The occupational therapists approach part 2 e x p l o r i n. Closed rupture of the flexor tendons of the little finger secondary to non union of fractures of the hook of the hamate published online. But the patients were generally satisfied with the results on the last followup. These fractures occur frequently in individuals participating in sports activities involving racquets, bats, or clubs. Diagnosis and management of hook of hamate fractures assaf. Fracture of the body of hamate associated with a fracture of the base of fourth metacarpal. Isolated hook of hamate fracture in sports that require a st. On a pa view three arcuate lines can be drawn along the carpal surfaces if there is disruption or widening of the spaces it may indicate carpal instability or damage to the ligaments ct scan is the preferred study for diagnosis of hook of hamate fractures. Hook of the hamate fracture in golfers another distinctive golf injury is fracture of the hook of the hamate, one of the small bones of the wrist. Although the risk of hook nonunion is difficult to quantify given that most are identified as delayed or nonunions rather than acute injuries, one. The most common history is of hitting the ground during a golf shot, with the handle of the club being forced into the palm of the left hand for a right handed golfer during the resulting jolt. In most cases, the lead wrist, which is the left wrist in a right handed golfer, is most commonly fractured when the player strikes the ground, root or rock prior to striking.
Often, however, the displaced hook has to be surgically removed to take pressure off the ulna nerve. If nonunion does occur excision or open reduction and. Finger tendon rupture secondary to fracture of the hamate. These fractures may occur by direct trauma or indirect mechanisms. Ultrasound treatment of nonunion of the hook of the hamate. This condition is known as fracture of hook of hamate. Advanced imaging with ct or mri usually establishes the diagnosis in the acute or chronic phase 2, 10. The fracture cannot always be detected clinically and standard radiographs do not always provide an overlapfree image of the hook of the hamate, so that fractures can easily be overlooked. Ununited hook of hamate fracture on ct sagittal view. The purpose of this study was to evaluate the time to diagnosis and management of hook of hamate fractures in an era of advanced imaging. Hamate hook nonunion initially mistaken for ulnar nerve. Fractures of the hook of the hamate are more common and have been associated with diagnostic delay and delayed or nonunion. Hamate hook hh stress fractures are rare, often presenting with misleading symptoms and easily overlookedmisdiagnosed.
Fracture of the hook hamulus of the hamate hamate treatment may consist of splinting or casting if the fracture is seen very early after injury. Treatment of symptomatic displaced fractures, nonunion, and nondisplaced hook fractures. Sep 03, 2018 hamate is a bone, which is located on the outside or the little finger side of the wrist and has a hook shaped structure at the end. Several professional baseball players have had the bone removed during the course of. Case report of right hamate hook fracture in a patient. Pdf surgical excision of ununited hook of hamate fractures via the. Hook of the hamate hamate fracture ulnar nerve cicompression of the nerve at gguyons canal ulnar volar fcu palpate at ulnar volar wrist. Hamate hook fractures are rare injuries, comprising 2% to 4% of all carpal fractures.
The two main types of hamate fractures are hook fractures type 1 and body fractures type 2. Displaced fractures require an anatomic reduction to prevent abnormal joint mechanics and softtissue irritation. Acute fractures of the hook of the hamate are frequently not seen on plain radiography. Diffinitively dx with carpal tunnel view radiograph if suspicion is high. As the table 1 showing, in 74 cases the main reason of hamate hook fracture is sports and 33 cases of trauma other than sports. Aug 06, 2018 in the past, hamate hook fractures were treated conservatively with lower arm cast immobilization for 6 weeks, provided the fracture was diagnosed within 1 week of the injury. The clinical presentation is pain with palpation over the hook and painful grip. It may result in guyons canal syndrome differential diagnosis. Hamate hook fracture is a common fracture in golfers and others who play sports that involve rackets or sticks such as tennis or hockey. Immobilisation has been an effective non invasive treatment to a hamate hook fracture, however is most effective if the fracture is treated within the first week. Twentynine patients with hamate fractures were treated. Cronic nonunions may result in flexor tendon rupure and other complications.
