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The treatment of choice in nondisplaced hook of hamate fractures is conservative, with lower arm splinting. Displaced fractures should be treated operatively, whereby excision of the fragment or open reduction and internal fixation are described. A hamulus ossis hamati fracture was verified in 14 patients (mean age, 42 years; range, 21 to 73 years) including 11 men and three women. In six patients (42.9 percent), conservative treatment was initiated immediately after trauma with a lower arm cast for 6 weeks, and eight patients (57.1 percent) were operated on primarily. In five patients (35.7 percent), the fragment was excised, and in three patients (21.4 percent), an open reduction and internal fixation was performed using a screw. In five of six patients treated conservatively, nonunion of the fracture with persisting clinical symptoms developed. All of those patients were treated operatively, whereby three patients underwent excision and two patients underwent screw fixation, which led to elimination of the symptoms. One patient was asymptomatic despite nonunion of the fracture and rejected surgery. All of the eight patients operated on primarily were asymptomatic 3 months after surgery. Therefore, the success rate of primary surgical treatment (eight of eight) was significantly higher compared with conservative treatment(one of six). Finally, all 14 patients were asymptomatic at late postoperative follow-up. The clinical outcome of patients with hook of hamate fractures treated conservatively was disappointing. Therefore, primary surgical treatment is recommended. In our patients, excision and open reduction and internal fixation led to comparable results.