Combined fractures of the body and hook of hamate: A form of ulnar axial injury of the wrist

Fractures of the hamate are rare, and usually associated with athletes. We describe an unusual form of the injury involving fractures of the hook as well as an intra-articular medial facet. It is likely to be a result of high velocity ulnar component of the axial injury. Surgical treatment is advocated to achieve accurate reduction and apposition of the fifth carpometacarpal joint.     

单纯钩骨钩骨折致尺神经深支损伤的临床研究

目的探讨单纯钩骨钩骨折致尺神经深支损伤的致病机理。方法采用16侧甲醛固定和4侧新鲜成人尸体标本。以钩骨钩中点为O,过O点作一条水平线及垂线,水平线与尺神经深支的交点为A点,与钩骨钩基底尺侧交点为B点,垂线与尺神经的交点为C点,分别测量OA、OB、OC、AB长度,并进行统计学分析;对1996年4月~2009年6月5例单纯钩骨钩骨折合并尺神经深支损伤进行回顾分析。结果尺神经深支绕过钩骨钩的基底部进入掌深间隙,OA的长度为(4.96±0.11)mm、OB的长度(3.69±0.12)mm、OC的长度(10.55±1.07)mm、AB的长度为(1.27±0.15)mm;5例根据中华医学会手外科学会上肢周围神经功能评定试用标准:优4例,良1例。结论单纯钩骨钩骨折可致尺神经深支损伤但临床容易漏诊,早期正确诊治是神经功能得以恢复的关键。     

Nonoperative treatment of acute hamate hook fractures.

Six patients with acute and two patients with subacute nondisplaced fractures of the hamate hook were treated with immobilization. The patients with acute fractures were treated within 7 days of the injury, and those with subacute fractures were treated after 7 days. Seven of the eight patients showed documented healing of their fractures. At follow-up (average 8 months) all seven were free of symptoms. One patient with a subacute fracture did not comply with treatment and had a painful nonunion. Our results show that hamate hook fractures that are diagnosed early may heal with nonoperative management. Fractures that fail to heal with immobilization or those with chronic nonunion should be treated with excision of the hook fragment.     

Diagnosis and management of hamate hook fractures

Hamate hook fractures, although uncommon, are now recognized with increasing frequency because of the increase in popularity of racket sports and golf. Careful clinical evaluation and adjunctive radiologic investigation help establish the diagnosis. Acute nondisplaced fractures can heal with immobilization, while displaced fractures and nonunions typically require open reduction and internal fixation (acute fractures) or hook excision.     

钩骨钩骨折的临床分型与治疗

目的 探讨钩骨钩骨折的临床分型,并探讨不同分型的钩骨钩骨折合理的治疗选择.方法 回顾性研究了12例钩骨钩骨折的病例,依据损伤特点和预后将其分为三型:Ⅰ型为钩骨钩尖端的撕脱骨折,Ⅱ型为钩骨钩中段的骨折,Ⅲ型为钩骨钩基底的骨折.依据这一分型,本组病例中Ⅰ型1例、Ⅱ型7例、Ⅲ型4例.其中保守治疗3例,骨折切开复位内固定4例,钩骨钩切除5例;术前合并尺神经损伤3例(2例Ⅱ型,1例Ⅲ型),合并小指指屈肌腱损伤2例(均为Ⅱ型骨折),合并豆三角关节脱位1例(Ⅱ型骨折).重点分析了术后功能恢复情况、恢复时间,以及临床分型与术前并发症和疗效的相关性.结果 本组随访时间为4～16个月,平均(8.4±3.9)个月.进行保守治疗和切开复位内固定7例中有2例Ⅱ型骨折发生骨折不愈合,其他5例骨折均愈合.所有患者至最终随访时均对疗效表示满意或非常满意,其疼痛评分、握力均较术前显著改善.术前并发症经手术治疗均完全缓解.采用钩骨钩摘除术的患者术后恢复时间显著短于其他两种治疗方法.Ⅱ型骨折术前并发症和骨折不愈合的发生率都较其他两型高.结论 钩骨钩骨折的总体疗效是非常令人满意的.对Ⅰ型骨折和无移位的Ⅲ型骨折,可采用保守治疗.对有移位的Ⅲ型骨折,可行切开复位内固定.对Ⅱ型骨折,由于其并发症的发生率较高,应尽早行钩骨钩摘除术.     

Traumatic combined radial and ulnar axial wrist dislocation.

In axial wrist dislocation, the proximal and distal transverse arches are disrupted and the carpus and metacarpal bases are split longitudinally. Early reduction and stabilization of the dislocation combined with exploration and decompression provide the best results.     

Fracture of the hamate hook

Twenty-one cases of hamulus fracture are presented. Diagnosis depends on clinical acuity. The most common symptom is pain in the palm that is aggravated by grasp. Weakness of grasp and dorsal wrist pain are also common. Ulnar nerve paresthesia or weakness and mild carpal tunnel syndrome are frequently present. Tenderness directly over the hamulus is always present, and grip strength typically is diminished. Tenosynovitis, tendon fraying, or tendon rupture may be demonstrated in 25% of the cases and is not related to the use of steroids. Lateral trispiral tomography is clearly superior to the other diagnostic methods. Excision produced generally excellent results, particularly in patients with an athletic injury or with no associated additional injury. A nonathletic injury or the presence of associated trauma adversely affected results. Immediate immobilization of acute fractures may result in fracture healing and obviate operative intervention. Open reduction and internal fixation is feasible but offers little advantage over excision.     

