Position Change of the Neurovascular Structures around the Carpal Tunnel with Dynamic Wrist Motion

Abstract

Objective : The purpose of this study was to determine the anatomic relationships between neurovascular structures and the transverse carpal ligament so as to avoid complications during endoscopic carpal tunnel surgery. Methods : Twenty-eight patients (age range, 35-69 years) with carpal tunnel syndrome were entered into the study. We examined through wrist magnetic resonance imaging in three different positions (neutral, radial flexion, and ulnar flexion) and determined several anatomic landmark (distance from the hamate hook to the median nerve, ulnar nerve, and ulnar vessel) based on the lateral margin of the hook of the hamate. The median nerve and ulnar neurovascular structure were studied with the wrist in the neutral, ulnar, and radial flexion positions. Results : The ulnar neurovascular structures usually passed just over or ulnar to the hook of the hamate. However, in 12 hands, a looped ulnar artery coursed 0.6-3.3 mm radial to the hook of the hamate and continued to the superficial palmar arch. The looped ulnar artery migrates on the ulnar side of Guyon's canal (-5.2-1.8 mm radial to the hook of the hamate) with the wrist in radial flexion. During ulnar flexion of the wrist, the ulnar artery shifts more radially beyond the hook of the hamate (-2.5-5.7 mm). Conclusion : It is appropriate to transect the ligament greater than 4 mm apart from the lateral margin of the hook of the hamate without placing the edge of the scalpel toward the ulnar side. We would also recommend not transecting the transverse carpal ligament in the ulnar flexed wrist position to protect the ulnar neurovascular structure.

Ulnar nerve cutaneous distribution in the palm: Application to surgery of the hand

“…Also, clinicians unaware of the high division of the nerve in the forearm can put the nerve in danger during surgical intervention in the area. Moreover, variations of the UN in Guyon's canal can present as a complication or as inadvertent surgical injury in cases such as Guyon's canal decompression or carpal tunnel release (Netscher et al, 1996;Boughton et al 2010;Kwon et al, 2011). Bonnel and Vila (1985) were the first to classify the UN into two types according to its number of branches in Guyon's canal.…”