Pearls in PACES- CNS (Upper Limb)

Adel Hasanin
CNS UPPER LIMB
STEPS OF EXAMINATION
(1) APPROACH THE PATIENT
Read the instructions carefully for clues
Approach the right hand side of the patient, shake hands, introduce yourself
Ask permission to examine him
Ask the patient to sit upright on the edge of the bed facing you with the upper limbs adequately
exposed
(2) GENERAL INSPECTION
STEPS
1. Scan the bedside.
2. Scan the patient.

3. Examine the eyes

4.

Examine the hands: tell the

patient outstretch your hands
like this (dorsum facing
upwards) then like this
(palms facing upwards)
demonstrate. Feel the radial
pulse for AF

POSSIBLE FINDINGS
Walking stick
Nutritional status: under/average built or overweight
Abnormal facies: Sad, immobile, unblinking facies
(Parkinsons disease), facial wasting (muscular dystrophy),
facial asymmetry (hemiplegia), Horners syndrome
(syringomyelia, Pancoasts syndrome)
Abnormal movement or posture: rest or intention tremors,
dystonia, choreoathetosis, hemiballismus, myoclonic jerks,
tics, pyramidal posturesee theoretical notes for description,
types, features and causes of abnormal movements
Abnormal facial movements: hemifacial spasm, facial
myokymia, blepharospasm, oro-facial dyskinesia
Nystagmus (cerebellar syndrome)
Scar or deformity underlying an ulnar nerve palsy
Peroneal wasting (Charcot-Marie-Tooth disease)
Pes cavus (Friedreichs ataxia, Charcot-Marie-Tooth disease)
Nystagmus (cerebellar syndrome)
Horners syndrome (syringomyelia, Pancoasts syndrome)
wasted hands (MND, Charcot-Marie-Tooth disease,
syringomyelia)
AF consider thromboembolic complications

Pearls in PACES- CNS (Upper Limb)

Adel Hasanin
(3) INSPECTION OF THE UPPER LIMB
Steps
Scan the upper limb from the shoulder


down to the upper arm, lower arm and


hands. Compare right with left

Pronator
drift test

1.

Tell the patient hold

your arms outstretched
in front of you, like this
(palms facing
upwards), and maintain
this position.

2.

3.

Tell the patient keep

your arms up and do
not let me push them
down. Press the
patients wrist
downward and then
suddenly release it.
Tell the patient now
close your eyes.

Possible findings
Muscle bulk: wasting or hypertrophy
Fasciculations: irregular twitches under the skin
overlying muscle at rest; represent contraction of a motor
unit. They occur in LMNL; usually in wasted muscles
(nearly always indicate MND). Flicking the skin over
wasted muscle may elicit fasciculations. Non-pathological
fasciculations occasionally occurs after vigorous exercise
in healthy people.
Winging of scapula (lifts off the chest wall) indicates
weakness of the serratus anterior muscle (long thoracic
nerve; C5-C7).
Passive abduction of the little finger (myelopathy hand
sign) indicates either a pyramidal lesion or ulnar nerve
palsy (sensory testing should distinguish). As the lesion
becomes more severe, adjacent fingers also passively
abduct. This sign is common in, but not specific for,
cervical pyramidal lesions.
Involuntary movements (e.g. intention tremor in
cerebellar disease the arm oscillates several times
before coming to rest)
Overshoot (rebound phenomenon): in case of cerebellar
disease, the arm will fly past the starting point without
reflex arrest.

Arm pronates and fall downwards indicates subtle

UMN Weakness
Fingers continuously move up and down (sensory
wandering / pseudoathetosis) indicates deficit of joint
position sense due to lesion of peripheral nerves, posterior
column, or parietal lobe (parietal drift).
Arm drifts upward indicates cerebellar lesion

(4) TONE
1.
2.

3.

