Recovery Timeline for Radial Nerve Injury with Wrist Drop at 21 Days Post-Injury
At 21 days post-injury with complete loss of wrist extensors despite full physiotherapy, you should expect potential recovery within 3-5 months if nerve continuity is intact, but formal electrodiagnostic testing at 3-4 weeks post-injury is critical to determine prognosis and guide further management. 1, 2
Immediate Assessment Priorities
Electrodiagnostic testing should be performed now (at 3-4 weeks post-injury) to distinguish between neurapraxia (temporary conduction block with good prognosis) versus axonotmesis or neurotmesis (requiring longer recovery or surgical intervention). 3
The radial nerve recovers better if repaired or reconstructed within 5 months of injury, making early prognostic assessment essential. 2
Expected Recovery Timeline Based on Injury Severity
For neurapraxia (best-case scenario):
- Recovery typically occurs within 6-12 weeks as remyelination progresses
- Wrist extension returns first, followed by finger and thumb extension 2
For axonotmesis (moderate injury with intact nerve sheath):
- Recovery follows Wallerian degeneration and axonal regrowth at approximately 1mm/day
- Expect 3-5 months for proximal injuries, potentially longer for distal injuries
- At least 80% of patients recover wrist extension regardless of injury level 2
For neurotmesis (complete nerve disruption):
- Spontaneous recovery will not occur
- Surgical intervention required within 5 months for optimal outcomes 2
Current Management During Recovery Period
Functional electrical stimulation (FES) is strongly recommended:
- Should be initiated within the first 6 months post-injury (you are well within this window at 21 days) 4
- Produces improved muscle force in wrist extension and increases motor strength and control 4
- Serves as adjunctive therapy during the recovery period 4
Splinting and positioning:
- Use resting wrist splints to support the limb and prevent contracture while awaiting recovery 4
- Perform daily passive stretching of the affected arm to avoid contractures 4
- Maintain wrist in neutral-to-slight extension to prevent flexion contracture
Critical Decision Point at 3-4 Months
If no wrist extensor recovery is evident by 3-4 months:
- Repeat electrodiagnostic testing to assess for any signs of reinnervation
- Begin discussing surgical options (nerve transfers or tendon transfers) with hand surgeon
- Early surgical planning allows for intervention before the 12-month window closes 1
Surgical Intervention Thresholds
Consider surgical reconstruction if:
- No wrist extensor recovery by 12 months post-injury 1
- Progressive loss of function or new symptoms suggesting nerve compression develop 1
- Earlier functional restoration is required for occupational reasons (nerve transfers may be considered before 12 months) 1
Surgical options include:
- Nerve transfers (median to radial nerve transfers): Can restore more normal function including independent finger motion, but must be performed within 6-12 months of injury 5
- Tendon transfers (pronator teres to ECRL/ECRB, or FDS transfers): Reliable option if nerve recovery fails, typically performed after 12 months 6, 7
Common Pitfalls to Avoid
- Do not wait passively beyond 5 months without electrodiagnostic assessment, as this is the critical window for nerve reconstruction if needed 2
- Do not assume recovery will occur simply because you are doing physiotherapy—the underlying nerve injury severity determines outcome, not therapy intensity 3
- Do not delay FES initiation—it should already be part of your current rehabilitation program 4
Realistic Expectations at 21 Days
At this early stage (3 weeks post-injury), it is too soon to determine final prognosis. The next 4-8 weeks are critical for observing early signs of recovery (return of wrist extension strength, even if weak). If you see no improvement by 8-12 weeks, the likelihood of complete spontaneous recovery diminishes significantly, and surgical planning should begin. 2