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Pisotriquetral loose body An unusual cause of wrist pain
PISOTRIQUETRAL
LOOSE
BODY
An unusual cause of wrist pain M. NEEDOFF
and S. P. FROSTICK
From Harlow Wood Orthopaedic Hospital, Nottingham, UK
A loose body flicking in and out of the pisotriquetral joint was found to be the cause of intermittent wrist pain and locking in two patients. Appropriate X-rays gave the diagnosis and surgical removal provided a satisfactory cure.
Journal of Hand Surgery (British and European Volume, 1994) 19B: 215-216 Loose bodies are commonly found in the knee, and have occurred in other joints, including the shoulder, elbow and ankle. They commonly cause symptoms of pain and intermittent mechanical locking and are usually amenable to surgical treatment. They are however extremely rare in the wrist, and have only been described once before in the pisotriquetral joint (Hall, 1981).
Fig 1
Oblique
Fig 2
Operative
pisotriquetral
view showing
view showing
CASE REPORTS Case 1
A 42-year-old woman was referred to the upper limb clinic with a l-year history of intermittent pain around the ulnar border of the left wrist, and more recent occasional swelling in the same area and a feeling of “locking” affecting the wrist joint. There was no history of trauma to the wrist. By flexing her wrist she was able to demonstrate a small lump just medial and proximal to the pisiform which came and went. Hand examination was otherwise normal. Standard AP and lateral X-rays of the wrist were completely normal, but the pisotriquetral view showed an ossified loose body lying beside a slightly degenerate pisotriquetral joint (Fig 1). At operation, the pisotriquetral joint was opened and a cartilage covered loose body 3 mm by 5 mm was removed (Fig 2). The joint was inspected but showed only very mild degenerative changes. The patient made an uneventful recovery and was cured.
the loose body
the loose body in the pisotriquetral
joint. 215
216
Case 2 A 5%year-old woman was referred to the upper limb clinic with a 2-year history of pain around the ulnar side of the right wrist and a sensation that something was moving within the joint, causing intermittent locking. There was again no history of any wrist trauma. Examination of the wrist and hand demonstrated mild discomfort around the pisiform area, but no loose body. A PA X-ray showed a suggestion of calcification at the level of the hamate, but an oblique film suggested a loose body arising from the pisotriquetral joint. At operation a small rounded loose body was found within a rather osteoarthritic pisotriquetral joint. The loose body was removed and consideration was given to excision of the degenerate pisiform. It was, however, left in place. Post-operatively, all the symptoms attributable to the loose body and her pisotriquetral arthritis disappeared. DISCUSSION Pisotriquetral osteoarthritis is a rare but well recognized cause of ulnar wrist pain (Paley et al, 1987) with
THE JOURNAL OF HAND SURGERY VOL. 19B No. 2 APRIL 1994
pisiform excision providing a reliable cure in most cases (Belliappa and Burke, 1992). Pain and locking of this type associated with a loose body has only been reported in one previous publication with two cases, one following trauma (Hall, 1981). In our two cases the X-rays were diagnostic, and surgery provided a cure. We would recommend that any patient giving a history of pain around the ulnar area of the wrist should have a pisotriquetral X-ray view taken with the hand supinated 30”-40” from true lateral with the thumb held extended. Acknowledgement We wish to thank Mr N. J. Barton for permission to study one of his patients.
References BELLIAPPA, P. P. and BURKE, F. D. (1992). Excision of the pisifom in pisotriquetral osteoarthritis. Journal of Hand Surgery, 17B: 2: 133-136. HALL, T. D. (1981). Loose body in the pisotriquetral joint: Report of two cases. Journal of Bone and Joint Surgery. 63A: 3: 49&500. PALEY, D., McMURTRY, R. Y. and CRUICKSHANK, B. (1987). Pathologic conditions of the pisifom and pisotriquetral joint. Journal of Hand Surgery. 128: 1: 110-119.
