RESUMO
Hamate fractures are uncommon, but early and accurate diagnosis is critical to prevent negative outcomes. Hamate fractures may present initially to emergency departments, and diagnosis can be challenging. This case report of a common hamate fracture may aid in increasing emergency advanced practice nurse knowledge to identify these fractures in practice.
Assuntos
Fraturas Ósseas , Hamato , Humanos , Hamato/lesões , Fraturas Ósseas/diagnóstico , Serviço Hospitalar de Emergência , Masculino , FemininoRESUMO
Background: We devised a new classification of hamate fractures named the TOUCH classification. Each letter of this acronym depicts a fracture type - Type I (Transverse fracture), Type II (Open and/or complex fracture), Type III (Ulnar/medial tuberosity fracture), Type IV (Coronal fracture) and Type V (Hook fracture). Each fracture type was further divided into two or three subtypes (a, b, and/or c) based on degree of severity. The aim of this study is to classify the hamate fractures treated at our centre using this classification. Methods: A retrospective review of all patients with hamate fractures treated at our hospital between 2003 and 2022 was done. Patient data with regard to age, gender, mechanism of injury, injured limb and any associated injuries was collected. Hamate fractures were classified based on the TOUCH classification. Results: A total of 247 patients with hamate fractures were included. Patients in the age group of 20-40 years accounted for 73.6% of all fractures. Female patients accounted for only 6.9% of all fractures and 76.5% of women with hamate fractures were older than 40 years. The incidence of hamate fracture tended to increase with age in women. The most common mechanism of injury was a fall (69 patients). The injury involved the right upper limb in 195 patients. And 164 patients had associated injuries in the same upper limb. Type III (coronal fracture of the hamate body) accounted for 57.4%, followed by type V (hook of hamate fracture) in 26.7% of patients. Conclusions: The TOUCH classification could cover all kinds of hamate fractures. It is easy to remember and may guide surgeons in considering treatment options. Level of Evidence: Level IV (Diagnostic).
Assuntos
Fraturas Ósseas , Hamato , Humanos , Feminino , Hamato/lesões , Masculino , Adulto , Estudos Retrospectivos , Pessoa de Meia-Idade , Fraturas Ósseas/classificação , Fraturas Ósseas/epidemiologia , Adulto Jovem , Adolescente , Idoso , Idoso de 80 Anos ou mais , CriançaRESUMO
PURPOSE: Hamate fractures are infrequent and often overlooked wrist injuries. Our objective is to present the Shish-Kebab method, a surgical approach utilized in the treatment of intra-articular Hamate body fractures occurring concurrently with fourth metacarpal base fractures and dislocations. METHODS: This study was conducted at a single-center using a prospective design. It included patients aged 16-65 with Kim Type IIB fractures affecting the dominant side. Patients with the same features of fracture and carpometacarpal (CMC) instability findings were divided into two groups according to the success of the closed reduction procedure. In the conservative group (8 patients), all fractures and instability findings were successfully resolved with closed reduction and a short arm plaster cast. The surgical group (8 patients), comprising those requiring open reduction and internal fixation, underwent the application of the 'shish kebab' method. RESULTS: At the 6th and 12th week follow-ups, no significant differences were observed between the groups concerning pVAS and QuickDash scores. However, upon examining the QuickDash scores, a statistically significant difference emerged between the 6th and 12th weeks within both the conservative (p = 0.017) and surgical (p = 0.012) groups in the intragroup analysis. Grip strength, measured as 83.78% of the contralateral side in the surgical group and 79.51% in the conservative group, did not exhibit a statistically significant difference (p = 0.462). CONCLUSION: In the management of Hamate body intra-articular fractures and accompanying fourth metacarpal base fracture dislocations, good clinical results can be achieved with the 'Shish-Kebab' method in cases where closed reduction is unsuccessful.
