Compression of the deep branch of the ulnar nerve in Guyon’s canal by a ganglion: two cases

INTRODUCTION: Ulnar nerve compression at the wrist can be caused by a variety of intrinsic and extrinsic factors. Isolated compression of only the deep branch of ulnar nerve by a ganglion is very uncommon. Ultrasound examination can clearly show the cystic lesion compressing the nerves. MATERIALS AND METHODS: We present two cases of compression of deep branch of ulnar nerve by a ganglion in the Guyon's canal. Two male patients presented with history of progressive weakness and paraesthesia in the medial 1(1/2) digits of the non-dominant hand. Interestingly, both the patients noticed sudden onset and rapid progress of the symptoms and signs. Clinical examination revealed typical symptoms of ulnar nerve (deep branch) palsy. Nerve conduction studies showed severe denervation of the deep branch of the ulnar nerves in both the patients and ultrasound confirmed the diagnosis. Surgical decompression led to complete recovery. RESULTS AND DISCUSSION: Whilst compression by a ganglion in the Guyon's canal is rare but well recognized, a feature of both of our cases was the rapid progression and severe nature of the compressive symptoms and signs. This is in contrast to the more typical features of compressive neuropathy and should alert the clinician to the possible underlying cause of compression. Early decompression has the potential to promote a complete recovery.     

Neuropathy of motor branch of median or ulnar nerve induced by midpalm ganglion.

Two cases of neuropathy of a motor branch caused by a midpalmal ganglion are presented. In the first case the ganglion originated from the midcarpal joint, protruded into the thenar muscle, and compressed the motor branch of the median nerve. In the second case the ganglion, distal to the fibrous arch of the hypothenar muscles, originated from the third carpometacarpal joint and compressed the motor branch of the ulnar nerve. In both cases muscle weakness and finger deformity recovered well after resection of the ganglion. This clinical condition is rare compared with carpal tunnel syndrome and Guyon's tunnel syndrome, which are caused by a ganglion in the wrist.     

Case report: intraneural ganglion cyst of the ulnar nerve at the wrist

We report a case of a 69-year-old male who presented with pain, weakness, and clumsiness of his right hand. Initial evaluation suggested possible neoplastic process affecting his cervical spine, which was fortunately ruled out by bone biopsy. Subsequent electrodiagnostic studies and magnetic resonance imaging confirmed a lesion of the deep ulnar motor branch. Exploration of Guyon’s canal was performed, and an intraneural ganglion involving the deep motor branch of the ulnar nerve was found and excised. Despite more than 14 months of symptomatic duration, the patient made a near-complete recovery with virtually no functional limitations. This provides supporting evidence for a functional benefit of intraneural ganglion excision and nerve decompression even in cases of chronic muscle atrophy.     

Compression of the Deep Palmar Branch of the Ulnar Nerve by a Ganglion

A ganglion originating from the pisotriquetral joint is the most common cause of distal ulnar nerve compression. Midpalmar ganglions causing ulnar nerve compression are rare. This case describes a ganglion arising from the third carpometacarpal joint causing compression of the deep motor branch of the ulnar nerve.Investigation performed at the Toronto Western Hospital, University Health Network Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada     

游离足底内侧皮瓣修复腕掌尺侧皮肤神经缺损

目的 探讨修复腕掌尺侧皮肤神经同时缺损的新方法.方法 2000年4月至2009年8月,应用游离足底内侧皮瓣修复腕掌尺侧皮肤并神经缺损5例.足拇趾胫侧趾底固有神经修复小指尺掌侧固有神经缺损1例;桡神经浅支修复尺神经及其深浅支缺损2例,修复尺神经浅支、第4指掌侧总神经及小指尺掌侧固有神经缺损1例;尺神经手背支修复尺神经浅支、第4指掌侧总神经及小指尺掌侧固有神经缺损1例.足底内侧血管与尺血管吻合.供区取同侧大腿皮片移植修复.结果 术后皮瓣及移植皮片全部成活.5例获得6个月至4年的随访,皮瓣质地好、外观满意,无手内肌萎缩和爪形手畸形,皮瓣和手指感觉恢复达S3～S3+,皮瓣两点辨距觉为7～10 mm.尺神经深浅支缺损病例术后综合评价均为优.结论 游离足底内侧皮瓣是修复腕掌尺侧皮肤神经缺损的有效方法.     

