How to treat Guyon s canal syndrome? Results … to treat Guyon’s canal syndrome? Results from the...

How to treat Guyon’s canal syndrome? Results fromthe European HANDGUIDE study: a multidisciplinarytreatment guidelineP Hoogvliet,1 J H Coert,2 J Fridén,3 B M A Huisstede,1 the European HANDGUIDEgroup

1Department of RehabilitationMedicine and Physical Therapy,Erasmus MC—UniversityMedical Center Rotterdam,Rotterdam, The Netherlands2Department of Plastic &Reconstructive Surgery & HandSurgery, Erasmus MC—University Medical CenterRotterdam, Rotterdam,The Netherlands3Department of Hand Surgery,Sahlgrenska University Hospitaland Institute of ClinicalSciences, SahlgrenskaAcademy, University ofGothenburg, Gothenburg,Sweden

Correspondence toDr B M A Huisstede,Department of RehabilitationMedicine and Physical Therapy,Erasmus MC—UniversityMedical Center Rotterdam,Room H-016, PO Box 2040,Rotterdam 3000 CA,The Netherlands;[email protected]

Accepted 12 June 2013Published Online First31 July 2013

▸ http://dx.doi.org/10.1136/bjsports-2013-093010

To cite: Hoogvliet P,Coert JH, Fridén J, et al. Br JSports Med 2013;47:1063–1070.

ABSTRACTBackground Although Guyon’s canal syndrome is nothighly prevalent, a considerable knowledge of anatomyis needed to localise and treat the pathology. Data onthe effectiveness of interventions for this disorder arelacking.Objective To achieve consensus on a multidisciplinarytreatment guideline for this disorder based on experts’opinions.Methods A European Delphi consensus strategy wasinitiated. In total, 35 experts (hand surgeons/handtherapists selected by the national member associationsof their European federations and Physical Medicine andRehabilitation physicians) participated in the Delphiconsensus strategy. Each Delphi round consisted of aquestionnaire, an analysis and a feedback report.Results After three Delphi rounds, consensus wasachieved on the description, symptoms and diagnosis ofGuyon’s canal syndrome. The experts agreed thatpatients with this disorder should always receiveinstructions and that these instructions should becombined with another form of treatment. Instructionscombined with splinting or with surgery were consideredas suitable treatment options. Details on the use ofinstructions, splinting and surgery were described. Mainfactors for selecting one of the aforementionedtreatment options were identified: severity and durationof the syndrome and previous treatments given.A relation between the severity/duration and choice oftherapy was indicated by the experts and reported in theguideline.Conclusions Although this disorder is less prevalentand not easy to diagnose, this guideline may contributeto better insight into and treatment of Guyon’s canalsyndrome.

INTRODUCTIONAlthough Guyon’s canal syndrome is a relativelyuncommon condition, it is a well-recognised entityof upper extremity musculoskeletal disorders.1 2

This disorder, caused by compression of the ulnarnerve as it passes Guyon’s canal, can lead to a spec-trum of sensory and/or motor symptoms—depend-ing on the exact location of the compression. Thestructures that form Guyon’s canal, as described byBachoura et al,3 can be found in table 1.Guyon’s canal syndrome is commonly experi-

enced by avid bicyclists4 due to the prolonged pres-sures on the handlebars.5 Especially in downhillriding, a large part of the body weight is supportedby the hand on the handlebar leading to anincreased pressure at Guyon’s canal resulting in

compression of the ulnar nerve.6 The incidence orprevalence rates for Guyon’s canal syndrome arenot reported in the literature.Because the clinical pictures of this disorder can

vary, the clinical diagnosis is not always easy tomake, particularly when the sensory symptoms areatypical or absent.7 There are several anatomic var-iations of Guyon’s canal.8 Two studies8 9 foundanomalous muscles in Guyon’s canal in 53% and22%, respectively, of the wrists and one of thesestudies8 also found a hypoplastic hamulus, multipleulnar nerve branches and increased amount of fattissue inside Guyon’s canal in 2%, 30% and 12%,respectively. Consequently, precise knowledge ofwrist anatomy, as well as of places where entrap-ment of the ulnar nerve can occur, is necessary torecognise the different clinical pictures.7 10

