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Hook of Hamate Excision

24 citationsUpdated Sep 2026
Illustration: wrist

For patients: a plain-language version of this topic is available. See the patient guide.

Overview

Surgical excision of the hook of the hamate is a safe and effective treatment for both acute and chronic fractures, yielding acceptable outcomes with a low risk of minor complications [1, 4]. The procedure is indicated for professional and elite baseball players, as well as high-level amateur athletes, where it facilitates a rapid return to sport [2, 3, 6]. In professional baseball players, 84% return to sport after excision, with 81% returning to the same or higher level of play [9]. A systematic review and meta-analysis documented return to play in 94.5% (778/823) of patients [11]. For elite baseball players, return to play typically occurs within six weeks of surgery [7, 10]. High-level amateur athletes achieve preinjury performance levels, normal function on validated objective measures, significant pain reduction, and high overall patient satisfaction following excision [6]. MLB players can reasonably expect to return to their pre-injury performance levels following operative treatment [15].

The procedure provides a predictable, early return to play with a limited complication rate [14]. While hook of hamate regeneration can occur after fracture fragment excision, this does not preclude successful outcomes [5]. The open carpal tunnel approach is a successful technique for excising symptomatic ununited fractures due to its familiarity, ease of performance, excellent visualization, and low morbidity [8]. Alternatively, a modified surgical approach through Guyon’s Canal and the proximal ulnar border of the carpal tunnel allows for safe excision [16]. This modified approach provides direct visualization of vital structures most at risk, including the motor branch of the ulnar nerve, while preserving the nerve and blood supply to the hypothenar muscles [16].

Anatomy & Pathophysiology

Bony Anatomy

The hamate consists of a body and a hook, or hamulus [30]. The hook projects into the palm from the hamate body, located 1 to 2 cm distal and lateral to the pisiform within the hypothenar eminence [22]. It is palpable deep beneath the skin, fibrofatty pad, and palmaris brevis [22]. The hook serves as an attachment site for the transverse carpal ligament [30] and provides an origin for both the flexor digiti minimi muscle and the opponens digiti minimi muscle [30].

Ligamentous Anatomy

Guyon’s canal is bounded radially by the hook of the hamate and ulnarly by the pisiform, with the volar carpal ligament and transverse carpal ligament forming its other boundaries [27]. This canal contains the ulnar artery and nerve [27].

Pathophysiology

Nonunion is one of the most common complications of hook of hamate fractures [17]. Multiple structures insert on the hook, transferring forces during hand and finger movement that may prevent bony union [17]. Specifically, the flexors of the ring and small fingers provide an ulnarly directed force to the hook, which may cause micromotion at the fracture site, especially in fractures at the midsubstance of the hook [17]. Immobilization of the thumb carpometacarpal joint leads to decreased motion at the fracture site [17]. This decreased thumb motion may lead to decreased forces transmitted through the transverse carpal ligament onto the hook of the hamate [17].

In the athletic population, hook of hamate fractures are likely associated with a pre-existing stress response in the hamate [18]. Multiple direct traumas in sports can cause a stress fracture with a sudden aggravation of symptoms leading to diagnosis [18]. Conversely, high-energy single-impact hamate fractures in non-athletic populations likely occur in otherwise healthy bone with no pre-existing stress response [18].

Classification

Temporal Status: Hook of hamate fractures are classified as either acute or chronic [4].

Displacement: Fractures are categorized based on displacement status as either displaced or non-displaced [13].

Healing Status: The classification distinguishes between united fractures and ununited fractures, the latter representing nonunion [8, 17].

Etiology: * Stress Fractures: These result from multiple direct traumas in sports [18]. * High-Energy Injuries: These occur as single-impact injuries in otherwise healthy bone [18].

Clinical Presentation

The clinical presentation of hook of the hamate fractures is dictated by the mechanism of injury and the biomechanical forces acting on the bone. High-energy single-impact fractures typically occur in otherwise healthy bone without a pre-existing stress response [18]. In contrast, fractures in the athletic population are distinct from high-energy injuries and involve a pre-existing stress response [18]. Multiple direct trauma in some sports can create chronic bone changes that lead to stress fracture [18]. The aetiology of fracture and nonunion is relevant to low-impact repetitive tight gripping activities [18].

