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OSTEOARTHRITIS, PISOTRIQUETRAL

Introduction

Osteoarthritis (OA) of the pisotriquetral (PT) joint is a disorder of the proximal hypothenar eminence and ulnar wrist. Instability of the PT joint is a recognized complication of OA at this location. This instability can lead to ulnar nerve irritation in Guyon’s canal and secondary OA. Although pathology of the PT joint has a high prevalence in the older population, OA at this location usually occurs via injury to the pisiform ligament complex (secondary OA). Injury can occur acutely after a fall onto an outstretched hand (FOOSH), or may be associated with a chronic, repetitive-motion-type injury.

The disorder is typically undiagnosed or diagnosed late because the pain is vague and often unrelated to trauma, routine radiographs are not diagnostic. Thus pathology often remain undiagnosed until a special X-ray such as the "ball catcher's" view is taken.

Pathophysiology

  • OA of the PT joint can be a result of aging, but also can occur after a fracture or in rheumatoid arthritis (RA), or as a consequence of chronic repetitive trauma (eg, in certain sports). Carpal tunnel release can aggravate it by causing a partial subluxation of the pisotriquetral joint.
  • The biomechanical theory is that, during wrist extension, the pisiform is pressed against the distal triquetrum while it translates distally. As ulnar deviation applies large forces to the PT joint, peak shearing forces affect the radial and distal aspects of the pisiform.

Related Anatomy

  • PT joint
  • Hypothenar eminence musculature
  • PT joint is surrounded by a loose but strong joint capsule that allows great mobility.
  • Degenerative changes in the PT joint occur most frequently in the distal, distal-radial, and radial aspect of the pisiform and triquetrum and in the distal-ulnar aspect of the triquetrum

Incidence and Related Conditions

  • In a study of 216 patients with pain at the PT joint, primary OA contributed to 2.3% of the findings
  • Primary OA (ie, due to normal aging) of the PT joint is rare

Differential Diagnosis

  • Distal radioulnar joint subluxation or osteoarthritis
  • Congenital malformation
  • FCU tendonitis
  • Fractures of the pisiform
  • Ganglion cyst
  • Lunotriquetral pathology
  • OA of the distal radioulnar joint (DRUJ)
  • Triangular fibrocartilage complex  (TFCC) injury
  • Tumor
  • Ulnar nerve impingement in Guyon's canal
  • Ulnar artery thrombosis
  • Ulnar collateral ligament injury
  • Ulnar styloid nonunion
ICD-10 Codes

  • OSTEOARTHRITIS, PISOTRIQUETRAL

    Diagnostic Guide Name

    OSTEOARTHRITIS, PISOTRIQUETRAL

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    OSTEOARTHRITIS, PISOTRIQUETRAL M19.032M19.031 

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Symptoms
Pain in the ulnar aspect of the wrist and the pisotriquetral joint
Stiffness in the wrist
Pain with grip and forceful ulnar deviation of the wrist
Typical History

There is no typical history for OA of the PT joint because the condition is rare, and the differential diagnosis is broad. OA at this location is likely due to injury or arthritis of the pisiform ligament complex; therefore, the patient may describe aggravating repetitive-motion activities or acute trauma. If primary OA is causative, the patient is likely to be >65 years of age.

