Upper limb neurological examination frequently appears in OSCEs. 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 step by step approach to examining the neurology of the upper limbs, with an included video demonstration.
The main point of a neurological examination is to localise where in the nervous system the problem is. This can seem daunting, but with practice, it is relatively straightforward. The most basic localisation question you have to think about during the upper(and lower) limb examination is:
- Is there an upper motor neurone (UMN) lesion? – i.e. in the brain or spine
- Or is there a lower motor lesion (LMN)? – i.e. in the nerve roots, peripheral nerve, neuromuscular junction or muscle
The following is a summary of some basic UMN and LMN signs that you should be looking out for during the upper and lower limb examinations:
|UMN signs||LMN signs|
|Inspection||No fasciculation or significant wasting (may be some disuse atrophy or contractures)||Wasting and fasciculation of muscles|
|Pronator drift||May be present||May be some drift/movement of arm(s) if weak or de-afferented, but not pronator|
|Tone||Increased (spasticity) +/- ankle clonus||Decreased (hypotonia) or normal|
|Power||Classically a “pyramidal” pattern of weakness (extensors weaker than flexors in arms, and vice versa in legs)||Different patterns of weakness, depending on cause e.g. classically a proximal weakness in muscle disease, a distal weakness in peripheral neuropathy|
|Reflexes||Exaggerated or brisk (hyper-reflexia)||Reduced or absent (hyporeflexia or areflexia)|
|Plantar reflexes||Upgoing/extensor (Babinski positive)||Normal (downgoing/flexor)|
Confirm patient details – name / DOB
Expose patient’s arms fully
Ask if the patient currently has any pain
- Tendon hammer
- Cotton wool
- Tuning fork (128Hz)
Observe for clues around the bed – wheelchair / walking stick / urinary catheter
General appearance – any limb deformity or posturing?
- Wasting of muscles
- Involuntary movements – dystonia / chorea / myoclonus
- Tremor – Parkinson’s disease / essential tremor
Don’t forget to look at the face for clues e.g hypomimia (lack of expression) in Parkinson’s disease, ptosis and frontal balding in myotonic dystrophy, ptosis and ophthalmoplegia in myasthenia gravis.
1. Ask the patient to close their eyes and place arms outstretched forwards with palms facing up.
2. Observe the hands and arms for signs of pronation.
If pronation occurs in one of the arms, it indicates upper motor neuron (UMN) pathology.
Ask the patient to let their arm go floppy, whilst you move each major joint.
1. Support the patient’s arm by holding their hand and elbow
2. Move the wrist through its full range of motion
3. Pronate and supinate the forearm – feel for any spasticity (“spastic catch”)
4. Flex and extend the elbow joint
5. Flex/extend/abduct/adduct the shoulder joint
Note the character of the movement – smooth / ↑tone/ ↓ tone (flaccid)
Feel for rigidity and cogwheeling – indicative of Parkinson’s disease
Spasticity indicates an UMN lesion and rigidity indicates an extrapyramidal lesion (Parkinsonism). Tone is increased in both of them, …what’s the difference???
- Spasticity is “velocity dependent” i.e. the faster you move the limb, the worse it is. This is why you get the “spastic catch”
- Rigidity is “velocity independent” i.e. it feels the same if you move the limb fast or slowly. This is termed “lead pipe rigidity”
Assess power one side at a time and compare like for like.
Remember to stabilise and isolate the joint when testing.
The following is a test of some of the main movements of the upper limbs, sufficient to show most pathology.
Use the MRC muscle power assessment scale for scoring muscle strength.
ABduction (C5) – “Don’t let me push your shoulders down”
ADduction (C6/7) – “Don’t let me pull your arms away from your sides”
Flexion (C5/6) – “Don’t let me pull your arm away from you”
Extension (C7) – “Don’t let me push your arm towards you”
Extension (C6) – “Cock your wrists back and don’t let me pull them down”
Flexion (C6/7) – “Point your wrists downwards and don’t let me pull them up”
Finger extension (C7) – “Put your fingers out straight and don’t let me push them down”
Finger ABduction (T1) – “Splay your fingers and don’t let me push them together”
- First dorsal interosseous (FDI)
- Abductor digiti minimi (ADM)
Thumb ABduction (C8/T1) – “Point your thumbs to the ceiling and don’t let me push them down”
*SEE RAPID SCREEN TABLE AT THE END FOR A QUICK WAY TO ASSESS NERVES
Deep tendon reflexes
For each of the reflexes, ensure the patient’s upper limb is completely relaxed (hold at the end of the handle and allow gravity to aid a good swing onto your finger).
