Upper Limb Neurological Examination: A Step-by-Step Guide

 


1️⃣ Introduction & Inspection

  • Introduce yourself, confirm patient identity, and explain the procedure.
  • Ask about weakness, numbness, tingling, or pain.
  • Observe for muscle wasting, fasciculations, tremors, or contractures.
  • Inspect hand posture for signs of ulnar claw, wrist drop, or resting tremors.

2️⃣ Muscle Tone

  • Passively move the shoulder, elbow, wrist, and fingers to assess resistance.
  • Spasticity → UMN lesion (e.g., stroke, MS).
  • Rigidity → Extrapyramidal disorder (e.g., Parkinson’s).
  • Cogwheel rigidity → Intermittent resistance in Parkinson’s disease.

3️⃣ Muscle Strength (Power)

Use the MRC scale (0-5) to test key muscle groups:

  • Shoulder abduction (C5, C6) → Raise arm sideways.
  • Elbow flexion (C5, C6) → Bend elbow against resistance.
  • Elbow extension (C7, C8) → Straighten elbow against resistance.
  • Wrist extension (C6, C7) → Extend wrist against resistance.
  • Finger flexion (C8, T1) → Grip strength test.
  • Finger abduction (T1) → Spread fingers apart.
  • Thumb abduction (T1) → Lift thumb upwards against resistance.

4️⃣ Reflexes

Test deep tendon reflexes with a reflex hammer:

  • Biceps (C5, C6) → Forearm flexion.
  • Triceps (C7, C8) → Forearm extension.
  • Brachioradialis (C5, C6) → Forearm flexion and supination.
  • Finger jerk (C8, T1) → Finger flexion.

5️⃣ Coordination (Cerebellar Function)

  • Finger-nose test → Check for intention tremor and dysmetria.
  • Rapid alternating movements → Assess dysdiadochokinesia (e.g., supination/pronation).
  • Rebound test → Loss of resistance control indicates cerebellar dysfunction.

6️⃣ Sensory Testing

Assess different modalities:

  • Light touch → Cotton wool.
  • Pain → Pinprick.
  • Temperature → Warm/cold object.
  • Vibration → 128 Hz tuning fork on bony prominences.
  • Proprioception → Move the patient’s finger up/down with eyes closed.

7️⃣ Special Tests

  • Tinel’s sign → Percuss the carpal tunnel for median nerve irritation.
  • Phalen’s test → Wrist flexion test for carpal tunnel syndrome.
  • Pronator drift → UMN dysfunction if arm drifts down and pronates.

8️⃣ Identifying the Lesion

  • UMN lesion? → Hypertonia, hyperreflexia, spasticity, positive pronator drift.
  • LMN lesion? → Hypotonia, hyporeflexia, muscle wasting, fasciculations.
  • Cerebellar dysfunction? → Intention tremor, dysdiadochokinesia, ataxia.
  • Peripheral neuropathy? → Glove-like sensory loss, weak grip strength.

A systematic approach helps localize the lesion and guide further diagnosis.



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