Ulnar Nerve Compression As a Consequence of Isolated Pisiform Dislocation

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CASE REPORT Ulnar nerve compression as a consequence of isolated pisiform dislocation

S. Sharma*, A. Massraf

Western Inﬁrmary, Glasgow, UK

Accepted 17 August 2004

Introduction his symptoms. On systemic enquiry he had no med- ical problems. General examination did not reveal Isolated dislocation of the pisiform is a rare injury. any ligamentous laxity. Examination of his wrist This is because of the sturdiness of the ligamentous revealed swelling and tenderness over the ulnar complex which stabilises the pisiform to the carpus. border of his wrist. He also had paraesthesia over So far, only 25 cases proved by radiographs have the little finger and medial border of his ring finger been reported.1—21 Of these 25 cases there were two on the volar side. In addition he had weakness of the reports of recurrent dislocation of the pisiform.7,14 abductor digiti mimimi. [Reduced power against This is the first report of associated ulnar nerve resistance –— Grade 4/5]. compression as a consequence of the dislocation. Radiographs (Fig. 1) revealed medial displace- ment of his right pisiform. The pisiform was reduced with ease by pushing on Case report the pisiform in a lateral direction. There was an audible clunk and the patient experience pain relief A 22-year-old man presented to the Accident and instantly. Repeat radiographs (Fig. 2) confirmed Emergency Department with a painful right [non reduction of the pisiform. He was admitted for dominant] wrist. There was no history of trauma. elevation of his right upper limb over the next The wrist pain started after he picked up a book with 12 h. Neurological examination the following day his right hand. He did however give a history of this was normal and the swelling had settled and the wrist ‘popping out’ several times (20—25) over the patient had a full range of pain-free movement of past 6 months. He was able to ‘pop’ the wrist back his wrist. He was discharged and is due to be fol- during all these previous episodes. He worked as a lowed up with the possibility of requiring excision of carpet fitter and for recreation enjoyed football his pisiform if he continues to have further episodes goalkeeping. He could not remember any specific of dislocation of the pisiform. episode of injury to his wrist over the last 6 months although he did not discount the possibility of a fooballing injury to his wrist prior to the onset of Discussion * Corresponding author. Present address: 47 Shuna Place New- ton Mearns, Glasgow 677 6TN, UK. Tel.: +44 141 6393820. A majority of the dislocations of pisiform have been E-mail address: [email protected] (S. Sharma). reported in young and active males as was the case

1572-3461 # 2004 Published by Elsevier Ltd. Open access under CC BY-NC-ND license. doi:10.1016/j.injury.2004.08.021 80 S. Sharma, A. Massraf

Figure 1 The medial dislocation of the pisiform is obvious in the anteroposterior radiograph. Figure 2 Radiograph of the wrist taken following closed reduction of the pisiform. in our report. Dislocations are commonly due to will help identify subtle medial deviation of the direct trauma to the ulnar and volar aspect of the pisiform. Emergency reduction of the pisiform is wrist although occasionally it could occur as a con- required if there are signs of neurological injury sequence of an indirect force such as a forceful to ulnar nerve. Excision of the pisiform may be muscular contraction. required in case closed reduction fails or if the Demartin2 reported this injury in a 81-year-old patient develops recurrent episodes of dislocation. woman in whom closed reduction failed to achieve reduction. The authors postulated that the reason for failed closed reduction was because of the action References of the Flexor carpi ulnaris tendon. We believe that closed reduction was possible in our case because of 1. Ashkan K, O’Connor D, Lambert S. Dislocation of the pisiform previous episodes of subluxation/dislocation of the in a 9-year-old child. J Hand Surg Br 1998;23:269—70. pisiform. Our patient had signs of ulnar nerve com- 2. Demartin F, Quinto O. Isolated dislocation of the pisiform. A pression. These signs resolved after closed reduc- case report. Chirurgia Degli Organi di Movimento tion. 1993;78:121—3. 3. Gainor BJ. Simultaneous dislocation of the hamate and pisiform: a case report. J Hand Surg Am 1985;10:88—90. 4. Garcia-Elias M. Simultaneous dislocation of the hamate and Conclusion pisiform bone. J Hand Surg Am 1985;10:908—9. 5. Georgoulis A, Hertel P, Lais E. Fracture and dislocation The diagnosis of an isolated pisiform dislocation fracture of the os pisiforme. Unfallchirurg 1991;94:182—5. should be considered in patients with wrist pain 6. Helal B. Chronic overuse injuries of the piso-triquetral joint in racquet game players. Br J Sports Med over the medial side of the wrist which may be 1979;12:195—8. associated with signs of ulnar nerve injury. Compar- 7. Ishizuki M, Nakagawa T, Itoh S, Furuya K. Positional disloca- ing radiographs of the wrist with the unaffected side tion of the pisiform. J Hand Surg Am 1991;16:533—5. Ulnar nerve compression as a consequence of isolated pisiform dislocation 81

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