Upper Limb

Question 1

Difference between upper and lower motor neuron origin?

Answer 1

Upper = brain or spinal cord
Lower = nerve root, peripheral nerve, NMJ or muscle

Question 2

What are the UMN signs?

Answer 2

No fascicultations or wasting, pronator drift may be present, increase tone (spasticity or rigidity), Pyramidal pattern of weakness e.g. extensors weaker than flexors in arms and opposite in legs) and exaggerated/brisk reflex (hyperreflexia)

Question 3

WHat are the LMN signs?

Answer 3

Wasting and fascicultations of muscles. May be some drift/movement of the arms if weakened or deafferented but not pronator drift, different patterns of weakness depending on cause e.g. proximal in muscle disease and distal in peripheral neuropathy, reduce or absnt (hyporeflexia or areflexia)

Question 4

What equipment wil you need?

Answer 4

Tendon hammer, neurotip, cotton wool, tuning fork 128Hx

Question 5

What clinical signs on general inspection?

Answer 5

Scars, wating of muscles (LMN or disuse atrophy), tremor, fasciculations, pseudoarthetosis, chorea, myoclonus, tardive dyskinesia, hypomimia, ptosis and frontal balding (with myotonic dystrophy) and ophthalmoplegia e.g. MS or myasthenia gravis

Question 6

How do you assess pronator drift?

Answer 6

Ask patient to hold arms out in front with palms up for 20-30 second and observe for pronation. Then check again with patients eyes closed

Question 7

What tone features are you looking for?

Answer 7

Spsticity, rigidity, cogwheeling and hypotonia.
Spasticity is associated with pyramidal tract lesions e.g. stroke and rigidity is associated with extrapyramidally e.g. Parkinsons

Spasticity is velocity dependent and rigidity is velocity independent.
Rigidity subtypes: cogwheel and lead pipe.

Cogwheel = tremor superimposed on hypertonia e.g. parkinsons.
Lead pipe = unifrom increased tone e.g. neuroleptic malignant syndrome

Question 8

Shoulder abduction myotome and muscles?

Answer 8

C5 axillary and deltoid + other shoulder abductors

Question 9

Shoulder adduction myotome and muscles?

Answer 9

C67 thoracodorsal nerve and teres major, lat dorsi and pec major

Question 10

Elbow flexion myotome and muscles?

Answer 10

C56 musculocutaneous and radial. Briceps brachii, coracobrachialis and brachialis

Question 11

Elbow extension myotome and muscles?

Answer 11

C7 radial and triceps brachii

Question 12

Wrist extension myotome and muscles?

Answer 12

C6 radial and wrist extensors

Question 13

Wrist flexion myotome and muscles?

Answer 13

C67 median and wrist flexors

Question 14

Finger extension myotome and muscles?

Answer 14

C7 radial and extensor digitorum

Question 15

Finger abduction myotome and muscles?

Answer 15

T1 ulnar and first dorsal interosseus and abductor digiti minimi

Question 16

Thumb abduction myotome and muscles?

Answer 16

T1 median and abductor pollicis brevis

Question 17

What scale to assess power?

Answer 17

MRC muscle power assessment scale

Question 18

What reflexes are you testing?

Answer 18

Biceps (C56), supinator/brachioradialis (C56), triceps reflex (C7)

Question 19

Describe hypo vs hyperreflexia?

Answer 19

Hyper = UMN lesions e.g. stroke or spinal cord lesions. Hypo = LMN e.g. brachial plexus pathology or peripheral nerve injury.

Question 20

Cerebellar disease reflex?

Answer 20

‘pendular’ which means less brisk and slower in their rise and fall.

Question 21

What are the areas for the dermatomes?

Answer 21

C5 = lateral aspect of the lower edge of the deltoid muscle (regimental badge)
C6 = palmar side of the thumb
C7 = palmar side of middle finger
C8 = palmar side of little finger
T1 = medial aspect of antecubital fossa, proximal to medial epicondyle of the humerus

Question 22

Describe light touch and pin prick test, and tuning fork.

Answer 22

Light touch does dorsal columns and spinothalamic. Pin prick just spinothalamic and tunic fork just dorsal columns

Question 23

Describe proprioception test?

Answer 23

Joint position sense via dorsal columns.

Question 24

Describe sensory loss in mononeuropathies?

Answer 24

Localised sensory disturbance in area supplied by affected nerve

Question 25

Describe sensory loss in peripheral neuropathy?

Answer 25

Symmetrical sensory deficits in ‘glove and stocking’ distribution in peripheral limbs. Most common causes are DM and alcohol excess

Question 26

Describe sensory loss in radiclopathy?

Answer 26

Nerve root damage e.g. compression by herniated intervertebral disc, resulting in sensory disturbances in the associated dermatomes

Question 27

Describe sensory loss in spinal cord damage?

Answer 27

Sensory loss both at and below the level of involvement in a dermatomal pattern due to its impact on the sensory tracts running through the cord

Question 28

Describe sensory loss in thalamic lesions?

Answer 28

Contralateral sensory loss e.g. stroke

Question 29

Describe sensory loss in myopathies?

Answer 29

Involve symmetrical proximal muscle weakness

Question 30

How to assess co-ordination?

Answer 30

Finger to nose test

Question 31

What does finger to nose test show?

Answer 31

Cerebellar pathology shows both dysmetria and intention tremor.

Dysmetria = lack of coordination of movement

Intention tremor = broad, coarse, low-frequency tremor that occurs as limb reaches end of deliberate movement.

Presence of both shows ipsilateral cerebellar pathlogy

Question 32

What is inability to do rapid, alternating movements?

Answer 32

Dysdiadochokinesia = feature of ipsilateral cerebellar pathology

Question 33

What further assessments would you do?

Answer 33

Cranial nerve, lower limbs and cerebellar assessment. Neuroimaging e.g. MRI spine and head