what is edematous in the distal to the level of the hook of the hamate mean
AJR Am J Roentgenol. Writer manuscript; bachelor in PMC 2018 Apr 10.
Published in final edited form every bit:
PMCID: PMC5892414
NIHMSID: NIHMS955807
Hook of the Hamate: The Spectrum of Frequently Missed Pathologic Findings
Derik L. Davis
iSection of Diagnostic Radiology and Nuclear Medicine, University of Maryland Schoolhouse of Medicine, 22 Southward Greene St, Baltimore, MD 21201
Abstract
OBJECTIVE
The purposes of this commodity are to review hook of the hamate anatomy, describe the imaging features of the spectrum of pathologic atmospheric condition, and discuss the pearls and pitfalls of imaging for clinical decision making for pathologic entities affecting the hook of the hamate.
Decision
Noesis of the anatomy, imaging appearance, and clinical direction of hook of the hamate abnormalities is important for radiologists in guiding the care of patients with ulnar-sided wrist symptoms.
Keywords: bipartite, coalition, delay in diagnosis, fracture, hamate, hook of the hamate, wrist
Pathologic conditions affecting the hook of the hamate are uncommon. Fractures are the well-nigh common abnormality but business relationship for less than 4% of carpal fractures [i, ii]. Despite its continued importance every bit a key anatomic landmark in modernistic medicine, the claw of the hamate remains a source of diagnostic errors in current clinical exercise [3, four]. Delay in diagnosis or missed diagnosis of abnormalities of the claw of the hamate is mutual [iv–6]. Imaging plays a primal function in identifying pathologic conditions affecting the hook of the hamate and in guiding clinical determination making. This article reviews the diagnostic imaging, clinical presentation, and treatment of hook of the hamate fracture, developmental anomalies, infection, avascular necrosis, and tumors.
Anatomy
The hamate is situated in the distal carpal row at the ulnar aspect of the wrist. The hook (too known as the hamulus) is a curved bony process that extends from the palmar surface of the body (Fig. 1). The claw of the hamate contributes to the medial edge of the carpal tunnel and the lateral border of the Guyon canal. The pisiform-hamate ligament, flexor retinaculum (also known as the transverse carpal ligament), flexor carpi ulnaris tendon, opponens digiti minimi tendon, and flexor digiti minimi tendon all attach to the hook. The biomechanical role of the claw is to deed as a caster for the flexor tendons of the band and pocket-sized fingers [7, 8].
31-year-old man with normal wrist
A, Axial proton density–weighted MR paradigm shows body of hamate (HB), capitate (C), small-finger flexor tendons (F), hook of hamate (HH), ulnar nervus and branches (1), ulnar avenue (two), ulnar vein (iii), flexor retinaculum (4), and median nerve (five).
B, Carpal tunnel view radiograph shows hook of hamate (HH) and pisiform (P).
Imaging
Radiography
The typical set of radiographs obtained for acute or chronic ulnar-sided wrist symptoms includes conventional posteroanterior, oblique, and lateral views. However, images in these standard views poorly show the hook of the hamate. Additional special projections for the claw of the hamate include the semi-supinated oblique view, carpal tunnel view, and lateral view with thumb abduction and radial deviation of the manus [ix]. Despite all-time efforts, some patients are unable to tolerate the positions required for these special views because of hurting [5].
CT
CT is the reference standard for diagnosis of claw of the hamate fracture. CT is highly sensitive and specific for detection of fracture, with an accuracy of 97.2% compared with 80.v% for radiography [10]. CT is the get-to option for imaging of the hook of the hamate in patients with suspected acute or chronic bony abnormalities.
MRI
MRI is an alternative to CT for the detection of radiographically occult pathologic conditions involving the hamate. Although less accurate than CT for visualization of hook cortical fractures, MRI is superior for characterization of associated bone marrow edema, ulnar nerve injury, tendon abnormalities, and carpal tunnel abnormalities [2, 11]. MRI is also a useful adjunct test after initial CT to determine the extent of soft-tissue abnormality related to claw of the hamate lesions.
