The Upper Limb Neuro Exam
Positioning: Patient sitting comfortably
Common central neurologic syndromes
Parkinsonism
Cerebellar Pathology
Spinal Cord Syndromes
Common peripheral neurologic syndromes
Upper Limb Radiculopathy (Nerve Root Palsy)
Brachial Plexopathy
Upper Limb Peripheral Mononeuropathy
Mononeuritis Multiplex
Peripheral Polyneuropathy
Signs of neurologic diseases
Multiple Sclerosis
Chronic Inflammatory Demyelinating Polyneuropathy
Motor Neurone Disease
Myaesthenia Gravis
Myotonic Dystrophy
The Patient
Around the Room
Mobility devices
General Features
Age, gender, general comfort
Skin
Cafe au lait spots, neurofibromas
Posturing
Decorticate (flexion) / decerebrate (extension)
Muscles
Wasting, fasciculations
Abnormal Movements
Tremor, chorea, dystonia, myoclonus, tics
Tremor
Resting / postural / intention / psychogenic
Rhythmic involuntary vibration of 1+ body parts
Chorea
Abrupt irregular movements
Dystonia
Contractions resulting in abnormal posture
Myoclonus
Shock-like jerking movements
Tics
Suppressible stereotyped movements preceded by urge
Peripheral Nerve Signs
Wrist drop, hand of benediction, claw hand
Carpal Tunnel Tests
Phalen's test, Tinel's sign
Phalen's Test
Reverse prayer sign for 60sec, ask re: paraesthesia
Tinel's Sign
Percuss over flexor retinaculum, ?paraesthesia
Pronator Drift
Arms extended, eyes closed, watch for movement
Functional Assessment
Buttoning a shirt, unscrewing a bottle cap, demonstrating use of a key
Motor Assessment
Summary of UMN and LMN findings
Patterns of weakness
Upper Motor Neuron Weakness
Cerebrum, brainstem or spinal cord pathology
Lower Motor Neuron Weakness
Spinal nerve root, brachial plexus or peripheral nerve pathology
Upper and Lower Motor Neuron Weakness
Classically motor neurone disease (ALS)
Proximal Weakness
More commonly muscular in aetiology
Distal Weakness
More commonly neurologic in aetiology
Tone
Passive movement of shoulders, elbows, wrists, hands
Power
0/5 no flicker, 3/5 vs. gravity, 5/5 normal
Movement against gravity & resistance, R vs. L
Reflexes
0 no response, 2+ normal, 3+ brisk, 4+ very brisk
Biceps, triceps, supinator ± reinforcement
Coordination Assessment
Sensory Assessment
Summary of sensory loss
Light Touch
Dermatomal / glove distribution
Pain
Dermatomal assessment
Vibration
DIPJ 3rd finger, ulnar styloid, olecranon, clavicle
Proprioception
Distal inter-phalangeal joint, PIPJ if abnormal
Hold sides of joint, angulate joint slightly
Cortical Sensory Modalities
Stereognosis, graphaesthesia, two-point discrimination
Stereognosis
Ability to identify an object (e.g. pen) by feel
Graphaesthesia
Ability to recognise symbols drawn on skin
Two-Point Discrimination
Ability to recognise touch at two adjacent points
Topognosis
Ability to point to part of body being touched