We describe a case of an 8-year-old boy who developed a combined motor and sensory neuropathy of the distal ulnar nerve, after sustaining a superficial injury to the right flexor carpi ulnaris tendon at the level of the distal wrist crease. Guyon's canal syndrome is a very rare entity during childhood. We have noted only one prior description of this syndrome in the pediatric age group in a review of the English literature

Doğramacı, Yunus

Kalacı, Aydıner

Sevinç, Teoman Toni

Yanat, Ahmet Nedim

English

PubMed

Aydıner Kalacı

Yunus Doğramacı

Teoman Sevinç

Ahmet Yanat

Crossref

Guyon tunnel syndrome secondary to excessive healing tissue in a child: a case report

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BioMed Central
Journal of Brachial Plexus and 
Peripheral Nerve Injury
ssOpen AcceCase report
Guyon tunnel syndrome secondary to excessive healing tissue in a 
child: a case report
Aydıner Kalacı*, Yunus Doğramacı, Teoman Toni Sevinç and 
Ahmet Nedim Yanat
Address: Dept. of Orthopaedics and Traumatology, Mustafa Kemal University, Faculty of Medicine, Antakya, Hatay, Turkey
Email: Aydıner Kalacı* - orthopedi@gmail.com; Yunus Doğramacı - yunus_latif85@hotmail.com; Teoman Toni Sevinç - sevinctt@mynet.com; 
Ahmet Nedim Yanat - an_yanat@yahoo.com
* Corresponding author    
Abstract
We describe a case of an 8-year-old boy who developed a combined motor and sensory
neuropathy of the distal ulnar nerve, after sustaining a superficial injury to the right flexor carpi
ulnaris tendon at the level of the distal wrist crease. Guyon's canal syndrome is a very rare entity
during childhood. We have noted only one prior description of this syndrome in the pediatric age
group in a review of the English literature.
Background
The distal ulnar tunnel, Guyon's canal, is 4–4.5 cm long.
It begins at the proximal edge of the palmar carpal liga-
ment and extends to the fibrous arch of the hypothenar
muscles. The tunnel has frequently changing boundaries
and does not have four distinct walls throughout its
course. From proximal to distal, the roof consists of the
palmar carpal ligament, the palmaris brevis, and the
hypothenar fibrous and fatty tissue. The floor of the tun-
nel is made up of the flexor digitorium profundus, the
transverse carpal ligament, the piso-hamate and piso-met-
acarpal ligament and the opponens digiti minimi. The
flexor carpi ulnaris, the pisiform, and the abductor digiti
minimi constitute the medial wall. The lateral wall is com-
posed of the tendons of the extrinsic flexors, the transverse
carpal ligament, and the hook of the hamate [1].
There are four levels in which the ulnar nerve may be com-
pressed at the wrist and hand: 1) The main trunk of the
nerve at the entrance to, or within Guyon's canal. These
lesions produce sensory loss in the distribution of the
superficial termination branch and weakness of all the
ulnar-innervated intrinsic muscles. 2) The deep terminal
motor branch of the ulnar nerve distal to Guyon's canal
but proximal to the branches that innervate the abductor
digiti minimi (hypothenar muscles). This produces weak-
ness of all ulnar-innervated muscles of the hand without
sensory loss. 3) The deep motor branch distal to the
branches that innervate the abductor digiti minimi and
the hypothenar muscles. This produces no sensory loss
but there is weakness of all the ulnar innervated intrinsic
hand muscles except the hypothenar muscles. 4) The
superficial terminal sensory branch which produces sen-
sory loss without muscle weakness [2].
Guyon's syndrome in the paediatric age group is
extremely rare; a search of the literature in English yielded
one case [3]. To our knowledge, this is the first reported
case of an isolated Guyon's syndrome secondary to an
injury of the flexor carpi ulnaris in a child.
Published: 28 May 2008
Journal of Brachial Plexus and Peripheral Nerve Injury 2008, 3:16 doi:10.1186/1749-7221-3-16
Received: 16 December 2007
Accepted: 28 May 2008
This article is available from: http://www.jbppni.com/content/3/1/16
© 2008 Kalacı et al; licensee BioMed Central Ltd. 
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 3
(page number not for citation purposes)
Journal of Brachial Plexus and Peripheral Nerve Injury 2008, 3:16 http://www.jbppni.com/content/3/1/16Case presentation
An 8-year-old boy presented to our clinic complaining of
numbness of the little finger and the ulnar aspect of the
ring finger. Ten days prior to presentation, the patient sus-
tained a 1 cm laceration at the level of the distal wrist
crease after falling on a piece of broken glass. On exami-
nation, he had weakness of abduction and adduction of
the fingers. Movement of the thumb was unaffected.
The injury was managed at the emergency department by
thorough wound irrigation. There was a partial irregular
cut of about 30% of the radial aspect of the FCU with
intact ulnar nerve and ulnar artery. The skin was sutured.
After the primary management the patient was sent to our
orthopaedic clinic for further follow up. The initial exam-
ination one week after the injury revealed a clean wound,
no hematoma or swelling, normal sensation of the fifth
and ulnar side of the fourth finger, and normal abduction
and adduction of the digits. However a gradual numbness
and weakness of intrinsic hand muscles was noted after 10
days that gradually worsened. On subsequent follow up a
total ulnar nerve deficit was noted distal to the injury, at
the wrist level involving motor and sensory branches.
Three weeks after the initial injury he developed marked
weakness of all ulnar supplied intrinsic muscles with total
sensory loss at the fifth and the ulnar side of the fourth
fingers. Due to the progressive nature of his symptoms,
exploration and decompression of the Guyon's canal was
done under general anaesthesia. Exploration revealed nor-
mal healing of skin and subcutaneous tissue with exces-
sive scar tissue at the radial edge of the FCU which
spanned the ulnar nerve, narrowing the entrance of
Guyon's canal and causing severe compression and cicri-
atrical constriction of the nerve.
The ulnar nerve was completely intact (Fig. 1). No organ-
ized hematoma or lesion of ulnar artery was observed.
Adhesions were released, excised and Guyon's canal was
completely released. Physiotherapy was started immedi-
ately post-operatively, encouraging the patient to move
the wrist and fingers. Sensation was markedly improved
by the first post-operative day with nearly complete return
of motor function at one week. At three months, the
recovery was complete.
Discussion
Intrinsic lesions (ganglia, lipoma, cysts, anomalies of lig-
aments or muscles, ulnar artery aneurysms, fracture of
hook of the hamate) as well as extrinsic pathologies
(chronic repetitive trauma) can damage the terminal
superficial and/or deep branches of the ulnar nerve at the
wrist and at the hand leading to distinct clinical features
[2-4].
The most common lesion, to the proximal Guyon's canal
(Type 1), is characterised by sensory loss at the ulnar por-
tion of the hand and weakness of all ulnar intrinsic hand
muscles (mixed sensory-motor dysfunction), whereas a
more distal lesion within Guyon's canal (Types 2 and 3)
causes an isolated palsy of the deep terminal motor
branch without sensory loss (pure motor dysfunction)
[2,4,5]. Numerous occupations and pastimes that are
associated with ulnar neuropathy have been described in
the literature. These include bicycle riding, pizza cutting,
and prolonged playing of video games, karate, and inten-
sive use of a computer mouse [6,7]. Traumatic causes of
ulnar neuropathies at the wrist include fractures of the dis-
tal radius or ulna and of the carpal bones [8]. In our case,
ulnar nerve compression was secondary to excessive cica-
tricial tissue from a partial laceration of the flexor carpi
ulnaris tendon at the proximal margin of Guyon's canal,
which was not repaired.
To our knowledge this is the first case in the literature pub-
lished in English language which reports Guyon's syn-
drome secondary to excessive healing tissue following
partial tendon injury in the paediatric age group. This may
be attributable to the high healing potential in paediatric
patients. In addition, the experience of this case presents a
challenge to the current dogma of withholding repair of
tendon lacerations of less than 60% of the tendon's cross-
sectional area [9].
Conclusion
In the paediatric age group, glass penetrating injuries in
proximity to neurovascular structures are best explored
irrespective of distal neurologic deficits. Clearly the surgi-
cal exploration should not supplant a thorough preopera-
tive clinical examination. The potential for otherwise
missing incomplete tendon and vascular injuries is high.
The ulnar nerve after release of the adhesion at the entry of the Guyon's canal; the  is marked compression and some proxim l bulging of the n rv  at site of the ad sion (Black ar ow)Figure 1
The ulnar nerve after release of the adhesion at the entry of 
the Guyon's canal; there is marked compression and some 
proximal bulging of the nerve at the site of the adhesion 
(Black arrow).Page 2 of 3
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BioMedcentral
It also gives one the opportunity to more thoroughly irri-
gate the wound and evaluate hematomas.
A neuroma-in-continuity found at delayed exploration is
more difficult to treat than the original acute injury. Sur-
gical exploration is indicated in all lacerations of the hand
and upper extremity unless the level of injury is suffi-
ciently superficial to enable exlusion of damage to vital
structures in the emergency department. The experience of
this case presents a challenge to the current dogma of indi-
cations for tendon repair, especially in the paediatric pop-
ulation.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
AK carried out the operation, YD participated in the
sequence alignment and drafted the manuscript, TTS and
ANY participated in the design and coordination of the
manuscript. All authors read and approved the final man-
uscript.
Consent
"Written informed consent was obtained from the patient
for publication of this Case report and accompanying
images. A copy of the written consent is available for
review by the editor-in-chief of this journal.
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(page number not for citation purposes)


