Wartenberg syndrome is a complex of symptoms caused by compression of the radial nerve in the forearm. The syndrome is limited to compressions of the sensory nerve branch and therefore does not cause motor dysfunction, only disturbances in sensibility. Treatment depends on the severity.
What is Wartenberg syndrome?
The radial nerve is a nerve of the brachial plexus. As a mixed nerve, it is responsible for motor innervation of various arm muscles and sensory innervation of various skin areas. It divides into a motor and a sensory branch. The sensitive branch is also known as the superficial ramus. Wartenberg syndrome occurs when the radial nerve is compressed. Nerve compression syndrome is also known as cheiralgia paraesthetica and is associated with sensory disturbances in the skin areas of the extensor thumb and index finger and sensory disturbances of the intermetacarpal space. Wartenberg syndrome was first described in the 1930s. Robert Wartenberg is considered to be the first describer. Wartenberg syndrome should be distinguished from radial palsy, which may not necessarily have peripheral mechanical nerve damage but may also have central nerve lesions as its cause, thus affecting the brain, spinal cord, or motor branch of the radial nerve.
Causes
Wartenberg syndrome results from a ramus superficialis injury of the radial nerve. It is an isolated injury that does not affect the entire radial nerve, for example, but only its sensory branch. In most cases, an isolated lesion of the ramus superficialis is preceded by impact injuries or cuts, which are located dorsally and radially on the distal forearm. In isolated cases, the lesions are mechanical compression injuries caused by shackles, bracelets, or handcuffs. Sometimes the cause of the lesion is intravenous injection or shunt surgery in the area between the cephalic vein and radial artery. Plaster casts that are applied too tightly can also compress the superficial ramus at the radial nerve, causing Wartenberg syndrome. Because of the causative association with restraints, the syndrome is also known as restraint syndrome. In isolated cases, the symptom complex is associated with diabetes mellitus.
Symptoms, complaints, and signs
Patients with Wartenberg syndrome suffer from a complex of different symptoms. Leading symptoms of the syndrome are sensory disturbances such as hypesthesia, hypalgesia, and dysesthesia, which occur predominantly in the region of the spatium interosseum I and are thus clearly located in the sensitive supply area of the radial nerve. Wartenberg syndrome need not be associated with subjectively significant discomfort. Many patients feel almost asymptomatic. Motor symptoms such as movement disorders or even paralysis of the arm muscles are never associated with the syndrome, since the motor branch of the radial nerve is completely intact. In individual cases, the syndrome may cause more or less severe pain that may radiate throughout the arm. If Wartenberg syndrome is caused by tethering, other symptoms may be present. For example, blood flow in the compressed area may also be affected by compressions. Such compressions of blood vessels may promote reduced blood flow and eventually even necrosis due to inadequate oxygen and nutrient supply. In some cases, the symptoms of Wartenberg syndrome were limited to pain. In such a case, no sensory disturbances are present and the symptoms resemble tendovaginitis stenosans de Quervain.
Diagnosis and course of the disease
The physician makes the diagnosis of Wartenberg syndrome on the basis of clinical symptoms. He examines the patient for the so-called Hoffmann-Tinel sign, which is positive in the case of Wartenberg syndrome. The Finkelstein test can also be positive in individual cases. However, a positive Finkelstein test is not a mandatory characteristic of the disease. Electroneurography may be useful in the diagnostic process. This procedure can be used to differentiate Wartenberg syndrome from carpal tunnel syndrome and from other types of radial nerve damage. The prognosis for patients with Wartenberg syndrome is significantly more favorable than that of patients with lesions of the central nervous system.Peripheral nerves may be able to fully recover from damage.
Complications
Wartenberg syndrome can cause various complications as it progresses. Typically, sensory disturbances such as hypesthesia significantly limit the affected person in his or her daily life, as everyday stimuli are no longer properly received. Numbness is a typical accompanying symptom and causes considerable movement restrictions when it occurs in the arms or legs. Furthermore, complaints of the eyes and/or ears may occur, such as visual disturbances or hearing difficulties. In individual cases, the syndrome causes severe, usually chronic pain that further reduces well-being. Circulatory disturbances, such as those that occur in Wartenberg syndrome, could promote reduced blood flow and ultimately necrosis. The affected body region is then permanently paralyzed or the respective limb even has to be amputated. Surgical treatment can lead to additional damage to the affected nerves. There is also a risk of nerve inflammation. If the wound is not properly cared for after surgery, wound healing problems can occur. This in turn results in scars and adhesions. The accompanying drug therapy can cause discomfort if the patient is allergic to one of the prescribed preparations. In general, various side effects and interactions may also occur.
