Hamatometacarpal Fractures in Trauma Including the Incidence of Missed Hamate Fractures on Plain Film Imaging: a Five-year Review
Jonathan Bass, MD1; Adnan Prsic, MD2; William K Snapp, MD2; Geoffrey Hogan, BS2; Nicholas Nissen, BS3; Reena A Bhatt, MD4; Jin Bo Tang, MD2; Scott Schmidt, MD1; (1)Department of Plastic and Reconstructive Surgery, Rhode Island Hospital and Alpert Medical School of Brown University, Providence, RI, (2)Alpert Medical School of Brown University, Providence, RI, (3)Brown University, Providence, RI, (4)Brown University & Rhode Island Hospital, Providence, RI
Non-scaphoid carpal fractures are estimated to comprise less than 2 % of all fractures and less than 2% of this subset are thought to involve the hamate. Injuries of the hamate are often associated with fifth or fourth through fifth metacarpal base fracture-dislocations. Hamate fractures can be challenging to assess in standard hand trauma views. CT scans better evaluate for these fractures but may not be routinely obtained in the emergency department. The aim of our study was to delineate the incidence of hamatometacarpal fractures in a population of hand fracture patients as well as the rate of missed diagnosis on plain film radiology report.
A retrospective chart review was performed on 33 patients with 4th and 5th carpometacarpal dislocations and fracture-dislocations treated between years 2011 and 2016. These patients were thought to be high risk for undiagnosed hamate fractures. A member of the hand surgery team reviewed the plain film imaging in anteroposterior, oblique, and lateral views, and identified those with any fracture involving the hamate. This review was then compared to the provided radiology report as finalized by a radiologist using Fisher Exact testing.
Of the 33 patients whose films were reviewed, 22 patients (67%) had involvement of the hamate in some fashion on review by the hand team, whereas only 8 (36%) were identified on the radiology report (p<.001). All hamate fractures seen were dorsal. The most likely patients to have hamatometacarpal injuries were those with radiology reports of base of 4th and 5th metacarpal fracture-dislocations (14 patients) of which 3 (21%) were reported to have hamate involvement but 10 (71%) were found on further review by the hand team to have hamate involvement (p<0.02). Of the 33 patients reviewed, 12 required operative intervention, and of these 12 only 2 did not involve the hamate. Of the 22 hamatometacarpal fractures, 10 (45%) required operative intervention with either closed pinning or open reduction. Of these 10 operative patients, 4 (40%) had missed hamatometacarpal injuries on their initial imaging (p<0.04).
Our study establishes that the majority of patients with injuries involving the base of 4th and 5th metacarpals have hamate involvement that can be seen on plain film imaging but that a majority of these patients' hamatometacarpal fractures are not indicated on radiology reporting. This is clinically significant as hamate involvement seems to be associated with failure of closed management and need for operative intervention.
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