Primary tabs

Upper Limb Examination

Edit this Article | Original article by Ruichong Ma and Tom Leach | Last updated on 21/11/2013 | View Revisions

Printer-friendly version
The key aim is to identify the anatomical site of the lesion: central (UMN - brain and spinal cord)versus peripheral (LMN - nerve roots and peripheral nerves).
• NB – neurological examination of the limbs tests both the peripheral and central nervous systems.
The pattern of signs is usually more important than a single sign (e.g. glove-and-stocking sensory loss, left-sided UMN weakness etc.)
Examination of the cranial nerves should be performed with neurological examination of the limbs as part of a complete neurological examination.
 
Mnemonic:
To Postpone Reflexes Constitutes Stupidity
Tone, Power, Reflexes, Co-ordination, Sensation
Upper Limb Examination
To start - WIPE
  • Wash your hands
  • Introduce yourself to the patient
  • Permission - to examine the patient
  • Position - start with the patient sitting
  • Pain - check that the patient has no pain
  • Exposure - both upper limbs from shoulders to fingers
End of the bed
Surroundings
  • Monitoring: ECG (Autonomic Problems)
  • Treatments: O2, IV Infusions (IV Ig)
  • Paraphernalia: Wheelchair, Mobility Aids
Patient
Asymmetry, Deformity Or Abnormal Posture (Dystonia). Often due to abnormal contraction of one group of muscles. Some common dystonias have their own descriptions:
  • Writer’s cramp the muscles of the hand and forearm cramp as the patient tries to write. They may only manage a few words before they have to stop.
  • Wry neck – torticollis – there is painful contraction of SCM – which cases the face to point to one side (Rarely it can be bilateral). Other variaionts involving other muscles are also possible; retrocollis head tilts backwards, antecollis – head tilts forwards.
  • Resting Tremor(Parkinsons) or intention tremor (cerebellar disorder)
  • Wasting (Proximally Deltoid, Supra-/Infraspinatus; Distally 1st Dorsal Interosseous)
  • Fasciculation (Anterior Deltoid Margin And 1st Dorsal Interosseous)
  • Pronator Drift (UMN weakness)
  • Psuedoathetosis (Proprioceptive loss) - involuntary slow ‘snake-like’ movements of the distal regions (fingers and toes).
  • Dysmetria – lack of co-ordination (Cerebellar lesion)
  • Myoclonus – brief jerks, that can move a limb. Usually restricted to one muscle groups, but can be more generalised. For example, in normal individuals, the ‘shock’ that many people experience just as they fall asleep is myoclonus.
  • Tics – borderline psychiatric/neuro in origin. They can be consciously suppressed. They tend to affect the face and upper body. Many normal individuals have tics, that are completely benign. The main manifestation is in Tourette’s syndrome. 
Tone
Ask patient to relax
Test shoulder, elbow, wrist and supinator catch - isolate each joint in turn.
Hypotonic - often can be subtle and difficult to distinguish. Possible LMN lesion.
Hypertonic:
Power
MRC scale of 0-5 (see below)
Start proximally
First, ask the patient to hold their arms out infront of them, supinated. This tests and major weakness. In cases of UMN, the arm will drift downwards,and will pronate.
When describing weakness, think in terms of:
  • Proximal versus distal
  • Unilateral versus bilateral
Movement
 

 

Muscle

 

Root
Nerve
Shoulder Abd
Deltoid
C5
Axillary
Elbow Flex
Biceps
C5, C6
Musculocutaneous
Elbow Ext
Triceps
C7
Radial
Wrist Flex
Flex carpi radialis & ulnaris
C8
Median & Ulnar
Wrist Ext
Ext carpi radialis & ulnaris
C7
Radial & posterior interosseous
Finger Abd
Dorsal interossei & Abd digiti minimi
T1
Ulnar
Thumb Abd
Abd pollicis brevis
C8
Median

If you suspect someone is just not trying very hard, this can mimic weakness. This may be because they are in pain. To differentiate this from true weakness, quickly release the resistance during the examination. In those who are using the full effort, there will be some ‘rebound’ against the now absent resistance – e.g. the limb will quickly fly past the point where the resistance was. In someone not putting in full effort, you won’t see this rebound.

Reflexes
Hold tendon hammer at the end, let it fall in a pendular movement.
If unable to elicit a reflex try with reinforcement - “clench your teeth
Look at the muscle belly when testing a reflex
Reflex
Root
Nerve
Biceps
C5, C6
Musculocutaneous
Supinator
C6, C7
Radial
Triceps
C7, C8
Coordination
cerebellar function - omit if upper limbs are weak.
  • Finger-nose test (look for dysmetria and intention tremor)
  • Alternating hand test looking for dysdiadochokinesis
Sensation
Test distally to proximally. Look for “glove” (peripheral neuropathy) or dermatomal loss (nerve root problem)
  • Light touch with fingers/cotton wool (tests spinothalamic pathway). Don’t stroke the skin, gently ‘dab’ it.
  • Get the patient to close their eyes and look for extinction
  • Test rapidly, running up the arms then work down the arms specifically testing dermatomes as per the diagram
  • If deficit detected, consider refining deficit by using wisp of cotton wool (dorsal columns) as well as pin prick and testing temperature sensation (spinothalamic pathway)
  • Proprioception dorsal columns)
Closure
  • Thank the patient
  • Make sure the patient is comfortable and clothed
  • Wash your hands
  • Put your findings together - is the lesion central or peripheral?
To Finish
Only if relevant to findings so far:
  • Other cerebellar signs: DANISH
  • Visual fields (UMN weakness suspected stroke)
  • Speech examination (UMN weakness suspected stroke)
  • FVC (Guillain Barré)
MRC Power Scale
0
No movement
1
Flicker of Movement
2
Movement with gravity but not against
3
Movement against gravity but not resistance
4
Reduced power against resistance
5
Normal power against resistance
 
Pattern of findings in UMN vs LMN lesion
 
 
UMN
LMN
Inspection
Spastic posture
Wasting after 2 - 3 weeks
Fasciculation
Tone
Increased +/- clonus
Decreased
Power
Weakness (in a pyramidal pattern if cortical UMN lesion)
Weakness in distribution of nerve/root/muscle group
Reflexes
Hyperreflexic, extensor plantars
Hyporeflexic, flexor plantars

 

Dermatomes