Wartenberg's sign

Wartenberg's sign is a neurological sign consisting of involuntary abduction of the fifth (little) finger, caused by unopposed action of the extensor digiti quinti.^[1][2]

This commonly results from weakness of some of the ulnar nerve innervated intrinsic hand muscles -in particular the palmar interosseous muscle to the little finger- caused by damage to their nerve supply (denervation). There may be different causes for this denervation and muscle imbalance including:

• An ulnar nerve neuropathy ^[3][4] usually from ulnar nerve entrapment somewhere along its course (most commonly around the cubital tunnel at the elbow where the nerve is exposed to tension, friction and compression^[5]). This muscle imbalance between the (intact) radial nerve innervated extensor digiti quinti and the (weak) ulnar innervated interossei in the context of ulnar neuropathy is what Wartenberg described.^[2]
• Cervical myelopathy^[6] most commonly due to mechanical compression of the spinal cord in the neck as occurs in spondylotic cervical spinal stenosis but also seen in other spinal cord disease including post-traumatic tetraplegia. This finding of weak finger adduction in cervical myelopathy is also called the "finger escape sign".^[7]
• Upper motor neuron disorders of the cerebral cortex such as mild hemiplegic stroke^[8] or hemiplegic migraine^[9] where the same clinical finding has been called the "digiti quinti sign"^[8]

Differentiation of the cause of Wartenberg's sign is based on associated clinical findings in the history and examination and sometimes involves investigations including radiographs and/or MRI of the cervical spine, elbow/wrist/hand and/or nerve conduction studies and EMG.

Wartenberg's sign is not a feature of, and should not be confused with, Wartenberg's syndrome. The later involves compression at the wrist of the superficial sensory branch of the radial nerve which does not innervate hand muscles.

Robert Wartenberg (1887-1956) was a neurologist born in Belarus who worked in Germany until 1935 when he emigrated to the United States, he was widely published and described a number of neurological signs and clinical tests.^[10]

References

1. Wilkinson, Iain and Lennox, Graham (June 2005). Essential Neurology (4th ed.). Wiley-Blackwell. p. 1184 ISBN 978-1-4051-1867-5.
2. Wartenberg, R. (1943-07-01). "Nerves of the Arm: Some of Their Affections; Their Diagnosis". California and Western Medicine 59 (1): 22–24. ISSN 0093-4038. PMC 1780592. PMID 18746534.
3. Goldman, Sarah B.; Brininger, Teresa L.; Schrader, John W.; Koceja, David M. (2009-09-01). "A review of clinical tests and signs for the assessment of ulnar neuropathy". Journal of Hand Therapy: Official Journal of the American Society of Hand Therapists 22 (3): 209–219; quiz 220. doi:10.1016/j.jht.2008.10.010. ISSN 0894-1130. PMID 19188042.
4. "Ulnar Neuropathy: Background, Anatomy, Pathophysiology".
5. Posner, M. A. (2000-01-01). "Compressive neuropathies of the ulnar nerve at the elbow and wrist". Instructional Course Lectures 49: 305–317. ISSN 0065-6895. PMID 10829185.
6. Micev, Alan J.; Ivy, Andre D.; Aggarwal, Sandeep K.; Hsu, Wellington K.; Kalainov, David M. (2013-12-01). "Cervical radiculopathy and myelopathy: presentations in the hand". The Journal of Hand Surgery 38 (12): 2478–2481; quiz 2481. doi:10.1016/j.jhsa.2013.07.020. ISSN 1531-6564. PMID 24054072.
7. Ono, K.; Ebara, S.; Fuji, T.; Yonenobu, K.; Fujiwara, K.; Yamashita, K. (1987-03-01). "Myelopathy hand. New clinical signs of cervical cord damage". Bone & Joint Journal 69–B (2): 215–219. ISSN 2049-4394. PMID 3818752.
8. Alter, M. (1973-05-01). "The digiti quinti sign of mild hemiparesis". Neurology 23 (5): 503–505. ISSN 0028-3878. PMID 4735466.
9. Vincent, M. B. (2009-05-01). "A Note on the Digiti Quinti Sign in Hemiplegic Migraine". Cephalalgia 29 (5): 580–582. doi:10.1111/j.1468-2982.2008.01743.x. ISSN 0333-1024. PMID 19025551.
10. Kuzuhara, Shigeki (2014-11-01). "[Robert Wartenberg: the neurologist, the teacher, and the man]". Brain and Nerve = Shinkei Kenkyū No Shinpo 66 (11): 1301–1308. doi:10.11477/mf.1416200032. ISSN 1881-6096. PMID 25407064.