Fractures of the hook of the hamate in athletes. 8 cases followed for 6 years

Surgical Management of Hook of Hamate Fractures: A Systematic Review of Outcomes

Purpose

This review aimed to compare the postoperative outcomes of open reduction internal fixation (ORIF) versus excision in the surgical treatment of hook of hamate fractures.

Methods

A systematic review of PubMed and EMBASE databases from 1954 to 2023 was performed using the search term "hook of hamate fracture" to identify all publications regarding the use of ORIF or excision in the treatment of hook of hamate fractures. Outcomes included a return to sport, pain, ulnar nerve dysfunction, flexor tendon dysfunction, union rate, wrist range of motion (ROM; % of contralateral hand), grip strength (% of contralateral hand), and quick disabilities of arm, shoulder, and hand scores.

Results

Twenty-seven of the 705 total screened articles were included. Excision of the hook of hamate (n = 779) resulted in a shorter return to sport time (6 vs 7.8 weeks), lower rates of postoperative pain (6.1% vs 33.3%), higher rates of ulnar nerve sensory dysfunction (4.2% vs 0%), and higher rates of ulnar nerve motor dysfunction (1.5% vs 0%) relative to ORIF (n = 51). Chronic fractures had a longer return to sport time (7.2 vs 5.7 weeks) relative to nonchronic injuries.

Conclusions

Both surgical procedures appear to yield acceptable outcomes in the treatment of hook of hamate fractures. However, based on the sparsity of available data, we are unable to determine a consistent difference between hook of hamate excision and ORIF.

Clinical relevance

To our knowledge, no current consensus on the optimal surgical treatment for hook of hamate fractures exists. Our findings emphasize the need for a large prospective cohort study using standardized outcomes to provide strong evidence as to whether surgical excision or ORIF yields greater outcomes in the treatment of hook of hamate fractures.

Grip strength after hamate hook excision and reconstruction surgery: A biomechanical cadaveric study

Fractures of the hamate hook are common among professional athletes. The recommended treatment for this is hamate hook excision. The purpose of this study is to evaluate the hand grip strength after hamate hook resection at different levels. Six cadaver forearm flexor digitorum profundus tendons were loaded with 5- to 15-kilograms force and grip strength was subsequently measured. The same measurements were performed in five hamate hook conditions: normal, one-third, two-thirds, total hamate excision, and after perihamate ligament reconstruction. Multilevel mixed-effect models were used to calculate the scaling ratios after each surgical intervention and compared them to a normal hamate hook. A 25%, 36%, 47% reduction, and 7% increase (107% of baseline) in grip strength was found after one-third, two-thirds, total bone was resected, and after perihamate ligament reconstruction, respectively. The study shows an association between grip strength reduction and the level of hamate hook resection. Perihamate ligament reconstruction is recommended as it restores grip strength to normal.

Excision of Hook of Hamate Fractures in Elite Baseball Players: Surgical Technique and Return to Play

Background:

Hook of hamate fractures are relatively common in baseball players, but the proper diagnosis and surgical technique can be challenging. Outcomes after surgical excision, as well as optimal surgical technique, in elite baseball players have not been clearly established.

Hypothesis:

Excision of hook of hamate fractures with a technique tailored to elite professional and collegiate baseball players will lead to high rates of return to play within a short time.

Study Design:

Case series; Level of evidence, 4.

Methods:

We reviewed the cases of 42 elite athletes who underwent surgical excision of 42 hook of hamate fractures at a single academic hand surgery practice from 2006 to 2020. The athletes competed at the professional (n = 20) or varsity collegiate (n = 22) baseball levels and were treated using the same surgical technique tailored toward the elite athlete. The clinical history, timing of surgery, complications, and time to return to play were recorded for each patient.

Results:

All 42 patients underwent an excision of their hook of hamate fracture at a mean of 7.2 weeks (range, 0.5-52 weeks) from the onset of symptoms. All but one patient were able to return to full preinjury level of baseball participation within 6 weeks from the date of surgery, with a mean return to sport of 5.4 weeks (range, 3-8 weeks). Two patients returned to the operating room—1 for scar tissue formation causing ulnar nerve compression and 1 for residual bone fragment causing pain and ulnar nerve compression.

Conclusion:

Surgical excision of hook of hamate fractures in elite baseball players showed a very high rate of return to play within 6 weeks. Meticulous adherence to the described surgical technique tailored to athletes optimizes clinical outcomes and avoids complications.

