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Physiotherapy Research International, 1(1) 41–49, 1996 © Whurr Publishers Ltd 41

Peripheral cutaneous nerve

distribution to the fingers

KAREL H. STAPPAERTS Faculty of Physical Education and Physiotherapy,

University of Leuven, Leuven, Belgium.
JOHAN VAN HEES University Hospitals of Leuven, Belgium.
ERIKA A. VAN DEN BROECK Asse, Belgium.

ABSTRACT Both sensory distribution charts and the unaffected side, are used as refer-
ence points in the assessment of cutaneous innervation. Sensory nerve conduction studies,
in particular, often use comparison between sides. However, remarkable differences can be
found between various sensory innervation maps, and no evidence was found in the litera-
ture for the assumption that the pattern of cutaneous sensory distribution of the peripheral
nerves between the left and right limbs is symmetrical. The purpose of this study was to
investigate variations in the sensory innervation of the fingers by means of a neurophysio-
logical method, and to compare the results for the left and right hands. The subjects of this
study were 31 young women. Percutaneous peripheral nerve stimulation was performed on
the four nerve branches providing sensory innervation to the fingers, and action potentials
were sought from the fingers by use of annular surface electrodes. Variations in the cuta-
neous innervation of the fingers between individuals often occurred and were found more
frequently on the dorsal than the palmar aspect. The distribution of sensory innervation
may even differ markedly between hands in the same individual. The cutaneous innervation
of all peripheral nerves supplying the fingers may differ from the innervation patterns
described in the various distribution charts. Prudence is called for when applying sensory
distribution charts as absolute references for the assessment of cutaneous sensation in
patients. Caution should also be applied when comparing one hand with the other when
assessing the cutaneous innervation of the fingers.

Key words: clinical assessment, cutaneous innervation, fingers, peripheral nerves.

INTRODUCTION
In order to conceptualise treatment and to evaluate its effect on functional recuper-
ation, the physiotherapist has to rely on clinical examination. Assessment of
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42 Stappaerts, Van Hees and Van den Broeck

