Initial Management of Radial Nerve Injury
Conservative management with observation is the recommended initial approach for radial nerve injury, as 95% of patients achieve normal or near-normal functional recovery without surgery. 1
Immediate Assessment and Initial Treatment
Clinical Evaluation
- Document the timing of nerve dysfunction (primary vs. secondary injury)
- Assess motor function: wrist extension, finger extension (MCP joints), and thumb abduction
- Test sensory function in the first dorsal web space
- Determine mechanism of injury (fracture-associated, laceration, contusion, or iatrogenic) 1, 2
Conservative Management Protocol
Splinting and Joint Protection
- Apply dynamic splints immediately to maintain joint mobility and prevent contractures 1
- Keep all joints of the hand and wrist supple through passive range of motion exercises 1
- This is an integral part of treatment and must be initiated early to maintain full passive range of motion in all affected joints 2
Observation Period
- Monitor for spontaneous recovery over 3-4 months 3
- Conservative management is recommended regardless of patient age, cause of injury, fracture level, fracture type, or whether paralysis is primary or secondary 1
Indications for Early Surgical Intervention
Immediate surgery is indicated only in specific circumstances:
- Open fractures requiring debridement 1
- Unacceptable fracture reduction 1
- Associated vascular injuries requiring repair 1
- Obvious nerve transection in open injuries 2
In all open procedures, the radial nerve should be explored at the same time and treated appropriately. 1
Electrodiagnostic Monitoring
- Perform EMG studies at 4 and 6 months post-injury 1
- If no evidence of recovery by 6 months, nerve exploration is indicated 1
- This timeline allows adequate time for spontaneous recovery while avoiding unnecessary surgery 1
Surgical Timing for Delayed Intervention
Defer tendon transfers for at least 6 months, preferably one year, except in cases of unequivocal irreparable radial nerve damage 1
Surgical treatment after the observation period (3-4 months) may include:
- Direct suture repair (91% achieve Grade 3 or better motor recovery) 4
- Nerve grafting (80% achieve Grade 3 or better motor recovery) 4
- Neurolysis (98% achieve Grade 3 or better motor recovery) 4
Key Clinical Pearls
Secondary radial nerve palsy (developing after initial treatment or manipulation) has an excellent prognosis, with 100% of patients achieving full functional recovery with conservative management 1
The radial nerve is the most frequently injured major nerve in the upper limb due to its proximity to the humeral shaft and long, tortuous course 2. However, radial nerve injuries are the least debilitating of upper limb nerve injuries, and results are usually satisfactory with appropriate management 2.