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  • A rare carpal fracture
  • Epidemiology
    • incidence
      • <1% of carpal fractures  
      • rare injury and often missed
  • 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
  • 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
  • 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
  • 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
    • indications
      • suspected carpal fracture with negative radiographs
    • findings
      • may show bone marrow edema within the pisiform indicating fracture
  • Nonoperative
    • early immobilization
      • indications
        • first line of treatment 
      • technique
        • 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
  • Malunion
  • Non-union
  • Chronic ulnar sided pain
  • Decreased grip strength

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Questions (1)

(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? Review Topic


Scapholunate ligament repair




Excision of the hook hamate




Excision of the pisiform




Open reduction internal fixation of the hamate




Open reduction internal fixation of the pisiform



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Based on clinical history and imaging shown, this patient has developed a pisiform fracture nonunion. Treatment of symptomatic nonunions of the pisiform is by pisiformectomy

Fractures of the pisiform are rare. They often occur in conjunction with injuries to the distal radius or carpus. Non-operative management with cast immobilization in 30 degrees of wrist flexion is the first line of treatment. Symptomatic nonunions are treated with pisiformectomy.

Palmieri et al. performed pisiformectomies on 21 patients who had pisiform area pain that was refractory to conservative management. Patients had a history of painful union or nonunion of pisiform fractures, arthritis or FCU tendonitis. In all cases, wrist strength and mobility was retained.

Lam et al. reviewed the effect of pisiform excision on wrist function in patients with piso-triquetral dysfunction. After an average follow up of 65 months, 75% of patients had complete relief of pisiform area symptoms. No differences in grip, wrist motion, strength or power were found in comparison to the contralateral side.

Figure A shows a lateral radiograph of a pisiform fracture nonunion. Figure B shows an axial CT scan sequence of the wrist. A pisiform fracture nonunion is identified with subtle comminution. The pisotriquetral joint appears to be congruent.

Incorrect Answers
Answer 1: The scapholunate ligament is not affected in this clinical situation.
Answers 2, 4: Although the hook of hamate can be a source of ulnar sided pain, it is not implicated in this clinical situation
Answer 5: An ORIF of the pisiform is not typically used for symptomatic pisiform fracture nonunions

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