The Open Orthopaedics Journal




ISSN: 1874-3250 ― Volume 13, 2019
LETTER

Fracture of the Body of the Hamate With Dorsal Dislocation of the 4th and 5th Metacarpals: A Case Report



Vasilis Athanasiou, Ilias D. Iliopoulos, Konstantinos Pantazis, Andreas Panagopoulos*
Department of Hand Surgery, Orthopaedic Clinic of Patras University Hospital, Patras, Greece

Abstract

Background:

Solitary fractures of the body of the hamate are rare. Their diagnosis is difficult and requires a high clinical suspicion and a proper radiological examination.

Case report:

We present a case of a 36-year-old male patient who sustained an intraarticular fracture of the body of the hamate along with dorsal dislocation of the 4th and 5th metacarpals on his right dominant hand. Through a dorsal surgical approach, he underwent ORIF of the hamate with screws and stabilization of the dislocated 4th and 5th metacarpals with KW. At his last follow-up appointment, 18 months postoperatively, he had no pain, almost full range of motion on his fingers and a Mayo Wrist score of 90 points.

Conclusions:

Hamate fractures are rare entities that can cause significant patient morbidity if not recognized and treated appropriately.

Keywords: Missed injury, Hamate body, Fracture, Dorsal dislocation, Metacarpals, Internal fixation.


Article Information


Identifiers and Pagination:

Year: 2017
Volume: 11
First Page: 447
Last Page: 451
Publisher Id: TOORTHJ-11-447
DOI: 10.2174/1874325001711010447

Article History:

Received Date: 06/02/2017
Revision Received Date: 08/03/2017
Acceptance Date: 09/03/2017
Electronic publication date: 30/05/2017
Collection year: 2017

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© 2017 Athanasiou et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this author at the in Orthopaedics, Department of Hand Surgery, Orthopaedic Clinic of Patras University Hospital, Papanikolaou str 1, 26504, Rio, Patras, Greece, Tel: +302613603883, Fax: +306944363624, E-mail: andpan21@gmail.com





INTRODUCTION

Fractures of the carpal hamate are not common injuries. These are estimated to occur in 2% - 4% of all carpal [bone fractures [1Roche S, Lenehan B, Street J, O’Sullivan M. Fourth metacarpal base fracture in association with coronal hamate fracture. Inj Extra 2005; 36(8): 316-8.
[http://dx.doi.org/10.1016/j.injury.2004.12.058]
]. Coexistence with lesser metacarpals dislocation accounts for less than 1% of all hand trauma and is often referred to as fourth and fifth carpometacarpal (CMC) fracture-dislocation or as ring and small finger CMC injury [2Cain JE, Shepler TR, Wilson MR. Hamatometacarpal fracture-dislocation: classification and treatment. J Hand Surg Am 1987; 12(5 Pt 1): 762-7.
[http://dx.doi.org/10.1016/S0363-5023(87)80064-3]
, 3Liaw Y, Kalnins G, Kirsh G, Meakin I. Combined fourth and fifth metacarpal fracture and fifth carpometacarpal joint dislocation. J Hand Surg [Br] 1995; 20(2): 249-52.
[http://dx.doi.org/10.1016/S0266-7681(05)80063-4]
]. Mechanism of injury is usually a clenched fist strike against an unyielding object, however, indirect trauma may also be the cause. Diagnosis of such lesions can often be missed due to lack of familiarity with the injury and absence of obvious physical and radiological features [4De Smet L. Fracture-dislocation of the hamatometacarpal joint: A case report. 1993; pp. 106-8.]. There is no clear consensus over the management of acute CMC fracture-dislocations, as both conservative and operative methods have been shown to produce good results [5Zhang C, Wang H, Liang C, et al. The effect of timing on the treatment and outcome of combined fourth and fifth carpometacarpal fracture dislocations. J Hand Surg Am 2015; 40(11): 2169-75.e1.
[http://dx.doi.org/10.1016/j.jhsa.2015.07.017]
]. However most authors agree that delayed cases should be treated with open reduction and internal fixation (ORIF) in order to restore anatomy, prevent secondary dislocation and achieve full functional grip [5Zhang C, Wang H, Liang C, et al. The effect of timing on the treatment and outcome of combined fourth and fifth carpometacarpal fracture dislocations. J Hand Surg Am 2015; 40(11): 2169-75.e1.
[http://dx.doi.org/10.1016/j.jhsa.2015.07.017]
, 6Syed a a, Agarwal M, Giannoudis PV, Matthews SJE. Dorsal hamatometacarpal fracture-dislocation in a gymnast. Br J Sports Med 2002; 36(5): 380-2.
[http://dx.doi.org/10.1136/bjsm.36.5.380]
]. We present the case of a missed hamate fracture associated with fourth and fifth CMC dislocation, which was treated with screw fixation of the hamate and KW fixation of the metacarpals.

