Hook of Hamate Fracture

Author: Patrick McCulloch

Topic updated on 02/20/13 5:42pm

Introduction

Hamate fractures includes
- hook of hamate fx (most common)
- hamate body fx (very rare)
Present with history of blunt trauma to palm of hand
- often seen in racquet sports
  - hockey
  - golf (miss ball and hit ground)
  - tennis
Must distinguish from bipartite hamate (will have smooth cortical surfaces)

Presentation

Symptoms
- hypothenar pain
- decreased grip strength
- paresthesias in ring and small finger (ulnar nerve compression in Guyon's canal) and occasionally in thumb, index, middle and ring finger (median nerve compression in carpal tunnel)
- motor weakness of intrinsics (ulnar nerve compression in Guyon's canal)

Imaging

Radiographs
- recommended views
  - difficult to visualize fracture on AP
  - best seen on a carpal tunnel view
CT
- best study to make diagnosis

Treatment

Nonoperative
- immobilization 4-6 weeks
  - acute hook of hamate fractures
  - body of hamate fx (rare)
Operative
- excision of hamate fracture fragment
  - indications
    - chronic hook of hamate fxs
- ORIF
  - indications
    - ORIF is possible but has little benefit

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Qbank (3 Questions)

TAG

(SBQ07.40) A 44-year-old man presents with ulnar-sided right wrist pain and mild constant tingling in the fourth and fifth digits after injuring his wrist while playing golf. Although pain and function have improved with conservative treatment 6 months following the injury, he still reports difficulty with his golf game. Which of the following should initially be obtained in this patient to aide in the diagnosis? Topic

Review Topic

1. Bone scan of the wrist and hand
2. EMG study of the affected extremity
3. Carpal tunnel view radiograph
4. CT scan of the distal forearm and wrist
5. Contrast enhanced magnetic resonance angiogram

PREFERRED RESPONSE ▶

DISCUSSION: This patients clinical presentation is most consistent with a chronic hook of the hamate fracture, which should initially be evaluated with a carpal tunnel view radiograph. Hook of the hamate fractures typically are associated with pain localized to the hypothenar eminence, and chronic cases can be associated with neuropathy of the ulnar nerve. Excision of the hook through the fracture site usually yields satisfactory results in the presence of chronic injuries.

Parker et al treated five patients with six hook of the hamate fractures over an eight year period. All patients ultimately underwent hook resection and returned to their previous level of activity in 6 to 8 weeks after surgery without loss of function. Based on their case series, they concluded that the entire hook should be resected to the base of the hamate as the primary form of treatment in hook of the hamate fractures.

Illustration A: Patient positioning for carpal tunnel radiograph-wrist is extended 70 degrees, and beam is angled 25-30 deg to the long axis of the hand(arrow).

Illustration B: Carpal tunnel view radiograph demonstrates a fracture at the base of the hook of the hamate(black arrow) and normal pisotriquetral joint space.

Incorrect Answers:
1-Bone scans are not typically indicated in the diganostic setting of acute or chronic hook of the hamate fractures.
2-Imaging should be obtained to rule out bony injury prior to obtaining an EMG study.
4-CT scans can used to confirm the diagnosis of a hook of the hamate fracture after obtaining a carpal tunnel view radiograph.
5-Contrast enhanged MRA of the wrist is typically used to diagnose hypothenar hammer syndrome or other vascular abnormalities.

Illustrations: A

REFERENCES:

1. Parker RD, Berkowitz MS, Brahms MA, Bohl WR. Hook of the hamate fractures in PMID:3799882 (Link to Abstract)

2. Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 113-128

Question Authors:

Joshua Blomberg MD, Michael Hughes MD, Jan Szatkowski MD,

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(OBQ11.130) A 24-year-old racquetball player presents after accidentally striking his racket against the wall during a match two months ago. He is tender to palpation over the hypothenar mass, and his pain is aggrevated by grasping. A radiograph and CT scan of his wrist are shown in Figures A and B. Which of the following treatment methods has been definitively shown in the literature to have a favorable outcome, and a high chance to return to pre-injury activities in patients with this injury? Topic

