Is my radial nerve injury worsening, given my history of lateral wrist drop and current symptoms of forearm heaviness with normal sensation?

Assessment of Radial Nerve Injury Progression

Your symptom of forearm heaviness with preserved sensation suggests motor nerve involvement without sensory deterioration, which may indicate either incomplete recovery or progression of your radial nerve injury and requires urgent clinical evaluation.

Understanding Your Current Symptoms

Your presentation of forearm heaviness with intact sensation is concerning for progressive or persistent motor dysfunction of the radial nerve. The radial nerve primarily controls wrist and finger extension (preventing wrist drop), and when motor function deteriorates while sensation remains intact, this suggests the injury may be affecting the deeper motor branches more than the superficial sensory branch 1.

Key clinical distinction: The superficial branch of the radial nerve (SBRN) provides sensation to the dorsal hand and thumb, while the posterior interosseous nerve (a motor branch) controls finger and wrist extension 2. Your preserved sensation with increasing heaviness suggests the motor component may be worsening while sensory fibers remain functional 1.

Determining if This is Worsening

Several factors indicate potential progression:

• Increasing heaviness in the forearm typically reflects progressive motor weakness or fatigue of denervated muscles attempting to compensate 3
• Radial nerve injuries have variable recovery patterns, with traumatic lesions generally having good prognosis, but recovery timelines extending 3-6 months or longer 1, 4
• The American Academy of Orthopaedic Surgeons emphasizes that unremitting pain or new symptoms during follow-up warrants immediate reevaluation, as this may indicate nerve compression or other complications 5

Immediate Action Required

You need urgent clinical reassessment including:

• Neurological examination to document current motor strength using standardized grading (Medical Research Council scale M0-M5) for wrist extensors, finger extensors, and thumb abductors 4, 6
• Electrodiagnostic studies (EMG/NCS) to assess for axonal degeneration versus demyelination and determine severity of nerve injury 3, 1
• Nerve imaging with ultrasound or MRI neurography is increasingly important for patients to identify structural nerve lesions, neuromas, or compression 1

Critical Timing Considerations

The window for optimal surgical intervention is typically 3-6 months post-injury 4, 6:

• Surgical exploration and nerve repair performed between 3-4 months shows favorable outcomes in combined humeral shaft and radial nerve injuries 4
• Nerve transfer procedures (median to radial nerve transfer) can be successful up to 6 months post-injury, though outcomes decline with longer delays 6
• One case series showed that a patient presenting at 8 months had significantly poorer outcomes (M2- finger extension) compared to those treated earlier (M4+ extension) 6

Treatment Pathway

If nerve injury is confirmed as progressive or non-recovering:

• Conservative management includes diclofenac, vitamin B supplementation, and aggressive physiotherapy, which can lead to complete motor recovery in some cases by 60 days 3
• Surgical options depend on the nature of injury and include neurolysis, nerve grafting, nerve transfers, or tendon transfers 1, 4, 6
• Nerve transfer is increasingly preferred over tendon transfer when independent finger function and fine motor control are priorities, particularly for patients needing to return to work 6

Common Pitfalls to Avoid

• Do not delay evaluation assuming spontaneous recovery will occur - while many radial nerve injuries recover spontaneously, progressive symptoms require active intervention 4
• Do not rely solely on sensation to gauge nerve recovery - motor and sensory fibers can be affected independently 1, 2
• The literature is insufficient regarding specific positioning strategies to prevent radial neuropathy, but avoiding prolonged pressure on the spiral groove of the humerus is recommended 7

Seek immediate evaluation by a hand surgeon or peripheral nerve specialist to determine if your symptoms represent expected recovery trajectory or require intervention before the optimal surgical window closes.