Wartenberg's Sign Research Articles

Cubital Tunnel Syndrome Due to Intraneural Ganglion Cysts of the Ulnar Nerve With Joint-Cyst Connection at the Elbow

BACKGROUND AND OBJECTIVES: The unifying articular theory suggests that intraneural ganglion cysts in the cubital tunnel arise from the elbow joint and are connected to the ulnar nerve through an articular branch. This study aimed to report our clinical experience with these cysts and our surgical findings and outcomes. METHODS: We retrospectively analyzed 13 patients who underwent surgery for cubital tunnel syndrome caused by an intraneural ganglion cyst of the ulnar nerve. Clinical symptoms, physical examination findings, nerve conduction testing electromyography, plain radiography, and ultrasonography were evaluated before and after surgery. MRI was performed in 2 patients. Cyst decompression, disconnection of the articular branch, and ulnar nerve transposition were performed in all. RESULTS: The mean follow-up was 29 months. After surgery, local elbow pain and Tinel sign disappeared in all patients, and the average Numerical Rating Scale dropped from 3.7 (2-5) to 0 (0-0). Two-point discrimination testing was normal (<5.0 mm) in 12 patients. Wartenberg sign and “claw hand” deformity became negative, and muscle function and motor nerve conduction velocity were improved in 12 patients. The Medical Research Council muscle strength grade was M4 or M5 in the flexor carpi ulnaris, flexor digitorum profundus of the 4th and 5th digits, and first dorsal interosseous muscle in 12 patients. Postoperative spontaneous potentials including fibrillation and sharp waves, and motor unit recruitment in the first dorsal interosseous muscle were obviously improved. A cystic articular branch was confirmed during surgery in all patients. No cyst recurred clinically or on follow-up ultrasonography. CONCLUSION: The unifying articular theory of intraneural ganglion cysts applies to those located in the ulnar nerve at the elbow. Surgical disconnection of the articular nerve branch from the ulnar nerve eliminated the pathway for cyst recurrence and achieved good long-term outcomes.

Modification of the Zancolli Lasso Procedure for Simultaneous Correction of Wartenberg's Sign.

Ulnar nerve injury initiates an imbalance between the intrinsic muscles and extrinsic extensors of the ring and small fingers, which leads to the characteristic hyperextension of the metacarpophalangeal (MP) joints and flexion of the proximal interphalangeal joints of these 2 digits-commonly referred to as the ulnar claw hand. In addition to these changes in the static posture of the hand, ulnar nerve palsy severely impairs grasp due to deficient active MP joint flexion. In most cases, motor balance can be restored by preventing MP joint hyperextension and augmenting MP joint flexion using the Zancolli lasso procedure (ZLP). Ulnar neuropathy can cause a second motor imbalance between the ulnar intrinsics and the extensor digit minimi leading to an abduction deformity of the small finger known as Wartenberg's sign. The inability to adduct the small finger can be a great source of frustration to patients. Using a cadaveric biomechanical model, we have developed a simple modification of the Zancolli lasso procedure that simultaneously corrects claw deformity and Wartenberg's sign and we report its efficacy in 2 clinical cases.

Intraneural or extraneural ganglion cysts as a cause of cubital tunnel syndrome: A retrospective observational study.

