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Excision of the pisiform in piso-triquetral osteoarthritis
EXCISION
OF THE PISIFORM IN PISO-TRIQUETRAL OSTEOARTHRITIS P. P. BELLIAPPA
and F. D. BURKE
From the Department of Hand Surgery, Derbyshire Royal Injirmary
12 patients with pain in the piso-triquetral region are described. 11 had radiological evidence of osteoarthritis of the piso-triquetral joint, which was confIrmed in the nine cases treated by excision of the pisiiorm. Seven of these had complete relief of symptoms. The clinical findhrgs are constant and relief of pain by conservative treatment is usuafly only temporary. ulnar nerve symptoms were present in four patients and these were also relieved by surgery. Excision of the pisiform is a useful operation for this condition, which often remains undiagnosed due to incomplete clinical and radiological evaluation. Full return to normal function is the rule if the problem is not associated with other wrist pathology. Journal of
Hand Surgery (British Volume, 1992) 17B : X33-136 rotation. Four had symptoms of ulnar nerve compression at the wrist with paraesthesiae in the appropriate distribution; one of them complained of ‘clumsiness’. Two of the four had nerve conduction studies done; both were normal. These symptoms resolved after surgery. Three constant physical signs were noted: pain on passive movement of the pisiform on the triquetrum, crepitus while performing this movement and pain on resisted flexion with ulnar deviation of the wrist. Only one patient (who had had a Colles’ fracture as well) had restriction of wrist motion. One patient had objective signs of ulnar nerve compression in the form of reduced sensation in the appropriate distribution and weakness of the small muscles of the hand. Radiological examination included P.A. and lateral views of the wrist and a tangential view of the pisotriquetral joint: this is a lateral view with the forearm supinated 10 to 30” and the thumb extended out of the way. X-rays confirmed osteoarthritis of the piso-triquetral joint (Fig. 1) in 11 patients and a deformed pisiform (presumed to be due to a malunited fracture of the pisiform) in one (Fig. 2). A bone scan to reinforce the diagnosis in one patient with atypical symptoms confirmed increased uptake at the piso-triquetral joint (Fig. 3). Excision of the pisiform was performed through a volar approach, shelling out the pisiform from an ulnar direction while maintaining the integrity of the flexor carpi ulnaris tendon and identifying and protecting the ulnar neurovascular bundle. No formal neurolysis was carried out in any of the patients. Post-operative immobilization was optional, though most of our patients were splinted in a volar plaster slab for ten days until suture removal.
Piso-triquetral osteoarthritis is a relatively uncommon condition but should always be considered when dealing with ulnar wrist pain. Routine radiographs are uninformative and the diagnosis must be sought specifically by provocative tests at clinical examination and by oblique radiographs to skyline the joint. Excision of the pisiform is of benefit, restoring function and alleviating symptoms. We present a retrospective review of 12 patients treated in the Derby Hand Unit during the last five years. Patients
Between 1985 and 1990, 12 patients with piso-triquetral pain were seen by the senior author at the Derbyshire Royal Infirmary. There were nine women and three men with an average age at presentation of 41 years (range 15-57). All were right-handed and the dominant hand was involved in eight. Ten of the 12 patients gave a history of a definite injury preceding the symptoms. As a consequence of this injury, three patients had a fracture of the pisiform, a fourth had a Colles’ fracture and another a fracture of the base of the fourth metacarpal. Two patients had an insiduous onset of symptoms increasing over a variable period and failing to respond to conservative measures. Pain was always the presenting symptom. The location of the pain was in the piso-triquetral region in 11 patients and in the ulnar styloid region in one. The pain varied from mild to severe, depending on the activity performed. It radiated to the little finger, especially in patients with ulnar nerve symptoms, and rarely proximally up the forearm. It was worse with direct pressure (ten patients) causing particular difficulty in the use of racquets at tennis, squash or badminton (five patients), golf clubs (one patient) and while writing (four patients). Alternating palmar flexion with ulnar deviation and dorsiflexion with radial deviation exacerbated the pain, while forearm rotation provoked discomfort in seven patients. Three patients specifically complained of difficulty in opening jars. Eight complained of clicking in the region of the pisotriquetral joint, especially in ulnar deviation and forearm
Results
Conservative treatment in the form of a wrist splint cured one patient with a pisiform fracture (and radiological evidence of osteoarthritis). A second improved with two local steroid injections into the joint. All the others had only temporary benefit from conservative measures 133
THE JOURNAL
Fig.
