Hook of hamate fracture excision seen as a preferred option in athletes
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Hook of hamate fractures, while uncommon in the general population, are more common among athletes.
These may occur due to repetitive stress on the hypothenar eminence of the hand from a bat, club or racket in sports such as baseball, golf or tennis. As a source of pain at a key anatomic area for these athletes, these fractures can limit performance. Diagnosis is often delayed due to an insidious onset and vague presentation. Radiographs, specifically carpal tunnel views, may provide the diagnosis. CT scan can confirm the diagnosis and inform chronicity or evidence of healing (Figure 1).
Source: Matthew I. Leibman, MD
Nonoperative management was historically a primary option for hook of hamate fractures, but it has shown mixed results. Open reduction and internal fixation, another accepted technique, can also have less desirable outcomes, with nonunion or hardware irritation among them. In high-demand athletes, consistent results with a fast return to play is highly sought after. Fragment excision has been shown to have a high rate of rapid return to play with low rates of complications and return to the OR. Therefore, this has become the preferred treatment strategy used in athletes.
Relevant anatomy
The hook of hamate, or hamulus, is located one fingerbreadth distal and radial to the more clearly palpable pisiform (Figure 2). It is the origin of the transverse carpal ligament. As the ulnar border of the carpal tunnel, its radial aspect is adjacent to the flexor tendons. On its ulnar aspect and superficial to the hamate lies Guyon’s canal, which contains the ulnar artery and superficial sensory and deep motor branches of the ulnar nerve. The superficial sensory branch supplies sensation to the fourth webspace and small finger while the deep motor branch innervates the hypothenar muscles, interossei and third/fourth lumbricals. Surgeons must be aware that the superficial and deep branches diverge proximal to the hook of hamate. Therefore, both branches must be visualized and protected in the approach to the hook of hamate — both the superficial branch coursing with the ulnar artery and the deep branch, which is only visible once these superficial structures are retracted.
Surgical technique
Following prepping and draping, a curvilinear skin incision is made over the hook of the hamate and Guyon’s canal (Figure 3). If a callus is present, the incision should be made through it so as not to impede visualization.
Dissection is taken through subcutaneous tissue to the palmaris brevis, which is divided at its radial aspect as it becomes confluent with fascia (Figure 4). The palmar cutaneous branch of the ulnar nerve seen at the distal aspect of the incision should be protected.
Guyon’s canal is visualized with the superficial sensory branch of the ulnar nerve and the ulnar artery within it (Figure 5). The neurovascular bundle is superficial and/or ulnar to the hook of hamate, but not deep to the hook. The nerve tends to lie deep to the artery.
In patients with paresthesias and numbness in the terminal ulnar nerve distribution, additional decompression of the ulnar nerve at the wrist may be needed. Dissection is taken proximally to the volar carpal ligament, which is released. Release may continue into the antebrachial fascia until the distal wrist flexion crease is reached. The neurovascular bundle is deep to these releases and should be protected.
Neurovascular structures
The superficial branch of the ulnar nerve and the ulnar artery are retracted ulnar. Proximally, the bifurcation of the superficial and deep branches may be visualized to locate the deep motor branch (Figure 6). This bifurcation may be just deep to the proximal origin of the hypothenar muscles. Release of the fibrous arch of the hypothenar origin allows deep branch decompression and mobilization ulnar, exposing the entire ulnar border of the hook of hamate. Careful retraction of the neurovascular structures throughout the remainder of the case is crucial.
The hook of hamate is cleared of soft tissue with a small scalpel while avoiding the neurovascular structures, particularly at the distal ulnar corner, where the deep motor branch is nearest. Flexor tendons are retracted radially. The fracture is defined. A rongeur is used to excise the fracture fragment (Figure 7). For partial healing in chronic injuries, a small osteotome is used to facilitate release. A rasp is used to even out the residual hamate. Bone wax may be used for hemostasis.
Neurovascular structures are examined. The wound is irrigated. Palmaris brevis may be closed to its attachment with absorbable suture. The skin is closed in standard fashion. The tourniquet may be let down before or after skin closure, giving attention to appropriate return of color to the small finger.
Tailored rehabilitation
Postoperative rehabilitation advances quickly and is tailored to the patient’s progress, with the goal of return to sports at 6 weeks. Generally, a plaster splint is placed for 1 week, with removal and check of the incision thereafter. Week 2 involves light wrist and finger range of motion and cardiovascular conditioning, with sutures removed at the end of the week. Week 3 is the beginning of a throwing program without catching, as well as dry swings and forearm strengthening. Week 4 progresses to letting the patient take swings off of a tee and light catches. During week 5, progression of prior activities continues with swings against slower throws. Week 6 marks full batting practice and fielding, with return to gameplay at the end of the week if the patient has appropriately progressed.
- References:
- Devers BN, et al. J Hand Surg Am. 2013;doi:10.1016/j.jhsa.2012.10.011.
- Engler ID, et al. Orthop J Sports Med. 2022;doi:10.1177/23259671211038028.
- Erickson BJ, et al. Am J Sports Med. 2020;doi:10.1177/0363546520949204.
- Scheufler O, et al. Plast Reconstr Surg. 2005; doi:10.1097/01.PRS.0000149480.25248.20.
- For more information:
- Gustavo Barrazueta, MD, an orthopedic hand surgeon at Adena Health System, can be reached at 272 Hospital Rd., Chillicothe, OH 45601; email: gbarrazueta@adena.org.
- Ian D. Engler, MD, is an orthopedic sports medicine surgeon at Central Maine Medical Center in Lewiston, Maine. He can be reached at 300 Minot Ave., Auburn, ME 04210; email: ian.engler@cmhc.org.
- Matthew I. Leibman, MD, is an orthopedic hand surgeon at Hand Surgery PC at Newton-Wellesley Hospital. He can be reached at 214 Washington St., Newton, MA 02462; email: mleibman@partners.org.
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