Benediction Hand (aka Benediction Sign or Preacher's Hand): Difference between revisions

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== Description  ==
== Description  ==
[[File:Benediction hand.jpg|thumb|284x284px]]The Benediction Sign is the result of peripheral neuropathy affecting musculature in the hand. It is seen when the patient is asked to make a fist and the ring and little finger flex but the index and middle finger can't flex at the metacarpal-phalangeal joint or interphalangeal joint.  
[[File:Benediction hand.jpg|thumb|284x284px]]The Benediction Sign is commonly associated with a [[Median Nerve|median nerve]] pathology. It is seen when the patient attempts to make a fist but is unable to flex the index and middle fingers at the metacarpophalangeal (MCP) and [[Interphalangeal Joints of the Hand|interphalangeal]] (IP) joints, causing these fingers to remain extended while the other fingers flex normally. This distinct clinical presentation is a result of damage to the median nerve, which impairs the function of the lateral lumbricals that flex these joints.  


There is some controversy as to the source of the Benediction Sign for many years, specifically if the median nerve or the ulnar nerve is involved<ref name="Futterman" />. According to Futterman, <ref name="Futterman">Futterman B. Analysis of the Papal Benediction Sign: The ulnar neuropathy of St. Peter. Clin Anat. 2015 Sep;28(6):696-701.</ref> the desired position of the hand during a blessing or benediction would typically have been an open position with the fingers extended. In fact, he notes that the 4th and 5th digits would have been abducted from the second and third digits (similar to the hand sign used by Vulcans in the Star Trek TV and movie series).&nbsp;<ref name="Futterman" /> Based on this author's research of cultural artwork, he asserts that Peter, the first Pope, had an ulnar neuropathy which limited Peter's ability to perform the then-traditional open hand blessing and has led to the hand position that has since become the norm for giving blessings.<ref name="Futterman" /><br>
== Historical and Cultural Context ==
Historically, the Benediction Sign has been linked to cultural representations of blessings and greetings, which typically involved an open hand with extended fingers. It was noted in some historical and cultural analyses, such as the research by Futterman <ref name="Futterman">Futterman B. Analysis of the Papal Benediction Sign: the ulnar neuropathy of St. Peter. Clinical Anatomy. 2015 Sep;28(6):696-701.</ref>, that figures like Peter, the first Pope, might have had an ulnar neuropathy, which influenced the traditional hand blessing posture. However, this specific condition affects the ability to abduct and flex the fourth and fifth digits and is distinct from the Benediction Sign associated with median nerve pathology.


In the presence of [[Ulnar Nerve Entrapment|ulnar neuropathy]], the function of the interossei and lumbrical muscles to the 4th and 5th digits would be compromised, thus the 4th and 5th digits could not abduct from the midline of the hand (interossei function) nor could those fingers flex at the MCP joints or extend at the IP joints (lumbrical function). Extensor digitorum (innervated by the radial nerve) acts primarily on the MCP joint, not the IP joints, therefore it could not extend the IP joints to compensate for the loss of lumbrical function.&nbsp;<ref>https://en.wikipedia.org/wiki/Extensor_digitorum_muscle. Last accessed 13 02 2016.</ref> As a result, during an attempt to extend the 4th and 5th digits (as in the open hand blessing described above) the MCP joints be extended but the IP joints would stay flexed.&nbsp; <br>
==Clinically Relevant Anatomy==
[[File:Muscles_of_the_hand_anterior_aspect_Primal.png|thumb|200x200px]]
The [[Median Nerve|median nerve]] originates from the [[Brachial Plexus|brachial plexus]] and primarily innervates the first and second lumbricals of the hand, among other structures. In the case of Benediction Sign, the inability to flex the second and third digits arises from damage to this nerve. However, [https://physio-pedia.com/Ulnar_Nerve?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal ulnar nerve] pathology affects the fourth and fifth digits, leading to what is often termed as "[[Claw Hand]]," where these digits may exhibit hyperextension at the MCP joints and flexion at the IP joints.


