Neuro Upper Limb Exam Flashcards
Describe the introduction of the upper limb neurology exam.
Introduction
- W- wash hands
- I- introduce self and state role
- I - identify patient (name + DOB)
- P- permission
- P - pain?
- E- exposure
- R- reposition
What are you looking for on general inspection in the upper limb exam?
Around the bed:
- Wheelchair, walking stick (mobility issues)
- Catheter bag (possible spinal issues)
- Spirometer (respiratory dysfunction e.g. Guillain-Barre syndrome)
Patient:
- S- symmetry
- W- wasting
- I- involuntary movements
- F- fasciculations
- T- tremor
- Face - look for hypomimia (lack of expression in Parkinson’s), ptosis, frontal balding in myotonic dystrophy, ophthalmoplegia in myasthenia gravis,
- Also: neurofibromas.
What should you assess for just after the general inspection?
Pronator drift - ask patient to close eyes and place arms outstretched forwards with palms facing up. Observe arms for pronation and distal flexion)
- Pronator drift and distal flexion = pyramidal weakness*
- Upward drift = cerebellar lesion. This can be further accentuated by “rebound”- pushing a patient’s wrists down briskly and then quickly letting go.*
How do you assess for tone? What are you looking for?
Ask to let their arm go floppy, whilst you move each major joint - “let me take the weight of your arm, try not to resist or help me move it”
- Hypotonia = LMN
- Hypertonia = UMN
Spasticity = “clasp knife” resistance - velocity DEPENDENT (the faster the limb is moved the greater the resistance produced )
Rigidity = “lead pipe” (extrapyramidal in Parkinsons’s) and “cog wheel”(when tremor is superimposed) - velocity INDEPENDENT(feels same if you move the limb fast or slow)
Describe the MRC grading of power.
- 5 – Full Strength
- 4 – Movement against partial resistance
- 3 – Movement against gravity
- 2 – Movement with gravity eliminated
- 1 – Feeble contractions
- 0 – Absent voluntary contraction
List the movements for power and the muscles/nerves/roots that they are testing.
Shoulder abduction (C5): Patient abduct shoulders and raise arms to horizontal plane. Now push them down.“Don’t let me push your arms down”
- Elbow flexion (C6): Patient bring arms into sagittal plane with elbows flexed. Hold ipsilateral elbow with one hand and try andpull wrist away.“Hold your arms like this, as if you are boxing. Now I’m going to try and pull your wrist away, don’t let me.”
- Elbow extension (C7): In the same position, try and push their wrist towards them.“Now I want you to try and push me away while I hold your wrist.”
Wrist extension (C7): Patient hold their arms out straight while making fists. Stabilise their ipsilateral wrist with one hand and use the posterior side of your fist to try and push theirs down.“Hold your fists out like this. Now I’m going to try and push your fists downwards, don’t let me.”
- Finger extension (C7): Patient hold their arms out straight with their fingers extended. Stabilise their ipsilateral metacarpals withone hand and use the posterior side of your other hand’s extended fingers to try and push theirs down.“Hold your fingers straight out. Now I’m going to try and push your fingers downwards, don’t let me.”
- Finger flexion (C8): Interlock grips with the patients and try to open their fingers. “Grip my fingers and don’t let me open your hand.”
- Finger abduction (T1): Ask patient to spread their fingers. Try to push their little and index fingers inwards, using your spreadfingers (with the same digits as the ones you are touching).“Spread your fingers. Don’t let me push them inwards.”
Thumb abduction (T1): Ask the patient to hold their palms facing up and point their thumbs into the air. Try to push their thumbsdown into their palms.“Don’t let me push your thumbs down.”
What must you remember when testing for power?
- Assess power one side at a time and compare like for like.
- Remember to stabilise and isolate the joint when testing.
Which reflexes should you test for in the upper limb exam? Which nerve roots are these?
1. Biceps reflex (C5/6) – located in the antecubital fossa
2. Triceps reflex (C7) – place forearm rested at 90º flexion – tap your finger overlying the triceps tendon
3. Supinator reflex (C6) – located 4 inches proximal to base of the thumb
In the acute setting, if no tendon hammer is available then a stethoscope can be used as a rough stand-in
Describe Jendrassik’s manoeuvre.How do you assess reflexes?
Ensure a reflex is in fact absent by reinforcing the reflex arc. To reinforce, ask the patient to clench their teeth or grasp hands together and pull apart just as you strike with the tendon hammer (Jendrassik’s manoeuvre)
Reflexes are either absent or present and are scored:
- hyporeflexic (present with reinforcement)
- ++ - normal
- +++ - brisk
Always compare the right and left before moving onto the next muscle group.
What is used to assess co-ordination of the upper limb?
Finger-Nose test -
- Ask the patient to touch their nose with an index finger.
- Hold your finger at arms-length distance from the patient and ask them to use the same finger to touch your finger.
- Then ask them to move between their nose and your finger as quickly and accurately as possible. Then repeat the same instructions with the other index finger.
- Look for past pointing and intention tremor i.e. dysmetria = cerebellar lesion
Dysdiadochokinesia -
- Ask the patient to clap their right hand on the palm of their left hand,then alternate clapping with the palm and dorsum of the right hand.
- Then switch hands (clap their left hand on their right hand.)
- Disorganisation in this alternating movement indicates dysfunction in the cerebellum(cerebellar ataxia) or associated circuitry i.e. dysdiadokinesia = cerebellar lesion. Can be impaired in sensory ataxia or with Parkinsonism.
What are the dermatomes of the upper limbs? Which modalities do you test for?
Pain(spinothalamic):use neurological pin
- “Close your eyes and every time you feel it say ‘sharp’if it feels sharp like it did on your sternum or ‘blunt’if it feels blunt”
Light touch (dorsal/posterior column and spinothalamic ):use cotton wool bud
- “Close your eyes and every time you feel it say ’yes’”
Vibration sensation ( dorsal/posterior columns)
Ask the patient to close their eyes. Tap a 128 Hz tuning fork and place onto sternum then joints distal to proximal.
Proprioception (dorsal/posterior columns)
- Hold the distal phalanx of the thumb by its sides. Demonstrate movement of the thumb “upwards” and “downwards” then ask them to close their eyes and state if you are moving the thumb up or down.
- If the patient is unable to correctly identify direction of movement, move to a more proximal joint (finger > wrist > elbow > shoulder)
What further investigations would you suggest?
- Cranial nerve examination
- Lower limb neurological examination
- Further imaging if indicated – e.g. CT / MRI cervical spine
