Isolated dislocation of pisiform in an 11-year-old, following a horse bite: a rare injury
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CASE REPORT
Isolated dislocation of pisiform in an 11-year-old, following a horse bite: a rare injury Pradyumna Raval & Nauman Saeed & Anant Narayan Mahapatra
Received: 13 November 2012 / Accepted: 11 January 2013 # EFORT 2013
Case report An 11-year-old, right-handed student presented to us with the complaint of right wrist pain, after being bit by a horse. On examination, there were multiple small abrasions on the wrist, consistent with teeth marks of a horse. There was minimal swelling on the wrist. There was a palpable gap and tenderness in the hypothenar area. There was pain upon movements of the wrist. There was no distal neurovascular deficit. The radiographs of the wrist showed a dislocated pisiform with anterior and distal displacement (Fig. 1). A 3D CT scan of the wrist confirmed the diagnosis (Figs. 2, 3 and 4). Initially, the patient's wounds were thoroughly cleaned and an appropriate antibiotic was started, given the history of animal bite. A dorsal back slab was applied. On reassessment after 3 days, his wounds had improved and he had a range of 40° of palmar and dorsiflexion of his wrist which was terminally painful. There was pain upon adduction and abduction. A below elbow moulded cast was applied and patient was called for a review in 3 weeks. At 3 weeks, the cast was removed. On examination, his wounds had completely healed. He had no tenderness
P. Raval : N. Saeed : A. N. Mahapatra Department of Orthopaedics, Our Lady of Lourdes Hospital, Drogheda, County Louth, Ireland P. Raval (*) Department of Orthopaedic Surgery, Our Lady of Lourdes Hospital, Drogheda, Ireland e-mail: [email protected]
anywhere on the wrist and had significant improvement in range of movement, which was painless. At 3 and 6 months, he continued to be asymptomatic. A follow-up radiograph done at 6 months revealed that the pisiform had reduced (Fig. 5), and on clinical examination, he had regained full range of movement (Figs. 6, 7 and 8).
Discussion Dislocation of pisiform is a rare occurrence and isolated dislocation is rarer. Literature consists primarily of case reports [1]. The anatomic location and the ligamentous attachments impart a stability to the pisiform and hence the rarity of its dislocation [1, 2]. Pisiform is a sesamoid bone and has become regressive in humans as we have evolved [3, 4]. Direct trauma to the wrist and a forceful muscular violence are thought to be the main causative factors [1, 5–7]. However, which one of the two is significant is controversial, with Immermann stating that muscular force is twice as important as trauma [5] and SchädelHöpfner et al. stating that direct trauma is more often the cause [1]. Very few cases of pisiform dislocations have been reported in children, with most having another concomitant fracture [6–9]. However, we did not find any isolated pisiform dislocation following an animal bite, in literature. Treatment recommendations have been surgical excision and soft tissue reconstruction [1], moulded plaster for acute dislocations and excision of pisiform in chron
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