Management of Two-Week-Old Wrist Drop Injury
For a two-week-old wrist drop injury, immediately initiate functional electrical stimulation (FES) to the wrist and forearm extensors combined with dynamic splinting and structured occupational therapy—avoid static immobilization which worsens outcomes and can trigger complex regional pain syndrome. 1
Immediate Diagnostic Workup
Obtain MRI with dedicated neurography sequences to visualize the injured nerve and determine the extent of radial nerve damage, as this is the imaging modality of choice for suspected traumatic nerve injury of the wrist 1. If MRI is unavailable, ultrasound is an equivalent alternative 1.
Critical Treatment Timeline
You are within the optimal intervention window. FES must be initiated within the first 6 months post-injury to produce improved muscle force in wrist extension and short-term increases in motor strength and control 1, 2. The evidence shows FES is most effective when started early, and you have already lost 2 weeks 1.
Immediate Therapeutic Interventions
Primary Treatment Protocol
- Start FES immediately as adjunctive therapy to motor practice, targeting wrist and forearm extensor muscles 1, 2
- Implement dynamic splinting that provides wrist and finger extension support through a tenodesis mechanism 1
- Begin structured occupational therapy focused on functional task training with normal movement patterns, even before imaging confirmation 1
What to Avoid
- Never use static immobilization or serial casting—this causes muscle deconditioning, promotes learned non-use, worsens symptoms, and can trigger complex regional pain syndrome 1
- Avoid compensatory movement strategies during rehabilitation 1
Rehabilitation Protocol
- Prescribe a directed home exercise program including active finger motion exercises and stretching exercises for wrist flexors and extensors 1
- Grade activities progressively to increase the time the affected hand is used within functional tasks, employing normal movement techniques 1
- Reassess function every 2-3 weeks to evaluate splint effectiveness, adjust therapy progression, and monitor for adverse effects 1
Surgical Consideration Timeline
If nerve injury is confirmed on MRI and there is no improvement with conservative management, median to radial nerve transfer should be performed within 6 months of injury 3. The procedure involves coapting branches of the flexor carpi radialis and flexor digitorum superficialis nerves to the posterior interosseous nerve and extensor carpi radialis brevis 3. Outcomes show M4+ wrist extension in all patients and M4+ finger extension in most patients when performed within this timeframe 3.
Critical caveat: Patients presenting at 8 months post-injury have significantly poorer outcomes (M2- finger extension) compared to those treated within 6 months 3.
Expected Recovery Timeline
- Extend recovery assessment beyond 90 days—emerging data confirms recovery takes 6-12 months, not the traditionally assumed 3 months 1
- With appropriate early intervention (FES, dynamic splinting, therapy), complete motor recovery is achievable in most cases 4, 5
- One case series showed complete wrist extensor recovery after 3 months of physical therapy and full finger extensor recovery at 4 months 5
Monitoring for Permanent Damage
The two-week mark is early enough to prevent permanent damage if you act now. The window for optimal nerve recovery is 6 months 3. Beyond this timeframe, functional outcomes deteriorate significantly, and tendon transfer becomes the only option—though this results in loss of independent finger function and devastating fine motor deficits 3.