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SCIENTIFIC ARTICLE
Pisotriquetral Arthrodesis for Pisotriquetral Instability:
Case Report
Georg Singer, MD, Robert Eberl, MD, Michael E. Hoellwarth, MD
A 22-year-old professional downhill mountain bike rider developed increasing posttraumaticpisotriquetral instability. To preserve full function of the pisiform bone, we performedpisotriquetral arthrodesis using a Herbert screw. Ten months after the splint was removed,the patient was free of symptoms and returned to professional downhill mountain bikingwithout limitations. This uncommon method seems to be a feasible treatment strategy andcan be recommended in high-demand patients. (J Hand Surg 2011;36A:299–303. Copyright© 2011 by the American Society for Surgery of the Hand. All rights reserved.)
Key words Pisiform, instability, adolescents, pisotriquetral joint.
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ALTHOUGH THE PISOTRIQUETRAL JOINT (PTJ) issmall, it is an anatomically complex structure.The pisiform serves as attachment for several
uscles and ligaments, including the flexor carpilnaris, abductor digiti minimi, pisometacarpal lig-ment, pisohamate ligament, and ulnar collateraligament.1 Moreover, the pisiform bone forms one
border of Guyon’s canal.Pathologies of the PTJ such as pisotriquetral insta-
bility are a common source for ulnar-sided wrist pain.2
The pisiform bone is held in place by a complex sus-pension mechanism involving tendons and ligaments.Traumatic events may cause rupture of the ligaments,leading to instability of the PTJ. Pisotriquetral instabil-ity and its possible sequelae have been described in theliterature.3,4 It is well recognized that instability of thePTJ ultimately leads to pisotriquetral arthrosis associ-ated with chronic ulnar-sided wrist pain. For diagnosisand treatment, local injection of steroids has beenrecommended.5 In patients who do not respond tononsurgical treatment, however, early recognitionand pisiformectomy with preservation of the soft
From the Department of Pediatric and Adolescent Surgery, Medical University of Graz, Graz, Austria.
Received for publication June 9, 2010; accepted in revised form October 12, 2010.
No benefits in any form have been received or will be received related directy or indirectly to thesubject of this article.
Corresponding author: Georg Singer, MD, Department of Pediatric and Adolescent Sur-gery, Medical University of Graz, Auenbruggerplatz 34, 8036 Graz, Austria; e-mail:[email protected].
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adoi:10.1016/j.jhsa.2010.10.010
tissues remains the treatment of choice.6 However,pisiformectomy is not always associated with com-plete relief of symptoms.
In athletes and other high-demand patients, however,excision of the pisiform may alter the mechanics of thewrist joint. Increased movement of the triquetrum afterremoval of the pisiform has been demonstrated.7 Thismay act as a predisposing factor for arthrosis. In addi-tion, a slight postoperative reduction of wrist flexionstrength was noted in patients after pisiformectomy.8
Abrams and Tontz9 were the first to report pisotrique-ral arthrodesis as a feasible alternative to excision ofhe pisiform bone in a female gymnast with symptom-tic pisotriquetral instability.
Here, we present the case of a 22-year-old profes-ional downhill mountain bike rider with increasingosttraumatic pisotriquetral instability. To preserve fullunction of the pisiform bone, we performed pisotrique-ral arthrodesis using a Herbert screw, which resulted inomplete pain relief and a return to professional down-ill biking.
ASE REPORT22-year-old professional downhill mountain bike
ider developed unilateral increasing instability of theTJ of the left wrist. The patient recognized suddennset of pain in his wrist joint in the extended positionfter he pushed his mountain bike uphill. Simultane-usly, loss of motion accompanied the described inci-ent. With a maneuver of palmar flexion and radial
bduction, the patient was able to relieve the blockade© ASSH � Published by Elsevier, Inc. All rights reserved. � 299
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300 PISOTRIQUETRAL ARTHRODESIS
and freely move his wrist joint. Because there weredecreasing time periods between recurrence of the de-scribed sensation, he decided to visit our department 8weeks after the first occurrence. The history of theinjury revealed no single high-impact trauma to thePTJ. Nevertheless, the wrist was exposed to chronicforce in extension according to the position whendownhill mountain biking.
