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Published on October 2nd, 2010 | by Lewis Potter

Upper Limb Neurological Examination – OSCE Guide

Upper limb neurological examination  frequently appears in OSCE’s.  You’ll be expected to pick up the relevant clinical signs using your examination skills. This upper limb neurological examination OSCE guide provides a clear concise, step by step approach to examining the neurology of the upper limbs, with an included video demonstration.

Introduction

Wash hands

Introduce yourself

Explain what you’d like to examine

Gain consent

Expose patients arms & trunk

Ask if patient has any pain anywhere before you begin!

Inspection

Observe for clues around the bed - wheelchair / walking stick /splints

General appearance - is the patient comfortable at rest?

Muscle wasting 

Tremor – parkinsons disease / benign essential tremor

Abnormal posture?

Tone

Ask the patient to relax & allow you to take control of their arm

1. Support the patients arm by holding their hand & elbow

2. Move the wrist through it’s full range of motion – 360º

3. Pronate & supinate the forearm

4. Flex & extend  the elbow joint

5. Flex/extend/abduct/adduct the shoulder joint

Note the character of the movement – smooth / ↑tone/ ↓ tone (flaccid)

Tone 2 Tone

 

Power
Shoulders

Abduction (C5) - “Don’t let me push your shoulders down”

Adduction  (C6/7) - “Don’t let me pull your arms away from your sides”

Shoulder Abduction Shoulder adduction

Arms

Flexion (C5/6)“Don’t let me pull your arm away from you”

Extension (C7) - “Don’t let me push your arm towards you”

Bicep Flexion Tricep Extension

 

 

Wrist

Extension (C6/7) “Cock your wrists back & don’t let me pull them down”

Flexion (C6/7) - “Point your wrists downwards & don’t let me pull them up”

Wrist Extension Wrist Flexion.

Fingers 

Finger extension (C7/8) - “Put your fingers out straight & don’t let me push them down”

Finger flexion (C8) - Put your fingers out straight & don’t let me push them up

Finger Extension fINGER flEXION

 

 

 

Finger abduction (T1)“Splay your fingers & don’t let me push them together”

Finger adduction (T1) - “Hold this paper between your fingers & don’t let me pull it out”

Finger abduction Finger adduction

 

 

 

 

Thumb abduction (C7/T1) - “Point your thumbs to the ceiling and don’t let me push them down”

Thumb adduction (C7/T1) - “Don’t let me push you thumb away from your palm”

Thumb abduction Thumb Adduction

 

Pincer Grip 

1. Get the patient to place their thumb & index finger together

2. Attempt to pull them apart

Pincer grip 
 
 
 
 
 
 
 
 
 
 
Power Grip

1. Get the patient to grip your fingers tightly

2. Attempt to remove your fingers from their grasp

3. If your fingers can easily escape it suggests an abnormally weak grip

Power grip

 

 

 

 

 

 

 

 

 

 

Reflexes

For each of the reflexes, ensure the patients’ upper limb is completely relaxed

Place your finger over tendon being assessed & strike with the tendon hammer

 

1. Supinator reflex (C6) - located 4 inches proximal to base of the thumb

2. Biceps reflex (C5/6) - located in the cubital fossa

Supinator ReflexBiceps Reflex

3. Triceps reflex (C7) - place forearm rested at 90º flexion - tap your finger overlying the triceps tendon

Triceps reflex

 

 

 

 

 

 

 

 

 

Sensation
Soft touch sensation

1. The patients eyes should be closed for this assessment

2. Ask the patient to say “yes” when they are touched

3. Using a wisp of cotton wool, gently touch the skin

4. Assess each of the dermatomes of the upper limbs / torso

5. Compare left to right, by asking the patient if it feels the same

Pin-prick sensation 

Repeat the previous assessment steps, but this time using the sharp end of a neuro-tip

Soft touch example Sharp sensation

 

Vibration sensation

1, Ask patient to close their eyes
2. Tap a 128hz tuning fork
3. Place onto patients sternum & confirm patient can feel it buzzing
4. Ask patient to tell you when they can feel it on their hand & to tell you when it stops buzzing
5. Place onto DIP joint of the forefinger

6. If sensation is impaired, continue to assess more proximally - e.g. IPJ / MCP

Proprioception

1. Hold the distal phalanx of the thumb by its sides

2. Demonstrate movement of the thumb “upwards” & “downwards” to the patient (whilst they watch)

3. Then ask patient to close their eyes & state if you are moving the thumb up or down

4. If the patient is unable to correctly identify direction of movement, move to a more proximal joint

Vibration sensation Proprioception

 

Co-ordination
Pronator drift

1. Ask patient to close eyes & place arms outstretched forwards with palms facing up

2. Observe the hands / arm for signs of pronation

If pronation occurs in one of the arms, it indicates contralateral UMN pathology

 

Finger to nose test

1. Ask patient to touch their nose with the tip of their index finger, then touch your finger tip

2. Position your finger so that the patient has to fully outstretch their arm to reach it

3. Ask them to continue to do this finger to nose motion as fast as they can manage

4. Move your finger, just before the patient is about to leave their nose,  to create a moving target (↑sensitivity)

An inability to perform this test accurately (past pointing/dysmetria) may suggest cerebellar pathology

Pronator drift Finger to nose

 

 

Dysdiadokinesia

1. Demonstrate patting the palm of your hand with the back/palm of your other hand to the patient

2. Ask the patient to mimic this rapid alternating movement

3. Then have the patient repeat this movement on their other hand

An inability to perform this rapidly alternating movement (very slow/irregular) suggests cerebellar ataxia

Palm tapping

 

 

 

 

 

 

 

 

To complete the exam

Thank patient

Wash hands

Summarise findings

.

Say you would…

Perform a full neurovascular examination of the upper limbs

Perform a full neurological examination if indicated

Request further imaging (CT/MRI head/spine) if indicated

..

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