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Phase 2b Medicine > Upper Limb Neuro Exam > Flashcards

Upper Limb Neuro Exam Flashcards

1
Q

Is there fasciculations or wasting in a UMN lesion?

A

No, but there may be some disuse atrophy

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2
Q

Is there fasciculations or wasting in a LMN lesion?

A

Yes

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3
Q

Is there a pronator drift present in a UMN lesion?

A

May be present

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4
Q

Is there a pronator drift present in a LMN lesion?

A

There may be some drift, but not pronator drift

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5
Q

What is tone like in a UMN lesion?

A

Increased (spasticity or rigidity)

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6
Q

What is tone like in a LMN lesion?

A

Decreased (hypotonia) or normal

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7
Q

What is power like in a UMN lesion?

A
  • Classically ‘pyramidal’

- Extensors weaker than flexors in arms and vice versa

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8
Q

What is power like in a LMN lesion?

A
  • Different patterns of weakness depending on the cause
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9
Q

What are reflexes like in a UMN lesion?

A

Exaggerated or brisk (hyperreflexia)

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10
Q

What are reflexes like in a LMN lesion?

A

Reduced or absent (hyporeflexia or areflexia)

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11
Q

What is a areflexia?

A

When the muscles don’t respond to stimuli

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12
Q

What is the relevance of looking for scars in an upper limb neuro exam?

A

May give clues regarding previous spinal, axillary or upper limb surgery

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13
Q

What is the relevance of looking for wasting of muscles in an upper limb neuro exam?

A

Suggests LMN lesion or disuse atrophy

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14
Q

What is the relevance of looking for tremor in an upper limb neuro exam?

A

May show resting or intention tremor

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15
Q

What are fasciciulations?

A

Small, local involuntary muscle contractions and relaxation which may be visible under the skin

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16
Q

What are fasciculations associated with?

A

LMN pathology e.g. amyotrophic lateral sclerosis

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17
Q

What is pseudoathetosis?

A

Abnormal writhing movements caused by a failure of proprioception

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18
Q

What is chorea?

A

Brief, semi-directed, irregular movements that are not repetitive or rhythmic but appear to flow from one muscle to the next

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19
Q

In which condition does chorea typically present?

A

Huntington’s disease

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20
Q

What is myoclonus?

A

Brief, involuntary, irregular twitching of a muscle or group of muscles

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21
Q

In what conditions may myoclonus be seen?

A
  • May be benign

- May be seen in several forms of epilepsy

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22
Q

What is tardive dyskinesia?

A

Involuntary, repetitive body movements which can include protrusion of the tongue, lip-smacking and grimacing

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23
Q

When may tardive dyskinesia show?

A

Secondary to treatment with neuroleptic medications including antipsychotics and antiemetics

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24
Q

What is hypomimia?

A

A reduced degree of facial expression

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25
Q

In which condition does hypomimia present?

A

Parkinson’s disease

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26
Q

In which condition does ptosis and frontal balding occur?

A

Myotonic dystrophy

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27
Q

What is ophthalmoplegia?

A

Weakness or paralysis of one or more extra ocular muscles responsible for eye movements

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28
Q

What conditions may present with ophthalmoplegia?

A

MS or myasthenia gravis

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29
Q

How do you assess for pronator drift?

A
  • Ask the patient to hold their arms out in front of them with their palms facing upwards
  • If none occurs, ask the patient to close their eyes and continue
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30
Q

What is the interpretation of a pronator drift?

A
  • If it pronates, they have a pronator drift on that side

- Indicates a contralateral pyramidal tract lesion

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31
Q

Why does pronator drift occur?

A

In the context of a UMN lesion, the supinator muscles are typically weaker than the pronator muscles

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32
Q

Which muscles groups should you assess for tone?

A

Shoulder, elbow and wrist of each arm

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33
Q

How do you assess for tone?

A
  • Support the patient’s arm by holding their hand and elbow
  • Ask the patient to relax and allow you to fully control the movement of their arm
  • Move the muscle groups of the shoulder, elbow and wrist through full range of movements
  • Feel for abnormalities of tone
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34
Q

What should be done to assess the tone of the shoulder?

A

Circumduction (round rotation)

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35
Q

What should be done to assess the tone of the elbow?

A

Flexion and extension

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36
Q

What should be done to assess the tone of the wrist?

A

Circumduction (round rotation)

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37
Q

What is spasticity associated with?

A

Pyramidal tract lesions (e.g. stroke)

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38
Q

What is rigidity associated with?