Fig. 1
Osteoarthritis of the piso-triquetral joint with reduction space, sclerosis and osteophyte formation.
of joint
3
OF HAND SURGERY
Isotope bone scan showing triquetral joint region.
VOL. 17B No. 2 APRIL 1992
increased
uptake
in the piso-
which included rest, non-steroidal anti-inflammatory drugs and local steroid injections. Nine patients had their pisiforms excised and one awaits surgery. At operation, eight of the nine patients were seen to have osteoarthritis of the piso-triquetral joint (Fig. 4); the ninth had evidence of a malunited pisiform fracture with irregularity of the articular surface and synovitis. Of the nine patients who had the pisiform excised, there was complete relief of pain in seven. The other two had some residual discomfort in the ulnar aspect of the wrist; one continued to have pain in the ulnar styloid region which was made worse by forearm rotation, while the other had minimal discomfort related to cold weather. Restoration of function was rapid, most patients retuming to full sporting activity in eight weeks. The range of motion was normal in seven of the nine patients. In one of the remaining two, the restriction of motion was attributed to the old Colles’ fracture but in the other the apparent loss of both active and passive motion could not be adequately explained, though a mild reflex sympathetic dystrophy was probably a contributing factor. There were no symptoms from the scar (which was placed on the volar surface) though two patients had minimal adherence of the scar to the underlying tissues. All six patients who had had problems with racquet sports and golf regained full use. Discussion
Fig. 2
Healed fracture triquetral joint.
of the pisiform
with osteoarthritis
of the piso-
The pisiform is a sesamoid bone in the tendon of the flexor carpi ulnaris. It articulates with the triquetrum, forming a synovial joint which communicates with the wrist joint in 76% of anatomical specimens (Kropp, 1945). It does not play any active role in the movement of the wrist joint but is thought to have a function similar to the patella, in that “it probably extends the lever arm
PISO-TRIQUETRIAL
Fig. 4
OSTEOARTHRITIS
Eburnation of the triquetrum seen after excision of the pisiform.
of the tendon of the flexor carpi ulnaris away from the centre of rotation of the wrist and increases the flexor force” (Hall, 1981). Piso-triquetral pain has been attributed to a variety of conditions. Fractures of the pisiform sometimes require a tangential view as well as the standard P.A. and lateral views to identify the injury. These fractures, by and large, settle rapidly with simple splintage. Excision of the pisiform for pain following malunion and non-union has been described, with good results and restoration of normal function (Palmieri, 1982b). The indications were failure of conservative measures which included splintage, N.S.A.1.D.s and local steroid injections. Two patients with loose bodies in the piso-triquetral joint were described by Hall in 1981, one following a fall on the outstretched hand and one without a history of injury. Both patients presented with intermittent episodes of pain in the piso-triquetral region radiating to the little finger and associated with ‘stiffening’of the I.P. joints in extension and M.P. joints in flexion. Simultaneously, the wrist ‘locked’ in the flexed position. Both patients had complete relief of symptoms after identification and removal of the loose body at exploration of the pisotriquetral joint. Palmieri (1982a) further reported a series of 33 patients, 21 of whom had excision of the pisiform. They included six for osteoarthritis of the piso-triquetral joint and ten
135
