Ulnar — MRCS Part B Physical examination

Wash Your Hands
Ensure that you are seen by the examiners to wash your hands using alcohol gel provided.

Introduce, Explain, Expose and Inspect
Begin by introducing yourself, explain what you are going to do and check that this is ok with the patient and that he/she is not in any pain.
To examine the cubital tunnel, expose the patients elbow and ideally the joint above and below.

Inspect
Inspect for scars, deformity and any erythema

Palpate
The patient is examined systematically, by inspection of the elbow joint, in particular the medial epicondyle. The cubital tunnel is palpated and any exacerbation of symptoms noted. The ulnar tap test or Tinel’s sign at the elbow is performed. Sensation in the ulnar nerve distribution and power are tested prior to commencing special tests such as Froment’s Sign.

Froment’s Test:
To perform the test, a patient is asked to hold an object, usually a flat object such as a piece of paper, between their thumb and index finger (pinch grip). The examiner then attempts to pull the object out of the subject's hands.
• A normal individual will be able to maintain a hold on the object without difficulty.
• However, with ulnar nerve palsy, the patient will experience difficulty maintaining a hold and will compensate by flexing the FPL (flexor pollicis longus) of the thumb to maintain grip pressure causing a pinching effect.
• Clinically, this compensation manifests as flexion of the IP joint of the thumb (rather than adduction, as would occur with correct use of the adductor pollicis).

Upper Limb Motor Function ‘I’m now going to test the nerves in your arms.’ 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.’
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)

Closing
Thank the patient. Inform them that they may now get dressed or ensure they are adequately covered.
Present your findings to the examiner.

Top Tips
• Ensure that you understand the tests and movements in the hand for each specific nerve – radial, median and ulnar.
• Have an efficient way of testing the sensation for each of the nerves above quickly (ulnar – little finger, median – thenar eminence and radial 1st dorsal interosseous (1st webspace).
• Common questions include the contents of the cubital and carpal tunnel, their location and the clinical significance of compression at these points.