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Órgano Oficial del Colegio Mexicano de Ortopedia y Traumatología

2026, Number 4

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Acta Ortop Mex 2026; 40 (4)

Early surgical management of hamate hook fractures with headless screw fixation: a Latin-American case series

Méndez-Daza, CH1,2; Montoya-Carvajal, JG1,3; Ospina, AF4; Castro-Rubio, DA5,6; Delgado-Baloco, OJ5,7; Bejarano, M8

Language: English
References: 29
Page: 268-274
PDF size: 2090.74 Kb.


ABSTRACT

Introduction: the diagnosis of hamate hook fractures based on clinical suspicion can be established with conventional radiographs and computed tomography (CT). Management options include immobilization, hook resection, and open reduction with internal fixation (ORIF). The aim of this study was to determine whether patients treated with ORIF recover wrist mobility and hand grip strength. Material and methods: a retrospective analytical case series was conducted in adult patients with hamate hook fractures treated with ORIF using headless cannulated screw fixation between 2019 and 2021. Patients with additional ipsilateral or contralateral upper-limb fractures and those lost to follow-up were excluded. Outcomes evaluated included wrist range of motion, grip strength, pain scores, and complications. Results: ten patients were included in the study, eight of whom were male. The mean follow-up was 16.7 months [range 12-25 months]. Postoperative evaluation showed low pain levels (mean VAS: 1.4) and functional improvement (mean QuickDASH: 2.7), with no statistically significant differences in grip strength and wrist range of motion between the affected and unaffected sides. One complication was observed due to screw malposition in the carpometacarpal joint, causing pain and requiring implant removal. Conclusion: patients with hamate hook fractures treated with ORIF recovered wrist mobility and grip strength of the affected hand.



ABBREVIATIONS:

  • ORIF = open reduction with internal fixation
  • SD = standard deviation
  • VAS = visual analog scale



INTRODUCTION

The hamate bone is located in the distal row of the carpus, and its hook-shaped process forms a palpable prominence in the hypothenar eminence. This structure serves as an attachment site for muscles and ligaments and lies in close proximity to the ulnar nerve. Fractures of the hamate are uncommon, representing 2-4% of all carpal fractures, and most frequently involve the hook. The mechanism of injury may be direct, occurring in sports that involve impact with instruments resting on the hypothenar eminence (such as baseball, tennis, or golf), or indirect, following a fall on the outstretched hand with the wrist in extension and ulnar deviation, which transmits force to the hook through ligamentous and muscular insertions.1,2,3,4,5,6,7

In a clinical setting, patients usually experience localized pain in the hypothenar region that is exacerbated by palpation or gripping. Initial diagnosis with conventional radiographs is often challenging due to overlapping bony structures, even when using special projections such as the carpal tunnel view.8,9 In such cases, computed tomography is considered the imaging modality of choice because of its superior sensitivity and specificity.10,11

The optimal management of hook of hamate fractures remains controversial. Reported options include cast immobilization, fragment excision, and open reduction with internal fixation (ORIF). Immobilization has been associated with symptomatic nonunion, whereas excision may lead to residual pain or decreased grip strength.1,4,12,13,14,15,16 In contrast, internal fixation aims to restore normal anatomy while preserving muscular and ligamentous attachments.

The purpose of this study was to evaluate functional recovery in patients with acute hook of hamate fractures treated with ORIF using a headless cannulated screw through a volar approach. A particular feature of this series is that fixation was performed early (within 24 to 48 hours after injury) unlike most previously published reports.



MATERIAL AND METHODS



STUDY DESIGN AND POPULATION

A retrospective case series was conducted including adult patients with hook of hamate fractures treated with ORIF using headless cannulated screws. All cases operated on by the hand surgery team between April 2019 and March 2021 with a diagnosis of hook of hamate fracture were reviewed.

Exclusion criteria included patients younger than 18 years, those presenting with additional injuries in the same or contralateral upper limb during the same traumatic event, and those who did not attend follow-up evaluations during the first postoperative year.



VARIABLES

All patients were examined for pain localized to the hypothenar region and during resisted flexion of the fourth and fifth fingers. Patients with these symptoms underwent standard wrist radiographs and computed tomography to confirm the diagnosis and minimize selection bias.

The minimum postoperative follow-up was 12 months. Standard wrist radiographs were obtained at follow-up visits. At the final evaluation, the QuickDASH questionnaire was administered,17 and pain intensity was recorded using a visual analog scale (VAS, 0-10).

