Ulnar Tunnel Syndrome (UTS)

A table to recap all the key details about Ulnar Tunnel Syndrome:

Aspect	Details
Definition	Compression of the ulnar nerve in Guyon’s canal at the wrist.
Incidence	Less common than Cubital Tunnel Syndrome.
Risk Factors	Repetitive trauma, cyclists ("handlebar palsy"), anatomical anomalies, ganglion cysts.
Etiology	Ganglion cysts (80% of non-traumatic cases), lipomas, ulnar artery thrombosis, fractures, inflammatory arthritis.
Anatomy	Guyon’s canal: 4 cm long, houses the ulnar nerve; contains zones for sensory and motor branches.
Symptoms	Sensory disturbances in the small and ring fingers, motor deficits in the hand’s intrinsic muscles.
Physical Exam Findings	Tinel’s sign, Froment’s sign, Jeane’s sign, Wartenberg’s sign.
Diagnostic Imaging	X-rays, CT scans, MRI, Doppler Ultrasound or Arteriogram.
Electrophysiology	Nerve Conduction Studies (NCS), Electromyography (EMG).
Differential Diagnosis	Cubital Tunnel Syndrome, Carpal Tunnel Syndrome, Radiculopathy.
Nonoperative Treatment	Activity modification, NSAIDs, wrist splinting.
Operative Treatment	Decompression of Guyon’s canal, resection of ganglion cysts, vascular surgery for ulnar artery issues.
Complications	Recurrence of symptoms, infection, scar formation.

Introduction

Ulnar Tunnel Syndrome, also known as Guyon's canal syndrome, is a condition characterized by the compression of the ulnar nerve as it passes through Guyon's canal at the wrist. This condition can lead to a variety of motor and sensory disturbances in the hand, particularly affecting the small and ring fingers. Understanding the pathophysiology, clinical presentation, and management strategies for Ulnar Tunnel Syndrome is crucial for effective diagnosis and treatment.

Epidemiology and Risk Factors

Ulnar Tunnel Syndrome is less common than Cubital Tunnel Syndrome, another condition affecting the ulnar nerve but at the elbow level. Certain groups, such as cyclists, are at increased risk due to repetitive trauma from handlebar pressure, a condition often referred to as "handlebar palsy."

Risk Factors:

• Repetitive trauma, especially in occupations or activities involving prolonged wrist pressure.

• Cyclists (due to handlebar pressure).

• Individuals with predisposing anatomical anomalies or masses.
  

Etiology and Pathophysiology

The compression of the ulnar nerve within Guyon’s canal can be attributed to several factors, both traumatic and non-traumatic. The most common cause is a ganglion cyst, accounting for approximately 80% of non-traumatic cases.

Common Causes of Compression:

• Ganglion cysts (most common non-traumatic cause)

• Lipomas

• Repetitive trauma (e.g., cycling, heavy lifting)

• Ulnar artery thrombosis or aneurysm

• Fractures (hook of hamate or pisiform)

• Inflammatory arthritis

• Fibrous or muscular anomalies

• Congenital bands

• Idiopathic causes

Anatomy of Guyon's Canal: Guyon’s canal is approximately 4 cm long, extending from the proximal border of the transverse carpal ligament to the aponeurotic arch of the hypothenar muscles. It houses the ulnar nerve, which bifurcates into superficial sensory and deep motor branches.

Zones of Guyon's Canal:

1. Zone 1: Proximal to the bifurcation, affecting both motor and sensory functions.

2. Zone 2: Surrounds the deep motor branch, affecting motor functions only.

3. Zone 3: Surrounds the superficial sensory branch, affecting sensory functions only.
   

Clinical Presentation

The symptoms of Ulnar Tunnel Syndrome vary depending on the site of nerve compression within Guyon's canal.

Symptoms:

• Sensory disturbances: Numbness or tingling in the small and ring fingers.

• Motor deficits: Weakness in the intrinsic muscles of the hand, particularly those innervated by the ulnar nerve (e.g., interosseous muscles, third and fourth lumbricals, hypothenar muscles).

Physical Examination Findings:

• Tinel’s sign: Tapping over Guyon’s canal may reproduce symptoms.

• Froment’s sign: Difficulty holding a piece of paper between the thumb and index finger due to weakness in the adductor pollicis.

• Jeane’s sign: Hyperextension of the thumb's metacarpophalangeal joint.

• Wartenberg’s sign: Involuntary abduction of the small finger.
  

Diagnostic Evaluation

Imaging Studies:

• X-rays and CT scans: Useful for identifying fractures of the hook of hamate or pisiform.

• MRI: Can detect soft tissue lesions such as ganglion cysts or ulnar artery aneurysms.

• Doppler Ultrasound or Arteriogram: Helpful in diagnosing vascular causes like ulnar artery thrombosis or aneurysm.

Electrophysiological Studies:

• Nerve Conduction Studies (NCS) and Electromyography (EMG): These are essential for confirming the diagnosis, determining the extent of nerve damage, and differentiating Ulnar Tunnel Syndrome from other neuropathies.
  

Differential Diagnosis

• Cubital Tunnel Syndrome: Typically presents with symptoms proximal to the wrist, including sensory deficits on the dorsum of the hand and motor deficits in ulnar-innervated extrinsic muscles. Positive elbow flexion test and Tinel sign at the elbow are characteristic.

• Carpal Tunnel Syndrome: Affects the median nerve and presents with symptoms in the thumb, index, middle, and radial half of the ring finger.

• Radiculopathy: Nerve root compression at the cervical spine can mimic ulnar nerve distribution symptoms.
  

Management

Nonoperative Treatment:

• Initial management: Activity modification, NSAIDs, and wrist splinting to minimize nerve compression.

• Indications: Suitable for mild to moderate symptoms or as a trial before considering surgery.

Operative Treatment:

• Indications: Severe symptoms unresponsive to conservative measures or the presence of a compressive lesion like a ganglion cyst.

• Surgical Options:

  • Decompression of Guyon’s Canal: Involves releasing the ligamentous and fascial structures compressing the nerve.

  • Resection of Ganglion Cysts: If present, these can be excised to relieve pressure on the ulnar nerve.

  • Vascular Surgery: In cases of ulnar artery thrombosis or aneurysm, surgical intervention may be required.

Postoperative Care:

• Rehabilitation: Physical therapy to restore strength and dexterity in the hand.

• Follow-up: Regular monitoring for recurrence of symptoms and assessment of functional recovery.
  

Complications

• Recurrence: Symptoms may recur, especially if the underlying cause is not addressed or if there is incomplete decompression during surgery.

• Infection or Scar Formation: Post-surgical complications, though rare, can occur and require management.
  

Conclusion

Ulnar Tunnel Syndrome is a condition that requires a thorough understanding of the anatomy and pathology of Guyon’s canal. Early diagnosis and appropriate management, whether conservative or surgical, are key to preventing permanent nerve damage and maintaining hand function. As such, clinicians must be adept at recognizing the signs and symptoms, performing the necessary diagnostic evaluations, and implementing a tailored treatment plan based on the severity and underlying cause of the syndrome.