UPPER LIMB EXAMINATION Flashcards
How would you start any examination?
WIPER QQ Wash hands Introduce yourself Ask permission Expose the patient Reposition the patient
Ask if they are in any pain or discomfort
How exposed should the patient be for the upper limb neurological examination?
Top half of their body fully exposed
How should the patient be positioned for the upper limb neurological examination?
Lying down at 45 degrees
What are you looking for during your inspection of the upper limb in the neurological examination?
From the end of the bed:
Any pain or discomfort
Any walking aids or signs of chronic discomfort
DWARFS: Deformities Wasting of muscles (especially small muscles of the hand) Asymmetry Rashes Fasciculations Scars
Abnormal posturing
Abnormal movements - tremor, dystonia, athetosis
Pronator drift
What is dystonia and what can it be a sign of?
Substained muscle contractions cause twisting and repetitive movements or abnormal postures.
The disorder may be hereditary or caused by other factors such as birth-related or other physical trauma, infection, poisoning (e.g., lead poisoning) or reaction to pharmaceutical drugs, particularly neuroleptics.
What is athetosis?
Slow, involuntary, convoluted, writhing movements of the fingers, hands, toes, and feet and in some cases, arms, legs, neck and tongue.
Related to degeneration of the basal ganglia as seen in Huntingdon’s disease. It is most commonly caused by a complication at birth.
What is pronator drift, how do you test for it and what is it a sign of?
Ask the patient to close their eyes with there arms out with their forearm in the supine position. Watch for gradual pronation.
Pronator drift can be a sign of pyramidal pathology caused by an upper motor neuron lesion.
Having inspected the patient as part of an upper limb neurological exam, what is the next thing to assess?
Tone
When assessing tone as part of an upper limb neurological exam, what must you ask before starting your assessment?
Whether they are in any pain in their hands, arms or shoulders.
How do you assess tone in a neurological exam of the upper limb?
Ask patient to relax/go floppy like a rag-doll.
Passively flex and extend the limb as well as pronating and supinating the forearm.
You are looking for increased (rigidity/spasticity) or decreased tone.
When might the tone of the upper limb be increased?
Upper motor neuron lesions
Basal ganglia dysfunction (Parkinson’s disease)
When might the tone of the upper limb be decreased?
Lower motor neuron lesions
Having assessed the patient’s muscle tone as part of an upper limb neurological exam, what is the next thing to assess?
Power
When assessing the power of the upper limb what must you remember to do?
Stabilise the joint above
Test each muscle group bilaterally before moving on to the next position - comparing like for like
What are the different movements that you assess the power of during an upper limb exam? For each movement say which muscle group or spinal nerve is being tested.
Abduction - Deltoid C5 Adduction - C6, C7 Flexion at elbow - Biceps C5, C6 Extension at the elbow - Triceps C7 Wrist dorsi flexion - C6, C7 Wrist palmar flexion - C6, C7 Finger extension - C7, C8 Finger flexion - C8 Finger abduction - T1 Finger adduciton - T1 Thumb abduction - C8, T1 Thumb opposition - Pincer movement C8, T1 Power grip - C5-T1
How do you assess the power of finger adduction in the neurological exam of the upper limb?
Get the patient to hold a piece of paper between two extended fingers of the same hand. Do the same and pull the paper away.
What scale is power measured on when assessing the neurological status of the upper limb?
MRC scale for power
What are the different levels on the MRC power scale used during a neurological exam of the upper limb?
0 - No muscle contraction is visible.
1 - Muscle contraction is visible but there is no movement of the joint.
2 - Active joint movement is possible with gravity eliminated.
3 - Movement can overcome gravity but not resistance from the examiner.
4 - The muscle group can overcome gravity and move against some resistance from the examiner.
5 - Full and normal power against resistance.
Does reduced power of any muscle group indicate upper or lower motor neuron lesions?
Either
During a neurological examination of the upper limb, what do you test having assessed the patient’s power?
Reflexes
What are the three reflexes to test in the upper limb? State which nerve(s) is/are being tested for each one.
Biceps - C5, C6
Triceps - C6, C7
Supinator - C5, C6
What might a hyperreflexia in the upper limb be indicative of?
Upper motor neuron lesion
What might a diminished or absent reflex in the upper limb be indicative of?
Lower motor neuron lesion
If you having trouble eliciting a reflex during an upper limb examination, what can you ask the patient to do?
‘Reinforcement’ (the Jendrassik manoeuvre) - Ask the patient to clench their teeth or squeeze their knees together while you try to elicit the reflexes again.
Having assessed the tone, power and reflexes in the upper limb, what might you next assess before moving on to sensation?
Coordination
How would you assess coordination as part of a neurological examination of the upper limb?
Finger to nose test
Clap front then back of hand
What are you testing when you assess coordination as part of a neurological examination of the upper limb?
The cerebellum. Dysdiadochokinesia (impaired ability to perform rapid, alternating movements) is a sign of cerebellar damage.
Also looking for intention tremors - indicative of multiple sclerosis.
When assessing the sensitivity of the upper limb to light touch, what must you first do?
Ask the patient to close their eyes and touch the sternal angle with the cotton wool to show them what it should feel like.
During a neurological examination of the upper limb, where should you touch to test the C5 dermatome?
Lateral aspect of the bicep
During a neurological examination of the upper limb, where should you touch to test the C6 dermatome?
Lateral aspect of the forearm or thumb
During a neurological examination of the upper limb, where should you touch to test the C7 dermatome?
Middle finger
During a neurological examination of the upper limb, where should you touch to test the C8 dermatome?
Medial aspect of the hand or little finger
During a neurological examination of the upper limb, where should you touch to test the T1 dermatome?
Medial aspect of the elbow
During a neurological examination of the upper limb, where should you touch to test the T2 dermatome?
Medial aspect of the tricep
When assessing sensitivity to light touch in an upper limb examination, what order must you test the dermatomes?
Compare right with left and ask the patient whether each side feels the same.
Having assessed the sensitivity to light touch in the upper limb, what do you then test? What tract is this testing?
Pin prick test to assess sensitivity to pain. Ask patient to tell you if it feels sharp or dull. Testing the spinothalamic tract.
What do you use to perform the pin prick test in a neurological examination of the upper limb?
A neurological pin
Having performed the pin prick test as part of the upper limb examination, what would you then test? What tract is this testing?
Vibration
Dorsal column
What frequency tuning fork must you use to assess vibration sensitivity in the upper limb?
128 Hz
Where would you test the sensitivity to vibration in the upper limb?
At the most distal bony prominence (eg DIP)
What should you ask the patient to tell you when assessing sensitivity to vibration in the upper limb?
Whether they can feel the vibration and then when the vibration stops (you stop it with your fingers, whilst they have their eyes closed)
Having assessed vibration as part of the neurological examination of the upper limb, what would you then test and how?
Proprioception
Hold the patients finger just proximal to the DIP, then move the distal phalanx with your other hand whilst they close their eyes. Ask them to tell you whether their finger is pointing up or down.
Having assessed sensation in the upper limb, how would you say you would conclude your examination if you had more time?
Do a lower limb exam
Assess gait
Do a cranial nerve exam
