Upper Limb Examination

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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	Radial

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

Examine the lower limbs and cranial nerves

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