Upper Limb Neurological Examination
Commonly Tested
A systematic upper limb neurological examination is essential for orthopaedic assessment. Examiners expect you to test key myotomes, dermatomes, and reflexes efficiently, and to differentiate between radiculopathy (root level) and peripheral nerve lesions based on the pattern of findings.
Quick Reference One-Pager
Exam day cheat sheet
Upper Limb Neurology Summary
Key Myotomes
- C5: Shoulder abduction (deltoid)
- C6: Elbow flexion, wrist extension
- C7: Elbow extension, wrist flexion
- C8: Finger flexion (grip)
- T1: Finger abduction (intrinsics)
Key Dermatomes
- C5: Lateral arm (regimental badge)
- C6: Thumb and radial forearm
- C7: Middle finger
- C8: Little finger and ulnar forearm
- T1: Medial arm
Key Reflexes
- C5-6: Biceps, brachioradialis
- C7: Triceps
- Note: Absent = LMN, Increased = UMN
Pattern Recognition
- Radiculopathy: Dermatomal, single root
- Peripheral nerve: Specific nerve territory
- Myelopathy: UMN signs below level
Systematic Approach
Examination Framework
The 4 Components:
- Motor: Power, tone, bulk
- Sensory: Light touch, pinprick, proprioception
- Reflexes: Biceps, triceps, brachioradialis
- Coordination: Finger-nose, rapid alternating
Key Principle: Always compare sides and document findings using MRC grading for power and noting sensory modalities tested.
Motor Examination
Inspection
Look For:
- Muscle wasting (compare sides)
- Fasciculations (LMN lesion sign)
- Posture at rest
- Trophic changes (skin, nails)
Key Areas to Compare:
- Thenar eminence (median nerve/T1)
- Hypothenar eminence (ulnar nerve/T1)
- First dorsal interosseous (ulnar/T1)
- Deltoid (C5, axillary nerve)
- Forearm flexor/extensor bulk
Tone Assessment
Technique:
- Patient relaxed
- Support arm and passively move through ROM
- Assess at wrist, elbow, and shoulder
Findings:
- Hypotonia: LMN lesion, acute UMN
- Hypertonia: UMN lesion (spasticity, clasp-knife)
- Rigidity: Extrapyramidal (lead-pipe, cogwheel)
Myotomal Testing
C5
- movement
- Shoulder abduction
- muscle
- Deltoid
- instruction
- Raise arms to sides, resist me pushing down
C5-6
- movement
- Elbow flexion
- muscle
- Biceps
- instruction
- Bend elbow, resist me straightening it
C6
- movement
- Wrist extension
- muscle
- ECRL/ECRB
- instruction
- Cock wrist back, resist me pushing down
C7
- movement
- Elbow extension
- muscle
- Triceps
- instruction
- Straighten elbow against my resistance
C7
- movement
- Wrist flexion
- muscle
- FCR/FCU
- instruction
- Flex wrist down, resist me lifting it
C8
- movement
- Finger flexion
- muscle
- FDP
- instruction
- Grip my fingers tightly
T1
- movement
- Finger abduction
- muscle
- Interossei
- instruction
- Spread fingers apart, don't let me push them together
Must Know
MRC Power Grading:
- 0: No contraction
- 1: Flicker of contraction
- 2: Movement with gravity eliminated
- 3: Movement against gravity only
- 4: Movement against resistance (4-, 4, 4+)
- 5: Normal power
Practical Tip: In exams, grade 3 is easy to identify (can/can't move against gravity). Focus on distinguishing 4 from 5.
Sensory Examination
Dermatomes
Key Landmarks:
- C5: Lateral arm (regimental badge area)
- C6: Thumb, lateral forearm, radial 2.5 digits
- C7: Middle finger
- C8: Little finger, ulnar 1.5 digits
- T1: Medial upper arm
- T2: Axilla and medial arm
Testing Technique:
- Light touch (cotton wool)
- Pinprick (disposable pin)
- Always compare sides
- Ask "Does this feel the same on both sides?"