游离足底内侧皮瓣修复腕掌尺侧皮肤神经缺损

目的 探讨修复腕掌尺侧皮肤神经同时缺损的新方法.方法 2000年4月至2009年8月,应用游离足底内侧皮瓣修复腕掌尺侧皮肤并神经缺损5例.足拇趾胫侧趾底固有神经修复小指尺掌侧固有神经缺损1例;桡神经浅支修复尺神经及其深浅支缺损2例,修复尺神经浅支、第4指掌侧总神经及小指尺掌侧固有神经缺损1例;尺神经手背支修复尺神经浅支、第4指掌侧总神经及小指尺掌侧固有神经缺损1例.足底内侧血管与尺血管吻合.供区取同侧大腿皮片移植修复.结果 术后皮瓣及移植皮片全部成活.5例获得6个月至4年的随访,皮瓣质地好、外观满意,无手内肌萎缩和爪形手畸形,皮瓣和手指感觉恢复达S3～S3+,皮瓣两点辨距觉为7～10 mm.尺神经深浅支缺损病例术后综合评价均为优.结论 游离足底内侧皮瓣是修复腕掌尺侧皮肤神经缺损的有效方法.     

游离足底内侧皮瓣修复腕掌尺侧皮肤神经缺损

目的 探讨修复腕掌尺侧皮肤神经同时缺损的新方法.方法 2000年4月至2009年8月,应用游离足底内侧皮瓣修复腕掌尺侧皮肤并神经缺损5例.足拇趾胫侧趾底固有神经修复小指尺掌侧固有神经缺损1例;桡神经浅支修复尺神经及其深浅支缺损2例,修复尺神经浅支、第4指掌侧总神经及小指尺掌侧固有神经缺损1例;尺神经手背支修复尺神经浅支、第4指掌侧总神经及小指尺掌侧固有神经缺损1例.足底内侧血管与尺血管吻合.供区取同侧大腿皮片移植修复.结果 术后皮瓣及移植皮片全部成活.5例获得6个月至4年的随访,皮瓣质地好、外观满意,无手内肌萎缩和爪形手畸形,皮瓣和手指感觉恢复达S3～S3+,皮瓣两点辨距觉为7～10 mm.尺神经深浅支缺损病例术后综合评价均为优.结论 游离足底内侧皮瓣是修复腕掌尺侧皮肤神经缺损的有效方法.

Abstract：

Objective To explore a new method for repair of concurrent skin and nerve defect at palm and carpal on ulnar side. Methods From April 2000 to August 2009, five cases with concurrent skin and nerve defect at palm and carpal on ulnar side were reconstructed with free medial plantar flaps.Palmar nervous proprii defect at ulnar side of little finger was repaired by the first toe tibia nervous proprii in one case. The superficial branch of radial nerve was applied to repair the defect of ulnar nerve, as well as its deep or superficial branch in two cases. The superficial branch of radial nerve was also used to repair the defect of superficial branch of ulnar nerve, common palmar digital nerve of the fourth finger, Little finger ulnar palmar nervous proprii in one case. The dorsal branch of ulnar nerve was applied to repair the defect of superficial branch of ulnar nerve, common palmar digital nerve of the fourth finger, little finger ulnar palmar nervous proprii in one case. The vascular bundle of medial plantar flap was anastomozised with ulnar vascular bundle. The wounds at donor sites were covered with free skin grafts which were obtained from upper leg. Results All the flaps and skin grafts were survived completely. The five patients were followed up for six months to four years with no muscular atrophy or claw hand deformity. The esthetic result was satisfied. The Sensory of flaps and fingers recovered to S3 to S3+. The two-point discrimination distance on flaps was range from 7 mm to 10 mm. The postoperative comprehensive evaluation was excellent in the cases whose superficial and deep branches of ulnar nerve were repaired.Conclusions Free medial plantar flap is an effective method to repair concurrent skin and nerve defect at palm and carpal on the ulnar side.     

Ulnar Nerve Compression in the Cubital Tunnel by an Epineural Ganglion: A Case Report

Epineural ganglia are considered to be a usual cause of peripheral nerve compression. In this report, we present a rare case of ulnar nerve compression by an epineural ganglion in the cubital tunnel. A 28-year-old right-handed female secretary developed progressive pain, numbness, and weakness in her right elbow, forearm, and hand for 6 months. Atrophy of the adductor pollicis and the first dorsal interosseous muscles was apparent. Clinical examination revealed a cystic mass at the posterior side of the elbow. Magnetic resonance imaging identified a ganglion while electrophysiologic studies revealed a severe conduction block of the ulnar nerve at the elbow. During surgery a 2-cm diameter epineural ganglion was identified compressing the ulnar nerve and was excised using microsurgery techniques. Two months postoperatively, the clinical recovery of the patient was very satisfactory, although the postoperative electrophysiologic studies demonstrated a less dramatic improvement.     

Ulnar nerve deep branch compression by a ganglion: A review of nine cases

Background and aim

Ulnar nerve compression is common at the elbow, but less common at the wrist. The purposes of this study were to report a series of nine patients with pure ulnar nerve deep branch compression by a ganglion and to evaluate the outcome following a surgical treatment.

