import { HighYieldBox, ExamCheatSheet, Tabs, Tab, ComparisonTable, VivaScenario, ContentSection, SpecialTestCard , MedicalImage} from '@/components/content' # Upper Limb Neurological Examination 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 ## Systematic Approach **The 4 Components:** 1. **Motor**: Power, tone, bulk 2. **Sensory**: Light touch, pinprick, proprioception 3. **Reflexes**: Biceps, triceps, brachioradialis 4. **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 **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 **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 **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 **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?" **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 **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 **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 **C6 Radiculopathy:** - **Motor**: Weak biceps, wrist extensors - **Sensory**: Thumb, lateral forearm - **Reflex**: Reduced biceps, brachioradialis **Common Cause:** C5-6 disc herniation (most common level) **C7 Radiculopathy:** - **Motor**: Weak triceps, wrist flexors, finger extensors - **Sensory**: Middle finger - **Reflex**: Reduced triceps **Common Cause:** C6-7 disc herniation **C8 Radiculopathy:** - **Motor**: Weak finger flexors (FDP), intrinsics - **Sensory**: Little finger, ulnar forearm - **Reflex**: None specific (may affect finger flexor) **Common Cause:** C7-T1 disc (less common) ## Differentiating Patterns **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 **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 ## Examination Sequence 1. **Inspection**: Wasting, fasciculations, posture 2. **Tone**: Wrist, elbow, shoulder bilaterally 3. **Power**: C5, C6, C7, C8, T1 myotomes bilaterally 4. **Sensation**: C5-T1 dermatomes, peripheral nerve territories 5. **Reflexes**: Biceps, triceps, brachioradialis 6. **Coordination**: Finger-nose, rapid alternating 7. **UMN signs**: Hoffman's, finger escape, pronator drift 8. **Special tests**: Spurling's, Lhermitte's if indicated 9. **Compare sides**: Every finding 10. **Document**: MRC grade, sensory modality, reflex grade ## Examiner Tips