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    Shoulder

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    Hand: Hook of the Hamate Fracture

    01-Jun-2015
    By

    X-rays don’t always reveal broken bones, especially difficult-to-spot ones like the Hook of Hamate bone in your hand. Illustration courtesy of Steve Graepel.I was climbing a vertical face in the Grampians, and the crux move was a dyno. I missed, and fell awkwardly, impacting the cliff with my left hand. The pain was immediate and intense, directly below my pinky at the bony protrusion. I was unable to climb, or even belay for the rest of the day. Two days later, I went to my doctor, and by then the finger was swollen and blue. My doctor said I hadn’t broken anything, probably just had soft-tissue damage, given the amount of bruising, and sent me home. Ten days later, x-rays showed no fracture. Ten weeks have now passed, and climbing is still prohibitively painful. Any pressure over that area, like mantling or riding a bike, causes a wave of pain. Crimping also creates a lot of discomfort.

    — Emma Carr, Rockandice.com Forum

    You could not even belay?!X-rays are great, but you need the right ones and, going by your GP’s approach, it does not sound like you have had them. Impact to the base of your palm on the little-finger side that results in severe pain, let alone with ongoing severe pain, is indicative of a fracture to the Hook of the Hamate bone. In a normal series of wrist x-rays, the Hook of the Hamate is superimposed over the body of the Hamate bone, and hence you are unable to appreciate any fracture of it. Your doctor would need to order a particular x-ray view that demonstrates this bone.

    Crimping hurts because you are basically doing an orthopedic test known as the Hook of Hamate Pull Test. If you curl your pinky and ring fingers into a crimp position and even slightly bend your wrist to the ulna side (toward the pinky), the tendons involved in flexing those fingers press on the hook part of the Hamate bone. If it’s fractured, you feel acute pain.

    Hook of Hamate fractures are not overly common, as it takes a very specific load to fracture it, but I’d bet my left testicle that this is the cause of your pain. Heck, I’ll throw in both nuts. You could start with another set of plain films looking at the Hook of the Hamate, and, if that doesn’t shed any light on the issue, I would graduate to an MRI. CT scans are more sensitive to bone fractures, but an MRI should be sufficient and has the added benefit of supplying information about ligament or cartilage damage. That said, I doubt the cause of your pain is soft-tissue damage, as it seems far more acute under mild pressure than I would expect from anything other than grinding two fractured bone ends together.

    If this is the case, I suspect you will have it immobilized for four to six weeks to see if the fracture heals; usually it does. Given the amount of time that has passed, however, you are at a higher risk of non-union (the bone ends do not rejoin) and necrosis (the fragment dies) of the hook component beyond the fracture line.

    Non-union or necrosis usually result in surgery to either remove the fragment if it is small or, if the fragment is large enough and still healthy, to install internal fixtures to stabilize the bone ends in the hope that they will then bond.

    Any way you look at it, you have a good prognosis and should return to climbing without any residual impact. Over what course of time is largely dependent on how it plays out diagnostically.


    This article was published in Rock and Ice 225 (April 2015).

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