General Guideline Principles for Ulnar Nerve Entrapment at the
Wrist (Including Guyon’s Canal Syndrome and Hypothenar
Hammer Syndrome) for workers compensation patients

The New York State workers compensation board has developed these guidelines to help physicians, podiatrists, and other healthcare professionals provide appropriate treatment for Ulnar Nerve Entrapment at the Wrist (Including Guyon’s Canal Syndrome and Hypothenar Hammer Syndrome).

These Workers Compensation Board guidelines are intended to assist healthcare professionals in making decisions regarding the appropriate level of care for their patients with ankle and foot disorders.

The guidelines are not a substitute for clinical judgement or professional experience. The ultimate decision regarding care must be made by the patient in consultation with his or her healthcare provider.

Ulnar Nerve Entrapment at the Wrist (Including Guyon’s Canal Syndrome and Hypothenar Hammer Syndrome) of Hand, Wrist and Forearm Injuries

Ulnar nerve entrapment involves delayed ulnar nerve conduction and the corresponding symptoms. Clinical symptoms can be predicted based on where the ulnar nerve lesion is located as it passes through Guyon’s canal and the wrist.

The tendons and their tenosynovium do not accompany the nerve in this canal, which makes most of the commonly postulated causal mechanisms for carpal tunnel syndrome impossible. However, one postulated occupational mechanism involves using the hypothenar region of the hand as a hammer.

Diagnostic Studies of Ulnar Nerve Entrapment at the Wrist (Including Guyon’s Canal Syndrome and Hypothenar Hammer Syndrome)

1. Diagnostic Electrodiagnostic Studies

   Diagnostic Electrodiagnostic Studies is recommended to confirm a clinical suspicion of wrist-based ulnar nerve entrapment.Rationale for Recommendation – Studies must be carried out by qualified electrodiagnosticians, ideally those who have earned certification from the American Board of Electrodiagnostic Medicine.

    

2. MRI or Ultrasound

   MRI or Ultrasound are not recommended to identify wrist ulnar nerve entrapment.MRI or Ultrasound are recommended regarding a possible soft tissue mass. In general, soft tissue masses like ganglion cysts are better treated with an MRI. Ulnar Nerve Entrapment at the Wrist: MRI and Ultrasound Data to Support Use

    

3. CT

   CT is recommended if a hook of the hamate fracture is suspected based on the history, a potential fracture mechanism, focal pain at the hamate, and where there are ulnar nerve symptoms, to diagnose ulnar nerve entrapment at the wrist. For the evaluation of fractures, CT is preferred.

Medications of Ulnar Nerve Entrapment at the Wrist (Including Guyon’s Canal Syndrome and Hypothenar Hammer Syndrome)

Ibuprofen, naproxen, or other NSAIDs from an earlier generation are suggested as first-line treatments for the majority of patients. For patients who are not candidates for NSAIDs, acetaminophen (or the analogue paracetamol) may be a viable alternative, even though the majority of research indicates it is only marginally less effective than NSAIDs.

There is proof that NSAIDs are less dangerous and just as effective at treating pain as opioids, such as tramadol.

1. Non-Steroidal Anti-inflammatory Drugs (NSAIDs) for Treatment of Acute, Subacute, or Chronic Ulnar Nerve Compression at the Wrist

   Non-Steroidal Anti-inflammatory Drugs (NSAIDs) for Treatment of Acute, Subacute, or Chronic Ulnar Nerve Compression at the Wrist are recommended for the treatment of wrist ulnar nerve compression that is either acute, subacute, or chronic.

   Indications – NSAIDs are advised as a treatment for acute, subacute, or chronic ulnar nerve compression at the wrist. First, try over-the-counter (OTC) medications to see if they work. As needed use may be appropriate for many patients in terms of frequency and duration

   Indications for Discontinuation: Symptoms go away, the medication is ineffective, or negative side effects arise that require stopping the medication.

    

2. NSAIDs for Patients at High Risk of Gastrointestinal Bleeding

   NSAIDs for Patients at High Risk of Gastrointestinal Bleeding is recommended for patients at high risk of gastrointestinal bleeding to take misoprostol, sucralfate, histamine Type 2 receptor blockers, and proton pump inhibitors concurrently.