PurposeCubital tunnel syndrome caused by ganglion cysts has rarely been reported. The purpose of this study was to evaluate the surgical treatment outcomes of a patient diagnosed with cubital tunnel syndrome caused by intraneural or extraneural cysts and to summarize our experience.MethodIn total, 34 patients were evaluated retrospectively from January 2011 to January 2020 with a follow-up of more than 24 months. Preoperative data, such as demographic data, clinical symptoms, physical examination findings, and laboratory tests, were all recorded and pre-operative and post-operative data were compared. The function was evaluated by the modified Bishop scoring system and the McGowan grade at the last follow-up.ResultsImprovement of interosseous muscle strength, the Visual Analog Scale (VAS), 2-point discrimination (2-PD), electromyogram (EMG) result, Wartenberg sign, claw hand, and weakness could be clearly observed in all patients. Extraneural cysts were completely removed and the pedicles of the cysts were ligated. Intraneural cysts were incised and drained, and part of their cyst walls were removed using a microsurgical technique. All patients underwent anterior subcutaneous transposition (AST). At the last follow-up, McGowan's (0-IIa) grade increased from seven patients (20.6%) preoperatively to 27 patients (79.4%); the excellent and good rate according to the modified Bishop scoring system was 82.4% (28 patients), and all patients had no symptoms of recurrence after surgery.ConclusionThe treatment of cubital tunnel syndrome caused by intraneural or extraneural cysts achieved good long-term results through extraneural cyst resection or intraneural cyst incision and drainage combined with subcutaneous transposition. Early diagnosis and surgical treatment are essential for the patient's postoperative recovery.

A clinico-radiological study of diagnostic accuracy of special clinical tests in diagnosing compressive myelopathy in patients of early cervical spondylitis symptoms along with its radiological correlation

Background. Cervical spine myelopathy occur due to compression of the spinal cord is present is quite common with a prevalence of around 90. Diagnosis of in the early stages of the condition, the patient may be symptomatic as neck pain, myelopathy or radiculopathy signs clinical examination findings, correlated by MRI findings. Aims & Objectives. To study the clinic-radiological correlation between these clinical signs and radiological imaging in patients with early cervical spondylotic symptoms. Methods and measures. A minimum of 100 cases shall be considered in this study. All the patients of either sex above the age of 12 years with early cervical spondylotic symptoms of SJMCH during the study period will be considered in this study Thorough clinical history including past medical, treatment and personal history is taken. The following clinical signs are assessed in them: clonus, Hoffman’s, Trömner, Wartenberg's sign, Deep tendon reflexes, Plantar reflexes The results of these tests are tabulated. MRI cervical spine is performed and cervical myelopathy is graded. MRI findings are correlated with the clinical signs and thus sensitivity, specificity and accuracy of each of these tests is calculated. Results. Four clinical diagnostic tests were found to have been quite reliable. None of the tests was self-diagnostic. Among various diagnostic tests Babinski, clonus sign has the highest specificity but low sensitivity. Conclusion. This study denotes that 6 tests used to diagnose myelopathy are interdependent, none is fully diagnostic.

Correction of ulnar claw hand and Wartenberg’s sign

Ulnar claw hand usually occurs when the ulnar nerve is damaged distally. Claw hand deformity is characterized by metacarpophalangeal hyperextension and interphalangeal flexion, making it impossible to oppose the fingers and thumb. Bouvier’s test is used to guide the procedure. Palliative surgery requires prior preparation of paralytic hands. In case of a positive Bouvier’s test, Zancolli’s lasso technique is preferred because of its effectiveness. Capsuloplasty with anteroposterior transosseous fixation is used if the bone is strong enough and when flexor digitorum profondus muscle is inactive and does not allow flexor digitorum superficialis tendon transfer. In case of a negative Bouvier’s test with interphalangeal extension deficit of 45° of less, direct interossei muscle restoration techniques by active transfers are performed. If the interphalangeal extension deficit is more than 45°, proximal interphalangeal arthrodesis is indicated.Wartenberg first described actively irreducible abduction of the little finger. Wartenberg’s sign is seen when ulnar paralysis occurs, and during ulnar nerve regeneration. Treatment of isolated Wartenberg's sign consists of re-routing the extensor digiti minimi. Among the other techniques, Belmahi’s “tie lasso” is preferred when flexible claw hand is associated with Wartenberg’s sign.

Influential factors of surgical decompression for ulnar nerve neuropathy in Guyon's canal.