cutaneous sensation is one of the clinical methods used to evaluate peripheral

nerve lesions. Sensory distribution charts, giving the ‘normal’ or usual cutaneous
innervation by different nerves are provided in many textbooks of physiotherapy
and anatomy, and are often used as a reference when assessing cutaneous sensation.
Comparison of the cutaneous sensory distribution of the peripheral nerves of the
fingers described in 31 of these books, revealed some remarkable differences, espe-
cially for the dorsal aspect of the fingers.
Apart from Hoppenfeld (1976), all textbooks gave almost the same information
on the cutaneous innervation of the palmar aspect of the fingers. They stated that
the median nerve innervates the thumb, index, and middle fingers, with the radial
side of the ring finger, whereas the little finger and the ulnar side of the ring finger
are innervated by the ulnar nerve. Hoppenfeld (1976), in contrast, stated that the
palmar surface of the ring finger was entirely innervated by the ulnar nerve.
Less consensus is seen in descriptions of the dorsal aspect of the fingers. Fourteen
authors stated that at least the proximal part of the thumb, the index finger, and the
radial side of the middle finger were innervated by the superficial branch of the radial
nerve, whereas the little and ring fingers, with the ulnar side of the middle finger, were
innervated by the dorsal branch of the ulnar nerve (Contamin & Sabouraud, 1968;
Rouvière & Delmas, 1974; Gardner, 1975; Gardner et al., 1975; Lumley et al., 1975;
Hollinshead, 1976; Langman & Woerdeman, 1978; Poeck, 1982; Anderson, 1983;
Kendall & Kendall McCreary, 1986; Frick, 1990; Beauthier & Lefèvre, 1991; Butler,
1991; Mumenthaler & Schliack, 1991). In 15 other charts, the demarcation between
the superficial radial and the dorsal ulnar nerves was indicated on the midline of the
dorsum of the ring finger (Cailliet, 1975; Francis & Martin, 1975; Russe et al., 1976;
Last, 1978; Anthony et al., 1979; Basmajian, 1980; Chusid, 1982; Anson & McVay,
1984; Pact et al., 1984; Frisch, 1987; Wadsworth, 1988; Backhouse & Hutchings,
1989; Gosling et al., 1990; Mink et al., 1990; Winkel, 1992). Hoppenfeld (1976) and
Crouch (1978) stated that the dorsal aspect of the thumb and the two radial fingers
were innervated by the superficial radial nerve, whereas the dorsal branch of the ulnar
nerve innervated the ring and little fingers.
Twelve authors stated that the median nerve innervated the dorsum of the distal
part of the thumb, the index, middle, and radial side of the ring fingers (Gardner,
1975; Hollinshead, 1976; Russe et al., 1976; Langman & Woerdeman, 1978; Last,
1978; Anthony et al., 1979; Anson & McVay, 1984; Frisch, 1987; Backhouse &
Hutchings, 1989; Frick, 1990; Gosling et al., 1990; Butler, 1991). Twelve others gave
the same distribution but excluded the thumb (Contamin & Sabouraud, 1968; Rou-
vière & Delmas, 1974; Cailliet, 1975; Gardner et al., 1975; Basmajian, 1980;
Chusid, 1982; Anderson, 1983; Pact et al., 1984; Kendall & Kendall McCreary,
1986; Wadsworth, 1988; Beauthier & Lefèvre, 1991; Mumenthaler & Schliack,
1991). According to Lumley et al. (1975), Hoppenfeld (1976), Crouch (1978) and
Poeck (1982), the entire dorsal aspect of the middle as well as the little finger was
innervated by the ulnar nerve. Some authors even stated that the median nerve was
not involved in the cutaneous innervation of the dorsum of the fingers at all (Last,
1978, Mink et al., 1990; Winkel, 1992).
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Cutaneous innervation of the fingers 43

Our analysis of the literature was in keeping with the observation of Turner who,
as early as 1872, stated that there was more variation in cutaneous innervation of
the dorsum of the hand than the palmar aspect. Another interesting study was
reported by Stopford (1918). Using cotton wool stimulation to determine the exclu-
sive cutaneous distribution of the median, ulnar, and superficial radial nerves in
cases of complete destruction of these nerves (mostly following gunshot wounds),
Stopford (1918) reported the following findings. In 51 median nerve lesions the
cutaneous supply conformed to that specifically described, i.e. it extended as far as
the radial side of the ring finger, only 72% of the time. For the ulnar nerve, varia-
tions were observed in about 20% of the 102 cases. After severance of the superficial
radial nerve (12 cases) cutaneous sensory loss was confined to the dorsum of the base
and first metacarpal of the thumb in four cases, and extended distomedially across
the dorsal aspect of the proximal phalanx to a line drawn along the ulnar margin of
the index finger in another four. Cutaneous sensory loss extended to the midline of
the middle finger in two cases and in two others, to the ulnar margin of the middle
finger. Other authors reported other anatomical variations (Hutton, 1906; Lear-
month, 1919; Linell, 1921; Kosinski, 1927; P’An, 1939).
In sensory nerve conduction studies to evaluate peripheral neuropathy, the unaf-
fected hand was often chosen as a reference for the affected hand. This assumed that
the cutaneous innervation in the hands was symmetric, however, no firm evidence
was found in the literature to support this supposition.
The aim of this study was to investigate the variation in sensory innervation of
the fingers by antidromic recording of digital nerve action potentials following sepa-
rate stimulation of each of the four contributing nerves, and to compare the results
in left and right hands. The authors were unaware of any other reports of studies
using this method for the investigation of the cutaneous sensory distribution of the
peripheral nerves of the fingers.