A Comparison of the Outcomes of Excision of the Fractured Hook of Hamate via a Carpal Tunnel Approach versus a Lateral Approach

Background: The excision of the hook of the hamate is an accepted modality for the treatment of hook of hamate fractures. Three surgical approaches to the hook of hamate have been described in literature. This includes two palmar approaches namely the Guyon canal approach and the carpal tunnel approach, and the lateral approach. The aim of this article is to compare the outcomes of the carpal tunnel approach and the lateral approach. Methods: Twenty-four patients with hook of hamate fractures were treated by excision of the hook of hamate. The hook of hamate was approached via the carpal tunnel in 15 patients and via the lateral approach in 9 patients. The outcomes with regard to duration of the surgery, complications such as pain, sensory disturbance and scar problems and time to return to sports were measured and analysed. Results: There were no significant differences in outcomes between the carpal tunnel and the lateral approach for excision of hook of hamate fractures. Conclusions: The outcomes of excision of the hook of hamate via the carpal tunnel approach and the lateral approach are similar. The decision to choose an approach should be based on the surgeon's familiarity with the approach. Future studies should include a comparison with the Guyon canal approach preferably in a homogenous group of patients. Level of Evidence: Level IV (Therapeutic).

Overview of Sport-Specific Injuries

Athletes are at risk for a variety of injuries not typically sustained in everyday life. The team physician must be capable of not only identifying and treating injuries as they occur, but he or she must be armed with the knowledge to minimize the risk of injuries before they occur. This review serves to provide an overview of the various sport-specific injuries typically encountered by team physicians. Injuries are grouped by body part and/or organ system, when possible. We do not aim to cover in detail the various treatments for these injuries; rather, we hope that this article provides a comprehensive overview of sport-specific injury, and demonstrate the well-roundedness in skills that must be possessed by team physicians.

Unsuccessful Intervention of CT-Assisted Osteosynthesis for Stress Fractures of the Hook of the Hamate: A Report of 3 Cases

CASE

We performed computed tomography (CT)-assisted dorsal approach osteosynthesis for stress fractures of the hook of the hamate using the dorsal approach in 3 high school baseball players in the hybrid operating room. Bony union was observed in all patients on CT. All patients were able to play baseball without pain for at least 6 months after surgery. However, refractures were observed in all patients at a mean 9.7 months after surgery.

CONCLUSION

The indications of osteosynthesis for stress fractures of the hook of the hamate in baseball players should be carefully considered.

Progression of Hamate Hook Stress Reactions in Elite Baseball Players

Background:

Hamate hook fractures can occur as a result of repetitive contact with the knob of the bat used in the sport of baseball. Hamate hook excision has resulted in excellent outcomes and return to sport (RTS) in elite baseball players. The ideal treatment for hamate stress response before the development of a fracture line is unknown.

Purpose:

To report the outcomes of elite baseball players with hamate bone edema.

Study Design:

Case series; Level of evidence, 4.

Methods:

We reviewed the medical records of all elite baseball players with hamate bone edema consistent with a stress response at 2 institutions. Players were eligible for inclusion if they played collegiate or professional baseball at the time of initial injury, had magnetic resonance imaging (MRI) showing hamate bone edema, and had no radiographic evidence of acute fracture lines at initial presentation.

Results:

A total of 4 players with a mean age of 22.8 years were included. All injuries occurred in the nondominant hand. All athletes had normal initial wrist radiographs and MRI showing hamate edema but no fracture line. Patients returned to play as tolerated and developed an acute injury at an average of 25.8 days (range, 10-56 days) from the initial presentation. Repeat radiographs demonstrated acute hamate hook fractures in all 4 (100%) athletes. All 4 athletes underwent hamate hook excision. There were no postoperative complications. All athletes returned to sport at their previous level of competition at a mean of 5.3 weeks (range, 3.6-7.3 weeks).

Conclusion:

There is a high rate of hamate bone edema progression to acute hamate hook fracture in elite baseball players, with 100% RTS at preinjury level after hamate hook excision. We therefore recommend against prolonged rest. Continuation of play with hamate bone edema followed by hamate hook excision for acute fracture limits the time missed and obtains a faster RTS in elite baseball players.

The Effect of Thumb Immobilization on Fractures of the Hook of the Hamate: A Cadaver Study

Background: Fractures of the hook of the hamate are rare. Nonoperative management has historically been immobilization in a short arm cast (SAC) without thumb immobilization with a high reported incidence of nonunion. The high prevalence of nonunion following nonoperative treatment may be secondary to motion at the fracture site. The transverse carpal ligament's attachment to the hook of the hamate results in movement at the fracture site during thumb motion. Methods: A cadaveric study using 8 fresh frozen cadaver arms amputated at the mid-humeral level was performed. Computed tomography (CT) imaging was used to assess the bony anatomy and assure no preexisting fractures were present. Osteotomy of the hook of the hamate was performed through a skin incision proximal to the hook of the hamate and the transverse carpal ligament. Each arm was then mounted in a jig designed to hold and stabilize the arm and hand in supination. CT scans were performed without cast immobilization with the thumb in extension and abduction, with SAC without thumb carpometacarpal joint immobilization, and SAC with thumb carpometacarpal joint immobilization. Results: Motion of the fractured hook of the hamate was found to occur in all noncasted specimens, greatest with base fractures. SAC without thumb immobilization had little to no effect in eliminating fracture motion. SAC including the thumb reduced fracture motion in all specimens. Conclusions: Previous poor experience with nonoperative management of fractures of the hook of the hamate may be partially due to inability to adequately immobilize the fracture fragment. Fracture motion of the hamate hook occurs during thumb movement, likely from traction on the fracture fragment by the transverse carpal ligament.

