Neurological examination - upper limb Flashcards
How should you start a neurological examination?
- introduce self
- confirm name and DOB
- explain procedure
- gain consent
- wash hands
What should you look for on general examination?
- comfortable at rest
- walking aids
- posture
- obvious deformity
- gait
How should you inspect the muscles?
- expose limbs
- look for asymmetry
- position of limbs
- abnrmal movements
- tremor
- muscle wasting/hypertrophy
What are fasciculations?
irregular ripples of twitches under the skin overlying muscles at rest
What are fasciculations a sign of?
LMN disease
How are fasciculations elicited
- flick over area of muscle wasting
What are myoclonic jerks?
sudden shock-like contractions of one or more muscles which may be focal or diffuse
What are myoclonic jerks a sign of?
- epilepsy
- diffuse brain damage
- dementias
What can cause muscle wasting?
LMN disease normally
wasting may occur from longstanding UMN lesions
What is a tremor?
An oscillatory movement about a joint or a group of joints resulting from alternating contractions and relaxations of muscles
What is flaccidity a sign of?
LMN lesion
AKA hypotonia
What is spasticity?
Hypertonia
- velocity-dependent resistence to passive movement
feature of UMN lesion
What is rigidity?
Hypertonia
- sustained resistance throughout range of movement
What is clonus?
rhythmic sesies of contractions evoked by sudden stretch of the muscles
sign of UMN lesion
How is tone assessed in the upper limbs?
- wrist clonus/spastic catch manoeuvre
How is power assessed in the upper limb?
- shoulder abduction/adduction
- elbow flexion/extension
- wrist flexion/extension
- finger flexion/extension
- finger abduction/adduction
- thumb adduction
How is power graded?
MRC scale
How are reflexes in the upper limbs reinforced?
clenching teeth
What reflexes do you test in the upper limb?
- biceps
- triceps
- supinator
What co-ordination tests do you carry out?
- finger to nose
- dysdiadochokinesis (alternate hand)
How do you end an upper limb examination?
- summarise key findings
- thank patient
- wash hands
What are the features of an upper motor neuron lesion?
Everything goes up
- increased tone
- increased reflexes
- upgoing plantars
- generally retained muscle bulk
- clonus
Which conditions lead to an upper motor neuron lesion?
- stroke
- traumatic brain injury
- cerebral palsy
Describe the upper motor neuron pathway
The pyramidal system is one of the motor control systems which enables purposive, skilled, intricate, strong and organized movements. The pathway originates in the motor cortex of the brain, travels through the internal capsule and crosses in the medulla (decussation of the pyramids).
What are the features of a lower motor neuron lesion?
“Everything is lowered”
- DECREASED TONE
- DEPRESSED REFLEXES
- DOWN GOING PLANTARS
- DECREASED MUSCLE BULK
- FASCICULATIONS
What conditions lead to a lower motor neuron lesion?
Cranial nerve palsy e.g. Bellʼs palsy
Cervical or lumbar disc protrusion
Peripheral or cranial nerve trauma or entrapment
What are the main reflexes tested in an upper limb neurological examination and their roots?
- Triceps = C7 and C8
- Biceps = C5 and C6
- Supinator = C5 and C6
What is the MRC scale?
Medical research council scale for assessment of muscle power
- NO POWER
- Flicker of contraction
- Some active movement but cannot overcome gravity
- Can overcome gravity but NO more
- Active power against resistance – but not normal
- Full power (allowing for age)
