SURGICAL TECHNIQUE

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
Jesse Dashe, MD,* Neil F. Jones, MD†

Hook of the hamate fractures can be treated by various methods including cast immobiliza-
tion, open reduction, and internal fixation and excision. Usually, those individuals who elect
for excision have acute fractures and need to return to sporting activity or work quickly or
have nonunions with persistent symptoms. There is a paucity of descriptions in the literature
and textbooks of a technique to safely excise the hook of the hamate. The authors present a
method of safely exposing and removing the hook of the hamate by visualizing the potential
structures at risk: the motor branch of the ulnar nerve, the ulnar digital nerve to the little
finger, and the flexor tendons to the ring and little fingers by an approach through Guyon’s
canal and the proximal ulnar border of the carpal tunnel. (J Hand Surg Am. 2019;-(-):1.e1-e5.
Copyright Ó 2019 by the American Society for Surgery of the Hand. All rights reserved.)
Key words Approach to hook of hamate, hook of hamate excision, hook of hamate fracture,
hook of hamate nonunion.

H
OF HAMATE FRACTURES have been
OOK
reported to comprise approximately 2% to
4% of carpal fractures and typically occur
from sport-related activities such as baseball, golf,
tennis, badminton, hockey, and squash.1,2 Imaging
to diagnose such injuries includes a carpal tunnel
view x-ray (Fig. 1) and/or more advanced imaging
such as computed tomography or magnetic resonance
image. 1e3 The usual treatment for acute injuries
From the *Department of Orthopaedic Surgery, UC Irvine Medical Center, University of
California at Irvine, Orange; and the †Department of Orthopedic Surgery, University of
California Los Angeles, Los Angeles, CA
Received for publication February 26, 2019; accepted in revised form July 25, 2019.
No benefits in any form have been received or will be received related directly or
indirectly to the subject of this article.
Corresponding author: Jesse Dashe, MD, Department of Orthopaedic Surgery, UC Irvine
Medical Center, 101 The City Drive, Pavilion 3, 2nd Floor, Orange, CA 92868; e-mail:
doctordashe@gmail.com.
0363-5023/19/---0001$36.00/0
https://doi.org/10.1016/j.jhsa.2019.07.015
involves immobilization for 4 to 6 weeks with re-
ported healing rates of approximately 50%.2,4 Treat-
ment for hook of hamate nonunions includes open
reduction and internal fixation and excision of the
fractured bone fragment for individuals who have
persistent symptoms.
The argument for excising the hook of the hamate
is that it allows the patient to return to activities faster
as fracture healing does not need to occur.1,2,4
Despite the recommendation for excision as a treat-
ment option, surgical techniques are rarely described
in the literature and in textbooks and often describe a
blind approach to the hook of the hamate with
inadequate exposure to protect adjacent vital struc-
tures including the motor branch of the ulnar nerve,
the ulnar digital nerve to the little finger, and flexor
tendons to the ring and little fingers.
In addition, in a survey in 1988 of 372 members
of the American Society for Surgery of the Hand or
American Orthopaedic Society for Sports Medicine,
only one third of these physicians reported ever

