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Hamate Fracture Treatment & Management

  • Author: Amy Powell, MD; Chief Editor: Sherwin SW Ho, MD  more...
Updated: Oct 13, 2015

Acute Phase

Medical Issues/Complications

Complications include ulnar nerve compression at the level of the Guyon canal. The hook of the hamate is the distal lateral border of the Guyon canal and is close to the motor branch of the ulnar nerve and ulnar artery as they pass through the canal. The ulnar nerve then turns around the hook of the hamate and travels deep to innervate the intrinsic musculature. When surgical treatment is indicated, care must be taken to prevent damage to the motor branch of the ulnar nerve. Additionally, rupture of the small- and ring-finger flexor tendons may occur if injured by the irregular fracture edges.

Surgical Intervention

In the past, hamate hook fractures were treated conservatively with lower arm cast immobilization for 6 weeks, provided the fracture was diagnosed within 1 week of the injury.[11] Retrospective analyses have demonstrated nonunion rates greater than 50% and as high as 80-90% with conservative treatment. These nonunions are likely multifactorial, involving poor blood supply, delayed diagnosis, and fragment displacement with continuous movement of the fourth and fifth digits while casted. Therefore, all hamate hook fractures should be referred to a hand surgeon for possible surgical intervention.

Two types of surgeries are commonly performed for hamate hook fractures.[5, 11] One involves excision of the hook itself. The other is an open reduction and internal fixation (ORIF) procedure. Of the 2 procedures, the former (excision of the hook) is considered the criterion standard.[12]

Complications that may arise from hook excision include decreased grip strength secondary to removal of the attachment for the transverse carpal ligament, pisohamate ligament, and flexor and opponens digiti minimi muscles. Because of this concern, 2 retrospective studies compared grip strength in patients who underwent excision versus those who underwent ORIF.[5, 11] Both studies failed to show any statistically significant difference in grip strength up to 3 years post procedure.

Hamate body fractures are commonly associated with dislocation of the fourth and fifth fingers.[13, 14, 15, 16] Shearing forces from the metacarpals can cause either a dorsal cortical hamate fracture or a coronal body fracture.[17, 18, 19, 20] These fractures can be reapproximated by reduction of the carpometacarpal joint; however, they usually require internal fixation because of the high incidence of instability in these injuries.[21]


Consultation with an orthopedist or hand surgeon is recommended for all patients with hamate fractures secondary to the high risk of nonunion with conservative treatment (see Surgical Intervention). If an ulnar nerve injury is suspected, an electrodiagnostic evaluation should be performed by a physiatrist or neurologist with electrodiagnostic expertise before surgical exploration and treatment in order to determine the degree of axonal injury.

Related Medscape Reference topics:


Physical Assessment for Electrodiagnostic Medicine

Other Treatment

Data are emerging that suggest ultrasound is useful in promoting fracture healing. Fujioka et al published a case report of a hamate nonunion in an 18-year-old woman treated with low-intensity ultrasound that was performed 20 min/d for 4.5 months.[22] During her ultrasound treatments, the patient was allowed routine activities and was not immobilized. CT scanning confirmed union of her fracture.

The role ultrasound will play in the future remains unclear; however, it will likely be limited because this imaging modality is both more time consuming and requires longer activity limitations than current treatments.[23, 24]


Recovery Phase

Rehabilitation Program

Physical Therapy

Recovery from injury occurs in 4 stages (ie, wound healing, recovery of motion, recovery of strength and power, and recovery of endurance). Although these divisions are arbitrary, they provide a progressive sequence for management and a target for physical therapy. Early motion, instituted before collagen cross-linking and scarring occur, favors functional recovery. Collagen has more elasticity in the earlier stages of formation; and this elasticity decreases with time and immobilization.

The goals of physical therapy are tailored to the desires of the patient and the demands of his or her occupation or lifestyle. In all phases of recovery, special attention is directed to any development of edema. Fibrin contained in the exudate has the potential to evolve into scar tissue and limit function. For this reason, recommend elevation, compression, and motion in order to mobilize excess fluid from around the wound until maximum medical recovery is achieved.

