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A Fascial Band Implicated in Wartenberg Syndrome

Patel, Anup M.D., M.B.A.; Pierce, Paul M.D.; Chiu, David T. W. M.D.

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Plastic and Reconstructive Surgery: March 2014 - Volume 133 - Issue 3 - p 440e-442e
doi: 10.1097/01.prs.0000438497.39857.97
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Sir:

In 1932, Wartenberg fashioned the term “cheiralgia paresthetica” to denote compression of the radial sensory nerve in the forearm.1 The superficial location of this nerve inherently leads to its susceptibility to external compression, with various etiologies reported.2–4 Tight wristwatches, handcuffs, lipomas, bony spikes, and work-related activities demanding repetitive supination and pronation have been implicated in producing Wartenberg syndrome. Specifically, in pronation, the brachioradialis and the extensor carpi radialis longus compress the nerve.

A 66-year-old, right-hand-dominant man presented with tingling, paresthesias, and pain over the dorsal aspect of his left thumb of 5 months’ duration. On physical examination, the patient had a positive Tinel’s sign over distribution of his left superficial branch of the radial nerve. There were no masses, bruits, or swelling observed. A magnetic resonance imaging scan of the left wrist and forearm demonstrated poor definition and loss of normal fat planes surrounding the proximal portion of the superficial branch of the radial nerve deep to the brachioradialis.

In the operating room, an oblique incision at a right angle to the superficial branch of the radial nerve was made over the dorsoradial aspect of the forearm at the level of the musculotendinous junction of the brachioradialis (Fig. 1, above, left). The nerve was identified in the subcutaneous tissue (Fig. 1, above, right). The tendinous portions of the brachioradialis and extensor carpi radialis longus were identified. Continuing the dissection proximally, the musculotendinous junction of the brachioradialis was identified. At this level, the superficial branch of the radial nerve was noted to exit at the dorsal aspect of the brachioradialis tendon. Upon dissecting the nerve proximally, a fascial ring from the dorsal edge of the brachioradialis was encountered circumferentially constricting the nerve (Fig. 1, below, left). The fascial ring was sharply incised while protecting the nerve. Upon releasing the fascial ring, an area of compression was clearly visible on the surface of the nerve (Fig. 1, below, right). A segment of dorsal brachioradialis tendon was also removed to prevent further compression.

Fig. 1
Fig. 1:
(Above, left) The oblique incision is marked over the musculotendinous junction of the brachioradialis. (Above, right) The branches of the superficial branch of the radial nerve are identified within the subcutaneous tissue. (Below, left) The fascial ring is implicated in the entrapment of the superficial branch of the radial nerve. (Below, right) An area of compression from the fascial ring can be seen on the superficial branch of the radial nerve.

Compression neuropathies create significant morbidity in the upper and lower extremities in terms of pain, sensory abnormalities, and motor weakness. The superficial branch of the radial nerve, due to its anatomic location, is vulnerable to compression from trauma, masses, and constriction from the fascia connecting the brachioradialis and extensor carpi radialis longus.5 To our knowledge, this report presents the first description of an extraneous fascial ring, outside of the brachioradialis and extensor carpi radialis longus fascia, that encompasses the nerve, necessitating release.

Anatomically, the superficial branch of the radial nerve exits from under the brachioradialis at the junction of the proximal two-thirds to distal one-third of the forearm. It then courses superficially into the subcutaneous plane, innervating the dorsum of the thumb, index, and radial half of the long finger. Compression of this nerve leads to sensory changes and pain within this distribution. While the fascia between the brachioradialis and the extensor carpi radialis longus is most often implicated in the compression of this nerve, other etiologies have been implicated, including lipoma and bony spurs. Nonetheless, there are no reports in the literature describing the separate fascial ring leading to Wartenberg syndrome, as described here.

Although Wartenberg syndrome is rare, its etiologies are numerous, including this anomalous fascial ring. Surgeons should be cognizant of this ring, and if they encounter it, they should transect it to circumvent the clinical symptoms resulting from compression of the superficial branch of the radial nerve.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.

Anup Patel, M.D., M.B.A.

Paul Pierce, M.D.

David T. W. Chiu, M.D.

Institute of Plastic and Reconstructive Surgery

New York University Medical Center

New York, N.Y.

REFERENCES

1. Mackinnon SE, Novak CGreen DP, Hotchkiss RN, Pederson WC, Wolfe SW. Compression neuropathies. Green’s Operative Hand Surgery. 2005;Vol. 15th ed New York Churchill Livingstone:999–1046
2. Lubahn JD, Cermak MB. Uncommon nerve compression syndromes of the upper extremity. J Am Acad Orthop Surg. 1998;6:378–386
3. Balakrishnan C, Bachusz RC, Balakrishnan A, Elliot D, Careaga D. Intraneural lipoma of the radial nerve presenting as Wartenberg syndrome: A case report and review of literature. Can J Plast Surg. 2009;17:e39–e41
4. 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;193:251–254
5. Dang AC, Rodner CM. Unusual compression neuropathies of the forearm: Part I. Radial nerve. J Hand Surg Am. 2009;34:1906–1914

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