Steps
Tell the patient Let your legs go loose and let me move them for
you
Hold the patients hand as if shaking hands, using your other hand
to support the patients elbow. Flex and extend the wrist in rolling
wave fashion (to elicit cog-wheel rigidity of Parkinsons disease).
Then pronate and supinate the patients forearm, and flex and
extend his elbow and shoulder in an irregular and unexpected
fashion (to elicit lead-pipe rigidity and clasp-knife spasticity).

Possible findings

Normally there is light
resistance through whole
range of movements.

See theoretical notes for
abnormalities of the tone

Pearls in PACES- CNS (Upper Limb)

Adel Hasanin
(5) POWER
Steps
Tell the patient I am going to test the strength of
some of your muscles. Fix the joint proximal to the
group of muscles you are testing. Give the patient a
space to show his power before resisting him and look
at the muscle contracts. Compare right with left
1. Shoulder abduction: tell the patient Hold your
arms up, like this (chicken wings). Now keep
them up and dont let me push them down.
2.

Shoulder adduction: tell the patient Now take

them in towards you, like this and push my
hands

3.

Elbow flexion: tell the patient Bend your arm,

like this. Pull it towards you and dont let me
straighten it
Elbow extension: tell the patient Now straighten
your arm and push my hand
Wrist flexion: tell the patient Clench your fists
and bend your hand up towards you, like this.
Push my hand
Wrist extension: tell the patient Now push the
other way

4.
5.

6.

7.

8.

Finger extension: tell the patient Straighten

your fingers, like this (palm down) and dont let
me bend them (fix the patients wrist with your
left hand and push against the fingers with the
ulnar surface of your right hand)
Finger flexion: tell the patient Grip my fingers
tightly (offer two fingers)

Possible findings
Describe any weakness in terms of the medical
research council (MRC) scale from 5 (normal)
down to 0 (no visible muscle contraction)see
theoretical notes for the MRC scale for power
grading
Action by the deltoids (supplied by the axillary
nerve; C5). N.B: Lifting the arm from the side to
90 degrees tests the supraspinatus muscle
(supplied by the suprascapular nerve; C5)
Action by the pectoral muscles mainly pectoralis
major and latissimus dorsi (supplied by multiple
nerves mainly medial and lateral pectoral nerves;
C6,7,8)
Action by the biceps (supplied by the
musculocutaneous nerve; C5,6)
Action by the triceps (supplied by the radial
nerve; C6, C7,8)
Action by the flexor carpi radialis&ulnaris
(supplied by the median and the ulnar; C7)
Action by the extensor carpi radialis&ulnaris
(supplied by the posterior interosseous nerve from
the radial nerve; C7).
Action by the extensor digitorum (supplied by the
posterior interosseous from the radial nerve;
C7,8).

Action by the flexor digitorum profundus, flexor

digitorum superficialis, flexor policies longus,
flexor policies brevis and lumbricals (supplied by
the median and the ulnar nerves; C8, T1).
Action by the dorsal interossei (supplied by the
ulnar nerve; T1).

Finger abduction: tell the patient Spread your

fingers wide apart like this and dont let me push
them together
10. Finger adduction: tell the patient Hold this
Action by the palmar interossei (supplied by the
piece of paper between your fingers and dont let
ulnar nerve; T1).
me pull it out
11. Thumb abduction: tell the patient Straighten
Action by the abductor pollicis brevis (supplied
your hand, like this (palm upwards) and point
by the median nerve: C8, T1).
your thumb towards the ceiling, like this. Now
keep it there and dont let me push it down
12. Thumb opposition: tell the patient Touch the
Action by the opponens pollicis (supplied by the
tip of your little finger with the tip of your thumb, median nerve; T1).
like this and dont let me pull them apart
N.B. you may wish to skip testing the power in fingers and thumb unless specific mononeuropathy or
radiculopathy is suspected or neurological examination of the hand is requested in the instructions.
See theoretical notes for:
 Features and causes of the different patterns of weakness
 Clinical approach to weakness
 Motor root values in the upper limb
 Examples of mononeuropathies and radiculopathies in the upper limb
9.