Several reports on patients treated for Guyon’scanal syndrome are available,11–14 but most con-cerned reports of surgical treatment. Some authorsstate that patients with mild symptoms should pri-marily be treated by non-surgical interventionsincluding rest, avoiding pressure on the ulnarnerve, splinting or anti-inflammatory medica-tion.4 7 15 Those not responding to non-surgicaltreatment are candidates for surgery.15 16 However,no firm evidence-based recommendations for thetreatment of Guyon’s canal syndrome can be made,as no data are available from randomised clinicaltrials (RCTs) assessing the effectiveness of interven-tions for this disorder.17 To assist physicians andallied healthcare professionals in the managementof patients with Guyon’s canal syndrome, a consen-sus treatment protocol made by experts in this fieldis required. Therefore, a Delphi consensus strategywas initiated. In a Delphi consensus strategy, aseries of sequential questionnaires (or rounds) ispresented to a panel of experts, interspersed withcontrolled feedback with the aim of achieving con-sensus of opinion among these experts18; thismethod is useful when there is a lack of empiricalevidence.19 European hand surgeons, hand thera-pists and Physical Medicine and Rehabilitation(PM&R) physicians specialised in hand disorderscooperated in this study. The aim was to achievemultidisciplinary consensus on a treatment guide-line for Guyon’s canal syndrome, including non-surgical and surgical strategies.

METHODSSteering committee and advisory teamA steering committee to initiate and guide theHANDGUIDE study was composed and consisted

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of a hand surgeon, a PM&R physician and a physiotherapist. Allthree members have a clinical and a scientific and/or epidemio-logical background; they designed the questionnaires, analysedthe responses, and formulated the feedback reports. Further, anadvisory team (consisting of two professors of hand surgery, oneprofessor of PM&R and an internationally renowned hand ther-apist) was formed which could be consulted at any time andcould give their opinions and advice as they saw fit.

Preparation of the HANDGUIDE studyEvidence for effectiveness of interventionsTo establish an evidence-based starting point for theHANDGUIDE study, systematic reviews including RCTs wereconducted on the evidence for the effectiveness of non-surgical,surgical and postsurgical interventions for the five non-traumatichand disorders included in this study: trigger finger, deQuervain’s disease, Dupuytren’s disease, carpal tunnel syndromeand Guyon’s canal syndrome.20–22 Because no studies onGuyon’s canal syndrome were included in these reviews, no con-clusions could be drawn on the evidence for the effectiveness ofinterventions for Guyon’s canal syndrome (searches in PubMed,EMBASE, CINAHL and PEDro up to February 2009).

Delphi consensus strategyIn the absence of sufficient evidence-based information, Delphiconsensus strategies were performed to achieve consensus oneach treatment guideline.

Within the HANDGUIDE study, three Delphi consensus strat-egies were performed: (1) trigger finger and de Quervain’sdisease, (2) Dupuytren’s disease and (3) carpal tunnel syndromeand Guyon’s canal syndrome.

Selection of expertsThe study was supported by the Federation of EuropeanSocieties for Surgery of the Hand (FESSH) and the EuropeanFederation of Societies for Hand Therapy (EFSHT). Thenational member associations of FESSH and EFSHT selectedexperts in their respective fields. Each national member associ-ation was invited to select a maximum of three representativeexperts per Delphi consensus strategy. In addition, someEuropean PM&R physicians specialised in hand rehabilitationwere invited to participate in this study. All participating expertsfulfilled all the criteria listed in table 2.

ProcedureThe questionnaires of the Delphi rounds on Guyon’s canal syn-drome included questions on the description, symptoms, diag-nosis and interventions for this disease. In this Delphi consensus

strategy, only the physicians answered questions on medicationand injections and only the hand surgeons answered questionson surgery. All the remaining questions were answered by all theexperts.

We used structured questions with answer formats such as‘yes/no/no opinion’, after which the experts were invited toexplain their individual choices. After each round, a feedbackreport was made to inform the experts about the answers andargumentations of all experts and on which items consensus wasachieved. On the basis of the answers and arguments of theexperts, the steering committee formulated the questions for thefollowing questionnaire. Finally, conclusions were presented andexplained in the feedback report.

