Latent pisotriquetral arthrosis unmasked following carpal tunnel release.
ABSTRACT The causes of persistent wrist pain following carpal tunnel release include scar tenderness and pillar pain. The goal of this study was to evaluate latent pisotriquetral arthrosis as a source of ulnar-sided wrist pain following open carpal tunnel release. Seven hundred consecutive carpal tunnel releases were reviewed, looking for postoperative presentation of pisotriquetral arthrosis, as well as management and outcome. Fourteen patients with long-standing postoperative pain at the base of the hypothenar eminence had clinical and radiographic signs of pisotriquetral degenerative arthrosis, which conceivably had existed preoperatively and been unmasked thereafter. In 6 patients with persistent symptoms despite conservative measures, excision of pisiform was curative. Altered isometric stresses over the pisotriquetral articulation as a result of releasing the transverse ligament, which constitutes a major radial static stabilizer of this joint, seems to cause articular maltracking, and consequently aggravates a preexisting asymptomatic pisotriquetral arthrosis. Long-standing discomfort is characteristically associated with loss of grip strength and dexterity. Pisotriquetral dysfunction and arthrosis should always be considered in the differential diagnosis of persistent wrist pain following either open or endoscopic carpal tunnel release that does not respond to nonoperative measures. Clinical scrutiny, adequate clinical inspection, and radiographic evaluation readily establish the diagnosis. Conservative treatment includes immobilization, nonsteroidal anti-inflammatory drugs, and intra-articular injection of corticosteroids under fluoroscopic control. The corticosteroid injection combined with a local anesthetic also serves as a diagnostic test. Excision of the pisiform is indicated where conservative treatment has failed.
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ABSTRACT: Pisotriquetral (PT) osteoarthritis (OA) and enthesopathy of the flexor carpi ulnaris (FCU) are pathologies of the hypothenar eminence which both often remain undiagnosed, but can cause ulnar wrist pain. This study determined the prevalence of these pathologies in an older donor population. Twenty wrists were obtained from 10 cadavers with an age ranging from 65 to 94 years. Radiographs were taken of all wrists with the hand in pisotriquetral view and were assessed for osteoarthritic changes of the PT joint and signs of enthesopathy of the FCU. Ten wrists were grossly dissected and the other ten wrists were sagitally sectioned at a thickness of 10 μm. The wrists were analyzed for type and grade of osteoarthritis and signs of enthesopathy. On radiology, 2 out of 20 wrists showed no signs of osteoarthritis, 5 wrists showed severe changes. One wrist showed signs of enthesopathy. On macroscopy, 9 out of 10 wrists showed osteoartritic changes; 5 of these were severely osteoarthritic. On microscopy, all wrists showed some degree of osteoarthritis of which five showed severe changes. Signs of enthesopathy were seen in seven wrists. Pisotriquetral osteoarthritis has a high prevalence in the older donor population and may therefore be a cause of ulnar sided wrist pain. It should therefore always be considered in the differential diagnosis of ulnar sided wrist pain. By performing clinical examination with these pathologies in mind, diagnosis could be a lot faster. Furthermore, based on our results, radiographs seem to be not accurate in diagnosing osteoarthritis of the PT joint and enthesopathy of the FCU.Journal of hand and microsurgery. 06/2014; 6(1):18-25.