I am 21 days post‑radial nerve injury with wrist drop, intact flexor function, and I am receiving full‑intensity physical therapy and splinting; will I recover?

Prognosis for Radial Nerve Injury with Wrist Drop at 21 Days

With intact flexor function and full physical therapy at 21 days post-injury, you have a 77% chance of spontaneous recovery if managed conservatively, but early surgical exploration (within 3 weeks) increases your recovery rate to 90%. 1

Understanding Your Current Status

Your preserved flexor function is an excellent prognostic sign—it confirms the injury is isolated to the radial nerve and not a more extensive brachial plexus injury. 2 At 21 days post-injury, you are at a critical decision point where the evidence strongly favors early intervention over continued observation alone.

Evidence-Based Recovery Rates

Conservative Management Outcomes

• Spontaneous recovery rate: 77.2% with nonsurgical management alone 1
• Recovery is significantly better when nerve repair occurs within 5 months of injury 2
• Patients who fail conservative management and undergo late exploration (>8 weeks) have only a 68.1% recovery rate 1

Early Surgical Exploration Outcomes

• 89.8% recovery rate when surgical exploration occurs within 3 weeks of injury 1
• This represents a statistically significant improvement over expectant management 1
• Level III injuries (lateral arm to antebrachial fossa) and Level IV injuries (posterior interosseous nerve) show the best outcomes, with at least 80% achieving wrist extension recovery regardless of injury level 2

Critical Time-Sensitive Recommendation

You are currently at day 21—still within the 3-week window for optimal surgical outcomes. The 2020 systematic review analyzing data from 1964-2017 demonstrates that early surgical exploration within 3 weeks yields significantly superior results compared to delayed intervention. 1

Immediate Action Required

• Request urgent nerve conduction studies and electromyography (EMG) to determine if you have a complete nerve transection (requiring immediate surgery) versus neuropraxia (which may recover spontaneously) 3, 4
• Consult a hand surgeon or peripheral nerve specialist immediately to evaluate for early surgical exploration before the 3-week window closes 1
• If EMG/NCV shows complete denervation or no signs of early reinnervation, surgical exploration should not be delayed 1

Current Conservative Management (Continue Regardless)

While awaiting specialist evaluation, maintain aggressive conservative therapy:

Splinting Protocol

• Wear a wrist extension splint continuously to prevent contracture development and maintain the hand in functional position 5
• The splint should position your wrist in neutral to slight extension to avoid overstretching the denervated extensor muscles 5
• Remove the splint only for therapy sessions and hygiene—continuous use prevents the functionally disabling complication of wrist contracture 5

Physical Therapy Regimen

• Perform active finger motion exercises for all uninjured fingers immediately and continuously—finger motion does not adversely affect nerve recovery and prevents the most functionally disabling complication of finger stiffness 6, 7
• Passive range-of-motion exercises for the wrist and fingers should be performed multiple times daily to prevent contracture 5
• Standing on a tilt table for 30 minutes daily may help prevent contractures in the affected limb 5
• Continue therapy even if no improvement is seen initially—nerve regeneration occurs at approximately 1mm per day, so proximal injuries take months to show clinical improvement 2

Expected Recovery Timeline

If Neuropraxia (Nerve Bruising Without Transection)

• Recovery typically begins within 3 months with gradual improvement 3, 8
• Complete recovery may take 4-6 months for mild injuries 3, 8
• Wrist extensors typically recover before finger extensors 2

If Nerve Transection Requiring Repair

• Recovery depends on the distance from injury site to target muscles 2
• Wrist extension recovers in at least 80% of patients regardless of injury level when repaired within 5 months 2
• Finger and thumb extension recovery is more variable, with Level IV (distal) injuries showing significantly better outcomes 2
• Mean follow-up showing recovery is approximately 21.5 months 2

Critical Pitfalls to Avoid

Do Not Wait Beyond 3 Weeks Without Specialist Evaluation

The evidence is unequivocal: early exploration within 3 weeks yields 90% recovery versus 77% with observation alone and only 68% with late surgery. 1 Waiting to "see if it gets better" may permanently reduce your recovery potential.

Do Not Neglect Uninjured Fingers

Finger stiffness is one of the most functionally disabling complications and can be very difficult to treat after healing, potentially requiring multiple therapy visits and surgical intervention. 6 Move all uninjured fingers through complete range of motion multiple times daily starting immediately. 6, 7

Do Not Discontinue Splinting Prematurely

Without wrist support, contractures will develop that may become permanent and require surgical release. 5 Continue splinting until you regain active wrist extension or until cleared by your surgeon.

Advanced Imaging Considerations

MRI with dedicated neurography sequences (diffusion-weighted imaging) provides improved visualization of injured nerves and can help determine the extent of injury. 5 This imaging should be obtained urgently if not already performed, as it can guide the decision between conservative management and early surgical exploration.

Bottom Line for Your Specific Case

At 21 days with complete wrist drop, you need urgent specialist evaluation with EMG/NCV studies to determine if you are in the 77% who will recover spontaneously or if you need early surgical exploration to achieve the 90% recovery rate. 1 Continue aggressive splinting and therapy regardless, as these interventions prevent the secondary complications that can be more disabling than the nerve injury itself. 5, 6