for flexor carpi ulnaris tendonitis; surgery for the last condition included a 5 mm step-lengthening of the flexor carpi ulnaris after pisiform excision. The results were uniformly good. Racquet player’s pisiform was described by Helal in 1978. This was attributed to minor degrees of subluxation of the pisiform diagnosed by the presence of ‘adventitious movement’ of the pisiform upon the triquetrum in a longitudinal and side-to-side direction with the relaxed wrist flexed and ulnarly deviated. Two patients had this instability confirmed under image intensification. All were cured by excision of the pisiform. Though Holly first described the method of profiling the piso-triquetral joint radiographically in 1945, it was Vasilas (1960) who reported comprehensively on the radiological assessment of the joint in 48 normal adult volunteers and laid down criteria for the diagnosis of subluxation of the pisiform in static plain radiographs. Seradge and Seradge (1989) reported on five patients with 500 consecutive carpal tunnel decompressions who had persistent piso-triquetral pain six months after surgery. All had physical signs incriminating the pisotriquetral joint with complete but temporary relief following injection of local anaesthetic into the joint. These persistent symptoms were attributed to displacement of the pisiform following division of the flexor retinaculum “in some patients who might have had a mild but asymptomatic chondromalacia and/or instability of the piso-triquetral joint”. All five patients were cured by excision of the pisiform. Osteoarthritis of the piso-triquetral joint can develop following injury to the pisiform or insiduously. Often injury initiates the symptoms in a previously arthritic joint. Though the case reported by LeCocq in 1951 was diagnosed as traumatic arthritis, it is conceivable that the “roughening” noted in the “special” radiographs taken nine months after the injury in fact existed, but was not identified, on the routine X-rays taken after the injury. However, the frequency of injury (usually a fall on the heel of the palm) is frequent enough to suggest a cause and effect relationship. Since the first reports of piso-triquetral osteoarthritis (Jenkins, 1951; LeCocq, 1951), few papers have been published (Carroll and Coyle, 1985; Paley et al., 1987; Krag, 1974; Palmieri, 1982) with small numbers in most series. The condition is regarded as rare and may be forgotten when assessing chronic wrist pain. Routine radiographs will not skyline the involved joint and the low incidence of the condition may simply indicate misdiagnosis. In a review of 216 reported cases of pisotriquetral pain identified in the world literature by Paley et al. (1987), a firm diagnosis could be made in 104 cases. 50% of the patients had osteoarthritis with flexor carpi ulnaris ‘enthesopathy’ (tendonitis) a close second with 44.6%. Of the patients with osteoarthritis only 2.3% were deemed to be primary. Ten of our 12 patients had a definite history of a single injury before the onset of symptoms, but in half of them it was felt that the injury
136
only served to initiate symptoms in a previously arthritic joint. In the majority of cases the patient localized the symptoms (in the absence of other wrist pathology) to the region of the piso-triquetral joint. Interestingly, forearm rotation worsened the pain in a significant number: seven out of 12. Distal radiation of pain was associated with ulnar nerve symptoms. Direct irritation of the nerve was the most likely cause. There were no abnormalities in nerve conduction studies in the two patients who underwent the test. The nerve was found at operation to be macroscopically normal and all four patients lost the symptoms following surgery. Three constant signs aid in the diagnosis of this condition : pain on passive movement of the pisiform on the triquetrum, crepitus while performing this movement and pain on resisted flexion with ulnar deviation of the wrist. Piso-triquetral osteoarthritis should be considered in the differential diagnosis of pain and/or clicking in the ulnar aspect of the wrist and hand, together with flexor carpi ulnaris tendonitis, hook of hamate fractures and disorders of the triangular fibrocartilage complex, ulnar collateral ligament, ulnar styloid, extensor carpi ulnaris and distal radio-ulnar joint. Once clinical suspicion is raised, radiological examination must include a view to profile the piso-triquetral joint: a lateral wrist X-ray with the forearm supinated 10 to 30”. Restoration of normal function and a painless wrist is
THE JOURNAL
OF HAND SURGERY
VOL. 17B No. 2 APRIL 1992
