Upper Limb Examination

Question 1

OBSERVATIONS

Answer 1

BBRSS, muscle wastage and aligment

G.A.F.A.T

Gait
Atrophy
Fasciculations
Asymmetry
Tremors

Question 2

OBSERVATION
Gait

Answer 2

May be wide, unsteady and dragging feet with cervical myelopathy

Question 3

OBSERVATION
Atrophy?

Answer 3

LMN sign
- Check normal asymmetry of muscle bulk espeically in hands
- Muscle wasting in thenar? Can be sign of median nerve entrapment e.g. Carpal tunnel or pronator teres syndrome

Question 4

OBSERVATION
Fasciculations

Answer 4

LMN Sign
- Twitches of muscle which can range from mild to severe
- Excess caffeine, nerve root compression or peripheral nerve compressions

Question 5

OBSERVATION
Tremor

Answer 5

Resting - Parkinsons with basal ganglia issues
Intentional - MS, Cerebellar problems

Question 6

OBSERVATION
Asymmetry

Answer 6

• Shoulder girdle (ears at different heights) with a poetenital torticollis)
• Wrist drop d/t radial nerve compression

Question 7

OBSERVATION
What test can be done to help see if theres a lesion in the corticospinal tract?

Answer 7

Pronator Drift-
Hands up with palms facing towards the sky and eyes closed

NORMAL RESPONSE -
Arms remain in position without drifting

ABNORMAL RESPONSE -
One palm or arm slightly droped or drifts down

This can indicate abnormality of the UMN in the brain or spinal cord that controls voluntary movement

Question 8

PALPATION
Tone

Answer 8

Should be no increase in tone -
Cause of increased tone
- Stroke (spasticity)
- Parkinson’s (Cogwheel rigidity)

Cause of decrease tone?
- LMN lesion(s)
- Cerebellar disease
Check intrinsic muscles of hand, hypothenar for atrophy

Question 9

AROM
Shoulder degrees?

Answer 9

Shoulder
- Flexion (180)
- Extension
- Abduction (130)
- ADduction (130)

Question 10

AROM
Elbow

Answer 10

Flex 130-150
Ext -6-10
Pronation 75-80
Supination 80-104

Question 11

AROM
Wrist

Answer 11

Flexion/Extension 70-80*
RD - 15-22
UD 30-38

Question 12

Passive ROM
What are you looking for?

Answer 12

Tone, end-feel (check at different rates)

Question 13

Passive ROM
Increased Tone?
Decreased Tone?

Answer 13

Increased Tone
- Ridigity: Basal ganglia or extrapyramidal lesiosn e.g. parkinsons (non-velocity dependant)
- Spasticity: UMN lesions in brain and spinal cord (Velocity dependant) so knife clasp phenimenon often at higher speeds

Decreased Tone
- Flaccidity: Excessive floppiness so reduced resistance to passive movement (belly may look flattened)

Question 14

REFLEXES
What reflexes can be tested within the Upper Limb?

What are you looking for?

Answer 14

Biceps (C5)
Brachioradialis (C6)
Triceps (C7)
Finger flexion (C8)

Looking for hypo or hyperflexia (LMN & UMN signs)
Make sure to test and compare both sides

Question 15

SENSORY TESTING
What tests can be done with this part of the examination?

Answer 15

Soft and Pinprick (lateral spinothalamic): Using cocktail stick & cotton wool & start distally - baseline on sternum

Vibration 128Hz (DCML): tuning fork at bony prominences
start distally and work proximally

Joint position sense(DCML): 2 Cocktail sticks togehter and see when can identify 1 or 2
Should be lose together at hands (3mm or less)

Temperature Lateral spinothalamic: Tuning fork cold & hot object

Stereognosis/Graphesthesia (DCML)
- Stereognosis with objects in their hand
- Graphesthesia with numbers/letters on hand

Sensory neglect phenomenom: If pt had a stroke on right MCA stroke which takes a decent amount from the parietal lobe, they might neglect his left side

Question 16

COORDINATION
What tests can be done with this aspect of the exam?

Answer 16

Finger to nose: Any intention tremor (cerebellar pathology - parkinsons is resting) checking for any over/undershooting that displays cerebellar damage e.g. MS, tumours or stroke

Dysdiadochokinesia: Slower performance in cerebellar pathology

Romberg’s Test: Unsteady with eyes opem or closed with cerebellar pathology but only unsteady with eyes closed if proprioception problem

Play piano: Fine dexterity

Rebound phenomenon - Exaggerated in spastic limbs or absent in limbs affected by cerebellar disease

Question 17

PATHOLOGICAL REFLEXES
What tests can be done?and what are they for?

Answer 17

Hoffmans - Flick down 3rd distal Phalanx & look for pincer between thuimb and infex finger or flexion of hand (UMN lesion)

Grasp - Stroke across palm with reflex hammer. Positive if hand closed. Frontal lobe pathology if present

Clonus - Extend wrist and hand gently then quickly & get rachet-like effect as hand kicks back into flexion. UMN lesion e.g. pryamidal or corticospinal tract

Scauplohumeral - Higher cervical cord issue (tap hammer on acromion

Question 18

MUSCLE TESTING
How would you do a muscle test within this section of the exam?

Answer 18

C5 - Shoulder ABduction - Axillary
C6 - Biceps Brachaii, Brachioradalias - Radial
C7 - Triceps - Radial
C8 - Finger flexion - Median
T1 - Interossei - Ulnar