Hamate Fracture Treatment & Management
- Author: Amy Powell, MD; Chief Editor: Sherwin SW Ho, MD more...
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.
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. 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.
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.
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.
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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. 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 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).
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.
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