Guyon's canal syndrome is nerve compressive pathology which can lead to sensory and/or motor function deficits. This problem is usually difficult to distinguish from cubital tunnel syndrome and relatively less common than cubital tunnel syndrome. This study evaluated the functional results and patient-reported outcomes following decompression of the ulnar nerve in Guyon's canal. Patients who were diagnosed with Guyon's canal syndrome confirmed by electrodiagnostic studies and underwent nerve decompression surgery were included in this study. The functional improvement by examining the Froment's sign, Wartenberg's sign, static two-point discrimination, and Semmes Weinstein monofilament examination as physical examination scores was evaluated. The visual analogue scale of satisfaction and the disabilities of the arm, shoulder, and hand questionnaire were used for the postoperative patient-reported outcome evaluation. From 2003 to 2019, 38 cases had been enrolled with a mean age of 53 years, ranging from 19 to 85 years. There were seven patients with comorbidity of diabetes mellitus and 28 patients who received additional neurolysis combined with the Guyon's release procedure. There were 19 patients with a good response to surgery and 10 patients with a poor surgical outcome due to persistent paresthesia or weakness. After statistical analysis, it was revealed that several influential factors could have been related to a compromised functional outcome, including a symptom duration of more than 3 months, combination with additional neurolysis of ipsilateral extremity, and/or comorbidity with diabetes mellitus. It was concluded that promising functional outcomes after surgical release of ulnar neuropathy in Guyon's canal could be achieved if the patients did not need additional neurolysis or the symptom duration was within 3 months.

Surgical outcome for severe cubital tunnel syndrome in patients aged >70years: a mean follow-up of 4.5years.

Surgical outcomes for cubital tunnel syndrome have been reported to be satisfactory, but could be compromised by advanced age and severe nerve compression. We aim to evaluate the prognosis of severe cubital tunnel syndrome in patients aged >70years. This retrospective study included 25 patients (26 extremities, all McGowan grade III, age >70years); 21 underwent subcutaneous transposition and 5 in situ decompression. Postoperative follow-up lasted >2years. Demographic data, clinical symptoms, physical examination findings, and the Disabilities of the Shoulder, Arm, and Hand Questionnaire were evaluated preoperatively and at final follow-up. Pain and weakness were evaluated using the visual analog scale and overall functional recovery using the modified Bishop's Score and McGowan Grade. Significant improvements were seen in both sensory and motor function. VAS pain and weakness, 2-PD, key-pinch strength, grip strength, first dorsal interosseous muscle strength, the Wartenberg sign, and claw hand all improved significantly. DASH scores improved from an average of 45.2 points preoperatively to 15.9 points postoperatively. According to the modified Bishop scoring system, 10 extremities were graded excellent; 12, good; 2, fair; and 2, poor. Improvement of at least one McGowan Grade was seen in 18 cases, but only 2 extremities recovered to normal. For patients aged >70years with severe cubital tunnel syndrome, surgical treatment is effective, but complete recovery is unlikely, and the recovery process is long.

Abduction permanente isolée du cinquième doigt sans paralysie ulnaire. À propos d’un cas

Wartenberg's sign, or permanent abduction of the little finger, occurs in the context of sequelae of ulnar nerve palsy. Its presence alone is rarely reported in the literature and is due to avulsion of the insertion of the third volar interosseous muscle. Several surgical techniques to correct this sign are reported in the literature. The authors report the case of a Wartenberg's sign without ulnar nerve palsy due to traumatic avulsion of the third volar interosseous muscle that was treated by a transfer of the extensor digiti minimi onto the radial side of the extensor digitorium communis according to technique of Bellan et al. After 1-year follow-up, result was good with no recurrence of any deformities and a normal active extension.

Bilaterale Fallhand – zentrale oder periphere Läsion?

The wrist drop, also called carpoptosis or drop hand, is a common clinical presentation in case of peripheral damage to the radial nerve. But what about the picture of a bilateral finger/wrist drop?! We report the case of a 61-year-old female patient who was admitted to the hospital for myocardial infarction. Subsequently she developed a right dominant bilateral wrist drop. Further neurological examination revealed a positive Wartenberg sign pointing towards a central motoric dysfunction. The following native cerebral CT scan demonstrated bilateral hypodense lesions in both hand knobs in the precentral gyri. Subsequent MRI confirmed acute cerebral infarction in these two but also several other, clinically silent, locations. Further diagnostic work-up revealed a hypokinetic cardiac apex suggesting cardiac embolism to be the cause for cerebral thrombembolism and the clinically leading symptom of right-dominant bilateral finger/wrist drop. Besides the case presentation also the differential diagnosis and clinical test for diagnostic work-up of wrist drops are presented and discussed.

