Table Of ContentHandClin21(2005)xi
Preface
Wrist Arthritis
BrianD.Adams,MD
GuestEditor
Althoughthepopulationisaging,demandsand medical adage that when multiple treatments are
expectationstomaintainanactivelifestylearein- being used for a condition it indicates no one
creasing. Arguably, arthritis is the most common treatment is particularly good does not apply to
cause of physical debilitation and is among the the wrist. Because the wrist is a complex inte-
topreasonsforseekingmedicalcare.Despitewide- grated system of joints, it requires a diversity of
spreadpublicfamiliarityofavailabletreatmentfor treatmentoptions.InthiseditionofHandClinics,
hipandkneearthritis,lackofknowledgeandcon- I have asked experts from around the world to
fusion is common not only in the lay public but offer their insights into the treatment of wrist ar-
also among physicians, other medical providers, thritis. I am indebted to these experts who have
andinsurersregardingavailabletreatmentforup- providedconsiderabletimeandefforttomakethis
perlimbarthritis.Perhapssomeofthisconfusion a successful publication. I am confident that you
relates to the higher complexity of the joints and will find these readings helpful to your practice.
thegreaterspectrumoftreatmentoptions.Inaddi- Some articles are intended to clarify and update
tion,peoplehavehistoricallybeenmoretolerantof more established procedures, whereas others in-
the functional loss caused by hand and wrist ar- troduce newer concepts and techniques. As the
thritis, but this tendency is changing, with more guesteditor,itiswithpridethatIpresentthisedi-
people seeking out specialized care and even spe- tiononatopicthathasbeenapassioninmypro-
cificsurgicalprocedures.Itisthusimperativethat fessional life.
healthcarespecialistsoftheupperlimbareknowl-
edgeable of the pathoanatomy, clinical presenta- BrianD. Adams, MD
tions, and surgical alternatives for arthritis. Departmentof OrthopedicSurgery
Furthermore,itisvitaltoourspecialtythatweed- University of IowaHospitalsandClinics
ucate other medical providers, insurers, and the LowerLevel, PappajohnPavilion
publicregardingourcapabilitytosubstantiallyim- 200Hawkins Drive
provethelivesofthosesufferingfromarthritis. IowaCity, IA52242,USA
By its very nature, treatment of the arthritic
E-mailaddress: [email protected]
wrist is fascinating and challenging. The old
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HandClin21(2005)507–517
Pisiform Ligament Complex Syndrome
and Pisotriquetral Arthrosis
Ghazi M. Rayan, MD
HandSurgerySection,OrthopedicSurgeryDepartment,UniversityofOklahomaCollegeofMedicine
andINTEGRISBaptistMedicalCenter,3366NWExpressway,Suite#700,OklahomaCity,OK73112,USA
Pisiformligamentcomplex(PLC)syndromeis Michelson [2] reported that the ossification of
defined as ulnar palmar wrist pain in the vicinity the pisiform occurs at a mean age of 8 years and
ofthepisiformcausedbyinjurytocomponentsof 9 months and by age 12 years the bone becomes
the PLC leading to pisotriquetral (PT) joint fully developed.
instability with subsequent arthrosis. PT joint Thepisiformisthesmallestcarpalboneandis
osteoarthritis is a degenerative joint disease in- locatedpalmartotheplaneoftheremainingthree
volving the articular surfaces of the pisiform and carpal bones of the proximal carpal row. Its
triquetrum.PrimaryosteoarthritisofthePTjoint articulation with the triquetrum seems to be
isuncommonandmanyarthriticdisordersofthis separatefromotherwristarticulations[3].Thepi-
joint are post-traumatic in nature preceded by siform is almost spherical and embedded within
chronicPTjointinstability.PTjointosteoarthritis theflexorcarpiulnaris(FCU)tendon,thusacting
therefore cannot be viewed in a vacuum, because asasesamoidbone.Itistheonlycarpalbonewith
itspathophysiologyoverlapsandintertwineswith onearticularsurfaceandanytendinousinsertion.