Hook of the Hamate Fractures
Hamate fractures are uncommon and represent two–4% of all carpal fractures [1]. Fractures involving the claw are the well-nigh common blazon of hamate fracture [ii]. The incidence of hook of the hamate fractures among professional and recreational athletes is much higher than in the full general population and is posited to be on the rising owing to the increasing popularity of golf game and racket sports [ix, 12]. Several mechanisms crusade hook of the hamate fractures, including blunt trauma, repetitive microtrauma, and avulsion injury. Fall on an outstretched paw, motor vehicle standoff, and direct strike from a projectile such as a baseball game are common causes of acute traumatic fracture [7, thirteen, xiv]. Gripping-related acute trauma to the hook when holding a bat, dissonance, golf club, or cycle handle is an additional mutual mechanism [vii, 9, 15] (Fig. 2A). Stress fractures occur every bit a issue of ongoing repetitive microtrauma from gripping a bat, racket, or golf lodge [2, 7, eleven] (Fig. 2B). Avulsion fractures occur as the consequence of ligamentous or tendinous forces tugging on the hook [9].
Ii patients with sports-related hook of hamate fractures
A, 21-year-old male baseball player with acute medial wrist pain while batting in game. Carpal tunnel radiograph shows astute nondisplaced transverse fracture (arrow) at base of claw.
B, 21-year-old male person lacrosse histrion with gradual onset of wrist discomfort over several weeks without blunt trauma. Axial CT paradigm shows nondisplaced transverse stress fracture (pointer) near base of operations of hook.
Hamate fractures are categorized as either hook or body fractures [8, xiii]. Combined fractures involving the body and claw of the hamate are rare [13] (Fig. 3). Hook of the hamate fracture has been classified into iii types co-ordinate to anatomic location: type i, distal tip; type ii, heart part; and blazon iii, base of the hook (Figs. 4 and five). Type 3 fractures business relationship for over 75% of hook of the hamate fractures [4, 12]. Acute traumatic fractures of the hook often present with other fractures of the distal upper extremity, particularly distal radial fractures [14] (Fig. half-dozen). Distal ulnar fractures, other carpal os fractures, hamate dislocations, and medial carpometacarpal joint disruptions are additional bone- and articulation-related injuries [xiii, sixteen, 17]. Soft-tissue abnormalities almost commonly associated with hook of the hamate fractures include ulnar nerve palsy and tear of the pocket-size finger flexor tendons [2, 7].
22-year-quondam man injured in clay bike accident
A, Axial CT image shows astute nondisplaced transverse fracture at tip of claw (black arrow) and nondisplaced vertical fracture of hamate body (white arrow).
B, Coronal CT prototype shows extent of acute hamate torso fracture (pointer).
Type 1 and type 2 claw of hamate fractures
A, 63-twelvemonth-one-time human after fall six weeks earlier. Sagittal CT epitome shows partially healed type i transverse fracture at tip of hook (arrow).
B, 53-year-one-time human being afterwards acute edgeless trauma. Axial CT image shows chronic nonunion of type ii transverse fracture at middle portion of hook (arrow), which was incidental finding in evaluation of acute displaced comminuted fractures at bases of fourth and 5th metacarpals.
C and D, 61-twelvemonth-sometime woman with chronic wrist pain. Centric proton density–weighted (C) and sagittal T1-weighted (D) MR images testify chronic nonunion of type 2 transverse fracture (arrow).
Type three hook of hamate fractures
A–C, 45-year-old man after falling down steps 5 weeks earlier. Posteroanterior radiograph (A) shows focal lucency (blackness arrow) at hamate and subtle overlap of hook with fourth carpometacarpal joint. Incidental lunotriquetral coalition is besides nowadays (white arrow). Centric T2-weighted fat-saturated (B) and sagittal T1-weighted (C) MR images testify displaced type 3 transverse fracture at base of operations of hook (arrow) with associated bone marrow edema and adjacent soft-tissue edema.
Type iii hook of hamate fractures. D, 56-year-old human subsequently recent motor vehicle collision. Axial CT epitome shows acute displaced comminuted blazon iii fracture of claw (pointer).
27-year-quondam human after fall from cycle
A–C, Two face-to-face sagittal CT images (A and B) and axial CT image (C) show acutely displaced claw of hamate transverse fracture (black pointer) in association with astute displaced oblique fracture of distal radius (white arrow, A and B).
