Isolated distal pisiform dislocation: Case Report / Luxação distal isolada do pisiforme: Relato de caso

Abstract Isolated pisiform dislocation is a rare lesion with few cases described in the literature. This type of lesion is typically observed in young males and can be easily overlooked at first assessment. Isolated proximal dislocation is more common due to the action of the flexor carpi ulnaris (FCU) muscle. We present the case of a 19-year-old male patient with isolated distal pisiform dislocation after wrist trauma. He underwent open reduction and internal fixation with Kirschner wires with excellent functional outcomes. Although there is no consensual therapeutic method, closed reduction is a first-line treatment for acute presentations. Pisiform open reduction or excision may be performed alternatively or after a failed closed reduction.

Resumo A luxação isolada do pisiforme é uma lesão rara com poucos casos descritos na literatura. Esse tipo de lesão é observado tipicamente em adultos jovens do sexo masculino e pode ser facilmente negligenciada numa primeira avaliação. A luxação proximal isolada é mais comum devido à ação do flexor ulnar do carpo (FUC). Apresentamos o caso de um paciente do sexo masculino, com 19 anos de idade, com luxação distal isolada do pisiforme após traumatismo do punho. O paciente foi submetido a uma redução aberta e fixação interna com fios de Kirschner com excelente resultado funcional. Apesar de não existir um método de tratamento consensual, a redução fechada perfila-se como tratamento de primeira linha na apresentação aguda. Em caso de insucesso ou como método alternativo pode-se optar pela redução aberta ou a excisão do pisiforme.

Diagnostic Significance of Ultrasonographic Measurements and Median-Ulnar Ratio in Carpal Tunnel Syndrome: Correlation with Nerve Conduction Studies

BACKGROUND AND PURPOSE: We determined the reliability of ultrasonography (US) measurements for diagnosing carpal tunnel syndrome (CTS) and their correlation with symptom duration and electrophysiology findings. We determined whether the ratio of the median-to-ulnar cross-sectional areas (CSAs) can support CTS diagnoses. METHODS: The pisiform CSA (CSA(pisiform)), swelling ratio (SR), palmar bowing, and CSA(pisiform)/ulnar CSA (CSA(ulnar)) measurements made in two subgroups of CTS patients (having sensory affection alone or having both sensory and motor affection) were compared with controls. CSA(ulnar) was measured in Guyon's canal at the level of most-protuberant portion of the pisiform bone. RESULTS: The values of all of the measured US parameters were higher in patients with CTS (n=50) than in controls (n=62). CSA(pisiform) could be used to diagnose CTS of mild severity. All of the parameters were positively correlated with the distal latency of the compound muscle action potential, and all of them except for SR were negatively correlated with the sensory nerve conduction velocity. A CSA(pisiform)/CSA(ulnar) ratio of ≥1.79 had a sensitivity of 70% and a specificity of 76% for diagnosing CTS. CONCLUSIONS: Only CSA(pisiform) measurements were reliable for diagnosing early stages of CTS, and CSA(pisiform)/CSA(ulnar) had a lower diagnostic value for diagnosing CTS.

Diagnostic Significance of Ultrasonographic Measurements and Median-Ulnar Ratio in Carpal Tunnel Syndrome: Correlation with Nerve Conduction Studies

BACKGROUND AND PURPOSE: We determined the reliability of ultrasonography (US) measurements for diagnosing carpal tunnel syndrome (CTS) and their correlation with symptom duration and electrophysiology findings. We determined whether the ratio of the median-to-ulnar cross-sectional areas (CSAs) can support CTS diagnoses. METHODS: The pisiform CSA (CSA(pisiform)), swelling ratio (SR), palmar bowing, and CSA(pisiform)/ulnar CSA (CSA(ulnar)) measurements made in two subgroups of CTS patients (having sensory affection alone or having both sensory and motor affection) were compared with controls. CSA(ulnar) was measured in Guyon's canal at the level of most-protuberant portion of the pisiform bone. RESULTS: The values of all of the measured US parameters were higher in patients with CTS (n=50) than in controls (n=62). CSA(pisiform) could be used to diagnose CTS of mild severity. All of the parameters were positively correlated with the distal latency of the compound muscle action potential, and all of them except for SR were negatively correlated with the sensory nerve conduction velocity. A CSA(pisiform)/CSA(ulnar) ratio of ≥1.79 had a sensitivity of 70% and a specificity of 76% for diagnosing CTS. CONCLUSIONS: Only CSA(pisiform) measurements were reliable for diagnosing early stages of CTS, and CSA(pisiform)/CSA(ulnar) had a lower diagnostic value for diagnosing CTS.

