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Orthopedics›Condition·Updated Apr 25, 2026·v1

Radial Nerve

The radial nerve (C5-T1) is the primary extensor nerve of the arm and forearm. It is most commonly injured at the spiral groove of the humerus. Evaluation focuses on differentiating high-level palsies (wrist drop) from PIN syndrome (finger drop with spared radial wrist extension). Most traumatic injuries are neuropraxic and managed expectantly for 3-4 months with splinting and PT. Surgical intervention, including decompression, nerve transfers, or tendon transfers, is reserved for failed recovery or confirmed nerve disruption.

High Evidence143 references·893 words·4 min read·v1
orthopedicsneurosurgeryperipheral-nerveupper-extremitytrauma

Quick Reference

RxDrug of choiceNSAIDs (e.g., Ibuprofen 400-600mg) for RTS pain; Gabapentin (300mg TID) for neuropathic pain.
AltAlternativesUltrasound-guided corticosteroid injection (e.g., 40mg Triamcinolone) for localized inflammation in the radial tunnel.
⊘AvoidAvoid prolonged immobilization in a neutral or flexed position, which exacerbates 'wrist drop' contractures.
DxTest of choiceElectromyography (EMG) at 4 weeks (functional); High-resolution Ultrasound (anatomical).
ScKey scoreMRC Muscle Scale (0-5) for tracking motor recovery; Rule of Nine for RTS diagnosis.
→When to referOpen humeral fractures with palsy; no recovery by 3-4 months; suspected neurotmesis on ultrasound.
Most radial nerve palsies from closed humeral fractures resolve spontaneously; monitor for 4 months before considering surgery.
The radial nerve is the largest terminal branch of the brachial plexus, originating from the posterior cord (C5-T1). It serves as the primary motor conduit for the extensor compartments of the upper limb and provides critical sensory innervation to the posterior arm, forearm, and dorsal hand. Clinically, the radial nerve is the most frequently injured nerve in the upper extremity, often due to its intimate relationship with the humerus in the spiral groove.

Overview and Recommendations

Key Facts and Anatomy

  • •Identify the radial nerve as the terminal continuation of the posterior cord, carrying fibers from the C5 through T1 spinal roots. It is the most robust output of the and is responsible for elbow extension, wrist extension, and finger/thumb extension.
  • •Recognize the critical anatomical landmarks along its course, starting from the axilla where it lies posterior to the axillary artery. It enters the posterior compartment of the arm through the triangular interval—bounded by the long head of the triceps, the teres major, and the humeral shaft—accompanied by the profunda brachii artery.
  • •Understand the significance of the spiral groove (radial groove) on the posterior humerus. In this region, the nerve is in direct contact with the periosteum, making it highly susceptible to injury during , particularly the Holstein-Lewis variant (distal third spiral fractures).
  • •Distinguish the terminal branches: the superficial branch of the radial nerve (SBRN), which is purely sensory, and the deep branch, which becomes the (PIN) after passing through the supinator muscle. The PIN provides motor supply to the majority of the forearm extensors.
  • •Note the sensory territories, which include the posterior cutaneous nerve of the arm, the posterior antebrachial cutaneous nerve, and the SBRN. The SBRN provides sensation to the radial two-thirds of the dorsal hand and the dorsal aspect of the lateral three and a half digits, excluding the nail beds.

Clinical Evaluation

  • •Suspect radial nerve injury in any patient presenting with 'wrist drop' or 'finger drop' following trauma, particularly humeral fractures or prolonged compression (e.g., 'Saturday Night Palsy').
  • •Perform a systematic motor exam starting proximally with the triceps brachii (elbow extension) to rule out high-level axillary lesions. If elbow extension is preserved but wrist extension is lost, the lesion is likely at or distal to the spiral groove.
  • •Evaluate the by testing elbow flexion with the forearm in a neutral (mid-prone) position. This is often the first muscle affected in mid-shaft humeral injuries but spared in distal forearm entrapments.
  • •Assess wrist extension strength and direction. Weakness with radial deviation suggests a high radial nerve palsy (loss of ECRL, ECRB, and ECU), whereas wrist extension with persistent radial deviation suggests a PIN palsy, as the (ECRL) is spared while the extensor carpi ulnaris (ECU) is paralyzed.
  • •Test finger extension at the metacarpophalangeal (MCP) joints. Isolated loss of MCP extension with preserved wrist extension is a hallmark of PIN syndrome.
  • •Examine thumb extension (extensor pollicis longus) and abduction (abductor pollicis longus). These are often the last functions to return during recovery due to their distal innervation.
  • •Map sensory deficits in the first dorsal webspace, which is the most reliable area for testing the superficial radial nerve. Paresthesia in this area without motor loss suggests Wartenberg syndrome (SBRN compression).
  • •Utilize the 'Rule of Nine' test for suspected (RTS). Divide the forearm into a 3x3 grid; tenderness localized 3–5 cm distal to the lateral epicondyle over the radial tunnel is highly suggestive of RTS, especially if exacerbated by resisted supination.
  • •Order high-resolution musculoskeletal ultrasound to visualize the nerve's integrity. A cross-sectional area (CSA) > 1.5 mm² at the Arcade of Frohse or a side-to-side ratio > 1.38 is indicative of PIN entrapment.
  • •Schedule electrodiagnostic studies (EMG/NCS) but delay testing until 3–4 weeks post-injury. This window allows for Wallerian degeneration to occur, making the absence of motor unit potentials (MUPs) in distal muscles like the extensor indicis proprius a reliable indicator of axonal loss.
  • •Rule out coexisting (tennis elbow), which presents with pain directly over the lateral epicondyle, whereas RTS pain is typically more distal and deep within the muscle mass.
  • •Consider MRI neurography if ultrasound is inconclusive or if a space-occupying lesion, such as a or lipoma, is suspected of compressing the nerve within the radial tunnel.