CASE REPORT

A 36-year-old male was attended the Α & E department of our hospital with a painful and swollen right (dominant) hand and wrist. He reported immediate onset of pain after a fist strike on a metallic door 3 days ago, for which he sought medical advice in another health institution in proximity to his residency. Initial radiographs of his wrist were interpreted as normal by the attending physician and the patient was discharged with painkillers and elastic bandage.

Upon admission to our department, physical examination revealed massive swelling of the right hand and tenderness over the ulnar side of his right wrist, both palmar and dorsal. He had limited motion at the wrist, ring and little finger with pain during passive motion. The extremity was neurovascularly intact. Radiographic evaluation included x-rays (anteroposterior, lateral and oblique views) and computed tomography scan, which clearly demonstrated a coronal fracture of the body of the hamate associated with fourth and fifth CMC dorsal dislocation (Figs. 1a-c). The patient underwent operative treatment at the day of presentation, consisting of ORIF of the hamate fracture and reduction of CMC dislocation with KW under image intensifier. Through a dorsal incision the hamate fracture was reduced and fixed with two small interfragmentary screws. The ring and little finger CMC dislocation was reduced applying longitudinal traction with a volar displacing force to the fourth and fifth metacarpals and 2 KW were driven to the third metacarpal and capitate bone (Fig. 1d).

Post-operatively, the wrist was immobilized with a volar splint for 4 weeks with the hand elevated in a sling and no neurovascular deficit was recorded. The patient was discharged after dressing change and surgical wound inspection two days after admission.

Sutures were removed at 2 weeks follow-up in the outpatient department and at 6 weeks after the operation KW were also removed and the patient was given instructions on activity modification and physiotherapy. However, he failed to comply with medical instructions and at 3 months follow-up he admitted to have returned to heavy manual labor without attending any physiotherapy sessions. Nevertheless, the patient was very satisfied with treatment outcome reporting just a slight discomfort when lifting heavy objects. At his last follow-up appointment 18 months post-surgery, the patient was asymptomatic with almost full range of wrist and finger motion and a Mayo wrist score of 90 points (Figs. 1e-g).

DISCUSSION

The hamate bone is wedge shaped and has a hook like process, the hamulus. The proximal part articulates mainly with triquetrum and the apical proximal part of the wedge with lunate. Laterally, it articulates with capitate and distally with the base of the fourth and fifth metacarpal. Hamate fractures are rare injuries and according to Milch’s classification there are two subtypes: fractures of the hook (type I) and fractures of the body (type II), these fractures were considered stable with no need for operative treatment [7Milch H. Fracture of the hamate bone. J Bone Jt Surg 1934; 16(2): 459-62.]. However, Ebraheim et al. [8Ebraheim NA, Skie MC, Savolaine ER, Jackson WT. Coronal fracture of the body of the hamate. J Trauma 1995; 38(2): 169-74.
[http://dx.doi.org/10.1097/00005373-199502000-00004]
] based on cadaveric studies, described 3 types of coronal hamate body fractures, which can result in highly unstable injuries associated with fifth and fourth CMC dislocation. These lesions usually require ORIF but were considered very rare to be included in Milch's classification.

