Radial Nerve Palsy Management
This patient has radial nerve palsy, and the immediate treatment is dynamic splinting combined with structured occupational therapy focused on functional task training—do NOT use static casting or prolonged immobilization as this demonstrably worsens outcomes. 1
Clinical Diagnosis
This presentation is diagnostic of radial nerve palsy:
- Weak wrist extension with preserved finger movements indicates isolated radial nerve dysfunction, as the radial nerve innervates wrist extensors while the median and ulnar nerves control wrist flexion 1
- Normal finger function (able to close/open fingers) rules out more proximal cervical cord pathology or combined nerve injuries 1
- Inward coiling of the hand represents the classic "wrist drop" posture from loss of wrist extensor function 1
- Significant wrist weakness (80% loss of wrist extension mobility) confirms severe motor impairment specific to radial nerve-innervated muscles 1
Immediate Management Algorithm
Step 1: Dynamic Splinting (Start Immediately)
- Provide dynamic splinting that supports wrist and finger extension through a tenodesis mechanism while avoiding static immobilization 1
- The splint should allow functional movement patterns, not lock the wrist in place 1
- Do NOT delay splinting while awaiting electrodiagnostic studies—early functional support is critical 1
Step 2: Occupational Therapy (Begin Concurrently)
- Functional task training with normal movement patterns as the primary therapy modality, including: 1
- Engage the patient in tasks that promote even weight-bearing when using the hand (e.g., placing hand on kitchen bench while standing to prepare food rather than letting it hang by the side) 2
- Avoid compensatory movement patterns during therapy, as these reinforce abnormal motor control and delay recovery 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
- This reduces healthcare costs while maintaining equivalent outcomes 1
Step 4: Consider Functional Electrical Stimulation (FES)
- 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
Critical Pitfalls to Avoid
- Never use serial casting or prolonged static immobilization—this has been associated with worsening symptoms and onset of complex regional pain syndrome 2, 1
- Avoid splinting that increases attention/focus to the area, as this can exacerbate symptoms 2
- Do not allow "nursing" of the affected limb—demonstrate and promote therapeutic resting postures and active limb use 2
- Avoid postures that promote prolonged positioning of joints at end of range (e.g., full wrist flexion while sitting) 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 (with consent) to demonstrate changeability in symptoms, highlight successes, and serve as reference points for replicating successful strategies 2, 1
- Monitor for signs of skin breakdown, increased pain, or muscle deconditioning from improper splint use 2
Therapeutic Strategies During Activities
- Employ anxiety management and distraction techniques when undertaking tasks, as these can be helpful across all symptom types 2
- Encourage bilateral tasks that engage the affected limb in functional activities to avoid learned non-use 2
- Support the affected limb when at rest using pillows or furniture to reduce muscle overactivity, pain, and fatigue 2