This chapter excludes radial nerve pathology proximal to the elbow.

Wartenberg's syndrome is the

eponym of distal radial sensory neuralgia. The irritation of the radial sensory nerve distal to the
brachioradialis (BR) musculotendinous junction to where it penetrates the forearm fascia from deep
to superficial produces paresthesia and pain. The Tinel sign can localize the level of the nerve injury;
however, confounding factors can exist. Patients with previous surgical scars can have neuroma or
multiple locations for nerve traction. Regeneration of nerve fibers can produce an advancing Tinel in
addition to the primary area of findings. Unless Tinel testing is performed over time the advancing
nerve regeneration could be noted as static. Concomitant tendinopathies, de Quervain's or
intersection syndrome, can influence the clinical picture. Wartenberg (1932) wasn't the first to
report radial sensory neuralgia; however he did report on five cases in 1932. Common histories
include crushing or compressive injuries, repetitive forceful pronation and extension activity, and
metabolic disturbances such as dia¬betes and dialysis. Braidwood (1975) reported a small series of
radial sensory neuritis. Two thirds responded to conservative means, the four treated by resection of
the nerve, allowing it to retract under the BR muscle belly for protection, with good results. Dellon
and Mackinnon (1986) reported on 51 patients, and 37% responded by conservative means. Of
those under¬going surgery 86% were considered good to excellent results. Only 43% returned to
their regular jobs; 22% were in vocational rehabilitation. Some patients had multiple conditions or
injuries that precluded a return to their previous occupations. Lanzetta and Foucher, 1993 published
a series of 52 cases in which 71% responded nonoperatively with good or excellent results. Of the 15
patients treated operatively, 74% rated good or excellent at follow-up. They report a high incidence
(50%) of associated de Quervain's in their population—a cautionary tale.

Mackinnon and Dellon's surgical approach is a 6-8 cm inci¬sion centered on the Tinel area
longitudinally but volar to place the scar away from the nerve. The dorsal fascia is opened retracting
the BR volarly and continuing the lysis of fascia between the BR and extensor carpi radialis longus
(ECRL) 6 cm proximally. Neurolysis is performed allowing the nerve mobility and is continued distally
until the nerve is loose in the subcuta-neous tissue. An internal neurolysis is considered or
performed in patients with chronic sensory deficits. The internal neurolysis continues until internal
fibrosis is lysed and a normal fascicular pattern is found. Consideration should be given to using a
nerve wrap technique to prevent adhesions in this scenario. Severe nerve trauma warrants
considering resecting and burying the radial sensory nerve stump.

Zoch and Aigner (1997) reported on 10 patients, nine women, treated over a 2-year period with
freeing the nerve and longitudinally cutting and repairing the BR tendon to transpose the nerve
dorsally. Their 10 patients were free of symptoms at 6 weeks.