Upper limb neuro exam

Question 1

What do you ask the patient at the beginning of an upper limb neuro exam?

Answer 1

Are you in any pain?
Are you right or left handed? (expect better performance in dominant hand)

Question 2

What are you looking for on inspection in an upper limb neuro exam?

Answer 2

SWIFT
Scars
Wasting of muscles (suggests LMN lesion, or disuse atrophy)
Involuntary movements (e.g. chorea, myoclonus)
Fasciculations (suggests LMN lesion)
Tremor

Question 3

How do you asses pronator drift in an upper limb neuro exam?

Answer 3

• Ask patient to hold arms out in front of them with palms facing upwards for 20-30 seconds
• Signs of pronation suggests an UMN lesion (closing eyes will accentuate)

Question 4

How do you asses tone in an upper limb neuro exam?

Answer 4

• Support the patients arm at the wrist and elbow, and ask them to relax fully
• Move the muscle groups of the wrist, elbow, and shoulder through their full range of movement
• Feel for increased (UMN lesion) or decreased tone (LMN lesion)
• Differentiate between the types of increased tone: spasticity = velocity dependent, rigidity = independent of velocity

Question 5

How do you asses power in an upper limb neuro exam?

Answer 5

• Shoulder abduction (C5): chicken wings, push down
• Shoulder adduction (C6/7): chicken wings, push up
• Elbow flexion (C5/6): boxer, pull away
• Elbow extension (C7): boxer, pull towards
• Wrist flexion (6/7): fists out straight, pull up
• Wrist extension (C6): fists out straight, push down
• Finger flexion (C8): grip interlocked fingers, open hands
• Finger extension (C7): fingers out straight, push down
• Finger abduction (T1): splay fingers, push together
• Thumb abduction (T1): palms up thumb to ceiling, push down
• Thumb adduction (T1): palms up thumb to ceiling, pull up
• Thumb flexion (T1): make fist with thumb on top, pull thumb away
• Thumb opposition (T1): ok sign, pull apart

Question 6

How is power described in an upper limb neuro exam?

Answer 6

MRC power scale:
0 = no contraction
1 = flicker or trace of contraction
2 = active movement when gravity is eliminated
3 = active movement against gravity
4 = active movement against gravity and resistance
5 = normal power

UMN lesion = pyramidal (mostly affects upper limb extensors)
LMN lesion = focal pattern

Question 7

How do you assess reflexes in an upper limb neuro exam?

Answer 7

Biceps (C5/6): tap thumb over biceps brachii tendon, observe contraction of biceps and flexion of elbow
Brachioradialis (C5/6): tap fingers over brachioradialis tendon, observe contraction of brachioradialis and flexion of the wrist
Triceps (C7): tap tendon of triceps, observe contraction of the triceps and extension of the elbow
* hyperreflexia = UMN lesion
* hyporeflexia = LMN lesion

Question 8

How do you assess sensation in an upper limb neuro exam?

Answer 8

Light touch (cotton wool, dermatomes)
Vibration (128Hz tuning fork, thumb/elbow/shoulder)
Proprioception (thumb/elbow/shoulder)
Stereognosis (identify object)
Pain (only describe in OSCE, sensory level)
Temperature (only describe in OSCE)

Question 9

Where are the dermatomes of the upper limb?

Answer 9

C5 = lateral aspect of the upper arm
C6 = palmar side of thumb
C7 = palmar side of middle finger
C8 = palmar side of little finger
T1 = medial aspect of upper arm

Question 10

How do you asses coordination in an upper limb neuro exam?

Answer 10

Finger to nose test
Dysdiadochokinesia
* difficulty suggests cerebellar pathology

Question 11

How do you complete in an upper limb neuro exam?

Answer 11

Assess cranial nerves
Perform a lower limb neuro exam
Cerebellar assessment