Methods

A retrospective study was conducted with nine patients from 2000 to 2011. The patients included four male and five female patients. The mean duration of symptoms before surgery was 16 months (range, 5–32 months). Different degrees of muscular atrophy and weakness of the interossei and adductor pollicis muscles were present without sensory loss in the hand. Ganglion excision and decompression of Guyon's canal were performed in all patients. We evaluated postoperative results of this uncommon nerve lesion based on the modified Bishop's scoring system.

Results

The ganglion compressing the deep branch originated from the pisohamate joint in eight cases and from the midpalmar space in one case. At the mean follow-up of 23 months (range, 17–31 months), strength improvement of the grip and tip pinch was achieved in all patients. In comparison, grip strength improved from a mean of 63% of the unaffected side preoperatively to 88% of the unaffected side postoperatively. Tip pinch strength improved from a mean of 61% to 87%. According to the modified Bishop's scoring system, six patients (67%) obtained excellent results, two (22%) had good results, and only one (11%) had a fair result.

Conclusions

A ganglion causing ulnar nerve deep branch compression is rare. Early surgical treatment can result in satisfactory functional recovery.     

Synovial chondromatosis of the pisotriquetral joint producing ulnar nerve palsy

A case of synovial chondromatosis compressing the motor branch of the ulnar nerve of the left hand is presented. Radiographs demonstrated soft tissue calcification. The electrophysiological study confirmed denervation of the intrinsic hand muscles. During surgical exploration, synovial chondromatosis arising from the pisotriquetral joint compressing on the motor branch of the ulnar nerve was seen. Treatment consisted of pisiformectomy, partial synovectomy and removal of loose bodies.     

尺神经深支卡压的解剖学及临床意义

目的：探讨尺神经深支卡压的病因及诊治方法：方法：显微镜下观测３０例成人手的尺神经深支。封闭及手术治疗９例患者。结果：尺神经深支分４段。封闭（４例）和手术（７例０各治愈同１例、５例。结论：腕尺管段尺神经深支最易受损,在其它部位也会被止准确无误。本病应尽早手术。     

A neural loop of the deep motor branch of the ulnar nerve: an anatomic study

A motor neural loop of the deep branch of the ulnar nerve was encountered on three occasions during neurolysis of the ulnar nerve through Guyon's canal. An anatomic study of the course of the deep motor branch of the ulnar nerve at the wrist was done to define the incidence of this neural loop. Seventy-seven cadaveric upper extremities were examined and seven (9%) cases of a neural loop were encountered. One of these cases was bilateral. This variation should be considered when there is an atypical clinical presentation after penetrating injuries or compression neuropathy of the ulnar nerve at the wrist. In addition, care must be taken not to injure this branch during decompression of Guyon's canal or excision of an ununited of the hook of the hamate.     

Compression of the deep motor branch of the ulnar nerve by a synovial cyst. A case report

The authors report a case of compression of the deep palmar branch of the ulnar nerve beyond the piso-uniform arch by a ganglion cyst. A review of the literature finds this pattern as uncommon.     

单纯钩骨钩骨折致尺神经深支损伤的临床研究

目的探讨单纯钩骨钩骨折致尺神经深支损伤的致病机理。方法采用16侧甲醛固定和4侧新鲜成人尸体标本。以钩骨钩中点为O,过O点作一条水平线及垂线,水平线与尺神经深支的交点为A点,与钩骨钩基底尺侧交点为B点,垂线与尺神经的交点为C点,分别测量OA、OB、OC、AB长度,并进行统计学分析;对1996年4月~2009年6月5例单纯钩骨钩骨折合并尺神经深支损伤进行回顾分析。结果尺神经深支绕过钩骨钩的基底部进入掌深间隙,OA的长度为(4.96±0.11)mm、OB的长度(3.69±0.12)mm、OC的长度(10.55±1.07)mm、AB的长度为(1.27±0.15)mm;5例根据中华医学会手外科学会上肢周围神经功能评定试用标准:优4例,良1例。结论单纯钩骨钩骨折可致尺神经深支损伤但临床容易漏诊,早期正确诊治是神经功能得以恢复的关键。     

Tardy ulnar tunnel syndrome caused by Galeazzi fracture-dislocation: a neuropathy with a new pathomechanism

We present a case of late-onset ulnar tunnel syndrome following a Colles fracture. The nerve palsy was caused by a vascular branch that stretched over the ulnar head, compressing the nerve and generating friction against the ulnar head when the forearm was rotated. This is the first report of such a pathomechanism.     