the rule after excision of the pisiform, provided there is no other wrist pathology. References CARROLL, R. E. and COYLE, M. P. (1985). Dysfunction of the piwtriquetral joint: treatment by excision of the pisifomx Journal of Hand Surgery, IOA: 5 : 703-707. JENKINS, S. A. (1951). Osteoarthritisof the pisiform-triquetral joint. Report of three cases. Journal of Bone and Joint Surgery, 33B: 4: 532-534. KRAG, C. (1974). Osteoarthritis of the piso-triquetral articulation. The Hand, 6: 2: 181-184. KROPP, B. N. (1945). A note on the piso-triquetral joint. Anatomical Record, 92: 91-92. HALL, T. D. (1981). Loose body in the pisotriquetral joint. Journal of Bone and Joint Surgery, 63A: 3: 498-500. HELAL, B. (1978). Racquet player’s pisiform. The Hand, 10: 1: 87-90. HOLLY, E. W. (1945). Radiography of the pisiform bone. Radiography and Clinical Photography, 21: 3: 69-70. LeCOCQ, E. A. (1951). Traumatic arthritis of the pisifomvtriangular joint. A case report. Western Journal of Surgery, Obstetrics and Gynaecology, 59: 357. PALEY, D., McMURTRY, R. Y. andCRUICKSHANK, B. (1987). Pathological conditions of the pisiform and pisotriquetral joint. Journal of Hand Surgery, 12A: 1: 110-119. PALMIERI, T. J. (1982a). Pisiform area pain treatment by pisiform excision. Journal of Hand Surgery, 7: 5: 477480. PALMIERI, T. J. (1982b). The excision of painful pisiform bone fractures. Orthopaedic Review, 11:6: 99-103. SERADGE, H. and SERADGE, E. (1989). Piso-triquetral pain syndrome after carpal tunnel release. Journal of Hand Surgery, 14A : 5 : 858-862. VASILAS, A., GRIECO, R. V. and BARTONE, N. F. (1960). Roentgenaspects of injuries to the pisiform bone and pisotriquetral joint. Journal of Bone and Joint Surgery, 42A: 8: 1317-1328.
Accepted:9 April 1991 F. D. Burke, 0
Derbyshire
Royal Infimxwy,
1992 The British Society
for Surgery
London
of the Hand
Road,
Derby DE1 ZQY.
OF THE PISIFORM IN PISO-TRIQUETRAL OSTEOARTHRITIS P. P. BELLIAPPA
and F. D. BURKE
From the Department of Hand Surgery, Derbyshire Royal Injirmary
12 patients with pain in the piso-triquetral region are described. 11 had radiological evidence of osteoarthritis of the piso-triquetral joint, which was confIrmed in the nine cases treated by excision of the pisiiorm. Seven of these had complete relief of symptoms. The clinical findhrgs are constant and relief of pain by conservative treatment is usuafly only temporary. ulnar nerve symptoms were present in four patients and these were also relieved by surgery. Excision of the pisiform is a useful operation for this condition, which often remains undiagnosed due to incomplete clinical and radiological evaluation. Full return to normal function is the rule if the problem is not associated with other wrist pathology. Journal of
Hand Surgery (British Volume, 1992) 17B : X33-136 rotation. Four had symptoms of ulnar nerve compression at the wrist with paraesthesiae in the appropriate distribution; one of them complained of ‘clumsiness’. Two of the four had nerve conduction studies done; both were normal. These symptoms resolved after surgery. Three constant physical signs were noted: pain on passive movement of the pisiform on the triquetrum, crepitus while performing this movement and pain on resisted flexion with ulnar deviation of the wrist. Only one patient (who had had a Colles’ fracture as well) had restriction of wrist motion. One patient had objective signs of ulnar nerve compression in the form of reduced sensation in the appropriate distribution and weakness of the small muscles of the hand. Radiological examination included P.A. and lateral views of the wrist and a tangential view of the pisotriquetral joint: this is a lateral view with the forearm supinated 10 to 30” and the thumb extended out of the way. X-rays confirmed osteoarthritis of the piso-triquetral joint (Fig. 1) in 11 patients and a deformed pisiform (presumed to be due to a malunited fracture of the pisiform) in one (Fig. 2). A bone scan to reinforce the diagnosis in one patient with atypical symptoms confirmed increased uptake at the piso-triquetral joint (Fig. 3). Excision of the pisiform was performed through a volar approach, shelling out the pisiform from an ulnar direction while maintaining the integrity of the flexor carpi ulnaris tendon and identifying and protecting the ulnar neurovascular bundle. No formal neurolysis was carried out in any of the patients. Post-operative immobilization was optional, though most of our patients were splinted in a volar plaster slab for ten days until suture removal.