Cut-off point for consensusTo avoid any imprecise definition for consensus, the expertswere consulted about the cut-off point for consensus.23

A cut-off point of 70% was proposed in the first round of eachDelphi consensus strategy because it is often used in Delphi con-sensus strategies.2 24 In case of a consensus, this percentage wasalso calculated for each of the three participating professionalgroups. To reveal any discordant viewpoints between thesegroups, a remark was made in the report when less than 50% ofthe experts within a professional group answered in accordancewith the achieved consensus.

Target populationThe target population of the HANDGUIDE study was surgeons,other physicians and allied healthcare professionals involved inthe treatment of patients with the aforementioned handdisorders.

Delphi consensus strategy on Guyon’s canal syndromeDescription, symptoms and diagnosis of Guyon’s canal syndromeFirst-round questionnaireThe guideline will include short descriptions of Guyon’s canalsyndrome, the International Classification of Diseases, 10thRevision (ICD-10) code, the symptoms and its diagnosticprocess. In the first round, we included a description of each ofthese items and asked the experts if they agreed with thisdescription.

Second-round and third-round questionnairesThe questions of the second and third rounds were formulatedbased on the results of the first and second rounds, respectively.

Table 2 Experts’ criteria for participation in the Delphi consensusstrategy

Criteria

1 The expert* should be a medical or allied healthcare professional withconsiderable experience in treating patients with non-traumatictendinopathies of hand disorders (tendinopathies, Dupuytren’s disease orneuropathies)

2 The expert should be considered by their own professional specialty to be akey person in the field of non-traumatic hand disorders

3 The expert should have a basic knowledge on evidence-based practice

*Participating hand surgeons and hand therapists participated as delegates for theirrespective professional association.

Table 1 Structures forming Guyon’s canal

Anatomic site ofGuyon’s canal Structures

Roof Palmar carpal ligament, palmaris brevis andhypothenar connective tissue

Medial wall Pisiform, abductor digiti minimi and the tendon of theflexor carpi ulnaris

Lateral wall Hook of the hamate, the transverse carpal ligamentand the flexor tendons

Floor Transverse carpal ligament, pisohamate ligament,pisometacarpal ligament, tendons of the flexordigitorum profundus and opponens digiti minimi

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Interventions to treat Guyon’s canal syndromeFirst-round questionnaireIn the first-round questionnaire, the non-surgical (ie, instruc-tions for the patient, non-steroidal anti-inflammatory drugs(NSAIDs), splinting and corticosteroid injection) and surgicalinterventions often reported in (scientific) literature to be usedfor Guyon’s canal syndrome were listed. It was noted that in thescientific literature no evidence for the effectiveness of theseinterventions was found.

The aforementioned interventions were then discussed. Foreach intervention, questions were included about the usefulnessand the main factors for starting and discontinuing the interven-tion. To identify useful (combinations of) treatments and a thera-peutic hierarchy of interventions, the experts were asked if theinterventions could be used as sole treatment and/or combinedwith another treatment, whether a specific intervention is thefirst choice in treatment, and to identify the treatment strategy incase the intervention was insufficient. Additional questions wereincluded on the use of instructions for the patient, NSAIDs,splinting, corticosteroid injection and surgery. In all situationswhere options were suggested by the steering committee, theexperts were invited to provide additional options. In this way,we aimed to avoid any limitations in the experts’ choices.

Second-round questionnaireThe treatment options (and their combinations) mentioned bythe experts were summarised. In the second round, the expertswere asked to state (separately for each treatment option/com-bination of treatment options) whether they agreed that thistreatment option (or combination thereof) was applicable in thetreatment of Guyon’s canal syndrome.

On the basis of the answers given by the experts in the firstround, a therapeutic hierarchy was formulated (ie, from thelightest form of treatment to the most severe form of treatment)and the experts were asked if they agreed with this.

The experts were also asked what they considered as the mainfactors for choosing a certain treatment option and in what waythey believed these factors influenced their choice.

For questions relevant for each specific intervention for whichno consensus was achieved in the first round, new questionswere added in the second round.

Third-round questionnairesIn the third round, the summary of the consensus on the mainfactors for choosing a treatment option for Guyon’s canal syn-drome was combined and presented in one table.

Any remaining questions on this table and all other items forwhich no consensus was achieved in the second round wereadded in the third-round questionnaire.

AnalysisA qualitative and quantitative analysis was made of theresponses from the Delphi rounds. Quantitatively, for each ques-tion we reported the number and percentages of experts whogave a certain answer. Qualitatively, the rationale for theanswers given by each expert was reported.

