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PisoTriquetral (PT) Tenderness

Exams and Signs

Description

  • Pisotriquetral (PT) tenderness is related to the pisiform, a carpal sesamoid bone that lies within the flexor carpi ulnaris (FCU) tendon.1 The pisiform holds the triquetrum in position and prevents its subluxation, even in extreme extension. It functions as a fulcrum while transducing strong forearm forces to the hand.2

Pathophysiology

  • PT tenderness may be caused by PT arthritis or posttraumatic arthritis. 
  • Chronic causes of PT tenderness include osteoarthritis, pisotriquetral joint (PTJ) arthrosis or tendinopathy.3

Instructions

  1. Record the patient’s history, including any sports-related injuries. Ask the patient to rate how much pain s/he usually experiences in the affected wrist on a scale from 1 to 10
  2. Check for tenderness, crepitus and pain
  3. Palpate the PT joint by hyperextension loading and radioulnar translation of the pisiform on the triquetrum3
  4. Examine the contralateral wrist for comparison

Variations

  • Consider neurological symptoms, including paresthesias4

Related Signs and Tests

  • Pisiform shear test 1
  • FCU tenderness
  • triangular fibrocartilage complex (TFCC) tenderness
  • Wrist range of motion (ROM)
  • Neurovascular exam
  • Arthroscopy

Diagnostic Performance Characteristics

  • Do not use other patients’ reactions as a comparison, because other patients may have different perceptions of similar tenderness and/or pain
Presentation Photos and Related Diagrams
Pisotriquetral Examination
  • Examine the pisiform triquetral joint for tenderness. FCU (flexor carpi ulnaris).
    Examine the pisiform triquetral joint for tenderness. FCU (flexor carpi ulnaris).
Definition of Positive Result
  • A positive result occurs when pressure applied to the PT joint causes increased tenderness. 
Definition of Negative Result
  • A negative result occurs when pressure applied to the PT joint does not cause increased tenderness.
Comments and Pearls
  • Pisiform excision may relieve pain and help preserve wrist motion and strength.4
  • In patients who place the wrist in maximal extension, such as gymnasts, it may be best to avoid excision. For treating PT injuries, pisotriquetral arthrodesis may be a useful alternative to excision.3
Diagnoses Associated with Exams and Signs
References
  1. Culp R, Jacoby S. Musculoskeletal Examination of the Elbow, Wrist and Hand: Making the Complex Simple. New Jersey: SLACK Incorporated, 2012.
  2. Beckers A, Koebke J. Mechanical strain at the pisotriquetral joint. Clin Anat 1998;11(5):320-6. PMID: 9725576
  3. Abrams R, Tontz W. Pisotriquetral Arthrodesis as an Alternative to Excision for Pisotriquetral Instability in High-Demand Patients: A Case Report in a Gymnast. J Hand Surg 2006;31A:611-4. PMID: 16632056
  4. Campion H, Goad A, Rayan G et al. Pisiform Excision for Pisotriquetral Instability and Arthritis. J Hand Surg Am 2014;39(7):1251-7. PMID: 24855969
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