Management and Clinical Significance

  • •Initiate conservative management for closed traumatic palsies (e.g., following a humeral fracture) with a 'wait and see' approach for 3–4 months, as approximately 70–90% of these injuries are neuropraxic and resolve spontaneously.
  • •Prescribe a 'cock-up' wrist splint (15–30 degrees of extension) to prevent flexion contractures and improve hand function by stabilizing the wrist, allowing the flexors to work more efficiently.
  • •Implement passive range-of-motion (ROM) exercises for the fingers and thumb immediately to prevent joint stiffness while awaiting nerve regeneration.
  • •Administer ultrasound-guided hydrodissection for Radial Tunnel Syndrome if conservative measures fail. Injecting 5–10 mL of saline or local anesthetic (e.g., 1% lidocaine) can release the nerve from the surrounding fascia and provide significant symptomatic relief.
  • •Perform surgical exploration if there is no clinical or electrophysiological evidence of recovery by 4 months, or immediately in the setting of open fractures with suspected nerve transection.
  • •Utilize the brachioradialis-splitting approach for radial tunnel decompression. Ensure the release of all five potential compression sites: fibrous bands at the radiocapitellar joint, the Leash of Henry (recurrent radial vessels), the ECRB aponeurotic edge, the Arcade of Frohse, and the distal supinator border.
  • •Execute primary nerve repair (neurorrhaphy) for clean transections using 8-0 or 9-0 nylon epineural sutures. If a tension-free repair is not possible, utilize nerve grafting.
  • •Consider the intra-septal sensory branch (common trunk of the ILBCN and PACN) as a local donor for nerve grafts up to 5 cm in length, which avoids the morbidity of a sural nerve harvest.
  • •Employ nerve transfers for chronic or high-level injuries to decrease reinnervation time. The 'SPIN' transfer (supinator motor branch to PIN) is highly effective for restoring finger and thumb extension.
  • •Perform the distal anterior interosseous nerve (AIN) to PIN transfer to restore thumb extension in cases where proximal radial nerve recovery is unlikely.
  • •Opt for tendon transfers if nerve recovery is not achieved by 12–18 months. The standard 'Jones transfer' includes transferring the to the ECRB to restore wrist extension.
  • •Manage Wartenberg syndrome (SBRN compression) initially with activity modification and avoiding tight watchbands or handcuffs. Refractory cases may require surgical release of the brachioradialis tendon.
  • •Avoid iatrogenic injury during humeral plating by identifying the nerve 2 fingerbreadths (approx. 3.5 cm) distal to the deltoid tuberosity. Use helical plates or anterior-posterior distal locking screws in intramedullary nailing to minimize risk.
  • •Monitor for 'treatment-related fluctuation' (TRF) in recovery. If a patient shows initial improvement followed by a plateau or decline, re-evaluate with ultrasound to rule out hardware irritation or callus entrapment.
  • •Refer to a hand surgeon or peripheral nerve specialist if there is no recovery of the brachioradialis (the most proximal post-spiral groove muscle) by 12 weeks post-injury.

Board Review — High Yield

  • •Saturday Night Palsy — Compression of the radial nerve at the spiral groove, typically causing neuropraxia with wrist drop but spared triceps function.
  • •Holstein-Lewis Fracture — A spiral fracture of the distal 1/3 of the humerus with a high incidence (up to 22%) of radial nerve entrapment.
  • •Arcade of Frohse — The fibrous proximal edge of the supinator muscle; the most common site of PIN entrapment.
  • •Wrist Drop vs. Finger Drop — High radial palsy causes both; PIN syndrome spares the ECRL, allowing wrist extension with radial deviation but causing finger drop.
  • •Wartenberg Syndrome — Isolated sensory compression of the SBRN between the brachioradialis and ECRL tendons; presents with dorsal-radial hand paresthesia.
  • •Leash of Henry — Recurrent radial vessels that can compress the radial nerve within the radial tunnel.
  • •Innervation Order — Triceps -> Brachioradialis -> ECRL -> ECRB -> Supinator -> EDC -> ECU -> APL -> EPL -> EIP.
  • •Crutch Palsy — Compression in the axilla affecting the radial, ulnar, and median nerves; radial involvement includes triceps weakness.

Deep Dive — Evidence Details

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