The ability to begin physical therapy and increase the intensity of exercises varies according to the initial treatment of the hamate fracture. Conservative treatment requires immobilization with casting for 6 weeks, followed by an additional 4-6 weeks of physical therapy. If the injury is treated surgically with hook excision, the patient can start physical therapy immediately, without limitations, and can return to full activity within 6-8 weeks. If the injury is treated surgically with ORIF, the patient requires casting for 2 weeks, followed by an additional 4 weeks of physical therapy without placing strain on the affected wrist, before progressing to full activity in 6-8 weeks (see Return to Play).[25]


Maintenance Phase

Rehabilitation Program

Physical Therapy

The maintenance phase is the final phase of the rehabilitation process. The goals for therapy are focused on specific functional activities, whether related to work or sports, to enable the patient to safely return to his or her premorbid level of functioning. In addition to working on specific strengthening activities with a physical therapist, the patient should also be independently engaging in a home exercise program for continued range-of-motion therapy and strengthening of the wrist and hand if optimum mobility and strength has not been attained.

Contributor Information and Disclosures

Amy Powell, MD Assistant Clinical Professor, Department of Orthopedics, University of Utah

Amy Powell, MD is a member of the following medical societies: American College of Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.


Janos P Ertl, MD Assistant Professor, Department of Orthopedic Surgery, Indiana University School of Medicine; Chief of Orthopedic Surgery, Wishard Hospital; Chief, Sports Medicine and Arthroscopy, Indiana University School of Medicine

Janos P Ertl, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, Hungarian Medical Association of America, Sierra Sacramento Valley Medical Society

Disclosure: Nothing to disclose.

Nancy J Taubenheim, DPT Staff Physical Therapist, Clinical Instructor, Department of Rehabilitation Services, Bryan LGH Medical Center

Disclosure: Nothing to disclose.

Warren S Theis, MD Staff Physician, Department of General Surgery, Carilion Roanoke Memorial Hospital

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Henry T Goitz, MD Academic Chair and Associate Director, Detroit Medical Center Sports Medicine Institute; Director, Education, Research, and Injury Prevention Center; Co-Director, Orthopaedic Sports Medicine Fellowship

Henry T Goitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine

Disclosure: Nothing to disclose.

Chief Editor

Sherwin SW Ho, MD Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago Division of the Biological Sciences, The Pritzker School of Medicine

Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Arthroscopy Association of North America, Herodicus Society, American Orthopaedic Society for Sports Medicine

Disclosure: Received consulting fee from Biomet, Inc. for speaking and teaching; Received grant/research funds from Smith and Nephew for fellowship funding; Received grant/research funds from DJ Ortho for course funding; Received grant/research funds from Athletico Physical Therapy for course, research funding; Received royalty from Biomet, Inc. for consulting.

Additional Contributors

Gerard A Malanga, MD Founder and Partner, New Jersey Sports Medicine, LLC and New Jersey Regenerative Institute; Director of Research, Atlantic Health; Clinical Professor, Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey-New Jersey Medical School; Fellow, American College of Sports Medicine

Gerard A Malanga, MD is a member of the following medical societies: Alpha Omega Alpha, American Institute of Ultrasound in Medicine, North American Spine Society, International Spine Intervention Society, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine

Disclosure: Received honoraria from Cephalon for speaking and teaching; Received honoraria from Endo for speaking and teaching; Received honoraria from Genzyme for speaking and teaching; Received honoraria from Prostakan for speaking and teaching; Received consulting fee from Pfizer for speaking and teaching.


Emily Harold, MD Staff Physician, Department of Internal Medicine, University of Utah Hospital

Disclosure: Nothing to disclose.

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Posterior (dorsal) view of the wrist.
Anterior palmar view.
Anteroposterior view of the wrist.
Lateral view of the wrist.
Oblique view of the wrist.
Computed tomography scan of the wrist.
Lateral computed tomography scan of the wrist.
Reconstruction of the hamate fracture.
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