A

Extrapyramidal tract lesions (e.g. Parkinson’s)

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39
Q

How is spasticity velocity dependent?

A
  • The faster you move the limb, the worse it is

- Typically increased tone in the initial movement, then suddenly reduces past a certain point

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40
Q

What is associated with spasticity?

A

Weakness

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41
Q

How is rigidity velocity independent?

A

It feels the same if you move the limb rapidly or slowly

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42
Q

What are the two main types of rigidity?

A

Cogwheel & lead pipe

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43
Q

How is cogwheel rigidity described?

A

A tremor superimposed on the hypertonia, resulting in intermittent increases in tone during movement of the limb

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44
Q

What disease is cogwheel rigidity associated with?

A

Parkinson’s disease

45
Q

How is lead pipe rigidity described?

A

Uniformly increased tone throughout the movement of the muscle

46
Q

What disease is lead pipe rigidity associated with?

A

Neuroleptic malignant syndrome

47
Q

When testing shoulder abduction, what myotome is assessed?

A

C5 (axillary nerve)

48
Q

What muscles are tested when doing shoulder abduction?

A
  • Deltoid (primary)

- Other shoulder abductors

49
Q

How do you test the power of shoulder abduction?

A
  • ‘Bend your elbows and bring your arms out to the sides like a chicken’
  • ‘Don’t let me push your shoulder down’
50
Q

When testing shoulder adduction, what myotome is assessed?

A

C6/7 (thoracodorsal nerve)

51
Q

What muscles are tested when doing shoulder adduction?

A
  • Teres major
  • Latissimus dorsi
  • Pectoralis major
52
Q

How do you test the power of shoulder adduction?

A
  • ‘Ask the patient to bring their elbows to a 45 degree angle’
  • ‘Don’t let me pull your arms away from your sides’
53
Q

When testing elbow flexion, what myotome is assessed?

A

C5/6 (musculocutaenous and radial nerve)

54
Q

What muscles are tested when doing elbow flexion?

A
  • Biceps brachii
  • Coracobrachialis
  • Brachialis
55
Q

How do you test the power of elbow flexion?

A
  • ‘Put your hands up like a boxer’

- ‘Don’t let me pull your arm away from you’

56
Q

When testing elbow extension, what myotome is assessed?

A

C7 (radial nerve)

57
Q

What muscles are tested when doing elbow extension?

A

Triceps brachii

58
Q

How do you test the power of elbow extension?

A
  • ‘Put your hands up like a boxer’

- ‘Don’t let me push your arm towards you’

59
Q

When testing wrist extension, what myotome is assessed?

A

C6 (radial nerve)

60
Q

What muscles are tested when doing wrist extension?

A

Extensors of the wrist

61
Q

How do you test the power of wrist extension?

A
  • ‘Hold your arms out in front of you, with your palms facing the ground’
  • ‘Make a fist, cock your wrists back and don’t let me pull them downwards’
62
Q

When testing wrist flexion, what myotome is assessed?

A

C6/7 (median nerve)

63
Q

What muscles are tested when doing wrist flexion?

A

Flexors of the wrist

64
Q

How do you test the power of wrist flexion?

A
  • ‘Hold your arms out in front of you, with your palms facing the ground’
  • ‘Point your wrists downwards and don’t let me pull them up’
65
Q

When testing finger extension, what myotome is assessed?

A

C7 (radial nerve)

66
Q

What muscles are tested when doing finger extension?

A

Extensor digitorum

67
Q

How do you test the power of finger extension?

A

‘Hold your fingers out straight and don’t let me push them down’

68
Q

When testing finger abduction, what myotome is assessed?

A

T1 (ulnar nerve)

69
Q

What muscles are tested when doing finger abduction?

A
  • First dorsal interosseous (FDI)

- Abductor digiti minimi (ADM)

70
Q

How do you test the power of finger abduction?

A

‘Splay your fingers outwards and don’t let me push them together’

71
Q

When testing thumb abduction, what myotome is assessed?

A

T1 (median nerve)

72
Q

When testing thumb abduction, what myotome is assessed?

A

Abductor pollicis brevis

73
Q

How do you test the power of thumb abdcution?

A

‘Point your thumbs to the ceiling and don’t let me push them down’

74
Q

What is 0 on the MRC muscle power assessment scale?

A

No contraction

75
Q

What is 1 on the MRC muscle power assessment scale?

A

Flicker or trace of contraction

76
Q

What is 2 on the MRC muscle power assessment scale?

