Upper Limb Examination

Introduction

Timings

• 6 minute Examination- practice on self: 4 mins, patients 5 mins

• 4 minute examiner discussion

Examination

Introduction

• Wash Hands

• Introduction, correct patient, consent, check for pain- can stop if painful

• Adequate exposure

Inspection:

• End of the bed- muscle wasting (dorsum hand), fasciculations; hands

• Tremor, pronator drift (palms upwards)

• Posture- kypho-scoliosis

• Consider pronator drift

• Hoffman's Sign- flick 3rd finger causes thumb flexion (UMN)

Motor

Tone

• Assess rigidity- global movements

• Spasticity- fast rotation of wrist

• Hoffman's Sign Reminder

Power

• Shoulder: 

  • • Abduction C5 - deltoid muscles, auxiliary nerve

    • Adduction C6,7,8- lat dorsi muscles, 

• Elbow

  • • Flexion C5/6- musculocutaneous, biceps

    • Extension C7- radial, triceps

• Wrist 

  • • Flexion C7, C8- musculocutaneous, 

    • Extension C6, C7- radial 

• Finger 3rd

  • • Extension: C7- radial 

    • Flexion: C8, medial + ulnar

    • Finger abduction T1- median

    • Finger adduction

• Thumb 

  • Abduction

  • Adduction T1- ulnar 

• Squeeze fingers

Reflexes

• Biceps C5/6

• Supinator C5/6

• Triceps C7

  • Arm across chest, consider reinforcement maneuvers- grit teeth (distraction

• Hoffman's Sign

Co-ordination

Both proprioception, motor and cerebellar integration

• Finger nose - option to do with eyes closed, also can detect intention tremor

• Dysdiadochokinesia- cerebellar lesion

Sensory

Sharp touch

• Start distal and move proximal

• If sensory loss localise to dermatomes

  • Lateral arm C5- can feel it, then same?

  • Lateral forearm C6

  • Lateral 2nd finger- C6, median nerve

  • Middle finger tip - C7, 

  • Medial palm of hand, ulnar nerve

  • Medial forearm, C8

  • Medial arm T1

Same as fine touch; spinothalamic pathway (stopped doing fine touch due to its lack of helpfulness). 

Temperature of tuning fork (or fine touch)

• Start distal and move proximal

  • Dermatomes if abnormal

• Dorsal column

• Use back of tuning fork 

Vibration

• Feel on sternum- sensation of buzzing, rather than metal

• Start distally on 2nd finger- eyes close, when stops

• If not sensation, move up joints: 2nd PIPJ, MCPJ, wrist, elbow, shoulder

• Dorsal column

Proprioception

• 2nd distal phalanx: up or down with eyes shut

• Move proximally to phalanx, finger, wrist, elbow, shoulder

• Dorsal column

Conclusion

Thank patient [name] for time, hand gel, re-exposure. 

To complete my examination I would examine the Cranial Nerves and Lower limbs. 

Signs 

Tone

• Increased tone: UMN sign

• Normal tone with weakness: myopathy, NMJ sign

• Reduced tone: LMN sign

• Led pipe rigidity- Neuroleptic Malignant Syndrome (NMS) 

• Cogwheel rigidity- Parkinson's Disease 

Conditions

Parkinson's Disease 

• Cogwheel rigidity, resting tremor

• Bradykinesia

• Shuffling gait, stooping posture, poor arm swing

Ulnar Lesion

• Sensory C8

• Power: 4th and 5th finger weakness

• Normal T1 sensation and abductus pollicus brevis power

C8/ T1 Lesion

• Sensory 

• Power abductus pollicus brevsi reduced

Discussion

Examiner Discussion (4 mins)

1. Please present your findings.

2. What are you differentials?

3. How would you complete your assessment?

4. Investigations?

5. Management?

Physiology