Piso-triquetral osteoarthritis is a relatively uncommon condition but should always be considered when dealing with ulnar wrist pain. Routine radiographs are uninformative and the diagnosis must be sought specifically by provocative tests at clinical examination and by oblique radiographs to skyline the joint. Excision of the pisiform is of benefit, restoring function and alleviating symptoms. We present a retrospective review of 12 patients treated in the Derby Hand Unit during the last five years. Patients
Between 1985 and 1990, 12 patients with piso-triquetral pain were seen by the senior author at the Derbyshire Royal Infirmary. There were nine women and three men with an average age at presentation of 41 years (range 15-57). All were right-handed and the dominant hand was involved in eight. Ten of the 12 patients gave a history of a definite injury preceding the symptoms. As a consequence of this injury, three patients had a fracture of the pisiform, a fourth had a Colles’ fracture and another a fracture of the base of the fourth metacarpal. Two patients had an insiduous onset of symptoms increasing over a variable period and failing to respond to conservative measures. Pain was always the presenting symptom. The location of the pain was in the piso-triquetral region in 11 patients and in the ulnar styloid region in one. The pain varied from mild to severe, depending on the activity performed. It radiated to the little finger, especially in patients with ulnar nerve symptoms, and rarely proximally up the forearm. It was worse with direct pressure (ten patients) causing particular difficulty in the use of racquets at tennis, squash or badminton (five patients), golf clubs (one patient) and while writing (four patients). Alternating palmar flexion with ulnar deviation and dorsiflexion with radial deviation exacerbated the pain, while forearm rotation provoked discomfort in seven patients. Three patients specifically complained of difficulty in opening jars. Eight complained of clicking in the region of the pisotriquetral joint, especially in ulnar deviation and forearm
Results
Conservative treatment in the form of a wrist splint cured one patient with a pisiform fracture (and radiological evidence of osteoarthritis). A second improved with two local steroid injections into the joint. All the others had only temporary benefit from conservative measures 133
THE JOURNAL
Fig.
Fig. 1
Osteoarthritis of the piso-triquetral joint with reduction space, sclerosis and osteophyte formation.
of joint
3
OF HAND SURGERY
Isotope bone scan showing triquetral joint region.
VOL. 17B No. 2 APRIL 1992
increased
uptake
in the piso-
which included rest, non-steroidal anti-inflammatory drugs and local steroid injections. Nine patients had their pisiforms excised and one awaits surgery. At operation, eight of the nine patients were seen to have osteoarthritis of the piso-triquetral joint (Fig. 4); the ninth had evidence of a malunited pisiform fracture with irregularity of the articular surface and synovitis. Of the nine patients who had the pisiform excised, there was complete relief of pain in seven. The other two had some residual discomfort in the ulnar aspect of the wrist; one continued to have pain in the ulnar styloid region which was made worse by forearm rotation, while the other had minimal discomfort related to cold weather. Restoration of function was rapid, most patients retuming to full sporting activity in eight weeks. The range of motion was normal in seven of the nine patients. In one of the remaining two, the restriction of motion was attributed to the old Colles’ fracture but in the other the apparent loss of both active and passive motion could not be adequately explained, though a mild reflex sympathetic dystrophy was probably a contributing factor. There were no symptoms from the scar (which was placed on the volar surface) though two patients had minimal adherence of the scar to the underlying tissues. All six patients who had had problems with racquet sports and golf regained full use. Discussion
Fig. 2
Healed fracture triquetral joint.