Biomechanically, multiple structures insert on the hook of the hamate, transferring forces to the hook during hand and finger movement that can prevent bony union [17]. Flexors of the ring and small fingers provide an ulnarly directed force to the hook, which may cause micromotion at the fracture site, especially in fractures at the midsubstance of the hook [17]. Immobilization of the thumb carpometacarpal joint leads to decreased motion at the fracture site [17].

Regarding management implications for presentation, short arm casts extending past the proximal interphalangeal joints of the ring and small fingers have not had great success achieving union [17].

Investigations

MRI: Magnetic resonance imaging is the modality of choice for imaging radiographically occult fractures of the hand and wrist [29]. It has an expanding role in the evaluation of acute wrist trauma [37]. High-resolution MRI aids in the evaluation of ligament injuries of the wrist [35]. A static magnetic field strength of at least 1.5 T using a dedicated wrist coil is recommended for analyzing interosseous, intrinsic, and extrinsic ligament insertions [35]. Higher magnetic field strengths result in a higher signal-to-noise ratio with shorter scan times [35].

MRI Protocol: The volar extrinsic, SL interosseous, dorsal intercarpal, and LT ligaments are best visualized using 1 mm slices (with no interslice gap) in the coronal plane [35]. The DRC and intercarpal ligaments are best viewed on both the coronal and sagittal images [35]. Oblique axial views along the longitudinal axes of ligaments allow further analysis, especially when an injury is suspected [35]. Concomitant cartilage-sensitive imaging is integrative to influence the assessment and surgical management [35].

MRI Findings: Bone marrow edema on MRI may reveal fractures of the carpal bones or distal radius that are radiographically occult [37]. MRI is useful in detecting additional marrow abnormalities in osteonecrosis, as seen in the lunate in Kienböck disease or in the scaphoid after fracture [37]. Asymmetry of marrow signal in proximal and distal fragments of a fractured scaphoid is suggestive of proximal pole ischemia [37]. Axial imaging with T2 weighting can clearly display masses within the confines of the carpal tunnel, as well as edema and swelling of the median nerve [37]. Tenosynovitis and tendon injuries in the wrist and hand can be assessed with MRI [37]. MRI provides earlier detection of synovitis and erosive bone changes associated with rheumatoid arthritis than do radiographs [37]. MRI currently has a limited role in the evaluation of carpal tunnel syndrome [37].

CT: CT scanning enables the 3D analysis of carpal dysfunction [35].

Dynamic Fluoroscopy: Dynamic fluoroscopy shows abnormal motion between the scaphoid and lunate and changes in the kinematics of the midcarpal joint [35].

Arthroscopy: Arthroscopy is considered by many to be the diagnostic intervention of choice for determining the degree of injury to the wrist [35]. It can assess the condition of the cartilage, ability to reduce the carpus, and any other associated injuries [35]. The degree of intrinsic and extrinsic ligament injury can be identified from arthroscopic evaluation [35].

Treatment

Non-Operative

Immediate immobilization of acute hook of hamate fractures may result in fracture healing and obviate operative intervention [22]. However, short arm casts that extend past the proximal interphalangeal joints of the ring and small fingers have not had great success achieving union [17]. Thumb immobilization in the form of a thumb spica cast may have greater success in achieving union [17], as a cadaveric study showed that immobilization of the thumb carpometacarpal joint leads to decreased motion at the fracture site [17]. Bayer was able to successfully treat a nondisplaced stress fracture in a cast with slight extension and radial deviation, thereby taking the ulnarly directed forces of the flexor tendons off of the fracture site [17]. One of the most common complications of hook of hamate fractures is nonunion [17].

Operative

Indications: Surgical excision remains an effective method of management for both acute and chronic hook of hamate fractures in professional baseball players, with a low risk of minor complications [4]. In high-level amateur athletes, surgical excision results in significant reduction in pain and high overall patient satisfaction [6]. Excision produced generally excellent results, particularly in patients with an athletic injury or with no associated additional injury [22]. Conversely, a nonathletic injury or the presence of associated trauma adversely affected results following excision [22].

Surgical Approach / Technique: Surgical excision of hook of hamate fractures is safe and allows a relatively rapid return to play in most cases [2]. Return to play was documented for 94.5% (778/823) of patients following hook of hamate fracture treatment [11]. Open reduction and internal fixation is feasible but offers little advantage over excision [22].