But if you live in an area with cold winters, golfs outdoor nature can be one of the worst things about it too. Aug 27, 2010 we report the case of a missed fracture through the body of the hamate bone, only detected on a later, mistakenly taken 30 oblique xray view. One patient with a subacute fracture did not comply with treatment and had a painful nonunion. The hook of the hamate acts as a pulley for the flexor tendons for the little and ring fingers. Nonunion was detected on computed tomography ct and was exposed to ultrasound for 20 min a day for 4 months. The hamate is the most ulnar carpal bone on the distal row. Hook of hamate fractures are prone to nonunion, and their diagnosis is frequently delayed or missed. There were 15 type 1, 11 type 2a and three type 2b fractures. Rupture of small finger flexor tendons secondary to. Therapeutic alternatives in nonunion of hamate hook.
The blood supply to the hamate is variable with 70% have only vascular supply to the body predisposing hook fractures to non union. Wrist secrets the occupational therapists approach part 2 e x p l o r i n g h a n d t h e r a p e y x p l o r i n g h a n d t h e r a p y t r e a t men t 2 g o w w w. Patients were sent a quickdash questionnaire regarding the outcomes of their treatment. The most common history is of hitting the ground during a golf shot, with the handle of the club being forced into the palm of the left hand. Although ulnar nerve compression has been associated with these fractures bishop and beckenbaugh, 1988, median nerve compression is an uncommon complication manske, 1978.
Urch et al have reported that, among total carpal bone cases, the hamate accounts for only 2% of fractures, in contrast with the scaphoid which accounts for 70%. The standard wrist radiographs ordered for assessment of the carpal bones include ap, lateral and oblique views. Because of the variable and occult presentation of the fracture, the diagnosis can be challenging. Pdf fragment excision for the treatment of hamate hook. Lessons to be learned from a missed case of hamate. Hamate body fractures are managed in a slightly different manner compared with hook fractures. Treatment of hook of the hamate fracture depends on the acuity of diagnosis, degree of displacement, and location of fracture.
We subdivided type 2 fractures according to the fracture line into coronal, type 2a and transverse, type 2b. The hook of hamate is particularly prone to fracture related complications such as non union due to its tenuous blood supply. The flexor tendon was repaired by using the ulnar half slip of the flexor superficialis of the ring finger as an interposed tendon graft. Fractures are the most common abnormality but account for less than 4% of carpal fractures 1, 2. If a symptomatic nonunion develops, the hook of hamate can be excised. Treatment of hamate hook fractures includes immobilisation with casting, excision or reduction and internal fixation 4. Several professional baseball players have had the bone removed during the course of their careers. Fracture of hook of hamatecausessignssymptomstreatment. Since the hook of the hamate forms the distal and ulnar border of the carpal tunnel, it is understandable that fractures of the hamate. The hook of the hamate fracture constitutes nearly 24% of carpal fractures and is typically caused by a direct blow, such as grounding a golf club or checking a baseball bat. Treatment for most patients is excision of the small fracture fragment.
Jun 04, 2015 the hook of the hamate pull test is a dynamic test commonly used to assess for hook fractures. The hook of hamate fracture is usually caused by inappropriate positioning of the instrument where the end of a club or butt of a racquet exerts force on the hamate directly or when there is a shearing force applied by the extrinsic flexor tendons of the ring and little fingers on the hook of hamate. The patients were baseball players and had been injured as a result of hitting repeatedly. Scaphoid and hook of hamate fractures move well pty ltd scaphoid fractures most commonly occur as a result of a fall onto an outstretched hand.
The hamate bone is one of eight carpal bones, it is a triangular bone, composed of a body and a hook hamulus, located on the ulnar side of the distal carpal row the hamate is a triangularshaped bone that forms part of the distal carpal row, articulating with the capitate radially, triquetrum proximally and fifth and fourth metacarpals distally. In both cases pain at the hypothenar eminence disappeared, and bone union was. Hook of hamate fractures in competitive baseball players. Symptoms are nonspecific and often mimic other clinical conditions, such as ulnar nerve entrapment or ulnar vessel thrombosis. Diagnosis of a hamate hook fracture with 3d reconstruction. The typical natural history patterns of missed hook of the hamate fractures include uncomplicated fracture healing, asymptomatic nonunion, and. The possibility of a hamate hook fracture should be considered even in the absence of tenderness over the hook or in the face of normal wrist imaging. Symptoms are non specific and often mimic other clinical conditions, such as ulnar nerve entrapment or ulnar vessel thrombosis. Most commonly, fracture of the hook of the hamate occurs in sports involving racquets or clubs. We performed a retrospective study of 51 patients treated for hook of hamate fractures. Fractured hamate bone from golf causes and treatment. Tendon rupture of the flexor digitorum profundus of the. They occur from the hamate fracturing after blunt trauma, falls, and in sports player e. This case highlights some of the problems encountered with traditional xray views, and the need to consider oblique views as either standard procedure or as an adjunct where clinical suspicion remains high even in the presence of normal xrays.