   Indications: Cytoprotective drugs should be taken into consideration for patients with a high-risk factor profile who also have indications for NSAIDs, especially if a longer course of treatment is planned. Patients who have a history of gastrointestinal bleeding in the past, the elderly, diabetics, and smokers are at risk.

   Frequency/Dose/Duration: H2 blockers, misoprostol, sucralfate, and proton pump inhibitors are advised. dosage recommendations from the manufacturer. It is generally accepted that there are no significant differences in effectiveness for preventing gastrointestinal bleeding.

   Discontinuation: Intolerance, the emergence of negative effects, or the stopping of NSAIDs.

    

3. NSAIDs for Patients at Risk for Cardiovascular Adverse Effects

   Patients with known cardiovascular disease or multiple risk factors for cardiovascular disease should have the risks and benefits of NSAID therapy for pain discussed.

    

   • NSAIDs for Patients at Risk for Cardiovascular Adverse Effects

     NSAIDs for Patients at Risk for Cardiovascular Adverse Effects is recommended As far as adverse cardiovascular effects go, acetaminophen or aspirin as first-line therapy seem to be the safest options.

      

   • NSAIDs for Patients at Risk for Cardiovascular Adverse Effects

     NSAIDs for Patients at Risk for Cardiovascular Adverse Effects is recommended As far as adverse cardiovascular effects go, acetaminophen or aspirin as first-line therapy seem to be the safest options.

     The NSAID should be taken at least 30 minutes after or 8 hours before the daily aspirin to reduce the chance that it will negate the protective effects of aspirin, whether for primary or secondary cardiovascular disease prevention.

      

4. Acetaminophen for Treatment of Ulnar Nerve Compression at the Wrist Pain

   Acetaminophen for Treatment of Ulnar Nerve Compression at the Wrist Pain is recommended for the treatment of ulnar nerve compression at the wrist pain, especially in patients who have medical conditions that make NSAIDs contraindicated.

   Indications: All patients, including those with acute, subacute, chronic, and post-operative ulnar nerve compression at the wrist pain.

   Dose/Frequency: As per the manufacturer’s recommendations; can be used as required. Over four gm/day, there is evidence of hepatic toxicity.

   Indications for Discontinuation: pain, side effects, or intolerance are gone.

    

5. Opioids of Ulnar Nerve Entrapment at the Wrist (Including Guyon’s Canal Syndrome and Hypothenar Hammer Syndrome)

   Opioids of Ulnar Nerve Entrapment at the Wrist (Including Guyon’s Canal Syndrome and Hypothenar Hammer Syndrome) is not recommended for ulnar nerve entrapment at the wrist that is either acute, subacute, or chronic.

   Opioids of Ulnar Nerve Entrapment at the Wrist (Including Guyon’s Canal Syndrome and Hypothenar Hammer Syndrome) is recommended for brief (no longer than seven days) use as an adjunctive therapy to more potent treatments for postoperative pain management.

   Indications: A brief prescription of opioids is frequently needed for post-operative pain management, especially at night, as an adjunct to more effective treatments (especially NSAIDs, acetaminophen).

   Frequency/Duration: As needed during the day, only at night later, and finally completely discontinued.

   Rationale for Recommendation: When NSAIDs are ineffective in relieving a patient’s pain, opioids should be used sparingly, especially at night. Opioids are advised for brief, selective use in postoperative patients, with nighttime use being the main recommendation for achieving postoperative sleep.

    

6. Glucocorticosteroids – Oral and/or Injected

   Glucocorticosteroids – Oral and/or Injected is not recommended for the treatment of wrist ulnar nerve compression that is either acute, subacute, or chronic.

Treatments Opioids of Ulnar Nerve Entrapment at the Wrist (Including Guyon’s Canal Syndrome and Hypothenar Hammer Syndrome)

Neutral Wrist Splinting

Neutral Wrist Splinting is recommended as a first-line therapy for ulnar nerve compression at the wrist that is acute, subacute, or persistent
Rehabilitation of Ulnar Nerve Entrapment at the Wrist (Including Guyon’s Canal Syndrome and Hypothenar Hammer Syndrome)

Rehab (supervised formal therapy) needed after a work-related injury should be concentrated on regaining the functional ability needed to meet the patient’s daily and work obligations and enable them to return to work, with the goal of returning the injured worker to their pre-injury status to the extent that is practical.

