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Wartenbergs Syndrome

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(Redirected from Wartenberg Syndrome)

Other Names

  • Cheiralgia Paresthetica
  • Compression Neuropathy of Superficial Branch of Radial Nerve
  • Wartenbergs Syndrome
  • Handcuff Neuropathy
  • Double Crush Syndrome

Background

History

  • First described in 1932 by Robert Wartenberg, a European-American Neurologist[1]

Epidemiology

  • Incidence is rare, epidemiology is poorly described
  • Affects adults age 20-69 and is more common in females[2]

Introduction

Illustration of course of the superficial branch of the radial nerve[3]
Illustration of the superficial branch of the radial nerve (click to enlarge).[4]

General

  • Rare entrapment of the superficial branch radial nerve
  • Sometimes termed superficial sensory radial nerve (SRN)
  • Sensory symptoms only, no motor
  • Symptoms can last from 15 days to 21 months[5]

Etiology

  • Entrapment between Brachioradialis and Extensor Carpi Radialis Longus tendons
  • Direct pressure
    • E.g. watch, wristband, handcuffs[6]
    • Tight plaster, cast or dressing
    • Other including scar entrapment
  • Stretching (e.g. forearm fracture)
  • Over exertion (repetitive pronation and supination)
  • Diabetes[7]
  • Mass occupying lesions (lipoma, abscess, neuroma)[8]
  • Iatrogenic
    • Previous hand or wrist surgery causing scar/ keloid formation
    • Opponens pollicis transfer
  • Variant of first dorsal extensor compartment causing irritation
  • Trauma[9]

Double Crush Syndrome

  • Wartenberg's syndrome occurring due to compression at a site proximal to the symptoms
  • Documented following:
    • Radial nerve compression at the spiral groove[10]
    • Lipoma at the elbow[11]

Associated Conditions

  • High association
  • Other, uncommon associations
    • Ganglions of first extensor compartment
    • Flexor carpi radialis tendinitis
    • Neuroma of the lateral antebrachial cutaneous nerve
    • Schwannoma of brachial plexus

Anatomy of the Superficial Branch of the Radial Nerve

  • Purely sensory branch of the radial nerve
    • Innervation of the dorsal lateral side of hand, proximal dorsal surface of thumb, index and half of middle finger
  • Originates in the cubital fossa
  • Courses down the forearm, lateral to the radial artery
  • Concealed between brachioradialis, pronator teres
  • About 7 cm proximal to wrist, pierces deep fascia, passes over [snuffbox] to dorsum of hand

Risk Factors

  • Females > Males

Differential Diagnosis

Differential Diagnosis Finger And Hand Pain

Clinical Features

History

  • Often poorly defined pain over dorsal hand and fingers
  • Sensory symptoms of burning, numbness, and tingling over the dorsal radial aspect of the wrist and hand

Physical Exam: Physical Examination Hand

  • Often normal
  • Try to map out distribution of sensory abnormality on dorsolateral hand
  • One study found diminished 2PV was altered in 100% of patients[12]
  • Pinch and grip strength may be reduced secondary to pain
  • Reproduce symptoms with forced pronation/ ulnar deviation and resisted isometric wrist extension

Special Tests

  • Tinel’s Test can be positive
    • Tap over the radial styloid or just distal to brachioradialis
  • Finkelstein's Test due to stretching of tendons
    • Can be positive due to co-occurrence with De Quervain's Tenosynovitis
    • In Wartenberg syndrome, pain is present regardless of position during Finkelstein[13]
Wartenberg’s syndrome. In the proximal portion of the wrist, the radial nerve (empty arrow) presents a normal fascicular appearance. Moving distally, this fascicular aspect is lost, and the nerve appears enlarged and hypoechoic (Wartenberg’s syndrome). The normal appearance is then restored in the more distal portion[14]