How to manage triquetrum and hamate fractures in unusual. Aids to the diagnosis of hook fractures have been the carpal tunnel view abbitt and riddervold, 1987. Fractures of the hook of the hamate are more common and have been associated with diagnostic delay and delayed or non union. Chronic symptomatic nonunion including chronic ulnarsided wrist pain, reduced grip strength, ulnar neuropathy secondary to nerve. Hamate nonunion is frequently associated with irritation of the adjacent soft tissues. Concomitant hook of hamate fractures in patients with scaphoid. Hamate hook fractures are rare injuries but appear to occur frequently in underwater rugby, the reason for which was investigated in this study. There are 157 males, 25 females and 23 cases not be discerned. Pdf fragment excision for the treatment of hamate hook nonunion.
An unrecognized and untreated hamate hook fracture may lead to a partial or complete rupture of the ivth or vth deep or superficial flexors fig. Wrist secrets the occupational therapists approach part 2. Hand xray appears nml ap view frequently is nondiagnostic with hamate fractures esp hook fx. Ultrasound treatment of nonunion of the hook of the hamate in. The prevalence of unanticipated hamate hook abnormalities in. The hook of hamate is particularly prone to fracturerelated complications such as nonunion due to its tenuous blood supply. Fracture of the hook of the hamate is often not seen on xray studies, and fracture fragments can cause compression of adjacent structures, including the ulnar and median nerves and ulnar artery. Nondisplaced body fractures are treated in a short arm cast for 4 to 6 weeks until radiographic evidence of union.
Despite its continued importance as a key anatomic landmark in modern medicine, the hook of the hamate remains a source of diagnostic errors in current clinical practice 3, 4. Diagnosis and management of hook of hamate fractures. Curvilinear incision centred over the carpal tunnel, then the transverse carpal ligament is identi. Request pdf therapeutic alternatives in nonunion of hamate hook fractures symptomatic nonunion frequently results after conservative treatment of. Features of intrahamate vascularity and its possible relati. A hook of hamate fracture is the term used for a break in the hook portion of the hamate bone. Pathologic conditions affecting the hook of the hamate are uncommon. Nondisplaced fractures within 3 months of injury initially receive conservative treatment with cast immobilization, 14, 21, 24.
Oct 24, 2019 nonoperative treatment of acute hamate hook fractures. Two cases of nonunion of the hook of the hamate were treated with lowintensity pulsed ultrasound. These fractures notoriously heal poorly and require quite significant immobilisation and rehabilitation following removal of the plaster cast. While fracture to the scaphoid or navicular is the most prevalent of wrist fractures, hamate hook fracture is the most frequent fracture in golfers. The hook is the particular part of that bone that protrudes toward your palm, and is vulnerable to injury from the club on a hard hit to the ground as the handle crosses right over the bony hook when.
If a symptomatic non union develops, the hook of hamate can be excised at a later date. Immobilisation has been an effective noninvasive treatment to a hamate hook fracture, however is most effective if the fracture is treated within the first week. Gittlen, 1984, oblique views, bone scan, tomograms, and cat scan. We report the case of hamate nonunion that was only detected because of a flexor digitorum profundus tendon rupture in the little finger, associated with. There was also a nondisplaced fracture line at the base of the fourth metacarpal bone. The initial xrays showed fracture lines in the mid portion of the triquetrum and body of the hamate bone, which were passing obliquely to the radial side of the hook figure 1. Classification and treatment of hamate fractures hand surgery. Case report of right hamate hook fracture in a patient with. Highlevel underwater rugby players with hook fractures diagnosed during a fiveyear interval 20052010 were studied retrospectively. Carpal fractures in athletes excluding the scaphoid. Further investigations, using 2d and 3d computerized tomography. Coronal non contrast undisplaced fracture through the base of the hook of the hamate.