Active therapy calls for the patient to put forth an internal effort to finish a particular exercise or task. The interventions known as passive therapy rely on modalities that are administered by a therapist rather than the patient exerting any effort on their part.

Passive interventions are typically seen as a way to speed up an active therapy programme and achieve concurrently objective functional gains. Over passive interventions, active interventions should be prioritised.

To maintain improvement levels, the patient should be advised to continue both active and passive therapies at home as an extension of the therapeutic process.

To facilitate functional gains, assistive devices may be used as an adjunctive measure in the rehabilitation plan.

Therapy – Active of Ulnar Nerve Entrapment at the Wrist (Including Guyon’s Canal Syndrome and Hypothenar Hammer Syndrome)

Therapeutic Exercise

Therapeutic Exercise is not recommended for severe wrist ulnar nerve compression

Therapeutic Exercise is recommended for use after surgery to treat wrist ulnar nerve compression

Therapeutic Exercise is recommended if functional deficits are present, for subacute and chronic ulnar nerve compression at the wrist.

Rationale for Recommendation – In general, acute exercise is not recommended; however, recovery or postoperative phases may require exercise. Increased grip strength, key pinch strength, range of motion, and the development of work skills should all be considered functional goals.

Frequency/Dose/Duration –With documentation of ongoing objective functional improvement, the total number of visits may be as low as two to three for patients with mild functional deficits or as high as 12 to 15 for those with more severe deficits.

If there is evidence of functional improvement toward specific objective functional goals, more than 12 to 15 visits may be necessary when there are persistent functional deficits (e.g., increased grip strength, key pinch strength, range of motion, advancing ability to perform work activities).

A home exercise programme should be created as part of the rehabilitation strategy and carried out alongside the therapy.

Therapy – Passive of Ulnar Nerve Entrapment at the Wrist (Including Guyon’s Canal Syndrome and Hypothenar Hammer Syndrome)

1. Ice – Self-application

   Ice – Self-application is recommended for the treatment of radial nerve entrapment that is either acute, subacute, or chronic.

    

2. Heat – Self-appliation

   Heat – Self-appliation is recommended for the treatment of radial nerve entrapment that is either acute, subacute, or chronic.

    

3. Manipulation/Mobilization

   Manipulation/Mobilization is not recommended for the treatment of radial nerve entrapment that is acute, subacute, or chronic.

   Iontophoresis

   Iontophoresis is not recommended for the treatment of radial nerve entrapment that is either acute, subacute, or chronic.

    

4. Massage, Friction Massage

   Massage, Friction Massage is not recommended for the treatment of acute, subacute, or chronic radial nerve entrapment.

    

5. Acupuncture

   Acupuncture is not recommended for the treatment of acute, subacute, or chronic radial nerve entrapment. Evidence for Ulnar Neuropathy at the Wrist: Physical Methods and Rehabilitation

    

6. Activity Modification

   Activity Modification is recommended For the treatment of ulnar nerve compression at the wrist, it is advised to avoid significant localised mechanical compression of the nerve or using the hand as a hammer.

Surgery of Ulnar Nerve Entrapment at the Wrist (Including Guyon’s Canal Syndrome and Hypothenar Hammer Syndrome)

Surgical Decompression

Surgical Decompression is recommended if non-operative treatment for subacute or chronic ulnar nerve compression at the wrist fails or if space-occupying lesions are present

Rationale for Recommendation – It is advised for certain patients who have tried and failed other non-operative treatments or if there are lesions that take up a lot of space. Additionally, those with diabetes mellitus may benefit more from it.

What our office can do if you have Ulnar Nerve Entrapment at the Wrist (Including Guyon’s Canal Syndrome and Hypothenar Hammer Syndrome)

We have the experience to help you with their workers compensation injuries. We understand what you are going through and will meet your medical needs and follow the guidelines set by the New York State Workers Compensation Board.

We understand the importance of your workers compensation cases. Let us help you navigate through the maze of dealing with the workers compensation insurance company and your employer.

We understand that this is a stressful time for you and your family. If you would like to schedule an appointment, please contact us so we will do everything we can to make it as easy on you as possible.