Median Nerve Essay

Phoenix Mombru
Describe the origin, course and distribution of the median nerve. What is meant by the power
grip? What is meant by wrist drop?
The median nerve is formed from the medial and lateral cords of the brachial plexus, which
originate from the C6, C7, C8 and T1 spinal nerves. The two cords wrap around the axillary
artery and join anterior to the axillary artery to form the median nerve. Moving down the arm,
the median nerve initially lies anterior to the axillary artery and then lies lateral to it. The
median nerve initially lies lateral to the brachial artery, on the coracobrachialis, and then
crosses anteriorly halfway down the humeral shaft to lie medial to the brachial artery, on the
brachialis, where it stays until the cubital fossa. At the cubital fossa, the median nerve passes
deep to the bicipital aponeurosis and between the two heads of pronator teres, innervating
pronator teres, flexor carpi radialis, palmaris longus and flexor digitorum superficialis. The
median nerve emerges deep to pronator teres and branches to form the anterior interosseous
nerve, which lies in the interosseous membrane and innervates flexor pollicis longus,
pronator quadratus and the radial half of flexor digitorum profundus. Continuing down the
forearm, the radial nerve lies within the deep surface of flexor digitorum superficialis and
emerges lateral to it. Proximal to the wrist, the radial nerve branches into its palmar
cutaneous branch, which passes superficial to the flexor retinaculum and innervates the skin
of the lateral side of the palm. The radial nerve continues deep to the flexor retinaculum and
through the carpal tunnel. Coming out of the carpal tunnel, the median nerve branches to
form its recurrent branch, which innervates the muscles of the thenar eminence. The
remainder of the median nerve innervates the first and second lumbricals and the palmar skin
and dorsal nail beds of the lateral 3.5 digits. See figure 1 for a diagram showing the branching
of the median nerve.
Figure 1: Branches of the median nerve

Phoenix Mombru
The power grip refers to flexion of the metacarpophalangeal and interphalangeal joints while
the wrist, or radiocarpal joint, is extended. This is called ‘power grip’ because it allows for
significantly stronger flexion of the metacarpophalangeal and interphalangeal joints than can
occur with the wrist flexed. This is due to active insufficiency. Active insufficiency occurs
when a muscle which crosses over multiple joints is shortened due to the action of one of the
joints, making the muscle slack and preventing it from being able to acquire the tension
needed to exert force at another joint. At the wrist joint, flexion of the wrist makes the
tendons of flexor digitorum superficialis and flexor digitorum profundus shorten and go
slack. When an object is slack there is no tension within it and tension is required to exert a
pulling force from afar. Since the flexor muscles are slack, they are unable to exert strong
pulling forces on the phalanges, weakening flexion of the metacarpophalangeal and
interphalangeal joints and, therefore, weakening grip. When the wrist is extended, the flexor
muscles are pulled taut, so there is tension within the muscles and they can exert pulling
forces on the phalanges, strengthening flexion of the metacarpophalangeal and
interphalangeal joints and, therefore, strengthening grip. See figure 2 for a diagram of the
power grip and active insufficiency.
Figure 2: The power grip vs. active insufficiency
Wrist drop occurs when the radial nerve is damaged. The radial nerve innervates the extensor
muscles of the posterior compartment of the forearm: extensor carpi radialis brevis, extensor
digitorum, extensor digiti minimi, extensor carpi ulnaris, extensor pollicis brevis, extensor
pollicis longus and extensor indicis, as well as abductor pollicis longus. These muscles
extend the radiocarpal, metacarpophalangeal and interphalangeal joints. When the radial
nerve is damaged, these muscles cannot function, resulting in inability to extend the wrist and
fingers. If a patient with radial nerve damage holds up their arm in a pronated position, their
wrist, and fingers to some extent, will flex due to gravity, ‘dropping’ the wrist. The patient
will still be able to flex their wrist and fingers if the median nerve is functional, but they will
not be able to move their wrist from the ‘dropped’ position independently, although the joints
can still be moved upon manipulation.
Phoenix Mombru
In conclusion, the median nerve is formed from the medial and lateral cords of the brachial
plexus. It branches to form the anterior interosseous nerve, palmar cutaneous branch and
recurrent branch and innervates all of the muscles of the anterior compartment of the forearm
apart from flexor carpi ulnaris and the ulnar half of flexor digitorum profundus. The power
grip refers to flexion of the metacarpophalangeal and interphalangeal joints when the wrist is
extended, which results in a strong grip because the flexor tendons are pulled taut over the
wrist joint and can generate the tension required to pull forcefully on the phalanges. Active
insufficiency occurs when the wrist is flexed and occurs because the flexor tendons are made
short and slack, so they can only pull weakly on the phalanges. Wrist drop occurs when the
radial nerve is damaged. The radial nerve innervates all the extensor muscles so the wrist and
fingers cannot extend if it is damaged. This means that the wrist drops due to gravity when
the arm is held up as the patient cannot hold their wrist in an extended position.

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Phoenix Mombru

Figure 1: Branches of the median nerve

Figure 2: The power grip vs. active insufficiency

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