Investigation of Radialization and Rerouting of the Extensor Digiti Minimi (EDM) in the Abduction Deformity of the Little Finger: A Cadaver Study

One of several operations to correct abduction deformity of the little finger, (Wartenberg's sign) in ulnar nerve palsy, is a combined procedure that radializes the extensor digiti minimi (EDM) at the level of the fifth metacarpophalangeal (MCP) joint and reroutes it from the fifth to fourth extensor compartment. This cadaveric study was designed to investigate the impact of both elements on adduction. Anatomy of the little finger extensor apparatus was studied in 16 freshly frozen cadaver hands sectioned at mid forearm. We observed little finger motion after different modifications of the EDM. We tested the effect of a rerouting maneuver by pulling on the EDM, as well as radialization of the EDM alone and in combination with rerouting. The EDM was present in all cases. Little finger extensor digitorum communis (EDC(V)) was missing in two cadavers. In no case was adduction created by rerouting the EDM to the fourth compartment. Radialization of the EDM corrected the abduction deformity beyond the axis of abduction/adduction of the fifth MCP joint in 13 cases and only up to it in three cases. In one of the three with limited correction, a rerouting maneuver allowed for further adduction. 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.

Analysis of Clinical Motor Testing for Adult Patients With Diagnosed Ulnar Neuropathy at the Elbow

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. Objective To compare the dichotomous results for 7 ulnar nerve clinical motor tests (Froment's sign, Wartenberg's sign, finger flexion sign, Jeanne's sign, crossed finger test, Egawa's sign, presence of clinical fasciculations) with motor nerve conduction velocity findings. Design A static group comparison design assessed for differences among dichotomous test outcomes with respect to motor nerve conduction velocity. Setting Five medical facilities throughout the United States provided data for this study. Participants Records from participants (N=26) with diagnosed ulnar neuropathy at the elbow were included for data analysis. Interventions Not applicable. Main Outcome Measures Demographic data included age, sex, handedness, duration of symptoms, and the number of days between the clinical and electrodiagnostic exam. Other dependent variables included motor conduction velocity of the ulnar nerve, compound muscle action potential amplitude, and the dichotomous clinical motor test outcomes. Results Two motor signs, the presence of clinical fasciculations and a positive finger flexion sign, were identified more frequently (each present in 11 patients) than the other motor signs. An analysis of covariance revealed significant differences in motor nerve conduction velocity between positive and negative results for all the clinical motor tests except for the finger flexion sign. Significant chi-square analyses were found for the following comparisons: the presence of clinical fasciculations and Froment's sign, the finger flexion sign and the crossed finger test, Egawa's sign and Froment's sign, Warteberg's sign and Froment's sign, the crossed finger test and Froment's sign, and Egawa's sign and Wartenberg's sign. Conclusions Some clinical motor tests are better than others at identifying early motor involvement, providing the rehabilitation professional some insight regarding the relative decrement of motor nerve conduction velocity when a selected test is positive.

Le « lasso en cravate » : une nouvelle technique pour le traitement simultané du signe de Wartenberg et des déformations en griffe des mains atteintes de paralysies cubitales

The "necktie lasso" is a new technique that allows the simultaneous active treatment, of both Wartenberg's sign and claw deformity of the fifth and the fourth digits in the hand with ulnar nerve palsy. The flexor sublimis of the fourth digit is taken by a palmar approach. It is then divided into two strips up to the proximal part of the palm; The radial strip is used as a classical "direct lasso" to treat the claw deformity of the fourth digit; The ulnar strip is wound around the base of the fifth digit by a palmar and dorsal approaches at the level of the proximal phalanx, like a necktie, being medial to its radial pedicle, dorsal and superficial to its extensor apparatus, then lateral to its ulnar pedicle; It is then recovered in the palm and sutured to itself. From September 1998 to April 2003, this technique has been used in eight patients aged between 21 and 35 years old and suffering from post traumatic low ulnar nerve palsy. It was always very effective in dealing with Wartenberg's sign: the active adduction of the fifth digit appearing at the start of flexion. The claw deformity of the fourth and fifth digits was equally actively corrected. No complications are reported in this series. With a mean follow-up of 3 years there was no recurrence of any of the deformities.