thoseofotherdisorders.Amorecatholictermfor Thepisiformreceivesitsbloodsupplythroughthe
arthritic conditions of this joint would be piso- proximalanddistalpolesfrombranchesoftheul-
triquetral arthrosis (PTA). Studying the anatomy nar artery. The triquetrum is pyramidal in shape
and biomechanics of the pisiform and PT joint andhasthreearticularsurfaces.Itspalmararticu-
ligaments and reviewing the clinical variants of larsurfaceisthesmallest,ovalinshapeandartic-
PLCsyndromeareessentialforunderstandingthe ulates with the pisiform. The medial wall of
natureofPTA. Guyon canal is formed by the pisiform, which is
in proximity to the ulnarnerveandartery.
In 1945 Kropp [4] published a brief anatomic
Anatomy study that ushered in the first known modern in-
terestintheanatomyanddescriptionofPTjoint.
In 1944 Harris [1] stated that in primates ex-
He observed a communication between PT and
ceptmanthepisiformhasasecondaryossification
radiocarpal joints in 76% of specimens. This
centerwithanepiphysis, which suggeststhat itis
was contradictory to descriptions by standard
analogous to the os calcis. The pisiform in hu-
anatomy textbooks at the time, which implied
mans is cartilaginous at birth and later develops
that the PT joint has separate articulation from
one and rarely a secondary ossification center. If
thewrist.Weston[5]inabriefreportonpostmor-
the secondary center is present and does not fuse
tem arthrography confirmed this communication
totheremainingbone,anaccessoryossicledevel-
between the PT and wrist joints. Viegas and
ops called os pisiforme secundarium. In 1945
colleagues [6] also reported a communication be-
tween the proximal wrist joint and PT joint in
88% of cadavers dissected. Pevny and colleagues
E-mailaddress:[email protected] [7] described 10 soft tissue attachments to the
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508 RAYAN
pisiform,includingtheFCUtendon,extensorret- radiographicallyandfoundthepisiformhasaspa-
inaculum, abductor digiti minimi, transverse car- tial motion in relation to the triquetrum that
pal ligament (TCL), anterior carpal ligament, occurs in four planes: proximal–distal (vertical
ulnarcollateralligament,triangularfibrocartilage gliding),anterior–posterior(gapping),uniaxialro-
complex (TFCC), pisohamate (PH) ligament, pi- tation (angulation), and ulnar–radial (horizontal
sometacarpal(PM)ligament,andPTjointfibrous gliding).
capsule. Yamaguchi and colleagues [8] identified Pevnyandcolleagues[7]foundthatthesofttis-
threedifferentanatomictypesofPHandPMlig- sue attachments to the pisiform were strongest
amentsbasedontheirattachmenttothepisiform. distally and weakest ulnarly. No significant de-
Recently Rayan and colleagues [9] coined the creaseinthestiffnessofthePTjointwasobserved
termpisiformligamentcomplex(PLC)todescribe in any direction tested after transection of the
a group of ligaments that attach to the pisiform TCL. Recently Rayan and colleagues [9] found
and contribute to its stability in different planes. the PLC to comprise primary and secondary sta-
The main ligaments that attach to the pisiform bilizers depending on the degree of stability pro-
are the PM, PH, radial PT, ulnar PT, and TCL. vided to the pisiform and PT joint. The primary
Theseligamentssecurethepisiformtothetrique- stabilizers are the PM ligament, which provides
trum, hamate, and base of the fifth metacarpal. stability against proximal displacement, PH liga-
The fibrous tissue connecting the pisiform to the ment against ulnar displacement, and ulnar PT
triquetrumthatisoftenreferredtoasthePTjoint ligament against radial displacement of the pisi-
capsule consists of the radial and ulnar PT form (Figs. 1 and 2). The radial PT ligament
ligaments. and TCL played a less important stabilizing
role. The TCL was observed to have no attach-
ment in the pisiform in 50% of specimens, and
in the remaining 50% it was attached only to
Kinematics andbiomechanics
20% of the pisiform distally. Releasing the TCL
The pisiform is not a mere focal point of ST for carpal tunnel syndrome therefore should not
attachments,ratheritisasesamoidbonethatacts have adverseeffects onPT jointstability.
