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Dorsal Fixation of Coronal Hamate and Fifth Metacarpal Base Fractures: An Anatomic Evaluation of the Ulnar Nerve

  • Pierce L. Janssen
    Correspondence
    Corresponding author: Pierce Janssen, MD, Division of Plastic and Reconstructive Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, 5 E 98th Street, 15th Floor, New York, NY 10029.
    Affiliations
    Division of Plastic and Reconstructive Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY

    Division of Hand Surgery, Department of Surgery, Elmhurst Hospital Center, Queens, NY
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  • Christopher P. Bellaire
    Affiliations
    Division of Plastic and Reconstructive Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY

    Division of Hand Surgery, Department of Surgery, Elmhurst Hospital Center, Queens, NY
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  • Dani C. Inglesby
    Affiliations
    Division of Plastic and Reconstructive Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY

    Division of Hand Surgery, Department of Surgery, Elmhurst Hospital Center, Queens, NY
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  • Dylan M. Taub
    Affiliations
    Division of Plastic and Reconstructive Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
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  • Peter J. Taub
    Affiliations
    Division of Plastic and Reconstructive Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
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  • Eitan Melamed
    Affiliations
    Division of Plastic and Reconstructive Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY

    Division of Hand Surgery, Department of Surgery, Elmhurst Hospital Center, Queens, NY
    Search for articles by this author

      Purpose

      Traumatic drill overshoot during dorsal fixation of coronal hamate and fifth metacarpal base fractures risks iatrogenic ulnar nerve injury. This study describes the anatomic relationships between exiting volar drill tips and ulnar nerve branches.

      Methods

      Dorsal drilling of hamate bones and fifth metacarpal bases was performed on cadavers. Dorsal hamate bodies were subdivided into 4 quadrants: (1) distal-ulnar, (2) distal-radial, (3) proximal-ulnar, and (4) proximal-radial. Screws measuring 5 mm more than the dorsal-to-volar bone depths were placed in each quadrant to represent drill exit trajectories with consistent overshoot. A single screw was similarly placed 5 mm distal to the midline articular surface of the dorsal fifth metacarpal base. Distances between estimated drill tips and ulnar nerve branches were measured.

      Results

      Ten cadaver hands were examined. The fifth metacarpal base screw tips directly abutted the ulnar motor branch in 6 hands, and were within 1 mm in 4 hands (mean, 0.4 ± 0.5 mm). Distances from the tips to the ulnar motor and sensory branches were largest in the distal-radial quadrant (11.8 ± 0.8 mm and 9.2 ± 1.9 mm, respectively) and smallest in the proximal-ulnar quadrant (7.3 ± 1.5 mm and 4.3 ± 1.1 mm, respectively). Distances to the ulnar motor and sensory branches were similar between the proximal-ulnar and distal-ulnar quadrants, and between the proximal-radial and distal-radial quadrants.

      Conclusions

      Dorsal drilling of coronal hamate fractures appears to be safe, as volar drill tips are well away from ulnar nerve motor and sensory branches. Distances to ulnar nerve branches are largest, and theoretically safest, with dorsal drilling in the distal-radial hamate. Dorsal drilling of fifth metacarpal base fractures appears to carry a high risk for potential ulnar motor nerve injury.

      Clinical relevance

      These findings may help minimize potential risks for iatrogenic ulnar nerve injury with dorsal drilling of hamate and fifth metacarpal base fractures.

      Key words

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      References

        • Bachoura A.
        • Wroblewski A.
        • Jacoby S.M.
        • Osterman A.L.
        • Culp R.W.
        Hook of hamate fractures in competitive baseball players.
        Hand (N Y). 2013; 8: 302-307
        • Tolat A.R.
        • Humphrey J.A.
        • McGovern P.D.
        • Compson J.
        Surgical excision of ununited hook of hamate fractures via the carpal tunnel approach.
        Injury. 2014; 45: 1554-1556
        • Fredericson M.
        • Kim B.J.
        • Date E.S.
        • McAdams T.R.
        Injury to the deep motor branch of the ulnar nerve during hook of hamate excision.
        Orthopedics. 2006; 29: 456-458
        • Dahlin L.
        • Palffy L.
        • Widerberg A.
        Injury to the deep branch of the ulnar nerve in association with dislocated fractures of metacarpals II-IV.
        Scand J Plast Reconstr Surg Hand Surg. 2004; 38: 250-252
        • Saing M.H.
        • Lee S.Y.
        • Raphael J.S.
        Percutaneous pinning of fifth carpal-metacarpal fracture-dislocations: an alternative pin trajectory.
        Hand (N Y). 2008; 3: 251-256
        • Eder C.
        • Scheller A.
        • Schwab N.
        • Krapohl B.D.
        Hamate's coronal fracture: diagnostic and therapeutic approaches based on a long-term follow-up.
        GMS Interdiscip Plast Reconstr Surg DGPW. 2019; 8: Doc05
        • Cano Gala C.
        • Pescador Hernández D.
        • Rendón Díaz D.A.
        • López Olmedo J.
        • Blanco Blanco J.
        Fracture of the body of hamate associated with a fracture of the base of fourth metacarpal: a case report and review of literature of the last 20 years.
        Int J Surg Case Rep. 2013; 4: 442-445
        • Wharton D.M.
        • Casaletto J.A.
        • Choa R.
        • Brown D.J.
        Outcome following coronal fractures of the hamate.
        J Hand Surg Eur Vol. 2010; 35: 146-149
        • Xiong G.
        • Dai L.
        • Zheng W.
        • Sun Y.
        • Tian G.
        Clinical classification and treatment strategy of hamate hook fracture.
        J Huazhong Univ Sci Technolog Med Sci. 2010; 30: 762-766
        • Langenhan R.
        • Hohendorff B.
        • Probst A.
        Coronal fracture dislocation of the hamate and the base of the fourth metacarpal bone: a rare form of carpometacarpal injury.
        Handchir Mikrochir Plast Chir. 2011; 43: 140-146
        • Hirano K.
        • Inoue G.
        Classification and treatment of hamate fractures.
        Hand Surg. 2005; 10: 151-157
        • Chase J.M.
        • Light T.R.
        • Benson L.S.
        Coronal fracture of the hamate body.
        Am J Orthop (Belle Mead NJ). 1997; 26: 568-571
        • Kang S.Y.
        • Song K.S.
        • Lee H.J.
        • Lee J.S.
        • Park Y.B.
        A case report of coronal fractures through the hamate, the capitate, and the trapezoid.
        Arch Orthop Trauma Surg. 2009; 129: 963-965
        • Ha A.Y.
        • Booth M.
        • Pet M.A.
        Two-incision approach for the open reduction internal fixation of intra-articular hamate body fractures using a cannulated headless compression screw.
        Tech Hand Up Extrem Surg. 2020; 24: 187-193
        • van Rijckevorsel V.A.J.I.M.
        • Selles C.A.
        • van der Vlies C.H.
        • Cleffken B.I.
        • Schep N.W.L.
        Functional outcome following headless compression screw fixation for hamate fractures.
        J Wrist Surg. 2020; 9: 164-169