Fracture of the hook of hamate with rupture of the flexor tendons of the small finger in a rheumatoid patient: a case report

A New Classification Scheme for Closed Avulsion Injuries of the Flexor Digitorum Profundus Tendon

BACKGROUND

Closed avulsion injury of the flexor digitorum profundus (FDP) tendon is a relatively common condition of the hand. Its present classification system seems to be deficient in including all possible patterns of injury, leading to improper selection of the best treatment method for the injury. We aim to provide a new classification scheme for this injury.

METHODS

We developed a new classification scheme based on the possible pattern of FDP tendon injury. It consisted of three main types, and 10 sub-types. This was used to classify the injury of 34 patients, and help in choosing the best management approach. All patients underwent surgical treatment of their injury. The distal interphalangeal (DIP) joint extension deficit and total active motion (TAM) of the proximal interphalangeal (PIP) and DIP joints were considered as the main outcomes. Five orthopaedic surgeons used the new classification system for our cases, and the inter-rater reproducibility was tested with Fleiss' kappa.

RESULTS

The multi-rater kappa for the classification was excellent. At the final follow-up visit 24 months following surgery, the mean loss of extension of the DIP joint was 13.76° ± 13.53° (range 0° to 45°), while the mean TAM was 148.88° ± 22.64° (range 94° to 172°). Based on the TAM score, 21 (61.76%), 8 (23.53%) and 5 (14.71%) patients had excellent, good and fair results, respectively. None of our patients had poor results.

CONCLUSIONS

Our new classification scheme of FDP tendon avulsion appeared to be comprehensive and useful in guiding the surgeon for the best treatment option. Nevertheless, this should be confirmed by using it for larger number of patients with different patterns of injury.

Closed Rupture of the Flexor Tendons of the Little Finger Secondary to Non-Union of Fractures of the Hook of the Hamate

We report six patients with closed flexor tendon rupture affecting the little finger, occurring secondarily to non-union of the hook of the hamate bone. The ununited fragments were separated from the basal part of the hook by more than 1 mm. The fragments were also rounded and showed marginal sclerosis. Non-union was located in the middle part of the hook in three patients, the tip in two, and the base in one. At operation, the fragments were removed in all patients. Five patients were treated by free tendon grafts using three palmaris and two plantaris grafts and one underwent tendon transfer. Postoperative total range of active motion of the little finger averaged 218° (range 185–265°). All patients returned to their original employment. This series would suggest that flexor tendon rupture can occur after fracture of the hook of the hamate bone, even when the ununited fragment is small and/or rounded.

Hamate fractures

OBJECTIVE

The purpose of this paper is to present our experience in the treatment of the fractures of the hamate and to make a review of the literature on this topic.

MATERIAL AND METHOD

We retrospectively reviewed 10 patients treated in our clinic between 2005-2012 suffering from fractures of the hamate. Six cases were fractures of the body and four were fractures of the hamate. Five cases were of associated injuries. Diagnostic delay ranged from 30 days to 2 years. Patient follow-up ranged from 1 to 10 years. Patient satisfaction was evaluated using the DASH questionnaire. Five patients with a fracture of the body underwent surgery, and one was treated conservatively. Two patients with fracture of the hook of the hamate were treated with immobilization, and two more patients had the fragment removed.

RESULTS

The grip strength and the digital clip were reduced in 2 cases. Flexion and extension of the wrist was limited in 3 cases. The mobility of the fingers was normal in all the cases, except in one. The results obtained from the DASH questionnaire were normal in all the cases, except in one case of fracture of the hamate, and in two cases of fracture of the body.

CONCLUSIONS

The surgical treatment should reduce the dislocation and stabilize the injuries with osteosynthesis. The fractures of the hamate are usually diagnosed late, and the most recommended treatment is removal of the fragment, although it cannot be deduced from this study.

