Ultrasound of the Hook of Hamate Region: Pictorial Review.

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.

Upper Extremity Injuries in Rock Climbers: Diagnosis and Management.

Rock climbing places substantial stress on the upper extremities and can lead to unique injuries not common to other sports. With increasing popularity of the sport, hand surgeons are expected to see more patients with these pathologies. An understanding of the sport, accurate diagnoses, and appropriate treatment protocols are critical to maintain climbers' competitive abilities.

Hook of Hamate Fractures in Major and Minor League Baseball Players.

PURPOSE: The purpose of this study was to describe an approach to surgical management of the hook of hamate fractures in professional baseball players. METHODS: A retrospective chart review was performed on Major and Minor League Baseball players who underwent surgical excision for the hook of hamate fracture between the years 2003 and 2019 by a single surgeon. Patient demographics, the mechanism and timing of the injury, diagnostic and operative details, postoperative complications, and timeline to return to baseball activities were recorded. RESULTS: A total of 145 professional baseball players affiliated with 17 Major League Baseball organizations were studied, with the majority of athletes playing at the Minor League Baseball level (91.7%). Subacute or chronic patterns of injury (81.7%) were found to be more common than acute patterns based on radiographic and intraoperative findings. Two patients reported transient numbness in the fourth and fifth digits after surgery, 6 patients reported pisotriquetral pain when returning to a hitting program, and 1 patient developed heterotopic ossification after surgery. All complications resolved during a strength and conditioning program. On average, players in our cohort began a hitting program at 4.6 weeks after surgery and were released into full baseball activities at 7.1 weeks after surgery. CONCLUSIONS: Surgical excision remains an effective method of management, with a low risk of minor complications for both acute and chronic hook of hamate fractures in professional baseball players. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic Level IV.

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.

A Modified Surgical Approach Through Guyon's Canal and the Proximal Ulnar Border of the Carpal Tunnel Allows for Safe Excision of the Hook of the Hamate.

Hook of the hamate fractures can be treated by various methods including cast immobilization, open reduction, and internal fixation and excision. Usually, those individuals who elect for excision have acute fractures and need to return to sporting activity or work quickly or have nonunions with persistent symptoms. There is a paucity of descriptions in the literature and textbooks of a technique to safely excise the hook of the hamate. The authors present a method of safely exposing and removing the hook of the hamate by visualizing the potential structures at risk: the motor branch of the ulnar nerve, the ulnar digital nerve to the little finger, and the flexor tendons to the ring and little fingers by an approach through Guyon's canal and the proximal ulnar border of the carpal tunnel.

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

OBJECTIVE: The scaphoid is the most commonly fractured carpal bone. The presence of a concomitant hook of hamate fracture is of particular relevance given that it is often occult on routine wrist/scaphoid radiographs and that hook of hamate fractures are prone to symptomatic non-union, resulting in chronic ulnar wrist pain. Prompt diagnosis and immobilisation/fixation may minimise such complications. Our study is aimed at assessing the frequency of concomitant hook of hamate fractures in patients with scaphoid fractures. METHODS: Hook of hamate fracture is often occult on wrist/scaphoid radiographs. Hence, we identified all 2,568 CT and MRI studies performed to investigate scaphoid fracture at our institution from April 2005 to March 2016. Three hundred and twelve out of 2,568 cases were confirmed to have a scaphoid fracture. Images were then retrospectively reviewed by a Consultant Musculoskeletal Radiologist and Musculoskeletal Radiologist Trainee to assess for the presence of concomitant hook of hamate fracture and, if present, whether this was identified on initial reporting. RESULTS: Concomitant hook of hamate fracture was identified in 10.3% of cases (32 out of 312, 30 on CT, 2 on MRI); most were minimally/non-displaced. Sixty percent of fractures identified on CT were missed on the initial review (18 out of 30). Both cases identified on MRI had been initially reported. CONCLUSION: Scaphoid fracture is associated with higher than expected rates of concomitant hook of hamate fracture. Given the potential morbidity associated with hook of hamate fracture, this should be considered a review area when investigating scaphoid injury. These fractures are often minimally displaced, hence easily overlooked on CT. MRI may therefore be superior when investigating radiographically occult scaphoid fractures.

Return to Play and Complications After Hook of the Hamate Fracture Surgery.

