Upper Limb Examination

Question 1

What is the order in which upper limbs would be examined?

Answer 1

• Observation
• Tone
• Power
• Coordination
• Reflexes
• Sensation

Question 2

Upper Limb Observation:
What do you look for?

Answer 2

SWIFT
* S: Scars/skeletal deformity
* W: muscle wasting/atrophy
* I: Involuntary muscle movement
* F:Fasiculations (muscle)
* T: Tremor

Question 3

What does muscle wasting/atrophy suggest?

Answer 3

• Denervation -> Lower motor neurone (LMN) lesions
• Disuse -> long term upper motor neurone (UMN) lesions

Question 4

What is dystonia?

Involutary muscle movement

Answer 4

Sustained muscle contractions which
are twisting & repetitive

Question 5

What are chorea and athetosis?

Answer 5

Writhing movements

Question 6

What is ballismus?

Answer 6

Violent flinging movements

Question 7

What are ticks?

Answer 7

Repetitive and stereotyped – these can be suppressed by the patient, unlike those described above.

Question 8

What are muscle fasiculations a sign of?

Answer 8

Denervation

Question 9

How should tremours be described?

Answer 9

Speed
Amplitude
When the tremour is maximal (rest/active movement)

Question 10

What are 2 commonly found tremors?

Answer 10

• Physiological – fine, fast upper limb tremor. Increased by anxiety, hyperthyroidism, alcohol excess & some drugs.
• Parkinsonian – slow, coarse, greater at rest, mostly upper limbs & usually asymmetrical.
  ‘pill rolling’

Question 11

What is tone?

Answer 11

Resistance felt by the examiner when moving a joint though its range of motion. The tone can be normal, decreased (hypotonia) or increased (hypertonia)

Question 12

What are the 2 main types of hypertonia?

Answer 12

Spaticity: velocity-dependent resistance to passive movement
**Rigidity: **sustained resistance even with slow movement, increased tone present throughout whole range of movements

Question 13

What is spasticity a sign of?

Answer 13

UMNL
* Accompanied by weakness and hyper-reflexia
* Extensor plantar response and ankle clonus

Question 14

How is tone tested?

Answer 14

Before undertaking passive movement of the limbs,
it is necessary to check that this is not likely to
cause pain. Ask the patient to relax, and test tone
by performing passive movement:
* Elbow flexion and extension, forearm pronation & supination and wrist flexion & extension.
Passive movements that are sudden and unpredictable, but still gentle, are probably the best way to eliminate
voluntary muscle contraction.

Question 15

How is power tested?

Answer 15

Test agaisnt resistance:
• shoulder abduction: elbows in teh air, try push down arms
• elbow flexion and extension: pull toards/push away
• wrist flexion and extension: cock wrist back/ bend fist down
• finger flexion and extension: flex at metacarpophalngeal joint/mokey grip and dont let uncurl fingers
• the intrinsic muscles of the hand: spread fingers apart, dont let close them
* Grip: squeeze fingers
* Pronaror drift: hold out arms straight in front, plams up to ceiling, close eyes. Watch for drifting of arms downwards or into pronation

Question 16

Which nerve innervates finger extensor muscles?

Answer 16

Radial n.

Question 17

Which spinal nerve innervates muscles of finger flexion?

Answer 17

C8

Question 18

What nerve innervates the hand abductor muscles?

Answer 18

Ulnar n.

Question 19

Which nerve innervates abductor pollicis?

Answer 19

Median n.

Question 20

Which nerves innervate the muscles required to perform the griping of the hand?

Answer 20

Median and ulnar n.

Question 21

What is positive pronator drift sign a sign of?

Answer 21

Cerebral hemisphere problem (not limb problem)

Question 22

How is coordination tested?

Answer 22

Hold out arms outstretched in front
* Finger nose test: as pt to touch tehir nose with index finger, then your finger, back and foth (test both sides, one at a time)
* Rapid alternating hand movements (dysdiadochokinesis): ask pt to hold left hand still and tap rapidly with right hand (pronated and supinated) (repeat on both sides)

Question 23

How are reflexes tested?

Answer 23

Palpate muscle tendon, ask pt to relax. Talk/distract the patient

• Biceps: place your thumb or index finger over
  the biceps tendon and then strike your own
  thumb or finger.
  • Supinator: place your thumb or index finger
  over a point 3-4 cm above the distal end of the
  radius with the patient’s arm semi-pronated
  and then strike your own thumb or finger.
  • Triceps: strike the tendon directly about 2
  cm above the olecranon whilst supporting the
  weight of the arm

Test both sides with reinforcement

Question 24

Which spinal nerve(s) innervate the biceps reflex?

Answer 24

C5/6

Question 25

Which spinal nerve(s) innervates the supinator reflex ?

Answer 25

C6

Question 26

Which spinal nerve innervates triceps reflex?

Answer 26

C7

Question 27

How is sensation tested?

Answer 27

• Light touch: cotton wool. Touch dermatomes C5-T1
• Pinprick (pain):neurotip, touch dermatomes C5-T1
• Vibration: distally 128 Hz tuning fork on DIP joint of finger. If cannot be felt, move to more proximal joint
• Joint position sense (proprioception): close eyes, move finger up and down

Question 28

Which tuning fork is used for virbartion sense?

Answer 28

128 Hz (large)

Question 29

Which spinal pathway carries fibres for fine touch, proprioception, vibration sense?

Answer 29

Dorsal column

Question 30

Which spinal pathwya carries fibres for pain and temperature sensation?

Answer 30

Spinothalamic