A

Active movement, with gravity eliminated

77
Q

What is 3 on the MRC muscle power assessment scale?

A

Active movement against gravity

78
Q

What is 4 on the MRC muscle power assessment scale?

A

Active movement against gravity and resistance

79
Q

What is 5 on the MRC muscle power assessment scale?

A

Normal power

80
Q

What should be done if there is an absent reflex?

A
  • Do a reinforcement manoeurve

- Ask the patient to clench their teeth while you perform

81
Q

What myotome does the biceps reflex test?

A

C5/6

82
Q

How do you perform the biceps reflex?

A
  • Place your non-dominant thumb on the biceps brachia tendon
  • Tap your thumb
  • Observe for a contraction of the biceps muscle and associated flexion of the elbow
83
Q

What myotome does the supinator reflex test?

A

C5/6

84
Q

How do you perform the supinator reflex?

A
  • Place two fingers on the brachioradialis tendon
  • Tap your fingers
  • Observe for contraction of the brachioradialis muscle and associated flexion, pronation or supination of the forearm at the elbow
85
Q

What myotome does the triceps reflex test?

A

C7

86
Q

How do you perform the triceps reflex?

A
  • Tap the triceps tendon (medial part of elbow crease)
  • Tap the tendon
  • Observe for a contraction of the triceps muscle
87
Q

What is hyperreflexia associated with?

A

Upper motor neuron lesions e.g. stroke, spinal cord injury

88
Q

What is hyporeflexia associated with?

A

Lower motor neuron lesions e.g. brachial plexus pathology or peripheral nerve injury

89
Q

What is a pendular reflex and what is it seen in?

A
  • Less brisk and slower in rise and fall

- Seen in cerebellar disease

90
Q

Where can the dermatome for C5 be assessed?

A

The lateral aspect of the lower edge of the deltoid muscle

91
Q

Where can the dermatome for C6 be assessed?

A

The palmar side of the thumb

92
Q

Where can the dermatome for C7 be assessed?

A

The palmar side of the middle finger

93
Q

Where can the dermatome for C8 be assessed?

A

The palmar side of the little finger

94
Q

Where can the dermatome for T1 be assessed/

A

The medial aspect antecubital fossa, proximal to the medial epicondyle of the humerus

95
Q

How do you assess sensation using light touch sensation?

A
  • Trace some cotton wool on the sternum
  • Ask the patient to say ‘yes’ when they feel the sensation
  • Assess across the dermatomes
96
Q

What does light touch sensation assess?

A
  • Dorsal columns

- Spinothalamic Tracys

97
Q

What does vibration sensation assess?

A

Dorsal columns

98
Q

How do you assess sensation using vibration?

A
  • Assess the tuning fork on the patients sternum with eyes closed
  • Use the tuning fork on the interphalangeal joint of the patient’s thumb & repeat on the other side
  • If impaired: thumb - elbow joint - shoulder joint
99
Q

What does proprioception sensation assess?

A

Dorsal columns

100
Q

How do you assess sensation using proprioception

A
  • Demonstrate ‘up’ and ‘ down’ to patient on thumb before starting
  • With eyes closed, ask them to state the movement 3-4 times
  • If not accurate: thumb - elbow joint - shoulder
  • Repeat on both sides
101
Q

Why is the finger-to-nose test used in this exam?

A

To assess upper limb co-ordination

102
Q

How do you perform the finger-to-nose test?

A
  • Place finger so patient has to fully outstretch their arm
  • Ask the patient to touch they nose, then touch your fingertip
  • Continue as fast as possible
103
Q

What may be displayed in the finger-to-nose test and what does this indicate?

A
  • Dysmetria and intention tremor

- Ipsilateral cerebellar tremor

104
Q

What is dysmetria?

A

Lack of coordination of movement

105
Q

What is intention tremor?

A

A broad, coarse, low-frequency tremor that develops as a limb reaches the endpoint of a deliberate movement

106
Q

What is dysdiadochokinesia and what may it indicate?

A
  • Inability to perform rapid, alternating movements

- Ipsilateral cerebellar tremor

107
Q

How do you test for dysdiadochokinesia and what may it indicate?

A
  • Hand turning alternating test

- May indicate cerebral ataxia = movements appearing slow and irregular

108
Q

What further assessments and investigations may be carried out?

A
  • Full neurological examination (cranial nerves, lower limbs and cerebellar assessments)
  • Neuroimaging e.g. MRI spine and head

Phase 2b Medicine (17 decks)

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