PURPOSE: The purpose of this study was to evaluate the efficacy of hook of the hamate excision for fracture in a large cohort of patients to better understand recovery time and complications. METHODS: We retrospectively reviewed the medical records of patients treated with surgical excision for hook of the hamate fractures at 2 different centers. We collected information on demographics, clinical presentation, and postoperative complications. Continuous outcome variables included time to surgery, return to play, and return to activity. RESULTS: Our cohort of 81 patients had a median age of 22 years and was composed of 74 athletes including 57 baseball players and 8 golfers. The median time to return to play was 6 weeks (range, 1-36 weeks) after surgery; 11 patients (14%) had a return at 12 weeks or longer. Seventy-eight patients returned to preinjury activity levels. Twelve patients with a full recovery continued to experience some level of intermittent, nonspecific pain in the affected hand, although this was not severe enough to require additional treatment. We observed a 25% incidence of postoperative complications with the majority consisting of transient ulnar nerve dysfunction. Complications were more common among nonathletes, those presenting with nonunions, and those experiencing longer intervals between injury and surgery. CONCLUSIONS: In most cases, surgical excision as treatment for hook of the hamate fractures is safe and allows a relatively rapid return to play. However, we found a higher incidence of complications, including transient ulnar nerve dysfunction, than has been previously reported. In addition, there is a group of patients with delayed return to play and continued discomfort after surgery. These findings should inform the discussion with surgical candidates. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Spontaneous flexor tendon rupture in systemic lupus erythematosus: A case report.

Spontaneous flexor tendon rupture is an unusual complication of systemic lupus erythematosus (SLE) and has not previously been reported. While tendon ruptures in association with SLE have been focused on the previous studies, upper extremity tendon ruptures are infrequently reported in the literature. Here, we present an uncommon case of spontaneous flexor tendon rupture of the ring and little fingers in a patient with SLE and discuss the mechanism of injury and its surgical treatment.

The aetiology of fracture and nonunion in the hook of the hamate.

Fractures of the hook of the hamate are traditionally thought to be caused by direct trauma. A review of the anatomy and function of the hamate hook suggests that fracture is more likely as a result of a fatigue response that develops in the hook from repetitive load applied by the adjacent deep flexor tendons. Additional vascular compromise, from direct pressure of the tendons on critical local vessels, reduces blood flow leading to both mechanical and vascular effects that create pathological osseous change and weakening. These changes are likely to predispose to stress fracture and nonunion in repetitive gripping activities and are consistent with radiological findings.

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.

Return to Play After Hook of Hamate Fracture: A Systematic Review and Meta-Analysis.

In athletes, a hook of hamate fracture is concerning in terms of time to return to sport and effect on performance upon return. This study aims to analyze the treatment of hook of hamate fractures in athletes to determine their rates of return to play, timelines of recovery, and performance level upon return to play. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to perform this analysis. The PubMed database was queried to perform the literature search. Data were pooled and analyzed. P values <.05 were considered significant. Data were analyzed using the Comprehensive Meta-Analysis software to determine heterogeneity. Twenty studies with 823 patients sustaining hook of hamate fractures that reported any competitive level of play were included in the analysis. Of the 823 patients, 778 (94.5%) were able to return to play with 91.2% (506/555) of patients demonstrating similar or improved performance. The mean time to return to play was 45 days (range: 21-168 days). Treatment included surgical excision for 787 patients (95.6%), open reduction and internal fixation for 18 patients (2.2%), stress reduction/casting for 13 patients (1.6%), and loss to follow-up or surgery refusal for 5 patients (0.6%). A very high number of athletes return to play following a hook of hamate fracture at the same or improved level of performance. In our study, the majority of injuries were treated with surgical excision of the fractured hook of hamate fragment. Most athletes returned to their sport at an average of 45 days.

Understanding the Injury Mechanism in Hamate Hook Fractures by Investigating Fracture Morphologies: A Case Series Study.