The clinical presentation of hook of the hamate fracture is often nonspecific and requires a high degree of clinical suspicion to establish the diagnosis. Patients accept reported sudden-onset generalized pain and swelling at the hypothenar region of the hand and wrist afterwards acute trauma [13, sixteen]. Hook of the hamate stress fractures present with a gradual onset of pain, over weeks to months, without report of a traumatic consequence [4, eight, xi]. Band- and small-finger paresthesias accept been reported with acute and chronic fractures [11, 13]. The site of maximal hurting may exist misleading at physical exam, and localizing signs directly attributable to the hook of the hamate are oft hard to detect [nine, 11]. Presence of the Tinel sign at the hypothenar region should heighten clinical suspicion of the presence of a claw fracture [7]. An increment in hypothenar pain or weakness with hand gripping is another associated sign of hook fractures [5, 8, 11].
On posteroanterior radiographs the hook of the hamate overlaps with the midportion of the distal hamate body and projects as an ovoid bony density. Radiographic signs of hook of the hamate fracture on posteroanterior images include an absent-minded or indistinct hook or sclerosis of the claw [18]. Evaluation of the claw is oftentimes limited on standard lateral images attributable to overlap with other carpal bones [8]. Carpal tunnel, supinated oblique, and lateral radiographs with thumb abduction and hand radial deviation radiographs are special views that improve visibility of the hook of the hamate. Overall, radiography has a sensitivity of 53–90% for detection of hook of the hamate fractures [x, 19]. Nonetheless, standard posteroanterior and lateral wrist images are often obtained without special views, and faux-negative radiographic findings oftentimes occur for hook of the hamate fractures, fifty-fifty when special views are used [nineteen]. Hook of the hamate fractures at the midpoint or distal tip are more readily detected in special views, whereas fractures at the base of the hook are more usually obscured [18].
The typical natural history patterns of missed hook of the hamate fractures include uncomplicated fracture healing, asymptomatic nonunion, and symptomatic nonunion or partial matrimony [five]. Advanced imaging with CT or MRI usually establishes the diagnosis in the acute or chronic phase [2, 10]. CT is considered the reference standard for detection of hook of the hamate fractures and has sensitivity of near 100% [ten]. CT has better sensitivity than radiography for the diagnosis of fractures occurring at the base of the claw [eighteen]. CT also has the added value of quantifying the caste of deportation, which has implications for clinical decision making [8]. Acute displaced fractures of the hook typically accept sharply defined margins on CT images, whereas chronic cases of nonunion present with sclerotic or corticated margins [xiii, 20]. On CT images, nondisplaced claw of the hamate fracture appears every bit a sharply defined, thin, lucent line with cortical disruption. Healing of nondisplaced hook fracture is less distinct and exhibits associated sclerosis [v, 11, 21]. CT is also an fantabulous modality for evaluating hook fracture healing after treatment [22, 23]. MRI is useful for detection of hook fractures and concomitant associated ulnar nervus and flexor tendon injury [2, 18]. Hook fractures present as low-bespeak-intensity lines and typically are associated with os marrow edema in the acute stage [11, 15, 18]. MRI also may provide information on the degree of deportation of claw of the hamate fractures [1].
Treatment of hook of the hamate fracture depends on the vigil of diagnosis, degree of displacement, and location of fracture. Nondisplaced fractures within three months of injury initially receive conservative treatment with cast immobilization [thirteen, 14, 21, 24]. Treatment of symptomatic displaced fractures, nonunion, and nondisplaced hook fractures older than three months is controversial [21]. Surgical excision of the claw of the hamate is a mutual treatment [v, seven, 17, 21]. The importance of preserving the hook of the hamate as a pulley for the medial flexor tendons continues to exist debated [21]. Surgical fixation has been advocated for restoring normal biomechanics of the wrist. Operative techniques include open palmar spiral or K-wire fixation, hook plate fixation, and dorsal percutaneous spiral fixation [7, 20, 21, 25]. Low-intensity pulsed ultrasound has been advanced every bit a noninvasive alternative to surgical intervention in nondisplaced fractures [22, 23].
Type 1 fractures involving the distal third of the hook are almost likely to receive conservative treatment regardless of other factors. Type 2 fractures at the middle part are theorized to be the most at risk of nonunion [12].
Developmental Anomalies
Bipartite Hook of the Hamate
Secondary hamate ossification centers typically fuse with the primary ossification center during adolescence. An accompaniment ossicle, the os hamuli proprium, forms when in that location is failure of fusion between the hook and body ossification centers [two, 26]. The accessory ossicle is bound to the hamate by a fibrous pseudoarthrosis instead of an osseous matrimony [26].
