What is the best course of treatment for a patient with intact small finger movements but inward coiling weakness of the wrist?

Radial Nerve Palsy: Immediate Dynamic Splinting and Functional Task Training

For a patient with intact small finger movements but inward coiling weakness of the wrist (indicating isolated radial nerve palsy), immediately initiate dynamic splinting combined with structured occupational therapy focused on functional task training—this is the definitive first-line treatment. 1

Diagnostic Confirmation

This clinical presentation is diagnostic of radial nerve palsy:

• Weak wrist extension with preserved finger movements confirms isolated radial nerve dysfunction, as the radial nerve innervates wrist extensors while median and ulnar nerves control finger flexion 1
• Intact finger movements rules out more proximal cervical cord pathology or combined nerve injuries 1
• The "inward coiling" pattern represents 80% loss of wrist mobility in the extension plane, confirming severe motor impairment specific to radial nerve-innervated muscles 1

Primary Treatment Protocol

Dynamic Splinting (Start Immediately)

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

• Do not delay splinting while awaiting electrodiagnostic studies—early functional support is critical 1
• Never use serial casting or prolonged static immobilization, as this demonstrably worsens outcomes, causes muscle deconditioning, promotes learned non-use, and can trigger complex regional pain syndrome 1

Functional Task Training (Primary Therapy)

Implement intensive task-specific practice focusing on wrist extension movements with progressive difficulty. 1, 2

• Repetitive, goal-oriented functional activities that require active wrist use promote neural reorganization and motor recovery 3
• Progress from supported (table-based) to unsupported wrist movements as motor control improves 2
• Gradually increase resistance and complexity as the wrist demonstrates improved control 3
• Avoid compensatory movement patterns during therapy, as these reinforce abnormal motor control and delay recovery 1

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

Adjunctive Therapy: Functional Electrical Stimulation

Add FES to the wrist and forearm extensor muscles for patients with demonstrated impaired muscle contraction. 4, 1, 2

• FES provides short-term increases in motor strength and motor control 4, 1
• Use FES as an adjunct to motor practice, not as standalone treatment 3, 2
• FES promotes neural reorganization by providing sensory input and facilitating more complete muscle contractions 3

Specific Exercise Prescription

Begin with low-intensity resistance exercises (40% of 1-RM) with 10-15 repetitions, progressing to moderate intensity (41-60% of 1-RM) with 8-10 repetitions as strength improves. 3, 2

• Increase resistance when 15 repetitions become only somewhat difficult (Borg RPE 12-14) 3
• Perform flexibility training 2-3 times per week, with static stretches held for 10-30 seconds and 3-4 repetitions for each stretch 3, 2
• Do not progress resistance too quickly—start with very low intensity during initial sessions to avoid muscle damage 2

Monitoring and Follow-Up

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 to demonstrate changeability in symptoms and highlight successes 1
• Continue rehabilitation for 9-12 months, depending on functional goals, to ensure optimal recovery 3, 2
• Most motor recovery gains occur within the first 6 months, making this a critical window for intensive rehabilitation 2

Critical Pitfalls to Avoid

• Never use static casting or prolonged immobilization 1
• Avoid prolonged positioning of the wrist at end ranges, which exacerbates symptoms and may impede recovery 3, 2
• Do not rely on passive range of motion alone—active motor practice is essential 2
• Do not use splinting in the recovery phase once voluntary wrist extension returns 2

Prognosis

Resolution of wrist drop indicates significant motor recovery has already occurred, which is the primary clinical goal in radial nerve injuries. 2 The presence of voluntary finger extension is a positive prognostic indicator for upper extremity motor recovery. 3, 2 Rapid relief of symptoms typically occurs within 3-4 months with appropriate structured rehabilitation, with maintenance of gains over 12 months. 2