Assuntos
Fixação Interna de Fraturas , Hamato , Fraturas Intra-Articulares , Ossos Metacarpais , Humanos , Hamato/lesões , Masculino , Adulto , Feminino , Ossos Metacarpais/lesões , Estudos Prospectivos , Pessoa de Meia-Idade , Fraturas Intra-Articulares/cirurgia , Fraturas Intra-Articulares/diagnóstico por imagem , Fixação Interna de Fraturas/métodos , Adolescente , Idoso , Moldes Cirúrgicos , Fraturas Ósseas/cirurgia , Redução Fechada/métodos , Luxações Articulares/cirurgia , Traumatismos do Punho/cirurgia , Adulto JovemRESUMO
OBJECTIVE: Treating high-level athletes involves a balance between early and safe return to play. Various types of protective immobilization have been recommended after operatively treated Bennett's fracture. The purpose of this study was to investigate if hand-based immobilization offers protection equivalent to forearm-based immobilization. MATERIALS AND METHODS: A cadaveric model of Bennett's fracture was created in 8 fresh-frozen, cadaveric forearms. Osteosynthesis was performed using a single headless compression screw. Three matched pairs were casted in either hand-based or forearm length, thumb spica casts, while 2 specimens remained un-casted as controls. Specimens were mounted on a custom testing apparatus. Weights were added in 6.8-kg increments until fixation failed and the fracture displaced. Fluoroscopy was performed after each trial. We used the Kruskal-Wallis non-parametric test to compare the groups. We considered P<.05 statistically significant. RESULTS: Failure of fixation occurred at 6.8 kg in the control specimens. Fixation failed in hand-based and forearm length casts at a mean of 18.1±5.1 kg. We did not find a statistically significant difference between median values of load at failure in kilograms across control specimens and 2 immobilization categories (P=.114). All specimens in the hand-based group sustained additional wrist injuries, while no additional injuries were noted in the forearm length group. CONCLUSION: Our study results showed that hand-based immobilization provides equivalent protection against fixation failure for operatively treated Bennett's fractures but may predispose athletes to increased risk of wrist injury compared with traditional, forearm-based casting. [Orthopedics. 2024;47(3):157-160.].
Assuntos
Cadáver , Moldes Cirúrgicos , Humanos , Fixação Interna de Fraturas/métodos , Imobilização/métodos , Masculino , Feminino , Hamato/lesões , Hamato/cirurgia , Idoso , Parafusos Ósseos , Pessoa de Meia-IdadeRESUMO
Volar proximal interphalangeal joint fracture-dislocations are rare injuries. Treatment is challenging when they are not identified acutely, with poor outcomes reported. We report a surgical technique to treat chronic volar proximal interphalangeal joint fracture-dislocations: a reverse hemi-hamate autograft.
Assuntos
Traumatismos dos Dedos , Fratura-Luxação , Hamato , Luxações Articulares , Humanos , Luxações Articulares/cirurgia , Autoenxertos , Articulações dos Dedos/cirurgia , Fratura-Luxação/diagnóstico por imagem , Fratura-Luxação/cirurgia , Hamato/lesões , Amplitude de Movimento Articular , Traumatismos dos Dedos/cirurgiaRESUMO
INTRODUCTION: This case report details the postsurgical rehabilitation and outcome of a 57-year old neurosurgeon who underwent hemi-hamate arthroplasty and volar plate repair for a complex ring finger proximal interphalangeal (PIP) fracture-dislocation sustained after a fall while snowboarding. Following re-rupture and repair of his volar plate, the patient was fitted for a "yoke" relative motion flexor orthosis, termed a JAY (Joint Active Yoke) orthosis, in a manner reverse to that which is commonly used for extensor-related injuries. STUDY DESIGN/METHODS: A 57 yo right hand-dominant male who suffered a complex PIP fracture-dislocation with failed volar plate repair undwent hemi-hamate arthroplasty and early active motion following using a custom-fabricated joint active yoke orthosis. PURPOSE OF THE STUDY: The purpose of this study is to illustrate the benefits of this orthosis design in allowing for active controlled flexion of the repaired PIP joint with assist from the adjacent fingers, while also reducing joint torque and dorsal displacement forces. RESULTS: A satisfactory active motion outcome was achieved with maintenance of PIP joint congruity allowing the patient to return to work as a neurosurgeon at 2-months post-operatively. DISCUSSION: There is little published literature on the use of relative motion flexion orthoses following PIP injuries. Most current studies are isolated case reports on boutonniere deformity, flexor tendon repair, and closed reduction of PIP fractures. The following therapeutic intervention was considered an important contributor to a favorable functional outcome, as it minimized unwanted joint reaction forces in a complex PIP fracture-dislocation and unstable volar plate. CONCLUSION: Future research with greater level of evidence is required to establish the various applications of relative motion flexion orthoses, as well as determine the appropriate time at which to place the patient in a relative motion orthosis following operative repair to prevent long-term stiffness and poor motion.
