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WARTENBERG'S SYNDROME

Introduction

Wartenberg syndrome, which is entrapment of the superficial (ie, sensory) branch of the radial nerve (SRN), was first described by Dr. Wartenberg in 1932. At the time, he suggested the name “cheiralgia paraesthetica,” because he observed a similarity to the isolated involvement of the thigh’s lateral cutaneous nerve. Wartenberg syndrome is a compressive neuropathy associated with sensory manifestations such as painful paresthesias on the dorsum of the thumb and radial hand.  Wartenberg syndrome is not associated with any motor deficits.

Pathophysiology

  • Due to its anatomic location, the SRN is highly vulnerable to compression from trauma, masses, and constriction from the fascia connecting the brachioradialis and extensor carpi radialis longus (ECRL).  
  • Although the SRN can be compressed anywhere along its course in the forearm, the point of greatest vulnerability is at the posterior border of the brachioradialis as the nerve transitions from a deep to a subcutaneous location.
  • The syndrome can be caused by:
    • Bony spurs
    • Colles’ fracture
    • Nerve tumors (eg, hemangioma, ganglion cyst)
    • Overexertion of the hand
    • Repetitive movements
    • Severe cold
    • Stretch injury to the SRN (eg, closed reduction of forearm fracture)
    • Trauma such as nail gun injuries
    • Tight fascial bands

Related Anatomy

  • The radial nerve bifurcates into the SRN and posterior interosseous nerve (PIN).
  • The SRN courses distally into the forearm deep to the brachioradialis. Approximately 9 cm proximal to the radial styloid, the SRN becomes a subcutaneous structure by traveling between the brachioradialis and ECRL tendons.
  • The SRN continues subcutaneously and branches out into dorsal digital nerves responsible for afferent sensory input from the dorsum of the thumb, index, and middle fingers proximal to the proximal interphalangeal (PIP) joints.

Incidence and Related Conditions

  • Wartenberg syndrome is rare.
  • Although Wartenberg syndrome often is confused with de Quervain’s tenosynovitis, the two disorders can present simultaneously occassionally.

Differential Diagnosis

  • de Quervain’s tenosynovitis (pain is not aggravated by wrist pronation)
  • Intersection syndrome
  • Lateral antebrachial cutaneous nerve (LACN) neuritis (positive Tinel’s sign over LACN can be mistaken for positive Tinel’s sign over SRN) This extremely rare.
ICD-10 Codes

  • WARTENBERG SYNDROME

    Diagnostic Guide Name

    WARTENBERG SYNDROME

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    WARTENBERG SYNDROME S64.22X_S64.21X_ 

    Instructions (ICD 10 CM 2020, U.S. Version)

    THE APPROPRIATE SEVENTH CHARACTER IS TO BE ADDED TO EACH CODE FROM CATEGORY S64
    A - Initial Encounter
    D - Subsequent Routine Healing
    S - Sequela

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Clinical Presentation Photos and Related Diagrams
Wartenburg Syndrome
  • Note the superficial radial sensory nerve (SRN) entering the subcutaneous tissue by passing through the interval between the brachioradialis (BR) and the extensor carpi radialis longus (ECRL).
    Note the superficial radial sensory nerve (SRN) entering the subcutaneous tissue by passing through the interval between the brachioradialis (BR) and the extensor carpi radialis longus (ECRL).
  • Wartenberg Syndrome with Tinel's sign over the radial sensory nerve (arrow) near the radial styloid (RS) with paresthesias in the are with cross hatch lines.
    Wartenberg Syndrome with Tinel's sign over the radial sensory nerve (arrow) near the radial styloid (RS) with paresthesias in the are with cross hatch lines.
Basic Science Photos and Related Diagrams
Wartenberg Basic Anatomy
Basic Science Pics
  • Dorsal radial sensory nerve (arrow) immediately under the skin just distal to the radial styloid
    Dorsal radial sensory nerve (arrow) immediately under the skin just distal to the radial styloid
Symptoms
Tingling, paresthesia, and pain of the dorsal radial forearm radiating to the thumb and index finger
Swelling, in presence of lipoma
Symptoms at rest, independent of thumb and wrist position
Typical History

