What is the diagnosis and recommended treatment for a patient with intact finger movements, no sensory loss, but weak dorsal (back) movement of the hand and significantly impaired wrist movement, with no other symptoms or medical history provided?

Diagnosis: Radial Nerve Palsy

This clinical presentation is diagnostic of radial nerve palsy, characterized by isolated weakness of wrist extension (dorsal movement) with preserved finger movements and no sensory loss, and the primary treatment is immediate initiation of dynamic splinting combined with structured occupational therapy focused on functional task training. 1

Clinical Reasoning

The pattern you describe is pathognomonic for radial nerve injury:

• Weak wrist extension (dorsal movement) with preserved palmar flexion indicates isolated radial nerve dysfunction, as the radial nerve innervates wrist extensors while the median and ulnar nerves control wrist flexion 1
• Intact finger movements rules out more proximal cervical cord pathology or combined nerve injuries 2
• Absence of sensory loss suggests the injury spares the radial sensory nerve (RSN) branches or involves the posterior interosseous nerve (motor branch only) 3
• 80% loss of wrist mobility in the extension plane confirms severe motor impairment specific to radial nerve-innervated muscles 1

Immediate Management Algorithm

Step 1: Dynamic Splinting (Initiate Immediately)

Provide dynamic splinting that supports wrist and finger extension through a tenodesis mechanism while avoiding static immobilization. 1

• Static casting or prolonged immobilization worsens symptoms, causes muscle deconditioning, promotes learned non-use, and can trigger complex regional pain syndrome 1
• The splint should allow functional movement while preventing wrist drop during activities 1

Step 2: Structured Occupational Therapy Program

Begin functional task training with normal movement patterns as the primary therapy modality. 1

Key components include:

• Functional tasks promoting normal movement: Use the affected hand to stabilize objects during activities, place the hand on surfaces while standing, and perform bilateral upper extremity tasks 1
• Progressive activity grading: Increase the time the affected hand is used within functional tasks, employing normal movement techniques and avoiding compensatory strategies that reinforce abnormal patterns 1
• Active range of motion exercises: Perform active finger motion exercises regularly from the initial encounter, including stretching exercises for wrist flexors and extensors 1

Step 3: Home Exercise Program

Prescribe a directed home exercise program as the primary therapy modality, as evidence shows home programs are equivalent to supervised therapy for uncomplicated radial nerve palsy cases. 1

Step 4: Consider Adjunctive Interventions

Functional Electrical Stimulation (FES) should be considered for patients with demonstrated impaired muscle contraction, specifically for wrist motor impairment, as it provides short-term increases in motor strength and motor control. 1

Monitoring Protocol

• Reassess function every 2-3 weeks to evaluate splint effectiveness, adjust therapy progression, and monitor for any adverse effects from splinting 1
• Use video recording interventions (with consent) to demonstrate changeability in symptoms, highlight successes, and serve as reference points for replicating successful strategies 1

Critical Pitfalls to Avoid

• Never use serial casting or prolonged static immobilization as this demonstrably worsens outcomes 1
• Avoid compensatory movement patterns during therapy, as these reinforce abnormal motor control and delay recovery 1
• Do not delay splinting while awaiting electrodiagnostic studies, as early functional support is critical 1

When to Consider Further Workup

If symptoms do not improve after 8-10 weeks of structured conservative therapy, consider:

• Electrodiagnostic testing (nerve conduction studies and electromyography) to localize the lesion and assess severity 4
• Evaluation for compressive neuropathy requiring surgical decompression 1
• Assessment for underlying systemic conditions (diabetes, inflammatory disorders) that may impair nerve recovery 5