Radiographic signs of hook of hamate fracture: evaluation of diagnostic utility

OBJECTIVE

Hook of hamate fracture, the most common swing-related wrist fracture, is commonly seen in high-level athletes. The fracture is rarely diagnosed on routine wrist radiographs, thus generally requiring CT or MR for diagnosis. Surgical excision has a high success rate, however diagnostic delay contributes to a high complication rate. Radiographic signs of hook of hamate fracture have been published, but uncertainty of the diagnostic accuracy limits application. The purpose of this study is to determine accuracy and interobserver reliability of radiographic signs of hook of hamate.

MATERIALS AND METHODS

This retrospective case-control study evaluated wrist radiographs of 50 patients, including 24 positive and 26 negative, for hook of hamate fracture, each proven by CT or MR. Five reviewers performed blinded, randomized evaluation of radiographs documenting whether the hook of hamate was normal or fractured, and if fractured, the radiographic signs present (ring sign, ghostly shadow, and diffuse sclerosis) and views that contributed to diagnosis.

RESULTS

Radiographic signs demonstrated high sensitivity (85%; 95% CI: 77-91), specificity (92%; 95% CI: 86-96), and accuracy (89%; 95% CI: 84-92) with substantial interobserver reliability (k = 0.652). The ring sign was the most sensitive radiographic sign. Diagnosis was most often supported by the oblique view (38%) and rarely the lateral view (15%).

CONCLUSIONS

Radiographic signs of hook of hamate fracture on routine radiographs can accurately and reliably diagnose hook of hamate fractures. Evaluation for discontinuity of the cortical ring will optimize sensitivity, allowing for timely diagnosis and treatment, and a reduction of complications.

Isolated hook of hamate fracture in sports that require a strong grip comprehensive literature review

BACKGROUND

The aim of the study was to report characteristics of isolated hook of hamate fractures related to sports that require a strong grip and to identify factors affecting early diagnosis and recovery period.

METHODS

A comprehensive literature search was conducted using MEDLINE, EMBASE, SCOPUS, Web of Science, the Cochrane Central Register of Controlled Trials, the World Health Organization International Clinical Trials Registry Platform, and the clinical trials registry and database of the US National Institutes of Health (ClinicalTrials.gov). There were no limits on the language or year of publication.This article included case reports and literature reviews for patients with isolated hook of hamate fractures related to sports that require a strong grip from 1977 to 2016.Two experienced reviewers extracted data from each study. The following data were extracted: sample size, patient's characteristics, cause of injury, injury side, time to diagnosis and symptoms, physical examination results, diagnostic work-up, treatment, complications, and recovery period.

RESULTS

A total of 21 case reports and literature reviews with 120 patients satisfied our inclusion criteria. There was no significant difference in the time to diagnosis between the group before computed tomography (CT) was widely used and the group after CT was widely used. Recovery period showed a positive relationship with age (coefficient = 0.418, P < .01), time from injury to diagnosis or surgery (coefficient = 0.206, P < .05), and type of athlete (coefficient = 0.270, P < .01). On multiple stepwise regression analysis, recovery period was significantly associated with age (β = 0.418, P = .00), but not with time from injury to diagnosis or surgery.

CONCLUSIONS

Advance in diagnostic techniques does not guarantee early diagnosis of hook of hamate fractures. Strong suspicion of the disease with physical examination and carefully hearing patient's history are important for early diagnosis and management for patients with hook of hamate fractures.

Return to Play After Hook of Hamate Excision in Baseball Players

Background:

Fractures of the hook of hamate in baseball players are significant injuries that can lead to pain and missed time from competition. The diagnosis is typically delayed because of the vagueness of symptoms and normal radiographic findings. Excision of the nonunited fragment has been supported as the primary treatment, but there are currently limited information and data on a timetable for return to competition after surgery.

Purpose:

To report on a large cohort of competitive baseball players with hook of hamate fractures treated with excision of the fragment and to assess the timetable for return to full athletic competition.

Study Design:

Case series; Level of evidence, 4.

Methods:

Competitive baseball players treated between 2012 and 2017 with hook of hamate excision for acute fractures or chronic fracture nonunions were retrospectively identified. All patients were treated by the same surgeon, and the time to return to full athletic competition was assessed. Return to play was defined as reaching the athlete’s preinjury level and being able to perform full sport activities.

