What is the best treatment approach for an adult patient with wrist drop and no visible wound, who has preserved finger function but lacks wrist extension power?

Wrist Drop with Preserved Finger Function: Treatment Approach

Begin intensive task-specific wrist practice combined with functional electrical stimulation (FES) to the wrist and forearm extensors—this is the evidence-based treatment for radial nerve injury with persistent wrist weakness when finger function is preserved. 1, 2

Primary Treatment Strategy

Task-Specific Wrist Practice (Core Intervention)

• Start with supported wrist movements on a table surface, then progress to unsupported movements as wrist control improves 2
• Practice functional activities that progressively challenge wrist extension and flexion with graded difficulty, focusing on normal movement patterns with good alignment 1, 2
• Perform repetitive, goal-oriented activities that require active wrist use to promote neural reorganization and motor recovery 2
• Gradually increase resistance and complexity as the wrist demonstrates improved control 2

Functional Electrical Stimulation (Essential Adjunct)

• Apply FES to the wrist and forearm extensor muscles—this is specifically recommended for patients with demonstrated impaired muscle contraction and wrist motor impairment 1, 2
• Use FES in combination with task-specific training, not as standalone treatment, to enhance motor control and provide sensory input that facilitates more complete muscle contractions 1, 2
• FES leads to short-term increases in motor strength and motor control when combined with active practice 2

Structured Resistance Training Protocol

When therapy time permits, implement the following progression 1, 2:

• Initial Phase: Start with low-intensity resistance at 40% of 1-repetition maximum (1-RM) with 10-15 repetitions 1, 2
• Progression: Advance to moderate intensity (41-60% of 1-RM) with 8-10 repetitions as tolerated 1, 2
• Advancement Criteria: Increase resistance when 15 repetitions become only somewhat difficult (Borg RPE 12-14) 2
• Frequency: Perform resistance training 2-3 times per week to allow adequate recovery between sessions 1, 2

Flexibility Work

• Perform static stretches held for 10-30 seconds with 3-4 repetitions for each stretch 1, 2
• Implement flexibility training 2-3 times per week in conjunction with resistance work 1, 2
• Focus on improving joint mobility to address any inward coiling of the hand 2

Critical Management Principles: What NOT to Do

Do NOT use splinting or immobilization—this prevents restoration of normal movement and function and may promote learned non-use 1, 2, 3. This is a common pitfall that must be avoided.

Additional contraindications include:

• Avoid prolonged positioning of the wrist at end ranges, which exacerbates symptoms and may impede recovery 1, 2, 3
• Do not rely on passive range of motion alone—active motor practice is essential for recovery 1, 2
• Do not progress resistance too quickly—start with very low intensity during initial sessions to avoid muscle damage 1

Prognostic Indicators and Timeline

Positive Prognostic Factors

• The presence of voluntary finger extension indicates good potential for upper extremity motor recovery 1, 2, 3
• Resolution of wrist drop (if previously present) indicates significant motor recovery has already occurred 1

Expected Recovery Timeline

• Most motor recovery gains occur within the first 6 months, making this a critical window for intensive rehabilitation 1, 2
• Continue rehabilitation for 9-12 months depending on functional goals for optimal recovery 1, 2
• Rapid relief of symptoms typically occurs within 3-4 months with appropriate structured rehabilitation, with maintenance of gains over 12 months 1

Important Clinical Caveat

The specific deficit pattern of preserved finger function with wrist weakness will not spontaneously improve without structured resistance training and task-specific practice 1, 2. This underscores the necessity of active intervention rather than expectant management.