I have wrist drop but can still flex and pinch my fingers; what is the appropriate management including splinting, functional electrical stimulation, TENS, and further work‑up?

Management of Wrist Drop with Preserved Finger Function

You should initiate dynamic splinting that provides wrist extension support through a tenodesis mechanism while avoiding static immobilization, combined with a structured functional task training program focused on normal movement patterns. 1

Splinting Strategy

Use dynamic splinting that allows functional movement, not static immobilization. The evidence strongly advises against serial casting or prolonged static splints, as these worsen symptoms through multiple mechanisms: increasing muscle deconditioning, promoting learned non-use, exacerbating pain, and potentially triggering complex regional pain syndrome. 2, 1

• Dynamic splints should provide wrist extension support while allowing your preserved finger flexion and pinch to function normally 1
• Monitor the splint's effectiveness every 2-3 weeks and discontinue immediately if adverse effects like pain or skin breakdown occur 2, 1
• The splint should facilitate rather than restrict your ability to use your hand in functional tasks 2

Functional Task Training (Primary Therapy)

Engage in functional tasks that promote normal movement patterns using your affected hand. 1, 3

• Use your hand to stabilize objects during daily activities, preventing learned non-use 1
• Place your hand on surfaces (kitchen counter, table) while standing rather than letting it hang at your side 2, 1
• Perform bilateral upper extremity tasks that incorporate the affected limb 1, 3
• Grade activities progressively to increase the time your affected hand participates in functional tasks 1, 3
• Avoid compensatory movement strategies that reinforce abnormal patterns 1

Home Exercise Program

A directed home exercise program should be your primary therapy modality. Evidence demonstrates home programs are equivalent to supervised therapy for uncomplicated radial nerve palsy. 1

• Perform active finger motion exercises regularly, including stretching for wrist flexors and extensors 1
• Practice repetitive movements using normal patterns to prevent learned non-use 3
• Employ anxiety management and distraction techniques during exercises to improve motor control 3

Functional Electrical Stimulation (FES)

FES is appropriate for your wrist motor impairment if you demonstrate impaired muscle contraction. 1, 3

• FES provides short-term increases in motor strength and motor control specifically for wrist extension weakness 1, 3
• This is an adjunctive intervention to complement, not replace, your functional task training 1

TENS Therapy

The guidelines do not support TENS as a primary intervention for radial nerve palsy with wrist drop. Focus instead on FES if electrical stimulation is desired, as it has specific evidence for motor impairment. 1, 3

Further Work-Up

Obtain nerve imaging with ultrasound or MRI if you lack a clear history of major arm or shoulder trauma. 4

• High-resolution nerve ultrasound can visualize nerve constriction, torsion, or other structural abnormalities that may require surgical intervention 5
• Electrodiagnostic studies (EMG/NCS) confirm the diagnosis and help localize the lesion more precisely 4
• Consider urgent imaging if symptoms are acute without clear traumatic etiology, as rare causes like nerve torsion may benefit from early surgical intervention 5

Common Pitfalls to Avoid

• Do not use static resting splints alone, as this increases attention to the affected area and can paradoxically worsen symptoms 2, 1
• Do not immobilize the hand completely, as your preserved finger flexion and pinch represent valuable function that must be maintained 2
• Do not delay imaging if the cause is unclear, particularly in acute presentations without obvious trauma 5, 6
• Do not accept bilateral wrist drop as purely peripheral without ruling out central causes (bilateral precentral gyrus lesions can present this way) 7