What is the treatment for drop wrist (radial nerve palsy)?

Treatment of Drop Wrist (Radial Nerve Palsy)

The primary treatment for drop wrist (radial nerve palsy) should focus on maintaining full passive range of motion in all affected joints while awaiting nerve recovery, with conservative management being the first-line approach in most cases. 1

Initial Management

• Wrist splinting: Apply a wrist splint in functional position (20-30° extension) to prevent contractures and maintain proper hand positioning
• Active finger motion exercises: Begin immediately to prevent finger stiffness, which is one of the most functionally disabling complications 2, 3
• Physical therapy program: Should include:
  • Regular passive range of motion exercises for all affected joints
  • Strengthening exercises for unaffected muscle groups
  • Gradually increasing active exercises as nerve function returns

Conservative Management Timeline

1. First 3 months: Conservative treatment is the mainstay approach as most radial nerve palsies recover spontaneously, particularly those associated with closed humeral shaft fractures (89% complete recovery rate in nonoperatively treated patients) 4
2. 3-6 months: Continue conservative management with regular clinical assessments and nerve conduction studies to monitor recovery
3. Beyond 6 months: Consider surgical options if no signs of recovery are evident

Surgical Options (if conservative management fails)

• Nerve repair/grafting: Indicated when nerve transection is obvious (open injuries) or when there's no clinical improvement after conservative treatment 1
• Tendon transfers: Can restore wrist and finger extension when nerve recovery is unlikely
• Direct nerve transfers: More recent technique that may provide faster functional recovery

Rehabilitation Considerations

• Maintain full passive range of motion in all affected joints to prevent contractures 1
• Use adaptive equipment to assist with activities of daily living
• Educate patients and caregivers on proper positioning and handling of the affected limb
• Consider circuit class therapy for improving overall function 2

Monitoring and Follow-up

• Regular clinical assessments (every 2-3 weeks initially)
• Electromyography (EMG) at 3-4 weeks after injury to establish baseline and again at 3 months to assess recovery
• Adjust treatment plan based on recovery progress

Pitfalls and Caveats

• Avoid prolonged immobilization which can lead to joint stiffness and contractures
• Do not allow weight-bearing on axillary crutches if these are used for mobility, as this can cause bilateral wrist drop 5
• Be aware that radial nerve palsy can occur as a complication of shoulder dislocations, requiring prompt diagnosis and management 6
• Even with appropriate treatment, some patients may have residual deficits requiring long-term adaptive strategies

The high spontaneous recovery rate of primary radial nerve palsies, particularly in closed injuries, supports a conservative approach as the initial treatment strategy in most cases 4. Surgical intervention should be reserved for cases with clear evidence of nerve transection or lack of recovery after an adequate trial of conservative management.