CHAPTER 54 • WRIST AND HAND FRACTURES 313HAMATE FRACTURES
- Hook or body of the hamate fractures is present in 2 to
4% of carpal bone fractures (Rettig, Ryan, and Stone,
1992).
HOOK OF THEHAMATEFRACTURES
- Injury commonly occurs from direct force of bat,
club, or racket. - Diagnosis is often missed; chronic fractures are asso-
ciated with flexor tendon rupture, and ulnar nerve
neuropathy.
•Pain localized over the hamate in the hypothenar emi-
nence. - Carpal tunnel view and CT scans aid in diagnosis.
- Direct repair of the fracture results in high nonunion
rates, therefore treatment usually requires removal of
the hook through the fracture site with early return to
sports (Parker et al, 1986; Bishop and Beckenbaugh,
1988).
BODY OF THEHAMATEFRACTURES
- Less common than hook fractures, often associated
with dislocation of fourth and fifth metacarpals
(Marck and Klasen, 1986). - Oblique radiographs of the carpus and CT scans can
assist in defining the fracture. - Nondisplaced fractures treated with cast immobiliza-
tion for 4 to 6 weeks. - Displaced fractures are treated with open reduction,
K-wire or screw fixation, and immobilization for 4 to
6 weeks.
RETURN TOSPORTS
- Athletes with fractures treated by conservative meas-
ures may return to sport immediately with protection
until pain free (McCue, Bruce, and Koman, 2003). - Athletes treated with excision of the hamate hook may
return to sport as tolerated, they will often have
hypothenar tenderness for several months and will
require the use of well-padded gloves for return to
sport (Geissler, 2001). - Athletes with surgically treated fractures are restricted
from sport until after healing is evident (4 to 6 weeks).
Participation may resume with splint or cast protec-
tion until normal strength and range of motion return
(McCue, Bruce, and Koman, 2003).
CAPITATE FRACTURES
- The capitate is centered within the carpus and is well
protected from injury and accounts for only 1% to 2%
of all carpal fractures (Geissler, 2001).- Fractures often occur from either a direct blow to the
dorsum of the wrist or from forced dorsi-flexion or
volar-flexion. Capitate fractures are often associated
with scaphoid fractures and perilunate dislocations
(Rand, Linscheid, and Dobyns, 1982). - Radiographic assessment with PA and lateral views,
CT scan or MRI. - Nondisplaced fractures are treated with immobiliza-
tion in short-arm cast for 6 to 8 weeks. - Capitate fractures are associated with poor outcomes
because the fractures are inherently unstable and
delayed union, nonunion and avascular necrosis are
common complications (Rand, Linscheid, and
Dobyns, 1982).
•Displaced fractures (2 mm of displacement) are
treated with open reduction, internal fixation(ORIF)
with K-wires or screw fixation and immobilized in
short-arm cast for 6 weeks.
- Fractures often occur from either a direct blow to the
RETURN TOSPORTS- Athletes with nonoperative fractures may return to
sport immediately with protective casting (McCue,
Bruce, and Koman, 2003). Close follow-up must be
maintained to assure that fracture displacement does
not occur obligating operative intervention. - Athletes with surgically treated fractures are restricted
from sport until after healing is evident (4 to 6 weeks).
Participation may resume with splint or cast protec-
tion for an additional 3 months or until normal
strength and range of motion return (McCue, Bruce,
and Koman, 2003).
PISIFORM FRACTURES- Pisiform fractures are rare and usually occur from
direct blow to the palm and account for 1 to 3% of all
carpal bone fractures (Geissler, 2001).
•Patients tend to have tenderness over the hypothenar
region. - Fractures are best visualized on 30°oblique AP view
or carpal tunnel view. - Acute nondisplaced fractures are managed by immo-
bilization in a short-arm cast for 3 to 6 weeks. - Comminuted fractures and symptomatic nonunions
are managed by excision, with care to preserve the
flexor carpi ulnaris tendon, with little or no functional
impairment (Arner and Hagberg, 1984).
RETURN TOSPORTS- Athletes return to sports as soon as acute pain sub-
sides with taping, padded gloves, or casting as needed
(McCue, Bruce, and Koman, 2003; Geissler, 2001;
Rettig et al, 1998).