Results:

A total of 41 baseball players were identified, all of whom were documented to have a chronic presentation of a nonunion or partial union. The population consisted completely of male athletes, with a median age of 21 years (range, 18-34 years). All patients were competitive athletes, with 12 professional baseball players, 17 collegiate baseball players, and 12 high school baseball players. All patients were treated with hook of hamate excision, with 7 patients undergoing concomitant procedures as indicated. The median time to return to play was 5 weeks (range, 3-7 weeks). The time to return to play was similar between professional, collegiate, and high school athletes. All athletes returned to their preinjury level of activity by 7 weeks postoperatively.

Conclusion:

This study confirms that excision of the fractured hook provides predictable, early return to play, with a limited complication rate.

Wrist Injuries in Tennis Players: A Narrative Review

The wrist/hand complex forms the crucial final link in the kinetic chain between the body and the racquet and therefore has a number of important roles in the production of all tennis strokes. However, the internal and external loads that are created at the wrist during these strokes have the potential to contribute to pain and injury. Therefore, the purposes of this narrative review are to (1) determine the extent of the problem of wrist pain/injury in tennis players, (2) identify bony and soft tissue structures of the wrist that are susceptible to damage as a result of tennis play and (3) explore factors that may influence the development of wrist pain/injury in tennis players. The epidemiological data revealed two important points. First, some evidence suggests wrist pain/injury accounts for a higher percentage of total injuries in more recent studies (2014-2015) than in early studies (1986-1995). Second, the relative frequency of wrist pain/injury compared with other well-recognized problem areas for tennis players such as the shoulder complex, elbow and lumbar spine is noticeably higher in more recent studies (2014-2015) than in early studies (1986-1995), particularly among females. Collectively, this would seem to indicate that the problem of wrist pain/injury has increased in the modern game. In fact, some wrist injuries appear to be related to the use of certain forehand grip types and the predominant use of the two-handed backhand. While the loads experienced at the wrist during tennis stroke production seem to be below threshold levels for a single event, the cumulative effects of these loads through repetition would appear to be an important consideration, especially when inadequate time is allowed to complete normal processes of repair and adaptation. This is supported by the evidence that most wrist injuries in tennis are associated with overuse and a chronic time course. The complex interaction between load, repetition, and training practices in tennis, particularly among young developing players who choose a path of early specialization, needs to be further explored.

Hamulus Stress Fracture in a Batsman: An Unusual Injury in Cricket - A Case report and Review of Literature

Introduction:

Hamulus fractures are uncommon injuries constituting 2-4% of carpal fractures and are usually reported in athletes. Stress fractures of hamulus are even rarer and very few cases have been reported till date. In this case report, we present the first documented case of stress fracture of hamulus in a cricket batsman and review the existing literature on hamulus fractures, both acute and stress fractures, in sportspersons in general.

Case Report:

A 23-year-old, right-handed, cricket batsman presented with pain in the hypothenar region of his left hand of 7 weeks duration. The pain typically worsened during batting, and he had difficulty in gripping the bat. Plain radiographs were largely inconclusive; magnetic resonance images, however, demonstrated a stress fracture of the hamate hook. The patient was put on conservative management, and his bat grip was modified. He recovered completely within 12 weeks and went back to playing professional cricket.

Conclusions:

Hamulus stress fractures should be considered in cricketers presenting with chronic, non-traumatic, and ulnar-sided hand pain. The nonleading hand is more likely to be involved in a batter, as seen in other sports with a double haSnd grip. Nonoperative treatment, change of grip and adequate rehabilitation give good outcomes in most cases.

Hamate hook nonunion initially mistaken for ulnar nerve compression: a case report with review of literature

BACKGROUND

Hamate hook (HH) stress fractures are rare, often presenting with misleading symptoms and easily overlooked/misdiagnosed. These fractures occur frequently in individuals participating in sports activities involving racquets, bats, or clubs. Symptoms are non-specific and often mimic other clinical conditions, such as ulnar nerve entrapment or ulnar vessel thrombosis.

CASE REPORT

A 17-year-old tennis player with no history of trauma presented with dominant hand weakness together with pain and paresthesia on the ulnar side, which exacerbated with tennis play. The patient was treated for ulnar nerve compression with activity cessation and rest for 2 months. After 6 months of persistent symptoms, the patient underwent open Guyon tunnel release, although preoperative electromyoneurography revealed no signs of nerve damage and bone scans showed a small area of increased uptake in the hypothenar region. Postoperatively, symptoms resumed and the patient reported to our department for a second opinion. Point tenderness over HH, hypothenar muscles hypotrophy, paresthesia, hand weakness and pain with ulnar deviation, and flexion of distal phalanges of the two ulnar fingers were observed. HH fracture was suspected. Computerized tomography scan revealed fractured HH and the patient underwent hook excision. One month postoperatively, the pain intensity reduced together with function and strength improvement; 2 months postoperatively, the patient was pain free and had returned to tennis.

