Concomitant hook of hamate fractures in patients with scaphoid fracture: more common than you might think

Study of Hamate Fractures in a Single Tertiary Hands Unit: A Retrospective Cohort Study and Literature Review

Purpose

The primary purpose of our study was to investigate hamate fractures at a single tertiary hand surgery unit in Western Australia, particularly comparing operative and nonsurgical outcomes.

Methods

Patients with hamate and/or hamate plus fifth carpometacarpal injury at our hand unit between 2019 and 2022 were identified. All patients had Quick Disability of the Arm, Shoulder and Hand (QuickDASH) patient-reported outcome measures recorded post treatment. Patients managed operatively and nonsurgically had a period of splinting with plaster of Paris and/or thermoplastic splint for a minimum of 2 weeks. All patients underwent hand therapy.

Results

Forty-eight patients with hamate and/or hamate plus fifth carpometacarpal injury were included in this study. Thirteen patients had Milch type 1 fractures, and 35 had Milch type 2 fractures. Six Milch type 1 fractures were managed operatively, and seven were managed nonsurgically. The average QuickDASH score for the operative group was 0.38. The average QuickDASH score for the nonsurgical group was 0.65. Sixteen Milch type 2 fractures were managed operatively, and 19 were managed nonsurgically. The average QuickDASH score for the operative group was 1.3. The average QuickDASH score for the nonsurgical group was 3.5.

Conclusions

For Milch type 2 fractures, patient-reported outcome measures were better for the operative group compared with the nonsurgical group.

Type of study/level of evidence

Therapeutic IV.

Wrist Trauma: More Than Bones

Acute and subacute wrist trauma predominantly consist of fractures of the distal radius in elderly patients and most frequently carpal fractures (scaphoid, followed by triquetrum and hamatum) and avulsion fractures of the ulnar styloid in younger patients, especially in sports-related injuries but also in work activities. The initial radiographs may miss the fractures and result when untreated in complications as nonunion, osteonecrosis, and degenerative osteoarthritis.

Fractures of the distal radius and of the scaphoid may be associated with ligament injuries, most frequently the scapholunate complex, which are often overlooked at the emergency department. Patients without osseous injuries may present intrinsic and extrinsic ligament tears that may lead to carpal instability when they are clinically and/or radiologically missed.

Therefore, in acute and subacute setting, computed tomography may be helpful for the detection of subtle fractures, and magnetic resonance imaging, for the early diagnosis of occult fractures and ligament injuries.

Comparison of the diagnostic accuracy of X-ray and computed tomography in patients with wrist injury

BACKGROUND

This study aimed to compare CT and XR images of patients admitted to the emergency department due to wrist injuries and to evaluate the accuracy of XR in the diagnosis of fractures.

METHODS

Patients; who admitted to ED with injuries due to wrist trauma and who underwent XR imaging and CT scans in the period from 1 January 2017 to 1 January 2018, were included in the study. CT scan image interpretation reports recorded in the hospital automation system were considered eligible to be included in the study. XR images were interpreted by an orthopedics and traumatology specialist. The sensitivity (Sn), specificity (Sp), positive predictive value (PPV), negative predictive value (NPV) and Kappa (κ) coefficient of XR were calculated according to CT. Inter-rater agreement was graded according to κ values.

RESULTS

A total of 274 patients were included in the study. Fractures were identified in the XR images in 180 (66%) patients and in the CT images in 196 (72%) patients. Compared to CT, the Sn, Sp, PPV, NPV and κ coefficient of XR were 89%, 92%, 97%, 77% and 0.764 respectively. Compared to CT, the highest sensitivity of XR was measured to detecting radius (Sn: 95%, κ: 0.896) and 5th metacarpal fractures (Sn: 77%, κ: 0.859), the lowest sensitivity of XR was calculated in detecting scaphoid, capitate, pisiform, trapezium hamate, and triquetrum fractures (Sn: 59-14%, κ: 0.619-0.240). The sensitivity and κ coefficient of XR were calculated 54% and 0.530 in the adjacent bone fracture, 83% and 0.830 in joint dislocation, 75% and 0.661 in the fractures extending to the joint space.

CONCLUSIONS

XR is the first-choice imaging modality in the evaluation of wrist injuries, but CT imaging should be preferred when fractures extending to the joint space, adjacent bone fracture and carpal bone fracture are being considered.

Review article: the differential diagnosis of bone marrow edema on wrist MRI

There is a large variety of conditions that can result in 'bone marrow edema' or 'bone marrow lesions' (BML) in the wrist on magnetic resonance imaging (MRI). The combination of clinical history and the distribution of the BML can serve as a valuable clue to a specific diagnosis. This article illustrates the different patterns of BML in the wrist to serve as a useful guide when reviewing wrist MRI studies. Imaging artefacts will also be briefly covered.

Evaluation of grip strength in hook of hamate fractures treated with osteosynthesis. Is this surgical treatment necessary?

Objective

The aim of this study was to evaluate the outcomes of open reduction and internal fixation (ORIF) in hamate hook fractures and review the literature on this surgical procedure.

Methods

We report the outcomes of ORIF of hamate hook fractures in 13 consecutive patients (12 men and 1 woman; mean age: 32 years (range, 22–48 years)). In eight patients (61%) the fracture was associated with ulnar nerve neuritis in Guyon's canal. We assessed the following clinical data: age, sex, mechanism of injury, side of the injured hand and associated lesions, fracture classification, average time from injury to correct diagnosis, surgical technique, complications, and length of follow-up.

All patients underwent radiological imaging, including standard radiographs in two planes (anteroposterior and lateral projections), and a CT study. Functional outcomes evaluated were pain, range of motion, grip strength, Disabilities of the arm, shoulder and hand (DASH) and Mayo wrist score.

Results

The mean follow-up was 36 months (range, 12–144 months). All 13 cases were treated with ORIF of the hook of the hamate. Mean VAS pain score was 5 preoperatively (4–9) and 1 (0–2) postoperatively. All patients returned to pre-injury level and only one patient felt pain on activity. Preoperative modified Mayo wrist score was 51 and the postoperative value was 94. All outcomes scores improved significantly from preoperative values. The patients who participated in sports postoperatively were able to do so at or near pre-injury levels. Postoperative average range of wrist motion was 76° in extension, 71° in flexion, 14° in ulnar deviation, and 21° in radial deviation.

Mean grip strength in the hand with the hook fracture was 58 kg compared with 53 Kg in the unaffected hand. All patients returned to their pre-injury level of functioning after 10–12 weeks and there were no complications. Analysis of grip strength revealed values comparable with the unaffected hand.

Conclusion

ORIF of hamate hook fractures is a safe and effective technique to restore normal grip strength and return to pre-injury level. In cases of ulnar nerve neuritis, neurolysis of the deep palmar branch is mandatory.

Level of evidence

Level IV, Therapeutic study.