Tendon rupture of the flexor digitorum profundus of the little finger secondary to hamate non-union

Several cases of hamate fracture and non-union have been reported. The hook of the hamate acts as a pulley for the flexor tendons for the little and ring fingers. Hamate non-union is frequently associated with irritation of the adjacent soft tissues. We report the case of hamate non-union that was only detected because of a flexor digitorum profundus tendon rupture in the little finger, associated with tendinopathy of both flexor tendons of the ring finger.

Spontaneous flexor tendon rupture in systemic lupus erythematosus: A case report

Spontaneous flexor tendon rupture is an unusual complication of systemic lupus erythematosus (SLE) and has not previously been reported. While tendon ruptures in association with SLE have been focused on the previous studies, upper extremity tendon ruptures are infrequently reported in the literature. Here, we present an uncommon case of spontaneous flexor tendon rupture of the ring and little fingers in a patient with SLE and discuss the mechanism of injury and its surgical treatment.

Fractures of the hamate and pisiform bones

Osseous injuries to the ulnar aspect of the carpus are increasing in frequency because of greater participation in sporting activities. Hamate body fractures are subdivided into coronal, sagittal oblique, proximal pole, and medial tuberosity fractures. Successful treatment of coronal fractures requires identification and treatment of associated disruption or instability of the ulnar 2 carpometacarpal joints. Displaced hamate hook fractures are optimally treated with early excision to avoid sequelae such as flexor tendon and nerve injury, and to allow early return to activity. Undisplaced pisiform fractures are managed nonoperatively, whereas displaced fractures and nonunions are treated by simple excision.

The future of rheumatoid arthritis and hand surgery - combining evolutionary pharmacology and surgical technique

Rheumatoid arthritis is a systemic autoimmune disease of uncertain aetiology, which is characterized primarily by synovial inflammation with secondary skeletal destructions.Rheumatoid Arthritis is diagnosed by the presence of four of the seven diagnostic criteria, defined by The American College of Rheumatology.Approximately half a million adults in the United Kingdom suffer from rheumatoid arthritis with an age prevalence between the second and fourth decades of life; annually approximately 20,000 new cases are diagnosed.The management of Rheumatoid Arthritis is complex; in the initial phase of the disease it primarily depends on pharmacological management. With disease progression, surgical input to correct deformity comes to play an increasingly important role. The treatment of this condition is also intimately coupled with input from both the occupational therapists and physiotherapy.

Two-staged tendon reconstruction in flexor tendon ruptures secondary to fracture of the hamate hook

We report a case of 2-staged reconstruction of flexor tendons ruptured spontaneously by attrition. A 49-year-old man presented with inability to flex the ring and little fingers of his left hand. Preoperative computed tomographic scans revealed fracture of the hamate hook. At the time of the operation, both the flexor superficialis and profundus of the little finger and the flexor profundus tendon of the ring finger were ruptured adjacent to the fracture site of the hamate. Because the flexor tendon rupture secondary to the fracture of the hamate is extremely rare, and surgical outcomes of previous reports are not satisfactory, a decision was made to perform 2-staged reconstruction of ruptured flexor tendons. The surgical result was excellent with complete restoration of full range of motion. This report describes for the first time to our knowledge, the technique, and rehabilitation of 2-staged tendon reconstruction in a patient with hook of hamate fracture.

Avulsion injuries of the flexor digitorum profundus tendon

Avulsions of the flexor digitorum profundus tendon may involve tendon retraction into the palm and fractures of the distal phalanx. Although various repair techniques have been described, none has emerged as superior to others. Review of the literature does provide evidence-based premises for treatment: multi-strand repairs perform better, gapping may be seen with pullout suture-dorsal button repairs, and failure because of bone pullout remains a concern with suture anchor methods. Clinical prognostic factors include the extent of proximal tendon retraction, chronicity of the avulsion, and the presence and size of associated osseous fragments. Patients must be counseled appropriately regarding anticipated outcomes, the importance of postoperative rehabilitation, and potential complications. Treatment alternatives for the chronic avulsion injury remain patient-specific and include nonsurgical management, distal interphalangeal joint arthrodesis, and staged reconstruction.

