Neuro Examination - Upper Limbs

Question 1

What are the steps?

Answer 1

Introduction etc

Observation

Tone

Power

Co-ordination

Reflexes

Sensation

Question 2

Observation

Answer 2

SWIFT

Scars

Muscle Wasting

Involuntary movements

Fasciculations

Tremors

Question 3

What are two commonly found tremors?

Answer 3

• Physiological - fine, fast upper limb tremor. Increased by anxiety, hyperthyroidism, alcohol excess & some drugs
• Parkinsonian - slow, course, greater at rest, mostly upper limbs & usually asymmetrical

Question 4

What are examples of involuntary movements?

Answer 4

• Dystonia - sustained muscles contractions which are twisting & repetitive
• Chorea & Athetosis - writhing movements
• Ballismus - violent flinging movements
• Ticks - repetitive and stereotyped - these can be suppressed by the patient, unlike those above

Question 5

Tone

Answer 5

Ask the patient to relax, test passively

• Elbow flexion & extension
• Forearm pronation & supination
• Wrist flexion & extension

Question 6

What are the two main types of hypertonia?

Answer 6

• Spasticity - feature of UMNL
• Rigidity

Question 7

Power

Answer 7

The examiner opposes the patient’s movements

• Shoulder abduction
• Elbow flexion and extension
• Wrist flexion and extension
• Hands
  
  • Hold fingers out as straight as possible as you try to flex them at the metacarpophalangeal nerve (radial nerve)
  • Squeeze your fingers (Median & Ulnar)
  • Spread fingers and resist (Ulnar)
  • Resist pushing thumb down whilst pointing up
• Pronator drift - patient holds arms out straight in front of them with palms up to the ceiling , and close their eyes

Question 8

Co-ordination

Answer 8

• Ask patient to hold their arms outstretched in front of them and look for postural tremor or dystonia
• Finger-nose test
  
  • Test both sides, one at a time
• Rapid alternating hand movements (dysdiadochokinesis) - rapidly tap both hands with the other, both sides

Question 9

Reflexes

Answer 9

• Biceps: thumb or index finger over biceps tendon
• Supinator: thumb or index finger over a point 3-4cm above the distal end of the radius with patients arm semi-pronated
• Triceps: strike the tendon directly about 2cm above the olecranon

Compare both sides

Remember - reinforcement if necessary

Question 10

Sensation

Answer 10

• Light touch (cotton wool)
  
  • Lightly touch thumb, middle and little fingers
  • Medial and lateral forearm
  • Medial and lateral aspect of the arm
• Pinprick sesation
  
  • Repeat in same areas
• Vibration sense
  
  • Large (128Hz) tuning fork on distal joint of a finger
• Joint position sense
  
  • Patient closes eyes and make small movements of one of their fingers