Wartenberg's Sign: Difference between revisions

(Undo revision 79585 by Scott Buxton (talk))
No edit summary
 
(38 intermediate revisions by 9 users not shown)
Line 1: Line 1:
<div class="noeditbox">Welcome to [[Vrije Universiteit Brussel Evidence-based Practice Project|Vrije Universiteit Brussel's Evidence-based Practice project]]. This space was created by and for the students in the Rehabilitation Sciences and Physiotherapy program of the Vrije Universiteit Brussel, Brussels, Belgium. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!</div> <div class="editorbox">
<div class="editorbox">
'''Original Editors '''  
'''Original Editor '''- [[User:Peter Sheehy|Peter Sheehy]]


'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}} &nbsp;
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}
</div>  
</div>
== Search Strategy ==
== Definition ==


Search engines: Pubmed, article database of Vubis, PEDro, web of knowledge.<br>Key words: wartenberg’s sign, wartenberg syndrome, neurologic electrical stimulation, physical therapy nerve, cheiralgia paraesthetica.<br>  
Wartenberg's Sign refers to the slightly greater abduction of the fifth digit, due to weakness or paralysis of the adducting palmar interosseous muscle and unopposed action of the radial innervated extensor muscles (digiti minimi, digitorum communis ).<ref name="larner">A.J. Larner; A Dictionary of Neurological Signs; Springer Science &amp; Business Media, 12-Nov-2010; page 369</ref>'''This should not be confused with [[Wartenberg's Syndrome]] which is described as the entrapment of the superficial branch of the radial nerve <ref>Tosun N, Tuncay I, Akpinar F. Entrapment of the sensory branch of the radial nerve (Wartenberg's syndrome): an unusual cause ;Tohoku J Exp Med. 2001 Mar;193(3):251-4.</ref> with only sensory manifestations and no motor deficits.&nbsp;'''


== Definition/Description ==
== Background&nbsp;<ref name="wartenberg">Robert Wartenberg, M.D ;A SIGN OF ULNAR PALSY ;JAMA. 1939;112(17):1688. doi:10.1001/jama.1939.62800170002011a.</ref> ==


Wartenberg’s sign or Wartenberg syndrome is an entrapment of the superficial branch of the radial nerve. It is similar to radial tunnel syndrome, but in radial tunnel syndrome there is a problem with a larger part of the radial nerve. In Wartenberg’s there’s an isolated injury of the superficial sensory branch. The condition is also known as hand cuff neuropathy or neuropraxia. The term wristlet watch syndrome or watch-strap nerve compression is also used. But the common name is named after Wartenburg who discovered the condition. Wartenberg himself suggested the name cheiralgia paraesthetica.  
The first literature regarding this sign appears to be the Letter to the Editor By Robert Wartenberg himself at 1939. In this ,he emphasize the diagnostic importance of this sign in ulnar nerve neuropathy which is not documented. The author further describes "this sign consists of position of abduction assumed by the little finger. Sometimes the fourth finger too has a tendency to assume a position of abduction, but usually it is only the little that is found in abnormal position. It was found to be most conspicuous when the patient was asked to extend his finger at the proximal joints. The importance of this sign has become increasingly evident from numerous experiences which indicate that this tendency of the little finger to be abducted may constitute an early (in some cases the first) and also a late sign of ulnar palsy".&nbsp;


== Clinically Relevant Anatomy  ==
"From the physiological standpoint , this sign is easily understandable. Adduction of the little finger is performed by the interosseous and abduction by the hypothenar muscles. Both groups of the muscles are innervated by the ulnar nerve. However, in abduction of the little finger, the extensor digiti minimi and the branch to the little finger of extensor digitorum communis also play a definite part.These both are innervated by radial nerve. If the muscles innervated by the ulnar nerve are weak, those innervated by the intact radial nerve predominate in strength and abduct the little finger. Thus it is understandable why this abduction of the little finger is best seen when extensor digitorum communis comes into action and extends the fingers and the hand. In cases with the combined palsy of ulnar nerve and radial nerve ,this sign would not be present" explains the author.&nbsp;