Bipartite hamate is rare and plant in less than one% of the general population [3]. Almost cases of os hamuli proprium are discovered incidentally and are often in the differential diagnosis of hamate fractures (Fig. 7A). Differentiating an accessory ossicle from a chronic nonunion of the hook may have no clinical relevance in patients without ulnar-sided wrist symptoms. Suggested criteria favoring os hamuli proprium over fracture include circular well-corticated margins of the ossicle and hamate, absenteeism of a history of trauma, and bilateral presentation of the ossicle [26]. Fracture of the bone hamuli proprium is rare (Figs. 7B and 7C).
Bipartite hook of hamate
A, 67-year-old man with acute wrist pain later on fall from continuing. Sagittal CT image shows displaced comminuted fracture (black pointer) at base of fourth metacarpal. Os hamuli proprium (white arrow) is incidental finding. Ossicle and side by side hamate have rounded well-defined margins.
B and C, 41-year-onetime man afterward motorcycle collision. Sagittal CT image (B) shows bipartite hook of hamate (arrow). Centric CT paradigm (C) shows astute displaced avulsion fracture of bone hamuli proprium (arrow).
Recognition of a bipartite hamate is critical for preoperative planning before open or endoscopic carpel tunnel release to avoid iatrogenic injury to the ulnar neurovascular packet [3]. In rare cases, resection of the os hamuli proprium is performed for treatment when the abnormality presents in association with carpal tunnel syndrome or ulnar tunnel syndrome [4, 26].
Pisiform-Hamate Coalition
The carpal bones arise from a single cartilaginous anlage before the 10th week of fetal life. Virtually carpal coalitions occur across the same carpal row; lunotriquetral coalition accounts for ninety% of cases [27–29]. Carpal coalition typically results from failure of routine programmed cell expiry, leading to the absenteeism of normal joint space between carpal bones [thirty, 31]. Still, pisiform-hamate coalition does non develop in this fashion. The pisiform is a sesamoid bone related to the flexor carpi ulnaris tendon and arises from its ain endochondral ossification center [27, 32, 33]. The machinery of pisiform-hamate coalition has been posited to issue from metaplasia of the pisohamate ligament or ossification of the distal flexor carpi ulnaris [32].
Pisiform-hamate coalition is exceedingly rare, there being only a handful of case reports in the literature. Pisiform-hamate coalition occurs in isolation or in clan with a congenital syndrome [27] (Fig. viii). Classification of pisiform-hamate coalition is based on the amount of osseous bridging between the pisiform and the hamate, every bit adopted from the Minaar classification arrangement for lunotriquetral coalition: type I, no osseous bridging, resembling pseudoarthrosis; blazon II, partial osseous bridging; type III, consummate osseous bridging; type Iv, consummate bridging with associated carpal anomalies [34].
Two patients with pisiform-hamate coalition
A–C, 21-yr-old homo after motor vehicle collision. Lateral radiograph of wrist (A) shows acute displaced comminuted distal ulnar shaft fracture. Osseous body (white arrow) was initially idea to represent anterior capitate dislocation. However, capitate was soon thereafter properly identified in its normal anatomic position (black arrow). Sagittal conventional (B) and sagittal volume-rendered (C) CT images testify complete osseous fusion of hamate (asterisk) and pisiform (arrow). (A and C adapted from presentation at Radiological Society of North America 2013 annual coming together, Chicago, IL)
D, 25-twelvemonth-old woman 2 days after autumn. Posteroanterior radiograph shows pisiform-hamate coalition (black arrow) and lunotriquetral coalition (white arrow). (Adapted from presentation at Radiological Gild of Northward America 2013 annual coming together, Chicago, IL)
Several cases of asymptomatic pisiform-hamate coalition have been described [27, 33, 35]. Symptomatic pisiform-hamate coalition has been reported to occur with or without associated trauma. Associated pathologic features include modest-finger flexor tendon rupture, ulnar and median nerve neuropathy, and degenerative arthropathy [27, 34, 36, 37]. Surgical resection of the pisiform and hook of the hamate is the typical definitive treatment for relief of symptomatic coalition, although spiral arthrodesis has been described as an alternative for fibrous type I coalitions [32, 34, 37].
