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Guyon's Canal Lipoma Causing Ulnar Neuropathy

¹ Department of Radiology, Wake Forest University School of Medicine, Medical Center Blvd., Winston-Salem, NC 27157-1088.
² Department of Radiology, Keller Army Community Hospital, West Point, NY 10996-1197.
³ Department of Radiology, Madigan Army Medical Center, Bldg. 9040, Fitzsimmons Dr., Tacoma, WA 98431.
⁴ Department of Surgical Pathology, Madigan Army Medical Center, Tacoma, WA 98431.
⁵ Orthopedic Service, Department of Surgery, Madigan Army Medical Center, Tacoma, WA 98431.

Received September 28, 2001; accepted after revision December 6, 2001.

 
From the radiologic—pathologic correlation conferences of Madigan Army Medical Center.

The opinions and assertions contained herein are those of the authors and should not be construed as official or as representing the opinions of the Department of the Army or the Department of Defense.

Address correspondence to L. T. Bui-Mansfield.

Introduction

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A 64-year-old man presented with a chronic history of ulnar-sided pain and paresthesia in his left hand. The physical examination revealed a soft-tissue mass in the palmar aspect of the wrist. Radiographs showed a radiolucent soft-tissue mass in the volar aspect of the wrist (Fig. 1A). The MR examination revealed a lipomatous mass in Guyon's canal that splayed the ulnar artery and nerve and displaced the carpal tunnel radially (Figs. 1B and 1C). The mass was completely excised. Histology showed mature adipose tissue consistent with a lipoma (Fig. 1D).

View larger version (109K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A. —64-year-old man with Guyon's canal lipoma causing ulnar neuropathy. Lateral radiograph of wrist shows radiolucent mass (arrow) in volar aspect of wrist.

View larger version (113K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B. —64-year-old man with Guyon's canal lipoma causing ulnar neuropathy. Sagittal T1-weighted MR image of wrist reveals lipomatous mass (L) in Guyon's canal.

View larger version (126K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C. —64-year-old man with Guyon's canal lipoma causing ulnar neuropathy. Axial T1-weighted MR image of wrist shows lipomatous mass (I) in Guyon's canal splaying ulnar artery (arrow) and nerve (arrowhead).

View larger version (163K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1D. —64-year-old man with Guyon's canal lipoma causing ulnar neuropathy. Photomicrograph of pathology specimen shows mature adipose tissue consistent with lipoma. Cells are of variable size, with small peripheral nuclei that lack atypia. (H and E, x400)

Guyon's canal is also known as the "pisohamate tunnel" or the "distal ulnar tunnel." The roof of the tunnel consists of the palmar carpal ligament, the palmaris brevis, and the hypothenar fat and fibrous tissue. The tendons of the flexor digitorum profundus, the transverse carpal ligament, the pisohamate and pisometacarpal ligaments, and the opponens digiti minimi form the floor of the tunnel. The medial wall includes the flexor carpi ulnaris, the pisiform, and the abductor digiti minimi manus. The tendons of the extrinsic flexors, the transverse carpal ligament, and the hook of the hamate constitute the lateral wall.

Guyon's canal consists of three zones. Zone 1 extends from the proximal edge of the palmar carpal ligament to the bifurcation of the ulnar nerve. Zones 2 and 3 are adjacent to each other, extending from the bifurcation of the ulnar nerve just distal to the fibrous arch of the hypothenar muscles. These zones contain the deep motor branch and the superficial sensory branch of the ulnar nerve, respectively. Clinical symptoms correlate with the zone in which ulnar nerve compression occurs: combined motor and sensory deficits occur in zone 1 lesions; pure motor deficits, in zone 2 lesions; and isolated sensory deficits, in zone 3 lesions.

Compressive neuropathies of the ulnar nerve occur most commonly at the elbow and less commonly at the wrist [1]. The most common causes of ulnar nerve compression at the wrist are ganglia, fractures, anomalous muscles, thrombosis, bursitis, and a thickened pisohamate ligament [2]. Repeated blunt trauma to the hypothenar area may cause ulnar neuritis, which is commonly seen in chiropractors, bikers, and construction workers [1].

Physical examination may reveal the presence of Tinel's sign, swelling, discoloration, or a palpable mass. When a vascular lesion is suspected, listening for a bruit and performing the Allen test and Doppler sonography are helpful. Electrodiagnostic studies are useful but are not always diagnostic. MR imaging is the most helpful radiologic examination.

Lipoma of the Guyon's canal is a rare cause of ulnar neuropathy [3, 4]. Treatment involves complete excision of the lipoma.

References

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1. Posner MA. Compressive neuropathies of the ulnar nerve at the elbow and wrist. Instr Course Lect 2000;49:305 -317[Medline]
2. Gross MS, Gelberman RH. The anatomy of the distal ulnar tunnel. Clin Orthop 1985;196:238 -247
3. McFarland GB, Hoffer MM. Paralysis of the intrinsic muscles of the hand secondary to lipoma in Guyon's tunnel. J Bone Joint Surg Am 1971;53:375 -376[Abstract/Free Full Text]
4. Zahrawi F. Acute compression ulnar neuropathy at Guyon's canal resulting from lipoma. J Hand Surg Am 1984;9:238 -240[Medline]

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