What are the next steps for treating radial nerve palsy that is not improving with a brace?

From the Research

For radial nerve palsy that is not improving with bracing, the next steps should include referral to a neurologist or hand specialist for further evaluation, as this approach is supported by the most recent and highest quality evidence available, such as the principles outlined in nerve conduction and electromyography studies 1.

Key Considerations

• Electrodiagnostic studies (EMG/NCS) should be performed to assess nerve function and determine the severity and location of the injury, as these tests are crucial for guiding further management, including the potential need for surgical intervention 1.
• Depending on the findings, surgical intervention may be necessary, particularly if there is evidence of nerve compression, laceration, or if no improvement occurs after 3-4 months of conservative management, highlighting the importance of timely and appropriate intervention to prevent long-term morbidity.
• While awaiting specialist care, patients should continue with a structured physical therapy program focusing on passive range of motion exercises to prevent contractures and maintain muscle tone, which is essential for preserving function and facilitating recovery.
• Occupational therapy for adaptive techniques and splinting to prevent wrist drop is also beneficial, as it can significantly improve the patient's quality of life and ability to perform daily activities.
• Pain management may include medications such as gabapentin (300-1200 mg three times daily) or pregabalin (75-300 mg twice daily) for neuropathic pain, although the choice of medication should be guided by the most recent evidence on efficacy and safety, such as the findings on pregabalin's benefits and harms in managing neuropathic pain 2.

Management Approach

• The management of radial nerve palsy requires a multidisciplinary approach, incorporating specialist evaluation, electrodiagnostic testing, physical and occupational therapy, and potentially surgical intervention, to optimize outcomes and minimize the risk of long-term disability.
• The use of bracing as an initial management strategy is not universally effective, as evidenced by the lack of improvement in some patients, underscoring the need for a comprehensive assessment and tailored treatment plan.
• The role of medications like pregabalin in managing neuropathic pain associated with radial nerve palsy should be considered in the context of the latest evidence on their efficacy and potential side effects, ensuring that treatment decisions prioritize the patient's quality of life and functional outcomes.