Upper Limb examination

Question 1

What do you inspect in the patient’s environment/upper limbs?

Answer 1

Environment:

• writing/walking aids
• ventilator machine/O2 support-in guillain barre syndrome
• prescriptions

Upper limbs:

• muscle bulk-proximal distal
• hypertrophy or muscle wasting-hypertrophy can be normal in athletes/ muscle wasting in LMN lesions
• fasciculations-LMN lesions; flick the patients’ arm
• myoclonus-epileptic jerks
• tremor
• frontal baulding and temporal atrophy and ptosis-myotonic dystrophy
• lip smacking automatism-temporal epilepsy
• pronator drift-ask them to stretch hands with palms up. Close eyes to allow dorsal column to work/not relying on vision and watch for this (drift indicates contralateral pyramidal tract lesion; tapping on palms can accentuate this)

Question 2

What are the different types of tremor?

Answer 2

• Physiological tremor due to caffeine/alcohol/beta agonists
• Essential tremor-AD condition worsened when hands are outstretched and consumption of alcohol and caffeine. Check for titubation
• resting tremor-unilateral pill rolling tremor in parkinson’s; bilateral pill rolling tremor in antipsychotics

Question 3

How do you check tone of arms? What are the 2 types?

Answer 3

• allow arms to go floppy and check if they have pain in the arms
• hypotonia-LMN lesions
• hypertonia-UMN lesions or parkinson’s
• 2 types:
• spasticity which is velocity dependent and detected on quicker movements
• rigidity which is throughout whole movement–> leadpipe or cogwheel (on/off) in parkinson’s

Question 4

How do you test for muscle power?

What is the MRC grade from 1-5?

Answer 4

Muscle power:

• shoulder abduction/adduction
• elbow flexion and extension
• wrist extension
• finger flexion and extension
• finger abduction and adduction
• thumb abduction

Question 5

What muscles are used in:

• shoulder abduction/adduction
• elbow flexion and extension
• finger flexion and extension
• finger abduction and adduction
• thumb abduction

Answer 5

muscles used in:

-shoulder abduction/adduction:

deltoid in shoulder abduction

-elbow flexion and extension

• biceps and brachioradialis in elbow flexion
• triceps in elbow extension

-finger flexion and extension

• finger flexion in flexion digitorum profundus
• finger extension in extensor digitorum

-finger abduction and adduction

• finger abduction in dorsal interossei
• finger adduction in palmar interossei

-thumb abduction

-thumb adduction in abductor pollicus longus

Question 6

How do you test for reflexes? What nerve roots do these involve?

Answer 6

• use the weight of the tendon hammer to hit tendon
• biceps: C5-C6
• triceps: C7-C8
• supinator: C6
• finger reflex: C8

Question 7

How do you test for cerebellum? What lesion does this indicate?

What are the other tests that you should do?

How do you test for apraxia and constructional apraxia and what does this indicate?

Answer 7

• Cerebellar rebound phenomenon
• ask them to keep arms straight and stay there while you put pressure. ask them to close eyes.
• if arm bounces out, rebound phenomenon is +ve.
• Finger-to-nose test
• keep it at arms length. change direction
• if unable to do so, lesion in cerebellar hemisphere
• dysdiadochokinesia

apraxia and constructional apraxia:

• ask them to sip cup of tea-apraxia is a lesion of motor function and often due to problems with the frontal/parietal lobe
• ask them to draw a figure like a start-constructional apraxia is a lesion in the parietal lobe (sensory)

Question 8

What are the dermatomes in the shoulder?

What do you test for in sensory examination?

What to do if patient can’t feel it? How do you map out area of lesion?

Answer 8

Sensory examination (always test on sternum first with eyes closed so that they can use the system)

• light touch-cotton wool. Ask them if it feels like cotton wool on sternum. Testing for dorsal column
• pain-neurotip. Ask them if it feels dull or sharp on sternum. Testing for both dorsal column/spinothalamic tract.
• temperature-tip of tuning fork. Ask them if it feels cold. Testing for spinothalamic tract
• vibration-with tuning fork. Testing for dorsal column
• proprioception. Testing for dorsal column

Map out area of lesion by moving proximally:

• DIP->PIP-> MCP-> wrist-> elbow-> shoulder-> clavicle

Question 9

How do you test for stereognosia/graphaesthesia/sensory inattention?

Answer 9

Stereognosia (inability to identify familiar objects)

• Place a familiar object like coin.
• If unable to identify it-> lesion in dorsal column or alzheimer’s dementia

Graphaesthesia

• Draw a figure/number in palm
• If unable to identify it-> lesion in dorsal column

Sensory inattention

• testing right and left and both