Peripheral Nerve Territories
Median Nerve:
- Palmar aspect of lateral 3.5 digits
- Key test point: Index finger pulp
Ulnar Nerve:
- Palmar and dorsal medial 1.5 digits
- Key test point: Little finger pulp
Radial Nerve:
- Dorsum of first web space
- Key test point: First dorsal web space
Musculocutaneous Nerve:
- Lateral forearm (lateral cutaneous nerve of forearm)
Reflexes
Special test
Biceps Reflex
Test C5-C6 nerve root
Technique
- 1Support arm in slight flexion
- 2Place thumb on biceps tendon in antecubital fossa
- 3Tap your thumb with reflex hammer
Positive Sign
Elbow flexion
Indicates
Intact C5-C6 reflex arc
Diagnostic Accuracy
Sensitivity85%
Ability to detect true positives
Specificity90%
Ability to exclude false positives
Special test
Triceps Reflex
Test C7 nerve root
Technique
- 1Support arm with elbow flexed
- 2Tap triceps tendon just above olecranon
- 3Observe for elbow extension
Positive Sign
Elbow extension
Indicates
Intact C7 reflex arc
Diagnostic Accuracy
Sensitivity80%
Ability to detect true positives
Specificity92%
Ability to exclude false positives
Special test
Brachioradialis Reflex
Test C5-C6 nerve root
Technique
- 1Arm resting on patient's lap, slightly pronated
- 2Tap brachioradialis tendon at radial styloid
- 3Observe for elbow flexion and forearm supination
Positive Sign
Elbow flexion with supination
Indicates
Intact C5-C6 reflex arc. Finger flexion instead = inverted reflex (myelopathy)
Diagnostic Accuracy
Sensitivity75%
Ability to detect true positives
Specificity88%
Ability to exclude false positives
Grading Reflexes
Scale:
- 0: Absent
- +: Diminished (may need reinforcement)
- ++: Normal
- +++: Brisk (may be normal)
- ++++: Clonus
Interpretation:
- Absent/diminished: LMN lesion at that level
- Brisk/clonus: UMN lesion above that level
- Inverted reflex: Myelopathy (LMN at level, UMN below)
Coordination
Cerebellar Tests
Finger-Nose Test:
- Touch nose then examiner's finger
- Look for: Intention tremor, past-pointing
Rapid Alternating Movements:
- Pat hand rapidly on thigh (pronation/supination)
- Look for: Dysdiadochokinesia
Finger Chase:
- Follow moving finger
- Look for: Dysmetria
Interpretation:
- Cerebellar dysfunction: Ipsilateral signs
- Usually not primary orthopaedic pathology
Pattern Recognition
C5 Radiculopathy:
- Motor: Weak deltoid, supraspinatus, infraspinatus, biceps
- Sensory: Regimental badge area (lateral arm)
- Reflex: Reduced biceps (C5-6)
Common Cause: C4-5 disc herniation
Differentiating Patterns
Pattern
- radiculopathy
- Dermatomal (follows root)
- peripheralNerve
- Specific nerve territory
- myelopathy
- Below level of lesion
Weakness
- radiculopathy
- Myotomes (multiple muscles, one root)
- peripheralNerve
- Muscles supplied by nerve
- myelopathy
- UMN pattern, pyramidal
Reflexes
- radiculopathy
- Reduced at level
- peripheralNerve
- May be reduced if motor nerve
- myelopathy
- Increased below level
Tone
- radiculopathy
- Normal or reduced
- peripheralNerve
- Normal or reduced
- myelopathy
- Increased (spasticity)
Other
- radiculopathy
- Neck pain, Spurling's positive
- peripheralNerve
- Tinel's over nerve
- myelopathy
- Gait changes, Hoffman's positive
Key Concept
Quick Differentiation:
- Single dermatome + single root myotome + reduced reflex = Radiculopathy
- Peripheral nerve sensory + specific muscles = Peripheral nerve lesion
- Increased reflexes + Hoffman's + gait changes = Myelopathy
Upper Motor Neuron Signs
UMN Assessment
In Upper Limbs:
- Hoffman's sign
- Finger escape sign
- Grip and release test
Pattern:
- Increased tone (spasticity)
- Hyperreflexia
- Weakness in pyramidal pattern (extensors weaker)
- Pronator drift
Significance: If UMN signs present in upper limbs = cervical myelopathy (cord compression)
Summary Presentation
Viva scenarioStandard
Presenting Your Findings
Clinical prompt
“55-year-old man with neck pain radiating to the right arm.”
Examination Sequence
Systematic Approach
- Inspection: Wasting, fasciculations, posture
- Tone: Wrist, elbow, shoulder bilaterally
- Power: C5, C6, C7, C8, T1 myotomes bilaterally
- Sensation: C5-T1 dermatomes, peripheral nerve territories
- Reflexes: Biceps, triceps, brachioradialis
- Coordination: Finger-nose, rapid alternating
- UMN signs: Hoffman's, finger escape, pronator drift
- Special tests: Spurling's, Lhermitte's if indicated
- Compare sides: Every finding
- Document: MRC grade, sensory modality, reflex grade
Examiner Tips
Exam day cheat sheet
Scoring High in Upper Limb Neurology
Do
- Test myotomes systematically (C5-T1)
- Always compare sides
- Know reflex levels (C5-6 biceps, C7 triceps)
- Check for UMN signs (myelopathy screen)
- Present findings as a pattern (radiculopathy vs peripheral)
Don't
- Forget to look for wasting before testing power
- Skip testing sensation (critical for localization)
- Miss the inverted brachioradialis reflex (myelopathy sign)
- Confuse dermatomes with peripheral nerve territories
- Forget that disc at C5-6 compresses C6 root (not C5)