What is the best splinting approach for managing radial nerve palsy with wrist drop and medial weakness, considering I've been using a wrist splint contiguous with the middle finger on and off?

Optimal Splinting for Radial Nerve Palsy with Wrist Drop

For radial nerve palsy with wrist drop and medial weakness, you should use a dorsal wrist cock-up splint with dynamic finger extension (extending to the middle finger and other digits), worn continuously during the recovery period, not intermittently. 1

Why This Specific Splint Design

The dorsal wrist cock-up with dynamic finger extension splint is the only design that demonstrates both statistically significant functional improvement AND patient compliance in radial nerve palsy. 1 This splint design:

• Provides wrist extension support while allowing dynamic finger extension through outriggers or elastic bands 1
• Enables completion of all functional tasks, unlike static wrist splints alone which leave patients unable to complete key activities 1
• Utilizes a tenodesis effect at the wrist to facilitate finger and thumb extension during functional use 2

Critical Error in Your Current Approach

Your "on and off" splinting pattern is compromising your recovery. The splint must be worn continuously (except for hygiene and therapy) to:

• Prevent wrist and finger flexion contractures, which develop in 60% of patients within the first year after nerve injury 3
• Maintain proper hand positioning for functional tasks while nerve regeneration occurs 2
• Avoid the functionally disabling complication of joint stiffness from inadequate support 3

Splint Specifications

Your splint should include:

• Extension from the proximal forearm to beyond the fingertips, incorporating the middle finger along with ring and small fingers 1
• Dynamic components (elastic bands or springs) that assist finger extension via tenodesis when the wrist is positioned 2
• Wrist positioned in slight extension (approximately 20-30 degrees) to optimize finger extension mechanics 1

Duration and Monitoring

• Continue splinting throughout the nerve regeneration period, which can take months depending on the level of injury 4, 2
• Re-evaluate at 2-week intervals initially to assess splint fit, skin integrity, and any adverse effects such as skin erosion or increased pain 5
• Maintain splinting until nerve recovery is confirmed by return of active wrist and finger extension (typically M4+ strength or better) 4

Essential Concurrent Management

While wearing the splint continuously:

• Perform daily passive stretching of all wrist and finger joints to prevent contractures 3
• Begin active range of motion exercises for ALL uninjured fingers immediately—finger motion does not adversely affect the condition and prevents stiffness 6
• Avoid immobilizing any uninjured digits, as this causes unnecessary joint stiffness that is difficult to reverse 6

Common Pitfalls to Avoid

• Static wrist splints alone (without dynamic finger extension) fail to restore adequate function and patients cannot complete essential tasks 1
• Intermittent splint use allows flexion contractures to develop, particularly at the wrist where contractures occur most commonly in patients without functional hand recovery 3
• Over-reliance on resting hand splints is controversial and not well-established for nerve palsy (these are primarily for stroke patients) 3

When Splinting Alone Is Insufficient

If no nerve recovery occurs by 6 months post-injury:

• Consider median to radial nerve transfer surgery, which can restore independent finger motion and normal radial nerve function when performed within 6-10 months of injury 4, 7
• Tendon transfer surgery remains an option but does not restore independent finger function and may not provide truly desirable results for fine hand function 4, 8