Assuntos
Traumatismos dos Dedos , Fratura-Luxação , Fraturas Ósseas , Hamato , Luxações Articulares , Humanos , Masculino , Pessoa de Meia-Idade , Fratura-Luxação/cirurgia , Dedos , Aparelhos Ortopédicos , Articulações dos Dedos/cirurgia , Traumatismos dos Dedos/cirurgia , Amplitude de Movimento Articular , Luxações Articulares/cirurgiaRESUMO
The hook of hamate is a complex anatomical region with many small but important structures. A sound knowledge of anatomy along with a systematic ultrasound technique can help delineate a variety of disorders. In this pictorial review, we discuss the ultrasound anatomy and the possible pathologies that can be encountered in this region.
Assuntos
Fraturas Ósseas , Hamato , Humanos , Hamato/diagnóstico por imagem , Ultrassonografia , Extremidade SuperiorRESUMO
Complete reconstruction of the hamate bone has been reported in the literature mostly following cancer excision or avascular necrosis. For the exiguity of the tissue deficit, bone grafting has usually been used as treatment option for its rapidity and easiness to perform, even if a variable amount of bone resorption may occur. In traumatic cases, microbial contamination may jeopardize the success of a well performed bone graft and vascularised bone grafts may represent a better reconstructive option. Here we describe the first case reported in the literature of a patient underwent complete hamate reconstruction following trauma with an osseous medial femoral condyle free flap as vascularized arthrodesis between the capitate and the 4th MTC base, in order to stabilize the 4th and 5th finger and the ulnar carpo-metacarpal joint.
Assuntos
Fraturas Ósseas , Fraturas Cominutivas , Retalhos de Tecido Biológico , Hamato , Traumatismos da Mão , Ossos Metacarpais , Humanos , Retalhos de Tecido Biológico/irrigação sanguínea , Ossos Metacarpais/cirurgia , Hamato/cirurgia , Hamato/lesões , Fraturas Ósseas/cirurgia , Fraturas Cominutivas/cirurgia , Traumatismos da Mão/cirurgiaRESUMO
BACKGROUND: Hook of the hamate fractures can be managed conservatively or fixed using a screw, but excision is recommended for prompt return to activities. Although various approaches have been described, there is no gold standard. Herein, the authors have described their clinical experiences in excising the hook of the hamate using the carpal tunnel approach, in athletes. METHODS: A total of 36 athletes underwent excision of the hamate hook using the carpal tunnel approach. The mean age of the patients was 23 years, and most of them were baseball players (n = 31). RESULTS: The mean operation time was 33 min. None of the patients presented with any complications aside from transient pillar pain in five cases. All of them returned to their sports activities within an average of 27 days. CONCLUSIONS: In our study, excision of the hook of the hamate was performed safely via the carpal tunnel. The carpal tunnel approach reportedly provides superior benefits over other approaches.