Ó 2019 ASSH r Published by Elsevier, Inc. All rights reserved. r 1.e1

1.e2 EXCISION OF HOOK OF HAMATE
FIGURE 1: Carpal tunnel radiograph displaying a hook of the
hamate fracture.
having excised a hook of the hamate in their
careers.5
Carter et al6 described an approach to the hook of
the hamate through Guyon’s canal, but this does not
allow adequate visualization of the vital structures on
the radial aspect of the hook of the hamate, namely
the ulnar digital nerve to the little finger and the
flexor tendons to the ring and little fingers. Tolat
et al3 described excision of a nonunion of the hook of
the hamate through a carpal tunnel incision, but
similarly, this does not allow adequate visualization
of the most important vital structure on the ulnar
aspect of the hook, namely the motor branch of the
ulnar nerve. Mizuseki et al7 described an incision
along the lateral aspect of the hypothenar eminence to
excise a fracture of the hook of the hamate. There-
fore, given the rarity of the procedure and the close
proximity of important neurotendinous structures, the
authors describe a combined approach through both
Guyon’s canal and the ulnar aspect of the carpal
tunnel for excision of the hook of the hamate.
INDICATIONS AND CONTRAINDICATIONS
Indications for hook of the hamate excision include
acute fractures in athletes, high-performance in-
dividuals, laborers, and others who cannot or are
unwilling to undergo a period of immobilization, or
for patients with nonunions with persistent symp-
toms.1,2,4 Another reported indication is prophylactic
excision of hook of the hamate fractures in asymp-
tomatic patients to avoid potential flexor tendon
attenuation and eventual rupture.7 Contraindications
include those patients who are medically unfit for
surgery or who are unwilling to accept the potential
risk to neurotendinous structures associated with
excision of the bone fragment.
J Hand Surg Am.
FIGURE 2: Surface anatomy of the hook of the hamate.
SURGICAL ANATOMY
The hook of the hamate is located at the junction of
Kaplan’s cardinal line and a line drawn proximally
from the ulnar border of the ring finger5 (Fig. 2). The
contents of the carpal tunnel and Guyon’s canal are
intimately involved with the hook of the hamate. The
bony boundaries of the carpal tunnel are the scaphoid
and trapezium radially and the hook of the hamate,
triquetrum, and pisiform ulnarly,8 whereas the bony
boundaries of Guyon’s canal are the hook of the
hamate radially and pisiform ulnarly.9 The motor
branch of the ulnar nerve passes from the superficial
ulnar to deep radially around the distal aspect of the
hook, whereas the ulnar digital nerve to the little
finger and the flexor tendons to the ring and little
fingers traverse immediately radial to the hook. Given
the proximity of these important structures to the
hook of the hamate, wide exposure, as opposed to a
small blind incision, is critical to avoid iatrogenic
injury to these vital structures.
SURGICAL TECHNIQUE
A curved incision is drawn along the radial border of
the hypothenar eminence extending proximally to the
wrist crease or alternatively parallel to the ulnar
border of the thenar eminence. The incision is
continued transversely and ulnarly along the wrist
crease for 1e1.5 cm and then proximally at a right
angle along the radial border of the flexor carpi
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 EXCISION OF HOOK OF HAMATE
FIGURE 3: Exposure of the hook of the hamate.
ulnaris (Fig. 2). The arm is exsanguinated and the
tourniquet is inflated. The proximal limb of the
incision is incised to the wrist crease first and the
ulnar artery and nerve identified, with the nerve being
the more ulnar structure.
Once the neurovascular bundle has been identi-
fied, the incision is continued distally along the
wrist crease and into the palm. The hypothenar
muscles and fat pad are elevated in a radial-to-ulnar
direction, attempting to maintain vessels and small
nerve branches supplying the muscles and fat pad.
The pisohamate ligament is released. The origin of
the motor branch from the ulnar nerve is the key
anatomic pointer. The motor branch is dissected
under loupe magnification as it passes from super-
ficial to deep in an ulnar-to-radial direction around
the distal aspect of the hook of the hamate. A
vessel loop is placed around the motor branch
(Fig. 3).
Next, the most proximal 0.5e1 cm of the trans-
verse carpal ligament is incised along its most ulnar
aspect to identify the flexor tendons to the ring and
little fingers, the ulnar aspect of the median nerve,
and with distal retraction, the ulnar digital nerve to
the little finger (Fig. 4).
At this point, all the key nerves and flexor tendons
have been identified and protected. The periosteum
overlying the hook of the hamate is sharply incised
and the periosteum is sharply elevated on its radial,
ulnar, proximal, and distal aspects in a vertical
J Hand Surg Am.
1.e3
FIGURE 4: Closer view of the hook of the hamate.
direction from superficial to deep, continuously
keeping the motor branch of the ulnar nerve under
direct visualization. The hook of the hamate fragment
is removed en bloc (Fig. 5).
The base of the hook of the hamate is then
explored as residual sharp bony surfaces may be left
behind (Fig. 6). It is important to smooth out the
exposed deep surface of the hamate, and if neces-
sary, the remaining bony surface can be covered with
bone wax to prevent attenuation of the flexor dig-
itorum superficialis and profundus tendons to the
ring and little fingers, which now will glide back and
forth across the base of the hamate in their new
location.
The tourniquet is released and hemostasis ach-
ieved. Occasionally, the incised ulnar and proximal
border of the transverse carpal ligament can be su-
tured to the radial periosteum of the hook of the
hamate. Only the skin is sutured and a drain is not
usually necessary. A resting volar orthosis is applied
to immobilize the wrist in 20 extension with the
fingers left free.
POSTOPERATIVE MANAGEMENT
The orthosis and sutures are removed 2 weeks post-
operatively and the patient uses a compression glove
or an off-the-shelf gym or biking glove (for padding).
Postoperative hand therapy is usually not required.
The patient massages the incision and can gradually
return to activities 8 to 12 weeks after surgery.
PEARLS AND PITFALLS
(1) Expose vital nerve structures from “known” to
“unknown” starting proximally and extending
distally.
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1.e4 EXCISION OF HOOK OF HAMATE