The hamatometacarpal articulation is a saddle joint with a convex base of the 5th metacarpal fitting into a concave facet on the hamate. Both bones have an additional flat facet for articulation with the 4th metacarpal. The hamatometacarpal joint is connected by strong volar, dorsal and interosseous ligaments. Stability is further reinforced by broad insertions of the wrist flexors and extensors, though, dorsal dislocation is prevented only by the dorsal ligament [6Syed a a, Agarwal M, Giannoudis PV, Matthews SJE. Dorsal hamatometacarpal fracture-dislocation in a gymnast. Br J Sports Med 2002; 36(5): 380-2.
[http://dx.doi.org/10.1136/bjsm.36.5.380]
]. Coronal fractures of the hamate have been shown to occur when a force is transmitted longitudinally along the lesser metacarpals (4th, 5th) with the wrist in ulnar deviation as, in a neutral position, the same force would most probably cause a boxer’s fracture [9Frcsc PAB, Rao J. Coronal fractures of the body of the hamate: Two case reports 1998; 6(2): 81-4., 10Kimura H, Kamura S, Akai M, Ohno T. An unusual coronal fracture of the body of the hamate bone. J Hand Surg Am 1988; 13(5): 743-5.
[http://dx.doi.org/10.1016/S0363-5023(88)80139-4]
]. Additionally, palmar flexion of the wrist at the moment of impact will result in the dorsal displacement of the involved metacarpals due to the obliquity of the fifth CMC joint and the pull of extensor carpi ulnaris (ECU) and flexor carpi ulnaris (FCU) tendons along with the hypothenar muscles [11Thomas AP, Birch R. An unusual hamate fracture. Hand 1983; 15(3): 281-6.].

Cain et al. [2Cain JE, Shepler TR, Wilson MR. Hamatometacarpal fracture-dislocation: classification and treatment. J Hand Surg Am 1987; 12(5 Pt 1): 762-7.
[http://dx.doi.org/10.1016/S0363-5023(87)80064-3]
] classified hamatometacarpal fracture-dislocation (HMFD) into 3 types based on hamate fragmentation but with several limitations. Their classification scheme was confined to a prerequisite fourth metacarpal base fracture, while complex intrarticular fracture patterns could be interpreted due to the limitations of plain radiography. Kim et al. [12Kim JK, Shin SJ. A novel hamatometacarpal fracture-dislocation classification system based on CT scan. Injury 2012; 43(7): 1112-7.
[http://dx.doi.org/10.1016/j.injury.2012.02.019]
] in a recent study of 21 patients with a HMFD, proposed a different classification for these injuries based on preoperative computed tomography (CT): type I consists of a simple dislocation while in type II there is an associated fracture, either at the base of the 4th metacarpal (subtype A) or the hamate’s articular surface (less than one third – subtype B). In type III, in which 11 out of 21 patents of the study were categorized, there is a dorsal hamate fragment of more than one-third of the articular surface. Kim recommends conservative treatment for type I lesions, percutaneous KW fixation for type II and ORIF for type III. However this treatment algorithm does not distinguish between acute and delayed cases.