Infection
Osteomyelitis of the carpus typically is the sequela of an open fracture, penetrating trauma, septic arthropathy, or infectious tenosynovitis in skeletally mature patients [38]. The nearly mutual organism associated with os infection is Staphylococcus aureus, although numerous pathogens are known to cause osteomyelitis [38, 39]. The clinical presentation typically involves fever, wrist hurting, edema, and erythema. The contiguous spread of infection from elsewhere in the wrist is the typical cause of hamate osteomyelitis (Fig. nine), and isolated infection of the hamate is rare [38, 39].
75-twelvemonth-old man with wrist sepsis that adult during long-term IV antibiotic handling of blood culture–positive methicillin-sensitive Staphylococcus aureus and mitral valve endocarditis
A, Posteroanterior radiograph obtained at hospital access shows no signs of infection.
B, Posteroanterior radiograph 5 weeks after hospital admission shows interval development of erosions (arrows), global joint space loss, and diffuse osteopenia at carpus.
C and D, Sagittal T1-weighted (C) and axial T2-weighted fatty-saturated (D) MR images five weeks after hospital admission prove abnormal marrow signal intensity, compatible with reactive bone marrow edema or osteomyelitis, involving hook of hamate (pointer), torso of hamate, capitate, and trapezoid bones. Synovitis of carpus and carpal tunnel flexor tendon compartment is besides nowadays.
CT findings of acute bone infection are lytic bone destruction, erosion, osteopenia, intraosseous gas, and ambitious periostitis. Chronic sequelae may effect in a sequestrum and involucrum [38]. MRI findings associated with osteomyelitis include bone marrow betoken intensity that is decreased on T1-weighted and increased on fluid-sensitive T2-weighted images and enhancement on contrast-enhanced images [40]. Abnormal os marrow signal intensity in a patient with suspected infection may represent either reactive edema or osteomyelitis, two entities that tin exist challenging to differentiate on the basis of MRI findings lone [40]. Treatment of osteomyelitis suspected on clinical grounds or based on a positive issue of biopsy or aspiration civilisation requires 4 antibiotics and on occasion surgical débridement [38–40].
Avascular Necrosis
The hamate receives blood supply from the ulnar avenue, dorsal intercarpal arch, and recurrent ulnar avenue. Avascular necrosis of the claw of the hamate is rare. The clinical presentation is often nonspecific; patients present with nonlocalizing ulnar-sided wrist pain. Range of motion and grip strength are oft variable [41]. Avascular necrosis is difficult to capeesh on radiographs and CT scans. MRI reveals decreased T1 bespeak intensity with variable T2 signal intensity. The diagnosis is confirmed at surgical pathologic analysis after surgical resection for a symptomatic hook of the hamate [41].
Tumor
Tumors of the body and hook of the hamate are rare. The clinical presentation of hamate tumors is variable. Reported cases in the literature include osteoid osteoma, giant jail cell tumor, intraosseous ganglion, osteoblastoma, chondroblastoma, aneurysmal os cyst, osteochondroma, unicameral bone cyst, intraosseous schwannoma, and lung metastasis [six, 42–52]. Radiographs are often noncontributory in evaluation of hook of the hamate tumors. The multiplanar capabilities of CT and MRI are more sensitive for detecting and characterizing bony masses in the hook (Fig. x). The definitive diagnosis of hamate tumors is nigh often established at surgical pathologic analysis subsequently surgical resection [43, 45, fifty].
63-year-old man with chronic wrist hurting and disability to flex small finger
A and B, Axial (A) and sagittal (B) CT images show ovoid lytic lesion with side by side sclerosis centered in hook of hamate (arrow) with thin cortical defect along radial aspect of claw. Surgical exploration 1 month later revealed pocket-sized-finger flexor tendon tear. After surgical resection of hook, pathologic analysis showed lytic mass to exist posttraumatic inflammatory cyst in setting of hook of hamate fracture nonunion.
Determination
Knowledge of the anatomy, imaging appearance, and clinical direction of the spectrum of pathologic weather condition affecting the hook of the hamate is important for the radiologist and then that they may guide the care of patients who present with ulnar-sided wrist symptoms.
Acknowledgments
D. L. Davis receives partial salary back up for an unrelated project from the Academy of Maryland Claude D. Pepper Older Americans Independence Center Junior Faculty Scholar Grant (NIA P30 2P30AG028747) and in 2016 received a research seed grant (without salary support) for an unrelated project from the Radiological Society of North America Research & Education Foundation and Hitachi Medical Systems.
Footnotes
Based on a presentation at the Radiological Society of North America 2013 annual meeting, Chicago, IL.
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5892414/
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