add text here
== Purpose  ==


== Epidemiology /Etiology  ==
Wartenburg’s sign is a test used for assessing integrity of the motor innervations of hand intrinsics in cases of suspected ulnar neuropathy. The inability to perform adducted digital extension is due to weakness in ulnar innervated intrinsic muscles, and the unopposed action of the slightly medially attached extensor digiti minimi results in extension and abduction of the 5th digit.<ref name="Dutton et al">Dutton, M. (2008). Orthopaedic: Examination, evaluation, and intervention (2nd ed.). New York: The McGraw-Hill Companies, Inc.</ref> A positive test indicates ulnar nerve neuropathy but does not determine site of compression (Guyon’s canal, cubital tunnel, arcade of Struthers).


&nbsp;This entrapment is caused by compression of the brachioradialis tendon and the extensor carpi radialis longus tendon in pronation of the hand. This compression can also occur during ulnar deviation of the wrist. As the superficial branch of the radial nerve emerges from beneath the brachioradialis and further trough the fascia that binds the brachioradialis tendon to the extensor carpi radialis longus tendon. this eventually leads to an inflammation of the superficial branch of the radial nerve.<br>
== Technique  ==


<br>
It is seen that the author (Robert Wartenberg) had not prescribed a specific technique to assess the sign. The literature describes few techniques of assessment based on the explanation given by the author.&nbsp;


The definition tells us that Wartenberg’s is a neuropraxia. This means that the axon is intact and the injury is incomplete. There will be a conduction block or a conduction slowing, this is due to segmental demyelination or ischemia. The nerve recovers when it is remyelinated, which happens spontaneously an relatively fast.<br>This entrapment can be caused by anatomic variations or overuse in these muscles. Other risk factors can also be included. These can be trauma, diabetes, repeated exposure to severe cold, over exertion of the hand, to tightly worn wrist watches, de Quervain’s disease, handcuffs ,lipoma, operations, tight fascial bands, a tight plaster or dressing and scar entrapment after previous operation.<br>
*A study by Goldman et al (2009) <ref name="goldman">Goldman SB, Brininger TL, Schrader JW, Curtis R, Koceja DM. Analysis of clinical motor testing for adult patients with diagnosed ulnar neuropathy at the elbow. Arch Phys Med Rehabil 2009;90:1846-52</ref> adopted the technique to assess Wartenberg's Sign - The patient is placed with wrist in neutral position and forearm fully pronated and instructed to perform full extension of all the fingers. Once digits are extended patient is asked to fully abduct all fingers and then adduct all fingers. A positive sign is indicated with the observation of abduction of the 5th digit, with the inability to adduct the 5th finger when extended.  
*David J Magee <ref name="Magee">David J. Magee: Orthopedic Physical Assessment: chapter 6-elbow ;sixth edition; Elsevier Health Sciences, 2008</ref> propose another technique with minor variation - The patient sits with his or her hand resting on the table. The examiner passively spreads the finger apart and asks the patient to bring them together again. Inability to squeeze the little finger to the remainder of the hand indicates positive test for ulnar neuropathy.&nbsp;


In sports, wartenberg’s sign occurs in hockey, football and lacrosse. The conditions is responsible by direct trauma in these sports. <br>
{{#ev:youtube|K7EmeSGqEp4}}


