Wartenberg's Sign

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Search Strategy

Search engines: Pubmed, article database of Vubis, PEDro, web of knowledge.
Key words: wartenberg’s sign, wartenberg syndrome, neurologic electrical stimulation, physical therapy nerve, cheiralgia paraesthetica.

Definition/Description

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.

Clinically Relevant Anatomy

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Epidemiology /Etiology

 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.

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.
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.

In sports, wartenberg’s sign occurs in hockey, football and lacrosse. The conditions is responsible by direct trauma in these sports.

Characteristics/Clinical Presentation

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Differential Diagnosis

• De Quarvain’s disease
• Cervical spondylosis: However here is seen a clear difference because Wartenberg symptoms are entirely distal of the arm.

Diagnostic Procedures

ICF:

Disfunction:	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.

As to the diagnosis, we base it on three conditions that we can diagnose positive for Wartenberg’s sign:

• Lanzetta and Dellon’s provocation test
• Tinel’s sign: The test is positive over the radial styloid process, there is either external compression on the overlying skin or a contact reaction around the first extensor compartment. (http://www.physio-pedia.com/index.php/Tinel%E2%80%99s_Test)
• Paraesthesia

An additional test can be an electrodiagnostic test where we can see a reduced sensory conduction.

Outcome Measures

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Examination

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Medical Management

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Physical Therapy Management

The treatment consists of:
• Electrical stimulation and decimeter wave therapy: According to a review (John Wiley & 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.
• Conservative treatment: steroid injection, this is more a medical intervention.
• 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.
• Rest

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.

Prevention can be:
• Conservative treatment: This consists of removal of tight watch-strap, splinting

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 & 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.

• 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 : 1B
• Lanzetta M., Foucher G. Entrapment of the superficial branch of the radial nerve (Wartenberg’s syndrome) : a report of 52 cases. International orthopaedics (SICOT) (1993) 17: 342-345 : 4
• John Wiley & 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

• 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
• John Wiley & 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
• 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
• Lanzetta M., Foucher G. Entrapment of the superficial branch of the radial nerve (Wartenberg’s syndrome) : a report of 52 cases. International orthopaedics (SICOT) (1993) 17: 342-345
• Stanley A.H., Akuthota V. Nerve and vascular injuries in sports medicine. Springer2009; 204p
• Braidwood A.S. Superficial radial neuropathy. The journal of bone and joint surgery, 1975. 57-B; 380-383

Clinical Bottom Line

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Recent Related Research (from Pubmed)

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References

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