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Background: High median nerve injuries are commonly presented in textbooks as adopting the typical posture of hand of benediction or preacher's hand. This study aimed to show that the hand of benediction or preacher's hand is incorrectly associated with a high median nerve paralysis. Methods: A retrospective review of four cases with a high median nerve injury is presented. Diagnosis of a high median nerve injury was performed by means of intraoperative findings, electrodiagnostic studies, or ultrasound imaging. None of the patients presented in this study had a hand of benediction on physical examination despite the presence of a high median nerve lesion. Results: All four patients with high median nerve injuries showed a similar hand posture when attempting to make a fist. Firstly, the index finger still flexed at the metacarpophalangeal joint because of the ulnar innervated interossei muscles. Secondly the thumb is completely abducted at the carpometocarpal joint and extended at the interphalangeal joint. Lastly, middle finger flexion is possible due to dual innervation of its flexor digitorum profundus by the ulnar nerve as well as due to the quadriga phenomenon. Conclusions: The clinical appearance of a high median nerve palsy is different from the classical hand of benediction or preacher's hand posture pointing finger. We have shown that this incorrect association can result in delayed referral of patients with high median nerve injuries.

We have read the valuable contribution of Videler et al. on signs of overwork weakness in patients with Charcot-Marie-Tooth (CMT). As in our study, overall, Videler et al. did not find a difference between the dominant and non-dominant hands in their CMT patients. This is in contrast with the study of Vinci et al., who, using manual muscle strength testing, found a stronger dominant hand in only 2 out of 212 muscles and a stronger non-dominant hand in 139 of these 212 muscles. When selecting only the more severely affected patients, Videler et al. did find in this group of 22 patients a small, but significantly stronger, non-dominant hand for the tripod pinch. We agree with Videler that the latter finding may fit with the hypothesis of overwork weakness. However, it should be noted that the difference in strength between both hands for the tripod pinch is relatively small and that the non-dominant hand is also severely weakened. Therefore, it is unclear if this difference is clinically relevant. As suggested by Videler et al., larger prospective cohort studies or interventions studies, preferably using more specific measures of intrinsic hand muscle function would be needed to conclude on the presence of overwork weakness. In summary, in the absence of a mechanism to explain overwork weakness in this population and in the absence of any data indicating that reducing activity would slow disease progression, we still feel that there is insufficient evidence to conclude that overwork weakness exists, and agree with Videler et al. that, at present, there are no grounds to advise patients to limit their activities.

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess the effects of decompression surgery for treating nerve damage in leprosy.