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Abstract

Background: A 21-year-old male collegiate baseball player reported to the athletic training staff complaining of pain along the hypothenar eminence of the left hand. The patient’s pain was intensified when swinging a bat but remained constant even at rest. The patient reported symptoms beginning approximately three weeks prior to being evaluated by the athletic training staff, but delaying reporting symptoms in order to continue playing. Physical exam revealed tenderness over the hook of the hamate and hypothenar eminence, decreased active wrist extension, decreased grip strength, and pain with resisted pronation and supination. At this time, the patient was removed from activities involving gripping or putting axial force on the wrist and referred to the team physicians. Differential Diagnosis: Hook of the hamate fracture, triangular fibrocartilage complex injury, wrist flexor tendinopathy. Treatment: Day 2: Initial exam by the team physician furthered the suspicion that the patient may have experienced a hook of the hamate fracture. X-rays were ordered for further evaluation, including a carpal tunnel view to evaluate the hook of the hamate. X-rays did not reveal a fracture, leading to the physician placing the patient in a volar wrist brace for two-weeks based on the tentative diagnosis of a hook of the hamate stress reaction. Day 16: Upon discontinuing the volar wrist brace, the patient attempted to return to activities, but experienced a similar magnitude of symptoms. At this time, the decision was made to obtain an MRI to evaluate the patient’s hand further. Day 18: Upon receiving the results of the patient’s MRI, it was determined that the patient had suffered a hook of the hamate fracture. The MRI also revealed that the patient was suffering from a stress fracture of the hamate bone. The patient was then referred to an orthopedic hand surgeon for consultation. Due to the nature of the patient’s health insurance, he was forced to return to his home state for his consultation. Day 28: Upon physical exam and review of the MRI findings, the orthopedic surgeon suspected the patient had been predisposed to the hook of the hamate fracture due to the stress fracture in the hamate. The patient was consented for surgery, with the goal of excising the fractured portion of the hamate. Day 29: The patient underwent successful surgery to excise the fractured portion of the hook of the hamate, and was discharged with instructions to follow up with the athletic training staff and team physician upon returning to his institution. Uniqueness: The nature in which the patient was injured is typical of hook of the hamate fractures in baseball players. However, the presence of a stress fracture of the body of the hamate bone is an uncommon predisposition to a hook of the hamate fracture. Stress fractures of the body of the hamate are not well described in the literature, making it an unlikely consideration when forming a differential diagnosis. Furthermore, the patient’s health insurance status made timely diagnosis and treatment difficult. Conclusions: When caring for a traumatic injury, early diagnosis is often critical to optimal patient outcomes. In the event a clinician is caring for a patient with restrictive health insurance, patient education on the potential ramifications of maintaining such an insurance plan is crucial. Should a patient with a restrictive insurance plan suffer an injury warranting advanced diagnostic testing and therapeutics, clinicians must work to expedite access to care as quickly as possible.

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