Recovery of Ulnar Innervated Intrinsic Muscles following Anterior Transposition of the Ulnar Nerve

A chart review of 26 patients who underwent anterior transmuscular transposition of the ulnar nerve and had a preoperative nerve conduction velocity less than 40 m/s across the elbow was completed. Patients with intrinsic muscle wasting before surgery were contacted for follow-up. One patient returned for follow-up evaluation. Preoperatively, this patient had complete numbness in the small and ring fingers, and severe intrinsic muscle wasting; left hand pinch and grip strengths were 4.5 kg and 34 kg, respectively. At the final evaluation, 67 months following surgery, left hand pinch and grip strengths were 10.9 kg and 54.5 kg, respectively. The patient had good intrinsic muscle reinnervation; his intrinsic hand muscle mass appeared to be equal to the uninvolved hand and there was no evidence of a Wartenberg's sign. This long term patient follow-up suggests that ulnar nerve transposition can facilitate the return of intrinsic muscle mass and function among patients with cubital tunnel syndrome.

Extensor digiti minimi tendon «rerouting transfer in permanent abduction of the little finger

Permanent abduction of the little finger is a bothersome deformity which usually occurs in the context of sequelae of ulnar nerve palsy (Wartenberg's sign), but also in rheumatoid arthritis. The authors report an original technique for correction of this deformity. The extensor digiti minimi tendon is sectioned at its distal insertion and transferred in the wrist through the extensor retinaculum. The "rerouted" tendon is finally resutured distally on the radial aspect of the interosseous muscle. Side-to-side suture of the transferred tendon to the extensor digitorum tendon of the little finger further reinforces the solidity of the procedure. The distal insertion of the extensor digiti minimi tendon is consequently radialized. Its new direction eliminates the abduction component, and the tendon then behaves as an active adductor of the little finger. Five cases (2 cases of ulnar nerve palsy, 3 cases of rheumatoid arthritis) are reported with a mean follow-up of 19 months. All patients have complete active adduction of the little finger in extension, with a persistent capacity for abduction. The other correction techniques published in the literature are discussed.

The extensor tendons to the little finger: An anatomic study

Fifty cadaver hands were dissected to better delineate the extensor tendon anatomy to the little finger. The extensor digitorum communis was present in 35. Of 15 hands without an extensor digitorum communis, 12 had a junctura present. Three hands lacked both extensor digitorum communis and juncturae. Transfer of the extensor digiti minimi tendon in these hands could cause loss of extension to the little finger. Ten hands had a direct attachment of the extensor digiti minimi tendon on the abductor tubercle. Twenty-two hands had either an attachment of the extensor digiti minimi on the abductor tubercle, an unbalanced ulnar slip of the extensor digiti minimi, or both, anatomic factors that could--in the event of ulnar nerve compression or laceration--cause Wartenberg's sign. Twenty-eight hands did not have an anatomic variant of the extensor that could cause ulnar deviation of the little finger.

Wartenberg's sign: A new method of surgical correction

A method of surgical correction is described for Wartenberg's sign, or persistent abduction of the little finger, using a slip of the extensor digitorum communis of the ring finger. The transferred component can be either the central slip, or the ulnar slip extended by the connexus intertendineus to the little finger. This technique maintains the integrity of the extensor mechanism of the little finger, avoiding loss of active extension, which is frequently observed when extensor digiti minimi is used. The donor site is dependable since the extensor digitorum communis tendon of the ring finger is always composed of several slips. This technique should be considered only in cases of isolated persistent abduction of the little finger, when there is no claw deformity.