Missing a Hook of Hamate Fracture presents a medico-legal nightmare somewhat like missing a scaphoid fracture. It is often a “unbalanced loaded” racket sports related injury or direct blow. Pain may not be severe and plain xrays are often normal. Early casting immobilization for 6-8 weeks is essential. Missing a fracture can lead to persistent pain from non-union, ulnar nerve injury in Guyon canal, and late rupture of little profundus/superficialis tendon. A New test has been devised for detection.
J Hand Surg Am. 2010 Oct 18. [Epub ahead of print]
Hook of Hamate Pull Test.
Wright TW, Moser MW, Sahajpal DT. abstract here
- Beware of in direct trauma and in racket users
- If now chronic, may present with ulnar(small finger side) volar (palm) wrist pain
- Tenderness over hook hamate present but is an old non-union may now be mild
- Plain xrays require carpal tunnel view,or a 30° supinated view.
- Complications are a nightmare and include persistent pain from nonunion, ulnar nerve damage with weakness fingers, and delayed tendon fraying and rupture with lateral fingers affected.
Easily missed but confirmed by new Hook of Hamate pull test:
- Supinated – palm up
- ulnar (little finger) deviated (bent)
- Outer 2 fingers bent up and held like that against resistance
- creates ulnar wrist pain if fractured
- Ct scan is the definitive evaluation.
- Early treatment involves immobilization, though it is suggested a hand surgeon follow because non-union is so common
- Late treatment involves excision of non-union fragment.
Comment – had one direct blow case. Plain carpal tunnel view suggested maybe a crush injury and further imaging, the same. Mercifully, case resolved with splinting. Scared me though… This test could have proved helpful.