The physical examination showed free range of mo-tion of the wrist joint without abnormalities of the softtissue. However, we noted an increased PTJ laxity ofthe involved side. In hyperextension, the patient couldprovoke ulnar luxation of the pisiform when applyingpressure with the thumb. With palmar flexion and radialabduction, the patient reduced the pisiform to normalposition. During this procedure, we clearly recognizedcrepitation in the PTJ. Conventional x-rays showed nopathological findings. Computed tomography scans inneutral position revealed correct alignment of thePTJ. In extension, however, ulnar luxation of the pisi-form was seen on computed tomography scan (Fig. 1).After a short deliberation, the patient elected to proceedwith pisotriquetral arthrodesis, which was performed 10weeks after the initial incident.
Surgical procedure
Under general anesthesia, the pisiform could be pas-sively luxated according to the preoperative findings.We made an incision directly over the pisiform on the
FIGURE 1: Three-dimensional reconstruction of computed tomwrist, correct alignment of the pisiform was seen. Note the gluxation of the pisiform could be enforced and the bone got cau
ulnar border of the wrist. The incision was carried down
JHS �Vol A, F
to the palmar aspect of the pisiform. After incision ofthe retinaculum overlying the PTJ and the jointcapsule, the pisotriquetral joint was exposed. Fi-brillations of the cartilage of the triquetrum wereseen. In addition, a groove in the radiodorsal as-pect of the articular surface of the triquetrum wasvisible (Fig. 2A).
Using an osteotome, we denuded the cartilage of thepisiform and triquetrum down to the cancellous bone.To facilitate stable reduction and prevent malrotation ofthe pisiform, a short step cut was made at the proximalpart of the triquetrum (Fig. 2B).
Under both direct and fluoroscopic vision, we placeda 1.0-mm guide wire through the pisiform into thetriquetrum. A 3.0-mm cannulated Herbert screw (Syn-thes, West Chester, PA) was then placed across the PTJafter drilling and tapping with cannulated instruments.We observed compression after this maneuver.
The wrist was splinted until suture removal at 14days, and a removable wrist splint was applied foranother 6 weeks. After the splint was removed, thepatient had no symptoms and we took conventionalx-rays to confirm correct bone healing and correctplacement of the pisiform (Fig. 3).
At 10 months after the splint was removed, thepatient continued to be symptom-free and had returnedto professional downhill mountain biking without lim-itations. Range of motion was equal on both sides, with
phy images of the affected wrist. A In neutral position of thee in the triquetrum (arrow). B In the extended position, ulnarin the groove of the triquetrum (arrow).
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a reduction of 5° in ulnar deviation.
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PISOTRIQUETRAL ARTHRODESIS 301
DISCUSSIONThe present case report describes an uncommon proce-dure to treat pisotriquetral instability in a young profes-sional downhill mountain bike rider. Instead of pisi-formectomy, we performed pisotriquetral arthrodesisusing a Herbert screw, which resulted in complete painrelief and a return to professional downhill biking.
Painful conditions of the PTJ are uncommon.3 Theyinclude fractures that are often missed owing to thecomplex anatomy of the carpal region.10 Late diagnosisof fractures of the pisiform can favor osteoarthriticsequelae of the PTJ associated with chronic pain on theulnar side of the wrist.10 In a review of the literature,Schädel-Höpfner et al.11 summarized 25 cases of dis-locations of the pisiform bone due to direct trauma,indirect force, or forceful muscular contraction. In mostcases, the pisiform was dislocated either proximally ordistally. Corten et al.3 described a closed rupture of theflexor digitorum profundus tendon of the small finger asa result of pisotriquetral instability.