Implant Selection: A simplified dorsal approach with percutaneous fixation using a mini-Acutrak screw is effective for reduction and fixation of the hamate hook, allowing rigid fixation of the fracture site [12]. Non-displaced acute fractures and delayed union of the hamate hook can be treated successfully by dorsal percutaneous cannulated mini-screw fixation with minimal morbidity and complications [13].

Complications

Wound complications: Surgical excision of hook of hamate fractures is associated with a low risk of minor complications in professional baseball players [4]. The open carpal tunnel approach for excision of ununited hook of hamate fractures is associated with low morbidity [8].

Other Considerations: Excision of the fractured hook provides a limited complication rate [14]. Dorsal percutaneous cannulated mini-screw fixation for hamate hook fractures is associated with minimal morbidity and complications [13].

Recovery

Other Considerations: Surgical excision of hook of hamate fractures in high-level amateur athletes is associated with significant reduction in pain [6].

Key Evidence

  • [L4] Both surgical procedures appear to yield acceptable outcomes in the treatment of hook of hamate fractures. [1] (10.1016/j.jhsg.2023.11.011)
  • [L4] In most cases, surgical excision as treatment for hook of the hamate fractures is safe and allows a relatively rapid return to play. [2] (10.1016/j.jhsa.2017.06.108)
  • [L4] Hook of hamate excision in baseball players is associated with high RTP rates and short RTP time, typically occurring between 5 and 7 weeks after surgery. [3] (10.1177/03635465261452783)
  • [L4] Surgical excision remains an effective method of management, with a low risk of minor complications for both acute and chronic hook of hamate fractures in professional baseball players. [4] (10.1016/j.jhsa.2021.03.015)
  • [L4] Hook of hamate regeneration can occur after fracture fragment excision. [5] (10.1016/j.jhsg.2024.08.008)
  • [L4] Surgical excision of hook of hamate fractures in high-level amateur athletes allows for successful return to sports participation at preinjury performance levels, achievement of normal function as measured by validated objective outcome measures, significant reduction in pain, and high overall patient satisfaction. [6] (10.1016/j.jhsa.2012.10.011)
  • [L4] Surgical excision of hook of hamate fractures in elite baseball players showed a very high rate of return to play within six weeks. [7] (10.1177/2325967121s00552)
  • [Paper] The study highlights the open carpal tunnel approach as a successful technique for open excision of symptomatic ununited hook of hamate fractures, because of its familiarity, ease of performance, excellent visualization and low morbidity. [8] (10.1016/j.injury.2014.05.008)
  • [L4] After surgical excision for hook of hamate fractures in professional baseball players, 84% were able to return to sport, with 81% returning to the same or higher level. [9] (10.1177/0363546520949204)
  • [L4] Surgical excision of hook of hamate fractures in elite baseball players showed a very high rate of return to play within 6 weeks. [10] (10.1177/23259671211038028)
  • [L1] Return to play was documented for 94.5% (778/823) of patients. [11] (10.1177/15589447241231303)
  • [L4] The authors conclude that the simplified dorsal approach with percutaneous fixation using a mini-Acutrak screw is effective for reduction and fixation of the hamate hook, allowing rigid fixation of the fracture site. [12] (10.3109/02844310801956714)
  • [L4] This pilot study demonstrates that non-displaced acute fractures and delayed union of the hamate hook can be treated successfully by dorsal percutaneous cannulated mini-screw fixation with minimal morbidity and complications. [13] (10.1142/s0218810412970039)
  • [L4] This study confirms that excision of the fractured hook provides predictable, early return to play, with a limited complication rate. [14] (10.1177/2325967118803090)
  • [L3] MLB players sustaining hook of hamate fractures can reasonably expect to return to their pre-injury performance levels following operative treatment. [15] (10.1123/jsr.2017-0071)
  • [L4] This modified approach allows direct visualization of the vital structures most at risk, including the motor branch of the ulnar nerve, unlike blind or unilateral approaches, and preserves the nerve supply and blood supply to the hypothenar muscles. [16] (10.1016/j.jhsa.2019.07.015)
  • [Paper] [17] (10.1016/j.hcl.2021.06.013)
  • [L5] [18] (10.1177/17531934241304249)
  • [Paper] [22] (10.1016/0363-5023(88)90217-1)

