Hand of Benediction

What Is It, Causes, and More

Author: Lily Guo

Editors: Ian Mannarino, MD, MBA, Ahaana Singh

Illustrator: Jillian Dunbar


What is hand of benediction?

Hand of benediction (AKA preacher’s hand) is a clinical sign indicating peripheral neuropathy, or damage of the nerves outside the brain and spinal cord, specifically those affecting the muscles of the hand. It is seen under certain conditions when a person is asked to make a fist or open their hand, resulting in the little finger (5th digit) and ring finger (4th digit) remain flexed or bent, while the index (2nd digit) and middle finger (3rd digit) are extended. This resembles the hand gesture of the pope giving their blessing (a papal benediction), lending to the name hand of benediction

What causes hand of benediction?

Hand of benediction can be caused by damage to either the ulnar or median nerve, resulting in dysfunction of the muscles of the hand. 

The ulnar nerve travels from the brachial plexus (bundle of nerves near the neck and shoulder), behind the elbow, and towards the front of the forearm and hand in order to innervate the muscles of the 4th and 5th digits. The location of the ulnar nerve makes it susceptible to compression if there is fracture or injury to the medial epicondyle of the humerus, a bone comprising the upper arm and elbow, or if there is damage to the wrist. Typically, falling on an outstretched hand will lead to damage of the hamate, a wedge-shaped bone on the outside of the wrist at the base of the 5th digit. This can also be a cause of ulnar nerve injury. 

The muscles specifically innervated by the ulnar nerve are the interossei, hypothenar, and two of the lumbrical muscles of the hand. They are involved in spreading the fingers outwards and bringing them together (respectively—abduction and adduction), as well as flexing them (flexion). In the case of ulnar nerve damage, the 4th and 5th digits are not able to abduct from the 3rd digit (middle finger) and they would not be able to bend at the point where they connect to the palm, known as the metacarpophalangeal (MCP) joints. Conversely, the proximal interphalangeal joints (PIP) and the distal interphalangeal joints (DIP), which are the joints closer to the fingertips, would remain slightly bent towards the palm. This results in the presentation of the hand of benediction when the individual tries to open their hand and extend the fingers. 

Median nerve injury can also lead to hand of benediction. Like the ulnar nerve, the median nerve originates from the brachial plexus and travels down the forearm in order to supply motor function to flex the joints of the 2nd and 3rd digits. Common causes of median nerve damage include direct trauma to the wrist or elbow, fracture of the humerus bone located in the upper arm, and carpal tunnel syndrome, or the compression of the median nerve at the wrist. Consequently, only the 4th and 5th digits are able to bend, while the 2nd and 3rd digits remain extended. This presentation of the hand of benediction occurs when the individual attempts to make a fist, resulting in the thumb and first two fingers remaining partially extended.

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What are the signs and symptoms of hand of benediction?

In addition to the characteristic appearance of the hand of benediction, individuals may also feel numbness of the digits, as well as weakness of the hand muscles. 

If the hand of benediction is caused by injury to the ulnar nerve specifically, the person may experience loss of wrist flexion, loss of flexion of the 4th and 5th digits at the MCP joints, an inability to extend the PIP and DIPs, and an inability to abduct and adduct the 4th and 5th digits. Damage to the ulnar nerve may also cause loss of sensation to half of the palm, half of the 4th digit, and to the entire 5th digit. 

For those with a median nerve injury, movements—such as bringing the thumb to touch the tips of the fingers, flexion of the wrist, flexion of the 2nd and 3rd digits at the MCP joints and extension at the PIP and DIP—can all be lost. The median nerve supplies sensation to the thenar eminence, the area at the base of the thumb, as well as the 2nd, 3rd, and half of the 4th digit. Damage to the nerve may result in loss of feeling and numbness of the skin in all of these areas. Finally, depending on the specific nerve injury, individuals may feel tenderness or pain at the wrist or elbow regions.

How do you diagnose hand of benediction?

A hand of benediction is usually classified based on its clinical appearance when an individual attempts to either close or extend their hand. If the presence of the hand of benediction is clear, a neurologist will typically evaluate further for neuropathy. This typically consists of a thorough physical examination to assess reflexes, muscle function, and sensation. Additional tests, such as imaging to look for traumatic fractures, as well as nerve function tests to determine potential causes for peripheral neuropathy, may also be performed.

How do you treat hand of benediction?

Treatment for hand of benediction involves managing and treating the peripheral neuropathy of the median or ulnar nerve. This often involves the use of non-steroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen, to prevent worsening of symptoms and help control pain. In some cases, the use of an arm or wrist brace may be helpful to prevent excessive bending and unwanted nerve-compression. In addition, individuals may benefit from hand therapy, performed by a physical therapist or occupational therapist, to help to strengthen and stretch the hand. Depending on the severity of the injury, however, muscle strength and sensation may not completely recover with therapy.

If the hand of benediction sign is caused by carpal tunnel syndrome affecting the median nerve, nerve decompression surgery may be performed. This involves cutting the tissue surrounding the nerves to reduce pressure, consequently relieving pain and numbness.

What are the most important facts to know about hand of benediction?

Hand of benediction results from ulnar or median nerve neuropathy, leading to a claw-like configuration of the hand. The ulnar nerve innervates muscles of the 4th and 5th digits and when damaged, the digits are unable to bend and extend properly. Meanwhile, the median nerve innervates the 2nd and 3rd digits, and if damaged, can prevent them from flexing all the way. Nerve damage may also lead to pain and numbness in the hand and digits. In order to diagnose hand of benediction, an assessment of clinical presentation is required along with further evaluation for neuropathy. Treatment focuses on managing the underlying neuropathy with nonsurgical treatments, such as NSAIDs, arm or wrist braces, and hand therapy. If symptoms persist despite these interventions, surgery may be required.

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Related links

Joints of the wrist and hand
Ulnar claw
Vessels and nerves of the forearm

Resources for research and reference

Alsaffar, R. & Hameed, S. (2020). Benediction Sign. In StatPearls. Retrieved November 25, 2020, from https://www.ncbi.nlm.nih.gov/books/NBK554458/

Benediction Hand (aka Benediction Sign or Preacher's Hand). (2020). In Physiopedia. Retrieved November 24, 2020, from https://www.physio-pedia.com/index.php?title=Benediction_Hand_(aka_Benediction_Sign_or_Preacher%27s_Hand)&oldid=253042

Nonsurgical Treatment for Ulnar Nerve Compression. (n.d.). In NYU Langone Health. Retrieved November 25, 2020, from https://nyulangone.org/conditions/ulnar-nerve-compression-in-adults/treatments/nonsurgical-treatment-for-ulnar-nerve-compression

Peripheral neuropathy. (2019). In Mayo Clinic. Retrieved December 1, 2020, from https://www.mayoclinic.org/diseases-conditions/peripheral-neuropathy/diagnosis-treatment/drc-20352067