If a reflex appears absent: make sure the patient is fully relaxed and then perform a reinforcement manoeuvre – ask the patient to clench their teeth together, whilst you hit the tendon.
1. Biceps reflex (C5/6) – located in the antecubital fossa
2. Triceps reflex (C7) – place forearm rested at 90º flexion – tap your finger overlying the triceps tendon
3. Supinator reflex (C6) – located 4 inches proximal to base of the thumb
It’s easy to get bogged down in examining sensation. Check at least one modality each from the dorsal columns and spinothalamic tracts. Demonstrate the normal sensation on their sternum and ask them if it feels the same on the limb.
Light touch sensation
Assesses dorsal/posterior columns and spinothalamic tracts.
1. Touch the patient’s sternum with the wisp of cotton wool to confirm they can feel it
2. Ask the patient to say “yes” when they are touched
3. Using the wisp of cotton wool, gently touch the skin
4. Assess each of the dermatomes of the upper limbs
5. Compare left to right, by asking the patient if it feels the same on both sides
Assesses spinothalamic tracts.
Repeat the previous assessment steps, but this time using the sharp end of a neuro-tip.
If loss of sensation is noted distally, test for “glove” distribution of sensory loss (peripheral neuropathy) by moving distal to proximal.
Assesses dorsal/posterior columns.
1. Ask the patient to close their eyes
2. Tap a 128 Hz tuning fork
3. Place onto the patient’s sternum and confirm they can feel it buzzing
4. Place onto the distal interphalangeal joint of the forefinger and ask them if they can feel it buzzing
5. If vibration sensation is impaired, continue to assess the bony prominence of more proximal joints (interphalangeal joint of thumb →carpometacarpal joint of thumb → elbow → shoulder)
Assesses dorsal/posterior columns.
1. Hold the distal phalanx of the thumb by its sides
2. Demonstrate movement of the thumb “upwards” and “downwards” to the patient (whilst they watch)
3. Then ask the patient to close their eyes and 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 (finger > wrist > elbow > shoulder)
Finger to nose test
1. Ask the patient to touch their nose with the tip of their index finger, then touch your fingertip
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 are able to
4. Repeat the test using the patient’s other hand
An inability to perform this test accurately (past pointing/dysmetria) may suggest cerebellar pathology. It can also be impaired in a sensory ataxia (caused by loss of proprioception) or if there is weakness in the arm.
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. Encourage them to do this alternating movement as fast as they are able to
4. Repeat test using the patient’s other hand
An inability to perform this rapidly alternating movement (very slow/irregular) suggests cerebellar ataxia (also can be impaired in a sensory ataxia or with Parkinsonism)
To complete the examination
Suggest further assessments and investigations
- Cranial nerve examination
- Lower limb neurological examination
- Further imaging if indicated – e.g. CT / MRI cervical spine
Rapid screen table
|Nerve (root)||Example muscle||Action||Sensation||Reflex|
|Axillary (C5)||Deltoid||Shoulder abduction||Regimental badge over deltoid muscle||–|
|Musculocutaneous (C5-C6)||Biceps||Elbow flexion||Lateral aspect of forearm||Biceps|
|Radial (C7)||Extensors (Extensor carpi radialis/ulnaris and digitorum)||Wrist/finger extension||Radial fossa (‘anatomical snuffbox’)||Triceps|
|Ulnar (T1)||First dorsal interosseus (FDI)||Index finger abduction||Palmar aspect of medial side of hand, little finger and medial border of ring finger||–|
|Median (T1)||Abductor pollicis brevis (APB)||Thumb abduction||Palmar aspect of lateral side of hand, thumb, index middle and lateral border of ring finger||–|
Dr Gemma Maxwell
Neurology Registrar (ST6)