What is the treatment for Saturday palsy, also known as radial neuropathy?

Saturday Night Palsy (Radial Neuropathy) Treatment

Primary Management

Saturday night palsy requires supportive care only—no pharmacological intervention is indicated, as there is no evidence supporting steroid use for radial nerve compression injuries. 1

The condition typically resolves spontaneously within 6 months in the vast majority of cases, making conservative management the standard approach. 2

Initial Assessment

When evaluating a patient with suspected Saturday night palsy, focus on:

• Mechanism of injury: History of prolonged compression of the radial nerve against the humerus, often during deep sleep, frequently associated with alcohol intoxication 2, 3
• Pattern of weakness: Characteristic wrist drop, finger extension weakness, and thumb drop 4
• Timing: Acute onset, typically noticed upon awakening 2
• Red flags requiring further workup:
  • Absence of clear compressive history suggests alternative diagnoses like neuroma formation 2
  • Severe or prolonged compression raising concern for rhabdomyolysis and crush syndrome 3
  • Progressive symptoms or failure to improve warrant electrodiagnostic testing and imaging 2, 5

Conservative Treatment Protocol

Supportive Care Measures

• Passive range of motion exercises to maintain joint mobility and prevent stiffness in the wrist and fingers 1
• Wrist splinting in neutral or slight extension to prevent contractures during recovery (general medical knowledge)
• Activity modification to avoid further compression or trauma to the affected nerve (general medical knowledge)

Monitoring Strategy

• Expectant observation for up to 6 months, as most cases demonstrate complete spontaneous recovery 2
• Serial clinical examinations every 4-6 weeks to document progressive improvement (general medical knowledge)

When Conservative Management Fails

Electrodiagnostic Testing Indications

Obtain nerve conduction studies and electromyography if:

• No clinical improvement by 6-8 weeks 2
• Severe axonal loss suspected clinically (general medical knowledge)
• Uncertainty about diagnosis or nerve injury severity 2

Advanced Imaging

High-resolution nerve ultrasound can identify structural causes like nerve torsion or constriction that may benefit from early surgical intervention 5

Surgical Exploration Criteria

Consider surgical intervention when:

• Structural lesion identified on imaging (neuroma, nerve torsion, constriction) 2, 5
• No recovery by 9-12 months with confirmed severe axonal injury on electrodiagnostic testing 2
• Progressive weakness despite conservative management (general medical knowledge)

Surgical options include neuroma excision with end-to-end nerve repair, which can achieve complete recovery within 9 months post-operatively 2

Critical Pitfalls to Avoid

• Do not prescribe corticosteroids—unlike Bell's palsy where steroids are strongly recommended 6, 1, there is no evidence supporting their use in radial neuropathy 1
• Screen for rhabdomyolysis in cases involving prolonged immobilization or severe compression, as crush syndrome can cause acute renal failure and carries high morbidity 3
• Consider toxic/metabolic mimics in atypical presentations: lead poisoning (plumbism) and acute porphyrias can present identically with wrist/finger drop but require entirely different management 4
• Avoid premature reassurance without establishing clear compressive etiology—spontaneous cases without trauma history may harbor underlying pathology like neuroma 2