Hamatometacarpal fracture-dislocation may be missed at initial presentation up to 71% in some studies [13Henderson JJ, Arafa MA. Carpometacarpal dislocation. An easily missed diagnosis. J Bone Joint Surg Br 1987; 69(2): 212-4.]. Pain and swelling are the main clinical findings but the rarity of this traumatic event along with subtle deformity in some cases, may cause it to go unnoticed [1Roche S, Lenehan B, Street J, O’Sullivan M. Fourth metacarpal base fracture in association with coronal hamate fracture. Inj Extra 2005; 36(8): 316-8.
[http://dx.doi.org/10.1016/j.injury.2004.12.058]
, 14Cano Gala C, Pescador Hernández D, Rendón Díaz DA, 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(5): 442-5.
[http://dx.doi.org/10.1016/j.ijscr.2013.01.023]
]. Moreover, routine radiographic evaluation with anteroposterior and lateral views of the wrist may not reveal the lesion, being only visible with an oblique view of 30° of forearm pronation [15Borse VH, Hahnel J, Faraj A. Lessons to be learned from a missed case of Hamate fracture: a case report. J Orthop Surg 2010; 5(1): 64.
[http://dx.doi.org/10.1186/1749-799X-5-64]
]. Nevertheless, a high resolution CT scan is considered mandatory to completely evaluate these injuries and decide on treatment plan [5Zhang C, Wang H, Liang C, et al. The effect of timing on the treatment and outcome of combined fourth and fifth carpometacarpal fracture dislocations. J Hand Surg Am 2015; 40(11): 2169-75.e1.
[http://dx.doi.org/10.1016/j.jhsa.2015.07.017]
, 12Kim JK, Shin SJ. A novel hamatometacarpal fracture-dislocation classification system based on CT scan. Injury 2012; 43(7): 1112-7.
[http://dx.doi.org/10.1016/j.injury.2012.02.019]
, 14Cano Gala C, Pescador Hernández D, Rendón Díaz DA, 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(5): 442-5.
[http://dx.doi.org/10.1016/j.ijscr.2013.01.023]
, 16Andresen R, Radmer S, Sparmann M, Bogusch G, Banzer D. Imaging of hamate bone fractures in conventional X-rays and high-resolution computed tomography. An in vitro study. Invest Radiol 1999; 34(1): 46-50.
[http://dx.doi.org/10.1097/00004424-199901000-00007]
].

Fig. (1)
(a) Oblique 30o X-ray of the injured wrist showing dislocation of the 4th and 5th metacarpals. (b) CT scan showing the fracture of the hamate body, (c) clinical photo of the wrist showing diffuse swelling over the lesser metacarpals, (d) anteroposterior intraoperative (C-arm) X-ray showing fixation of the hamate with 2 small screws and reduction of the CMC dislocation with 2 KW, (e, f) anteroposterior and oblique X-rays of the wrist at 18 months showing healing of the hamate and congruent hamatometacarpal joint and (g) clinical photos of the wrist showing good range of motion and grip at the latest follow up.


Different treatment options have been proposed in the literature to address these lesions and decision over operative or conservative approach for the simple types remains controversial [5Zhang C, Wang H, Liang C, et al. The effect of timing on the treatment and outcome of combined fourth and fifth carpometacarpal fracture dislocations. J Hand Surg Am 2015; 40(11): 2169-75.e1.
[http://dx.doi.org/10.1016/j.jhsa.2015.07.017]
, 9Frcsc PAB, Rao J. Coronal fractures of the body of the hamate: Two case reports 1998; 6(2): 81-4., 14Cano Gala C, Pescador Hernández D, Rendón Díaz DA, 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(5): 442-5.
[http://dx.doi.org/10.1016/j.ijscr.2013.01.023]
]. Conservative treatment has been proposed for acute cases with very good results but, in the setting of late presentation, closed reduction seems to be inadequate and lead to poor outcome [5Zhang C, Wang H, Liang C, et al. The effect of timing on the treatment and outcome of combined fourth and fifth carpometacarpal fracture dislocations. J Hand Surg Am 2015; 40(11): 2169-75.e1.
[http://dx.doi.org/10.1016/j.jhsa.2015.07.017]
, 6Syed a a, Agarwal M, Giannoudis PV, Matthews SJE. Dorsal hamatometacarpal fracture-dislocation in a gymnast. Br J Sports Med 2002; 36(5): 380-2.
[http://dx.doi.org/10.1136/bjsm.36.5.380]
]. Zhang et al. [5Zhang C, Wang H, Liang C, et al. The effect of timing on the treatment and outcome of combined fourth and fifth carpometacarpal fracture dislocations. J Hand Surg Am 2015; 40(11): 2169-75.e1.
[http://dx.doi.org/10.1016/j.jhsa.2015.07.017]
] reported on 26 patients with fourth and fifth CMC fracture-dislocation up to a follow-up of 1 year. They reported excellent functional outcome for 20 acute cases treated conservatively but noticeable deformity, pain and a poor functional result for 3 out of 6 delayed cases managed non-operatively. Closed reduction and percutaneous KW fixation has also been reported in the literature but with inferior results comparing to ORIF in the setting of displaced fractures [17Arora S, Goyal A, Mittal S, Singh A, Sural S, Dhal A. Combined intraarticular fracture of the body and the hook of hamate: An unusual injury pattern. J Hand Microsurg 2012; 5(December): 92-5., 18Wharton DM, Casaletto JA, Choa R, Brown DJ. Outcome following coronal fractures of the hamate. J Hand Surg Eur Vol 2010; 35(2): 146-9.
[http://dx.doi.org/10.1177/1753193408098907]
]. Wharton et al. [18Wharton DM, Casaletto JA, Choa R, Brown DJ. Outcome following coronal fractures of the hamate. J Hand Surg Eur Vol 2010; 35(2): 146-9.
[http://dx.doi.org/10.1177/1753193408098907]
] used this method to treat 14 patients with coronal hamate fractures and reported incomplete reduction and less favorable results for patterns with displacement.

