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Pisiform – Review Of Imaging & Proposal Of New View

AK Ghosh, J Relwani

Address for Correspondence:
AK Ghosh


Carpal fractures are common but are often associated with a difficulty in diagnosis. One reason of this is that the configuration of the carpal bones often results in poor radiological outcome. The pisiform is one such carpal bone that suffers from poor radiological clarity in standard and available special views. Delayed diagnosis may result in mistreatment and a permanent dysfunction of the wrist. We present a new method of obtaining radiographs of the pisiform that allows clear depiction of the pisiform and the piso-triquetral articulation that will aid in diagnosis of injury.

J.Orthopaedics 2010;7(1)e9


carpal; pisiform


The incidence of hand fractures in the UK is approximately 400 out of every 100000 of the population per year. Of fractures of the hands the phalanges have been shown to be the most common (59%) followed by the metacarpals (33%) and then the carpal bones (8%).  Pisiform fractures make up 2% of all carpal fractures. However fractures of the pisiform are often overlooked as they generally not visible on routine radiological views of the wrist. We propose taking a lateral radiograph with the wrist in flexion, which we have found to show the pisiform and pisi-triquetral articulation clearly and as such help in diagnosis of bony injury.

Materials and Methods:

The patient is positioned such that the forearm is in pronation and the wrist joint is fully flexed. A radiolucent wedge may be used to assist the patinet to achieve this position. The xray source and plate are positioned to obtain a lateral view of the wrist in this position (fig1). The radiograph thus taken demonstates clearly the architecture of the pisiform as well as the pisio-triquetral joint (fig 2).

Discussion :

The pisiform lies medially, volar to the proximal row of the carpal bones, articulating with the volar aspect of the triquetral, which it overlies. It is a sesamoid bone, and is attached proximally to the flexor carpi ulnaris, and distally to the pisohamate, pisometacarpal and pisotriquetral ligaments. Other soft tissue attachments include the abductor digiti minimi and the transverse carpal ligament. The ulnar nerve and artery lie immediately radial to the pisiform in Guyon’s canal.  The pisiform acts to increase the distance of the FCU from the centre of rotation of the wrist, increasing the strength of the muscle by lengthening the distance of the lever arm. Its function is therefore similar to that of the patella in the knee, and it also suffers from the same spectrum of disorders (fractures, chondromalacia osteoarthritis and instability). It is most often injured in falls on an outstretched hand or by direct trauma. The former may cause an avulsion fracture, while both may result in a comminuted body or transverse fracture.

The clinical examination is invaluable in diagnosing injury to the pisiform. The bone itself is very easily palpated on the palmer aspect of the wrist, just distal to the distal wrist crease, at the base of the hypothenar eminence where it also forms a visible elevation. Examination will reveal tenderness and swelling in this area. It is important to also examine ulnar nerve function and wrist function as it has been shown that up to 50% of pisiform fractures may be associated with other wrist pathology (perilunate dislocation, distal radius fracture, additional carpal bone fracture).

Standard radiographs of the wrist are very poor at detecting pisiform fractures. Due to the inadequacy of AP and lateral views of the wrist other views have been suggested- carpal tunnel view, 30 degree supinated lateral radiograph and oblique views. However these views are also not ideal as fractures are not always shown. We feel that optimum clarity of the pisiform and the piso-triquetral joint is achieved by taking a lateral radiograph with the wrist hyperflexed as detailed above. We surmise that this allows relaxation in the soft tissues around the bone, namely the FCU, causing the pisiform to drop away from its articulation with the triquetrum and in the process allowing it to be visualised better. This view allows clear visualisation of the pisiform enabling the clinician to verify pisiform bony injury or disease with high reliability.


Pisiform injury is an important but easily overlooked condition. One of the reasons for this is that standard radiographic imaging allows only poor visualisation of the pisiform. We propose the use of a lateral view with the wrist in flexion to allow high-quality visualisation of the pisiform and the pisi-triquetral articulation.

Reference :

  1. Hand Fractures. Campbell, DA. 12, 2006, Surgery, Vol. 24, pp. 437-440.

  2. Prevalence and distribution of hand fractures. Van Onselen, EBH, et al. 5, 2003, Journal of Hand Surgery, Vol. 28, pp. 491-495.

  3. Fractures of the hand: distribution and relatvie incidence. Hove, LM. 1993, Scand J Plast Reconstr Surg Hand Surg, Vol. 27, pp. 317-319.

  4. Forearm and wrist radiology: part 2. Propp, DA and Chin, H. 1989, The journal of emergency medicine, Vol. 7, pp. 491-496.

  5. Fractures of the carpal bones excluding the scaphoid. MA, Shah and Viegas, SF. 2002, Journal of the american society of surgery of the hand, Vol. 2, pp. 129-140.

  6. Examination of the wrist—soft tissue, joints and special tests. Reddy, RS and J, Compson. 2005, Current orthopaedics, Vol. 19, pp. 180-189.

  7. Simon, R, Sherman, S and Koenigsknecht, SJ. Emergency orthopaedics- the extremities. s.l. : McGraw-Hill Professional. 2006.

  8. Examination of the wrist—surface anatomy of the carpal bones. Reddy, JS and Compson, J. 2005, Current orthopaedics, Vol. 19, pp. 171-179.

  9. Roentgen aspects of injuries to the pisiform bone and pisotriquetral joint. Vasilas, A, Grieco, V and Bartone, NF. 1960, Journal of bone and joint surgery (Am), Vol. 42, pp. 1317-1328.

This is a peer reviewed paper 

Please cite as: AK Ghosh: Pisiform – Review Of Imaging & Proposal Of New View

J.Orthopaedics 2010;7(1)e9





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