When should one go to the doctor?
The affected person should definitely see a doctor about Wartenberg syndrome. This disease usually cannot heal on its own, so treatment by a doctor is always necessary. The earlier a doctor is contacted, the better the further course of the disease usually is, so that the affected person should see a doctor already at the first symptoms and signs. The doctor should be consulted in Wartenberg syndrome when the affected person suffers from severe paralysis. In most cases, it is mainly different muscles that are affected by these paralyses. If the paralyses occur over a longer period of time and do not disappear on their own, a doctor should be consulted in any case. Likewise, disturbed blood circulation in various regions of the body may indicate Wartenberg syndrome, resulting in disturbances of sensitivity. In the first instance, a general practitioner or a neurologist can be consulted for this syndrome. Further treatment itself depends strongly on the cause and on the severity of the symptoms, so that no general prediction can be made in this regard.
Treatment and therapy
The therapy of Wartenberg syndrome depends on the severity of the manifestation in each individual case. Low-grade damage to the superficial ramus of the radial nerve does not necessarily require treatment. The nerve branch will probably regenerate on its own. Therefore, if the patient subjectively perceives hardly any discomfort or impairment, no therapy is performed. Therapeutic intervention is only required in cases of pronounced discomfort or complete interruption of the nerve continuity, as can occur, for example, as a result of cuts. In such a case, surgical intervention is usually performed. The physician must reattach the two ends of the superficial ramus on the radial nerve so that they can grow together. After surgery, stabilization with a dorsal forearm cast splint may be required. The splint immobilizes the arm to allow the two nerve endings to fuse together at rest. Several conservative drug therapy steps may also be considered to treat Wartenberg syndrome. The main conservative steps include steroid injections and administration of nonsteroidal anti-inflammatory drugs. After the nerves have fused, minimal sensory disturbances may remain in individual cases. However, these remnants are usually contained to the extent that the patient hardly notices them subjectively.
Prevention
One preventive measure for Wartenberg syndrome is the thoughtful selection of bracelets, watches, and other jewelry of the forearm. Jewelry that is too tight can compress the sensitive branch of the radial nerve and cause Wartenberg syndrome in this way.
Follow-up
Affected individuals usually have very limited measures of direct aftercare available for Wartenberg syndrome.Therefore, in the first place, this disease should be diagnosed quickly and, above all, at an early stage in order to prevent the occurrence of further complications and complaints. As a rule, self-healing is not possible, so that the person affected by this syndrome is always dependent on treatment by a doctor. Since Wartenberg syndrome is also inherited, genetic testing and counseling should always be performed if the patient wishes to have children, so that a recurrence of the disease can be prevented. As a rule, patients with this disease are dependent on taking various medications. It is always necessary to pay attention to a correct dosage and also to a regular intake in order to counteract the symptoms permanently and correctly. Also the care and the support by the own family can be very meaningful with this illness and reduce thereby also depressions and other psychological illnesses. The further course depends strongly on the time of the diagnosis, so that a general prediction cannot be made. Possibly, the life expectancy of the affected person is also reduced by this disease.
What you can do yourself
A mild Wartenberg syndrome does not necessarily need to be treated. If severe limitations or pain are present, medication must be taken. Medication use must be closely monitored and recorded. Patients should also be aware of any side effects or interactions and inform the doctor. Severe Wartenberg syndrome must be treated surgically. After surgery, bed rest and sparing apply. Again, the doctor’s instructions must be followed exactly to rule out complications. It is also important to determine the cause of Wartenberg syndrome. Often, tight watches or jewelry bracelets are causative for the nerve damage. If the cause is unknown, the most important measure is to observe the symptoms and consult the doctor if they intensify. In the case of Wartenberg’s syndrome, sports activity that could put additional strain on the nerve should be avoided. Which measures are suitable for staying fit despite physical limitations is best discussed with a physiotherapist. The physician can name special exercises that can be used to relieve the pain at home. Under certain circumstances, massages or treatment using acupuncture may also help.
