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Upper limb neurological examination

Diagnosing in neurology

Ask yourself throughout if the pathology is:

  • Unilateral/bilateral UMN (pyramidal weakness)
  • Unilateral LMN (weakness depends on lesion)
  • Bilateral LMN (distal weakness)
  • Proximal weakness

By the time you get to the sensory exam you should know what you are expecting to find and use it to confirm or narrow down differentials (see neurology differentials).

Introduction

  • Wash hands
  • Introduce self
  • Ask Patient’s name, DOB and what they like to be called
  • Explain examination and obtain consent
  • Expose patient’s upper body (leave bra on) 

Inspection

  • General inspection
    • Look at the patient in general, note their: posture, habitus, any signs of neurological conditions (e.g. hypomimia, facial muscle wasting)
    • Look around the bed: mobility aids, orthoses
  • Local inspection – look at the arms closely
    • Tremors
    • Muscles: muscle wasting – look in general and then closely for thenar/hypothenar wasting and for dorsal hand guttering (LMN lesion); fasciculations (LMN lesion)
    • Skin: neurofibromas, café au lait spots, scars (including small muscle biopsy scars)

Tone

  • Pronator drift: ask patient to hold their arms out fully extended with palms facing upwards and their eyes closed
    • Pronator drift and distal flexion = pyramidal weakness
    • Upward drift = cerebellar pathology. Upward cerebellar drift can be accentuated by ‘rebound’ – pushing patient’s wrists down briskly and then quickly letting go.
  • Tone (↑ = UMN lesion; ↓ = LMN lesion; cogwheel rigidity = Parkinsonian tremor superimposed on increased tone)
    • Elbow: hold the patient’s hand as if you are shaking it. Support their elbow with your other hand and repeatedly flex and extend their elbow to full range.
    • Forearm: in the same position, with their elbow at 90˚ flexion, repeatedly pronate and supinate their hand in alternating directions 
    • Wrist: hold their forearm just proximal to their wrist. Flex and extend, then rotate their hand on their wrist. 

Power

Test one joint at a time and compare sides. Always support the joint being tested with one hand (use it as a lever). Use all your strength!

MRC power grades

5 = full power

4 = some resistance

3 = GRAVITY

2 = gravity eliminated

1 = flicker of muscle contraction

0 = nothing.

Shoulder abduction (C5)Patient should abduct their shoulders to the horizontal plane with flexed elbows. Now push them down. ‘Don’t let me push your arms down.’
Elbow flexion (C6)Patient should bring arms into sagittal plane with elbows flexed. Hold the elbow with one hand and try to pull away at the wrist with the other. ‘Hold your arms like this, as if you are boxing. I’m going to try and pull them away – don’t let me.’
Elbow extension (C7)In the same position, try and push their wrist towards them. ‘Now I want you to try to push me away while I hold your wrist.’
Wrist extension (C7)Patient should hold their arms out straight while making fists and extending their wrists. Stabilise their wrist with one hand and use the dorsum of your other fist to try to push theirs down. ‘Hold your fists out like this. Now I’m going to try to push your fists downwards – don’t let me.’
Finger extension (C7)Patient should hold their arms out straight with fingers extended. Stabilise their metacarpals with one hand and use the dorsal surface of your other hand’s extended fingers to try and push theirs down. ‘Hold your fingers straight out. Now I’m going to try and push your fingers downwards, don’t let me.’
Finger flexion (C8)Interlock gripped fingers with the patient and try to open their hand. ‘Grip my fingers and don’t let me open your hand.’
Finger abduction (T1)Patient should spread their fingers. Try to push their little and index fingers inwards with your fingers, using the same digits as the ones you are touching. ‘Spread your fingers. Don’t let me push them inwards.’
Thumb abduction (T1)Patient should hold their palms facing up and point their thumbs up to the ceiling. Try to push their thumbs down into their palms. ‘Don’t let me push your thumbs down.’

Reflexes

Hold the tendon hammer by the end of the plastic rod to make a pendulum-type swing. Ensure the patient is fully relaxed. If you cannot elicit a reflex, ask them to close their eyes and grit their teeth when you strike the tendon.

Reflexes may be brisk (UMN), normal, reduced (LMN) or absent.

  • Biceps (C5/6): ask patient to relax their arm across their lap with palm facing up. Place your index finger across their biceps tendon and then strike your finger.
  • Supinator (C4/6): with the patient’s arm still relaxed across their lap, place your index and middle fingers over the brachioradialis tendon (4 inches proximal to base of thumb on lateral border of forearm), and strike your fingers.
  • Triceps (C7): hold up the patient’s wrist against their torso with one hand to flex their elbow to 90˚, while they let the arm go floppy. Strike their triceps tendon (just above the olecranon process) directly with the tendon hammer.

Co-ordination

  • Finger-nose test: ask the patient to hold their pointed index finger straight forwards. Now position your index finger tip touching theirs and ask them to alternate between touching the tip of their nose and your finger tip as fast as they can. Repeat on the other side (intention tremor and past-pointing/dysmetria = cerebellar pathology).
  • Dysdiadochokinesia: ask the patient to hold one palm up and repeatedly hit the palmar surface of the extended fingers of their contralateral hand onto the palm. Then ask them to alternate hitting the palm with the palmar and dorsal surfaces of their extended fingers (disorganisation of alternating movement, i.e. dysdiadochokinesia = cerebellar pathology).

Sensation

For pain and light touch, first show the patient how each should feel on their sternum. Then start distally. If there is distal sensory loss or if from the motor exam you suspect ‘glove and stocking’ sensory loss, test from distal to proximal in 2-3 straight lines. If distal sensation is intactor if from the motor exam you suspect nerve/nerve root pathology, test dermatomes ± peripheral nerves: 

  • Pain (spinothalamic): use neurological pin
    • Close your eyes and say “yes” every time you feel the pin. Please also let me know if it feels blunt.’
  • Light touch (dorsal column): touch the skin with a cotton wool ball (don’t stroke it)
    • ‘Close your eyes and say “yes” every time you feel the cotton wool.’

For the modalities below, start distally and only move proximally if the patient cannot feel it:

  • Proprioception (dorsal column)
    • Hold the proximal phalanx of the patient’s thumb with your index finger above and your thumb below
    • Move the distal phalanx up and down with the thumb and index finger of your other hand, holding it on each side
    • Show the patient the up and down positions
    • Now ask them to close their eyes and repeatedly wiggle the distal phalanx up and down. Stop in one position and ask them if it is up or down. Do this three times
    • If they get it wrong, move to the metacarpophalangeal joint, then the wrist, and so on until they can correctly state the position.
  • Vibration (dorsal column)
    • Twang the prongs of a 128Hz (long) tuning fork
    • Place the round base on their sternum to demonstrate how it should feel
    • Now ask them to close their eyes and hold it over the interphalangeal joint of their thumb. Ask if they can feel it vibrate and when it stops vibrating. (Grip the prongs to stop the vibration yourself.)
    • If they cannot sense vibration, move to the metacarpophalangeal joint, radial styloid and so on until they can
  • Temperature (spinothalamic)
    • Use the prongs of the tuning fork on the patient’s sternum to test if they can identify them as cold
    • If so, touch a prong horizontally to the skin on the dorsum of their hand and ask if the patient can feel it as cold. If not, move proximally up the arm until they can
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Upper limb dermatomes

To complete

  • Thank patient and restore clothing
  • ‘To complete my examination, I would examine the cranial nerves and perform a lower limb neurological examination.’
  • Summarise and suggest further investigations you would consider after a full history

Clinical features of upper and lower motor neuron lesions

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