What's the diagnosis? By Dr. Erica Schramm
A 45 year old male presents for pain and swelling in his left medial hand days after punching a wall. His x-ray is shown below. What's the diagnosis? (Identify the two fractures) Scroll down for answer.
For a review about Boxer’s Fractures see here
- rare fractures (less than 2% of carpal bone fractures)
- hamate body fracture: most common mechanism is a direct blow with a closed fist (punching a wall); body fractures are often associated with a 4th or 5th metacarpal fracture
- hook of hamate fracture: most common mechanism is an interrupted swing (with a baseball bat, golf club, etc.); a “carpal tunnel view” x-ray is useful for investigate the hook of the hamate; Guyon’s canal: runs under the hook of the hamate and contains the ulnar nerve and ulnar artery; physical exam should include evaluation of ulnar nerve and artery
- point tenderness over the hamate should raise suspicion for a fracture, and if plain films are negative a CT should be considered
- hook of hamate and non-displaced body fractures can be splinted in the ED with a volar splint and prompt outpatient orthopedics follow up
- non-union of hamate hook fractures is common and many ultimately require surgery
- displaced body fractures and fractures with associated signs of neurovascular injury require ORIF
Blome, Andrea L and Megan E Healy. “Wrist.” Simon’s Emergency Orthopedics, 8e. Scott E Sherman Ed. New York, NY: McGraw-Hill, 2019.
Escarza, Robert et al. “Wrist Injuries”. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e. Judith E Tintinalli, et al. New York, NY: McGraw-Hill, 2016.