as a lever to enhance the function of the FCU BeckersandKoebke[13]studiedthemechani-
muscle in a similar fashion to the patella and cal strain at the PT joint and transfer of forces
quadriceps muscle. Its attachment to the hamate within the carpus. They suggested that the pisi-
throughthePHligamentactsasanadditionallink form contributes to the stability of the ulnar col-
to the triquetrohamate ligament between the umn of the wrist by holding the triquetrum in
proximalanddistalcarpalrows.TheFCUtendon a correct position and preventing its subluxation
istheonlydynamicstructurethatactsdirectlyon and by acting as a fulcrum while transducing
the pisiform exerting proximally directed force. powerful forearm forces to the hand. They con-
Wrist extensors and radial/ulnar deviators act cluded that excision of the pisiform should be
indirectly by generating forces that result in
pisiformdisplacement.
Weston [5] observed a substantial mobility of
the pisiform during wrist motion and attributed
this mobility to a lax capsule. Vasilas and col-
leagues [10] found that the PT joint space ranges
from1–4mmin neutral wristpositionandnoted
widening of this space with wrist flexion and its
narrowingwithextension.Moojenandcolleagues
[11] studied the pisiform kinematics and found
that during extension the pisiform translates and
presses against the distal part of the triquetrum
but moves away from it during flexion. With ra-
dial wrist deviation the pisiform flexes while the
triquetrum extends; with ulnar deviation the
Fig.1. Cadaverspecimenshowingtheulnarsideofthe
triquetrum shows more ulnar deviation and ex- wristwiththeextensorretinaculum(ER),pisiform(P),
tension. Jameson and colleagues [12] evaluated flexorcarpiulnaris(FCU),pisohamate(PHL),andpiso-
wrists of normal volunteers fluoroscopically and metacarpal(PML)ligaments.
PLCSYNDROMEANDPISOTRIQUETRALARTHROSIS 509
Fig.4. Motionviewsforoptimumviewingofthepiso-
Fig.2. ThesamespecimenasinFig.1,showingtheul- triquetraljoint;theforearmispositionedin45(cid:1)ofsupi-
nar pisotriquetral ligament (UPTL) after removing the
nation,wristinflexion,andthumbabducted.
extensorretinaculum.
reconsidered. This conclusion, however, is not for pisiform excursion, PT wedge angle, PT joint
substantiated by clinical studies. Studies from space,andPHdistancecanbeusedasparameters
the author’s institute suggest that the lunotrique- for comparison wheninstability issuspected [12].
tral ligament may be an extension of the PLC. It Carpal tunnel views may visualize the pisiform
isyettobedetermined, however, whatifanyad- fromadifferentprojectionbutcannotbeobtained
versechangespisiformexcisionhasonthebiome- easilyandarelessusefulthanthesemilateralviews.
chanicsof the ulnarwrist. Real time fluoroscopy during wrist flexion and
extension with comparison to the contralateral
normal side can add more information if needed
Imaging aboutPTjointinstability.Bonescanmaybeposi-
tiveinfracturesandtumorsofthepisiformbutis
The radiographic technique for PT joint eval-
nothelpfulindiagnosingPTA.Trispiraltomogra-
uation used at the author’s institute includes at
phycandelineatePTloosebodies.
least three semilateral wrist motion views, full
wrist extension with the forearm in 30(cid:1) of
supination (Fig. 3), neutral wrist position with
30(cid:1) of supination, and full wrist flexion (active
andpassiveoptional)with45(cid:1)ofsupinationwhile
the thumb is fully abducted [12] (Fig. 4). These
views show pisiform pathology or fractures and
PTA. Also they can give the clinician insight
into the pisiform motion and degree of PT joint
instability(Figs.5–8).Theaveragenormalvalues
Fig.3. Motionviewsforoptimumviewingofthepiso-
triquetraljoint;theforearmispositionedin30(cid:1)ofsupi- Fig. 5. The radiographic appearance of the pisotrique-
nationandwristinextension. traljointspaceinneutralwristposition.
