in men of
working age with industrial occupations involving repeti-
tive blunt trauma to the hands [8].
Ulnar artery pseudoaneurysms often go unsuspected on
clinical examination. Most present as a soft-tissue mass
suggestive of tumor, and some as a soft-tissue mass
associated with peripheral symptoms, such as irritation of
the sensory branch of the ulnar nerve [9]. The correct
diagnosis is clinically important, because patients with
these lesions are at increased risk of distal thrombosis with
digital ischemia, gangrene, nerve compression, rupture or
bone erosion, and joint degeneration [2, 5, 7, 9].
Although only four of 25 patients with suggested hand
pseudoaneurysm in Anderson’s review underwent ultra-
sound study and the diagnosis was established in three, we
believe that sonography is the imaging method of choice
for diagnosing this entity [10]. The sonographic features of
ulnar artery pseudoaneurysm include a saccular cystic
formation arising directly from the adjacent ulnar artery
with internal turbulent blood flow [11]. Multidetector
computed tomography angiography and magnetic reso-
931
nance angiography (MRA) are recommended, to exclude
distal thromboembolic disease or thrombosis and to provide
preoperative information, such as normal anatomy and
anatomic variants [4, 12]. Visualization of a mass originat-
ing from the neurovascular bundle that has continuity with
the ulnar artery excludes all the radiological differential
diagnoses [6].
Other considerations in the differential diagnosis include
ganglion cyst, vascular malformation and benign and
malignant soft-tissue tumors. A ganglion cyst is not
vascular in nature and frequently demonstrates rim en-
hancement; it is often related to osteoarthritis of the
pisotriquetral joint. Benign tumors, such as schwannoma
of the ulnar nerve, are more common than malignant
tumors. They often have well-defined margins. Malignant
soft-tissue tumors are usually larger and may exhibit
irregular margins and occasional cystic or hemorrhagic
components [9].
Most authors recommend surgical treatment for ulnar
artery pseudoaneurysm. Resection of the affected arterial
segment is usually performed, with reconstruction by direct
anastomosis, when possible, or by interpositional venous
grafting. The choice of method depends on the size of the
lesion and the complications [4, 13, 14].
The presence of a soft-tissue mass in the hypothenar
region should alert the radiologist to pseudoaneurysm in the
differential diagnosis Awareness of the features of ulnar
artery pseudoaneurysm allows an accurate diagnosis to be
made and a prompt preoperative work-up to be done. [6].
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