Introduction Overview hook of hamate fractures are rare, often missed, injuries generally as a result of a direct blow to the hamate bone most commonly seen in athletes treatment is generally patient-specific and depends on chronicity of injury Epidemiology incidence 2-4% of carpal fractures demographics more common in males (2:1 ratio) location hamate body hook of hamate (this topic) risk factors often seen in athletes in sports requiring gripping golf baseball hockey Pathophysiology mechanism of injury typically caused by a direct blow to the volar proximal palm grounding a golf club checking a baseball bat falling on outstretched hand Associated conditions bipartite hamate will have smooth cortical surfaces small finger/ring finger flexor tendonitis or tendon rupture ulnar neuropathy in Guyon's canal ipsilateral carpal bone fracture Prognosis high non-union rate with conservative management (up to 50%) Anatomy Hamate osteology carpal bone that is distal and radial to the pisiform articulates with fourth and fifth metacarpals capitate triquetrum hook of hamate forms part of Guyon's canal, which is formed by roof - superficial palmar carpal ligament floor - deep flexor retinaculum, hypothenar muscles ulnar border - pisiform and pisohamate ligament radial border - hook of hamate one of the palpable attachments of the flexor retinaculum deep branch of ulnar nerve lies under the hook blood supply vessels enter the hamate base via a radial and ulnar foramina to supply the hook of the hamate ulnar vessel is absent in 29% of patients absent ulnar vessel considered the reason for high non-union rate of hook of hamate fractures Classification Milch Classification Description Subtypes Image Type I Hook of hamate fx (most common) • I - avulsion • II - middle of hook • III - base of hook Type II Body of hamate fx • IIA - coronal • IIB - transverse Presentation History commonly a delay in diagnosis average of 4 weeks from injury to diagnosis Symptoms ulnar-sided wrist pain most common complaint hypothenar pain pain with activities requiring tight grip Physical examination motion limitation in ulnar deviation decreased grip strength neurovascular exam paresthesia in ulnar nerve distribution positive tinel's over Guyon's canal may be present motor weakness in intrinsics provocative maneuver tenderness over the hook of hamate most common finding (80% sensitivity) hook of hamate pull test hand held in ulnar deviation as patient flexes DIP joints of the ulnar 2 digits against resistance the flexor tendons act as a deforming force on the fracture site, positive test elicits pain 70% sensitivity pain with dorsoulnar deviation of wrist Imaging Radiographs recommended views PA and lateral of wrist 10% sensitivity carpal tunnel view best radiograph to see hook of hamate fracture 40% sensitivity findings PA view absence of eye sign or cortical ring normally produced by intact hook CT indications establish diagnosis if radiographs are negative 92% sensitivity can be missed if nondisplaced and if CT cuts greater than 1 mm MRI indications most accurate method of diagnosis in cases of high-clinical suspicion 100% sensitivity Treatment Nonoperative immobilization 6 weeks indications majority of nondisplaced acute hook of hamate fractures outcomes high-levels of non-union (40-50%) majority of patients are pain-free and have full ROM despite non-union Operative excision indications symptomatic chronic hook of hamate fractures with non-union hook of hamate fractures with ulnar neuritis high-level athletes outcomes surgical treatment of choice fastest recovery and return to play noted for athletes who wish for prompt return to play some studies show decreased small finger FDP tendon strength by 10-15% with excision excision leads to 5 mm of ulnar displacement of small finger FDP tendon ORIF indications acute and significantly displaced fractures in patient's unable to tolerate reduction in grip strength outcomes small case series have shown nearly 100% union rate theoretically improved grip strength compared to excision Techniques immobilization technique short arm ulnar gutter cast excision approach modified volar wrist incision in lined with the ulnar border of ring finger technique release of the guyon canal generally also performed hook should be removed subperiosteally to avoid damage to motor branch of ulnar nerve ORIF approach see above technique small-fragment headless compression or countersunk screws screws need to be countersunk to prevent irritation of the deep motor branch of the ulnar nerve in cases of ulnar neuritis neurolysis of deep motor branch of ulnar nerve is recommended. Complications Non-union incidence (most common) 50% rate of non-union risk factors considered natural course of fracture given fracture site motion and poor blood supply Ulnar nerve neuritis in Guyon's canal incidence 20% rate of ulnar neuropathy treatment hook of hamate excision Closed rupture of the flexor tendons to the small finger incidence very rare (only case reports) Weakened grip strength risk factors excision of large hook of hamate fractures
QUESTIONS 1 of 8 1 2 3 4 5 6 7 8 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ11.130) A 24-year-old racquetball player presents after accidentally striking his racket against the wall during a match three 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? Review Topic | Tested Concept QID: 3553 FIGURES: A B Type & Select Correct Answer 1 Activity restriction and continued monitoring 4% (141/4005) 2 Open reduction and internal fixation 4% (150/4005) 3 Casting for 6 weeks, followed by physical therapy 6% (238/4005) 4 Corticosteroid injection and immediate return to play 0% (16/4005) 5 Surgical excision 86% (3437/4005) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review tested concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? Review Topic | Tested Concept QID: 409 Type & Select Correct Answer 1 PA wrist 2% (58/3195) 2 AP wrist in ulnar deviation 4% (134/3195) 3 Lateral wrist 5% (150/3195) 4 Carpal tunnel 88% (2816/3195) 5 Scaphoid 1% (17/3195) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review tested concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ07SM.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? Review Topic | Tested Concept QID: 1425 Type & Select Correct Answer 1 Bone scan of the wrist and hand 1% (17/3138) 2 EMG study of the affected extremity 17% (537/3138) 3 Carpal tunnel view radiograph 74% (2320/3138) 4 CT scan of the distal forearm and wrist 4% (115/3138) 5 Contrast enhanced magnetic resonance angiogram 4% (129/3138) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review tested concept (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? Review Topic | Tested Concept QID: 132 FIGURES: A Type & Select Correct Answer 1 pisiform excision 2% (40/2500) 2 hook of hamate excision 92% (2291/2500) 3 carpal tunnel release 0% (7/2500) 4 decompression of Guyon's canal 1% (14/2500) 5 open reduction and internal fixation 5% (128/2500) L 1 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review tested concept
All Videos (2) Podcasts (0) Upgrade to View Premium Videos Upgrade to View Premium Videos Everything You Need to Know About the Hook of Hamate Richard Yoon General - Hook of Hamate Fracture 2/8/2015 909 views (5) Upgrade to View Premium Videos Upgrade to View Premium Videos Hook of hamate palpation Richard Yoon Hand - Hook of Hamate Fracture 2/8/2015 2041 views (11)
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