Accepted: 21 May M. Needoff FRCS, 4TH, UK. 0 1994 The British
1993 Harlow Society
Wood Orthopaedic for Surgery
Hospital,
of the Hand
Mansfield
Road,
Nottingham,
NG18
LOOSE
BODY
An unusual cause of wrist pain M. NEEDOFF
and S. P. FROSTICK
From Harlow Wood Orthopaedic Hospital, Nottingham, UK
A loose body flicking in and out of the pisotriquetral joint was found to be the cause of intermittent wrist pain and locking in two patients. Appropriate X-rays gave the diagnosis and surgical removal provided a satisfactory cure.
Journal of Hand Surgery (British and European Volume, 1994) 19B: 215-216 Loose bodies are commonly found in the knee, and have occurred in other joints, including the shoulder, elbow and ankle. They commonly cause symptoms of pain and intermittent mechanical locking and are usually amenable to surgical treatment. They are however extremely rare in the wrist, and have only been described once before in the pisotriquetral joint (Hall, 1981).
Fig 1
Oblique
Fig 2
Operative
pisotriquetral
view showing
view showing
CASE REPORTS Case 1
A 42-year-old woman was referred to the upper limb clinic with a l-year history of intermittent pain around the ulnar border of the left wrist, and more recent occasional swelling in the same area and a feeling of “locking” affecting the wrist joint. There was no history of trauma to the wrist. By flexing her wrist she was able to demonstrate a small lump just medial and proximal to the pisiform which came and went. Hand examination was otherwise normal. Standard AP and lateral X-rays of the wrist were completely normal, but the pisotriquetral view showed an ossified loose body lying beside a slightly degenerate pisotriquetral joint (Fig 1). At operation, the pisotriquetral joint was opened and a cartilage covered loose body 3 mm by 5 mm was removed (Fig 2). The joint was inspected but showed only very mild degenerative changes. The patient made an uneventful recovery and was cured.
the loose body
the loose body in the pisotriquetral
joint. 215
216
Case 2 A 5%year-old woman was referred to the upper limb clinic with a 2-year history of pain around the ulnar side of the right wrist and a sensation that something was moving within the joint, causing intermittent locking. There was again no history of any wrist trauma. Examination of the wrist and hand demonstrated mild discomfort around the pisiform area, but no loose body. A PA X-ray showed a suggestion of calcification at the level of the hamate, but an oblique film suggested a loose body arising from the pisotriquetral joint. At operation a small rounded loose body was found within a rather osteoarthritic pisotriquetral joint. The loose body was removed and consideration was given to excision of the degenerate pisiform. It was, however, left in place. Post-operatively, all the symptoms attributable to the loose body and her pisotriquetral arthritis disappeared. DISCUSSION Pisotriquetral osteoarthritis is a rare but well recognized cause of ulnar wrist pain (Paley et al, 1987) with
THE JOURNAL OF HAND SURGERY VOL. 19B No. 2 APRIL 1994
pisiform excision providing a reliable cure in most cases (Belliappa and Burke, 1992). Pain and locking of this type associated with a loose body has only been reported in one previous publication with two cases, one following trauma (Hall, 1981). In our two cases the X-rays were diagnostic, and surgery provided a cure. We would recommend that any patient giving a history of pain around the ulnar area of the wrist should have a pisotriquetral X-ray view taken with the hand supinated 30”-40” from true lateral with the thumb held extended. Acknowledgement We wish to thank Mr N. J. Barton for permission to study one of his patients.
References BELLIAPPA, P. P. and BURKE, F. D. (1992). Excision of the pisifom in pisotriquetral osteoarthritis. Journal of Hand Surgery, 17B: 2: 133-136. HALL, T. D. (1981). Loose body in the pisotriquetral joint: Report of two cases. Journal of Bone and Joint Surgery. 63A: 3: 49&500. PALEY, D., McMURTRY, R. Y. and CRUICKSHANK, B. (1987). Pathologic conditions of the pisifom and pisotriquetral joint. Journal of Hand Surgery. 128: 1: 110-119.
Accepted: 21 May M. Needoff FRCS, 4TH, UK. 0 1994 The British
1993 Harlow Society
Wood Orthopaedic for Surgery
Hospital,
of the Hand
Mansfield
Road,
Nottingham,
NG18