SUBJECTS AND METHODS

Peripheral nerve stimulation was performed on 31 female subjects (mean age 21 years,
range 19–25). The four nerves, the median, ulnar, superficial branch of the radial, and
dorsal branch of the ulnar, which could contribute to the cutaneous innervation of the
fingers, were stimulated at each wrist independantly. The median nerve was stimulated
between the tendons of the palmaris longus and flexor carpi radialis muscles and the
ulnar nerve on the radial side of the flexor carpi ulnaris muscle. The superficial branch
of the radial nerve was stimulated at a point about 4 cm proximal to the wrist on the
lateral border of the forearm, and the dorsal branch of the ulnar nerve at a point just
medial to the ulnar styloid. A bipolar stimulator with 3 cm interelectrode distance was
used, the anode being kept proximal to the points of stimulation stated above. Rectan-
gular electrical pulses of 0.1 ms duration were delivered at 0.8 Hz, starting at zero and
increasing the stimulus amplitude until no further increase in the response was
obtained.
The finger to be examined was first cleaned with alcohol. Two ring-shaped sur-
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44 Stappaerts, Van Hees and Van den Broeck

face recording electrodes (Medelec no. 16639) were immersed in a physiologic salt
solution before being fixed to the finger 3 cm apart. A neutral (grounding) electrode
was placed on the dorsum of the same hand. Recording electrode impedance was
kept below 10 KOhm. Sensory nerve action potentials (SNAPs) were recorded with
a Medelec MS20 (Mystro) apparatus. Sensitivity was adjusted from 20 µV per divi-
sion up to 2 µV per division as necessary. The proximal recording electrode was
placed at the proximal interphalangeal joint for stimulation of the median or ulnar
nerves, whereas for the superficial branch of the radial and dorsal branch of the
ulnar nerves it was positioned close to the metacarpophalangeal joint.
SNAPs were identified by a latency of 2–3 ms and their biphasic waveform
with a negative onset, whereas the muscle action potentials from intrinsic hand
muscles activated by stimulation of mixed nerves (i.e. median and ulnar) had a
positive onset, a longer latency period, and a low amplitude due to the distal loca-
tion of the recording electrode (at the interphalangeal joint). Stimulation of the
superficial radial or the dorsal ulnar nerve did not evoke a motor response. If the
amplitude of a SNAP was low, some 2–30 responses were averaged and the mea-
surement repeated at least twice. Only reproducible responses were accepted.
When stimulating the median nerve or superficial branch of the radial nerve, the
SNAP was first recorded at the thumb. If a SNAP was observed the procedure was
repeated, recording from the index finger then from each subsequent finger until
no action potential could be detected. The reverse order was followed when stimu-
lating either the ulnar or the dorsal branch of the ulnar nerve, when recording was
started at the fifth finger.

RESULTS
Table 1 shows the results in the form of contingency tables. There is one contin-
gency table for each of the four nerves stimulated. The figures in the cells are the
number of subjects in whom a SNAP was recorded from the fingers indicated in the
row and column headings.
Stimulation of the superficial branch of the radial nerve produced a SNAP
recording from the thumb only in three right hands (10%) and two left hands
(6%). The most frequent finding was a SNAP recording from both the thumb and
index finger, being observed in 18 left and 18 right hands (58%). In addition, a
SNAP could be recorded from the middle finger in 10 right hands (32%) and 11
left hands (35%). When comparing the number of fingers from which a SNAP was
recorded in both hands for each subject (Table 1, sum of the figures in bold on the
diagonal), symmetry was found to be present in 21 subjects (68%). A difference in
symmetry of one finger was observed in eight subjects (26%) and of two in two sub-
jects (6%).
Stimulation of the dorsal branch of the ulnar nerve, produced no digital SNAP
from two right and two left hands (6% each). SNAPs were obtained most frequently
from both the little and ring fingers, (16 left and 16 right hands, 52%). In addition,
a SNAP could also be recorded from the middle finger in eight right hands (26%)
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Cutaneous innervation of the fingers 45

TABLE 1: Frequency of SNAP recording from fingers of left and right hands after stimulation of indi-
vidual nerves (the fingers in the cells of the contingency table represent the number of subjects)
(N=31)