510 RAYAN
Fig. 6. Theradiographicappearanceofthe pisotrique-
traljointspaceinwristextension. Fig. 8. Theradiographicappearanceofthe pisotrique-
traljointspaceinactivewristflexion.
Theumann and colleagues [14] found in a ca- that this modality improves the visualization of
daver study that the ECU tendon sheath, fibrous osteoarthritis of the PTjoint.
capsule,andcartilaginoussurfacesofthePTjoint
are better visualized at MR arthrography than
Pathology andclinical variantsof pisiform
MRimaging.Thesametechniqueallowedvisual-
ligament complexsyndrome
izationofPHandPMligaments.Theyconcluded
Paley and colleagues [15] reported 16 patients
with symptomatic PT joints and made correla-
tionsbetweenetiologicfactorsandthepathologic
diagnosis. They retrieved pathologic–etiologic
data from 216 cases identified from the literature
and organized them into four pathologic groups:
primaryosteoarthritis(2.3%),secondaryosteoar-
thritis(48.4%),otherarthritides(4.7%),andFCU
enthesopathy (44.6%). The most common causes
were acute and chronic trauma and instability.
Theyhypothesizedthatlossofintegritytothesur-
rounding retinacular structures of the pisiform
may lead to its instability and thus dysfunction
ofthejoint.Thefollowingarevariouspathologic
disorders that affect the pisiform and PT joint
causingulnarsidedwristpain.Someofthesecon-
ditionsmaycontributetothedevelopmentofPLC
syndrome and predispose toPTA.
Congenital disorders
Congenital anomalies of the pisiform and PT
joint include accessory ossicle of the pisiform,
Fig. 7. Theradiographicappearanceofthe pisotrique- whichiscalledospisiformesecundarium,pisiform
traljointspaceinpassivewristflexion. hamate coalition, which is often bilateral, and
PLCSYNDROMEANDPISOTRIQUETRALARTHROSIS 511
congenital absence of the pisiform, which is occult malunion, malalignment of the PT joint,
associatedwithulnardeficiencyandectrodactyly. earlyPTAorassociatedPLCinjury,andpisiform
These anomalies are rare and usually asymptom- instability.
atic. Recognizing the abnormal anatomy is im-
portant to avoid misdiagnosing the condition as
PTA, pisiform fracture, or scaphoid dislocation
Pisiform instability
[16].
In1948Immerman[21]reportedacaseofdis-
tal pisiform dislocation and found that by 1901
Pisiform tumors
there were seven such reports that antedated the
Ganglionsweredescribedtooriginatefromthe discovery of radiographs. Since this publication
PT joint [17] or intraosseous from the pisiform there have been many sporadic case reports, but
[18].Osteoidosteomaofthepisiformalsowasre- no series or clinical studies have been published
ported,butwithdifficultyanddelayinthediagno- on pisiform dislocation or its sequelae. Pisiform
sis. Surgical removal of the nidus was curative in dislocation occurs in isolation or in association
one case report [19]. Primary malignant tumors withotherinjuries,suchasdistalradiusfractures
andmetastaticlesionsofthepisiformareextremely [22]orhamatedislocation[23].Themechanismof
rare.Painfulpisiformenlargementandsclerosisof pisiform dislocation is direct force, such as a fall
the entire bone in one case report was attributed on the heel of the hand, or indirect force from
possibly to avascular necrosis. Pisiform excision wrist extension andFCU musclecontraction.
did not reveal specific diagnosis but relieved the Two case reports described surgical treatment
patient’ssymptoms[20]. for acute pisiform dislocation, including open
reduction and temporary internal fixation [24]
andopenreductionandreconstructionofthelig-
Flexorcarpi ulnaristendinopathy
aments [25] with subsequent subluxation of the
This probably is caused by degenerative pisiform after both treatment modalities and
changeswithintheFCUtendonnearitsinsertion post-traumatic arthritic changes in onecase[25].