== Characteristics/Clinical Presentation ==
== Really Ulnar Neuropathy? ==


add text here <br>  
The mere presence of this sign doesn’t warrant ulnar neuropathy as the various studies reported abducted posture of little finger in patients without ulnar nerve involvement or even without neurological involvement. A study by Kilgus et al (2003) <ref name="kilgus">Kilgus M , Burg D, Loss M, Weishaupt D, Meyer VE.: Wartenberg's Sign of Ulnar Nerve Lesion. A Contribution to Pathophysiology and to the Differential Diagnosis; Handchir Mikrochir Plast Chir. 2003 Jul;35(4):2518.</ref> analysed the aetiology of the Wartenberg sign. In this study five cases suffering from bothersome permanent abduction of the small finger and referred under the diagnosis of ulnar nerve paresis are presented. The authors commented that the Clinical, electrodiagnostic and imaging evaluation of three neurogenic cases disclosed a lesion of the ramus profundus distal to the branches innervating hypothenar muscles in one case, ulnar nerve injury with neuromuscular hyperactivity of the abductor digiti minimi muscle following split repair in another case and syringomyelia in the third case. Two patients revealed an abduction posture of the little finger of nonneurogenic origin. One of them showed closed ligament injuries. The other patient revealed necrosis, scarring and contracture of hypothenar muscles and atrophy of the third palmar interosseous muscle following compression in a tight cast.<br> <br>  


== Differential Diagnosis ==
== Management&nbsp; ==


• De Quarvain’s disease<br>• Cervical spondylosis: However here is seen a clear difference because Wartenberg symptoms are entirely distal of the arm.<br>
As there is no general consensus regarding the aetiology of the Wartenberg's sign, managment cannot be attempted for the sign alone. Hene it would be optimal to analyse the reason for the abducted posture of the little finger and can be managed accordingly. There are few surgical procedures documented for the correction of abduction deformity of the little finger.  


== Diagnostic Procedures ==
A cadaveric study<ref name="aaken">Jan van Aaken, Jin Zhu, Jean H. D. Fasel, Jean-Yves Beaulieu ; Investigation of radialization and rerouting of the extensor digiti minimi (EDM) in the abduction deformity of the little finger: a cadaver study ; HAND June 2011, Volume 6, Issue 2, pp 202-205</ref>&nbsp;investigated the impact of the&nbsp;radialization of the extensor digiti minimi (EDM) at the level of the fifth metacarpophalangeal (MCP) joint and reroutes it from the fifth to fourth&nbsp;extensor compartment. The study was done in&nbsp;16 freshly frozen cadaver hands sectioned at mid-forearm.The authors concluded that the key to correct abduction deformity of the little finger is radialization of the EDM, which can be done through a solitary incision at the level of the MCP joint. Rerouting alone does not correct the abduction deformity, and in combination with radialization it does not predictably enhance the correction.  


ICF:
The '''Physiotherapy management''' may include &nbsp;


{| style="width: 506px; height: 206px" border="1" cellspacing="1" cellpadding="1" width="506"
*Electrical stimulation
|-
*Exercise program
| Disfunction:
*Splinting
| Restriction in activities:
| Participation problems:
|-
| Pain and numbness of paraesthesia in the area over the lateral aspect of the wrist, thumb or on the dorso-radial part of the hand.
| Some limitations in daily activity, especially when using the affected hand. The restriction in activity is due more to pain than the sensory changes.
| Some limitations in professional activity but unable to work depends of kind of work.
|}


