What is the best course of management for a patient with sudden onset pisiform area pain, no history of trauma, that worsens with splint use and immobilization?

Management of Pisiform Area Pain Without Trauma

For a patient with sudden onset pisiform area pain without trauma that worsens with immobilization, discontinue splinting immediately and initiate conservative management with NSAIDs, activity modification, and local corticosteroid injection—reserving pisiform excision only after 3-6 months of failed conservative therapy. 1, 2

Immediate Management: Stop Immobilization

• Remove the splint immediately, as immobilization is contraindicated when pisiform pain worsens with splinting 1
• The pisiform functions as a fulcrum (hypomochlion) that transduces powerful forearm forces to the hand, and immobilization may paradoxically increase mechanical strain at the pisotriquetral joint 3
• Immobilization was historically used but has been abandoned in favor of more effective treatments when symptoms worsen with this approach 1

Conservative Treatment Protocol (First-Line)

• Prescribe oral NSAIDs as the initial pharmacologic intervention for symptomatic relief 1, 2
• Administer local corticosteroid injection into the pisiform area if NSAIDs provide inadequate pain control 1, 2
• Recommend activity modification to reduce repetitive stress on the flexor carpi ulnaris insertion 1, 2
• Continue conservative management for at least 3-6 months before considering surgical intervention 1, 2

Diagnostic Evaluation

• Obtain plain radiographs of the wrist to evaluate for pisiform fracture (painful union or nonunion), pisotriquetral arthritis, or other bony pathology 1, 2
• Consider ultrasound if clinical examination suggests flexor carpi ulnaris tendonitis at its pisiform insertion 1
• The differential diagnosis includes: pisotriquetral arthritis (second most common degenerative arthritis in the wrist), flexor carpi ulnaris tendonitis, pisiform fracture, or chronic microtraumatic injury 3, 2

Surgical Management (Reserved for Refractory Cases)

• Pisiform excision is indicated only after failed conservative treatment lasting 3-6 months with persistent intractable pain 1, 2
• Perform subperiosteal dissection and removal to preserve the flexor carpi ulnaris tendon insertion and its distal extensions (pisohamate and pisometacarpal ligaments) 1
• Expected outcomes after pisiformectomy: excellent or good results in 93% of cases (14/15 patients), with pain scores decreasing from 6.4 to 0.8 points on analog scale 2
• Wrist strength and mobility are maintained postoperatively when proper surgical technique preserves the FCU tendon insertion 1

Critical Pitfall to Avoid

• Never continue immobilization when symptoms worsen with splinting, as this indicates the mechanical strain at the pisotriquetral joint is being exacerbated rather than relieved 1, 3
• The pisiform prevents triquetral subluxation and maintains ulnar column stability—prolonged immobilization may disrupt this biomechanical function 3
• Premature surgical excision without adequate conservative trial (minimum 3-6 months) should be avoided, as most patients respond to non-operative management 1, 2

Follow-Up Protocol

• Reassess at 2-4 week intervals during conservative management to monitor symptom progression 2
• If symptoms persist beyond 3-6 months despite maximal conservative therapy, refer for surgical consultation 1, 2
• Post-pisiformectomy follow-up at 6 weeks and 3 months to assess wrist range of motion and grip strength 2