Motor system of the upper limbs examination

Question 1

When inspecting the patient, what should you be observe for?

Answer 1

General overall appearance
Abnormal movements (i.e. dystonia, chorea)
Tremor
Scars
Muscle wasting/hypertrophy
Fasciculation

Question 2

What is a fasciculation?

Answer 2

A muscle twitch - a small, local, involuntary muscle contraction and relaxation which may be visible under the skin

Question 3

What is dystonia?

Answer 3

A movement disorder in which a person’s muscles contract uncontrollably. The contraction causes the affected body part to twist involuntarily, resulting in repetitive movements or abnormal postures. Dystonia can affect one muscle, a muscle group, or the entire body.

Question 4

What is chorea?

Answer 4

A neurological disorder characterized by jerky involuntary movements affecting especially the shoulders, hips, and face

Question 5

If you suspect muscular wasting or hypertrophy in an arm, what could you do to confirm this?

Answer 5

Measure the circumference of the arms

Question 6

If you suspect increased tone in the patient’s arms what would you ask them to do before re-testing?

Answer 6

You would ask them to clench their teeth before re-testing

Question 7

What does increased tone suggest if it is described as spasticity (clasp-knife)?

Answer 7

Spasticity suggests a pyramidal lesion

Question 8

What does increased tone suggest if it is described as rigidity (lead pipe)?

Answer 8

Rigidity suggests an extra-pyramidal lesion

Question 9

What are the motor signs that a patient has Parkinson’s disease?

Answer 9

Motor signs include forward-flexed posture, mask-like facial expression, speech difficulties, resting tremor, cogwheel rigidity, bradykinesia

Question 10

What are the motor signs that a patient has a cerebellar lesion?

Answer 10

Motor signs depend on the anatomy of the lesion, and may include nystagmus, slurred or staccato speech, hypotonia, hyporeflexia, intention tremor, dysmetria, dysynergia, dysdiadochokinesis, ataxia

Question 11

What are the motor signs a patient has an ulnar nerve lesion?

Answer 11

Wasting, weakness, numbness, and tingling in the fish finger and in the medial half of the fourth finger
Curling up of the fifth and fourth fingers (‘ulnar claw’) indicates that the nerve is severely affected

Question 12

What are the motor signs that a patient has a median nerve lesion?

Answer 12

A lesion at the level of the wrist produces wasting of the thenar muscles, weakness of abduction and opposition of the thumb, and numbness over the palmar aspect of the thumb, index finger, third finger, and lateral half of the fourth finger

A lesion at the level of the forearm produces additional weakness of flexion of the distal and middle phalanges

A lesion at the level of the elbow or above produces additional weakness of pronation of the forearm and ulnar deviation of the wrist on wrist flexion

Question 13

What are the motor signs that a patient has a radial nerve lesion?

Answer 13

A lesion at the level of the axilla or above produces weakness of the elbow extension and flexion, weakness of wrist and finger extension with attending wrist drop and finger drop, weakness of thumb abduction and extension, and sensory loss over the dorsoradial aspect of the hand and the dorsal aspect of the radial 3 1/2 fingers (usually circumscribed to a small, triangular area over the first dorsal web space)

Inferior lesions are likely to spare triceps (elbow extension), brachioradialis (elbow flexion), and extensor carpi radialis longus (wrist extension and radial abduction, but this muscle is only one of five wrist extensors)

Question 14

What are the motor signs that a patient has radiculopathy, affecting a single root nerve?

Answer 14

For the bicep reflex - C5, C6
For the supinator reflex - C6
For the tricep reflex - C7

Question 15

What are the motor signs that a patient has hemiplegia/hemiparesis?

Answer 15

Paralysis or weakness on one side of the body accompanied by decreased movement control, spasticity, and hyper-reflexia (upper motor neurone syndrome)

Question 16

What are the motor signs that a patient has myopathy?

Answer 16

Symmetrical weakness predominately affecting proximal muscle groups
In contrast to neuropathy, in myopathy muscle atrophy and hyporeflexia occur very late

Question 17

What are the five stages to an examination of the motor system of the upper limbs?

Answer 17

Inspection
Tone 
Power
Reflexes
Cerebellar signs

Question 18

What are the three ‘S’ you look for when inspecting the patient’s hands, arms, and shoulder girdle?

Answer 18

Size, Shape and Symmetry

Question 19

How do you assess tone of the upper limbs?

Answer 19

Ask the patient to relax their arms 
Hold the patients hand as if shaking hands - while supporting the elbow
Supinate and pronate the forearm
Flex and extend the elbow
Roll the wrist

Question 20

How do you test for muscle strength in the shoulder?

Answer 20

By assessing shoulder abduction and adduction

• With the patient’s elbow flexed, the patient abducts the upper arm against the examiners resistance
• Patient also adducts their upper arm back towards the trunk against resistance

Question 21

How do you test for muscle strength in the arms?

Answer 21

By assessing elbow flexion and extension

• The patient extends the elbow against the resistance of the examiners hand
• The patient also flexes the elbow against resistance

Question 22

How do you test for muscle strength in the wrist?

Answer 22

By assessing wrist flexion and extension

• The patient attempts to flex wrist agains examiners resting hand
• The patient attempts to extend wrist against the examiners hand

Question 23

How do you test for muscle strength in the fingers?

Answer 23

By assessing finger flexion, extension and abduction

• The patient grips and squeezes two of the examiners finger
• The patient holds their finger out straight. The examiner pushes down on the patient’s proximal phalanges with the side of his/her hand in an attempt to induce flexion at the patient’s metocaropo-phalangeal joints
• The patient spreads out their fingers and resists the examiner trying to push them together

Question 24

How do you test for muscle strength in the thumbs?

Answer 24

By assessing thumb abduction and opposition

• The patient attempts to lift the thumb vertically from the plane of the palm against resistance
• The patient attempts to touch the tip of the little finger with the top of the thumb (opposition) whilst the examiner resists the movement