Will Wrist Drop Be Corrected with FES, TENS, Splinting, and Active Exercise?
Yes, wrist drop from recent radial nerve injury with intact finger flexors can be corrected using functional electrical stimulation (FES), splinting, and active exercise, though the prognosis depends critically on timing of intervention and nerve injury severity. 1
Treatment Algorithm for Radial Nerve Wrist Drop
Immediate Intervention (First 6 Months)
Functional electrical stimulation should be initiated immediately as the American Heart Association specifically recommends FES for patients with wrist motor impairment within the first 6 months post-injury. 1 This produces:
- Improved muscle force in wrist extension 1
- Short-term increases in motor strength and motor control 2
- Reduction in impairment severity 2
FES is recommended for patients who have demonstrated impaired muscle contraction, specifically with wrist motor impairment. 2 The evidence shows FES leads to improved muscle force in the muscle groups receiving stimulation, though functional outcomes beyond motor strength are less well documented. 2
Splinting Strategy
Resting wrist splints combined with regular stretching and spasticity management should be considered for patients lacking active wrist movement. 2 However, the effectiveness of resting hand/wrist splints is not well established, with controversy in the literature. 2
- The Royal College of Physicians guidelines recommend against resting hand splints 2
- The Veterans Affairs/Department of Defense guidelines recommend their use 2
- Application of resting hand splints combined with other treatments may be beneficial 2
Active Exercise Protocol
Active wrist and finger motion exercises should be performed immediately following diagnosis to prevent stiffness. 3, 4 This is critical because:
- Hand stiffness is one of the most functionally disabling adverse effects following nerve injury 3
- Finger motion does not adversely affect adequately stabilized conditions in terms of healing 4
- Failure to encourage early motion can lead to significant stiffness that is difficult to treat 3, 4
Daily stretching of the affected limb should be performed to avoid contractures, with patients and families taught proper stretching techniques. 2
TENS Consideration
The evidence provided does not specifically support TENS for radial nerve wrist drop recovery. FES is the electrical stimulation modality with guideline-level recommendations for wrist motor impairment. 2, 1
Prognosis and Timeline
Recovery potential is excellent if intervention occurs within 6 months of injury. 1 Recent research demonstrates:
- Independent wrist extension achieving M4+ strength in all patients when surgery performed within 6 months 5
- Complete recovery possible with physical therapy within 3-4 months 6
- Patients presenting late (8 months post-injury) had significantly poorer outcomes with only M2- finger extension 5
Critical Pitfalls to Avoid
The 6-month window is crucial - FES should be initiated within the first 6 months post-injury for optimal outcomes. 1 Beyond this timeframe, recovery becomes significantly compromised. 5
Do not immobilize without concurrent active exercise - immobilization alone without regular range of motion exercises leads to devastating stiffness. 3, 4
Monitor for lack of progress - if no improvement occurs after 3-6 months of conservative management with FES and exercise, surgical options including nerve transfers or tendon transfers should be considered. 7, 5
Surgical Backup Plan
If conservative management with FES, splinting, and active exercise fails to restore function by 6 months, median to radial nerve transfers are a reliable surgical option that can restore independent wrist and finger extension with M4+ strength. 7, 5 This is superior to tendon transfers which cannot restore independent finger function. 5