BACKGROUND: Many studies have described hamate hook fractures resulting from direct force from sporting tools. However, several authors have reported fractures that did not occur during swing-related activities. This study aimed to understand the injury mechanism of fractures by investigating their morphologies. METHODS: We selected patients with hamate hook fractures and collected data on computed tomography scans, injury causes, and how athletes handled sporting tools. RESULTS: We investigated 50 patients, and the study cohort included 32 patients who sustained injuries during sports: 24 during baseball (group A) and 8 during other sports (group B). Sixteen patients sustained injuries from falls (group C), and 2 had their hands crushed while using an industrial press machine (group D). In group A, most patients had a fracture line starting from the middle section of the radial side, accompanied by osteosclerotic changes in their lower hand. In group B, most patients had fracture morphologies similar to those of most patients in group A. The main morphology of fractures in group C was a transverse fracture at the base. Two patients in group D had minimal fragments at the tip of the hooks. CONCLUSIONS: Our results question the theory that most hamate hook fractures in athletes are caused by direct force exerted on the palm because the fracture morphology was different from that of patients injured by acute trauma from direct force. Instead, these fractures likely stem from an indirect mechanism involving repetitive force generated by the tendons and muscles acting on the hook.

Snapping Wrist From Bowstringing of the Digital Flexors After Carpal Tunnel Release: A Case Report.

Symptomatic bowstringing of digital flexor tendons is a rare complication of carpal tunnel release (CTR). Two weeks after open CTR, a 47-year-old man with severe carpal tunnel syndrome had relief of his preoperative median paresthesia but complained of new-onset painful snapping of the wrist and transient ulnar paresthesia occurring with wrist dorsiflexion and concomitant digital flexion. Physical examination localized the audible snapping to the hook of hamate (HOH) where manual pressure eliminated the wrist motion-induced snapping and the associated ulnar paresthesia. Wrist radiographs showed stage III scapholunate advanced collapse (SLAC) with marked palmar subluxation of the lunate. Wrist magnetic resonance imaging revealed palmar and ulnar subluxation of the digital flexors over the HOH due to the mass effect of the palmarly displaced lunate and the chronic carpal malalignment. The snapping wrist and accompanying ulnar paresthesia resolved after HOH excision, and no additional treatment for the asymptomatic SLAC wrist deformity was required. Satisfactory clinical outcome was observed at 5-year follow-up.

An Evaluation of Variations in the Carpal Tunnel Dimensions of Adult Subjects in a Hospital-Based Population: An Ultrasonographic Cross-Sectional Study.

Background The carpal tunnel is a groove that spans the palm as a 'U.' The ulnar and radial sides of the wrist are made up of the scaphoid tubercle and trapezium while the palmar aspect is made up of carpal bones. Our study aimed to see whether there were differences in carpal tunnel size between men and women. Material and methods The study was conducted on 65 healthy adults, 13 (20%) were males and 52 (80%) were females (both non-pregnant and pregnant). Inclusion criteria were healthy adults and bilaterally symmetrical limbs. Exclusion criteria were chronic disease, diabetes, hypertension, immunological disorders, any visible abnormalities, and a history of upper extremity pain on either side. A high-resolution ultrasound machine with a linear transducer was used to perform an ultrasound scan of the carpal tunnel. The anteroposterior dimension was measured at the midline, or along the axis of the middle finger, and the transverse diameter was measured at the midpoint of the flexor retinaculum. The cross-sectional area of the tunnel was measured at its largest diameter within the carpal tunnel. All the dimensions were measured in centimeters. Results The mean transverse diameter of the right side was 1.824 ± 0.223 cm (p-value 0.002) and of the left side was 1.742 ± 0.197 cm (p-value 0.004). The mean cross-sectional area of the carpal tunnel on the right side was 1.417 ± 0.379 cm2 (p-value 0.008) and on the left side was 1.306 ± 0.303 cm2 (p-value 0.004), respectively. Age, sex, weight, and BMI were discussed. The carpal tunnels of females were found to be comparatively squarer and smaller than those of males. Conclusion The transverse diameter and cross-sectional area of the carpal tunnel and their correlation with carpal tunnel syndrome are predicted by age, sex, weight, and BMI. Both sexes had the same wrist ratio.

Treatment of Intractable Pillar Pain With Excision of the Hook of Hamate.

