What is the recommended rehabilitation protocol, including splinting, functional electrical stimulation (FES), fine flexor strengthening, and expected recovery timeline, for acute wrist drop due to radial nerve injury?

Rehabilitation Protocol for Acute Wrist Drop from Radial Nerve Injury

Immediately initiate dynamic splinting with a tenodesis mechanism combined with functional electrical stimulation (FES) to the wrist extensors, while implementing a structured home exercise program focused on task-specific wrist extension training. 1, 2

Immediate Management: Dynamic Splinting

• Apply a dynamic splint that supports wrist and finger extension through a tenodesis mechanism within the first clinical encounter, allowing the patient to extend fingers via wrist flexion while preventing static immobilization 1, 3
• The tenodesis splint enables functional hand use during nerve regeneration by positioning the wrist properly for functional tasks 3
• Never use static casting or prolonged immobilization, as this demonstrably worsens outcomes by causing muscle deconditioning, promoting learned non-use, and potentially triggering complex regional pain syndrome 1, 2
• Reassess splint fit and function every 2-3 weeks to adjust therapy progression and monitor for adverse effects 1

Essential Adjunctive Therapy: Functional Electrical Stimulation

FES is strongly recommended for patients with wrist motor impairment and should be initiated immediately alongside splinting. 4, 2

• Apply FES to the wrist and forearm extensor muscles to address impaired muscle contraction 4, 2
• Use FES in combination with active task practice, not as standalone treatment, as it provides sensory input that facilitates more complete muscle contractions and promotes neural reorganization 4, 2
• FES leads to short-term increases in motor strength and motor control when combined with active practice 2
• The electrical stimulation causes muscle contraction with carefully timed application to allow functional limb use 4

Primary Rehabilitation: Task-Specific Functional Training

A directed home exercise program is the primary therapy modality, as evidence demonstrates home programs are equivalent to supervised therapy for uncomplicated radial nerve palsy cases. 1, 4

Progression of Wrist Extension Training:

• Begin 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 2, 5
• Perform repetitive, goal-oriented activities that require active wrist use to promote neural reorganization and motor recovery 2, 5
• Gradually increase resistance and complexity as the wrist demonstrates improved control 2

Active Range of Motion:

• Instruct the patient at the first encounter to move the fingers regularly through complete range of motion to prevent finger stiffness, which is one of the most functionally disabling complications 4
• Finger motion does not adversely affect an adequately stabilized injury and is an extremely cost-effective intervention 4
• Avoid compensatory movement patterns during therapy, as these reinforce abnormal motor control and delay recovery 1

Fine Flexor Strengthening Protocol

Implement structured resistance training as an adjunct when the patient demonstrates initial wrist control recovery. 2

• Start with low-intensity resistance at 40% of 1-repetition maximum (1-RM) with 10-15 repetitions 2
• Progress to moderate intensity (41-60% of 1-RM) with 8-10 repetitions as tolerated 2
• Increase resistance when 15 repetitions become only somewhat difficult (Borg RPE 12-14) 2
• Perform resistance training 2-3 times per week to allow adequate recovery between sessions 2
• Do not progress resistance too quickly—start with very low intensity during initial sessions to avoid muscle damage 5

Flexibility Work:

• Perform static stretches held for 10-30 seconds with 3-4 repetitions for each stretch 2
• Implement flexibility training 2-3 times per week in conjunction with resistance work 2

Expected Recovery Timeline

Most motor recovery gains occur within the first 6 months, making this a critical window for intensive rehabilitation. 2, 5

• Rapid relief of symptoms typically occurs within 3-4 months with appropriate structured rehabilitation 5
• Continue rehabilitation for 9-12 months depending on functional goals for optimal recovery 2, 5
• Resolution of wrist drop indicates significant motor recovery has occurred, which is the primary clinical goal in radial nerve injuries 5
• The presence of voluntary finger extension is a positive prognostic indicator for upper extremity motor recovery 2, 5

Monitoring and Follow-Up

• Reassess function every 2-3 weeks to evaluate splint effectiveness, adjust therapy progression, and monitor for any adverse effects from splinting 1
• Use video recording interventions to demonstrate changeability in symptoms, highlight successes, and serve as reference points for replicating successful strategies 1
• Reevaluate any patient with unremitting pain during follow-up, as this warrants further assessment 4, 2

Critical Pitfalls to Avoid

• Do NOT delay splinting while awaiting electrodiagnostic studies, as early functional support is critical 1
• Never rely on passive range of motion alone—active motor practice is essential for recovery 4, 2
• Avoid prolonged positioning of the wrist at end ranges, which exacerbates symptoms and may impede recovery 2, 5
• Do not use Constraint-Induced Movement Therapy (CIMT) until sufficient wrist extension (20 degrees) has been restored, as it requires specific motor criteria that wrist drop patients do not meet 4, 5