Positive Tests, Exams or Signs
Work-up Options
Images (X-Ray, MRI, etc.)
Osteoarthritis, pisotriquetral
  • Pisotriquetral Osteoarthritis with minimal joint space narrowing. No cysts, no osteophytes and intact cartilage space as seen on this "ball catcher's" view of the wrist.
    Pisotriquetral Osteoarthritis with minimal joint space narrowing. No cysts, no osteophytes and intact cartilage space as seen on this "ball catcher's" view of the wrist.
  • Pisotriquetral joint very difficult to visualize on routine lateral X-ray of the wrist.
    Pisotriquetral joint very difficult to visualize on routine lateral X-ray of the wrist.
  • Pisotriquetral Osteoarthritis (arrow) - Note marked joint narrowing and osteophytes in this "ball catcher's view of the wrist.
    Pisotriquetral Osteoarthritis (arrow) - Note marked joint narrowing and osteophytes in this "ball catcher's view of the wrist.
  • Pisotriquetral Osteoarthritis (arrow) - Note marked joint narrowing and pisiform cysts in this "ball catcher's view of the wrist.
    Pisotriquetral Osteoarthritis (arrow) - Note marked joint narrowing and pisiform cysts in this "ball catcher's view of the wrist.
  • Pisotriquetral Osteoarthritis AP X-ray with pointing to osteophyte. OA of P-T joint difficult to visualize on AP view.
    Pisotriquetral Osteoarthritis AP X-ray with pointing to osteophyte. OA of P-T joint difficult to visualize on AP view.
Treatment Options
Conservative
  • Anti-inflammatory medications
  • Rest
  • Splints
  • Steroid injections inti the pisotriquetral joint
Operative
  • Pisiformectomy
Treatment Photos and Diagrams
Surgical Excision of Pisiform
  • Excision of the pisiform for pisotriquetral osteoarthritis through the proximal part of an extended carpal tunnel incision. Pisiform (P); Neurovascular bundle (NVB); Flexor car ulnas (FCU)
    Excision of the pisiform for pisotriquetral osteoarthritis through the proximal part of an extended carpal tunnel incision. Pisiform (P); Neurovascular bundle (NVB); Flexor car ulnas (FCU)
  • Excision of the pisiform. The FCU has been splitted and the attachments to the volar pisiform are being removed sharply. Pisiform (P); Flexor Carpi Ulnas (FCU)
    Excision of the pisiform. The FCU has been splitted and the attachments to the volar pisiform are being removed sharply. Pisiform (P); Flexor Carpi Ulnas (FCU)
  • Excision of the pisiform. The pisotriqutral ligaments as the final step in pisiform excision. Pisiform (P); Flexor Carpi Ulnaris (FCU)
    Excision of the pisiform. The pisotriqutral ligaments as the final step in pisiform excision. Pisiform (P); Flexor Carpi Ulnaris (FCU)
  • Excision of the pisiform. Pisiform completely removed (P). The neurovasciular bundle (NVB) i.e. ulnar artery and nerve intact. Flexor Carpi Ulnaris (FCU) split to be sutured before closure.
    Excision of the pisiform. Pisiform completely removed (P). The neurovasciular bundle (NVB) i.e. ulnar artery and nerve intact. Flexor Carpi Ulnaris (FCU) split to be sutured before closure.
Complications
  • Complications related to pisotriquetral arthritis other than localized pain and swelling are rare.
  • Complications of surgical excision of the pisiform are very rare but can include infection, bleeding, nerve injury, ulnar artery injury, FCU tendon damage and persistent pain and weak grip.
Outcomes
  • Most patients respond to conservative management.
  • In a study of 12 patients who had undergone pisiformectomy, all patients were satisfied, and pain was relieved while retaining wrist motion and strength.
  • Other studies have shown that pisiformectomy consistently provides pain relief with no functional limitations.
Key Educational Points
  • PT shear or compression test: symptom recurrence on translation of the pisiform radially and ulnarly while applying dorsally directed pressure
  • OA of the PT joint should always be considered in the differential diagnosis of ulnar-sided wrist pain.
  • The PT joint has no bony stability but multiple ligaments act as the primary stabilizers.
  • The pisiform is a fulcrum for force transmission and a controller that prevents the triquetrum’s palmar subluxation during extension.
  • It is important to protect the ulnar artery and nerve as well as the FCU tendon during surgery.
  • Associated ulnar nerve compression can be a confounding factor that affects outcomes. 
References

New Articles

  1. Chae HD, Yoo HJ, Hong SH, et al. Assessment of pisotriquetral misalignment with magnetic resonance imaging: is it associated with trauma? Eur Radiol 2016 Epub. PMID: 27921157
  2. Rancy SK, Trehan SK, Li AE, et al. The prevalence of pisotriquetral arthritis in the setting of scapholunate advanced collapse. J Wrist Surg 2016;5(4):261-4. PMID: 27777815

Reviews

  1. Kleinmann WB. Physical examination of the wrist: Useful provocative maneuvers. J Hand Surg Am 2015;40(7):1486-1500. PMID: 26043802
  2. Watanabe A, Souza F, Vezeridis PS, et al. Ulnar-sided wrist pain. II. Clinical imaging and treatment. Skeletal Radiol 2010;39(9):837-57. PMID: 20012039

Classics

  1. Carroll RE, Coyle MP Jr. Dysfunction of the pisotriquetral joint: Treatment by excision of the pisiform. J Hand Surg Am 1985;10(5):703-7. PMID: 4045152
  2. Green DP. Pisotriquetral arthritis: A case report. J Hand Surg 1979;4(5):465-7.
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