Upper Limb Flashcards
Observation
Scars –
Represent previous trauma or upper limb surgery
Wasting of muscles –
Atrophy of the shoulder, Arms and Hand , Thenar (median nerve compression) Hypothenar (Ulnar nerve compression)
Atrophy is usually a sign of LMNL
Involuntary movements
Such as Dyskinesia which could be related to Cerebral Palsy and Parkinson’s
Fasciculations
Commonly seen in LMNL – Indicate damage to anterior horn cell or axon
Tremors
Such as resting tremors commonly seen in Parkinson’s disease
Paleness –
On the face could indicate any vascular disorders
Injury, swelling and edema – especially at the carpal tunnel or cubital tunnel which could cause compression
Gait
- Normal
- Ask the patient to walk to the other end of the room, turn, and come back
- Observe the speed, symmetry, balance and arm swing
- If mild unilateral loss in arm swing – Indicative of early Parkinson’s
- Tandem (Heel to toe)
- Ask the patient to walk with one foot in front of the other
- Tests balance and coordination
- If they fall to the same side each time – May indicate and ipsilateral cerebellar lesion
- Romberg
- Ask the patient to put their feet together, hands by your side
- Ask them to close their eyes
- “I’m here to catch you if you feel unsteady”
- If they fall with there eyes closed – Indicates a loss of proprioception (Sensory ataxia)
Palpation
Assess the muscles via palpation for Tone assessing for any lack or increase in tone and obvious muscle atrophy, Lower motor neuron lesion decrease tone in contrast to increased tone observed in Spasticity which is associated with pyramidal tract lesion and Rigidity associated with extrapyramidal tract lesion.
Checking the small intrinsic muscles of the hand, Thenar and Hypothenar, and the muscle bulk within the upper arm and shoulder girdle
Any bony protuberance which could suggest fracture, and feeling for any swelling, heat and pain which could be signs of inflammation
AROM/PROM
AROM Assessing patient willingness and ability, and their level of pain and range
Shoulder, Elbow,Wrist and fingers
PROM
Assess the patients pain, range and End-Feel.
Tone (Tension in the muscle) – Assess Muscle groups at the shoulder, elbow and wrist joints comparing both sides,
Hypotonia – Decrease in tone usually due to LMNL
Hypertonia - Which can be described as Spasticity and Rigidity UMNL
With spasticity I am looking for an increased resistance in tone that diminishes as the movement continues which could indicate UMNL such as stroke
And rigidity where there is a sustained resistance in passive movements which could be associated with Parkinson’s
Coordination
Finger to nose – Observing for any tremors, or undershooting/overshooting
Rapid alternating movements - Amplitude rhythm, Precision movement
-Finger-to-nose
- Ask patient to touch their nose and then to touch your finger and to go back and forth as quick as they can
- Observe for intention tremors and past pointing
- This will test for dysmetria (Lack of coordination) – Indicative of cerebellar pathology
- Check this bilaterally
-Rapid alternating movement
- Ask patient to place one hand on top of the other
- Ask them to “Turn it over for me”
- “Keep going back and forth as quickly as you can”
- Observe for irregularities in rate, rhythm and amplitude
- This will test for Dysdiadochokinesia – Indicative of cerebellar pathology
- Do this bilaterally
- Also ask to “play the piano”
Sensory testing
Sensory testing Dermatome pattern
Gross touch
Soft, Pinprick,
Sharp(Spinothalamic tract) + Soft (Dorsl column lemniscus)
Tell me if its soft or sharp; Start at sternum to establish baseline then go onto limb in dermatome pattern and Cutaneous pattern.
If I detect a sensory loss I’m going to map out if it follows the dermatome pattern or cutaneous pattern.
Temperature – Use Tuning fork (hot or cold) Spinothalamic
Vibration - (bony prominences from distal to proximal) DCML
Joint position sense – patient close eyes, move middle finger up and down (stop) and then ask patient if it is up or down DCML
Two point discrimination – Use 2 pinpricks DCML
Steregnosis – Ability to tell what an object is without looking at it (Paperclip+Pinprick) DCML
Graphesthesia - Write a number on patient palm and ask them what number DCML
Sensory neglect phenomenon. Parietal Lobe
Myotomes
C5
C5/C6
C7
C8
T1
Deep tendon reflex
We are looking for a twitch response
C5/C6 - Tendon stretch induce a stretch on the tendon with youre thumb
C6 - Tendon stretch induce a stretch on the tendon with youre thumb
C7
C8
The muscle spindles are responsible for the reflex sensory information reaching the spinal cord level, The motor afferent output from the anterior horn allow for that motor neuron to contract the muscle
So if you hit the tendon the muscle spindle stretches, The nrvous system detects stretch and the muscle contracts
Hypoflexia or absent deep tendon reflexes are seen in lower motor neuron lesions
May be seen in disease states such as hypothyroidism, hypothermia, cerebellar dysfunction, or beta-blockade
Hyperflexia: Seen in UMNL, usually indicate an interruption of corticospinal and other descending pathwaysIt can happen due to certain neurological conditions, like amyotrophic lateral sclerosis (ALS) and multiple sclerosis (MS)
Pahtological reflex
These reflexes shouldnt be present,
Hoffman’s - Tip of 3rd finger and flick downwards, In a normal response we shouldn’t see anything in a pathological response may see pincer action of the Thumb and first digit and may see contraction of the hand. This is a hyperreflex response and could indicate pathology in the pyrimidal tract
Wrist Clonus - Take hand passively into extension a few times and a qucik impulse backwards. In a normal healthy reflex response is no response; Pathological response it may start to kick back. That again can indicate pathology in the pyrimidal tract, cerebellar cortex on the contralateral side, medullary pyramids or corticospinal tracts within the spine.
Grasp Reflex - Indicates pathology in the frontal lobe
Primitive reflex that should become absent after maturity of the nervous system.
Blunt end of reflex hammer and stroke against the palm, Looking for no response and a pathological response is a grasp response. (close the hand inresponse to stimuli)
Scapula humeral reflex Scapula humeral reflex; Blunt end of reflex hammer and stroke against the palm, Looking for no response and a pathological response is a grasp response. (close the hand inresponse to stimuli)
