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Radiology Review - Hook of hamate fracture - an unusual cause of hand pain

This 42-year-old male recreational football player presented with an eight-week history of hand and wrist pain following a fall onto his right hand. He was found to have localised tenderness over the volar aspect of his wrist and mild discomfort with gripping activities.

In this case a routine x-ray series of the wrist was completed at the time of his injury and again several weeks later. Both of these sets of images were normal. Carpal tunnel views, a dedicated view which profiles the hook of hamate, were not completed. A subsequent MRI scan showed a comminuted, displaced fracture through the tip of the hook of the hamate with a small (6 mm) bony fragment at the flexor retinaculum attachment.

This player was diagnosed with a hook of hamate fracture. As the fracture fragment was very small he was managed with a period of relative rest. He was able to run and play running-based sport within a few weeks of his injury. He had to avoid movements at work (like using a hammer) that aggravated his symptoms but reported a progressive improvement in his symptoms over a period of four months. At this point he was able to return to all normal activities.

Hook of hamate fractures are relatively rare. In sport the classic mechanism is a direct blow to the volar aspect of the hand or wrist from a “duffed” golf swing. Any direct blow to the volar aspect of the hand or wrist can cause this injury. While in this case the fracture was not seen on x-ray images, a specialised x-ray view (carpal tunnel view) may be used to document the injury. When the fracture fragment is small it can generally be treated with a short period of immobilisation and/or observation. When the fragment is larger, or when the symptoms fail to settle, excision of the fragment is generally considered.