Hook of the hamate fractures in competitive golfers: results of treatment by excision of the fractured hook of the hamate

Seven competitive golfers presented with isolated fractures of the hook of the hamate. All patients were treated with excision of the fractured hook of the hamate, with complete resolution of pain. All patients returned to their previous level of play. It is reasonable to deduce, with this group of patients, that this fracture pattern represents an overuse or repetitive motion injury. Regardless of etiology, prompt diagnosis and treatment of this injury with excision of the fractured hook of the hamate bone allows competitive golfers to return to their previous level of competition.     

Surgical excision of ununited hook of hamate fractures via the carpal tunnel approach

Introduction

Direct excision of a symptomatic ununited hook of hamate fracture is the gold standard, most frequently via a Guyon space approach. The open carpal tunnel approach is another option, which has not previously been commonly considered and not reported in a peer review journal. Our study aims to highlight the carpal tunnel approach as a successful technique in a consecutive series of ununited hook of hamate fractures.

Patients and methods

Seven patients (all male and mean age 30.7 years) were reviewed with symptomatic ununited fractures following a period of cast immobilization. All the patients operated on underwent excision of the hook of hamate fragment via the open carpal tunnel approach.

Results

All patients successfully returned to their pre-injury level of functioning after 8–12 weeks and there were no complications.

Conclusions

Our study highlights the open carpal tunnel approach as a successful technique for open excision of symptomatic ununited hook of hamate fractures, because of its familiarity, ease of performance, excellent visualization and low morbidity.Level of Evidence IV Case Series.     

Fractures of the hook of the hamate

Fractures of the hook of the hamate have been infrequently reported in the literature. A high index of suspicion is required if the correct diagnosis is to be established. We report three cases of fractures of the hook of the hamate and postulate a mechanism of injury in sportsmen. Once established, an excision of the hook is usually necessary to resolve the discomfort.     

Fracture of the hook of the hamate

We removed the fracture fragment from fifty-nine patients who had an isolated fracture of the hook of the hamate. Preoperatively, all had complained of pain and tenderness on the ulnar side of the palm or on the dorsal ulnar aspect of the wrist. Most fractures were thought to have occurred while the patient was swinging a racquet, golf club, or baseball bat. Some fractures were caused by striking the palm on a solid object, by falling on the palm, or by a crush injury to the hand. Most of the fractures were diagnosed conclusively on a carpal tunnel roentgenogram or on a special oblique roentgenogram of the wrist supinated. We now believe that computed axial tomography is the best imaging technique for demonstrating this fracture. Except for two patients who had a crush injury, all of the patients returned to their regular occupational and athletic pursuits. There were no surgical complications.     

Fracture of the hook of the hamate

Fracture of the hook of the hamate most often occurs in athletes in the hand that holds a club, racket, bat or hockey stick, when the end abuts against the palm of the hand. The authors report six patients with this rare fracture, including the only known case of spontaneous healing. Because this fracture is associated with nonunion, surgical excision of the hook through the fracture site is recommended in most cases.     

Fractures of the hook of the hamate

Fractures of the hook of the hamate are rare injuries. Six new cases are presented; the most usual mechanism is probably a direct blow to the area of the hook. The diagnosis, which can only be made by special roentgenographic techniques is usually missed at the acute phase. Most of the cases are diagnosed when painful non-union, fraying tendinitis of the flexor tendons to the ulnar fingers, ulnar or median nerve deficits appear. The adequate treatment is usually excision of the hook fragment.     

Radiographic evaluation of the hook of the hamate: a new technique

Radiographic confirmation in cases of suspected hook of hamate fractures can be very difficult. Films, including the carpal tunnel view, may be difficult to interpret. We describe a new semisupine oblique radiographic view of the carpus that permits excellent visualization of the hamate hook, is cost efficient, and allows for patient comfort during the study.     

Bilateral fracture of the hook of the hamate

Bilateral hamate fractures in a physician sportsman were treated successfully by surgical excision of the fracture fragment. This case demonstrates the importance of carpal tunnel roentgenograms and of a high index of suspicion in making an accurate diagnosis in wrist injuries.     

The gymnast's wrist: acquired positive ulnar variance following chronic epiphyseal injury.

Five cases of symptomatic acquired positive ulnar variance are described. All cases occurred due to premature physeal closure of the growth plate in teenage girl gymnasts. All cases demonstrated ulnocarpal impingement, for which we describe a clinical test. Arthroscopic assessment of the wrist allowed us to assess the integrity of the TFCC (triangular fibrocartilaginous complex) and decide on the most appropriate surgery. Two patients needed distal ulna recession and one needed shaving for a TFCC perforation, with a good result.