BACKGROUND: Pisiform fractures are rarely occurring carpal injuries and often are undetected due to more obvious associated injuries and subtle radiographic findings. While nondisplaced fractures are typically treated conservatively, significantly displaced fractures can be treated operatively; however, there is a lack of consensus given the injury's rarity and limited research. This study offers an extensive analysis of pisiform fractures, associated fractures, treatment methods, and long-term outcomes.

METHODS: A retrospective review of patients with diagnosed pisiform fractures from 2017 to 2025 at a level 1 trauma center was performed. Thirty-four patients, treated by the orthopaedic or plastic surgery departments, were ultimately included. Patient demographics, injury pattern and mechanism, treatment method, and outcomes at final follow-up were collected. Data analysis was completed using Fisher exact test and unpaired test to compare patients with and without additional fractures of the carpus, distal radius/ulna, and metacarpals.

RESULTS: Of 34 patients, 21 had additional fractures, most frequently the distal radius, triquetrum, and distal ulna. Advanced imaging (computed tomography or magnetic resonance imaging) was required for diagnosis in 7 patients, 6 of whom had additional injuries. Thirty-two patients were treated nonoperatively. Persistent pain and decreased range of motion at final follow-up is associated with the presence of associated fractures.

CONCLUSION: Pisiform fractures are a rare, likely underdiagnosed injury. Conservative treatment is indicated in most patients. Associated injuries, rather than the pisiform fracture itself, are likely more predictive of long-term dysfunction. Larger studies are required, especially to characterize outcomes in patients treated operatively.