Relationship Between Electrodiagnosis and Various Ultrasonographic Findings for Diagnosis of Carpal Tunnel Syndrome

OBJECTIVE: To investigate the relationship between electrodiagnosis and various ultrasonographic findings of carpal tunnel syndrome (CTS) and propose the ultrasonographic standard that has closest consistency with the electrodiagnosis. METHODS: Ultrasonography was performed on 50 female patients (65 cases) previously diagnosed with CTS and 20 normal female volunteers (40 cases). Ultrasonography parameters were as follows: cross-sectional area (CSA) and flattening ratio (FR) of the median nerve at the levels of hamate bone, pisiform bone, and lunate bone; anteroposterior diameter (AP diameter) of the median nerve in the carpal tunnel; wrist to forearm ratio (WFR) of median nerve area at the distal wrist crease and 12 cm proximal to distal wrist crease; and compression ratio (CR) of the median nerve. Independent t-test was performed to compare the ultrasonographic findings between patient and control groups. Significant ultrasonographic findings were compared with the electrodiagnosis results and a kappa coefficient was used to determine the correlation. RESULTS: CSA and FR of median nerve at the hamate bone level, CSA of median nerve at pisiform bone level, AP diameter of median nerve within the carpal tunnel, CSA of median nerve at the distal wrist crease and WFR showed significant differences between patient and control groups. WFR showed highest concordance with electrodiagnosis (κ=0.71, p<0.001). CONCLUSION: These findings suggested the applicability of ultrasonography, especially WFR, as a useful adjunctive tool for diagnosis of CTS.

Surgical Management of Pisiform Bone Deformity Associated with Tendonitis of Flexor Carpi Ulnaris

PURPOSE: This study was performed to investigate the degree of symptom improvement after removal of bone fragment in patients with deformed pisiform bone associated with tendonitis of flexor carpi ulnaris. METHODS: Pisiform bone fragment removal was performed in 12 patients who had failed conservative treatment from January 2008 to December 2011. They were followed up at 2 weeks, 1 month, 2 months, 6 months, and 12 months after surgery. Their symptoms were assessed with Green score. RESULTS: Eleven of 12 patients who underwent bone fragment removal showed symptom improvement. Symptoms worsened in 1 patient due to pain and restricted range of motion caused by postoperative scar. CONCLUSION: The results of this study suggest that removal of bone fragment may be an effective treatment in patients with tendonitis of flexor carpi ulnaris accompanied by pisiform bone deformity whose pain does not improve with conservative management.

Accessory muscle in the forearm: a clinical and embryological approach / 대한해부학회지

Muscular variations of the flexor compartment of forearm are usual and can result in multiple clinical conditions limiting the functions of forearm and hand. The variations of the muscles, especially accessory muscles may simulate soft tissue tumors and can result in nerve compressions. During a routine dissection of the anterior region of the forearm and hand, an unusual muscle was observed on the left side of a 65-year-old male cadaver. The anomalous muscle belly arose from the medial epicondyle approxiamately 1 cm posterolateral to origin of normal flexor carpi ulnaris muscle (FCU), and from proximal part of the flexor digitorum superficialis muscle. It inserted to the triquetral, hamate bones and flexor retinaculum. Passive traction on the tendon of accessory muscle resulted in flexion of radiocarpal junction. The FCU which had one head, inserted to the pisiform bone hook of hamate and palmar aponeurosis. Its contiguous muscles displayed normal morphology. Knowledge of the existence of muscle anomalies as well as the location of compression is useful in determining the pathology and appropriate treatment for compressive neuropathies. In this study, a rare accessory muscle has been described.

Mobilização do osso pisiforme no tratamento da neuropraxia do nervo ulnar no canal de Guyon: relato de caso / Pisiform bone mobilization for treating ulnar nerve neuropraxia at Guyon's canal: case report

As neuropraxias do nervo ulnar são lesões bastante freqüentes que provocam efeitos deletérios, como diminuição de força muscular e parestesias; geralmente ocorrem no nível do epicôndilo medial e do túnel ulnar (canal de Guyon). São escassos os relatos referentes a técnicas de terapia manual para compressões do nervo ulnar no canal de Guyon. Este trabalho relata o uso da técnica de mobilização do pisiforme na compressão do nervo ulnar no canal de Guyon de um homem que sofreu luxação do punho direito aos 8 anos e, aos 25, queixava-se de um deficit para adução do dedo mínimo, que atrapalhava a realização de algumas atividades de vida diária. O paciente foi submetido a uma única sessão de mobilização articular do pisiforme. Após a aplicação da técnica, o sinal positivo do teste foi eliminado, restabelecendo-se a função de adução do 5o dedo. Embora carecendo de maior fundamentação teórica, pode-se afirmar que a técnica usada, de mobilização articular do osso pisiforme, é eficaz para melhora do quadro de paresia por neuropraxia do nervo ulnar no canal de Guyon...

A common ulnar nerve neuropraxia is lesion that may result in muscle strength decrease and/or paresthesia; it usually takes place at medial epicondylelevel and the ulnar tunnel (Guyon’s canal). Studies on manual therapy techniques for ulnar nerve compression in Guyon’s canal are scarce. This paper reports the use of a technique of pisiform bone mobilization for relieving ulnar nerve compression in Guyon’s canal, in a man who had suffered a luxation of the right wrist at the age of 8 and, at 25, complained of adduction deficit of the fifth finger that interfered in his daily life activities. He was submitted to one session of pisiform mobilization; after the session, the positive test sign was eliminated, thus restoring the fifth finger function. Though lacking further grounding, it may be said that the technique used, of mobilizing the pisiform bone joint, is effective to restore normal function after ulnar nerve compression at the Guyon’s canal...