Rupture of small finger flexor tendons secondary to asymptomatic nonunion of the hamate hook

The incidence of fractures of the hamate hook (hamulus) has been reported to be between 2% and 4% of all carpal fractures. Untreated hamulus nonunion can cause attritional rupture of the ulnar digits' flexor digitorum profundum tendons. Rupture of flexor tendons due to nonunion of the hook of the hamate is an uncommon injury. Most surgeons treat the tendon lesion by a graft, transfer of the superficial flexor of the ring finger, or terminolateral suture of the distal stump of the deep flexor tendon of the little finger to the deep flexor tendon of the ring finger. This article reports a case of a 52-year-old right-handed man who presented with weakness of grip and loss of active flexion of both distal and proximal interphalangeal joints of the right small finger lasting 2 weeks due to grip strength while working. The clinical history and the physical examination were dissonant, and a computed tomography scan revealed a nonunion of the hamulus. Intraoperatively, the nonunion of the hamate hook was identified and the bony ossicle excised. The flexor digitorum profundus and superficialis to the small finger were both ruptured. The flexor digitorum profundus tendon was repaired with a termino-terminal suture. The patient returned to work within 3 months without restriction. Six months postoperatively, the patient had no pain and achieved full active flexion of the small finger.

Closed rupture of the flexor tendons caused by carpal bone and joint disorders

We analysed 21 patients with closed rupture of the flexor tendons caused by carpal bone and joint disorders. The tendon that ruptured depended on the location of the bone perforation into the carpal tunnel. Radiocarpal arthrography was performed in 13 patients and capsular perforation was demonstrated by contrast medium leakage into the carpal canal in 11 patients. This proved a useful diagnostic test. The flexor tendon(s) were reconstructed with free tendon graft in 17 patients, cross-over transfer of flexor tendons from adjacent digits in two and buddying to an adjacent flexor tendon in one patient. Postoperative total active range of motion in the fingers after 13 free tendon graft reconstructions averaged 213 degrees (range 170-265 degrees ). The active range of motion of the thumb-interphalangeal joint after free tendon graft reconstruction in three cases improved from 0 degrees to 33 degrees on average (range 10 degrees -40 degrees ).

Le poignet rhumatoïde

Wrist involvement in Rheumatoid Arthritis (RA) is frequent, variable in its presentation, heterogeneous in its evolution and has an important impact on the function of the affected hand. Surgery must be indicated within the framework of a structured medical and surgical approach that considers the whole patient. Surgical treatment at the wrist level is indicated in cases of resistant chronic pain, persistent articular synovitis, or chronic tenosynovitis and also in cases of painful limitation of supination, risk of complications due to wrist deformity and tendinous or neurological complications. The surgical goal in RA is to restore correct function but not neccessarily normal anatomy, with the goal of achieving a painless, stable wrist, correctly positioned. Motion depends on the status of the different joints and on the bone stock. Knowledge of the natural progression of the disease helps in the surgical decision making process. The pathogenesis and patterns of deformity, the clinical and X-ray appearances and the various techniques applied to the surgery of the rheumatoid wrist are studied and discussed including palmar wrist and dorsal wrist procedures, conservative and non-conservative options.

Avulsion fracture of the hamulus from clay gunshot sport: a case report

We report a case of hamulus (hook of hamate) fracture nonunion and secondary flexor digitorum profundus tendon rupture caused by repetitive wrist hyperextension sustained during clay shotgun shooting. The hyperextension caused avulsion of the hamulus by the pisohamate ligament. The hamulus was excised and a flexor digitorum profundus tendon transfer of the ring to small finger side to side was performed with satisfactory outcome.

Diagnostic imaging for fracture of the hook of the hamate

We experienced 16 patients with a fracture of the hook of the hamate. The routine posteroanterior view raised the suspicion of fracture in four of 13 patients (31%), the carpal tunnel view showed the actual fractures in six of 14 patients (43%), and the supine oblique radiographic view of the wrist showed fractures in eight of ten patients (80%). Computed tomography corroborated the fracture in all eight patients (100%). Computerized tomography proved most useful for accurate diagnosis of fracture of the hook of the hamate.