What are the treatment options for a patient with drop wrist (radial nerve palsy)?

Treatment of Drop Wrist (Radial Nerve Palsy)

The treatment approach for drop wrist depends critically on distinguishing between peripheral radial nerve compression (most common) and central causes like stroke, with peripheral compression typically managed conservatively through activity modification, splinting, and corticosteroids, while central causes require urgent stroke protocols.

Initial Diagnostic Differentiation

The first priority is determining whether the wrist drop has a peripheral or central etiology, as this fundamentally changes management:

• Peripheral radial neuropathy presents with wrist drop, finger extension weakness, and paresthesia on the dorsum of the 1st to 3rd fingers 1
• Central causes (stroke) can rarely present with isolated wrist drop affecting the hand area of the motor cortex, requiring urgent neuroimaging and potential thrombolysis 2, 3
• Ultrasound of the radial nerve can confirm peripheral compression and should be performed when peripheral etiology is suspected 4
• Electrophysiologic evaluation after 2 weeks typically shows delayed nerve conduction velocity in peripheral compression 1

Treatment for Peripheral Radial Nerve Palsy

Immediate Management (First 2-4 Weeks)

• Activity modification is the cornerstone of treatment—eliminate the compressive activity that caused the neuropathy 4
• Systemic corticosteroids should be prescribed to reduce nerve inflammation 4
• Wrist splinting with a cock-up splint maintains the wrist in extension to prevent contractures while the nerve recovers
• Active finger exercises should begin immediately to prevent finger stiffness, which is a common and disabling complication 5
• Ice application in the first 3-5 days can help reduce inflammation and pain 5

Expected Recovery Timeline

• Improvement typically begins after a mean of 2.4 weeks 1
• Near-complete recovery is expected in most cases of compressive radial neuropathy with appropriate conservative management 4, 1
• The condition generally has a good prognosis within several weeks 1

Rehabilitation Protocol

• During the acute phase, focus on maintaining passive range of motion in all affected joints (wrist, fingers, thumb) to prevent contractures 6
• A structured home exercise program is as effective as supervised therapy for uncomplicated cases 5
• Physiotherapy should emphasize maintaining full passive range of motion in the wrist and fingers while awaiting nerve recovery 6

Special Circumstances

Radial Nerve Palsy After Shoulder Dislocation

• When radial nerve palsy occurs after anterior shoulder dislocation, closed reduction should be performed first 6
• Electromyography at 3 weeks can confirm the extent of nerve injury 6
• Shoulder rehabilitation should be delayed until 6 weeks post-injury, while wrist and finger exercises begin immediately 6

Post-Traumatic or Post-Surgical Cases

• If wrist drop occurs after wrist fracture with external fixation, follow the rehabilitation protocol for external fixation 5
• Vitamin C supplementation should be considered to prevent disproportionate pain 5
• Avoid overdistraction if external fixation is used, as this may contribute to finger stiffness 5

Critical Pitfalls to Avoid

• Do not miss central causes: Isolated wrist drop can be the sole presentation of stroke, particularly in diabetic and hypertensive patients 2, 3
• Do not delay finger exercises: Finger stiffness is one of the most functionally disabling complications and is difficult to treat after it develops 5
• Do not perform unnecessary evaluations: Once compressive radial neuropathy is confirmed, extensive workup for stroke or cervical pathology is not needed 1
• Do not assume all wrist drops are peripheral: Always consider stroke in patients with vascular risk factors, even without other neurological deficits 2, 3