Open reduction and internal fixation seems to be preferred over conservative treatment or closed reduction and percutaneous pinning, especially for delayed cases and large displaced fragments of the hamate bone [1Roche S, Lenehan B, Street J, O’Sullivan M. Fourth metacarpal base fracture in association with coronal hamate fracture. Inj Extra 2005; 36(8): 316-8.
[http://dx.doi.org/10.1016/j.injury.2004.12.058]
, 3Liaw Y, Kalnins G, Kirsh G, Meakin I. Combined fourth and fifth metacarpal fracture and fifth carpometacarpal joint dislocation. J Hand Surg [Br] 1995; 20(2): 249-52.
[http://dx.doi.org/10.1016/S0266-7681(05)80063-4]
, 9Frcsc PAB, Rao J. Coronal fractures of the body of the hamate: Two case reports 1998; 6(2): 81-4., 14Cano Gala C, Pescador Hernández D, Rendón Díaz DA, 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(5): 442-5.
[http://dx.doi.org/10.1016/j.ijscr.2013.01.023]
, 19Pundkare GT, Patil AM. Carpometacarpal joint fracture dislocation of second to fifth finger. Clin Orthop Surg 2015; 7(4): 430.
[http://dx.doi.org/10.4055/cios.2015.7.4.430]
-22Fakih RR, Fraser AM, Pimpalnerkar AL. Hamate fracture with dislocation of the ring and little finger metacarpals. J Hand Surg Am 1998; 32(B(1)): 96-7.
[http://dx.doi.org/10.1016/S0266-7681(98)80231-3]
]. Anatomic reduction and congruent stability of the CMC arch is mandatory to achieve a good result. Finally, Carrico et al. [21Carriço F, Ferreira N, Frada T, Pereira B, da Silva MV, Sevivas N. A complex coronal fracture dislocation of the hamate-5th metacarpal. Eur Orthop Traumatol 2015; 6(3): 295-9.
[http://dx.doi.org/10.1007/s12570-014-0287-6]
] in their recent case report of a complex coronal hamate fracture and fifth CMC dislocation, recommended the use of a temporary spanning external fixator for 6 weeks in order to maintain reduction of the little finger CMC joint [21Carriço F, Ferreira N, Frada T, Pereira B, da Silva MV, Sevivas N. A complex coronal fracture dislocation of the hamate-5th metacarpal. Eur Orthop Traumatol 2015; 6(3): 295-9.
[http://dx.doi.org/10.1007/s12570-014-0287-6]
].

CONCLUSION AND TAKE HOME MESSAGE

Coronal hamate fracture-dislocations are rare injuries with a high rate of missed initial diagnosis. A high degree of suspicion is needed to reveal the lesion. When a traumatic event is associated with proper clinical examination, an oblique x-ray of the wrist must be obtained followed by CT confirmation and further evaluation of fracture morphology to allow optimal surgical planning. In most cases, these injuries should be managed as intrarticular fractures with ORIF in order to achieve anatomic and stable reduction and allow for early mobilization and good functional outcome.