We certainly have to keep in mind that the ICF depends from patient to patient.<br>
As to the diagnosis, we base it on three conditions that we can diagnose positive for Wartenberg’s sign:
<br>• Lanzetta and Dellon’s provocation test<br>• Tinel’s sign: The test is positive over the radial styloid process, there is either external compression on the overlying skin or&nbsp;a contact reaction around the first extensor compartment. (http://www.physio-pedia.com/index.php/Tinel%E2%80%99s_Test)<br>• Paraesthesia<br>
An additional test can be an electrodiagnostic test where we can see a reduced sensory conduction.<br>
== Outcome Measures  ==
add links to outcome measures here (also see [[Outcome Measures|Outcome Measures Database]])
== Examination  ==
add text here related to physical examination and assessment<br>
== Medical Management <br>  ==
add text here <br>
== Physical Therapy Management <br>  ==
The treatment consists of:<br>• Electrical stimulation and decimeter wave therapy: According to a review (John Wiley &amp; Sons, Ltd.) it is not yet clear if patients benefit from electrical stimulation and further study was needed. A year later an article was published about electrical stimulation and decimeter wave therapy. This treatment shortens the recovery time of peripheral nerve function (Li GF, et al.). This was however rated a 4 on PEDro an is only tested in patients who have received surgery before therapy started. It is possible to exclude the factor of surgery because there was a general effect of the treatment on peripheral nerve function.<br>• Conservative treatment: steroid injection, this is more a medical intervention.<br>• Operation (post-operative physiotherapy): The reason why to mention operation in physical therapy management is not the operation itself but the importance of early movement after the operation. This movement prevents recurrence of compression or traction lesion due to the formation of adhesions between the muscle tendons (Lanzetta M., Foucher G.). Early movement was mentioned under mobilisations and muscle strength exercises but further study is needed to prove its effectiveness.<br>• Rest<br>
When it comes to physical therapy, there are not many articles who prove effectiveness. Wartenberg’s sign is rather a rare condition but it can be important to find more prove for treatment. The literature also shows us that the articles found about Wartenberg’s are rather old. Therefore it is of great importance to work out new studies to find new therapies.<br>
Prevention can be:<br>• Conservative treatment: This consists of removal of tight watch-strap, splinting <br>
== Key Research  ==
Evidence levels are necessary to prove the efficacy of the treatment. Electrical stimulation and decimetre wave therapy (Li GF, et al.) have a level of evidence of 1B because it’s an individual RCT. The next evidence is that of early movement after operation (Lanzetta M., Foucher G.). The evidence level is 4, which is rather poor. The last article just about electrical therapy is scored an evidence level of 1A because it’s a review of multiple RCT’s (John Wiley &amp; Sons, Ltd.). This is very strong evidence but the review tells us that it is yet not certain that it’s effective in al neurologic conditions.
<br>• Li GF, et al. Synergistic effects of compound physical factor treatment on neurological outcome after peripheral nerve entrapment surgery: a randomized controlled study. Neural Regeneration Research 2008 Jan;3(1):97-100&nbsp;: 1B<br>• Lanzetta M., Foucher G. Entrapment of the superficial branch of the radial nerve (Wartenberg’s syndrome)&nbsp;: a report of 52 cases. International orthopaedics (SICOT) (1993) 17: 342-345&nbsp;: 4<br>• John Wiley &amp; Sons, Ltd. Efficacy of electrical stimulation to increase muscle strength in people with neurologic conditions: a systematic review. Physiotherapy research international 2007; 12/3; 175-194: 1A
== Resources <br>  ==
• N. Tosun et al. Entrapment of the sensory branch of the radial nerve (Wartenberg’s syndrome): an unusual cause. Tohoku J. Exp. Med., 2001, 193, 251-254<br>• John Wiley &amp; Sons, Ltd. Efficacy of electrical stimulation to increase muscle strength in people with neurologic conditions: a systematic review. Physiotherapy research international 2007; 12/3; 175-194<br>• Li GF, et al. Synergistic effects of compound physical factor treatment on neurological outcome after peripheral nerve entrapment surgery: a randomized controlled study. Neural Regeneration Research 2008 Jan;3(1):97-100 <br>• Lanzetta M., Foucher G. Entrapment of the superficial branch of the radial nerve (Wartenberg’s syndrome)&nbsp;: a report of 52 cases. International orthopaedics (SICOT) (1993) 17: 342-345 <br>• Stanley A.H., Akuthota V. Nerve and vascular injuries in sports medicine. Springer2009; 204p<br>• Braidwood A.S. Superficial radial neuropathy. The journal of bone and joint surgery, 1975. 57-B; 380-383
== Clinical Bottom Line  ==
add text here <br>
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
see tutorial on [[Adding PubMed Feed|Adding PubMed Feed]]
<div class="researchbox">
<rss>Feed goes here!!|charset=UTF-8|short|max=10</rss>
</div>
== References  ==
== References  ==
see [[Adding References|adding references tutorial]].


