What are the causes and treatment options for pisiform hand pain?

Pisiform Hand Pain: Causes and Treatment

Primary Causes of Pisiform Pain

Pisiform pain most commonly results from pisotriquetral joint degenerative arthritis, traumatic injury (fracture or nonunion), or flexor carpi ulnaris tendinopathy. 1, 2, 3

Degenerative Arthritis

• Pisotriquetral osteoarthritis is the second most common degenerative arthritis in the wrist after scaphotrapezial arthritis 4
• Chondromalacia and osteoarthritis of the pisotriquetral joint are frequently identified pathologies 3
• Degenerative changes may occur with or without associated ganglion cysts 1

Traumatic Etiologies

• Painful union or nonunion of pisiform fractures is a common indication for surgical intervention 2
• Professional traumatic injuries represent the most common etiology in surgical series 5
• Previous trauma history was documented in 42 of 67 patients in one large series 3

Tendon Pathology

• Flexor carpi ulnaris (FCU) tendinopathy at its insertion on the pisiform causes localized pain 1, 2
• Calcifications within the FCU tendon insertion can contribute to symptoms 1

Associated Ulnar Nerve Compression

• Ulnar neuropathy occurs in approximately one-third of patients with pisotriquetral dysfunction 3, 5
• The abductor and flexor digiti minimi and palmar carpal ligament are the most common compressing structures 3
• This is particularly common with associated wrist fractures or pisiform subluxation/dislocation 3

Clinical Presentation

Key Physical Examination Findings

• Pain with direct pressure over the pisiform bone is the hallmark finding 1
• Side-to-side passive motion of the pisiform may elicit pain and crepitus 1
• Tenderness localized to the palmar and ulnar aspects of the wrist in the pisiform area 4

Diagnostic Imaging Approach

Initial Imaging

Begin with plain radiographs as the mandatory first imaging study. 6, 7

• Obtain a lateral wrist radiograph in 30 degrees supination to visualize the pisotriquetral joint 1
• Radiographs can demonstrate degenerative arthritis and calcifications in the pisotriquetral joint 1

Advanced Imaging When Radiographs Are Nondiagnostic

If radiographs are normal or equivocal, ultrasound or MRI without IV contrast are equivalent next-step options for evaluating soft tissue pathology. 6

• Ultrasound is preferred for initial evaluation due to superior availability, lower cost, and ability to perform dynamic assessment 6, 7
• MRI without IV contrast is appropriate for comprehensive soft tissue evaluation including tendon abnormalities and bone marrow edema 6
• MRI with IV contrast improves detection of tenosynovitis if inflammatory pathology is suspected 6

Treatment Algorithm

Conservative Management (First-Line)

• Immobilization 2
• Local corticosteroid injection into the pisotriquetral joint 2
• Anti-inflammatory medication 2
• Diagnostic local anesthetic injection can confirm the pain source (temporarily resolved symptoms in 5 of 21 patients in one series) 1

Surgical Management (When Conservative Treatment Fails)

Subperiosteal excision of the pisiform is the definitive treatment for intractable pisiform pain unresponsive to conservative measures. 1, 2, 3, 5

Surgical Technique Considerations

• Perform subperiosteal dissection to preserve the FCU tendon insertion 2
• Preserve the pisohamate and pisometacarpal ligaments 2
• Perform ulnar nerve neurolysis if ulnar neuropathy is present 3

Expected Outcomes

• Complete relief of localized hypothenar pain in 97% of cases (65 of 67 wrists) 3
• No loss of wrist motion or strength postoperatively 3
• Excellent or good results in 93% of patients (14 of 15 cases) 5
• Pain scores improved from 6.4 preoperatively to 0.8 postoperatively on analog scale 5
• Full sensory recovery in all patients with ulnar neuropathy; full motor recovery in 5 of 6 patients 3
• Follow-up studies show sustained benefit with no late complications related to FCU tendon function 3

Critical Clinical Pitfalls to Avoid

• Do not order MRI as the initial imaging study—radiographs must come first to rule out obvious bony pathology 6, 7
• Do not perform pisotriquetral arthrodesis—pisiformectomy provides superior results and there is no role for joint fusion 5
• Do not overlook associated ulnar neuropathy—examine for motor and sensory deficits and perform neurolysis during pisiformectomy if present 3, 5
• Recognize that the pisiform serves important biomechanical functions—it prevents triquetral subluxation and acts as a fulcrum for force transmission, though excision does not result in functional deficits in clinical practice 4