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Pisiform Fracture

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Topic updated on 01/23/15 12:45pm
Introduction
  • A rare carpal fracture
  • Epidemiology
    • incidence
      • <1% of carpal fractures  
  • Pathophysiology
    • mechanism of injury
      • usually occurs by direct impact against a hard surface
      • fall on outstretched hand 
  • Associated conditions
    • 50% occur as isolated injuries
    • 50% occur in association with other carpal fractures or distal radius fractures
Anatomy
  • Pisiform Bone
    • osteology
      • pea shaped, seasmoid bone
    • location 
      • most ulnar and palmar carpal bone in proximal row
      • located within the FCU tendon
    • function
      • contributes to the stability of the ulnar column by preventing triquetral subluxation
Presentation
  • History
    • rare injury and often missed
  • Symptoms
    • ulnar sided wrist pain after a fall
    • grip weakness
  • Physical exam
    • inspection
      • hypothenar tenderness and swelling
      • rule out associated injury to other carpal bones and distal radius
Imaging
  • Radiographs  
    • recommended views
      • AP and lateral views of wrist
    • additional views
      • pronated oblique and supinated oblque views
      • carpal tunnel view
    • findings
      • best seen with 30 deg of wrist supination or utilizing the carpal tunnel view
  • CT  
    • indications
      • may be required to delineate fracture pattern and determine treatment plan
  • MRI
    • indication
      • suspected carpal fracture with negative radiographs
    • findings
      • may show bone marrow edema within the pisiform indicating fracture
Treatment
  • Nonoperative
    • early immobilization
      • indications
        • first line of treatment 
        • short arm cast with 30 degrees of wrist flexion and ulnar deviation for 6-8 weeks
      • outcomes
        • most often go on to heal without posttraumatic osteoarthritis
  • Operative
    • pisiformectomy
      • indications
        • severely displaced and symptomatic fractures
        • painful nonunion 
      • outcomes
        • studies show a pisiformectomy is a reliable way to relieve this pain and does not impair wrist function
Complications
  • Malunion
  • Non-union
  • Chronic ulnar sided pain
  • Decreased grip strength

 

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(OBQ07.102) A 28-year-old man fell while ice skating 6 months ago and has had ulnar-sided wrist pain ever since. The patient's lateral radiograph of the wrist is shown in Figure A and a CT scan is shown in Figure B. What is the most appropriate treatment? Topic Review Topic
FIGURES: A   B        

1. Scapholunate ligament repair
2. Excision of the hook hamate
3. Excision of the pisiform
4. Open reduction internal fixation of the hamate
5. Open reduction internal fixation of the pisiform

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Lam KS, Woodbridge S, Burke FD
J Hand Surg Br. 2003 Feb;28(1):69-72. PMID: 12531672 (Link to Pubmed)
2/8/2014
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