What are the next steps for a patient with sudden onset pisiform area pain that worsens with splint use and immobilization?

Discontinue the Splint Immediately and Reassess

If a patient with sudden onset pisiform area pain experiences worsening pain with splint use and immobilization, the splint should be discontinued immediately, as immobilization can exacerbate pain and lead to complications including complex regional pain syndrome. 1

Why Splinting May Be Harmful in This Case

Splinting can worsen symptoms through multiple mechanisms:

• Increased pain from immobilization: Splinting may increase attention and focus to the injured area, thereby exacerbating symptoms 1
• Muscle deconditioning: Immobilization leads to muscle deconditioning and increased accessory muscle use 1
• Risk of complex regional pain syndrome: Serial immobilization has been associated with worsening symptoms and onset of complex regional pain syndrome 1
• Learned non-use: Prolonged immobilization can lead to learned non-use of the affected limb 1

Immediate Assessment Steps

Check for these critical warning signs that require emergency evaluation:

• Neurovascular compromise: Blue, purple, or extremely pale discoloration of the fingers indicates a medical emergency 2, 3
• Neurological symptoms: Numbness, tingling, or inability to move the fingers suggests neurovascular compromise 3
• Progressive swelling: Worsening edema despite elevation indicates potential underlying pathology 3

Specific Evaluation for Pisiform Pathology

Pisiform injuries are frequently missed and misdiagnosed as simple wrist sprains:

• High index of suspicion needed: Young patients with ulnar-sided wrist pain after trauma require careful evaluation for pisiform dislocation or fracture 4
• Obtain proper imaging: Standard wrist X-rays may miss pisiform pathology; consider carpal tunnel view or CT imaging 1
• Palpate the pisiform directly: Focal tenderness over the pisiform bone distinguishes pisiform pathology from general wrist sprain 5

Alternative Management Strategy

Encourage normal movement patterns and therapeutic resting postures rather than rigid immobilization 1:

• Active range of motion: Allow immediate active motion of adjacent joints (fingers) to prevent stiffness 2
• Therapeutic positioning: Support the affected limb when at rest using pillows or furniture rather than rigid splinting 1
• Cold therapy: Apply ice-water mixture for 15-20 minutes several times daily to reduce pain and swelling 2, 3
• Elevation: Keep the hand elevated above heart level to minimize swelling 3

When Conservative Measures Fail

If pisiform area pain persists despite discontinuing immobilization and using conservative measures:

• Consider pisiform excision: For intractable pisiform pain not relieved by conservative methods (immobilization, local steroid injection, anti-inflammatory medication), pisiform excision is indicated 5
• Indications for surgery: Painful union or nonunion of pisiform fractures, pisiform-triquetral arthritis, and tendonitis of the flexor carpi ulnaris insertion 5
• Surgical technique: Subperiosteal dissection and removal preserves the FCU tendon insertion and maintains wrist strength and mobility 5

Follow-Up Timeline

• Reassess within 48-72 hours: Evaluate response to discontinuing the splint and implementing alternative management 3
• Two-week evaluation: If symptoms persist beyond 2 weeks, investigate for underlying pathology including occult fractures 3, 6
• Advanced imaging: Consider MRI if symptoms persist or worsen after initial conservative management to evaluate for occult fractures or soft tissue pathology 6

Critical Pitfall to Avoid

Do not continue splint use when pain worsens with immobilization 1. The traditional approach of "rest and immobilization" can be counterproductive for certain conditions, particularly functional disorders and pisiform pathology where movement and function are therapeutic 1, 5.