Assuntos
Síndrome do Túnel Carpal , Fraturas Ósseas , Hamato , Esportes , Humanos , Adulto Jovem , Adulto , Hamato/diagnóstico por imagem , Hamato/cirurgia , Hamato/lesões , Fraturas Ósseas/cirurgia , Extremidade Superior , Síndrome do Túnel Carpal/diagnóstico por imagem , Síndrome do Túnel Carpal/cirurgia , AtletasRESUMO
PURPOSE: The management of a proximal interphalangeal (PIP) joint fracture dislocation becomes more challenging when the joint surface is damaged because of severe comminution or inadequate treatment in the acute phase. The purpose of this study was to evaluate the clinical outcomes of an osteochondral autograft for the reconstruction of the joint surface in patients with a partial PIP joint defect. METHODS: Twelve patients underwent osteochondral autograft surgery from May 2007 to July 2018. The average age at the time of surgery was 38 years (range, 21-67 years), and there were 10 men and 2 women. Plain radiographs and computed tomography scans showed a partial middle phalangeal base defect in all the cases. The surgeries were performed 2 weeks to 20 months after the fracture or a previous surgery. Partial hamate grafts were harvested to reconstruct volar lip (n = 7), middle portion (n = 2), and dorsal lip (n = 3) defects of the middle phalangeal base. Bone healing, postoperative range of motion, instability, and pain were evaluated. The average follow-up duration was 27.8 months (range, 12-53 months). RESULTS: Radiographic graft union was observed in all the patients 6-8 weeks after the surgery. The deformity was corrected in 11 patients. The active range of motion of the involved PIP joint was improved from 28.3° (range, 0°-60°) to 75.0° (range, 25°-95°). Complications were observed during follow-up, including degenerative arthritis (n = 2), instability (n = 3), and stiffness (n = 5). CONCLUSIONS: Various types of partial joint defects of the middle phalangeal base following a PIP fracture dislocation can be reconstructed using an osteochondral autograft from the hamate. The functional recovery is generally acceptable, with a well-restored joint architecture. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.
Assuntos
Traumatismos dos Dedos , Falanges dos Dedos da Mão , Fratura-Luxação , Hamato , Fraturas Intra-Articulares , Luxações Articulares , Masculino , Humanos , Feminino , Adulto Jovem , Adulto , Pessoa de Meia-Idade , Idoso , Autoenxertos , Articulações dos Dedos/cirurgia , Fraturas Intra-Articulares/cirurgia , Hamato/transplante , Falanges dos Dedos da Mão/cirurgia , Amplitude de Movimento Articular , Traumatismos dos Dedos/cirurgia , Luxações Articulares/cirurgia , Estudos RetrospectivosRESUMO
Intra-articular fracture dislocations of the base of the middle phalanx are complex and debilitating injuries that present a management conundrum when nonreconstructable. Hemi-hamate arthroplasty (HHA) is a treatment modality of particular use in the setting of highly comminuted fractures. This systematic review aims to summarize the reported outcomes of HHA in this context. A literature search was conducted using MEDLINE, Embase, and PubMed, yielding 22 studies with 235 patients for inclusion. The weighted mean postoperative range of movement at the proximal interphalangeal joint was 74.3° (range, 62.0°-96.0°) and at the distal interphalangeal joint was 57.0° (range, 14.0°-80.4°). The weighted mean postoperative pain Visual Analog Scale was 1.0 (range, 0.0-2.0). The weighted mean postoperative grip strength was 87.1% (range, 74.5%-95.0%) of the strength on the contralateral side. Posttraumatic arthritis was reported in 18% of cases, graft collapse in 4.2%, and donor site morbidity in 3.0%, with a mean follow-up period of 28.4 months (range, 1-87 months). Hemi-hamate arthroplasty is a reliable and effective technique for the reconstruction of intra-articular base of middle phalangeal fracture dislocations, affording symptomatic relief and functional restoration. Further research is required to assess the true incidence of long-term complications.
