Updated: 10/4/2016

Wartenberg's Syndrome

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Introduction
  • Definition
    • compressive neuropathy of the superficial sensory radial nerve (SRN)
    • also called "cheiralgia paresthetica"
    • sensory manifestation only 
    • no motor deficits
  • Epidemiology
    • incidence
      • rare
    • demographics
      • male:female ratio is 1:4, more common in women
      • age bracket is 20-70 years
  • 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%
  • Prognosis
    • spontaneous resolution of symptoms is common
    • treatment outcomes
      • 74% success after surgical decompression
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 9cm 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
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
 

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