Upper Limb Neuro Exam Flashcards
What are some upper motor neurone signs?
- Hypertonicity (spasticity)
- “Pyramidal” pattern of weakness
- Hyper-reflexia
- Pronator Drift
- Babinski positive (not in upper limb)
Potentially:
- Disuse atrophy
What are some lower motor neurone signs?
- Muscle wasting
- Fasciculations
- Hypotonia
- Varying patterns of weakness
- Hyporeflexia or areflexia
What around the bed may suggest neurological problems?
- Wheelchair
- Walking aids
- Catheter
What menmonic can help with a neuro visual inspection?
A SWIFT
What does the mnemonic A SWIFT mean?
A - Asymmetry
S - Scars
W - Wasting
I - Involuntary movements
F - Fasciculations
T - Tremor
What are some involuntary movements to look for in neuro inspection?
- Dystonia
- Chorea
- Myoclonus
- Athetosis
- (Fasciculations)
- (Tremor)
What is an important distinction to make about tremors?
Resting vs Kinetic
Involuntary sustained or intermittent muscle contractions cause twisting and repetitive movements, abnormal postures, or both
Dystonia
Random-appearing sequence of one or more discrete involuntary movements
Chorea
Slow, continuous, involuntary writhing movements often affecting the extremities
Athetosis
Repeated, often non-rhythmic, brief shock-like jerks due to sudden involuntary contraction or relaxation of one or more muscles
Myoclonus
Rhythmic back-and-forth or oscillating involuntary movement about a joint axis
Tremor
Give 2 cause of dystonia
- Parkinson’s Disease
- Dyskinetic Cerebral Palsy
Give 2 causes of chorea
- Dyskinetic Cerebral Palsy
- Huntington’s Disease
Give 2 causes of athetosis
- Dyskinetic Cerebral Palsy
- Huntington’s Disease
Give a cause of myoclonus
Myoclonic epilepsy
What is a common cause of resting tremor?
Parkinson’s Disease
What is a common cause of a kinetic tremor?
Benign essential tremor
When inspecting a patient in a neuro exam, what clues may be seen in the face?
- Hypomimia
- Ptosis
- Ophtalmoplegia
What is hypomimia?
Lack of facial expression
What is a common cause of hypomimia?
Parkinson’s Disease
What systemic neurological condition can cause ptosis and ophthalmoplegia?
Myasthenia gravis
What is shown here?
Muscle wasting (thenar atrophy)
What is a common LMN lesion that can cause thenar eminence wasting?
Carpal Tunnel Syndrome
How is pronator drift tested for?
- Ask patient to close eyes and outstretch arms with palms up
- Observe for pronation
What does a positive pronator drift indicate?
UMN pathology
How is tone assessed in the upper limb?
- Ask patient to let their arm go floppy
- Move each major joint in (wrist to shoulder) all directions
- Pronate and supinate the arm
- Feel for changes in tone
What are some changes in tone?
- Spasticity
- Rigidity
What is spasticity?
Velocity dependent increase in tone - the faster you move it the worse it is
What is rigidity?
Velocity independent increased tone - same at all speeds
What does spasticity indicate?
UMN lesion
What does rigidity indicate?
Extrapyramidal lesion
What is a major cause of rigidity?
Parkinson’s Disease
What type of rigidity in the arms is often seen in Parkinson’s disease?
Cogwheeling
What is cogwheeling?
Ratchet-like start-and stop movements through the range of motion
How should power be assessed in the upper limbs?
- Assess each function one side at a time, comparing like for like
- Stabilise limb to isolate the joint
- Test each muscle group with your own similar muscle group e.g. thumb vs thumb
- Use MRC muscle power assessment scale
Power in which joints should be tested in an upper limb neuro exam?
- Shoudlers
- Elbows
- Wrists
- Finger and thumbs
Power of which shoudler motions should be tested in a neuro exam?
- Abduction
- Adduction
What nerve root(s) provide power of shoulder abduction?
C5
What nerve root(s) provide power of shoulder adduction?
C6/7
Power of which elbow motions should be tested in a neuro exam?
- Flexion
- Extension
What nerve root(s) provide power of elbow flexion?
C5/6
What nerve root(s) provide power of elbow extension?
C7
Power of which wrist motions should be tested in a neuro exam?
- Extension
- Flexion
What nerve root(s) provide power of wrist extension?
C6
What nerve root(s) provide power of wrist flexion?
C6/7
Power of which finger and thumb motions should be tested in a neuro exam?
- Finger extension
- Finger abduction
- Thumb abduction
What nerve root(s) provide power of finger extension?
C7
What nerve root(s) provide power of finger abduction?
T1
What nerve root(s) provide power of thumb abduction?
C8/T1
How can you test shoulder abduction?
“Don’t let me push your arms towards your side”
How can you test shoudler adduction?
“Don’t let me pull your arms away from your sides”
How can you test elbow flexion?
“Don’t let me pull your forearm away from you”
How can you test elbow extension?
