Neurological - Upper Limb

Question 1

Muscular clinical signs on general inspection

Answer 1

Wasting
Tremor
Fasciculations or pseudoathetosis (writhing)
Chorea
Myoclonus
Tardive dyskinesia

Question 2

Non-muscular clinical signs on general inspection

Answer 2

Scars, hypomimia (reduced facial expression in Parkinson’s), ptosis and frontal balding (myotonic dystrophy), ophthalmoplegia (weakness/paralysis of extraocular muscles)

Question 3

Objects or equipment on general inspection

Answer 3

Walking aids, prescriptions, any medical devices

Question 4

Pronator drift = ?

Answer 4

Contralateral pyramidal tract lesion (UMN lesion where pronator muscles stronger than supinator muscles)

Question 5

Types of abnormalities with tone + implications

Answer 5

Spasticity + rigidity = both increased tone

Spasticity = pyramidal tract lesions (e.g. stroke)
Rigidity = extrapyramidal tract lesions (e.g. Parkinson’s)

Spasticity = velocity-dependent so worse when you move the limb faster
Rigidity = velocity-independent so same regardless of how fast you move the limb

Spasticity typically associated with weakness
Rigidity split into cogwheel (tremor on top so intermittent increases in tone throughout movement) and lead pipe (uniformly increased tone)
- cogwheel - Parkinson’s
- lead pipe - neuroleptic malignant syndrome

Question 6

Myotome + nerve for shoulder abduction?

Answer 6

C5 (axillary nerve)

Question 7

Myotome + nerve for shoulder adduction?

Answer 7

C6/7 (thoracodorsal nerve)

Question 8

Myotome + nerve for elbow flexion?

Answer 8

C5/6 (musculocutaneous + radial nerve)

Question 9

Myotome + nerve for elbow extension?

Answer 9

C7 (radial nerve)

Question 10

Myotome + nerve for wrist extension?

Answer 10

C6 (radial nerve)

Question 11

Myotome + nerve for wrist flexion?

Answer 11

C6/7 (median nerve)

Question 12

Myotome + nerve for finger extension?

Answer 12

C7 (radial nerve)

Question 13

Myotome + nerve for finger abduction?

Answer 13

T1 (ulnar nerve)

Question 14

Myotome + nerve for thumb abduction?

Answer 14

T1 (median nerve)

Question 15

Muscle weakness patterns for UMN vs LMN lesion?

Answer 15

UMN - ‘pyramidal’ - upper limb EXTENSORS and lower limb FLEXORS disproportionately affected
LMN - ‘focal’ - only muscles directly innervated by damaged neurone(s)

Question 16

Power scale (MRC scale)

Answer 16

0-5
- 0 - no contraction
- 1 - any contraction
- 2 - active movement, gravity eliminated
- 3 - active movement against gravity alone
- 4 - active movement against gravity + resistance
- 5 - normal power

Question 17

Nerve roots for bicep, supinator, triceps reflexes?

Answer 17

Biceps - C5/6
Supinator - C5/6
Triceps - C7

Question 18

UMN vs LMN lesions in reflexes?

Answer 18

HyPERreflexia = UMN
HyPOreflexia = LMN

Question 19

C5-T1 dermatomes? (for sensory testing)

Answer 19

C5 = lateral aspect, upper arm
C6 = palm side of thumb
C7 = palm side of middle finger
C8 = palm side of little finger
T1 = medial aspect, upper arm (just above medial epicondyle)

Question 20

Spinal cord segments for light touch, pin-prick, vibration, and proprioception?

Answer 20

Light touch = dorsal columns + spinothalamic tracts
Pin-prick (pain) = spinothalamic tracts
Vibration = dorsal columns
Proprioception = dorsal columns

Question 21

Patterns of sensory loss?

Answer 21

Mononeuropathy = localised sensory problem
Peripheral neuropathy = GLOVE and STOCKING symmetrical sensory deficit
Radiculopathy = sensory loss in associated nerve root dermatomes
Spinal cord damage = sensory loss at and below nerve root level in dermatomes
Thalamic lesions (e.g. stroke) = contralateral sensory loss
Myopathy = symmetrical proximal muscle weakness

Question 22

Abnormal finger-to-nose test interpretation?

Answer 22

Cerebellar pathology (ipsilateral)
- dysmetria - misses target (lack of coordination)
- intention tremor - tremor increases as they get closer to your finger (action tremor just the same throughout)

Question 23

Interpretation of abnormal rapid/alternating movements test?

Answer 23

Dysdiadochokinesia = ipsilateral cerebellar pathology

Question 24

Tone assessment technique

Answer 24

Hold hand + elbow
Shoulder circumduction + elbow flexion/extension + wrist circumduction

Question 25

Upper limbs power assessment technique

Answer 25

Shoulders - flex elbows + abduct to 90 and apply resistance downward (abduction), then adduct to 45 and apply resistance outward (adduction)
Elbows - arms up like a boxer then pull away from pt (flexion) and push toward pt (extension)
Wrists - arms out straight with palms down, cock wrists back and try to press them down (extension), then flex wrists and try to pull them up (flexion)
Fingers + thumb - arms out palms down fingers out straight and try to push down (extension), then try to push them together (abduction), then palms up point thumb at ceiling and try to push down (abduction)

Question 26

Sensory assessment technique

Answer 26

Light touch - cotton bud
Pin-prick - sharp end of neuro-tip
Vibration - 128 Hz tuning fork, ask for start and stop of vibration, only need to do IP joint of thumbs (move upwards if negative here)
Proprioception - move thumb joint with their eyes closed and ask for direction

Question 27

Coordination assessment technique

Answer 27

Finger-to-nose = Position finger so patient has to fully stretch to reach, ask pt to touch their nose then your finger and then repeat as fast as they can

Dysdiadochokinesia = Place left palm on right palm, then left dorsal on right palm, then back and repeat as fast as they can