Updated: 5/14/2021

Pisiform Fracture

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  • Summary
    • Pisiform fractures are rare carpal fractures associated with falls on an outstretched hand.
    • Diagnosis is often made with orthogonal radiographs but may require CT for confirmation.
    • Treatment is primarily nonoperative with painful nonunions requiring surgical excision.
  • Epidemiology
    • Incidence
      • <1% of carpal fractures
      • rare injury and often missed
  • Etiology
    • 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
    • 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
        • lateral
        • ER oblique
        • carpal tunnel
        • best seen with ER oblique or 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
  • Differential
    • Hamate body fracture
    • Hook of hamate fracture
    • FCU tendonitis
  • Diagnosis
    • Radiographic
      • diagnosis confirmed by history, physical exam, and radiographs
  • Treatment
    • 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
  • Complications
    • Malunion
    • Non-union
    • Chronic ulnar sided pain
    • Decreased grip strength
Questions (2)
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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 wrist radiograph is shown in Figure A and a CT scan is shown in Figure B. What is the most appropriate treatment?

QID: 763
FIGURES:
1

Scapholunate ligament repair

1%

(54/3644)

2

Excision of the hook hamate

14%

(511/3644)

3

Excision of the pisiform

73%

(2651/3644)

4

Open reduction internal fixation of the hamate

3%

(116/3644)

5

Open reduction internal fixation of the pisiform

8%

(289/3644)

L 3 D

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