CONCLUSIONS

In patients involved in racquet sports with hypothenar pain and paresthesia of the ulnar side of the hand, HH fracture should be suspected. Symptoms can mimic ulnar nerve entrapment and may lead to overlooking the correct diagnosis. Treatment of choice is fractured fragment excision.

Sports-related wrist and hand injuries: a review

Background

Hand and wrist injuries are common during athletics and can have a significant impact especially if initially disregarded. Due to their high level of physical demand, athletes represent a unique subset of the population.

Main body

The following is an overview of hand and wrist injuries commonly seen in athletics. Information regarding evaluation, diagnosis, conservative measures, and surgical treatment are provided.

Conclusion

Knowledge of these entities and special consideration for the athlete can help the team physician effectively treat these players and help them achieve their goals.

Closed Rupture of the Flexor Tendons of the Little Finger Secondary to Non-Union of Fractures of the Hook of the Hamate

We report six patients with closed flexor tendon rupture affecting the little finger, occurring secondarily to non-union of the hook of the hamate bone. The ununited fragments were separated from the basal part of the hook by more than 1 mm. The fragments were also rounded and showed marginal sclerosis. Non-union was located in the middle part of the hook in three patients, the tip in two, and the base in one. At operation, the fragments were removed in all patients. Five patients were treated by free tendon grafts using three palmaris and two plantaris grafts and one underwent tendon transfer. Postoperative total range of active motion of the little finger averaged 218° (range 185–265°). All patients returned to their original employment. This series would suggest that flexor tendon rupture can occur after fracture of the hook of the hamate bone, even when the ununited fragment is small and/or rounded.

Ulnar tunnel syndrome

Ulnar neuropathy at or distal to the wrist, the so-called ulnar tunnel syndrome, is an uncommon but well-described condition. However, diagnosis of ulnar tunnel syndrome can be difficult. Paresthesias may be nonspecific or related to coexisting pathologies, such as carpal tunnel syndrome, cubital tunnel syndrome, thoracic outlet syndrome, C8-T1 radiculopathy, or peripheral neuropathy, which makes accurate diagnosis challenging. The advances in electrodiagnosis, ultrasonography, computed tomography, and magnetic resonance imaging have improved the diagnostic accuracy. This article offers an updated view of ulnar tunnel syndrome as well as its etiologies, diagnoses, and treatments.

HIGH INCIDENCE OF HAMATE HOOK FRACTURES IN UNDERWATER RUGBY PLAYERS: DIAGNOSTIC AND THERAPEUTIC IMPLICATIONS

Hamate hook fractures are rare injuries but appear to occur frequently in underwater rugby, the reason for which was investigated in this study.

High-level underwater rugby players with hook fractures diagnosed during a five-year interval (2005–2010) were studied retrospectively. Medical data on these patients were reviewed for information on the mechanism of injury, type of fracture, radiological imaging, treatment, and outcome.

In ten patients, hook fractures of the leading hand were confirmed by computed tomography, all of which were associated with specific injuries during underwater rugby games. Conservative treatment resulted in delayed healing or non-union, wherefore fragment excision and open reduction and internal fixation was performed in ten and five patients, respectively, while two patients declined surgery. After surgery, all patients were able to play underwater rugby again.

In underwater rugby, hook fractures occur frequently due to high and repeated forces applied to the leading hand during games.

Hook of hamate fractures in competitive baseball players

BACKGROUND

Baseball players are susceptible to a number of specific upper extremity injuries secondary to batting, pitching, or fielding. Fractures of the hook of hamate have been known to occur in batters. The purpose of this study is to present our experience with the surgical management of hook of hamate fractures and their short-term impact on the playing capability of competitive baseball players.

METHODS

A retrospective chart review was performed on patients with hook of hamate fractures between the years 2000 and 2012. The inclusion criteria were (1) hook of hamate fracture, (2) competitive baseball players, and (3) surgical treatment of the injury. Patient demographics, mechanism of injury, surgical treatment, and outcome were collected from the medical records. Information on return to play was collected from the Internet when applicable.

RESULTS

There were seven male patients that underwent eight procedures. The mechanism of injury was attributed to batting in six cases and rogue pitches in two cases. All surgeries consisted of hamate hook excision and ulnar tunnel decompression. One patient had concomitant carpal tunnel release. The median time between surgery and return to play was 5.7 weeks (range, 4.3 to 10.4 weeks).

CONCLUSIONS

The mechanism of hook of hamate fractures in baseball players is predictable, most often developing secondary to repetitive swinging. This injury may occur at all levels of competition. Ulnar tunnel decompression with hook of hamate excision provides good outcomes, with minimal complications and early return to play.

