Upper Limb Neurological Examination

TO START

W2I2P4E

  • Wash your hands

  • Wear appropriate PPE

  • Introduce yourself and check patient’s Identity

  • Permission: “May I examine your arms?”

  • Privacy: Ensure curtains to the bay are closed

  • Pain: “Are you in any pain at all?” 

  • Position: Patient sitting

  • Exposure: Both arms exposed, shoulders to fingers

INSPECTION

Surroundings

  • Monitoring – ECG (autonomic problems)

  • Treatments – oxygen, IV infusions (IV Ig), feeding tubes, FVC monitor

  • Paraphernalia – nil by mouth signs, mobility aids, glasses, etc

Patient

  • Asymmetry, deformity, scars, abnormal posture, facial expression

  • Abnormal movements - tremor, dystonia, chorea, athetosis, tics 

  • Wasting, fasciculations

SCREENING TESTS

Pseudoathetosis

  • Ask the patient to hold their arms out extended with hands pronated (palms down) with their eyes closed

  • Positive if there is finger movement (looks like playing the piano) - suggests proprioceptive loss

Pronator drift

  • Now ask the patient to hold their hands in supination (palms up) with their eyes closed for 20-30 secs

  • Positive if pronation is observed - suggests contralateral UMN lesion affecting pyramidal tract

Rebound

  • Still with eyes closed, push down on the patient’s outstretched arm

  • Positive if the patient’s arm swings upwards towards their face - suggests cerebellar lesion

TONE


Assessment

  • Assess the tone in both shoulders, elbows and wrists

  • Ask the patient to relax - ‘let me take the full weight of your arm’

  • Test shoulder circumduction, elbow flexion and extension (vary speed), wrist circumduction 

Findings

  • Hypotonia - difficult to detect (acute spinal injury, acute stroke, cerebellar disease)

  • Hypertonia

    • Spasticity - velocity-dependent, increased tone with faster movements (‘clasp-knife’), pyramidal lesion

    • Rigidity - velocity-independent, increased tone whether moved quickly or slowly, extra-pyramidal lesion

      • Cogwheel rigidity - a feature of Parkinson’s disease, due to tremor superimposed on hypertonia 

      • Lead pipe rigidity - increase tone throughout range of movement (eg neuroleptic malignant syndrome)

POWER


Notes

  • Assess power for individual muscles, isolate each joint and examine each side separately assessing like for like against resistance

  • Use the MRC power scale to grade each muscle

  • It’s useful to act out movements as well as giving clear instructions

Shoulder

  • Test shoulder ABduction and ADduction

  • Ask the patient to raise their arms up ‘like a chicken’ - push up and down on the patient’s arms

Elbow

  • Test elbow flexion and extension - remember to isolate the joint

  • Ask the patient to position their arms ‘like a boxer’ - ask the patient to push towards you with their forearms, then pull back towards them

Wrist

  • Test wrist flexion and extension

  • Ask the patient to make fists in front of them ‘like riding a motorbike’ and push up against your fist and down

Fingers

  • Test finger ABduction - use your own little finger and index finger to resist against abduction of their little and index finger

  • Test thumb ABduction - against resistance using your thumb

MOVEMENT

MUSCLE

ROOT

NERVE

Shoulder abduction

Deltoid

C5,6

Axillary

Elbow flexion

Biceps

C5,6

Musculocutaneous

Elbow extension

Triceps

C6,7

Radial

Wrist flexion

Flexor carpi radialis/ulnaris

C6,7

Median/ulnar

Wrist extension

Extensor carpi radialis/ulnaris

C6,7,8

Radial/ posterior interosseous

Finger abduction

Dorsal interossei

T1

Ulnar

Thumb abduction

Abductor pollicis brevis

C8

Median

REFLEXES


Notes

  • Test the biceps, triceps and supinator reflexes using a tendon hammer

  • Ask the patient to completely relax

  • Watch to see the muscle belly contract to confirm presence of the reflex

  • Compare like for like (ie biceps reflex on their R then L)

  • Try a reinforcement manoeuvre (eg ask patient to clench their jaw as you tap the tendon) if unable to elicit the reflex 

Biceps (C5/6)

  • Rest the patient’s arms on their legs, slightly bent

  • Palpate the biceps tendon and place two fingers of your non-dominant hand over it

  • Tap the tendon hammer on your fingers and observe for biceps contracting and elbow flexion

Triceps (C6/7)








Supinator (C5/6)

  • Abduct the patient’s arm and take its full weight

  • Palpate for the triceps tendon (superior to the olecranon) and tap with the tendon hammer

  • Observe for triceps contraction and elbow extension


  • Palpate for brachioradialis tendon on the posterolateral aspect of the forearm

  • Place two fingers over it and tap with the tendon hammer

  • Observe for supinator contraction and flexion and supination at the wrist

COORDINATION 


Notes

  • Tests cerebellar function

  • Intention tremor, dysmetria and dysdiadochokinesia are signs of ipsilateral cerebellar pathology

Finger-nose test

  • Ask the patient to alternate touching their nose and your finger in front of them with their index finger, move your finger to a different point in space each time

  • Repeat using their other hand

  • Ensure your finger is at a distance such that they fully extend their arm

  • Assess for intention tremor (tremor towards the endpoint of a movement) and dysmetria (missing the target, under/overshooting)

Dysdiadochokinesia

  • Dysdiadochokinesia is the inability to complete rapid, alternating movements 

  • Ask the patient to rest one hand on their leg, palm face-up and clap their other palm into it, then raise that hand and turn it over to clap the back of the hand into the resting palm - repeat this quickly

  • Repeat on the other side


SENSATION


Light touch

  • Explain to the patient that you are going to test the sensation in their arms and will require them to close their eyes

  • Ask the patient to confirm when you are touching their left or right side, and whether it feels the same on both sides

  • Start by confirming normal sensation at the patient’s sternum

  • Ideally, assess with cotton wool (if unavailable - your fingertip)

  • Assess each dermatome on each side

    • Deltoid: C5

    • Thumb: C6

    • Middle finger: C7

    • Little finger: C8

    • Medial forearm: T1

  • Consider testing vibration sense using a 128Hz tuning fork on bony prominences and pain sensation using a neurotip (spinothalamic tracts)


Proprioception

  • Assess the thumb on each hand

  • Assess the interphalangeal joint by stabilising the proximal phalanx and holding the sides of the distal phalanx between your thumb and 1st finger (avoid holding the nailbed, this can allow the patient to determine movements based on pressure)

  • Ask the patient to close their eyes and move the thumb up/down and ask them to tell you which way it has been moved - this should be obvious even with minute movements

  • If the patient cannot accurately discern the movements carry out the test on more proximal joints until they can (eg carpometacarpal, wrist, elbow)

CLOSURE 


Closure

  • Thank the patient, ensure they are comfortable and dressed 

  • Remove PPE

  • Clean equipment and wash hands

To complete

  • Full neurological examination (lower limb, cranial nerves)

  • Consider other neurological exams:

    • Cerebellar examination (DANISH - dysdiadochokinesia, ataxia, nystagmus, intention tremor, slurred speech, hypotonia)

    • Parkinson’s examination

    • Speech exam

  • Consider imaging (CT, MRI)

💡
In summary, I performed an upper limb neurological examination on [name], a [age] year old [sex]. On inspection s/he had no asymmetry, wasting, involuntary movements, or fascinations. The tone, power and coordination were normal throughout and reflexes intact. Sensation was normal across all modalities. In conclusion, this was a normal neurological examination.