Grip strength was measured with the elbow flexed at 90° and the forearm in a neutral position using a Jamar hand dynamometer, and pinch strength was assessed with a Jamar hydraulic pinch gauge (Patterson Medical, Bolingbrook, IL, USA). Each test was performed three times, and the mean value was recorded.

The clinical assessment also included measurement of wrist range of motion (flexion, extension, radial and ulnar deviation). Potential signs of ulnar nerve involvement, such as sensory disturbance or motor weakness, were specifically evaluated.



STATISTICAL ANALYSIS

Data were collected from patient medical records and entered into a dedicated database. Given the sample size, the Shapiro-Wilk test was applied to assess whether each variable followed a normal distribution. For normally distributed variables, results were expressed as mean and standard deviation (SD); for non-normally distributed variables, results were expressed as median and interquartile range (IQR).

To compare wrist range of motion and grip strength between the operated and contralateral hands, the paired Student's t-test was used for normally distributed variables, and the Wilcoxon signed-rank test was applied for non-normally distributed data. A p-value < 0.05 was considered statistically significant.



SURGICAL PROCEDURE

It was performed under general anesthesia and pneumatic tourniquet control. A Brunner-type incision18 was made, centered over the anatomical location of the hook of the hamate, approximately 2 cm distal to a line drawn from the pisiform to the head of the second metacarpal (Carter's line) (Figure 1).19 The hook of the hamate was identified after elevation of the skin flap. Medially, Guyon's canal was exposed and released, allowing identification of the ulnar neurovascular bundle (Figure 2) which was protected during open reduction of the fracture under direct visualization.

After anatomical reduction, fixation was carried out with a 1.0 mm threaded guide wire advanced toward the body of the hamate under fluoroscopic guidance (Figure 3), and its position was verified in all projections. Screw length was measured, and definitive fixation was performed ensuring compression and stability of the fracture. In all cases, 2.5-mm headless cannulated screws (MicroAcutrak®, Hillsboro, OR, USA) were used (Figures 4 and 5).

Skin closure, dressings, and a forearm-palmar splint were applied. After two weeks, the splint and skin sutures were removed, and patients initiated a supervised physical-therapy and rehabilitation program.



RESULTS

During the study period, 18 patients underwent surgery using the described technique for fixation of a hook of hamate fracture. Seven patients were excluded due to associated fractures in the same limb or contralateral upper-limb injuries, and one patient was excluded for loss to follow-up. Ten patients met the inclusion criteria, eight of them male, with a mean age of 27.6 years (range, 18-40 years) (Table 1). In all cases, the fracture resulted from a motorcycle accident.

Computed tomography revealed that seven fractures were located at the base of the hook and three at the middle third. In five patients, the injury occurred on the dominant hand. Nine patients underwent surgery one day after trauma, and only one underwent fixation two days post-injury. The mean follow-up period was 16.7 months (range, 12-25 months; SD 4.2).

All patients experienced transient hypersensitivity over the palmar scar during the initial postoperative months, which progressively resolved. Pain assessment using the visual analog scale (VAS) at final follow-up showed a mean score of 1 (range, 0-4; SD 2.8). The QuickDASH questionnaire yielded a median score of 2.3 (range, 0-9.1; IQR 3.9). Regarding wrist range of motion, mean flexion on the affected side was 74° (range, 30-80°) compared with 75° on the contralateral side (p = 0.285). Mean extension was 70° (range, 46-80°) versus 71° on the contralateral side (p = 0.180). Radial and ulnar deviation values also showed no statistically significant differences (Table 2).

Grip strength measured with a Jamar dynamometer averaged 81 lbs on the affected side (range, 45-110 lbs) and 84 lbs on the unaffected side (range, 45-120 lbs) (p = 0.357). Lateral pinch strength averaged 14.8 lbs on the affected side (range, 6-20 lbs) and 15.6 lbs on the contralateral side (range, 8-20 lbs) (p = 0.335). None of the patients presented clinical signs of ulnar nerve injury or involvement of its branches.

One patient (case 6 in the supplementary data) reported persistent wrist pain that worsened with motion. Six months after surgery, a repeat computed tomography scan confirmed fracture consolidation of the hook of hamate but revealed screw penetration into the carpometacarpal joint (Figure 6). Hardware removal was therefore performed, resulting in partial symptom improvement. At final follow-up, this patient reported the highest pain score in the series.