Assuntos
Traumatismos do Braço , Traumatismos dos Dedos , Fraturas Ósseas , Hamato , Hemiartroplastia , Luxações Articulares , Humanos , Articulações dos Dedos/cirurgia , Fraturas Ósseas/complicações , Hamato/lesões , Traumatismos dos Dedos/cirurgia , Traumatismos do Braço/cirurgia , Luxações Articulares/cirurgiaRESUMO
BACKGROUND: The objective of this study was to determine whether reconstruction of the proximal pole of the scaphoid with a proximal hamate graft restores native carpal kinematics. METHODS: A cadaveric study was designed assessing wrist kinematic after proximal hamate graft for proximal pole of the scaphoid nonunion. Wireless sensors were mounted to the carpus using a custom pin and suture anchor system to 8 cadavers. A wrist simulator was used to move the wrist through a cyclical motion about the flexion/extension and radial/ulnar deviation axes. Each specimen was tested under a series of 3 conditions: (1) a native state, "Intact"; (2) fractured scaphoid proximal pole, "Fracture"; and (3) post-reconstruction of the proximal pole of the scaphoid using a proximal hamate graft, "Graft." RESULTS: The fracture condition resulted in a statistically significant change in scapholunate kinematics across the entire arc of motion relative to the intact condition. Reconstruction with proximal hamate grafts restored scapholunate kinematics close to the intact state in both flexion/extension and radial/ulnar deviation axes. The lunocapitate flexion during wrist flexion was significantly different after the hamate graft reconstruction. CONCLUSIONS: Proximal hamate to scaphoid transfer resulted in restoration of near normal carpal kinematics to the intact state.
Assuntos
Fraturas Ósseas , Hamato , Osso Escafoide , Humanos , Punho , Fenômenos Biomecânicos , Osso Escafoide/cirurgia , Hamato/transplante , Articulação do Punho/cirurgiaAssuntos
Artroscopia , Hamato , Humanos , Artroscopia/métodos , Hamato/cirurgia , Extremidade SuperiorRESUMO
OBJECTIVE: The aim of this study was to demonstrate a new robotic technique for the fixation of the fracture of the hook of hamate. METHODS: In this retrospective study, six patients who had undergone treatment of the hook of hamate fracture with a new technique using robot navigation were included. Patients were evaluated postoperatively with flexion - extension and radial-ulnar range of wrist motion, and were measured using a goniometer. Grip strength and pinch strength were measured and compared with the contralateral wrist at the final follow-up. The Visual Analog Scale (VAS) and the Mayo Wrist Score were used to evaluate and record the recovery outcome of the wrist. RESULTS: Primarily, healing was achieved at 12.3 weeks postoperatively. At the final follow-up (5-22 months, average 13.1 months) the VAS score of the wrist was an average of 0.3 (0-2); the mean radial-ulnar deviation was 64.7°; the average of the flexion and extension range of motion was 141.9°; the average grip strength was 40.9 Kg; the average pinch strength was 11.8 Kg and the average Mayo Wrist Score was 95.8. CONCLUSION: This study has shown us that treatment of nondisplaced or minimal displaced fractures of the hook of the hamate with robot navigation is a viable technique with satisfactory clinical and radiological results.
Assuntos
Fraturas Ósseas , Hamato , Traumatismos da Mão , Robótica , Traumatismos do Punho , Fraturas Ósseas/diagnóstico por imagem , Fraturas Ósseas/cirurgia , Hamato/lesões , Humanos , Estudos Retrospectivos , Traumatismos do Punho/cirurgiaRESUMO
Hook of hamate fracture occurs in baseball players during bat swing. These fractures are usually treated by excision of the fracture fragment and the players can return to the game without delay. We report a professional baseball player who presented with a hook of hamate fracture. He gave history of undergoing excision of the hook 4 years earlier for a fracture of the hook. He underwent re-excision of the regenerated hook and was asymptomatic at his final follow-up. Level of Evidence: Level V (Therapeutic).
Assuntos
Beisebol , Fraturas Ósseas , Hamato , Traumatismos da Mão , Traumatismos do Punho , Fraturas Ósseas/cirurgia , Hamato/lesões , Hamato/cirurgia , Humanos , MasculinoRESUMO
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.