Resisted flexion of the fourth and fifth digits displaces the fracture and causes pain. Scaphoid and hook of hamate fractures move well pty ltd. Yamazaki h, kato h, nakatsuchi y, murakami n, hata y. Lessons to be learned from a missed case of hamate fracture. Delayed diagnosis in nonunion of the body of the hamate. Hamate fractures can be diagnosed incidental to other hand and wrist problems on ct. The blood supply to the hamate is variable with 70% have only vascular supply to the body predisposing hook fractures to nonunion. Therapeutic alternatives in nonunion of hamate hook fractures.
The inclusion criteria were 1 hook of hamate fracture, 2 competitive baseball players, and 3 surgical treatment of the injury. Retrospective analyses have demonstrated nonunion rates greater than 50% and as high as 8090% with conservative treatment. During a forceful swing, the base of the club can impinge against the hook of the hamate and cause a fracture fig. From the view of classification, the fracture of the hamate hook has a significantly high rate of non union p 0. Coronal noncontrast undisplaced fracture through the base of the hook of the hamate. Hook of hamate fracture radiology reference article.
These small carpal bones form two rows of four, the cubelike bones articulate on one side with the radius and ulna bones of the forearm and on the other side with the. The hook of hamate is raised from the body of the hamate bone. Anatomical variants of incomplete fusion of the hook of the hamate to the body os hamulus proprius may be confused with nonunion. Nov 15, 2016 hamate hook hh stress fractures are rare, often presenting with misleading symptoms and easily overlookedmisdiagnosed. Golfs association with the beautiful outdoors is one of the best things about it. Dorsal percutaneous cannulated miniscrew fixation for fractures of the hamate hook. The primary etiology of the hamate hook fracture is athletics 74205,36%, and the second is fall and traffic accident 61205,30%. There was also a non displaced fracture line at the base of the fourth metacarpal bone. Theres nothing like soaking in some glorious vitamin d while working on your swing. Surgical excision of ununited hook of hamate fractures via the carpal tunnel approach. The hook of the hamate pull test is a dynamic test commonly used to assess for hook fractures.
From the view of classification, the fracture of the hamate hook has a significantly high rate of nonunion p 0. Non displaced fractures within 3 months of injury initially receive conservative treatment with cast immobilization, 14, 21, 24. Diagnosis of a hamate hook fracture with 3d reconstruction of. If displaced or seen late with continued pain, numbness and tingling, or tendon irritation, surgery is usually performed to remove the broken bone fragment. Sep 20, 2003 two cases of nonunion of the hook of the hamate were treated with lowintensity pulsed ultrasound. Anatomical variants of incomplete fusion of the hook of the hamate to the body os hamulus proprius may be confused with non union. Hook of the hamate fracture 24 % of all carpal fractures golf, baseball, and hockey mechanism of injury blunt trauma end of swing fall on extended wrist hook of hamate fracture presentation pain at the volar ulnar aspect of the hand worsened with a tight grip examination point tenderness pain with grip. A 19 year old male presented with a complaint of right wrist pain on the ulnar side of the wrist with no apparent mechanism of injury. Their exact frequency is unknown due to the lack of clear data. Nonoperative treatment of acute hamate hook fractures.
Wrist pain is often seen in chiropractic practices. Computed tomography, hamate hook fracture, nonunion. Features of intrahamate vascularity and its possible. Fractures of the hook can occur as a result of impact with the handle of a racquet or club during ball strike or from a fall on the volar, ulnar aspect of the hand. Hamate is a bone, which is located on the outside or the little finger side of the wrist and has a hook shaped structure at the end. If non union does occur excision or open reduction and. Isolated hook of hamate fracture in sports that require a. In most cases, the lead wrist, which is the left wrist in a right handed golfer, is most commonly fractured when the player strikes the ground, root or rock prior to striking the ball. Surgical excision of ununited hook of hamate fractures via. The fracture fragment and sharp spicules were re moved, and the rough surface of the body of the ha mate at the site of nonunion was smoothed. This patient had a previous hamate fracture in the opposing wrist along with potential features of hamate bipartite. Carpal fractures musculoskeletal medicine for medical. The hook shaped part of the hamate bone which protrudes outwards may break easily due to injury.
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