Dorsal side
Radial nerve, superficial branch
Left
T TI TIM Total
Right T 0 2 1 3
TI 1 14 3 18
TIM 1 2 7 10
Total 2 18 11 31
Ulner nerve, dorsal branch
Left
NO L LR LRM Total
Right NO 1 0 0 1 2
L 0 0 3 2 5
LR 1 4 8 3 16
LRM 0 0 5 3 8
Total 2 4 16 9 31
Palmar side
Median nerve
Left
TIMR TIMRL Total
Right TIMR 29 2 31
TIMRL 0 0 0
Total 29 2 31
Ulnar nerve
Left
LR LRM Total
Right LR 28 0 28
LRM 3 0 3
Total 31 0 31

T = SNAP recorded from thumb; TI = SNAP recorded from thumb and index finger; TIM = SNAP
recorded from thumb, index and middle fingers; NO = No SNAP recorded; L = SNAP recorded from
little finger; LR = SNAP recorded from little and ring fingers; LRM = SNAP recorded from little,
ring and middle fingers; TIMR = SNAP recorded from thumb, index, middle and ring fingers; TIMRL
= SNAP recorded from thumb, index, middle, ring and little fingers.

and nine left hands (29%). By comparing hands in each subject, symmetry of SNAP
recording was found in 12 subjects (39%). A difference in one finger was seen in 15
subjects (48%) and in two fingers in three subjects (10%). One subject showed a dif-
ference in three fingers (3%).
Median nerve stimulation produced SNAP recordings from the thumb, the
index, middle and ring fingers of both hands in all subjects. In two left hands an
additional SNAP was recorded from the little finger.There was symmetry of record-
ing in 29 subjects.
Stimulation of the ulnar nerve gave SNAP recordings from the little and ring fin-
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46 Stappaerts, Van Hees and Van den Broeck

gers of both hands in all subjects. In three right hands a SNAP was also recorded
from the middle finger. Symmetry was therefore noted in 28 subjects.
Results were combined in order to estimate symmetry of innervation for the
dorsal and palmar aspects of the fingers. For the dorsal aspect, combining results
from the stimulation of superficial radial and dorsal ulnar nerves demonstrated sym-
metrical SNAP recordings in only nine subjects (29%). Combining the results of
stimulation of median and ulnar nerves showed symmetrical recordings for the
palmar aspect in 27 subjects (87%).

DISCUSSION
The technique of antidromic recording of digital nerve action potentials in man was
described by Sears (1959), and is now a standard method used in clinical neurophys-
iology for examination of the sensory conduction of the median and ulnar nerves
(Kimura, 1989). To our knowledge, however, no data has been published on record-
ings from the second to fifth finger after stimulation of the superficial branch of the
radial nerve or the dorsal branch of the ulnar nerve. Our study showed that these
responses were of a low amplitude, ranging from 0.1 to 10 µV, and that a better
recording was made if the cathode was placed at the finger base instead of the usual
position at the proximal interphalangeal joint. Recording from each finger sepa-
rately whilst stimulating sequentially the four nerves that can contribute to finger
innervation, the contribution of each nerve to each finger in both hands in a group
of subjects was measured.
In his classic work on nerves and nerve injuries, Sunderland (1978) gave some
general analysis on the cutaneous innervation of the hand. Some of his findings were
confirmed by our study; others were contradicted.
It was also clear from our study that the distribution of the cutaneous nerves on
the dorsum of the fingers was subject to greater variation than on the palmar aspect.
These findings were already reported by Turner (1872), Kosinski (1927), and P’An
(1939).
Sunderland (1978) further stated that the palmar aspects of the digits were con-
sistently innervated by the median and ulnar nerves, the relative areas served by
these two nerves being subject to some variation. This can partially be explained by
communications between these nerves. In the forearm, one or more fine communi-
cating branches may link the median nerve to the ulnar nerve. This communication,
which has been studied by Spinner (1972) amongst others, is known as the
Martin–Gruber anastomosis. This anastomosis is mostly described as transferring
motor fibres from the median to the ulnar nerve, but Ranschburg (1917) also
described sensory fibres passing from the ulnar to the median nerve. Ulnar–median
communications deep in the palm of the hand, known as the Cannieu–Riche anas-
tomosis, were described by Kaplan (1965) and by Harness and Sekeles (1971). Sun-
derland (1978) assumed that these communications transmitted both motor and
sensory fibres. He also noted that the most medial branch of the median nerve,
which is destined for the third interspace, gave a branch which joins another from
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Cutaneous innervation of the fingers 47