RESULTSExpert panelA total of 112 experts (52 hand surgeons, 47 hand therapistsand 13 PM&R physicians) from 17 European countries wereselected to participate in one of the three Delphi consensusstrategies of the HANDGUIDE study, which was performedbetween June 2009 and December 2012.

For the Delphi consensus strategy on Guyon’s canal syn-drome, 36 experts were selected (18 hand surgeons, 13 handtherapists and 5 PM&R physicians). Of these, one expert (ahand surgeon) did not finish any of the questionnaires. Theresponse rates of the 35 remaining experts for rounds 1–3 were89%, 94% and 89%, respectively.

Table 3 lists the participating countries, the total number ofexperts of the HANDGUIDE study, the number of experts par-ticipating in the Delphi consensus strategy on Guyon’s canalsyndrome and their years of experience with this topic.

Results of Delphi consensus strategy on Guyon’s canalsyndromeConsensusCut-off point for consensusIn the first round, consensus was achieved on a cut-off point of70% for consensus. In this Delphi consensus strategy, there wasno discordant viewpoint between a professional group and thegeneral consensus.

Guideline for Guyon’s canal syndromeThree rounds were needed before consensus on the treatmentguideline for Guyon’s canal syndrome was achieved. The guide-line is reported in figure 1.

Description, symptoms and diagnosis of Guyon’s canal syndromeIn the first round, consensus was achieved on the short descrip-tion of Guyon’s canal syndrome, its ICD-10 code and

Table 3 Experts and participating countries

Participating countries and number of experts in the HANDGUIDE study

Profession(EuropeanFederation) Participating countries (in alphabetic order)

Total number of experts inthe HANDGUIDE study

Number of experts for Guyon’s canalsyndrome and years of experience, mean(range)

Hand surgeons(FESSH)

Belgium, Denmark, Estonia, Finland, France, Germany, Italy,Norway, the Netherlands, Spain, Sweden, Switzerland, Turkeyand the UK

52 17, 19.2 (7–37)

Hand therapists(EFSHT)

Belgium, Denmark, Finland, France, Italy, Norway, theNetherlands, Slovenia, Sweden, Switzerland, Turkey and the UK

47 13, 16.7 (2–30)

PM&R physicians(not applicable)

Austria, the Netherlands, Portugal , Slovenia, Switzerland andTurkey

13 5, 14.0 (8–20)

Total 112 35, 17.4 (3–37)

EFSHT, European Federation of Societies for Hand Therapy; FESSH, Federation of European Societies for Surgery of the Hand; PM&R, Physical Medicine and Rehabilitation.


Consensus statement




Figure 1 The multidisciplinary treatment guideline for Guyon’s canal syndrome.


Consensus statement




symptoms. In the second round, the experts agreed on the diag-nosis of the disorder.

Interventions to treat Guyon’s canal syndromeTreatment options and therapeutic hierarchyExperts did not add any interventions to the list of non-surgicaland surgical interventions (as described in the Methods section).In the first and second Delphi rounds, consensus was achievedthat NSAIDs and corticosteroid injections, respectively, are notuseful for the treatment of Guyon’s canal syndrome.

The experts agreed that instructions to the patient should notbe used as a sole treatment but always combined with anotherform of treatment. Consensus was achieved that instructionscombined with splinting or surgery are applicable treatmentoptions for Guyon’s canal syndrome. In the third Delphi round,the experts agreed on a therapeutic hierarchy (table 4).

Additional questions for instructions, splinting and surgeryFor instructions, splinting and surgery, consensus was achievedon the aim of the treatment. For the latter two treatments, con-sensus was achieved concerning when the treatment should beadjusted or discontinued. Other items for each specific treat-ment are discussed below.

Instructions to the patientConsensus was achieved that the following advice should begiven to the patient: (1) to avoid local pressure on Guyon’scanal, for example, by weight bearing or bicycling and (2) tolimit mechanical overload, for example, caused by repetitivemovements or static postures such as extension of the wrist.