Review Topic

FIGURES: A

1. Activity restriction and continued monitoring
2. Open reduction and internal fixation
3. Casting for 6 weeks, followed by physical therapy
4. Corticosteroid injection and immediate return to play
5. Surgical excision

PREFERRED RESPONSE ▶

DISCUSSION: The patients history and imaging are consistent with a subacute hook of the hamate fracture. This is demonstrated by the carpal tunnel view radiograph in Figure A, and confirmed by the CT scan of the wrist in Figure B. CT scan of the wrist is usually indicated to definitively diagnose these fractures. Current literature supports the most favorable results and ability to return to pre-injury activities with excision of the fracture fragment. There is little available literature reporting the results of open reduction and internal fixation of these fractures.

Rettig et al review traumatic wrist injuries in athletes. With regards to treatment of hook of the hamate fractures, they state that ORIF and excision are the two viable treatment options in athletes. Of these, the literature supports fragment excision, which has an average return to sport time of 7-10 weeks.

Welling et al determined which wrist fractures are not diagnosed with initial radiography, using CT as a gold standard and identified specific fracture patterns. In their series, they found that only 40% of hamate fractures were diagnosed on plain radiography, suggesting that CT should be considered after a negative radiographic finding if clinically warranted.

REFERENCES:

1. Rettig AC. Athletic injuries of the wrist and hand. Part I: traumatic injuries of the wrist. Am J Sports Med. 2003 Nov-Dec;31(6):1038-48. Review. PMID:14623677 (Link to Abstract)

2. Welling RD, Jacobson JA, Jamadar DA, Chong S, Caoili EM, Jebson PJ. MDCT and radiography of wrist fractures: radiographic sensitivity and fracture patterns. AJR Am J Roentgenol. 2008 Jan;190(1):10-6. PMID:18094287 (Link to Abstract)

Question Authors:

Joshua Blomberg MD, Ben Taylor MD, John Badylak MD,

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(OBQ08.23) A professional baseball player develops acute hand pain after fouling off a pitch. He is tender over the hypothenar eminence and has paresthesias in the ring and small fingers. Which radiographic view is most likely to reveal the pathology? Topic

Review Topic

1. PA wrist
2. AP wrist in ulnar deviation
3. Lateral wrist
4. Carpal tunnel
5. Scaphoid

PREFERRED RESPONSE ▶

DISCUSSION: Plain radiographs usually do not reveal the fracture; carpal tunnel and supinated oblique views should be obtained. Diagnosis is confirmed by CT scan and bone scan.

Fractures of the body of the hamate may occur from trauma and may occur in combination with fractures of the base of the fourth and fifth metacarpals. Fractures of the hook of the hamate are more common in athletes. The incidence of hook of the hamate fractures is 2% to 4% of all carpal fractures. The mechanism of injury is thought to be caused by abutment of the hook on an object or by a shearing force applied by the flexor tendon of the small and ring fingers. The injury usually occurs in athletes who participate in baseball, golf, and racquet sports because of the position of the implement in the hand.

Rettig reviewed hand injuries in athletes. He noted that hamate hook fractures occur in a watershed area that may explain the high incidence of nonunion post fractures. Hook of the hamate fracture must be suspected in athletes participating in racquet sports, golf, or baseball who are seen with ulnar wrist pain. Examination reveals tenderness over the hook of the hamate, which lies on a line between the pisiform and second metacarpal head. Treatment of hook of the hamate fractures in athletes varies from casting to open reduction and internal fixation to excision.

Bishop and Beckenbaugh reported 21 cases of this fracture: 17 were treated by excision, 3 underwent ORIF, and 1 had casting. Although two of three fractures that were treated with ORIF healed, many authors recommend excision, which has an average return to sport of 6 to 10 weeks.

Illustration A shows a representative carpal tunnel view, with the bony anatomy labeled.