The patient usually reports pain over the distal radial forearm radiating to the thumb and index finger and associated with paresthesia over the dorsal radial hand. Symptom location can vary slightly due to anatomic differences. Weakness is unlikely (may be present with rare lipoma).  Grip strength is reduced only if the patient presents with chronically untreated symptoms that cause pain that interferes with use. Questioning may elicit a history previous surgery of the hand or wrist, or a fracture, or work activities involving repetitive supination and pronation, but a variety of other causes are possible. Patients who smoke or abuse alcohol are at increased risk of nerve entrapment syndromes.

Positive Tests, Exams or Signs
Work-up Options
Treatment Options
Conservative
  • Massage
  • Nonsteroidal anti-inflammatory drugs (NSAIDs)
  • Observation, if asymptomatic intraneural lipoma (also known as lipofibromatous hamartoma)
  • Peripheral nerve stimulation
  • Physical therapy
  • Removal of external element causing compression
  • Rest
  • Splinting
  • Ultrasound, therapeutic 
Operative
  • Mechanical cause: surgical decompression (neurolysis)
    • Including excision of symptomatic and/or space-occupying lesions
  • Lipofibromatous hamartoma: treatment is controversial, but complete excision of the tumor is not recommended if significant deficits may result
    • Decompression and debulking of fibro-fatty sheath
    • Microsurgical dissection of neural elements
    • Excision of involved nerve segment with or without nerve grafting
  • After surgical decompression, splint with neutral forearm and wrist, and elbow flexed to 90° for several days
    • Followed by early range of motion (ROM) exercises to stretch tight muscles and restore flexibility
    • Progressive strengthening exercises added as tolerated
Complications
  • Failed decompression
  • Infection
  • Nerve damage
    • Intraneural lipoma/lipofibromatous hamartoma: in most cases, can be enucleated without damage to nerve fibers
  • Persistent pain and numbness
  • Wound dehiscence
Outcomes
  • Conservative treatment: 71% success rate was reported for 29 patients who underwent removal of external sources of compression and underwent splinting
  • Surgical treatment: 74% success rate was reported for 23 patients who had failed conservative therapy and underwent surgical decompression  
  • Maximum medical improvement: typically 60–90 days post-surgery 
Video
Eliciting the Tinel's sign associated with Wartenberg's Syndrome
YouTube Video
Wartenberg's Syndrome and Wartenberg's Sign
Key Educational Points
  • Wartenberg syndrome is extremely rare.
  • Radial neuropathy is twice as likely to occur in men as in women.
  • Even handcuffs or a tight wristwatch can cause Wartenberg syndrome.
  • Wartenberg syndrome should not be confused with Wartenberg sign, which is slightly greater abduction of the fifth digit, due to paralysis of the abducting palmar interosseous muscle and unopposed action of the radial innervated extensor muscles. 
  • Spontaneous resolution of Wartenberg syndrome is common.
References

New Articles
 

  1. Amadei F. Wartenberg’s syndrome: an unusual bilateral case. Ortho Rheumatol Open Access J 2016;2(4): Accessed October 24, 2016 at https://www.juniperpublishers.com/oroaj/pdf/OROAJ.MS.ID.555595.pdf
  2. Patel A, Pierce P, Chiu DT. A fascial band implicated in Wartenberg syndrome. Plast Reconstr Surg 2014;133(3):440e-2e. PMID: 24572905

Review

  1. Kowalska B, Sudol-Szopinska I. Ultrasound assessment on selected peripheral nerve pathologies. Part I: Entrapment neuropathies of the upper limb – excluding carpal tunnel syndrome. J Ultrason 2012;12(50):307-18. PMID: 26674101

Classic

  1. Braidwood AS. Superficial radial neuropathy. J Bone Joint Surg Br 1975;57(3):380-3. PMID: 1158953
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