What is the best course of action for a patient with a partial radial nerve injury, 10 days post-injury, with no pain, wound, or erythema?

Management of Partial Radial Nerve Injury at 10 Days Post-Injury Without Pain, Wound, or Erythema

Continue conservative management with close clinical monitoring and active finger/wrist mobilization exercises, while scheduling follow-up evaluation at 8-12 weeks post-injury to assess for nerve recovery before considering surgical exploration. 1, 2, 3

Immediate Management Strategy

Continue Observation Period

• The standard approach for closed radial nerve injuries is conservative management for the first 8-12 weeks, as most radial nerve palsies associated with fractures recover spontaneously without surgical intervention 2, 3, 4
• At 10 days post-injury, you are still well within the appropriate observation window 3, 5
• Surgical exploration is typically reserved for cases showing no clinical improvement after 8-12 weeks of conservative treatment 3, 5

Active Mobilization Protocol

• Immediately initiate active finger motion exercises to prevent the most functionally disabling complication—hand stiffness 1, 6
• Patients should move all fingers through complete range of motion multiple times daily 1
• Begin active wrist range of motion exercises (flexion/extension/rotation) if not already started, as the patient is beyond the initial 0-3 week period 1
• These exercises do not adversely affect adequately stabilized fractures and are extremely cost-effective in preventing complications 1, 6

Clinical Monitoring Requirements

Serial Neurological Examination

• Assess motor function of radial nerve-innervated muscles at each follow-up:
  • Wrist extension (extensor carpi radialis longus/brevis)
  • Finger extension at metacarpophalangeal joints (extensor digitorum communis)
  • Thumb extension (extensor pollicis longus/brevis)
  • Thumb abduction (abductor pollicis longus) 3

Red Flags Requiring Earlier Intervention

• Any patient with unremitting pain during follow-up should be reevaluated immediately, as this may indicate nerve entrapment, malunion, or other complications 1, 6
• Development of new symptoms or worsening neurological function warrants earlier surgical consideration 3, 7

Radiographic Follow-Up

• Obtain radiographs at 10-14 days post-injury (if not already done) to ensure fracture position is maintained 1
• Repeat imaging at approximately 3 weeks to assess healing 6

Decision Point at 8-12 Weeks

Indications for Surgical Exploration

• No clinical improvement in motor function after 8-12 weeks of conservative treatment is the primary indication for surgical exploration 3, 5
• The American Academy of Orthopaedic Surgeons notes that evidence regarding nerve decompression timing is inconclusive, but clinical practice supports this 8-12 week window 8

Expected Outcomes with Conservative Management

• Motor function recovery to Grade 3 or better occurs in approximately 80-98% of radial nerve injuries managed appropriately, depending on injury severity 4
• Recent literature shows improved outcomes of nerve repair even up to 5 months after injury, which has changed the treatment algorithm to allow longer observation periods 5

Rehabilitation Approach

Home Exercise Program

• A home exercise program is equally effective as supervised physiotherapy for uncomplicated cases 1, 6
• Supervised therapy should be reserved only for patients developing complications such as stiffness or complex regional pain syndrome 1
• This approach is cost-effective and achieves equivalent outcomes in uncomplicated cases 1, 6

Critical Pitfalls to Avoid

• Never restrict finger motion during the observation phase—failure to encourage early finger exercises leads to severe stiffness requiring extensive therapy or surgery 1, 6
• Do not routinely prescribe supervised physiotherapy for all patients, as home programs achieve equivalent outcomes 1, 6
• Avoid premature surgical exploration before 8-12 weeks unless there are specific indications (open injury, obvious nerve transection, or progressive neurological deterioration) 2, 3, 5
• Be aware that atypical nerve injuries (such as nerve penetration by sharp bone fragments) may not recover with conservative management alone, though these are typically identified during initial injury assessment 7