SplintingIn the first-round questionnaire, two types of splints regularlyused in clinical practice to treat Guyon’s canal syndrome werepresented to the experts: wrist in neutral position with thefingers free, or the same splint with the fingers included in thesplint. No other splints were considered to be applicable.Consensus was achieved that a neutral splint with the fingersfree is preferable. In the first Delphi round, the experts agreedthat the splint should be used for a number of weeks.Consensus was achieved to use the splint for 1–12 weeks.Attempts to narrow this relatively wide range did not result inconsensus. Therefore, the guideline states that the duration ofsplinting should be somewhere between 1 and 12 weeks. Theexperts agreed that the splint should be worn at least during thenight. Further, although most experts indicated that the splintsshould also be used during the daytime in case of aggravatingactivities, no consensus on this point was achieved.

SurgeryConsensus was achieved on the use of open surgery (in prefer-ence to percutaneous or other surgical techniques) using a

Table 4 Therapeutic hierarchy of suitable treatments for Guyon’scanal syndrome

Therapeutic hierarchy*

1 IS (instructions plus splinting)2 IO (instructions plus operative treatment/surgery)

*A therapeutic hierarchy does not mean that all steps should always be performed foreach patient.

Figure 1 (Continued)


Consensus statement




regional anaesthetic technique (in preference to local, bierblock, general or other anaesthetic techniques). The woundshould be closed with non-resorbable sutures. No consensus wasachieved on a preferred incision. The experts indicated that thefollowing can be used for Guyon’s canal syndrome: (1) carpaltunnel incision, that is, longitudinal, extended proximally acrossthe wrist flexion crease with a transverse component at the wristcrease, (2) ulnar hypothenar approach, Brunner (extended ornot extended) and (3) the ulnar hypothenar approach, longitu-dinal (extended or not extended; figure 2).

Further, the experts agreed on recommendations to be given tothe patient for treatment of the primary postoperative period,that is, up to 10–15 days after surgery, until the sutures areremoved. After surgery for Guyon’s canal syndrome, a rehabilita-tion programme could be performed. Consensus was alsoachieved that instructions can be indicated after surgery.Futhermore, the experts agreed on the content of these instruc-tions. Postsurgical splinting after surgery is not routinely indi-cated: this is restricted to patients with severe pain after surgeryand those who have a tendency to put mechanical load on thecanal. Postsurgical exercises after surgery are indicated for thosewith reduced mobility of the hand, in case of oedema, if thepatient is afraid to use the hand, and to promote nerve glidingand strength of the muscles of the hand.

Other therapeutic interventionsAs suggested by several experts, the steering committee pro-posed to include the following note in the guideline:“Depending on the patient’s situation and personal preferences,additional therapeutic modalities, such as ultrasound or nervegliding exercises, can be added to the treatment”; however, noconsensus was achieved to add this note to the guideline.

Main factors for choosing a specific treatment optionIn the first Delphi round, experts’ answers suggested that themain factors for choosing a treatment option are: (1) the sever-ity of the syndrome, (2) the duration of the syndrome and (3)previous treatments given. The latter item was also incorporatedin the therapeutic hierarchy. The relation between severity/dur-ation and the choice of therapy was further explored in the con-secutive Delphi rounds.

In the first Delphi round, the experts described the severity ofGuyon’s canal syndrome in terms of the amount of severity ofsymptoms (mild, severe, etc) of numbness, pain, motor weak-ness and atrophy of the intrinsic muscle of the hand). The dur-ation of Guyon’s canal syndrome was expressed in terms of‘acute, subacute and chronic’ or by mentioning the exact dur-ation in terms of the number of weeks or months.

Combining these expressions for severity and durationresulted in the identification of five subgroups for both severityand duration (table 5).

In the second round, the experts were asked for what sub-group/subgroups of severity of symptoms the use of each suit-able treatment option, as listed in table 4, was indicated. Thesame was performed for the duration of the complaints.Subsequently, the steering committee calculated, for both sever-ity and duration, which subgroup(s) reached or exceeded thecut-off point of 70%. The results were combined and reportedin a table, as shown in the final guideline. In this table, each cellrepresents a subgroup of patients with a certain severity andduration of Guyon’s canal syndrome and the correspondingtreatment options. See the table in the guideline (figure 1). Theaim was to provide a complete overview of the treatmentoptions for all levels of duration and severity of a patient withthis disorder. However, after the third round, no consensus ontreatment options was achieved for some cells (ie, these cellsremain empty in the table). Because of the diversity of theexperts’ opinions, no consensus could be expected and it wasdecided not to initiate a fourth Delphi round. In the case of anempty cell, the treatment option(s) suggested by the majority ofthe experts was reported in the legend of the table.