Outcomes of hook of hamate fracture excision in high-level amateur athletes

PURPOSE

To determine the overall long-term postoperative clinical and functional results of high-level amateur athletes after hook of hamate excision, based on complications; return to sport; Disabilities of the Arm, Shoulder, and Hand (DASH) score; and a self-reported questionnaire.

METHODS

We evaluated 11 patients representing 12 cases of hook of hamate excision. All patients were high-level amateur athletes (rising collegiate or collegiate level). We performed a retrospective chart review to elicit information pertaining to the patient's injury. We assessed long-term postoperative outcomes with a self-reported questionnaire, the DASH form, and the DASH Sport/Performing Arts Module form.

RESULTS

All patients successfully returned to full participation in their respective sports an average of 6 weeks after surgery. The average postoperative DASH score was less than 1, and all patients scored a 0 on the DASH Sports form. There was a significant improvement in preoperative pain after surgical intervention. There was no significant difference between preinjury and postoperative performance scores. Finally, every patient was very satisfied with the surgical outcome. There was only 1 postoperative complication in which a patient developed transient ulnar nerve paresthesias, which completely resolved by 6 weeks after surgery.

CONCLUSIONS

Surgical excision of hook of hamate fractures in high-level amateur athletes allows for successful return to sports participation at preinjury performance levels, achievement of normal function as measured by validated objective outcome measures, significant reduction in pain, and high overall patient satisfaction. We consider surgical excision to be a safe and effective technique to restore normal function and hasten return to play for high-level amateur athletes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Ulnar tunnel syndrome

Ulnar tunnel syndrome could be broadly defined as a compressive neuropathy of the ulnar nerve at the level of the wrist. The ulnar tunnel, or Guyon's canal, has a complex and variable anatomy. Various factors may precipitate the onset of ulnar tunnel syndrome. Patient presentation depends on the anatomic zone of ulnar nerve compression: zone I compression, motor and sensory signs and symptoms; zone II compression, isolated motor deficits; and zone III compression; purely sensory deficits. Conservative treatment such as activity modification may be helpful, but often, surgical exploration of the ulnar tunnel with subsequent ulnar nerve decompression is indicated.

Two-staged tendon reconstruction in flexor tendon ruptures secondary to fracture of the hamate hook

We report a case of 2-staged reconstruction of flexor tendons ruptured spontaneously by attrition. A 49-year-old man presented with inability to flex the ring and little fingers of his left hand. Preoperative computed tomographic scans revealed fracture of the hamate hook. At the time of the operation, both the flexor superficialis and profundus of the little finger and the flexor profundus tendon of the ring finger were ruptured adjacent to the fracture site of the hamate. Because the flexor tendon rupture secondary to the fracture of the hamate is extremely rare, and surgical outcomes of previous reports are not satisfactory, a decision was made to perform 2-staged reconstruction of ruptured flexor tendons. The surgical result was excellent with complete restoration of full range of motion. This report describes for the first time to our knowledge, the technique, and rehabilitation of 2-staged tendon reconstruction in a patient with hook of hamate fracture.

Rupture of small finger flexor tendons secondary to asymptomatic nonunion of the hamate hook

The incidence of fractures of the hamate hook (hamulus) has been reported to be between 2% and 4% of all carpal fractures. Untreated hamulus nonunion can cause attritional rupture of the ulnar digits' flexor digitorum profundum tendons. Rupture of flexor tendons due to nonunion of the hook of the hamate is an uncommon injury. Most surgeons treat the tendon lesion by a graft, transfer of the superficial flexor of the ring finger, or terminolateral suture of the distal stump of the deep flexor tendon of the little finger to the deep flexor tendon of the ring finger. This article reports a case of a 52-year-old right-handed man who presented with weakness of grip and loss of active flexion of both distal and proximal interphalangeal joints of the right small finger lasting 2 weeks due to grip strength while working. The clinical history and the physical examination were dissonant, and a computed tomography scan revealed a nonunion of the hamulus. Intraoperatively, the nonunion of the hamate hook was identified and the bony ossicle excised. The flexor digitorum profundus and superficialis to the small finger were both ruptured. The flexor digitorum profundus tendon was repaired with a termino-terminal suture. The patient returned to work within 3 months without restriction. Six months postoperatively, the patient had no pain and achieved full active flexion of the small finger.

