I am an occupational therapist working in a hand clinic. We get a fair number of sports athletes in here with various injuries. Just lately I have seen three cases of hook of the hamate fractures from golfers here on vacation. When they don't get better with hand therapy, they go back to the surgeon for further evaluation. Is there some way to identify these injuries sooner than later?
Hand surgeons from the University of Florida have recently published a case study to demonstrate a new test for fractures of the hamate bone in the hand. For those readers who don't know, the hamate bone is one of the many small bones in the wrist. It lines up with the base of the fourth (ring) and fifth (baby) fingers.
On the palmar side of the hand and wrist, the hamate bone has a projection of bone. This bit of bone is referred to as the hook of the hamate. There are many ligaments, muscles, and tendons that either attach directly to the hook of the hamate or sling around it like a pulley.
The anatomy is significant because with so many different soft tissues affecting the hamate bone, it is at risk for injury. When does this happen most often? When a baseball player, golfer, or racquet sports player of any kind swings the bat, golf club, or racquet held in the hands.
While swinging the bat, club, or racquet, the hand and wrist move into a position of ulnar deviation (movement toward the small finger). The forearm, wrist, and hand move from a position of pronation (palm down) to supination (palm up). Direct pressure and shearing forces are applied to the hook of the hamate. It's actually a wonder the hook of the hamate doesn't break off more often.
The surgeons introduced a clinical test they call the hook of the hamate pull test or HHPT to help diagnose these problems. Here's how it's done: the patient's hand is placed palm up. The wrist is placed in a fully ulnar deviated position (wrist tilted away from the thumb). The proper test position is essential to getting accurate test results.
The small and ring fingers are flexed or bent as the examiner applies pressure to the pads of the tips of those two fingers (as if trying to straighten the fingers). The test position loads the flexor profundus tendons of the two fingers. Those two tendons come alongside the hook of the hamate. When they contract, they push (displace) the broken hook off to the side. The result is a reproduction of the severe, sharp pain at the wrist where the hamate is located.
In all the cases tested, the pull test was always positive when there was a true hook of the hamate fracture. The test is not considered positive when generalized wrist pain occurs -- only when the severe, sharp pain from the original injury is reproduced. A CT scan can confirm the diagnosis.
Thomas W. Wright, MD, et al. Hook of Hamate Pull Test. In Journal of Hand Surgery. November 2010. Vol. 35. No. 11. Pp. 1887-1889.
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