<references />  
<references />  


[[Category:Vrije_Universiteit_Brussel_Project|Template:VUB]]
[[Category:Assessment]]
[[Category:EIM_Student_Project_2]]
[[Category:Elbow]]
[[Category:Musculoskeletal/Orthopaedics]]
[[Category:Special_Tests]]
[[Category:Neurological - Assessment and Examination]]
[[Category:Elbow - Assessment and Examination]]
[[Category:Elbow - Special Tests]]
[[Category:Hand]]

Latest revision as of 13:57, 10 September 2021

Original Editor - Peter Sheehy

Top Contributors - Sheik Abdul Khadir, Admin, Gertjan Pauwels, Scott Buxton, Rachael Lowe, Kim Jackson, Peter Sheehy, 127.0.0.1, Evan Thomas, Naomi O'Reilly, WikiSysop and Amanda Ager

Definition[edit | edit source]

Wartenberg's Sign refers to the slightly greater abduction of the fifth digit, due to weakness or paralysis of the adducting palmar interosseous muscle and unopposed action of the radial innervated extensor muscles (digiti minimi, digitorum communis ).[1]This should not be confused with Wartenberg's Syndrome which is described as the entrapment of the superficial branch of the radial nerve [2] with only sensory manifestations and no motor deficits. 

Background [3][edit | edit source]

The first literature regarding this sign appears to be the Letter to the Editor By Robert Wartenberg himself at 1939. In this ,he emphasize the diagnostic importance of this sign in ulnar nerve neuropathy which is not documented. The author further describes "this sign consists of position of abduction assumed by the little finger. Sometimes the fourth finger too has a tendency to assume a position of abduction, but usually it is only the little that is found in abnormal position. It was found to be most conspicuous when the patient was asked to extend his finger at the proximal joints. The importance of this sign has become increasingly evident from numerous experiences which indicate that this tendency of the little finger to be abducted may constitute an early (in some cases the first) and also a late sign of ulnar palsy". 

"From the physiological standpoint , this sign is easily understandable. Adduction of the little finger is performed by the interosseous and abduction by the hypothenar muscles. Both groups of the muscles are innervated by the ulnar nerve. However, in abduction of the little finger, the extensor digiti minimi and the branch to the little finger of extensor digitorum communis also play a definite part.These both are innervated by radial nerve. If the muscles innervated by the ulnar nerve are weak, those innervated by the intact radial nerve predominate in strength and abduct the little finger. Thus it is understandable why this abduction of the little finger is best seen when extensor digitorum communis comes into action and extends the fingers and the hand. In cases with the combined palsy of ulnar nerve and radial nerve ,this sign would not be present" explains the author. 

Purpose[edit | edit source]

Wartenburg’s sign is a test used for assessing integrity of the motor innervations of hand intrinsics in cases of suspected ulnar neuropathy. The inability to perform adducted digital extension is due to weakness in ulnar innervated intrinsic muscles, and the unopposed action of the slightly medially attached extensor digiti minimi results in extension and abduction of the 5th digit.[4] A positive test indicates ulnar nerve neuropathy but does not determine site of compression (Guyon’s canal, cubital tunnel, arcade of Struthers).

Technique[edit | edit source]

It is seen that the author (Robert Wartenberg) had not prescribed a specific technique to assess the sign. The literature describes few techniques of assessment based on the explanation given by the author. 

  • A study by Goldman et al (2009) [5] adopted the technique to assess Wartenberg's Sign - The patient is placed with wrist in neutral position and forearm fully pronated and instructed to perform full extension of all the fingers. Once digits are extended patient is asked to fully abduct all fingers and then adduct all fingers. A positive sign is indicated with the observation of abduction of the 5th digit, with the inability to adduct the 5th finger when extended.
  • David J Magee [6] propose another technique with minor variation - The patient sits with his or her hand resting on the table. The examiner passively spreads the finger apart and asks the patient to bring them together again. Inability to squeeze the little finger to the remainder of the hand indicates positive test for ulnar neuropathy. 

