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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?
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.
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
J Hand Surg Am. 1982 Sep;7(5):477-80. PMID: 7130657 (Link to Abstract)
Lam KS, Woodbridge S, Burke FD
J Hand Surg Br. 2003 Feb;28(1):69-72. PMID: 12531672 (Link to Abstract)
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