Variations and Morphometry of the Carpal Tunnel and Its Related Structures

OBJECTIVE: The purpose of this study was to find out diagnostic clue for the carpal tunnel syndrome. So we investigated the postional relationships between the structures, the degree of entrance of the muscle bellies in the carpal tunnel, the location of flexor retinaculum (FR) and the cross sectional area to the tunnel of the tendons, the median nerve and the soft tissues occupied with the wrist. METHOD: Seventy-seven wrists of Korean adults's cadavers were dissected. Fifty-three wrists were examined by posteroanterior view of X-ray. The area of each structure was measured by image analyzer (Optimas Co. WA). The upper and lower borders the FR were confirmed at the sagittal plane after sagittal section. RESULTS: Frequency of the bellies of FDS, FDP and lumbricalis observed in each finger, the length of these bellies entering into the carpal tunnel were obtained. The cases that the third and fourth FDS were located side by side, the second FDS tendon under the third FDS tendon and the fifth tendon under the fourth FDS tendon were most common. The cases that the median nerve was bordered on the third FDS and the second FDS deep inside of the median nerve were most common. Mean length of the FR was 32.1 mm. The cases that the location of the upper margin of the FR was 10 mm and 15 mm from the end of radius were most common (44%). The cases that the margin of FR was 5 mm and 10 mm from the base of the 3rd metacarpal bone were most common (52%). The cross sectional area ratios to the carpal tunnel of the tendon, median nerve and connective tissues were 30%, 4%, 66% at the level of the pisiform bone, 36%, 4%, 60% at the level of the hook of hamate and 28%, 3%, 67% at the level of the lower margin of the FR, respectively. CONCLUSION: These results could help to understand the etiology of the carpal tunnel syndrome and would be a helpful information to the diagnostic imaging of the carpal tunnel.

A longitudinal study on the skeletal maturity of the hand and wrist among various malocclusion groups (I) / 대한치과교정학회지

Growth and development evaluation of patients with growth potential is of great importance for orthodontic treatment planning. Timing of orthodontic intervention greatly depends on one`s developmental status, thus if there is a difference in skeletal maturation among malocclusion types different treatment timing should be applied. The objective of this study was to evaluate and compare skeletal maturation among different malocclusion types. The samples used in this study was 38 ClassI. 36 ClassII and 33 ClassIII females aging from 8 to 10 years. Handwrist X-rays were taken with 6 month interval till 12-13 years of age. The results were as follows. 1. There was no skeletal maturity difference among different malocclusion types. 2. The hamular process of hamate was observed at 9.16+/-0.72 years, pisiform bone at 9.13+/-0.71 years and the ulnar sesamoid at 10.34+/-0.84 years. 3. The timing of epiphyseal capping on the third finger was 10.96+/-0.80 years for distal phalanx and 11.27+/-0.87 years for middle phalanx, 11.12+/-0.86 years for proximal phalanx of the first finger, 11.21+/-0.82 years for radius and 11.62+/-0.85 years for middle phalanx of the fifth finger. 4. The appearance of pisiform bone showed high correlation with appearance of hamular process of hamate(r=0.91), and ulnar sesamoid bone appearance showed high correlation with advanced ossification of hamular process(r=0.86). Timing of epiphyseal capping among different parts showed high correlation(r=0.80-0.90). 5. The shape of middle phalanx of the fifth finger showed the highest variability (20.6%).

Subclinical Ulnar Neuropathy in Carpal Tunnel Syndrome

BACKGROUND: When performing routine diagnostic nerve conduction studies in patients with carpal tunnel syndrome(CTS), we sometimes happen to be confronted with patients who have also ulnar nerve abnormality without any clinical symptoms or signs, although not so common. Anatomically, the borders of the carpal tunnel and the Guyon canal share common features, separated from each other by the pisiform bone, and the volar carpal ligament forming both the roof of the carpal tunnel and the floor of the Guyon canal. Therefore, if there is an entrapment syndrome at the carpal tunnel with subsequent electrophysiological changes for the median nerve, the same process could also affect the ulnar nerve in the Guyon canal. METHODS: We analyzed 283 patients who were diagnosed as CTS clinically and electrophysiologically for the past 5 years in this hospital. RESULTS: Of 283 patients(491 hands) with CTS, 15 patients(16 hands) had ulnar nerve involvement(5%). Of 75 patients with unilateral CTS, 2 patients(2%) had ulnar nerve involvement; whereas of 208 patients with bilateral CTS, 13 patients(6%) had ulnar nerve involvement. CONCLUSIONS: This study cannot conclusively explain why there is involvement of the ulnar nerve in CTS, but ulnar nerve may be involved at the level of the Guyon canal in some patients with CTS as an entrapment phenomenon and the patients with bilateral CTS may have a more tendency to have ulnar nerve lesion than those with unilateral CTS. In patients with CTS, it would be better to check up if there is also ulnar nerve involvement.