of the pisiform
with osteoarthritis
of the piso-
The pisiform is a sesamoid bone in the tendon of the flexor carpi ulnaris. It articulates with the triquetrum, forming a synovial joint which communicates with the wrist joint in 76% of anatomical specimens (Kropp, 1945). It does not play any active role in the movement of the wrist joint but is thought to have a function similar to the patella, in that “it probably extends the lever arm
PISO-TRIQUETRIAL
Fig. 4
OSTEOARTHRITIS
Eburnation of the triquetrum seen after excision of the pisiform.
of the tendon of the flexor carpi ulnaris away from the centre of rotation of the wrist and increases the flexor force” (Hall, 1981). Piso-triquetral pain has been attributed to a variety of conditions. Fractures of the pisiform sometimes require a tangential view as well as the standard P.A. and lateral views to identify the injury. These fractures, by and large, settle rapidly with simple splintage. Excision of the pisiform for pain following malunion and non-union has been described, with good results and restoration of normal function (Palmieri, 1982b). The indications were failure of conservative measures which included splintage, N.S.A.1.D.s and local steroid injections. Two patients with loose bodies in the piso-triquetral joint were described by Hall in 1981, one following a fall on the outstretched hand and one without a history of injury. Both patients presented with intermittent episodes of pain in the piso-triquetral region radiating to the little finger and associated with ‘stiffening’of the I.P. joints in extension and M.P. joints in flexion. Simultaneously, the wrist ‘locked’ in the flexed position. Both patients had complete relief of symptoms after identification and removal of the loose body at exploration of the pisotriquetral joint. Palmieri (1982a) further reported a series of 33 patients, 21 of whom had excision of the pisiform. They included six for osteoarthritis of the piso-triquetral joint and ten
135
for flexor carpi ulnaris tendonitis; surgery for the last condition included a 5 mm step-lengthening of the flexor carpi ulnaris after pisiform excision. The results were uniformly good. Racquet player’s pisiform was described by Helal in 1978. This was attributed to minor degrees of subluxation of the pisiform diagnosed by the presence of ‘adventitious movement’ of the pisiform upon the triquetrum in a longitudinal and side-to-side direction with the relaxed wrist flexed and ulnarly deviated. Two patients had this instability confirmed under image intensification. All were cured by excision of the pisiform. Though Holly first described the method of profiling the piso-triquetral joint radiographically in 1945, it was Vasilas (1960) who reported comprehensively on the radiological assessment of the joint in 48 normal adult volunteers and laid down criteria for the diagnosis of subluxation of the pisiform in static plain radiographs. Seradge and Seradge (1989) reported on five patients with 500 consecutive carpal tunnel decompressions who had persistent piso-triquetral pain six months after surgery. All had physical signs incriminating the pisotriquetral joint with complete but temporary relief following injection of local anaesthetic into the joint. These persistent symptoms were attributed to displacement of the pisiform following division of the flexor retinaculum “in some patients who might have had a mild but asymptomatic chondromalacia and/or instability of the piso-triquetral joint”. All five patients were cured by excision of the pisiform. Osteoarthritis of the piso-triquetral joint can develop following injury to the pisiform or insiduously. Often injury initiates the symptoms in a previously arthritic joint. Though the case reported by LeCocq in 1951 was diagnosed as traumatic arthritis, it is conceivable that the “roughening” noted in the “special” radiographs taken nine months after the injury in fact existed, but was not identified, on the routine X-rays taken after the injury. However, the frequency of injury (usually a fall on the heel of the palm) is frequent enough to suggest a cause and effect relationship. Since the first reports of piso-triquetral osteoarthritis (Jenkins, 1951; LeCocq, 1951), few papers have been published (Carroll and Coyle, 1985; Paley et al., 1987; Krag, 1974; Palmieri, 1982) with small numbers in most series. The condition is regarded as rare and may be forgotten when assessing chronic wrist pain. Routine radiographs will not skyline the involved joint and the low incidence of the condition may simply indicate misdiagnosis. In a review of 216 reported cases of pisotriquetral pain identified in the world literature by Paley et al. (1987), a firm diagnosis could be made in 104 cases. 