Abstract We describe a case of an 8-year-old boy who developed a combined motor and sensory neuropathy of the distal ulnar nerve, after sustaining a superficial injury to the right flexor carpi ulnaris tendon at the level of the distal wrist crease. Guyon's canal syndrome is a very rare entity during childhood. We have noted only one prior description of this syndrome in the pediatric age group in a review of the English literature.</p

Sevinç Teoman

Doğramacı Yunus

Kalacı Aydıner

Yanat Ahmet

Directory of Open Access Journals

Journal of Brachial Plexus and Peripheral Nerve Injury

AJ: Ulnar nerve entrapment at the wrist. In Entrapment neuropathies 3rd edition. Edited by:

Compression syndrome of the motor branch of the ulnar nerve. Case report and review of the literature. Chirurg

Flexor tendon injury(Acute injuries). In Green's Operative Hand Surgery. Part 2 5th edition. Edited by:

Gelberman RH: Acute ulnar neuropathy with fractures at the wrist.

Gelberman RH: The anatomy of the distal ulnar tunnel. Clin Orthop Relat Res

Mouse&quot;-trap or personal computer palsy. Lancet

Thoracic outlet syndrome combined with carpal tunnel syndrome and Guyon canal syndrome in a child. J Orthop Sci

Ulnar neuropathies at the wrist and the hand. In Focal peripheral neuropathies 2nd edition. Edited by: Stewart JD.

Video-game palsy: distal ulnar neuropathy in a video-game enthusiast.

http://citeseerx.ist.psu.edu/viewdoc/summary?doi=10.1.1.274.7574

Guyon tunnel syndrome secondary to excessive healing tissue in a child: a case report

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