Pisiform Fracture

Introduction
The pisiform is a sesamoid bone located within the FCU tendon origin for abductor digiti minimi Epidemiology incidence 1%-3% of carpal fractures Mechanism fall on outstretched hand Associated conditions 50% of pisiform fractures occur with distal radius, hamate, or triquetral fractures
Anatomy
Function pisiform mechanically contributes to the stability of the ulnar column by contributes to the stability of the ulnar column by preventing triquetral subluxation acts as a fulcrum for forces transmitted from the forearm to the hand. preventing triquetral subluxation and also acts as a fulcrum for the powerful forces that are transmitted from the forearm to the hand.
Presentation
Symptoms ulnar sided wrist pain Physical exam point tenderness
Imaging
Radiographs recommended views pisotriquetral joint is best seen in lateral view with 30 deg of wrist supination or utilizing the carpal tunnel view CT best seen on CT scan
Treatment
Nonoperative immobilization indications first line of treatment short arm cast with 30 degrees of wrist flexion and ulnar deviation for 6 weeks outcomes patients that sustain fracture of pisiform most often go on to heal without posttraumatic osteoarthritis Operative pisiformectomy indications painful nonunion outcomes studies show a pisiformectomy is a reliable way to relieve this pain and does not impair wrist function

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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

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

PREFERRED RESPONSE ▶

DISCUSSION: The radiograph and CT scan demonstrate a comminuted pisiform fracture. Incongruity and/or arthritis at the pisotriquetrial joint can cause ulnar-sided wrist pain. Studies show a pisiformectomy is a reliable way to relieve this pain and doesn’t impair wrist function. Lam et al in a study of 20 patients who underwent pisiformectomy for pisotriquetral joint dysfunction reported 15 with complete relief and 5 with mild discomfort at a mean follow-up of 65 months. They reported "no significant differences in grip strength and wrist movement, static strength and dynamic power" when compared to the unaffected wrist.

REFERENCES:

1. Pierre A, Le Nen D, Hu W, Dubrana F, Saraux A, Chaise F. Treatment of piso-triquetral pain by excision of the pisiform: report of fifteen cases. Chir Main. 2003 Feb;22(1):37-42. PMID:12723308 (Link to Abstract)

2. Lam KS, Woodbridge S, Burke FD. Wrist function after excision of the pisiform. J Hand Surg Br. 2003 Feb;28(1):69-72. PMID:12531672 (Link to Abstract)

Question Authors:

Greg Galano MD, Derek Moore,

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Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012

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Lam KS, Woodbridge S, Burke FD. Wrist function after excision of the pisiform. J Hand Surg Br. 2003 Feb;28(1):69-72. PMID:12531672 (Link to Abstract)
Pierre A, Le Nen D, Hu W, Dubrana F, Saraux A, Chaise F. Treatment of piso-triquetral pain by excision of the pisiform: report of fifteen cases. Chir Main. 2003 Feb;22(1):37-42. PMID:12723308 (Link to Abstract)

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