in the pisiform. Paley and colleagues [15] found Recurrent dislocation of the pisiform was
thatFCUenthesopathyisthecauseofsymptoms reportedbyIshizuki[26]tooccurdistaltothetri-
in44%ofpatientsstudiedwhohadulnarpalmar quetrum when the wrist was extended to 45(cid:1) or
wrist pain. FCU tendinopathy, however, seldom moreandthepisiformwasreducedtoproperjoint
occurs in isolation and often is associated with congruityafterwristflexionof55(cid:1)ormore.Pevny
other conditions, especially PT instability and andRayan[27]reportedacaseofrecurrentradial
PTA. Diagnosing FCU tendinopathy therefore dislocationofthepisiform.Atsurgerythepathol-
must raise the suspicion of other associated ogywas attenuationof the ulnarPTligament.
conditions. PT joint instability without dislocation is
a common but unrecognized and under-reported
cause of ulnar palmar wrist pain. Injuries of the
Pisiform fracturemalunion
PLC can be acute or chronic. There are two
Fractures of the pisiform can be displaced or possiblemechanismsbywhichacutePLCinjuries
nondisplaced or they can be extra-articular or occur that are similar to those of pisiform
intra-articular. Most pisiform fractures are non- dislocation. The first is direct, caused by a fall
displaced, but many are intra-articular. Most on the outstretched hand with the force directed
pisiform fractures initially can be treated non- to the pisiform causing displacement and defor-
operativelywithsplintorcastimmobilizationwith mationofitsligamentsbutnotseverelyenoughto
at least short-term satisfactory results. Severely causepisiformdislocation.Thesecondisindirect,
comminuted intra-articular fractures with articu- caused by wrist hyperextension with the genera-
larcartilagedamage anddisplacedintra-articular tion of tensile forces through the ligaments, in
fracturescanresultlaterinmalunionandPTA.In particular the strong PH ligament or ulnar PT
some cases, however, despite healing with near ligament, causing their elongation and failure.
anatomic alignment, painful union develops and Although complete rupture of the PH ligament
the patient continues to experience PT pain de- has not been reported, the author encountered
spite normal appearing radiographs. In these a case of avulsion fracture of the hamulus from
cases the residual pain is caused by healing with its base by the PH ligament caused by wrist
512 RAYAN
hyperextension[28].PTinstabilitywasreportedto
causedigitalflexor tendon rupture[29].
Chronic PLC injuries may be a sequela of
pisiform dislocation or may be caused by re-
petitive occupational or recreational activities. If
adequate treatmentorimmobilization isnotpro-
videdinitiallyforacutePLCinjury,thisalsomay
resultinchronicpisiforminstability.Conceivably
any of the PLC components can be injured, but
injuries to the primary stabilizers of the PT joint
are probably the culprit of this joint’s instability.
This instability compromises the PT joint kine-
matics and predisposes to chondromalacia and
subsequent degenerative changes. PTA is there-
fore an end stage on the spectrum of PLC
syndrome. Pisiform instability in relation to the
trapezium is not easily recognized radiographi-
callyandalsowasdescribedintheliteratureunder
pisiformsubluxation.SubluxationofthePTjoint
Fig.10. Thepatient’sradiographshowingmarkedwid-
withoutpisiformdislocationwasnotedin12of40
eningofpisotriquetraljointspaceduringwristflexion.
patients who had distal radius fracture [10]. Ra-
diographically instability of the PT joint can be
classifiedintothreestages:I,withoutradiographic Pisotriquetral jointloose bodies
findings;II,withalterednormalparameters(Figs.
9 and 10) with or without subluxation; and III, LoosebodiesmayformwithinthePTjointor
manifestedasdislocation.StageIradiographicin- migrate from the radiocarpal joint. They may
stability, however. clinically can be a cause of develop in the presence of a normal joint or in
chronicand unremitting pain. association with PTA. These are often cartilagi-
nousandthereforecannotalwaysbeidentifiedon
radiographs. Tomography or MRI studies allow
better visualization of these loose bodies. Treat-
ment of symptomatic cases is by excision of the
loose body or pisiformectomy if PTA is encoun-
tered duringsurgery.
