Neuro Upper Limb Examination

Question 1

Order of the exam?

Answer 1

1. Inspection – general and closer
2. Tone
3. Power
4. Reflexes
5. Coordination
6. Sensation

Question 2

Introduction?

Answer 2

1. Wash hands with water or alcohol gel
2. Check equipment – cotton / pin / tendon hammer
3. Approach the patient from the right hand side of the couch
4. Introduce self and confirm patient’s name
5. Explain procedure and obtain verbal consent to examine – ‘ I want to…? Is that ok?’
6. Ask if patient is in any pain or discomfort
7. Explain clearly, before each test, what you are going to do, and what you would like the patient to do. Demonstrate if necessary.

Question 3

General inspection?

Answer 3

Check:
1. Around the bed (e.g. walking stick, frame).
2. Posture, symmetry, muscle wasting, abnormal movements
3. Skin e.g. scars, neurofibromatosis, rash (herpes zoster)

Question 4

Assessment of tone?

Answer 4

Resistance to passive movement
1. Ask patient to relax
2. Fix joint, and passively move elbow and wrist
3. Compare left and right

Question 5

Assessment of power?

Answer 5

Power is assessed by active movements against resistance of each joint in turn.
1. Stabilise it
2. Make the muscles act
3. Try to overcome it (by pushing or pulling against it)

Question 6

How to assess power?

Answer 6

1. Deltoid
2. Elbow flexion (biceps) and extension (triceps)
3. Wrist flexion and extension
4. Finger flexion
5. Small muscles of hand – finger abduction (ulnar n) and abductor pollicis brevis (median n.)

Question 7

Shoulder abduction?

Answer 7

deltoid C5
make wings with your arms, keep your arms up, don’t let me push them down

Question 8

Elbow flexion?

Answer 8

biceps C5/6 musculocutaneous n.
pull me towards you

Question 9

Elbow extension?

Answer 9

triceps C6/7/8 radial n.
now push me away

Question 10

Wrist extension?

Answer 10

C6/7/8
make a fist, push up against my hand

Question 11

Wrist flexion?

Answer 11

C6/7/8
make a fist, push down against my hand

Question 12

Finger flexion?

Answer 12

long and short finger flexors C8
squeeze my fingers, hard as you can

Question 13

Finger abduction/adduction?

Answer 13

intrinsic muscles T1 ulnar n.
spread your fingers apart, don’t let me squash them together

Question 14

Thumb abduction?

Answer 14

abductor pollicis brevis T1 median n.
put your thumb up, don’t let me push it down”

Question 15

How do you grade power?

Answer 15

0 - No muscle contraction discernable
1 - Flicker of contraction but no movement
2 - Joint movement when effect of gravity eliminated
3 - Movement against gravity but not examiner’s resistance
4 - Movement against resistance is weaker than normal
5 - Normal power

Question 16

What deep tendon reflexes are tested?

Answer 16

Testing reflex arc at:
1. Biceps (C6)
2. Triceps (C7)
3. Brachioradialis (C6)

Question 17

Biceps reflex (C5)?

Answer 17

support the patients arm with it flexed at roughly 60 degrees placing your thumb over the biceps tendon and hitting your thumb with the tendon hammer

Question 18

Triceps reflex (C7)?

Answer 18

rest the patients arm across their chest and it the triceps tendon just proximal to the elbow

Question 19

Brachioradialis/Supinator (C6) reflex?

Answer 19

place 3 fingers about 10 cm above the wrist on the radial aspect of the forearm on the supinator tendon as it crosses the radius and hit the fingers

Question 20

How do you grade reflexes?

Answer 20

0 = absent
1 = reduced (hypoactive)
2 = normal
3 = increased (hyperactive)
4 = clonus

Question 21

How to test Co-ordination?

Answer 21

ask the patient to touch their nose with their index finger with their eyes open and then shut - compare side to side

Question 22

Pathology of uncoordination?

Answer 22

1. Repetitive movements - dysdiadokinesia
2. Ataxia = failure of coordination
3. Sensory ataxia vs cerebellar ataxia

Question 23

How to test for sensation?

Answer 23

1. Light touch - Posterior (dorsal) columns and Spinothalamic tracts
2. Pain (pin prick) - spinothalamic tract
3. temperature 0 spinothalamic tract
4. joint position - posterior (dorsal) column
5. vibration - posterior (dorsal) column
6. 2 pt discrimination - posterior (dorsal) column

Question 24

Light touch?

Answer 24

1. ask patient to place arms by their sides with their palms facing upwards
2. lightly touch the sternum or forehead with a piece of cotton wool so that they know how it feels
3. with patients eyes shut lightly touch their arm with cotton wool
4. test each of the dermatomes
5. ask the patient to say yes every time they feel the cotton wool as t felt before

Question 25

Vibration?

Answer 25

1. place sounding tuning fork on the sternum
2. place tuning fork on bony prominence at the base of the thumb and ask them if it feels the same
3. if it feels the same dont move higher
4. move to radial stylus and then to olecranon until it feels normal

Question 26

Proprioception?

Answer 26

1. hold distal phalanx of the thumb on each side so that you can flex the interphalangeal joint
2. show the patient
   joint extended = up
   joint flexed = down
3. ask patient to close their eyes and move the joint up and down
4. ask the patient which position the joint is in

Question 27

Conclusion??

Answer 27

Thank patient and wash hands with alcohol gel or water
Summarise and present findings orally (and in patient’s notes)
1. Patient’s name, age and date of birth
2. General observation and stigmata of neurological disease
3. Tone
4. Power
5. Reflexes
6. Co-ordination
7. Sensation
9. Summary – UMN or LMN lesion?
10. Differential diagnosis