What is the management of radial nerve palsy?

Management of Radial Nerve Palsy

The management of radial nerve palsy should begin with observation for spontaneous recovery in most cases, as the majority will recover without surgical intervention, especially when associated with humeral shaft fractures. 1

Initial Assessment

• Evaluate the mechanism of injury (trauma, fracture, iatrogenic, compression)
• Assess for complete vs. partial palsy
• Document specific motor deficits:
  • Wrist extension
  • Finger extension at metacarpophalangeal joints
  • Thumb extension and abduction
• Check sensory function over the dorsal aspect of the hand and first web space

Management Algorithm

Phase 1: Initial Management (0-3 months)

1. Conservative Management

   • Wrist splint in functional position (20-30° extension)
   • Maintain full passive range of motion in all affected joints 2
   • Prevent contractures with regular stretching
   • Physical therapy to maintain muscle tone and joint mobility

2. Indications for Early Surgical Exploration

   • Open fractures with visible nerve damage
   • Severe nerve damage confirmed by ultrasonography
   • Laceration injuries with obvious nerve transection 1
   • Longitudinal fractures of the distal third of humerus (higher risk of nerve entrapment) 3

Phase 2: Follow-up Period (3-6 months)

1. Monitor for Recovery

   • Clinical examination for signs of motor recovery
   • Electroneuromyography (EMG) studies to assess nerve function
   • Ultrasonography to evaluate nerve continuity

2. Decision Making at 3-6 Months

   • If signs of recovery present: continue conservative management
   • If no recovery by 6 months in younger patients: consider nerve repair options 1

Phase 3: Definitive Management (6-12 months)

1. Nerve Repair Options (if no recovery by 6 months)

   • Nerve autograft (for younger patients with suitable local conditions) 1
   • Nerve transfers (can be performed up to 10 months post-injury) 1

2. Tendon Transfer Options (if no recovery by 10-12 months)

   • Gold standard for long-standing radial nerve palsy 1
   • Provides reliable and rapid functional improvement
   • Common transfers:
     • Pronator teres to extensor carpi radialis brevis (for wrist extension)
     • Flexor carpi radialis to extensor digitorum communis (for finger extension)
     • Palmaris longus to extensor pollicis longus (for thumb extension)

Post-operative Rehabilitation

Following tendon transfers, a structured rehabilitation program is essential:

• Protected immobilization for 3-4 weeks
• Gradual active motion exercises
• Strengthening exercises
• Functional retraining for activities of daily living 4

Special Considerations

• Transverse fractures of the middle third of the humerus have better prognosis (85% show only slight nerve bruising) 3
• Younger patients have better outcomes with nerve repair procedures
• Tendon transfers remain the only option beyond 10-12 months post-injury 1
• Maintain full passive range of motion throughout the observation period to prevent contractures 2

Common Pitfalls to Avoid

• Premature surgical exploration in cases likely to recover spontaneously
• Delayed intervention beyond the optimal window for nerve repair (6 months)
• Inadequate splinting leading to contractures and functional impairment
• Neglecting physical therapy during the observation period
• Failing to monitor for signs of recovery with regular clinical examinations

The management approach should be tailored based on patient age, timing since injury, and presence of clinical recovery, with tendon transfers providing reliable outcomes when nerve recovery fails to occur.