Illustrations: A

REFERENCES:

1. Miller, Cooper, Warner (eds) Review of Sports Medicine and Arthroscopy. Phila, PA 2003, pp 240-260.

2. Rettig AC: Athletic injuries to the wrist and hand. Part I: Traumatic injuries of the wrist. Am J Sports Med 2003; 31:1038-1048. PMID:14623677 (Link to Abstract)

3. Bishop AT, Beckenbaugh RD. Fracture of the hamate hook. J Hand Surg Am. 1988 Jan;13(1):135-9 PMID:3351218 (Link to Abstract)

Question Authors:

Patrick McCulloch MD, Derek Moore, Ben Taylor MD,

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(OBQ04.21) A 24-year-old professional baseball outfielder reports persistent pain in the hypothenar region when batting for the past year. His CT scan is shown in Figure A. What is the recommended treatment? Topic

Review Topic

FIGURES: A

1. pisiform excision
2. hook of hamate excision
3. carpal tunnel release
4. decompression of Guyon's canal
5. open reduction and internal fixation

PREFERRED RESPONSE ▶

DISCUSSION: The history is typical of a hook of the hamate fracture, which is confirmed on the CT image. A carpal tunnel view radiograph of this injury is shown in Illustration A. It commonly occurs in baseball players and golfers. Physical exam findings include point tenderness at the hamate, ulnar nerve paresthesias (hemorrhage within Guyon's canal), and pain with axial load of ring and little fingers. For cases seen late, with few exceptions, the recommended treatment has been excision of the hook fragment. Marchessault provides a review of diagnoses and treatment for carpal fractures. They discuss the treatment of these injuries, indicating that acute, nondisplaced fractures may be placed in a cast, and excised if nonunion develops. The authors go on to say that certain investigators recommend excision of asymptomatic nonunions to minimize the risk for flexor tendon rupture.

Illustrations: A

REFERENCES:

1. Marchessault J, Conti M, Baratz ME. Carpal fractures in athletes excluding the scaphoid. Hand Clin. 2009 Aug;25(3):371-88. PMID:19643337 (Link to Abstract)

Question Authors:

Mark Vitale MD, Derek Moore, Patrick McCulloch MD,

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Posts

MDCT and Radiography of Wrist Fractures: Radiographic Sensitivity and Fracture Patterns. Includes Poll

Welling RD, Jacobson JA, Jamadar DA, Chong S, Caoili EM, Jebson PJ
AJR Am J Roentgenol. 2008 Jan;190(1):10-6. PMID: 18094287 (Link to Pubmed)

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Evidence & References Show References

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012

Undefined

Bishop AT, Beckenbaugh RD. Fracture of the hamate hook. J Hand Surg Am. 1988 Jan;13(1):135-9 PMID:3351218 (Link to Abstract)
Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 113-128
Marchessault J, Conti M, Baratz ME. Carpal fractures in athletes excluding the scaphoid. Hand Clin. 2009 Aug;25(3):371-88. PMID:19643337 (Link to Abstract)
Miller, Cooper, Warner (eds) Review of Sports Medicine and Arthroscopy. Phila, PA 2003, pp 240-260.
Parker RD, Berkowitz MS, Brahms MA, Bohl WR. Hook of the hamate fractures in PMID:3799882 (Link to Abstract)
Rettig AC. Athletic injuries of the wrist and hand. Part I: traumatic injuries of the wrist. Am J Sports Med. 2003 Nov-Dec;31(6):1038-48. Review. PMID:14623677 (Link to Abstract)
Rettig AC: Athletic injuries to the wrist and hand. Part I: Traumatic injuries of the wrist. Am J Sports Med 2003; 31:1038-1048. PMID:14623677 (Link to Abstract)
Welling RD, Jacobson JA, Jamadar DA, Chong S, Caoili EM, Jebson PJ. MDCT and radiography of wrist fractures: radiographic sensitivity and fracture patterns. AJR Am J Roentgenol. 2008 Jan;190(1):10-6. PMID:18094287 (Link to Abstract)

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Hook of Hamate Fracture

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