Elsevier

The Journal of Hand Surgery

Volume 35, Issue 11, November 2010, Pages 1887-1889
The Journal of Hand Surgery

Surgical technique
Hook of Hamate Pull Test

https://doi.org/10.1016/j.jhsa.2010.08.024Get rights and content

Hook of hamate fractures are often missed despite a distinct history. The purpose of this report was to describe a specific physical examination test that is diagnostic for a hook of hamate fracture, the hook of hamate pull test. It is highly sensitive and was positive in a consecutive series of 5 patients treated for a hook of hamate fracture. These patients also had a distinctive history of playing racket- or club-type sports and presented with longstanding wrist or palm pain.

Section snippets

Anatomy

The hook of hamate forms the ulnar border of the carpal canal. Multiple structures insert on the hook of hamate, including the transverse carpal ligament, hypothenar muscles, and pisohamate ligament. The ulnar finger flexor tendons run around the base of the hook in a pulley fashion when the wrist is in ulnar deviation. The hook of hamate therefore experiences load from these multiple structures in different directions: Transverse carpal ligament loads it in a radial direction, pisohamate

The Patients

The first case was a 26-year-old male professional baseball player who developed ulnar volar left wrist pain after batting practice 3 months before our evaluation. He attempted to play through the injury but was not successful. Previous evaluation elsewhere including a CT scan ruled out fracture. On initial evaluation, the patient reported ulnar volar vague wrist pain. He was minimally tender over the hook of hamate. However, use of the hook of hamate pull test (HHPT) reproduced the acute pain

HHPT

The HHPT is a dynamic test performed by placing the wrist in full ulnar deviation with the fingers of the patient's involved hand flexed. The examiner then pulls on the 2 ulnar digits, with the patient resisting the pull (Fig. 2). This would be analogous to having the patient pick up a briefcase with the wrist in ulnar deviation and gripping it predominantly with the ulnar 2 digits. This test will elicit moderate to severe pain located in the patient's wrist and sometimes radiating through the

Results

Five patients with medical history suggestive of hook of hamate fracture each had a markedly positive HHPT. The CT scans confirmed the fractures. All were ultimately treated with hamate excision. No patient had a flexor tendon rupture, but upon exploration we found marked fraying of the small profundus in 2 patients. All patients returned to playing sports, including the professional baseball player.

Discussion

The HHPT is an easy, cheap, sensitive, and specific test that can be readily performed in the clinic. We have not had a false-positive test, although we have tried it only when the medical history suggested a hook of hamate fracture. The pull test can create pain in the ulnar aspect of the wrist in patients with ulnar wrist pain and no hook fracture, but it is different. Pain in these cases is ulnar wrist and not sharp in the area of the hook, as occurs with hook fractures. Flexor tenosynovitis

References (10)

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    Patients with complete ruptures will present with complete lack of active motion at the respective interphalangeal joints. Because the hook of the hamate acts as a pulley around which the flexor tendons run, Wright and colleagues described the hook of hamate pull test, in which the patient flexes their ring and small fingers with the wrist held in ulnar deviation.27 The examiner then pulls on the distal phalanxes while the patient resists extension; pain indicates a positive test.27

  • Non-union in a hook of hamate fracture of a skeletally immature baseball player

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    At physical examination, patients may present decreased grip strength, mild symptoms of carpal tunnel syndrome, and continuous pain that is exacerbated by movement and tight gripping [2,3]. When there is high suspicion, HHPT can provide an easy and specific test to clinically diagnose this fracture [9]. Computed tomography is frequently used to diagnose hamate fractures in SM patients [3].

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    The hook of hamate pull test may be used to diagnose a hook of hamate fracture. With the patients wrist held in full ulnar deviation, resisted flexion of the ring and small finger elicits pain in the hypothenar eminence as the flexor digitorum profundus (FDP) tendons are pulled across the hook of hamate as a pulley.26 Standard AP and lateral radiographs often do not show the fracture but a carpal tunnel view should be performed if suspected.

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