Upper Limb Neurological Examination

MRCS Part B OSCE Revision

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Upper Limb Neurological Examination

Right side of patient
Wash hands
‘May I now examine you? Are you in any pain?’

Upper Limb
Motor
‘I’m now going to test the nerves in your arms and legs.’
Compare both limbs

Inspect
‘Are you right or left handed?’
Look at skin, muscles and look for wasting and fasciculations.
Pronator drift – arms outstretched, palms facing up, eyes closed. Pronation=weakness on that side

Tone
Isolate the limb. Hold the joint above and move the limb. Compare sides.
‘I’d like you to relax, let your arm go floppy.’
Take hold of hand as if to shake, hold forearm + elbow to stabilise. Pronate, supinate, flex and extend.

Power
Deltoid (C5,6) –ask patient to raise arm up like a chicken wing, hold shoulder. ‘Don’t let me move your arm’.
Biceps (C5,6) –ask patient to raise forearms up like a boxer, hold elbow. ‘Stop me from pushing, stop me from pulling’.
Wrist (C7,8)– hold wrist ‘stop me from pushing up and pushing down on outstretched fingers’/’grip my fingers’
Fingers (C8,T1) – ‘spread your fingers apart and stop me from trying to close them.’


Muscle grading


    Reflexes
    Ask patient to relax their arms and rest them in their lap.
    Biceps tendon (C5) – finger on tendon and hit finger using tendon hammer. Compare sides.
    Triceps tendon (C7) – hold arm up slightly and hit behind elbow
    Supinator tendon (C6) – radial aspect 10cm above wrist joint

    Sensory

    Pain (Spinothalamic)
    Use neurotip. ‘I’m going to press this onto your arm. I’d like you to close your eyes and say ‘Yes’ when you can feel it.’
    Test dermatomes. Compare both arms. ‘Was it the same feeling on both sides?’ Remember to dispose of neurotip after use.
    Arm Dermatomes: See map at end of sheet. From outside shoulder: C5, C6, C7(middle finger), C8, T1, T2

    Proprioception
    (Dorsal Column)
    ‘I’d like you to close your eyes and tell me whether your finger is up or down?’
    Hold patient’s terminal phalanx between thumb and forefinger on either side while immobilising the proximal phalanx with other hand.

    [Vibration (Dorsal Column)
    With patient’s eyes closed place tuning fork on little finger or wrist. ‘Can you feel that? Now tell me when it stops.’

    Light touch (Spinothalamic)
    Use cotton wool. ‘I’m going to press this onto your arm. I’d like you to say ‘Yes’ when you can feel it.’
    Test dermatomes moving up from little finger and then thumb sides. ‘Was it the same feeling on both sides?’]

    Coordination
    Ask patient to pretend to play the piano
    Ask patient to touch their nose and then touch your finger, move finger around and keep at patient’s maximum reach.
    Ask patient to rapidly pronate and supinate left hand onto dorsum of right hand. Then swap hands. (Dysdiadochokinesis)

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