Closed rupture of the flexor tendons caused by carpal bone and joint disorders

We analysed 21 patients with closed rupture of the flexor tendons caused by carpal bone and joint disorders. The tendon that ruptured depended on the location of the bone perforation into the carpal tunnel. Radiocarpal arthrography was performed in 13 patients and capsular perforation was demonstrated by contrast medium leakage into the carpal canal in 11 patients. This proved a useful diagnostic test. The flexor tendon(s) were reconstructed with free tendon graft in 17 patients, cross-over transfer of flexor tendons from adjacent digits in two and buddying to an adjacent flexor tendon in one patient. Postoperative total active range of motion in the fingers after 13 free tendon graft reconstructions averaged 213 degrees (range 170-265 degrees ). The active range of motion of the thumb-interphalangeal joint after free tendon graft reconstruction in three cases improved from 0 degrees to 33 degrees on average (range 10 degrees -40 degrees ).

Optimierung von konventionellen Röntgenaufnahmen zur Erkennung von Hamulus ossis hamati Frakturen

Fractures of the hook of the hamate are a rare event. The fracture cannot always be detected clinically and standard radiographs do not always provide an overlap-free image of the hook of the hamate, so that fractures can easily be overlooked. The objective of the present study was to examine if the sensitivity of detecting hamulus ossis hamati fractures can further be improved by a modified conventional radiographic projection. After dissection of the hook of the hamate on 10 cadaver hands, a fracture was produced close to the base using a surgical chisel. Conventional radiographs were then performed in four different projections (dorso-palmar, lateral, carpal-tunnel and oblique view). The oblique view was obtained in a 45 degrees supination position, slight extension and radial duction, with the tube tilted from distal to proximal by 30 degrees. An axial spiral CT was used as a reference for detection of the fracture. The highest sensitivity of the conventional radiographs, with 8/10 identified fractures (80%), was achieved by the oblique view. The carpal-tunnel view with 4/10 (40%) and the dorso-palmar projection with 3/10 (30%) were much lower. All fractures were missed in the lateral projection. If all of the conventional radiographic projections are taken into account, the sensitivity is increased to 90%. All of the fractures were reliably detected in the axial CT-image. If a hamulus ossis hamati fracture is suspected clinically, in addition to the dorso-palmar and carpal-tunnel view, the special oblique view described here should be performed as a third projection plane, while the lateral view can be dispensed with. However, even if all projections are taken into account, a negative finding in the conventional radiographic imaging does not exclude a fracture with absolute certainty. In such cases, a CT or MRI should be performed to exclude a fracture.

Therapeutic Alternatives in Nonunion of Hamate Hook Fractures

Symptomatic nonunion frequently results after conservative treatment of hamate hook fractures, emphasizing the need of appropriate surgical strategies. A retrospective analysis of 8 patients with nonunions treated by fragment excision or open reduction and internal fixation (ORIF) at 3 centers was performed. The literature was reviewed for treatment options, as bone grafting and low-intensity pulsed ultrasound. Although fragment excision is advocated as the "gold standard" in nonunion, reports on functional results are controversial, and recent anatomic and biomechanical studies of the hook challenge this opinion. In our patients, complete relief of symptoms and comparable functional results were observed after ORIF or fragment excision. Bone grafting could supplement ORIF in selected cases. Low-intensity pulsed ultrasound may evolve as a conservative treatment option. Several alternatives to hook excision are available aiming at complete anatomic and functional recovery of hamate hook nonunion. Further experience is needed before general recommendations can be formulated.

Avulsion fracture of the hamulus from clay gunshot sport: a case report

We report a case of hamulus (hook of hamate) fracture nonunion and secondary flexor digitorum profundus tendon rupture caused by repetitive wrist hyperextension sustained during clay shotgun shooting. The hyperextension caused avulsion of the hamulus by the pisohamate ligament. The hamulus was excised and a flexor digitorum profundus tendon transfer of the ring to small finger side to side was performed with satisfactory outcome.

Hook of Hamate Fractures: Critical Evaluation of Different Therapeutic Procedures

The treatment of choice in nondisplaced hook of hamate fractures is conservative, with lower arm splinting. Displaced fractures should be treated operatively, whereby excision of the fragment or open reduction and internal fixation are described. A hamulus ossis hamati fracture was verified in 14 patients (mean age, 42 years; range, 21 to 73 years) including 11 men and three women. In six patients (42.9 percent), conservative treatment was initiated immediately after trauma with a lower arm cast for 6 weeks, and eight patients (57.1 percent) were operated on primarily. In five patients (35.7 percent), the fragment was excised, and in three patients (21.4 percent), an open reduction and internal fixation was performed using a screw. In five of six patients treated conservatively, nonunion of the fracture with persisting clinical symptoms developed. All of those patients were treated operatively, whereby three patients underwent excision and two patients underwent screw fixation, which led to elimination of the symptoms. One patient was asymptomatic despite nonunion of the fracture and rejected surgery. All of the eight patients operated on primarily were asymptomatic 3 months after surgery. Therefore, the success rate of primary surgical treatment (eight of eight) was significantly higher compared with conservative treatment(one of six). Finally, all 14 patients were asymptomatic at late postoperative follow-up. The clinical outcome of patients with hook of hamate fractures treated conservatively was disappointing. Therefore, primary surgical treatment is recommended. In our patients, excision and open reduction and internal fixation led to comparable results.

