Pisiform Fracture Evaluation and Treatment
For suspected pisiform fractures, obtain standard wrist radiographs (PA, lateral, and oblique views) as initial imaging, and if clinical suspicion remains high despite negative radiographs, proceed directly to CT scan for definitive diagnosis; treat non-displaced fractures conservatively with 2-4 weeks of ulnar gutter splint immobilization, and reserve pisiformectomy for displaced fractures or symptomatic nonunions.
Diagnostic Approach
Clinical Presentation
Look specifically for:
- Localized pain over the pisiform bone on the ulnar side of the wrist
- Tenderness with direct palpation of the pisiform
- Pain exacerbated by wrist flexion
- History of fall onto outstretched hand or direct trauma to hypothenar eminence
Imaging Algorithm
Initial imaging: Standard wrist radiographs are the appropriate first-line examination 1. Obtain PA, lateral, and oblique views - the oblique view is critical as pisiform fractures are frequently missed on standard two-view radiographs 2.
Advanced imaging when needed: If radiographs are normal or equivocal but clinical suspicion persists with ulnar-sided pain, CT scan is the definitive diagnostic modality 3, 4. In a recent analysis, 7 of 34 patients (21%) required CT or MRI for diagnosis, with 6 of these having associated injuries 3. CT without IV contrast is usually appropriate for this indication 1.
Common Diagnostic Pitfalls
- Pisiform fractures are easily missed due to subtle radiographic findings and tendency to focus on more obvious associated injuries 2
- Check for associated fractures: 62% of pisiform fractures occur with other injuries, most commonly distal radius, triquetrum, and distal ulna fractures 3
- Patients with multiple injuries are more likely to require advanced imaging for diagnosis 3
Treatment Algorithm
Non-Displaced Fractures (Majority of Cases)
Conservative management is indicated for most patients 3, 5, 6:
- Below-elbow ulnar gutter splint in mild palmar flexion
- Duration: 2-4 weeks of immobilization 5
- Progressive mobilization after initial immobilization period
- Expected outcome: Full range of motion by 4-6 weeks post-injury 5
In the largest recent series, 32 of 34 patients (94%) were successfully treated nonoperatively 3.
Displaced Fractures
Pisiformectomy (simple excision) is the treatment for displaced fractures and symptomatic nonunions 6. This allows early return to activity and avoids potential complications.
Prognostic Considerations
The presence of associated fractures, rather than the pisiform fracture itself, predicts long-term dysfunction 3. Patients with additional carpal, distal radius/ulna, or metacarpal fractures are more likely to have:
- Persistent pain at final follow-up
- Decreased range of motion
- Prolonged recovery
When to Consider Operative Treatment
While rare, operative intervention beyond simple excision (such as pisotriquetral arthrodesis) may be considered in young, active patients with chronic pisotriquetral instability or associated triquetral articular fractures 7, though this represents an exceptional circumstance requiring specialist consultation.