Assuntos
Fraturas Ósseas , Hamato , Cadáver , Fraturas Ósseas/cirurgia , Hamato/cirurgia , Força da Mão , Humanos , Tendões/cirurgiaRESUMO
Avascular necrosis (AVN) and subsequent fragmentation of the proximal pole of the scaphoid following fracture is a challenging problem to treat. Multiple treatment methods have been described, although they have been shown to have varying degrees of success and are associated with donor site morbidities. This case report demonstrates a technique and the excellent radiographic and clinical outcome at 8 months postoperatively for reconstruction of the proximal pole of the scaphoid using an ipsilateral proximal pole of the hamate autograft.
Assuntos
Fraturas não Consolidadas , Hamato , Osso Escafoide , Autoenxertos , Fraturas não Consolidadas/cirurgia , Hamato/cirurgia , Hamato/transplante , Humanos , Osso Escafoide/diagnóstico por imagem , Osso Escafoide/cirurgia , Tomografia Computadorizada por Raios XRESUMO
Hamatolunate impingement syndrome is an uncommon cause of ulnar-sided wrist pain in the general population. Often misdiagnosed and untreated by non-specialized physicians, it is an important source of chronic ulnar wrist pain in golfers. The purpose of this retrospective study was to report results of arthroscopic burring of the apex of the hamate for hamatolunate impingement, whether isolated or not, in golf players, with a minimum of six months follow-up. Fifteen golf players (10 amateur, 2 semi-professional and 3 professional players), aged 40-61 years, with ulnar carpal pain implicating hamatolunate impingement with Viegas type-II carpal configuration, were included. Treatment consisted in arthroscopic burring of the apex of the hamate. At an average follow-up of 11 months (range, 6-24 months), all patients were satisfied with functional results, except 1 with persistent pain and stiffness; 93% returned to sport to their prior level. Mean range of motion was improved by 17 ° for wrist flexion (range, 15 ° to 30 °) and 15 ° for wrist extension (range, 10 ° to 25 °). All patients except 1 recovered grip strength, improving from 27 kg (range, 12-53) preoperatively to 35 kg (range, 17-61) at last-follow-up, and ulnar-sided pain was alleviated during golf practice. Return to prior sport level was possible by 5.5 months for professional players and by 9 months for amateurs. Arthroscopic burring of the apex of the hamate provided good clinical results for function and pain, with fairly rapid return to sport. Hamatolunate chondritis does not always mean pathology but represents the natural progression of Viegas type II wrists.
Assuntos
Ossos do Carpo , Hamato , Artralgia , Ossos do Carpo/cirurgia , Hamato/cirurgia , Humanos , Dor/etiologia , Estudos Retrospectivos , Articulação do Punho/cirurgiaRESUMO
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).
Assuntos
Síndrome do Túnel Carpal , Fraturas Ósseas , Hamato , Traumatismos do Punho , Síndrome do Túnel Carpal/diagnóstico por imagem , Síndrome do Túnel Carpal/cirurgia , Fixação Interna de Fraturas , Fraturas Ósseas/diagnóstico por imagem , Fraturas Ósseas/cirurgia , Hamato/diagnóstico por imagem , Hamato/lesões , Hamato/cirurgia , HumanosRESUMO
We examined the MRI scans of 35 adult hands to assess the feasibility of the hamate and the capitate as potential donor grafts in the management of comminuted intra-articular fractures at the base of the middle phalanges. Essentially neither the hamate nor the capitate were perfect anatomic matches in most digits, but the capitate had the advantage of having more uniform facets, and the capitate facet shapes were similar to those of the little finger. The measurement of angles in the coronal and sagittal plane showed that in some respects the differences between the potential graft and the base of the middle phalanges were smaller for the capitate than for the hamate. Moreover, the sagittal morphology of the capitate made it less prone to joint overstuffing than the hamate. We conclude that the capitate may be considered as a graft donor in selected cases, especially for the little finger.