Upper Limb Neuro

Question 1

What should you start the examination with?

Answer 1

1. Wash your hands
2. Introduce yourself
3. Identify the patient
4. Ask for consent (this is to test nerve and muscles in your arms, it will involve me moving your arm and testing their power etc)
5. Ask if the patient has any pain
6. Ask patient to expose arms and chest (+chaperone)

Question 2

What is a specific question that should be asked before you start examining the patient?

Answer 2

Which is your dominant arm? Are you right or left-handed?

Question 3

What should you look for on inspection?

Answer 3

Posture, muscle wasting, tremor, fasciculations, involuntary movements

Question 4

How do you assess pronator drift? What is this a sign of?

Answer 4

Pronator drift: Ask patient to stand with arms out in front of them with palms facing upwards. Ask them to close their eyes and watch for pronation of one or both limbs.

This is a sign of UMN pyramidal lesion

Question 5

How do you assess upward drift? What is this a sign of?

Answer 5

Upward drift: Ask patient to stand with arms out in front, palms upwards, eyes closed and do a quick downwards tap on their hands and let go. Watch for upwards movement of their hands

This is a sign of a cerebellar lesion

Question 6

What order do you normally do each type of neuro assessment in?

Answer 6

1. Inspection
2. (pronator and upward drift)
3. Tone
4. Power
5. Reflexes
6. Coordination
7. Sensation
8. To complete (cranial nerves, lower limbs, gait)

Question 7

Describe how you would test tone

Answer 7

Passively move each joint
Shoulder: flexion, extension, abduction, adduction, internal and external rotation
Elbow: flexion, extension, pronation, supination
Wrist: flexion, extension

Question 8

What does hypertonia suggest + what different types of hypertonia may there be? What does hypotonia suggest?

Answer 8

Hypertonia = upper motor neuron lesion
Types could be spasticity or rigidity (spasticity is rate-dependent hypertonia)
Hypotonia = lower motor neuron lesion

Question 9

Describe what movements would you use to assess power on each joint?

Answer 9

Shoulder: flexion, extension, abduction, adduction (chicken arms)
Elbows: flexion, extension (double fist fight), pronation, supination??
Wrists: flexion, extension (cock up,down)
Fingers: flexion, extension, abduction (adduction with piece of paper grip)
Thumb: palmar abduction and opposition = median, palmar adduction = ulnar

Question 10

Describe MRC grading of power

Answer 10

5/5 = full power against resistance
4/5 = move against gravity and resistance to slight, moderate and strong resistance (4-,4,4+)
3/5 = move against gravity only without resistance
2/5 = muscle contraction and active movement only when gravity removed
1/5 = muscle contraction, no movement
0/5 = no muscle contraction

Question 11

Myotomes

Answer 11

To be completed

Question 12

Describe how you would assess reflexes in upper limbs

Answer 12

Biceps: place fingers over insertion of biceps tendon and tap with tendon hammer looking for flexion of limb and contraction of biceps
Triceps: tap tendon hammer over lower triceps - contraction of triceps and extension of arm
Supinator/brachioradialis: place fingers over brachioradialis and tap to look for supination and contraction of brachioradialis
(if needed, clench teeth)

Question 13

Describe how you would test coordination in the upper limbs

Answer 13

1. Fingers from nose to examiner’s finger and back + fast as possible (move finger)
2. Fingers to own nose with eyes closed
3. Fine movements (thumb to each finger)
4. Dysdiadochokinesis

Question 14

Which modalities of sensation do you test in OSCE and which do you say you would test?

Answer 14

Test in OSCE: soft-touch, vibration, proprioception, cortical localisation/stereognosis, 2 point-discrimination (graphaesthesia)
Say: pain/pin-prick, temperature

Question 15

How would you test soft-touch sensation?

Answer 15

Use cotton wool and place on sternum and ask if they feel it
Ask them to close their eyes and test each dermatome asking them to say “yes” when they feel it
Ask after if it felt different between both sides or in any region
Dermatomes - C5 (deltoid), C6 (distal radial and proximal phalanx of thumb), C7 (proximal phalanx of middle finger), C8 (proximal phalanx of little finger), T1 (medial upper arm)

Question 16

How would you test vibration sensation?

Answer 16

Use 128Hz tuning fork, make it vibrate and place on sternum and ask if they can feel it. Eyes closed, place on interphalangeal joint of thumb and ask them to say “yes when they feel it vibrating. Then ask them to tell you when it stops vibrating and stop it vibrating. If vibration sense not clearly intact, move up arm to check for “glove and stocking” peripheral neuropathy.

Question 17

How would you test proprioception?

Answer 17

Place fingers medially and laterally to interphalangeal joint of the thumb. Show patient moving joint “up” and moving joint “down”. Then ask them to close eyes and tell you whether the joint is up or down.

Question 18

How would you test stereognosis?

Answer 18

Ask patient to identify a small object (coin/key) placed in hand with eyes closed

Question 19

How would you test graphaesthesia?

Answer 19

Ask them to close their eyes and draw a letter on their palm. Get them to tell you what letter you drew.

Question 20

How would you end the examination?

Answer 20

1. Thank the patient
2. Tell them they can get dressed
3. Wash hands