Biomechanical evaluation of flexor tendon function after hamate hook excision

PURPOSE

Hamate hook fractures are uncommon injuries for which treatment is controversial. Excision of the hamate hook is considered to be the preferred method of treatment but the effects of hamate excision are not clearly delineated. The purpose of this study was to determine what effect, if any, excision of the hamate has on flexor tendon function.

METHOD

The biomechanical effects of hamate hook excision on flexor tendon function were studied in fresh cadaveric forearm specimens with wrists fixed in 3 positions (neutral, 30 degrees extension, 30 degrees extension with 30 degrees ulnar deviation). Flexor tendon force, flexor tendon excursion, and flexor tendon shift were evaluated.

RESULTS

Flexor tendon force decreased after hamate hook excision (11% in neutral, 14% in 30 degrees extension, and 15% in 30 degrees extension with 30 degrees ulnar deviation). The flexor profundus tendons had a 7- to 11-mm increase in proximal tendon excursion after hamate hook excision depending on the position of the wrist, and the flexor profundus tendons of the small finger shifted 4 to 5 mm in ulnar direction.

CONCLUSIONS

The hamate hook provides some biomechanical advantage for flexor tendon function and cadaveric changes in tendon force after its excision suggest that power grip may be decreased after hamate hook excision.

Symptomatic, partial union of the hook of the hamate fracture in athletes

BACKGROUND

Many clinicians believe that after fracture of the hook of the hamate, nonunions are the rule rather than the exception.

PURPOSE

To describe a previously unreported condition in which the fractured hook of the hamate unites only along its ulnar column and causes pain similar to that in cases of nonunion.

STUDY DESIGN

Retrospective review.

METHODS

Eight patients who had sustained a hook of the hamate fracture were identified, on the basis of their persistent pain, as having achieved only partial union. This diagnosis was made despite evidence on computed tomography of healed bone across a significant portion of the fracture. All eight patients underwent subperiosteal excision of the hamulus because of persistent pain. At an average of 4 years after excision, each patient was evaluated by dynamometer grip strength testing and a subjective outcome assessment.

RESULTS

All patients were able to return to their preinjury level of sports participation at an average 8 weeks after excision of the hook of the hamate. Grip strength was not adversely affected in any patient. Subjective evaluation of each patient revealed no residual pain.

CONCLUSIONS

Chronic or unresolved pain on the ulnar side of the wrist after hook of the hamate fracture can be due to partial union. This condition should be managed no differently from a symptomatic nonunion, with excision of the hook of the hamate and repair of the ligament attachments.

Carpal fractures in athletes

A review of the literature shows that 3% to 9% of all athletic injuries occur to the hand or wrist. Also, hand and wrist injuries are more common in pubescent and adolescent athletes than adults. Although knee and shoulder injuries are more common athletic injuries, an injury to the hand or wrist significantly can impair the athlete's ability to throw or catch a ball, or swing a bat or racquet. A college football player trains year round for just 11 or 12 hours of playing time. An athletic injury that occurs during the season can have profound consequences for the athlete's career and emotions. When defining a management plan for a particular wrist athletic injury, the time to heal the injury and the time to rehabilitate fully must be considered. The athlete must be informed fully of the length of recovery. The continued advancement of fixation methods and techniques are diminishing fracture morbidity considerably. Small-cannulated compression screws that provide rigid fixation can be inserted with decreased surgical dissection, thus preserving critical vascular supply and promoting accelerated healing and earlier rehabilitation. The arthroscope as a valuable adjunct in the management of wrist fractures was virtually unheard of years ago, but is now common. The ability to arthroscopically guide a cannulated compression screw to stabilize a scaphoid fracture without a formal open volar approach can reduce surgical morbidity significantly and allow the athlete to return to competition more quickly. Mechanisms of injury that cause osseous fractures of the wrist are fairly high energy. A high index of suspicion for associated soft tissue injuries should be kept in mind when fractures of the wrist are identified. The wrist is composed of eight carpal bones tightly interwoven with each other by intrinsic and extrinsic wrist ligaments. The management of carpal fractures depends on prompt diagnosis, stable and anatomic alignment of the involved carpal bone, protective immobilization of the injury, and thorough rehabilitation. Displaced fractures of the hook of the hamate, trapezial ridge fractures, and comminuted pisiform fractures are managed best by early excision to promote uncomplicated recovery and early return to sport. For most athletes, return to competition can be expedited safely with the use of padded gloves and custom playing splints or casts. The sports medicine physician always must put the athlete's safety first when deciding the appropriate time for return to competition.