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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