DISCUSSION

Hamate hook fractures remain a rare and often underdiagnosed condition, largely due to the limitations of conventional radiography. The superimposition of carpal structures frequently obscures the lesion, even with specialized carpal tunnel views.8,9 Computed tomography is therefore considered the diagnostic gold standard, with a sensitivity approaching 100% and specificity of 98.4%.10,11 This technique allows detection of both acute fractures and nonunions, while magnetic resonance imaging may provide complementary information about tendon, nerve, and vascular involvement,12,20 though its routine use is limited by cost.

Treatment remains controversial. Immobilization in a short-arm cast has historically resulted in nonunion rates between 24 and 50%,19,21 probably due to limited fragment vascularization, delayed diagnosis, and traction forces transmitted through the flexor tendons. Triplet et al.22 demonstrated in a cadaveric study that the fractured hook fragment moves during wrist motion despite casting, a finding that explains the high rate of nonunion and supports surgical management.

Tanaka et al.23 recently reported a series of 16 patients with hook of hamate fractures treated conservatively with immobilization, initially in a cast and subsequently with a splint, resulting in complete fracture union in all cases. This study underscores the relevance and ongoing validity of conservative management as a viable treatment option for this condition, with no reported complications such as nonunion.

Among surgical options, hook excision provides predictable pain relief and rapid return to activity,24 yet may lead to decreased grip strength and scar hypersensitivity.1,4,16 Demirkan et al.25 and Kuptniratsaikul et al.26 reported a reduction of 11-15% in flexor-tendon traction force following excision, although reconstruction of perihamate ligaments can partially restore strength. Luxenburg et al.24 in a 2024 meta-analysis confirmed that internal fixation yields faster return to sports and better grip strength preservation than fragment excision. These findings support fixation whenever feasible, particularly in young, active individuals.

A 2023 systematic review27 compared ORIF with fragment excision and found no consistent differences between the two treatments. However, patients treated with fragment excision demonstrated slightly earlier return to work and less postoperative pain, but a higher incidence of ulnar nerve motor dysfunction. Based on these findings, the authors recommended conducting studies with larger sample sizes and emphasized the need for a broad prospective cohort using standardized outcome measures to provide stronger evidence on whether surgical excision or open reduction and internal fixation offers superior results in the management of hook of hamate fractures.

The present series highlights a distinct population profile. All patients sustained high-energy motorcycle-related trauma (rather than sports injuries) reflecting the epidemiology of upper-limb trauma in Latin-American urban settings. Despite the small sample size, early open reduction and internal fixation (within 48 hours) produced excellent pain relief, near-normal motion, and full grip-strength recovery without nonunion. These results are consistent with those of Lamas-Gómez et al.28 and expand the evidence supporting volar fixation as an effective and reproducible technique.

Recent innovations, such as robotic-assisted navigation for screw insertion29 further demonstrate the trend toward minimally invasive precision surgery. Nevertheless, the fundamental principle remains the same: accurate reduction, stable fixation, and early rehabilitation are key to restoring hand function.

Despite the inherent limitation of a small cohort, this study adds valuable regional data, reinforcing the role of early fixation as a determinant of successful outcomes in acute hamate hook fractures.



CONCLUSIONS

Early open reduction and internal fixation of acute hamate hook fractures is a safe, reproducible, and functionally superior technique. It restores carpal anatomy, preserves grip strength, and minimizes the risk of nonunion. Prompt diagnosis and surgical management within 48 hours may represent the critical factor for optimal recovery, particularly in young, active patients.

These results contribute novel data from a Latin-American trauma population and support the inclusion of early fixation as the treatment of choice in properly selected cases.


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AFFILIATIONS

1 Hand and upper limb Surgeon, Clínica Cali. Cali, Colombia.

2 Hand and upper limb Surgeon, Clínica Sebastián de Belalcázar. Cali, Colombia. ORCID: 0000-0002-2872-7258

3 ORCID: 0009-0008-8392-3420

4 Plastic and hand Surgeon, Clínica Cali. Cali, Colombia. ORCID: 0009-0001-3349-1067

5 General practitioner, Orthopedic Department assistant, Clínica Cali. Cali, Colombia.

6 ORCID: 0009-0006-8635-7829

7 ORCID: 0009-0003-3318-4969

8 Department of Surgery, Hospital Universitario Fundación Valle de Lili. Cali, Colombia. ORCID: 0000-0002-2356-1383



CORRESPONDENCE

Carlos Hernán Méndez-Daza, MD. E-mail: mendezdaza@gmail.com




Received: 09-14-2025. Accepted: 01-04-2026.

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