DISCUSSIONIn this European study, consensus was achieved on a multidiscip-linary treatment guideline for Guyon’s canal syndrome. Becauseevidence for effectiveness of interventions to treat this syndromewas lacking, a Delphi consensus strategy was applied to gainadditional data for a multidisciplinary consensus.

Interventions to treat Guyon’s canal syndromeOnly instructions plus splinting (IS) or surgery (IO) were foundto be applicable in the treatment of Guyon’s canal syndrome.The main factors for using IS or IO were identified: severity,duration and previous treatments received. A relation betweenthe severity/duration and choice of therapy was indicated by the

Figure 2 Incisions used in surgery for Guyon’s canal syndrome. (A) Carpal tunnel incision, that is, longitudinal, extended proximally across thewrist flexion crease with a transverse component at the wrist crease. (B) Ulnar hypothenar approach, Brunner (not extended). (C) Ulnar hypothenarapproach, Brunner (extended). (D) Ulnar hypothenar approach, longitudinal (not extended). (E) Ulnar hypothenar approach, longitudinal (extended).Access the article online to view this figure in colour.

Table 5 Subgroups related to the severity and duration ofGuyon’s canal syndrome

5 Subgroups for severity5 Subgroups forduration

Symptoms Duration (stage)

1: very mild Very mild symptoms* 1: ≤1 month (acute)2: mild 2: 1≤2 months (subacute)3: moderate 3: 2≤3 months (subacute)4: severe 4: 3≤6 months (chronic)5: verysevere

Continuous, very severesymptoms†

5: ≥6 months (chronic)

*Very mild symptoms of numbness, pain, no motor weakness or atrophy of theintrinsic muscles of the hand.†Continuous, very severe symptoms of numbness, pain, significant motor weakness orsignificant atrophy of the intrinsic muscles of the hand.


Consensus statement




experts and reported in the guideline. The experts agreed thatIS can be used to treat the lightest forms of Guyon’s canal syn-drome (very mild to moderate symptoms with a duration of lessthan 3 months), and IO for the more severe forms of thisdisease (moderate to very severe symptoms with a duration of atleast 2 months).

As stated in the guideline, instructions to the patients shouldalways be given and should include advice in order to avoidactivities that cause mechanical loading of the ulnar nerve inGuyon’s canal. In case Guyon’s canal syndrome is caused bybicycling, individual adaptation of the handlebar and riding pos-ition can help in preventing this type of ulnar nervecompression.6

Consensus was achieved that a neutral wrist splint, fingersfree is preferable to treat Guyon’s canal syndrome. Consensuswas achieved to use the splint during 1–12 weeks. Attempts tonarrow this relatively wide range did not result in consensus.This may reflect the different types of underlying aetiology, butit may also reflect differences of personal preferences or differ-ent grades of severity of the syndrome. The exact cause(s) of apossible positive effect of splints incorporating the wrist but notthe fingers in this syndrome is unknown. An immobilising effecton aberrant muscles is unlikely because these are mainly acces-sories of the abductor digiti minimi.25 A volume-decreasingeffect on a ganglion is theoretically possible when this originatesfrom a carpal joint or flexor tendon sheath. An alternativeexplanation could be that splinting of the wrist decreases theamount of traction on the ulnar nerve that normally occurs withwrist movements.26

In the first Delphi round, 94.7% of the experts agreed thatNSAIDs are not useful for treating Guyon’s canal syndrome,and in the second round corticosteroid injections were judgedto be not useful for this purpose. Guyon’s canal is a very smallcanal. According to Bianchi and Martinoli,27 30–40% ofGuyon’s canal syndromes may be caused by ganglion cysts.Other causes include injuries of the ulnar artery causing throm-bosis and pseudoaneurysm formation. Also, anomalous muscles,such as abductor digiti minimi, within Guyon’s canal may leadto ulnar nerve compression. Further, Murata et al28 found that45% of cases were idiopathic. It remains questionable whetheror not corticosteroid injection can reduce the symptoms ofGuyon’s canal syndrome. It seems that, in most cases, the dis-order is caused by the presence of structures within or in thevicinity of Guyon’s canal but without a significant inflammatorycomponent. In these cases, the therapeutic effect of corticoster-oids seems unlikely, although a temporary positive effect of cor-ticosteroids in the absence of inflammation is reported in thetrigger finger.20 29 Nevertheless, because a comparable effectcould not be found in Guyon’s canal syndrome, it seems reason-able that the experts agreed to exclude corticosteroid injectionfrom the list of treatments for this disorder.

