Upper Limb Exam

Question 1

General inspection from end of bed of pt

Answer 1

• any limb deformity or posturing
• SWIFT: scars, wasting of muscle, involuntary movements (dystonua, chorea, myoclonus), fasciculations, tremor
• ask pt to close eyes and place arms outstretched with palms facing up (look for pronator drift = UMN pathology)

Question 2

How do you assess tone?

Answer 2

Ask pt to let their arm go floppy

• rotate wrist
• supinate and pronate arm
• move elbow and shoulder joints

Smooth, Dec tone = LMN
Inc tone = UMN

Feel for rigidity and cogwheeling = Parkinson’s

Question 3

How do you assess power in the shoulder?

Answer 3

Always compare each side when testing

• put one hand on shoulder to stabilise joint
• “put your arms up like a chicken and push against my arm” (abduction C5, adduction C6/7)
• push down on one arm, then next
• push up on one arm, then next

Question 4

How do you assess power in the elbow?

Answer 4

Stabilise elbow joint

• put your arms up like a boxer and don’t let me pull your arm away/towards
• flexion = C5/6, extension = C7

Question 5

How do you assess wrist power?

Answer 5

• stabilise wrist joint
• cock wrists back and push against my hand (extension C6)
• flatten wrists and push down against my hand (flexion C6/7)

Question 6

How do you assess power in the fingers?

Answer 6

• stabilise wrist joints
• splay your fingers and don’t let me push them together (finger abduction T1)
• point you’re thumb to the ceiling with palms up and push against my thumb (thumb adduction C8/T1)
• squeeze my fingers as hard as you can (power grip)
• make the on sign with your fingers and don’t let me pull them apart (opposition)

Question 7

What reflexes do you need to do?

Answer 7

• biceps reflex (C5/6)
• triceps reflex (C7)
• supination reflex (C6): 4 inches proximal to base of thumb. Ask pt to wiggle their thumb and feel for the tendon

Question 8

How do you test for sensation?

Answer 8

• get it to close eyes and ask them to say yes whenever they feel it
• first test on pt sternum
• test all dermatomes on upper limb, compare left to right
• LIGHT TOUCH and PIN PRICK
• offer to test temperature sensation using hot and cold

Question 9

How do you test vibration sensation?

Answer 9

• ask pt to close eyes and tap a 128Hz tuning fork
• test on pt sternum and make sure they can feel it
• place it on DIP of forefinger and ask pt to report when they can feel vibration and when it stops
• if vibration sense is impaired, continue to assess bony prominence of more proximal joints

Question 10

How do you test proprioception?

Answer 10

• hold distal phalanx of thumb by its sides
• demonstrate movement of thumb up and down to pt whilst they watch
• ask the pt to close their eyes and state of you are moving the thumb up or down
• move the thumb up/down 3 times on each hand
• if it is unable to correctly identify direction of movement, move to a more proximal joint (finger, wrist, elbow, shoulder)

Question 11

How do you test coordination?

Answer 11

FINGER TO NOSE TEST:

• ask pt to touch their nose and then your finger as quickly as they are able to
• move your finger when pt is about to leave nose (moving target)

DYSDIADOCHOKINESIA:

• ask pt to pat palm of one hand with palm and back of other hand as fast as possible
• inability to do this suggests cerebellum ataxia/Parkinson’s

Question 12

How do you present it to examiner?

Answer 12

• pt was clam and comfortable at rest and there was no paraphernalia of neurological disease
  EXAMINATION:
• tone: normal on both sides
• power: 5/5 on MRC scale in all muscle groups tested
• reflexes: intact and normal in areas testes
• coordination: normal, no evidence of dysdiadochokinesia
• light touch and pain sensation were normal in all dermatomes tested
• vibration sense and propriocetion were intact

Question 13

How would you finish the exam?

Answer 13

• full history
• cranial never and lower limb exam
• GALS screen
• further imaging if indicated (CT/MRI cervical spine)