Steinmann and colleagues [30] repotted eight
patients who underwent excision of PT loose
bodies; four patients reported traumatic onset
of symptoms and four reported an insidious
onset. Nonoperative treatment failed in all pa-
tients. Routine radiography revealed a loose
body in only four patients. Trispiral tomography
delineated all loose bodies. Three patients under-
went loose-body excision only; five had PT joint
degeneration and underwent additional pisi-
formectomy. All patients had pain relief and
improvement in strength.
Pisotriquetral jointarthrosis
Although inflammatory arthritic conditions
such as rheumatoid arthritis can affect the PT
Fig.9. Narrowingofpisotriquetraljointspacewhilethe
wristisinneutralpositioninapatientwhohaschronic joint, they are described rarely in the literature
instability of the pisotriquetral joint and moderate and do not seem to be a problem to the patient.
arthrosis. MostPT arthritic disordersare post-traumaticin
PLCSYNDROMEANDPISOTRIQUETRALARTHROSIS 513
nature and few are caused by primary osteoar- PTA is rare in young patients and may be
thritis. Paley and colleagues [15] found that most difficulttodistinguishfromotherulnocarpalcon-
cases of ulnar palmar wrist pain were caused by ditions.Trailandcolleagues[33]reportedPTAin
acuteandchronictraumaandinstability.Patterns 12 patients younger than 40 years of age, 10 of
of degenerative joint disease were described by whomhad a historyof trauma.
Yamaguchi and colleagues [8] and Jameson and
colleagues [9], both of whom reported peripheral
arthritic changes in the pisiform (Fig. 11). Theu-
Clinical presentation
mann and colleagues [14] found on cadaver wrist
MR arthrography, pisiform cartilaginous lesions Patients with PLC syndrome have ulnar pal-
in 91% with a mean grade of 2.3; 50% were pe- mar wrist pain that may radiate distally toward
ripheral and 50% were global, 55% had osteo- thehypothenarareaorproximallyalongtheFCU
phytes most often proximal, although these can andulnaraspectoftheforearm.Thepaincanbe
be located distally or proximal and distally. Tri- vague and ill defined, but often is located in the
quetral cartilaginous lesions were observed in hypothenar area. The pain can be deep and
73% of the specimens with a mean grade of 1.6 occasionally radiates dorsally and is aggravated
and osteophytes were present in only 5%. FCU bywristmotionorbyusingthehandinactivities
tendinopathy and ulnar tunnel syndrome may be ofdailyliving.Inseverecasesthepainmayoccur
associated with PTA. Takami and colleagues at rest. Examination reveals tenderness over and
[31] reported attrition ruptures of the flexor digi- around the pisiform and in the soft tissues
torum profundus tendon of the little finger sec- surrounding this bone. The tenderness can be
ondary to osteoarthritis of the PT joint. elicitedalso overthePT jointimmediatelydorsal
Mechanical attrition against the radial side of to the pisiform. Snapping or popping sensation
the pisiform was believed to be responsible for in the ulnar palmar area may be produced with
the rupture. Caroll and Coyle [32] treated 67 pa- active wrist motion because of pisiform subluxa-
tientswhohadpainfulPTjoints;42hadprevious tion. The patient may give a history of acute
traumasand22hadassociatedulnarneuropathy, injury or chronic repetitive trauma or antecedent
particularly in those who had a history of wrist– wrist orcarpalfracture.
hand fractures and subluxation or dislocation of Helal [34] described four patients whose sport
the pisiform. Chondromalacia was present in 29 involved wielding a racquet and who presented
andPT jointosteoarthritis in20patients. with symptoms at the hypothenar eminence
caused by minor subluxation of the pisiform. In
two patients there was in addition a chondroma-
lacia of the articular cartilage of the joint, one
of whom had recurrent dislocation. The physical
findingsinthesepatientswereexaggeratedmobil-
ity of the pisiform in axial and transverse
direction.