In patients with osteoarthritic changes of the PTJ orpisotriquetral instability, local injection of steroids hasbeen recommended for diagnosis and treatment.5 Whenconservative management is futile, pisiformectomy isstill the reference standard of treatment.12,13
Although a good outcome has been described afterpisiformectomy, there is not always complete relief ofsymptoms.14 Lam et al.14 performed a functional eval-
FIGURE 2: Intraoperative view of the pisotriquetral joint. A Wincised. The cartilage of the triquetrum was effaced and a not(arrow). A plane key-and-slot resection of the pisiform and triqprevent malrotation during fixation with a single screw. B Acompression of the arthrodesis.
uation of 20 hands in 20 patients who had undergone
JHS �Vol A, F
pisiformectomy for PTJ dysfunction. At a mean fol-low-up of 65 months, 15 patients had complete relief ofsymptoms and 5 continued with mild discomfort. Pierreet al.15 reported similar results: 15 pisiformectomies ledto fair or good outcome in 20% of cases and excellentoutcome in 80%.
A cadaver study performed in 5 hands demonstratedthat excision of the pisiform influences the kinematicsof the wrist.7 In 5 cadaver hands, Beckers et al.7 foundthat movement of the triquetrum increased after re-moval of the pisiform. This can act as a predisposingfactor for arthrosis of the ulnar wrist joint. In addition,a slight postoperative reduction of wrist flexion strengthwas noted in patients after pisiformectomy.8 Excisionof the pisiform should therefore be carefully consid-ered, especially in high-demand patients, because thereare still scarce data concerning function of the wristjoint and long-term outcome after pisiformectomy inthose patients.
For that reason, we were concerned whether ourpatient would be able to return fully to profes-sional downhill mountain biking in case the me-chanics of the wrist joint were altered by pisi-formectomy, because downhill bikingcontinuously stresses the wrist joint in extension.Saint-Cyr and Kleinert16 described the case of apatient with a hypermobile pisiform bone causingcompression of the ulnar nerve and spasm of the
spected the pisotriquetral joint after the elongated capsule wasn the ulnar aspect had developed owing to recurrent luxationsm was performed to create a stable bed for the arthrodesis andinsertion of the double-threaded screw, we observed proper
e inch ouetrufter
ulnar artery. We speculated that pisiformectomy
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302 PISOTRIQUETRAL ARTHRODESIS
may put the ulnar neurovascular bundle at risk ofbeing injured.
Therefore, we decided to test the strategy of treatingour patient with pisotriquetral arthrodesis. To ourknowledge, Abrams and Tontz9 first described success-ful pisotriquetral arthrodesis in a gymnast with pisotri-quetral instability. Complete pain relief and sufficientfunctional return allowed the patient to resume gym-nastics. However, at final follow-up, the patient haddeveloped a popping sensation over the palmar-ulnaraspect of the wrist, brought on only by extreme wristflexion coupled with forearm rotation. Hence, the pa-tient discontinued gymnastics. As a consequence, theauthors speculated that their patient’s limitation mayhave arisen from arthrodesing the PTJ with the pisiformtranslated too far proximally.
We modified the surgical approach described byAbrams and Tontz9 and inserted the Herbert screwmore distally, following their recommendation. In ad-dition, we decided to create a step cut to facilitate stablereduction and prevent malrotation of the pisiform
FIGURE 3: Postoperative AP A and lateral B x-rays 8 weeks aof symptoms.
(Fig. 2B). We were able to achieve complete re-
JHS �Vol A, F
mission of symptoms, and our patient returned toprofessional downhill mountain biking.
Data concerning long-term outcome of pisotriquetralarthrodesis using Herbert screws are not yet available;nevertheless, this uncommon method seems to be afeasible treatment strategy and can be recommended inhigh-demand patients.
REFERENCES1. Rayan GM, Jameson BH, Chung KW. The pisotriquetral joint:
anatomic, biomechanical, and radiographic analysis. J Hand Surg2005;30A:596–602.