Really Ulnar Neuropathy?[edit | edit source]

The mere presence of this sign doesn’t warrant ulnar neuropathy as the various studies reported abducted posture of little finger in patients without ulnar nerve involvement or even without neurological involvement. A study by Kilgus et al (2003) [7] analysed the aetiology of the Wartenberg sign. In this study five cases suffering from bothersome permanent abduction of the small finger and referred under the diagnosis of ulnar nerve paresis are presented. The authors commented that the Clinical, electrodiagnostic and imaging evaluation of three neurogenic cases disclosed a lesion of the ramus profundus distal to the branches innervating hypothenar muscles in one case, ulnar nerve injury with neuromuscular hyperactivity of the abductor digiti minimi muscle following split repair in another case and syringomyelia in the third case. Two patients revealed an abduction posture of the little finger of nonneurogenic origin. One of them showed closed ligament injuries. The other patient revealed necrosis, scarring and contracture of hypothenar muscles and atrophy of the third palmar interosseous muscle following compression in a tight cast.

Management [edit | edit source]

As there is no general consensus regarding the aetiology of the Wartenberg's sign, managment cannot be attempted for the sign alone. Hene it would be optimal to analyse the reason for the abducted posture of the little finger and can be managed accordingly. There are few surgical procedures documented for the correction of abduction deformity of the little finger.

A cadaveric study[8] investigated the impact of the radialization of the extensor digiti minimi (EDM) at the level of the fifth metacarpophalangeal (MCP) joint and reroutes it from the fifth to fourth extensor compartment. The study was done in 16 freshly frozen cadaver hands sectioned at mid-forearm.The authors concluded that the key to correct abduction deformity of the little finger is radialization of the EDM, which can be done through a solitary incision at the level of the MCP joint. Rerouting alone does not correct the abduction deformity, and in combination with radialization it does not predictably enhance the correction.

The Physiotherapy management may include  

  • Electrical stimulation
  • Exercise program
  • Splinting

References[edit | edit source]

  1. ↑ A.J. Larner; A Dictionary of Neurological Signs; Springer Science & Business Media, 12-Nov-2010; page 369
  2. ↑ Tosun N, Tuncay I, Akpinar F. Entrapment of the sensory branch of the radial nerve (Wartenberg's syndrome): an unusual cause ;Tohoku J Exp Med. 2001 Mar;193(3):251-4.
  3. ↑ Robert Wartenberg, M.D ;A SIGN OF ULNAR PALSY ;JAMA. 1939;112(17):1688. doi:10.1001/jama.1939.62800170002011a.
  4. ↑ Dutton, M. (2008). Orthopaedic: Examination, evaluation, and intervention (2nd ed.). New York: The McGraw-Hill Companies, Inc.
  5. ↑ Goldman SB, Brininger TL, Schrader JW, Curtis R, Koceja DM. Analysis of clinical motor testing for adult patients with diagnosed ulnar neuropathy at the elbow. Arch Phys Med Rehabil 2009;90:1846-52
  6. ↑ David J. Magee: Orthopedic Physical Assessment: chapter 6-elbow ;sixth edition; Elsevier Health Sciences, 2008
  7. ↑ Kilgus M , Burg D, Loss M, Weishaupt D, Meyer VE.: Wartenberg's Sign of Ulnar Nerve Lesion. A Contribution to Pathophysiology and to the Differential Diagnosis; Handchir Mikrochir Plast Chir. 2003 Jul;35(4):2518.
  8. ↑ Jan van Aaken, Jin Zhu, Jean H. D. Fasel, Jean-Yves Beaulieu ; Investigation of radialization and rerouting of the extensor digiti minimi (EDM) in the abduction deformity of the little finger: a cadaver study ; HAND June 2011, Volume 6, Issue 2, pp 202-205
Retrieved from "https://www.physio-pedia.com/index.php?title=Wartenberg%27s_Sign&oldid=282056"