Two useful clinical tests can be used for
diagnosing PLC syndrome, in particular PTA,
bywhichulnarpalmarpainisprovoked.Thefirst
isfullpassivewristextensionandthesecondisthe
pisiform tracking test. The pisiform tracking test
is a provocative maneuver that elicits pain and
possibly crepitation and is done by flexing the
wrist to relax the FCU tendon and moving the
pisiform ulnarly and radially in a grinding like
motionagainstthetriquetrum.Thediagnosisalso
can be confirmed by pain relief with local anes-
thetic injection of the PTjoint.
Tenderness and pain proximal to the pisiform
area can be caused by FCU tendopathy. In fact,
Fig.11. Cadaverspecimenshowingthearthriticchanges diagnosing FCU tendinopathy must raise suspi-
(arrow)intheperipheryofthepisiform. cion of PLC syndrome and the presence of
514 RAYAN
pathology in the PT joint. In some cases of fragment and repair or reattachment of the
pisiform instability neurologic symptoms may be ligament may provide stability and prevent re-
present because of associated ulnar tunnel syn- sidual pain andperhaps future PTA.
drome. Closed rupture of the flexor digitorum Surgical treatment is indicated for chronic
profundustendonofthesmallfingershouldraise severePLCinjuriesandPTAthatdonotrespond
thesuspicionofunrecognizedhamulusfracturein to nonoperative treatment measures. Pisiform
addition to PLC syndrome, because it was re- excisionistheuniversaltreatmentformostsevere
portedwithPTinstabilityandPTA[29,31].When chronic cases of PLC syndrome, especially if the
evaluatinga patient who hassuspected PLC syn- patient’s symptoms are intolerable and nonoper-
drome,otherwristligamentinjuriesmustberuled ative treatment measures failed. Pisiformectomy
out,suchastheTFCCandthoseofthedistalra- was used for various PT instabilities, including
dioulnar and lunotriquetral joints. This can be primary excision for acute pisiform dislocation
accomplished by careful wrist examination to lo- [35], subluxation [18], and recurrent dislocation
calize the area of pathology. Provocative maneu- [26,27]. It also was used for various PT pain
vers specific to these ligament injuries would be and arthrosis [15,32–34,36–39] with satisfactory
positive. results.
Palmieri [40] reported on 33 patients who had
pisiform area pain and used pisiformectomy in
21 cases with satisfactory results. Indications for
Treatment
pisiformectomywerepainfulunionandnonunion
Preventive measures for PLC syndrome in- of the pisiform, PTA, and FCU tendinitis. Paley
clude appropriate treatment of pisiform fractures and colleagues [15] achieved satisfactory results
and dislocations. Treatment of acute dislocations after pisiformectomy in 8 of 16patients who had
of the pisiform is closed reduction and splint or symptomatic pisotriquetraljoints.
cast immobilization. The same treatment is Carroll and colleagues [32] treated 67 painful
appropriate for nondisplaced fractures of the pisotriquetral joints by excision of the pisiform
pisiform. This treatment provides satisfactory over a 30-year period. Forty-two patients had
outcome in most patients. Cast or rigid splint a previous history of trauma. Ulnar neuropathy
immobilization of the wrist should be attempted was noted in 22 patients, particularly in those
forallacutePLCinjuriesalso,whichmayprevent withassociatedwrist–handfracturesandsubluxa-
the development of chronic PLC pain. Nonoper- tionsordislocationsofthepisiform.Theabductor
ativetreatmentofchronicPTinstabilityandPTA andflexordigitiminimiandthepalmarcarpallig-
isrecommendedinmostcasesandshouldbeused amentwiththeircommonfibrousoriginwerethe
initially. This could be in the form of modifying most common compressing structures on the ul-
themethodofusingthehand,avoidingrepetitive nar nerve. Chondromalacia was found in 29 and
forceful wrist flexion, and refraining from appli- osteoarthritis in 20 PT joints. Pisiformectomy
cation of direct pressure on the ulnar palmar provided complete relief of localized hypothenar
aspectofthehand.Theuseofweightliftinggloves pain in 65 wrists with no loss of wrist motion or
can provide padding to the heel of the hand and strength. Neurolysis produced full sensory recov-
can minimize symptoms. A period of splint ery in all 22 patients and full motor recovery in
immobilization, anti-inflammatory drugs, and lo- 5 of 6. No late problems associated with the
cal steroid injection may ameliorate the patient’s FCU tendon were foundafter pisiformectomy.