腕部尺神经深支卡压综合征

目的了解腕部尺神经卡压的受压因素及其临床特点。方法对１０具２０侧成人上肢标本进行解剖,仔细观察腕部尺神经深支解剖特点;并对临床５例腕部尺神经深支卡压患者行手术治疗。结果尺神经深支均穿过小指短屈肌的腱性纤维弓,平均长５．２ｍｍ,此处尺神经深支有伴行动脉横跨;手术切开该纤维弓并作神经松解,经２～４年随访,疗效满意。结论尺神经深支卡压主要是小指短屈肌的腱性弓状缘,术中应彻底切开该缘。     

联合尺神经束支和臂丛外神经移位治疗臂丛损伤

目的 观察联合尺神经束支和臂丛外神经移位治疗臂丛损伤的临床效果.方法 臂丛损伤6例,其中单纯上干损伤4例;上中干为主,合并下干部分损伤2例.伤后平均2.8个月接受手术.术式包括尺神经部分束支转位至肌皮神经肱二头肌肌支,膈神经或者副神经斜方肌支转位至肩胛上神经,桡神经肱三头肌长头肌支转位修复腋神经肌支.用肱二头肌、岗上肌和三角肌肌力,肩外展和上举角度,尺神经功能损失等指标对手术方式和效果进行评估.结果 6例中5例得到随访,平均随访时间18个月,肱二头肌均在术后3～4个月开始恢复肌力.随访时间18个月以上的4例屈肘M_4~+～M_5;随访时间4个月的1例屈肘M_3~+.其中3例行外展功能重建,单用膈神经修复的病例上臂可上举至180°,外展肌力M_4~+;联合副神经和肱三头肌长头肌支修复的病例上肢可外展90°,肌力M_4~-;单用副神经修复的病例上肢可外展80°,肌力M_3~+.3例手部握持力与术前相同,2例增强.4例手部尺神经供区功能无明显影响,1例小指掌侧皮肤感觉减退,第一骨间背侧肌萎缩.结论 尺神经部分束支转位修复肱二头肌支可以有效的恢复臂丛损伤后屈肘功能;用膈神经修复肩胛上神经可能取得更好的肩外展和上举效果;本组臂丛下干部分损伤的病例受伤均在3个月内,采用此术式同样恢复了肱二头肌功能,未加重原有的手功能障碍.     

骨间前神经旋前方肌支移位在高位尺神经损伤中的应用

目的研究高位尺神经损伤后用骨间前神经旋前方肌肌支移位修复尺神经深支的手术方法。方法2002年10月-2005年8月，对18例高位尺神经损伤的患者，应用骨间前神经旋前方肌肌支移位与尺神经腕部深支进行吻合。结果术后15例获得随访，随访时间为3个月～3年，平均1．7年。手内肌肌力恢复M2 2例，M3 2例，M4 6例，M5 5例，优良率为73％。结论骨间前神经旋前方肌支转位修复尺神经深支可达到肌支-肌支修复，缩短了神经再生的距离和时间，有利于手内在肌功能的恢复，是一种有效的手术方法。     

Intraneural ganglion cyst of the ulnar nerve causing cubital tunnel syndrome masquerading a peripheral nerve abscess of a neuritic leprosy

Cubital tunnel syndrome is a common entrapment neuropathy affecting the ulnar nerve. Intraneural ganglion cyst and nerve abscess due to leprosy can cause cubital tunnel syndrome. In this article, we are presenting a case of cubital tunnel syndrome caused due to an intraneural ganglion cyst in a 48-year-old lady. It had produced some diagnostic confusion due to its clinical similarity with nerve abscess. This is the first report of a case of an intraneural ganglion cyst of the ulnar nerve masquerading the diagnosis of a nerve abscess.     

尺神经手背支卡压所致腕尺侧痛的解剖和临床研究

目的 对尺神经手背支卡压引起腕尺侧痛的机理进行研究并探讨尺神经手背支卡压症的诊断和治疗。方法 对40侧福尔马林固定的成人尸体前臂部和腕部进行大体解剖和显微解剖。在临床上诊治了13例尺神经手背支卡压的病例并进行分析。结果 尺神经手背支在尺骨茎突以近5.6-6.8cm处尺侧腕屈肌（腱）深面内侧缘穿出,紧贴尺骨行走,在尺骨小头内侧分成2－3大支,其中的横支紧贴骨膜,横跨尺骨小头或绕经尺骨小头远端斜行向桡侧,腕关节活动和尺骨小头的位置改变极易对其造成损伤。临床发现患该症的患者尺骨小头远端或尺侧缘有一显著而局限的压痛点,其周围有局部的皮肤感觉改变。13个病例中,7例局部封闭,6例手术,其中9例随访4个月－1年,未见复发。结论 腕关节反复屈伸时尺神经手背支尤其是横支被牵拉和压迫是造成尺神经手背支卡压的解剖学基础。临床上对腕尺侧痛并有皮肤感觉改变的病例,应考虑尺神经手背支卡压的可能性。