INTRODUCTION
Hamate hook fractures are rare, accounting for 2%-4% of all carpal bone fractures[1,2], and are most prevalent among athletes engaged in sports requiring repetitive gripping, such as tennis , golfers, baseball[3,4]. The injury mechanism typically involves direct trauma to the hook or repetitive stress from sports activities. Early diagnosis remains challenging due to the limitations of conventional radiography, contributing to delayed detection[5], which can negatively impact healing outcomes and wrist function, posing a significant challenge for surgeons. Current treatment options for hook fractures include conservative management (cast immobilization), open reduction and internal fixation, and hook bone resection[6]. The choice of a particular approach depends primarily on the expertise and experience of the surgeon, as well as on the individual characteristics of the patient.
Treatment of hook fractures depends on the accuracy of the diagnosis, the degree of displacement, and the location of the fracture. Conservative management is commonly used for undisplaced or slightly displaced uncinate fractures without adjacent joint instability or poor alignment[7,8]. The management of symptomatic displaced fractures, nonunions, and nondisplaced fractures persisting beyond 3 months remains controversial[9]. Scheufle et al[10] reported 5 of the 6 patients who underwent conservative management had nonunions and was initiated immediately after trauma. Previous study reported suboptimal outcomes in conservatively managed patients, with treatment failure rates(painful nonunions) as high as 90%-100%[11]. In recent studies by Tanaka and Yoshii[12], all 16 patients achieved fracture healing following conservative treatment (4 weeks of casting followed by splinting), despite 25% presenting > 6 weeks post-injury, and although the healing process was slower, all patients eventually achieved bone healing. Similarly, the diagnosis is a minor or non-displaced fracture, and conservative management has resulted in different clinical outcomes. Critical considerations include the timing of diagnosis, fracture location, comorbidities, and therapeutic strategy.
Surgical intervention is recommended for severely displaced or unstable hook fractures, as well as for unstable carbometacarpal fractures[13]. The goal of surgical treatment is to restore stability to the wrist joint, especially the 4th and 5th carpometacarpal joints[14]. Closed reduction and percutaneous K-wire immobilization are effective in treating fractures of the hook bone with minor comminuted. To restore and maintain the stability of the wrist joint after fracture, open reduction and internal fixation with compression screws or low-notch plates is used if necessary. Open reduction and internal fixation usually use a dorsal approach to access the hook and carpophal joints by separating the extensor ulnaris carpi from the extensor tendon of the little finger, taking care to identify and protect the dorsal sensory branch of the ulnar nerve. Compared with the open surgical method, the robot can accurately locate the screw during the operation, determine the size and trajectory of the screw, and accurately fix the small fragments of the fracture with minimal iatrogenic injury, showing its unique advantages. Jie et al[11] retrospectively analyzed 14 patients with non-displaced or slightly displaced hook fractures using computed tomography (CT) images who underwent closed reduction and minimally invasive percutaneous fixation under robotic navigation, all of whom successfully inserted a guidewire on the first attempt without causing any iatrogenic injury to adjacent tissues. The average duration of surgery was 40.1 minutes. After surgery, the visual analogue score was used to assess wrist pain and the Mayo wrist score was used to reflect the recovery of the wrist joint. After 6-36 months of follow-up, all fractures healed whin an average of 3.0 months, and the Mayo wrist joint score was 95 points, 12 cases were excellent, 2 cases were good, the efficacy was satisfactory, and there were no complications such as infection or nerve palsy.
This article critically evaluated the study of Tanaka and Yoshii, which demonstrated favorable outcomes in the conservative management of hook fractures, with particular emphasis on the need for CT diagnosis and follow-up, and its longitudinal imaging data providing new insights into trabecular bone regeneration patterns, as well as the possibility that allowing splints to be removed during low-risk activities (e.g., bathing) during treatment may help maintain range of motion, This patient-centered adaptation reflects an understanding of balancing fixed efficacy with quality of life. These findings aid clinicians in refining diagnostic accuracy and therapeutic decision-making through evidence-based insight.
Early diagnosis and postoperative functional recovery are key factors in the initiation of interventions and the assessment of clinical outcomes. Due to its rarity and insidiousness, hook fractures may be difficult to detect by routine X-ray examination in the early stage, and the missed diagnosis rate is extremely high[15]. CT is considered the reference standard for detection of hook of the hamate fractures and has sensitivity of nearly 100%[16]. Tanaka and Yoshii[12] highlighted that CT provides superior sensitivity for detecting fractures and monitoring healing, reducing missed diagnoses and delayed healing rates. The use of a removable splint after the 5th week of the treatment period, while avoiding activities that exert force on the ulnar side, and strengthening management with a patient-centered approach to improve treatment adherence.
Despite the good clinical outcomes, several limitations need to be considered: The small sample size (n = 16) and potential selection bias limit statistical power and generalizability. In addition, there was a lack of comparative data, and it was not possible to directly compare outcomes between conservative and surgical approaches as there were no surgical control groups. In addition, long-term follow-up was inadequate. While the study focused on achieving bone healing, it provided limited data on long-term functional outcomes such as grip strength, return-to-sport timelines, or patient-reported pain scores beyond visual analogue scales. More comprehensively respond to clinical outcomes of conservative treatment should be needed. Overall, this study provides convincing evidence highlighting the need for CT diagnosis and follow-up to confirm the clinical efficacy of conservative management of hook fractures, such as bone healing in all patients without joint contractures or movement limitation after treatment. These findings help clinicians develop more precise diagnosis and treatment measures and provide evidence-based insights.
Although the conservative treatment of hook fracture has achieved good clinical efficacy, it is still necessary to consider advantages (avoids surgical trauma, reduces infection risk, preserves hamate anatomy) and risks (prolonged immobilization may lead to joint stiffness). Thus, combined the current research trends are needed.
Tailored rehabilitation protocols combined with biologic agents and adjuvant therapies may accelerate healing and enhance functional outcomes. The management of fractures emphasizes tailored rehabilitation rather than a strictly fixed schedule, such as the concept of functional bracing that allows graded activities to promote healing while minimizing stiffness. In addition to mechanical fixation, it can also be combined with adjuvant therapies such as low-intensity pulsed ultrasound or teripartaine, which have shown promise in enhancing bone regeneration in other fractures. Einhorn et al[17] explored the mechanisms and interventions of fracture healing, noted the role of parathyroid in promoting bone regeneration. Schandelmaier et al[18] demonstrated low-intensity pulsed ultrasound (LIPUS) promotes bone regeneration through randomized controlled trials. Integrating these modalities may reduce immobilization duration while optimizing outcomes.