symptomsandnegatesurgery.Inearlycaseswith Trail and colleagues [33] reported PTA in 12
mild or moderate PTA, local steroid injection of patientsyoungerthan40yearsofagewhounder-
the PT joint together with a period of splint wentpisiformectomy.Theyobservedthatpatients
immobilizationmaybringaboutalongremission who had a history of trauma and a positive re-
andsurgerycan bepostponedoravoided. sponsetointra-articularlocalanestheticinjection
Although repairing components of the PLC did well postoperatively. Patients who had an in-
seems theoretically possible, practically it is not definite history and bilateral symptoms did not
feasible and has not been used clinically. One dosowell.Trispiraltomographyistheradiologic
reason for that trend is the apparent difficulty in investigation of choice.
diagnosing which component of the PLC is Johnston and colleagues [41] treated eight pa-
damaged.IfPHligamentavulsionisencountered tients with PTA using pisiformectomy that pro-
with a hamulus fracture, excision of the bony duced satisfactory relief of pain after they had
PLCSYNDROMEANDPISOTRIQUETRALARTHROSIS 515
Fig.12. Theincisionforpisiformectomy.
failed to respond to splints, anti-inflammatory Fig. 13. Intraoperative picture showing the soft tissue
agents, and local steroid injection. Associated confluencebeingretractedandthepisiformexposed.
with pisotriquetral arthritis were cases of ulnar
neuritis, rheumatoid arthritis, pisotriquetral joint
Fifteen patients had complete relief of symptoms
loosebodies, andan anomalous muscle. In seven
andfivehadresidualmilddiscomfort.Compared
of eight patients, pisiformectomy with release of
withtheunaffectedwrist,therewerenosignificant
Guyon canal afforded prompt relief of pain. A
differencesingripstrength,wristmovement,static
palmar approach was necessary for simultaneous
strength, and dynamic power. They concluded
ulnar tunnel release and pisiform excisions. One
that pisiformectomy can be performed safely
patient with rheumatoid arthritis required a
and restoration of function with a painless wrist
further Darrach procedure before pain was
is the expected outcome. Arner and colleagues
eliminated.
[44] used isokinetic measurements with a strain-
Belliappa and colleagues [42] reported on 12
gauge dynamometer to assess wrist flexion
patientswithPTregionpain,11ofwhomhadra-
strength after pisiformectomy. They found slight
diologic evidence of PTA that was confirmed in
postoperative reduction of wrist flexion strength
the nine cases treated by pisiformectomy. Seven
compared with the contralateral wrist, without
of these had complete relief of symptoms. Ulnar
clinical significance. They concluded that one
nerve symptoms were present in four patients
should not refrain from excision of the pisiform
andthesealsowererelievedbysurgery.Theycon-
bone forfear of considerableloss of wristflexion
cluded that pisiformectomy is a useful operation
strength.
for this condition, which often remains undiag-
nosed because of incomplete clinical and radio-
logicevaluation.
Surgicaltechnique ofpisiformectomy
There is concern that pisiformectomy may
result in residual pain, because it may disturb A2.5-cmlateralV-shapedincisionwitharadi-
the mechanical stability it provides to the ulnar ally-oranulnarly-basedflapandapexatthewrist
column of the wrist and loss of wrist flexion creaseisplanned(Fig.12).Alongerincisionmay
strength because of the FCU tendon insertion in be needed if ulnar nerve decompression is neces-
the pisiform. Lam and colleagues [43] performed sary. The skin flap is raised and the underlying
functional evaluation of 20 patients who had un- pisiform and FCU tendon are identified. The ul-
dergonepisiformectomyforPTjointdysfunction. nar nerve is dissected proximal and distal to the