Futterman <ref name="Futterman" /> notes that Benediction Sign is often described as a median nerve injury because this would result in an inability to perform flexion at the MCP and IP joints of the 2nd and 3rd digits. However, he notes that this would only make sense if the injured person was trying to make a fist and since a fist is not a historically-known sign of blessing or greeting, Benediction Sign must stem from an ulnar neuropathy and the subsequent inability to fully open the hand. <br>
== Clinical Presentation  ==
Patients with Benediction Sign may experience numbness and muscle weakness primarily in the second and third digits. The presentation involves these fingers remaining extended during an attempt to make a fist. This should not be confused with ulnar nerve symptoms, which affect the outer digits of the hand.


=== '''Clinically relevant anatomy''' ===
<ref>Floranda EE, Jacobs BC. [https://www.ncbi.nlm.nih.gov/pubmed/24209726 Evaluation and treatment of upper extremity nerve entrapment syndromes]. Primary care. 2013 Dec;40(4):925.</ref>[[Image:Benediction hand ulnar claw.JPG|center|300px]]
[[File:Interactive hand - hand - L17F1.jpg|thumb]]
The [https://physio-pedia.com/Ulnar_Nerve?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal ulnar nerve] originates from the terminal branch of the medial cord of the [[brachial plexus]] and contains fibers from C8, T1, and, occasionally, C7. It innervates muscles in the anterior compartment of the forearm; [https://physio-pedia.com/Flexor_Carpi_Ulnaris_Muscle?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal Flexor carpi ulnaris] and medial half of [https://physio-pedia.com/Flexor_Digitorum_Profundus?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal Flexor digitorum profundus], and muscles of the hand; Hypothenar muscle, Medial two lumbricals, Adductor pollicis, [[Palmar Interossei|Palmar]] and [https://physio-pedia.com/Dorsal_Interossei_of_the_hand dorsal interossei] of the hand, and Palmaris Brevis.


For more detailed information on the [https://physio-pedia.com/Ulnar_Nerve?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal anatomy of the ulnar nerve]
==  Differential Diagnosis ==
The differential diagnosis should consider other conditions that mimic the posture of Benediction Sign but are due to different underlying causes, such as [[Rheumatoid Arthritis|rheumatoid arthritis]] or other forms of peripheral neuropathy.
== Management and Treatment ==
The treatment of Benediction Hand involves the management and treatment of the underlying median nerve pathology.  Treatment options may include: <ref>Hand of Benediction. What Is It, Causes, and More. Available from: <nowiki>https://www.osmosis.org/answers/hand-of-benediction</nowiki> ( Accessed, 19/07/2021).</ref>


== Clinical Presentation  ==
* Non-steroidal inflammatory drugs (NSAIDs) to control pain and prevent symptoms to get worse.
Benediction Hand is presented with numbness of the fourth and fifth fingers and hand muscle weakness. The 4th and 5th fingers show a clawed-like appearance, with hyperextension at the metacarpophalangeal joints (MCP) and flexion of the proximal and distal interphalangeal joints, and the fingers and thumb are held slightly abducted. Tenderness or pain may be observed at the medial wrist or medial elbow region.


[[Image:Benediction hand ulnar claw.JPG|center|300px]]
* Use of hand or wrist brace to minimise further nerve compression and excessive bending.
* [[Hand Exercises|Hand stretching and strengthening exercises]] with a Physiotherapist or Occupational Therapist if needed.
* Nerve decompression surgery to reduce pressure and relieve pain if the median nerve is affected because of the [[Carpal Tunnel Syndrome]].<br />
{{#ev:youtube|0AAligXLJ1A |300}}<ref>FSUMedMedia. Claw Hand, Ape Hand, and the Sign of Benediction: Animated Review. Available from: https://www.youtube.com/watch?v=0AAligXLJ1A [Accessed, 19/07/2021]</ref>


== Resources ==
== Summary ==
<br>[http://teachmeanatomy.info/upper-limb/nerves/ulnar-claw-vs-hand-of-benediction/ The Ulnar Nerve Anatomy]<br>
It is important to distinguish the Benediction Sign, primarily a median nerve issue, from conditions affecting the ulnar nerve. Understanding the specific nerve involvements helps in accurate diagnosis and effective management of the condition.