2. Watanabe A, Souza F, Vezeridis PS, Blazar P, Yoshioka H. Ulnar-sided wrist pain. II. Clinical imaging and treatment. Skeletal Radiol2010;39:837–857.
3. Corten EM, van den Broecke DG, Kon M, Schuurman AH. Pisotri-quetral instability causing an unusual flexor tendon rupture. J HandSurg 2004;29A:236–239.
4. Paley D, McMurtry RY, Cruickshank B. Pathologic conditions of thepisiform and pisotriquetral joint. J Hand Surg 1987;12A:110–119.
5. Trail IA, Linscheid RL. Pisiformectomy in young patients. J HandSurg 1992;17B:346–348.
6. Rayan GM. Pisiform ligament complex syndrome and pisotriquetralarthrosis. Hand Clin 2005;21:507–517.
surgical intervention showed bony union. The patient was free
fter7. Beckers AG, Bade H, Koebke J. Movements of the pisiform and
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PISOTRIQUETRAL ARTHRODESIS 303
triquetrum bones and their significance for kinematics of the ulnarwrist. Handchir Mikrochir Plast Chir 1998;30:10–14.
8. Arner M, Hagberg L. Wrist flexion strength after excision of thepisiform bone. Scand J Plast Reconstr Surg 1984;18:241–245.
9. Abrams R, Tontz W. Pisotriquetral arthrodesis as an alternative toexcision for pisotriquetral instability in high-demand patients: a casereport in a gymnast. J Hand Surg 2006;31A:611–614.
10. Ozalp T, Kurt C, Coskunol E, Ozdemir O, Begue T. Bilateralfracture of the pisiform bone. Rev Chir Orthop Reparatrice ApparMot 2007;93:859–862.
11. Schädel-Höpfner M, Junge A, Böhringer G. Dislocation of the pisi-form bone. A review of the literature. Handchir Mikrochir Plast Chir
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12. Carroll RE, Coyle MP Jr. Dysfunction of the pisotriquetral joint: treat-ment by excision of the pisiform. J Hand Surg 1985;10A:703–707.
13. Ishizuki M, Nakagawa T, Itoh S, Furuya K. Positional dislocation ofthe pisiform. J Hand Surg 1991;16A:533–535.
14. Lam KS, Woodbridge S, Burke FD. Wrist function after excision ofthe pisiform. J Hand Surg 2003;28B:69–72.
15. Pierre A, Le Nen D, Hu W, Dubrana F, Saraux A, Chaise F.Treatment of piso-triquetral pain by excision of the pisiform: reportof fifteen cases. Chir Main 2003;22:37–42.
16. Saint-Cyr M, Kleinert HE. Compression of the ulnar nerve andspasm of the ulnar artery in Guyon’s canal caused by a hypermobilepisiform bone. Scand J Plast Reconstr Surg Hand Surg 2008;42:215–
2002;34:168–172. 217.
ATOUCHOFHUMANITY
Hands on Stamps: Finland 1973—Canoeing
ht, MD
FinlandScott Catalogue # 530Day of Issue: July 18, 1973Value: 60 pThis stamp celebrates the 1973 World Canoeing
Championship held in Tampere, Finland. The com-petition, now known as the International Canoe Fed-eration Sprint World championship, is held in thesummer of non-Olympic years. The competition con-sists of both canoeing and kayaking races of varyingdistances. Hungary, the Soviet Union, and Romaniadominated the 1973 championships.
Received for publication November 18, 2010; accepted in revised form November 18, 2010.
No benefits in any form have been received or will be received related directly or indirectly to thesubject of this article.
Corresponding author: Terry R. Light, MD, Loyola University Chicago Stritch School of Medicine,Department of Orthopaedic Surgery and Rehabilitation, 2160 South First Avenue, Maywood, IL60153; e-mail: [email protected].
0363-5023/11/36A02-0016$36.00/0
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