Other therapeutic interventionsTo indicate that the guideline concentrates on the most com-monly used interventions, but that additional therapeuticmodalities can be added, the steering committee (as suggestedby several experts) proposed to include the following note inthe guideline: “Depending on the patient’s situation and per-sonal preferences, additional therapeutic modalities such asultrasound or nerve gliding exercises can be added.” Althoughthe most commonly used interventions to treat Guyon’s canalsyndrome are a combination of instructions, splinting andsurgery, several other additional therapeutic modalities werementioned (including ultrasound and exercises such as nerve

gliding exercises). However, no consensus was achieved toinclude this note in the guideline. Inclusion of the note in theguideline would have strengthened the idea that the guidelineshould not be considered as a rigid set of rules. It describes themost favourable treatment options of a certain condition accord-ing to a certain group of experts at a certain period of time.

DiagnosisGuyon’s canal syndrome is sometimes difficult to diagnose dueto differences in clinical presentation7 and also because thereare several anatomic variations of Guyon’s canal.8

The experts of the Delphi consensus strategy also expressedconcern about these facts. When a case of Guyon’s canal syn-drome is known to be caused by an anatomical entity in or nearGuyon’s canal, its removal is generally the preferred treatmentoption. However, it is when there is no specific cause forGuyon’s canal syndrome, either because it has not yet beeninvestigated or when it does not exist, that it is difficult tochoose an appropriate therapeutic approach. The experts agreedthat Guyon’s canal syndrome is an uncommon ulnar nerve com-pression and remarked that it is important to ensure that thereis no underlying anatomical cause for Guyon’s canal syndrome,such as a ganglion, aberrant muscle or adipose tissue. Theyadvised to always evaluate the chosen intervention to determinewhether or not it was effective. The primary purpose of thisguideline was to achieve consensus on the treatment of Guyon’scanal syndrome. It was decided that only a short description ofthe diagnostic process would be included in the guideline andquestions to refine this topic were not incorporated in theDelphi consensus strategy. Future updates of the treatmentguideline could further refine the diagnostic approach to decide,for example, whether every patient suspected of Guyon’s canalsyndrome should have an MRI or should be assumed to haveidiopathic Guyon’s canal syndrome until they respond insuffi-ciently to appropriate treatment. After all, these are relevantquestions, especially in a society in which healthcare budgets areconstantly under pressure. Moreover, future updates can bemade more specific when treatment options with respect to theaetiology would be included.

Delphi consensus strategySome weaknesses of a Delphi consensus strategy have beendescribed, including bias due to the selection of experts and lowresponse rates.30 In the present study, most of the Europeanexperts (ie, the hand surgeons/therapists) were selected by theirown national professional association. Further, several PM&Rphysicians in Europe, specialised in hand disorders, were invitedto participate in the study; thus, the expert group consisted ofprofessionals with various (para)medical backgrounds. This isbeneficial for the decision-making process because heterogeneityis preferred to homogeneity in terms of considering all relevantaspects of the topic for a Delphi consensus strategy.31 Moreover,physicians willing to participate in an expert panel are represen-tative of their colleagues.32 To maintain rigour when using aDelphi consensus strategy, a 70% minimum response rateshould be achieved.23 In the three Delphi rounds of this study,high response rates (89–94%) were achieved. Advantages of aDelphi consensus strategy are the anonymity of the experts, theavoidance of bias through status, or dominant personality, andthe fact that the experts do not have to meet at a certain placeat a certain time.


Consensus statement




Future researchThe experts in this Delphi consensus strategy on Guyon’s canalsyndrome mentioned that Guyon’s canal syndrome is less preva-lent than the cubital tunnel syndrome. Therefore, they advisedto also initiate a Delphi consensus strategy for the cubital tunnelsyndrome. Further, as clinical experience increases for Guyon’scanal syndrome, the opinions of experts may also change andthe guideline should then be re-evaluated.33 Furthermore,because evidence for the effectiveness of interventions to treatGuyon’s canal syndrome is lacking, high-quality studies are def-initely needed in this field.