== References  ==
== References  ==

Latest revision as of 11:34, 6 May 2024

Original Editor -Pamela Gonzalez

Top Contributors - Laura Ritchie, Aminat Abolade, Kirenga Bamurange Liliane, Kim Jackson, Admin, Pamela Gonzalez, Rachael Lowe, David Adamson, WikiSysop, Lauren Kwant, Evan Thomas and Richard Benes  

Description[edit | edit source]

Benediction hand.jpg

The Benediction Sign is commonly associated with a median nerve pathology. It is seen when the patient attempts to make a fist but is unable to flex the index and middle fingers at the metacarpophalangeal (MCP) and interphalangeal (IP) joints, causing these fingers to remain extended while the other fingers flex normally. This distinct clinical presentation is a result of damage to the median nerve, which impairs the function of the lateral lumbricals that flex these joints.

Historical and Cultural Context[edit | edit source]

Historically, the Benediction Sign has been linked to cultural representations of blessings and greetings, which typically involved an open hand with extended fingers. It was noted in some historical and cultural analyses, such as the research by Futterman [1], that figures like Peter, the first Pope, might have had an ulnar neuropathy, which influenced the traditional hand blessing posture. However, this specific condition affects the ability to abduct and flex the fourth and fifth digits and is distinct from the Benediction Sign associated with median nerve pathology.

Clinically Relevant Anatomy[edit | edit source]

Muscles of the hand anterior aspect Primal.png

The median nerve originates from the brachial plexus and primarily innervates the first and second lumbricals of the hand, among other structures. In the case of Benediction Sign, the inability to flex the second and third digits arises from damage to this nerve. However, ulnar nerve pathology affects the fourth and fifth digits, leading to what is often termed as "Claw Hand," where these digits may exhibit hyperextension at the MCP joints and flexion at the IP joints.

Clinical Presentation[edit | edit source]

Patients with Benediction Sign may experience numbness and muscle weakness primarily in the second and third digits. The presentation involves these fingers remaining extended during an attempt to make a fist. This should not be confused with ulnar nerve symptoms, which affect the outer digits of the hand.

[2]

Benediction hand ulnar claw.JPG

Differential Diagnosis[edit | edit source]

The differential diagnosis should consider other conditions that mimic the posture of Benediction Sign but are due to different underlying causes, such as rheumatoid arthritis or other forms of peripheral neuropathy.

Management and Treatment[edit | edit source]

The treatment of Benediction Hand involves the management and treatment of the underlying median nerve pathology. Treatment options may include: [3]

  • Non-steroidal inflammatory drugs (NSAIDs) to control pain and prevent symptoms to get worse.
  • Use of hand or wrist brace to minimise further nerve compression and excessive bending.
  • Hand stretching and strengthening exercises with a Physiotherapist or Occupational Therapist if needed.
  • Nerve decompression surgery to reduce pressure and relieve pain if the median nerve is affected because of the Carpal Tunnel Syndrome.

[4]

Summary[edit | edit source]

It is important to distinguish the Benediction Sign, primarily a median nerve issue, from conditions affecting the ulnar nerve. Understanding the specific nerve involvements helps in accurate diagnosis and effective management of the condition.

References[edit | edit source]

  1. ↑ Futterman B. Analysis of the Papal Benediction Sign: the ulnar neuropathy of St. Peter. Clinical Anatomy. 2015 Sep;28(6):696-701.
  2. ↑ Floranda EE, Jacobs BC. Evaluation and treatment of upper extremity nerve entrapment syndromes. Primary care. 2013 Dec;40(4):925.
  3. ↑ Hand of Benediction. What Is It, Causes, and More. Available from: https://www.osmosis.org/answers/hand-of-benediction ( Accessed, 19/07/2021).
  4. ↑ FSUMedMedia. Claw Hand, Ape Hand, and the Sign of Benediction: Animated Review. Available from: https://www.youtube.com/watch?v=0AAligXLJ1A [Accessed, 19/07/2021]


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