LIST OF ABBREVIATIONS

CMC  = Carpo Meta Carpal
ECU  = Extensor Carpi Ulnaris
FCU  = Flexor Carpi Ulnaris
HMFD  = Hamato Metacarpal Fracture Dislocation
KW  = Kirschner Wire
ORIF  = Open Reduction Internal Fixation

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

Not applicable.

HUMAN AND ANIMAL RIGHTS

No Animals/Humans were used for studies that are base of this research.

CONSENT FOR PUBLICATION

Not applicable.

CONFLICT OF INTEREST

The authors confirm that this article content has no conflict of interest.

ACKNOWLEDGEMENTS

Declared none.

REFERENCES

[1] Roche S, Lenehan B, Street J, O’Sullivan M. Fourth metacarpal base fracture in association with coronal hamate fracture. Inj Extra 2005; 36(8): 316-8.
[http://dx.doi.org/10.1016/j.injury.2004.12.058]
[2] Cain JE, Shepler TR, Wilson MR. Hamatometacarpal fracture-dislocation: classification and treatment. J Hand Surg Am 1987; 12(5 Pt 1): 762-7.
[http://dx.doi.org/10.1016/S0363-5023(87)80064-3]
[3] Liaw Y, Kalnins G, Kirsh G, Meakin I. Combined fourth and fifth metacarpal fracture and fifth carpometacarpal joint dislocation. J Hand Surg [Br] 1995; 20(2): 249-52.
[http://dx.doi.org/10.1016/S0266-7681(05)80063-4]
[4] De Smet L. Fracture-dislocation of the hamatometacarpal joint: A case report. 1993; pp. 106-8.
[5] Zhang C, Wang H, Liang C, et al. The effect of timing on the treatment and outcome of combined fourth and fifth carpometacarpal fracture dislocations. J Hand Surg Am 2015; 40(11): 2169-75.e1.
[http://dx.doi.org/10.1016/j.jhsa.2015.07.017]
[6] Syed a a, Agarwal M, Giannoudis PV, Matthews SJE. Dorsal hamatometacarpal fracture-dislocation in a gymnast. Br J Sports Med 2002; 36(5): 380-2.
[http://dx.doi.org/10.1136/bjsm.36.5.380]
[7] Milch H. Fracture of the hamate bone. J Bone Jt Surg 1934; 16(2): 459-62.
[8] Ebraheim NA, Skie MC, Savolaine ER, Jackson WT. Coronal fracture of the body of the hamate. J Trauma 1995; 38(2): 169-74.
[http://dx.doi.org/10.1097/00005373-199502000-00004]
[9] Frcsc PAB, Rao J. Coronal fractures of the body of the hamate: Two case reports 1998; 6(2): 81-4.
[10] Kimura H, Kamura S, Akai M, Ohno T. An unusual coronal fracture of the body of the hamate bone. J Hand Surg Am 1988; 13(5): 743-5.
[http://dx.doi.org/10.1016/S0363-5023(88)80139-4]
[11] Thomas AP, Birch R. An unusual hamate fracture. Hand 1983; 15(3): 281-6.
[12] Kim JK, Shin SJ. A novel hamatometacarpal fracture-dislocation classification system based on CT scan. Injury 2012; 43(7): 1112-7.
[http://dx.doi.org/10.1016/j.injury.2012.02.019]
[13] Henderson JJ, Arafa MA. Carpometacarpal dislocation. An easily missed diagnosis. J Bone Joint Surg Br 1987; 69(2): 212-4.
[14] Cano Gala C, Pescador Hernández D, Rendón Díaz DA, 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(5): 442-5.
[http://dx.doi.org/10.1016/j.ijscr.2013.01.023]
[15] Borse VH, Hahnel J, Faraj A. Lessons to be learned from a missed case of Hamate fracture: a case report. J Orthop Surg 2010; 5(1): 64.
[http://dx.doi.org/10.1186/1749-799X-5-64]
[16] Andresen R, Radmer S, Sparmann M, Bogusch G, Banzer D. Imaging of hamate bone fractures in conventional X-rays and high-resolution computed tomography. An in vitro study. Invest Radiol 1999; 34(1): 46-50.
[http://dx.doi.org/10.1097/00004424-199901000-00007]
[17] Arora S, Goyal A, Mittal S, Singh A, Sural S, Dhal A. Combined intraarticular fracture of the body and the hook of hamate: An unusual injury pattern. J Hand Microsurg 2012; 5(December): 92-5.
[18] Wharton DM, Casaletto JA, Choa R, Brown DJ. Outcome following coronal fractures of the hamate. J Hand Surg Eur Vol 2010; 35(2): 146-9.
[http://dx.doi.org/10.1177/1753193408098907]
[19] Pundkare GT, Patil AM. Carpometacarpal joint fracture dislocation of second to fifth finger. Clin Orthop Surg 2015; 7(4): 430.
[http://dx.doi.org/10.4055/cios.2015.7.4.430]
[20] Kerr HD. Hamate-metacarpal fracture dislocation. J Emerg Med 1992; 10(5): 565-8.
[http://dx.doi.org/10.1016/0736-4679(92)90138-J]
[21] Carriço F, Ferreira N, Frada T, Pereira B, da Silva MV, Sevivas N. A complex coronal fracture dislocation of the hamate-5th metacarpal. Eur Orthop Traumatol 2015; 6(3): 295-9.
[http://dx.doi.org/10.1007/s12570-014-0287-6]
[22] Fakih RR, Fraser AM, Pimpalnerkar AL. Hamate fracture with dislocation of the ring and little finger metacarpals. J Hand Surg Am 1998; 32(B(1)): 96-7.
[http://dx.doi.org/10.1016/S0266-7681(98)80231-3]

