Medically Fit For Exams
Medically Fit For Exams

Upper limb peripheral nerve examination

  • Wash your hands and introduce yourself
  • Check the patient’s name and DOB
  • Explain the examination and gain consent

 

Inspection

  • Ask the patient to undress sufficiently to see the whole upper limb
  • Look for walking aids
  • Look for waster, hypertrophy or asymmetry
  • Look for abnormal movement, posture, fasciculations (especially in triceps)
  • Ask the patient to hold out both of their hand with palms up and close their eyes
  • Look for a ‘pronator drift’ – one hand starts to pronate and lower
    • Sign of upper motor neuron lesion

 

Tone

  • Ask the patient to relax their arm
  • Ask the patient if they have any pain in their shoulder
  • Take their hand in your hand, and place your other hand on their shoulder
  • Move their arm around including:
    • Elbow flexion
    • Supination, feeling for supination ‘catch’
    • Wrist circumduction, feeling for cogwheeling

 

Power

  • Inform the patient that you are going to ask them to do some specific movements
  • In turn ask them to do the following, against resistance:
    • Put your arms out level with your shoulders like a chicken, and don’t let me push them down
    • Put your arm in front of you with your elbow bent like a boxer, and pull my hand towards you
    • Keep your arm in that position and push my hand away from you

Scale of muscle power

0

No movement

1

Flicker of movement

2

Movement only with gravity

3

Movement against gravity, but not resistance

4

Some movement against resistance

5

Full power against resistance

  •  Put your arms out straight with your wrists back and fists clenched, push against my hand (push from above and below, extending and flexing the wrist)
  • Squeeze my fingers as hard as you can
  • Spread your fingers out and don’t let me close them
  • Hold your palms upwards, with your thumb pointing towards the ceiling, don’t let me pull your thumb down

 

Reflexes

  • Biceps (musculocutaneous nerve, C5)
    • Ask the patient to rest their hand in their lap and relax their arm
    • Place your left thumb on the biceps tendon and hit with the tendon hammer
    • Observe for a flicker of the biceps or twitch of the hand
  • Triceps (radial nerve, C7)
    •  Stand behind the patient, bend their elbow to 90 degrees and hold it across their chest
    • Ask them to relax and let you take the weight
    • Hit the triceps tendon directly with the hammer
    • Observe for flicker of the triceps muscle, or movement of the forearm
  • Brachioradialis (radial nerve, C6)
    • Place a finger just proximal to the head of the radius (thumb side)
    • Ask the patient to relax
    • Hit your thumb with the tendon hammer
    •  Observe for flicker of the hand
  • Reinforce by clenching the teeth as necessary

 

Coordination

  • Cerebellar rebound
    • Ask the patient to stand and hold their arms out straight in front of them
    • Tell them you are going to press down on their arms and let go, they need to bring their arms back to the original position
    • Observe for overshoot
  • Finger-nose test
    • Ask the patient to rapidly move their finger between their nose and your outstretched finger
    • Move your finger slightly between each attempt
    • Observe for intension tremor and missing of targets
  •  Dysdiadochokinesia
    • Ask the patient to hold one palm up, and with the other hand slap it with the palm and back of hand alternatively as quickly as possible

 

Sensation

  • Light touch:
    •  Using a piece of cotton wool, touch the tip to the sternum as a reference
    • Ask the patient to close their eyes and say ‘yes when they feel the cotton wool’
    • Map down the limb in the dermatomes, switching between arms for comparison
    • Ask if it feels the same on each side
  • Pain:
    • Explain to the patient and use the neurotip to reference on the sternum
    •  Ask the patient to say ‘sharp’ or ‘dull’
    • As above
  • Proprioception
    • Ask the patient to close their eyes
    • Reference with movement of the interphalangeal joints
    • Pick one joint on each hand, flex or extend at random and ask the patient to say 'up' or 'down'

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