Ulnar tunnel syndrome

Definition
Compression of the ulnar nerve within the canal of Guyon.
History
Described by Guyon, a French urologist, in 1861.
Anatomy
The roof of the tunnel is formed by the volar carpal ligament. The floor is formed by the
transverse carpal ligament. The ulnar wall is the pisiform. The radial wall is the hook of the
hamate. The fibrous arch of origin of the hypothenar muscles separates the deep branch,
which runs between ADM and FDM and pierces opponens digiti minimi, before curling
around the hamate on its ulnar border to run radially, from the superficial branch.
The tunnel contains only the nerve (lying ulnarly) and the artery. There are no tendons.
The distal ulnar tunnel is divided into three zones.
Zone I is the area proximal to the bifurcation of the nerve. It is three cm long, extending from
the transverse carpal ligament.
Zone II surrounds the deep motor branch.
Zone III surrounds the superficial sensory branch
The dorsal cutaneous branch of the ulnar nerve leaves the nerve 5cm proximal to the tunnel.
Aetiology
The commonest causes are ganglia and hook of hamate fractures (zone I and II) and
aneurysms of the ulnar artery (zone III). Zone III compression is also commonly seen with
inflammatory lesions.
Overall ganglia and other soft tissue masses cause 45% of cases, and anomalous muscles
cause another 16%. The ganglion most commonly originates from the triquetrohamate joint.
Clinical
Numbness and weakness predominate, with pain much less of a feature than in CTS.
The numbness should only be in the ulnar nerve innervated digits, and the dorsal cutaneous
branch of the ulnar nerve should be spared. Numbness should not increase with elbow
flexion this is a sign of cubital tunnel syndrome.
Weakness of the intrinsics may be found, but the FDP to the middle and ring fingers should
be of normal strength. The patient may complain of weakness of grip, particularly when
torque is required.
Investigation
XR of the wrist including carpal tunnel views. XR of the chest to rule out a Pancoast tumour.
Fractures of the hook of the hamate are best seen on CT scan.

US of the wrist to look for ganglia and aneurysms.

NCS to confirm level (cubital tunnel syndrome is much more common).
Differential diagnosis
Cubital tunnel syndrome
Thoracic outlet syndrome
Cervical radiculopathy
Pancoast tumour
Management
Initially conservative if intermittent numbness and no wasting.
Surgical decompression of all three zones if no relief with splinting and NSAIDs, or wasting.
Any coexisting pathology is dealt with: ganglia are removed, a hook of hamate nonunion is
excised, vascular anomalies are resected or reconstructed.
The incision begins 3cm proximal to the proximal wrist crease along the radial border of the
FCU tendon, crosses the wrist creases at a 60 degree angle, continues distally to bisect the
angle between the pisiform and hamate, then curls radially and distally.