FIGURE 5: Excised hook of the hamate.

(2) Do not approach the hook of the hamate blindly.

FIGURE 6: Remaining bone of the hamate.
(3) Inadequate exposure poses great risk to the
adjacent structures, especially the motor branch
of the ulnar nerve.
(4) Be sure to smooth the deep surface of the remaining
hamate so as not to leave an abrasive surface, which
may predispose the ring and little finger flexor
tendons to attenuation and subsequent rupture.

COMPLICATIONS
Given the close proximity of the hook of the hamate
to the median nerve and flexor tendons in the carpal
tunnel and the motor branch of the ulnar nerve in
Guyon’s canal, any of these vital structures may
potentially be injured.2,4,5 If a nerve or the ulnar ar-
tery is injured, primary microsurgical repair is rec-
ommended. The flexor tendons to the ring and little
fingers are potentially at risk of rupture if the FIGURE 7: T1 magnetic resonance image of the right wrist dis-
remaining deep surface of the hamate is not smoothed playing a nondisplaced hook of the hamate fracture.
after the excision. Flexor tendon adhesions have been
reported postoperatively5 as well as weakness of the
palm after batting while playing baseball. After the
ulnar flexor tendons, specifically the ring and little
initial pain subsided, the patient took a 2-week break
fingers, because the hook of the hamate acts as a
from baseball and his pain resolved. He went back to
pulley for these tendons.1,4
playing baseball full time and his symptoms of pain
recurred.
CASE ILLUSTRATION Radiographs and a magnetic resonance image
A 16-year-old right-handed boy presented with pain confirmed a hook of hamate fracture (Figs. 7, 8). He
over the palmar and ulnar aspect of his left wrist and was immobilized in a short arm cast for 6 weeks and

J Hand Surg Am. r Vol. -, - 2019

 EXCISION OF HOOK OF HAMATE
FIGURE 8: T2 magnetic resonance image of the right wrist dis-
playing a nondisplaced hook of the hamate fracture.
was able to return to playing baseball for approxi-
mately 11 months. After a batting event, he devel-
oped severe pain, and imaging revealed a displaced
hook of the hamate fracture nonunion (Fig. 1). After
discussion of treatment options with the patient and
his parents, they elected for excision of the hook of
hamate given that prior non-operative management
had failed and his desire to return to sporting activ-
ities as quickly as possible.
The hook of the hamate was excised through a
modified Guyon’s canal and carpal tunnel approach
as an outpatient under axillary block anesthesia. The
orthosis was discontinued, and sutures were removed
2 weeks postoperatively, and he wore a bicycle glove
for protection until 6 weeks. He returned to playing
J Hand Surg Am.
1.e5
baseball 8 weeks postoperatively with complete relief
of his previous symptoms of pain.
In conclusion, this modified approach both
through Guyon’s canal and the proximal and ulnar
aspect of the carpal tunnel allows direct visualization
of the vital structure most at risk, the motor branch of
the ulnar nerve, as well as the ulnar digital nerve to
the little finger and flexor tendons to the ring and little
fingers unlike the blind direct approach or unilateral
approaches, and furthermore preserves the nerve
supply and blood supply to the hypothenar muscles.
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