The majority of hamate fractures are type 1, and tend to occur from a FOOSH injury (falling on an outstretched hypothenar eminence) or as a sports injury when a bat, racket, or club held loosely kicks back against the hook. Only an estimated two to four percent of all carpal fractures are classified as either type 1 (of the hook) or type 2 (of the body). These "parallel M lines" can help pick up a carpal metacarpal dislocation. In retrospect, a problem of the metacarpals or hamate should have been considered on the PA film because there was a loss of the usual zigzag clear space between the hamate and its associated metacarpals. This patient has a fracture of the body of the hamate and a fourth metacarpal dislocation with the metacarpal going with the displaced fracture fragment. The metacarpals were completely intact! The lateral and oblique gave the answer, however. Shockingly, the expected fracture was missing on the first film. Clearly, the force of the fist against an immovable object caused the proximal fifth metacarpal to break. One glance at the swelling of the lower lateral aspect of his dorsal hand, and the diagnosis is virtually certain. A young man watching the game at a local bar hit a wall when an argument broke out. It's Saturday night, and the next patient in the rack has hand pain.
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