Evaluation

Radiographs

EMG/NCS

  • EMG/NCS can be helpful
  • Limited diagnostic effectiveness

Ultrasound

  • Can show thickening of the SRN

Diagnostic Nerve Block

Classification

  • N/a

Management

Nonoperative

  • First line therapy, spontaneous resolution common
  • Removal of offending compressive device
    • Removal of the compressive force (wrist watch, hand cuffs, plaster cast, etc)
  • Discontinue repetitive exercise/activity if present
  • NSAIDS
  • Wrist splint
  • Physical Therapy
  • Role of Superficial Radial Nerve Injection is unclear

Operative

  • Indications
    • Refractory to nonoperative therapy for 6 months
  • Technique
    • Fascial release along the course of the SRN

Rehab and Return to Play

Rehabilitation

  • Needs to be updated

Return to Play/ Work

  • Needs to be updated

Prognosis and Complications

Prognosis

  • Conservative treatment
    • One study found good to excellent in 71% of patients following conservative treatment[5]
    • Another study showed only 30% of patients improved after 6 months of conservative treatment[12]
    • Duration over 6 months by suggest refractory to conservative therapy, indicate need for surgical intervention
  • Risk factors to fail conservative treatment
    • Previous operation
    • Chronic occupational injuries
    • Severe crush injury to the forearm and wrist
    • Neuroma
  • Surgical outcomes
    • 74% to 86% reporting excellent or good outcomes[2][5]

Complications

  • Needs to be updated

See Also

Internal

External

References

  1. ↑ Wartenberg R. Cheiralgia paresthetica. Z Ger Neurol Psychiatry 1932; 141: 145-55. [Isolated neuritis of the superficial radial nerve.].
  2. ↑ 2.0 2.1 Dellon, A. Lee, and Susan E. Mackinnon. "Radial sensory nerve entrapment in the forearm." The Journal of hand surgery 11.2 (1986): 199-205.
  3. ↑ Image courtesy of orthobullets.com
  4. ↑ Image courtesy of healthjade.net, "warternberg syndrome
  5. ↑ 5.0 5.1 5.2 Lanzetta, M., and G. Foucher. "Entrapment of the superficial branch of the radial nerve (Wartenberg's syndrome) A report of 52 cases." International orthopaedics 17.6 (1993): 342-345.
  6. ↑ Dorfman, Leslie J., and Attigupam R. Jayaram. "Handcuff neuropathy." Jama 239.10 (1978): 957-957.
  7. ↑ Massey, E. Wayne, and John T. O'Brian. "Cheiralgia paresthetica in diabetes mellitus." Diabetes Care 1.6 (1978): 365-366.
  8. ↑ Neogi, Devdatta Suhas, et al. "An unusual cause of Wartenberg’s syndrome: tuberculosis of brachioradialis muscle." European Journal of Orthopaedic Surgery & Traumatology 20 (2010): 335-338.
  9. ↑ Stahl, S., and T. Kaufman. "Cheiralgia paresthetica—entrapment of the superficial branch of the radial nerve: a report of 15 cases." European Journal of Plastic Surgery 20 (1997): 57-59.
  10. ↑ Chang, Ke-Vin, Chen-Yu Hung, and Levent Özçakar. "Snapping thumb and superficial radial nerve entrapment in De Quervain disease: ultrasound imaging/guidance revisited." Pain Medicine 16.11 (2015): 2214-2215.
  11. ↑ Lewkonia, Peter, Shaun AC Medlicott, and Kevin A. Hildebrand. "Intramuscular myxoid lipoma in the proximal forearm presenting as an olecranon mass with superficial radial nerve palsy: a case report." Journal of medical case reports 5 (2011): 1-4.
  12. ↑ 12.0 12.1 Robson AJ, See MS, Ellis H (2008) Applied anatomy of the superficial branch of the radial nerve. Clinical Anatomy. 21(1):38– 45.
  13. ↑ Plancher, Kevin D., Robert K. Peterson, and James B. Steichen. "Compressive neuropathies and tendinopathies in the athletic elbow and wrist." Clinics in sports medicine 15.2 (1996): 331-371.
  14. ↑ Image courtesy of radiologykey.com
Created by:
John Kiel on 21 June 2019 14:02:12
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Last edited:
24 August 2025 23:49:13
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