Updated: 5/18/2021

Wartenberg's Syndrome

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  • Summary
    • Wartenberg's Syndrome, also called "cheiralgia paresthetica," is a compressive neuropathy of the superficial sensory radial nerve at the wrist.
    • Diagnosis is made clinically with pain and paresthesias over the dorsoradial hand without any motor deficits.  
    • Treatment is conservative with rest, wrist splints and CSIs with surgical decompression reserved for refractory cases.
  • Epidemiology
    • Incidence
      • rare
        • < 1 per 100,000 annually
    • Demographics
      • male:female ratio is 1:4, more common in women
      • age bracket is 20-70 years
  • Etiology
    • Pathoanatomy
      • SRN compressed by scissoring action of brachioradialis and ECRL tendons during forearm pronation
      • also by fascial bands at its exit site in the subcutaneous plane
    • Associated conditions
      • associated with De Quervain's disease in 20-50%
  • Anatomy
    • The superficial sensory branch of the radial nerve
      • arises from the bifurcation of the radial nerve in the proximal forearm
      • travels deep to the brachioradialis in the forearm
      • emerges from between brachioradialis and ECRL 9 cm proximal to radial styloid
      • bifurcates proximal to the wrist
        • dorsal branch lies 1-3cm radial to Lister's tubercle
          • supplies 1st and 2nd web space
        • palmar branch passes within 2cm of 1st dorsal compartment, directly over EPL
          • supplies dorsolateral thumb
  • Presentation
    • History
      • may have history of trauma
        • forearm fracture
        • handcuffs
        • tight wrist band, wristwatch band, bracelet or plaster cast
    • Symptoms
      • ill-defined pain over dorsoradial hand (does not like to wear watch)
      • paresthesias over dorsoradial hand
      • numbness
      • symptom aggravation by motions involving repetitive wrist flexion and ulnar deviation
      • no motor weakness
    • Physical exam
      • provocative tests
        • Tinel's sign over the superficial sensory radial nerve (most common exam finding)
        • wrist flexion, ulnar deviation and pronation for one minute
        • Finkelstein test increases symptoms in 96% of patients
          • because of traction on the nerve
  • Imaging
    • Radiographs
      • of limited value
      • may demonstrate old forearm fracture
  • Studies
    • Electrodiagnostic tests
      • EMG and NCV of limited value
    • Diagnostic injection
      • diagnostic wrist block may temporarily relieve pain
  • Differential
    • De Quervain's tenosynovitis
      • pain is not aggravated by wrist pronation, unlike Wartenberg Syndrome
    • Lateral antebrachial cutaneous nerve (LACN) neuritis
      • positive Tinel's sign over LACN can be mistaken for positive Tinel's over superficial sensory radial nerve
    • Intersection syndrome
      • may have dorsoradial forearm swelling
      • symptom exacerbation and "wet leather" crepitus on repeated wrist flexion/extension
  • Diagnosis
    • Clinical
      • diagnosis is made with careful history and physical examination
  • Treatment
    • Nonoperative
      • rest, activity modification, NSAIDS, and wrist splints
        • indications
          • first line of treatment
        • techniques
          • avoid aggravating activities
          • remove inciting factors (e.g. tight wristwatch band)
      • corticosteroid injection
        • although evidence to support this is limited
    • Operative
      • surgical decompression
        • indications
          • symptoms persist after 6 months
  • Surgical Technique
    • Surgical Decompression
      • approach
        • longitudinal incision volar to Tinel's sign
          • to avoid injury to LACN
          • to avoid tethering of incision scar over SRN
      • decompression technique
        • neurolysis and release of fascia between brachioradialis and ECRL
  • Complications
    • Failed decompression
    • Persistent pain and numbness
    • Wound dehiscence
    • Infection
  • Prognosis
    • Spontaneous resolution of symptoms is common
    • Treatment outcomes
      • 74% success after surgical decompression
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