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Sean L. Kitson
(Almac Sciences, Northern Ireland)

"In principle, all scientific journals should have open access, as should be science itself. Open access journals are very helpful for students, researchers and the general public including people from institutions which do not have library or cannot afford to subscribe scientific journals. The articles are high standard and cover a wide area."


Hubert Wolterbeek
(Delft University of Technology, The Netherlands)

"The widest possible diffusion of information is critical for the advancement of science. In this perspective, open access journals are instrumental in fostering researches and achievements."


Alessandro Laviano
(Sapienza - University of Rome, Italy)

"Open access journals are very useful for all scientists as they can have quick information in the different fields of science."


Philippe Hernigou
(Paris University, France)

"There are many scientists who can not afford the rather expensive subscriptions to scientific journals. Open access journals offer a good alternative for free access to good quality scientific information."


Fidel Toldrá
(Instituto de Agroquimica y Tecnologia de Alimentos, Spain)

"Open access journals have become a fundamental tool for students, researchers, patients and the general public. Many people from institutions which do not have library or cannot afford to subscribe scientific journals benefit of them on a daily basis. The articles are among the best and cover most scientific areas."


M. Bendandi
(University Clinic of Navarre, Spain)

"These journals provide researchers with a platform for rapid, open access scientific communication. The articles are of high quality and broad scope."


Peter Chiba
(University of Vienna, Austria)

"Open access journals are probably one of the most important contributions to promote and diffuse science worldwide."


Jaime Sampaio
(University of Trás-os-Montes e Alto Douro, Portugal)

"Open access journals make up a new and rather revolutionary way to scientific publication. This option opens several quite interesting possibilities to disseminate openly and freely new knowledge and even to facilitate interpersonal communication among scientists."


Eduardo A. Castro
(INIFTA, Argentina)

"Open access journals are freely available online throughout the world, for you to read, download, copy, distribute, and use. The articles published in the open access journals are high quality and cover a wide range of fields."


Kenji Hashimoto
(Chiba University, Japan)

"Open Access journals offer an innovative and efficient way of publication for academics and professionals in a wide range of disciplines. The papers published are of high quality after rigorous peer review and they are Indexed in: major international databases. I read Open Access journals to keep abreast of the recent development in my field of study."


Daniel Shek
(Chinese University of Hong Kong, Hong Kong)

"It is a modern trend for publishers to establish open access journals. Researchers, faculty members, and students will be greatly benefited by the new journals of Bentham Science Publishers Ltd. in this category."


Jih Ru Hwu
(National Central University, Taiwan)


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