the ulnar nerve to form a communicating loop. This permits the exchange of cuta-
neous fibres between the median and ulnar nerves and involves an overlap of the
cutaneous innervation of the contiguous sides of the middle, ring and little fingers.
One of the variations observed was a lateral extension of the ulnar field that
overlaps or may replace the median nerve area. The ulnar field has been reported to
extend as far as the ulnar side of the index finger; however, in our subjects, it
extended no further than to the middle finger. Another variation described was the
extension of the median field to include the ulnar side of the ring finger or even the
adjacent radial aspect of the little finger. Our findings agree with this. In two people,
the palmar aspect of all five fingers was innervated by the median nerve. This vari-
ant was not described in the literature, probably because the equipment used in ear-
lier studies was less sophisticated. Bergman et al. (1970) reported an unusual case in
which, following resection of the median nerve at the wrist, there was no sensory
loss in the normal median field in the hand, whereas blocking the superficial radial
nerve immediately resulted in anaesthesia of that area.
On the dorsum of the hand, the most common variations in cutaneous innerva-
tion seen were in those areas served by the superficial radial and the dorsal cuta-
neous (ulnar) nerves and, in particular, their digital branches (Sunderland, 1978).
Our study confirmed the findings of P’An (1939), who found it was more usual for
the dorsal branch of the ulnar nerve to extend its area of supply radially than to
show a reduced distribution. This was in keeping with the observations of Kosinski
(1927) in 43% of 300 dissections.
The superficial branch of the radial nerve had been reported as being absent by
several authors (Hutton, 1906; Appleton, 1911; Linell, 1921; Sunderland, 1948),
which was not the case in any of our subjects. In contrast, we found that in four
hands no fingers were innervated by the dorsal branch of the ulnar nerve.
It was surprising that, in the literature, no experimental nor clinical reports could
be found describing the symmetry of cutaneous innervation between the left and
right hands. We often found some asymmetry in sensory distribution between hands
in the same person. These asymmetries occurred more on the dorsum of the fingers
than on the palmar aspect, and were more often related to the cutaneous innerva-
tion of the dorsal branch of the ulnar nerve than that of the superficial branch of the
radial nerve. Therefore, caution should be exercised when comparing one hand with
the other when assessing the cutaneous innervation.

CONCLUSION
From previous experiments, as well as from our findings, it could be concluded that
the cutaneous innervation of all the peripheral nerves in the fingers may deviate
from the innervation patterns given by the various sensory distribution charts. These
variations occurred fairly frequently, and were more often to be found on the dorsum
of the fingers than on the palmar aspect. So, physiotherapists in clinical practice
should be aware that existing sensory distribution charts are not absolute references
for the assessment of cutaneous sensation in the individual patient.
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48 Stappaerts, Van Hees and Van den Broeck

In addition, our findings demonstrated that the distribution of sensory innerva-

tion could differ markedly between hands in the same individual. These asymmetries
also occurred more often on the dorsum of the fingers, in particular, for the dorsal
branch of the ulnar nerve but also for the superficial branch of the radial nerve.

ACKNOWLEDGEMENT
We would like to thank Mrs Helen Burnett, MCSP, DipTP, for language revision.

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Address correspondence to Professor K. Stappaerts. Faculteit Lichamelijke Opvoeding en Kinesitherapie, KU

Leuven, Tervuursevest 101, B-3001 Heverlee-Leuven, Belgium.