See Also

References

[1] Surgical Management of Hook of Hamate Fractures: A Systematic Review of Outcomes. Journal of Hand Surgery Global Online. 2024. DOI: 10.1016/j.jhsg.2023.11.011

[2] Return to Play and Complications After Hook of the Hamate Fracture Surgery. The Journal of Hand Surgery. 2017. DOI: 10.1016/j.jhsa.2017.06.108

[3] Return to Play After Hook of Hamate Excision in Baseball Players: A Systematic Review. The American Journal of Sports Medicine. 2026. DOI: 10.1177/03635465261452783

[4] Hook of Hamate Fractures in Major and Minor League Baseball Players. The Journal of Hand Surgery. 2021. DOI: 10.1016/j.jhsa.2021.03.015

[5] Hook of Hamate Regrowth After Surgical Excision: A Report of Two Cases. Journal of Hand Surgery Global Online. 2024. DOI: 10.1016/j.jhsg.2024.08.008

[6] Outcomes of Hook of Hamate Fracture Excision in High-Level Amateur Athletes. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2012.10.011

[7] PAPER 14: Excision of Hook of Hamate Fractures in Elite Baseball Players: Surgical Technique and Return to Play. Orthopaedic Journal of Sports Medicine. 2022. DOI: 10.1177/2325967121s00552

[8] Surgical excision of ununited hook of hamate fractures via the carpal tunnel approach. Injury. 2014. DOI: 10.1016/j.injury.2014.05.008

[9] Performance and Return to Sport After Excision of the Fractured Hook of the Hamate in Professional Baseball Players. The American Journal of Sports Medicine. 2020. DOI: 10.1177/0363546520949204

[10] Excision of Hook of Hamate Fractures in Elite Baseball Players: Surgical Technique and Return to Play. Orthopaedic Journal of Sports Medicine. 2022. DOI: 10.1177/23259671211038028

[11] Return to Play After Hook of Hamate Fracture: A Systematic Review and Meta-Analysis. HAND. 2024. DOI: 10.1177/15589447241231303

[12] Simplified dorsal approach to fracture of the hamate hook with percutaneous fixation with screws. Journal of Plastic Surgery and Hand Surgery. 2010. DOI: 10.3109/02844310801956714

[13] DORSAL PERCUTANEOUS CANNULATED MINI-SCREW FIXATION FOR FRACTURES OF THE HAMATE HOOK. Hand Surgery. 2012. DOI: 10.1142/s0218810412970039

[14] Return to Play After Hook of Hamate Excision in Baseball Players. Orthopaedic Journal of Sports Medicine. 2018. DOI: 10.1177/2325967118803090

[15] Performance Outcomes After Hook of Hamate Fractures in Major League Baseball Players. Journal of Sport Rehabilitation. 2018. DOI: 10.1123/jsr.2017-0071

[16] A Modified Surgical Approach Through Guyon’s Canal and the Proximal Ulnar Border of the Carpal Tunnel Allows for Safe Excision of the Hook of the Hamate. The Journal of Hand Surgery. 2019. DOI: 10.1016/j.jhsa.2019.07.015

[17] Hook of Hamate Fractures. Hand Clinics. 2021. DOI: 10.1016/j.hcl.2021.06.013

[18] Re: Campbell FC, Jones SW, Campbell DA. The aetiology of fracture and nonunion in the hook of the hamate. J Hand Surg Eur. 2024, 49: 1172-8. Journal of Hand Surgery (European Volume). 2024. DOI: 10.1177/17531934241304249

[22] Fracture of the hamate hook. The Journal of Hand Surgery. 1988. DOI: 10.1016/0363-5023(88)90217-1

[27] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 2Musculoskeletal Trauma Surgery > FRACTURES AND DISLOCATIONS OF THE DISTAL AND MID-FOREARM.

[29] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Anatomy, Evaluation, Clinical Examination, and Imaging > Imaging: Advances in Imaging of the Hand and Upper Extremity > Magnetic Resonance Imaging.

[30] Aaos Comprehensive Orthopaedic Review 3. Anatomy of the Hand and Wrist > VII. The Wrist.

[35] Green S Operative Hand Surgery. Advanced Imaging.

[37] Campbell S Operative Orthopaedics 4 Volume Set. WRIST AND ELBOW.

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