Comprehensive upper limb neurological examination including dermatomal and myotomal testing, peripheral nerve assessment, and differentiation of radiculopathy from peripheral nerve lesions.
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.
High-Yield Exam Summary
The 4 Components:
Key Principle: Always compare sides and document findings using MRC grading for power and noting sensory modalities tested.
Look For:
Key Areas to Compare:
Technique:
Findings:
| root | movement | muscle | instruction |
|---|---|---|---|
| C5 | Shoulder abduction | Deltoid | Raise arms to sides, resist me pushing down |
| C5-6 | Elbow flexion | Biceps | Bend elbow, resist me straightening it |
| C6 | Wrist extension | ECRL/ECRB | Cock wrist back, resist me pushing down |
| C7 | Elbow extension | Triceps | Straighten elbow against my resistance |
| C7 | Wrist flexion | FCR/FCU | Flex wrist down, resist me lifting it |
| C8 | Finger flexion | FDP | Grip my fingers tightly |
| T1 | Finger abduction | Interossei | Spread fingers apart, don't let me push them together |
MRC Power Grading:
Practical Tip: In exams, grade 3 is easy to identify (can/can't move against gravity). Focus on distinguishing 4 from 5.
Key Landmarks:
Testing Technique:
Median Nerve:
Ulnar Nerve:
Radial Nerve:
Musculocutaneous Nerve:
Test C5-C6 nerve root
Elbow flexion
Intact C5-C6 reflex arc
Ability to detect true positives
Ability to exclude false positives
Test C7 nerve root
Elbow extension
Intact C7 reflex arc
Ability to detect true positives
Ability to exclude false positives
Test C5-C6 nerve root
Elbow flexion with supination
Intact C5-C6 reflex arc. Finger flexion instead = inverted reflex (myelopathy)
Ability to detect true positives
Ability to exclude false positives
Scale:
Interpretation:
Finger-Nose Test:
Rapid Alternating Movements:
Finger Chase:
Interpretation:
C5 Radiculopathy:
Common Cause: C4-5 disc herniation
| feature | radiculopathy | peripheralNerve | myelopathy |
|---|---|---|---|
| Pattern | Dermatomal (follows root) | Specific nerve territory | Below level of lesion |
| Weakness | Myotomes (multiple muscles, one root) | Muscles supplied by nerve | UMN pattern, pyramidal |
| Reflexes | Reduced at level | May be reduced if motor nerve | Increased below level |
| Tone | Normal or reduced | Normal or reduced | Increased (spasticity) |
| Other | Neck pain, Spurling's positive | Tinel's over nerve | Gait changes, Hoffman's positive |
Quick Differentiation:
In Upper Limbs:
Pattern:
Significance: If UMN signs present in upper limbs = cervical myelopathy (cord compression)
"55-year-old man with neck pain radiating to the right arm."
High-Yield Exam Summary