CONCLUSIONIn conclusion, in view of the lack of empirical evidence for theeffectiveness of interventions to treat Guyon’s canal syndrome, aDelphi consensus strategy was considered the most appropriatemethod to develop a multidisciplinary treatment guideline forthis disorder. During the Delphi consensus study, many interest-ing discussions took place before consensus was finally achievedon the main aspects of the conservative and surgical treatmentof this disorder. Although the disorder is not highly prevalent,not easy to diagnose and considerable knowledge of theanatomy is needed to localise and treat the pathology, thisguideline is expected to contribute to a better insight into thetreatment of Guyon’s canal syndrome.

What are the new findings?

▸ In the absence of evidence for effectiveness of interventionsfor Guyon’s canal syndrome, this study presents amultidisciplinary treatment guideline for this disorder basedon European experts’ opinions.

▸ The experts agreed that patients with Guyon’s canalsyndrome should always be instructed and that instructionsshould be combined with splinting or surgery.

▸ A practical tool is included in this treatment guideline: theexperts agreed on a table showing the relation between twoof the main factors for choosing one of the aforementionedinterventions, that is, severity and duration, and the choiceof therapy for Guyon’s canal syndrome.

How might it impact on clinical practice in the nearfuture?

▸ Although Guyon’s canal syndrome is less prevalent and noteasy to diagnose, this guideline may contribute to betterinsight into this disorder.

▸ The guideline can also contribute to better treatment ofGuyon’s canal syndrome.

▸ The aforementioned table showing the relation betweenseverity/duration and the choice of therapy for Guyon’scanal syndrome can make the choice for treatment of apatient with this disorder in clinical practice easier.

Acknowledgements The authors would like to thank the following organisationsand persons for their participation in the HANDGUIDE study: Selection expertsDelphi consensus strategy—the Federation of the European Societies for Surgery ofthe Hand (FESSH), the European Federation of Societies for Hand Therapy (EFSHT),and the national member associations of the FESSH and the EFSHT. The EuropeanHANDGUIDE group consisting of the experts participating in the Delphi consensusstrategy on Guyon’s canal syndrome. Hand surgeons: J Bahm, L Dahlin, P Jørgsholm,H Kvernmo, A Lluch, R Luchetti, C Meuli, B Munk, R Rosales, M Schädel-Höpfner,

J Stiasny, H Taskinen, N Thomsen, J van Uchelen and M Wiberg. Hand therapists:M Ahlström, A Alexander, A Enhos, T Fairplay, V Ferrario, P Hermsen,S Knijnenburg, M Marincek, D Pipe, K Akre-Roos, A Sørensen, R Ylvisaker andA Zeipel. Physical Medicine and Rehabilitation (PM&R) physicians: C Emmelot,L Gonçalves, M de Haart, T Paternostro-Sluga and A Sousa. Their participation inthis project does not necessarily mean that they fully agree with the final achievedconsensus. The treatment guideline for Guyon’s canal syndrome is the result of a‘communis opinio’. The authors also thank the following from Erasmus MC: SERHovius and HJ Stam for being part of the advisory team; AR Schreuders for beingpart of the advisory team and for his cooperation in the initiation of this researchproject; and J Soeters for being our webmaster.

Contributors PH and BMAH contributed to the conception and design, interpretationof data, performed the Delphi consensus strategy, drafted the article and approved thefinal version of the manuscript to be published. JHC contributed to the interpretation ofdata and approved the final version of the manuscript to be published. JF wasresponsible for the interpretation of data; he revised the article critically for importantintellectual content and approved the final version of the manuscript to be published.The European HANDGUIDE group consisted of the experts (hand surgeons, handtherapist and PM&R physicians) who participated in the Delphi consensus strategy thatresulted in consensus on the treatment guideline of Guyon’s canal syndrome.

Funding This study was funded by Fonds Nuts Ohra.

Competing interests None.

Provenance and peer review Not commissioned; externally peer reviewed.

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Consensus statement




study: a multidisciplinary treatment guidelineResults from the European HANDGUIDE How to treat Guyon's canal syndrome?

HANDGUIDE groupP Hoogvliet, J H Coert, J Fridén, B M A Huisstede and the European

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