50% of the patients had osteoarthritis with flexor carpi ulnaris ‘enthesopathy’ (tendonitis) a close second with 44.6%. Of the patients with osteoarthritis only 2.3% were deemed to be primary. Ten of our 12 patients had a definite history of a single injury before the onset of symptoms, but in half of them it was felt that the injury
136
only served to initiate symptoms in a previously arthritic joint. In the majority of cases the patient localized the symptoms (in the absence of other wrist pathology) to the region of the piso-triquetral joint. Interestingly, forearm rotation worsened the pain in a significant number: seven out of 12. Distal radiation of pain was associated with ulnar nerve symptoms. Direct irritation of the nerve was the most likely cause. There were no abnormalities in nerve conduction studies in the two patients who underwent the test. The nerve was found at operation to be macroscopically normal and all four patients lost the symptoms following surgery. Three constant signs aid in the diagnosis of this condition : pain on passive movement of the pisiform on the triquetrum, crepitus while performing this movement and pain on resisted flexion with ulnar deviation of the wrist. Piso-triquetral osteoarthritis should be considered in the differential diagnosis of pain and/or clicking in the ulnar aspect of the wrist and hand, together with flexor carpi ulnaris tendonitis, hook of hamate fractures and disorders of the triangular fibrocartilage complex, ulnar collateral ligament, ulnar styloid, extensor carpi ulnaris and distal radio-ulnar joint. Once clinical suspicion is raised, radiological examination must include a view to profile the piso-triquetral joint: a lateral wrist X-ray with the forearm supinated 10 to 30”. Restoration of normal function and a painless wrist is
THE JOURNAL
OF HAND SURGERY
VOL. 17B No. 2 APRIL 1992
the rule after excision of the pisiform, provided there is no other wrist pathology. References CARROLL, R. E. and COYLE, M. P. (1985). Dysfunction of the piwtriquetral joint: treatment by excision of the pisifomx Journal of Hand Surgery, IOA: 5 : 703-707. JENKINS, S. A. (1951). Osteoarthritisof the pisiform-triquetral joint. Report of three cases. Journal of Bone and Joint Surgery, 33B: 4: 532-534. KRAG, C. (1974). Osteoarthritis of the piso-triquetral articulation. The Hand, 6: 2: 181-184. KROPP, B. N. (1945). A note on the piso-triquetral joint. Anatomical Record, 92: 91-92. HALL, T. D. (1981). Loose body in the pisotriquetral joint. Journal of Bone and Joint Surgery, 63A: 3: 498-500. HELAL, B. (1978). Racquet player’s pisiform. The Hand, 10: 1: 87-90. HOLLY, E. W. (1945). Radiography of the pisiform bone. Radiography and Clinical Photography, 21: 3: 69-70. LeCOCQ, E. A. (1951). Traumatic arthritis of the pisifomvtriangular joint. A case report. Western Journal of Surgery, Obstetrics and Gynaecology, 59: 357. PALEY, D., McMURTRY, R. Y. andCRUICKSHANK, B. (1987). Pathological conditions of the pisiform and pisotriquetral joint. Journal of Hand Surgery, 12A: 1: 110-119. PALMIERI, T. J. (1982a). Pisiform area pain treatment by pisiform excision. Journal of Hand Surgery, 7: 5: 477480. PALMIERI, T. J. (1982b). The excision of painful pisiform bone fractures. Orthopaedic Review, 11:6: 99-103. SERADGE, H. and SERADGE, E. (1989). Piso-triquetral pain syndrome after carpal tunnel release. Journal of Hand Surgery, 14A : 5 : 858-862. VASILAS, A., GRIECO, R. V. and BARTONE, N. F. (1960). Roentgenaspects of injuries to the pisiform bone and pisotriquetral joint. Journal of Bone and Joint Surgery, 42A: 8: 1317-1328.
Accepted:9 April 1991 F. D. Burke, 0
Derbyshire
Royal Infimxwy,
1992 The British Society
for Surgery
London
of the Hand
Road,
Derby DE1 ZQY.