Introduction: A common consequence of carpal tunnel release (CTR) is ulnar palmar pain termed pillar pain. Some (very rare) patients do not improve with conservative treatment. We have been treating recalcitrant pain with excision of hook of the hamate. Our purpose was to evaluate a series of patients undergoing excision of the hook of the hamate for post CTR pillar pain. Methods: A retrospective review of all patients undergoing hook of hamate excisions over a 30-year period was performed. Data collected included: gender, hand dominance, age, time-to-intervention, preoperative and post-operative pain scores, and insurance. Results: Fifteen patients were included with a mean age of 49 (range 18-68) years, 7 female (47%). Twelve (80%) of the patients were right handed. Mean time between CTR and excision hook of hamate was 7.4 months (range 1-18 months). Pain prior to surgery was 5.44 (range 2-10). Post-operative pain was 2.44 (range 0-8). Mean follow-up was 4.7 months (range 1-19 months). Patients with a good clinical outcome were 14 (93%). Conclusions: Excision of hook of hamate seems to provide clinical improvement in patients who remain painful despite exhaustive conservative treatment. It may be considered as a very last resort for persistent pillar pain after CTR.

Introduction : Une conséquence fréquente de la libération du tunnel carpien (TC) est une douleur ulnaire palmaire appelée douleur du pilier. Quelques (très rares) patients ne sont pas améliorés par le traitement conservateur. Nous avons traité une douleur récalcitrante avec une ablation du crochet (ou hamulus) de l'os hamatum. Notre objectif était d'évaluer une série de patients subissant une ablation du crochet de l'os hamatum pour douleur du pilier après libération du TC. Méthodes : Une analyse rétrospective de tous les patients subissant une ablation du crochet de l'os hamatum a été menée sur une période de 30 ans. La collecte de données a inclus: le sexe des patients, la main dominante, l'âge, le délai jusqu'à l'intervention, les scores de douleur avant et après l'opération, ainsi que l'assurance. Résultats : Quinze patients ont été inclus; leur âge moyen était de 49 ans (18 à 68 ans); il y avait 7 femmes dans la population (47 %). Douze patients (80 %) étaient droitiers. Le délai moyen écoulé entre la libération du TC et l'ablation du crochet de l'os hamatum a été de 7,4 mois (extrêmes: 1 à 18 mois). Le score de douleur avant chirurgie était de 5,44 (extrêmes: 2 à 10). Le score de douleur postopératoire était de 2,44 (extrêmes: 0 à 8). Le suivi moyen a été de 4,7 mois (extrêmes: 1 à 19 mois). Un bon résultat clinique a été obtenu chez 14 patients (93 %). Conclusion : L'ablation du crochet de l'os hamatum semble procurer une amélioration clinique chez les patients qui restent douloureux malgré un traitement conservateur exhaustif. Cette option peut être envisagée en dernier ressort chez les patients ayant une douleur du pilier après libération du TC.

Common Hand Injuries in the Baseball Player.

PURPOSE OF THE REVIEW: The list of potential hand and wrist injuries among baseball players is numerous and includes fractures, dislocations, strains, and sprains. The purpose of this review, however, is to highlight injuries to the hand and wrist which are either particularly common or unique to professional baseball players with an emphasis on diagnostic pearls and treatment principles. RECENT FINDINGS: For many baseball-related hand and wrist injuries, descriptions of the pathophysiology, diagnosis, and treatment options are based on single institution case series. With the implementation of Major League Baseball's Health and Injury Tracking System, our understanding of the epidemiology of these injuries in professional baseball players has greatly improved. The most common injury requiring operative treatment is a hook of hamate fracture, and recent evidence increasingly supports fracture fragment excision for early pain-free return to sport. Fractures of the proximal phalanges of fingers, thumb phalangeal fractures, and UCL injuries are the most common indication for surgery of the digits. A4 pulley ruptures in pitchers and repetitive trauma to the vasculature of the palm and digits are relatively unique to professional baseball players and are frequently able to be managed non-operatively. While injuries to the hand and wrist are common, the median number of days missed due to such an injury was only 4 days among professional baseball players. Statements and Declarations" for inclusion in the published paper. Please note that submissions that do not include relevant declarations will be returned as incomplete.

Refracture of a Regenerated Hook of Hamate in a Professional Baseball Player: A Case Report.

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).

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.

Unusual twisting of a reconstructed FDP tendon of the little finger after spontaneous attrition rupture on the hamate bone: a case report.

We describe a case of attrition rupture of flexor digitorum profundus tendon of the right little finger in a 64-year-old lady caused by a prominent hook of hamate. The tendon was reconstructed primarily by palmaris longus tendon graft and was complicated by tendon graft twisting by scar tissue, resulting in the inability to fully extend the finger.

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).