“Don’t let me push your forearm towards you”
How can you test wrist extension?
“Cock your wrists back and don’t let me pull them down”
How can you test wrist flexion?
“Point your wrists downwards and don’t let me pull them up”
How can you test finger extension?
“Put your fingers out straight and don’t let me push them down”
How can you test finger abduction?
“Splay your fingers and don’t let me push them together”
How can you test thumb abduction?
“Point your thumbs to the ceiling and don’t let me push them down”
Which deep tendon reflexes should be tested in an upper limb neuro exam?
- Biceps reflex
- Triceps reflex
- Supinator reflex
What nerve roots supply the biceps reflex?
C5/6
What nerve roots supply the triceps reflex?
C7
What nerve root supplies the supinator reflex?
C6
How should tendon reflexes be tested?
- Ensure patient’s limb is completely relaxed
- Hold hammer at end and use gravity to aim a good swing at a finger overlying the tendon (no finger needed for triceps)
- Observe for absent or exaggerated reflexes
Where is the biceps reflex tested?
Where is the tricpes tendon tested?
Where is the supinator reflex tested?
If a reflex is absent, what should you ask the patient to do?
Clench their teeth and try again
What sensory modalities should be tested in the upper limbs?
- Pin prick
- Light touch
- Proprioception
- Vibration
Which tested sensory modality(s) are carried by the spinothalamic tracts?
Pin prick
Which tested sensory modality(s) are carried by the dorsal columns?
- Light touch
- Proprioception
- Vibration
What should be used to assess light touch sensation?
A wisp of cotton wool
What should be used to assess pin-prick sensation?
Sharp end of a neuro tip
How should light touch and pin-prick sensation be tested?
- Demonstrate sensation on the sternum
- Ask the patient to close their eyes
- Assess each dermatome in turn
- Ask patient to say yes when touched
- Compare left to right and ask for any differences
- Assess distal sensation at the tips of the 2nd and 5th digits, move gradually more proximally if no sensation
What are some common distributions of sensory loss?
- Dermatomal
- Glove🧤 (and stocking)🧦
- Loss of all sensation below a certain level
- (Brown-Sequard syndrome)
*
What does a glove and stocking distribution of sensory loss commonly suggest?
Peripheral neuropathy
Is glove and stocking distribution usually symmetrical or asymmetrical?
Symmetrical
What does a dermatomal sensory loss suggest?
Radiculopathy (compression of the nerve root)
What commonly causes complete loss of sensation below a certain level?
Complete cord transection
What should be used to test vibration sensation?
128 Hz tuning fork
How should vibration sense be tested?
- Tap tuning fork
- Place on sternum to confirm feeling
- Ask patient to close their eyes
- Place on distal interphalangeal joint and ask if they can feel vibration and when it stops
- If not felt move to the next most proximal joint (if felt can leave it there)
- Compare both sides
How should proprioception be tested?
- Demosntrate movement of the distal phalanx upwards and downwards with the patient watching
- Ask patient to close their eyes
- Ask them to identify the position of the finger as you move it
- If unable to do so, move more proximally
What tests of co-ordination can be tested in the upper limb?
- Finger nose test
- Dysdiadochokinesia
How should a finger nose test be performed?
- Ask patient to touch the tip of their nose
- Ask patient to then your finger tip
- Ask them to repeat this as fast as they can
- Repeat with the other hand
What abnormal signs can be seen on the finger nose test?
- Intention tremor
- Past pointing (dysmetria)
What is dysmetria?
Under-shooting or over-shooting when reaching for the finger
What can cause dysmetria?
- Cerebellar lesion
- Loss of proprioception
What is an intention tremor?
A tremor that increases as the patient reaches the endpoint of a deliberate and visually guided movement (e.g. moving finger to finger)
What can cause an intention tremor?
Cerebellar lesion
How is dysdiadochokinesia tested for?
- Ask the patient to repeatedly pronate and supinate their hand against the palm of their other hand
- Ask them to do this as fast as they can
- Repeat with the other hand
What is a positive test for dysdiadochokinesia?
Slow or irregular movement
What can cause dysdiadochokinesia?
- Cerebellar ataxia
- Sensory ataxia (impaired proprioception)
- Parkinsonism
How should an upper limb neuro exam be completed?
- Thank patient
- Wash hands
- Summarise findings
What further investigations/examinations can be performed following an upper limb neuro exam?
- Cranial nerve examination
- Lower limb neuro examination
- Imaging e.g. CT/MRI if required
Which region is innervated by C4?
Clavicle
Which region is innervated by C5?
Lateral upper arm
Which region is innervated by C6?
Lateral forearm, thumb and palmar index finger
Which region is innervated by C7?
Middle finger, dorsal index finger and associated palm areas
Which region is innervated by C8?
Palm and dorsum of ring and little finger and associated Palm areas
Which region is innervated by T1?
Medial forearm
Which region is innervated by T2?
Medial upper arm
What is shown here?
Cogwheel rigidity
What is shown here?
Parkinson’s Tremor