Pearls in PACES- CNS (Upper Limb)

Adel Hasanin

(6) REFLEXES
Steps
Explain to the patient. place the patient supine on the bed in
a comfortable relaxed position. Use a long tendon hammer;
flex your wrist and let the hammer fall with its own weight
onto the muscle. Compare right with left. If the reflex
appears to be absent, ask the patient to clench his teeth as
you swing the hammer (reinforcement).
1. Biceps reflex: place the patients hands on his abdomen
(with the arms semiflexed and semipronated). Place your
index finger on the biceps tendon. Swing the hammer on
to your finger while watching the biceps muscle.
2. Supinator reflex: place your index finger on the radial
tuberosity. Swing the hammer on to your finger while
watching the brachioradialis muscle
3. Triceps reflex: draw the patients arm across the chest,
flexing the elbow to a right angle. Swing the hammer
directly on to the triceps tendon (just above the
olecranon) while watching the triceps muscle.
4. Finger reflex: rest the patient hand on the bed in partial
supination with the fingers slightly flexed. Place the
palmar surface of your middle and index fingers across
the palmar surface of the patients proximal phalanges.
Tap the back of your own fingers with the hammer.
Observe for flexion of the patient fingers (FDP and
FDS).
5. Hoffmans reflex: Hold the patients wrist (with your
left hand) in the horizontal pronated position with the
fingers and wrist relaxed. Place the ulnar surface of your
right index finger under the palmar surface of the DIP
joint of the patients middle finger. Using your right
thumb flick the patients finger downwards.

Possible findings
Grade the response from 0 (absent) up to
4+ (clonus) see theoretical notes for
reflexes grading

Reflex arc through the musculocutaneous

nerve; C5,6

Reflex arc through the radial nerve; C5,6

Reflex arc through the radial nerve; C7

Reflex arc through the median and ulnar

nerves; C8

Normally no reflex occurs unless the

patient is under emotional tension.
In UMNL, the patients thumb undergoes a
quick flexion-adduction-opposition
movement while the other fingers move in
flexion-adduction. This response is
labelled as a positive Hoffmanns sign.
5. Abdominal reflexes: the patient should be supine and
Normal response is contraction of the
relaxed. Using an orange stick lightly scratch the
recti with the umbilicus moving away
abdominal wall towards the umbilicus in the four
from the direction of the scratch.
quadrants of the stomach.

Afferent: segmental sensory nerves

Efferent: segmental motor nerves

Roots: T8,9 above the umbilicus, and
T11,12 below the umbilicus

Abdominal reflexes are absent in
UMNL above their spinal level, and in
LMNL affecting T8-12.

It is often impossible to elicit
abdominal reflexes in anxious patients,
elderly, obese, multiparous women,
and those who have had abdominal
surgery
N.B. you may wish to skip testing the finger reflex and Hoffmans reflex unless specific mononeuropathy
or radiculopathy is suspected or neurological examination of the hand is requested in the instructions.
See theoretical notes for abnormal tendon reflexes, and the root values for reflexes

Pearls in PACES- CNS (Upper Limb)

Adel Hasanin
(7) COORDINATION
Steps
1.

Finger-nose test: hold your index finger out an arms

length in front of the patient and tell the patient Touch
my finger with your index finger; now touch your nose;
repeat faster. Consider repeating the test while the
patients eyes are closed to test for sensory ataxia.
Compare right with left. Expect the right side to be
slightly better in right handed persons

Possible findings

Dyssynergia or incoordination
(cerebellar upper limb ataxia):
movements are imprecise in force and
direction.
Dysmetria: movements are imprecise
in distance. The finger overshoots its
target (past pointing) or it stops before
the target.
Intention tremor the patient
develops a tremor as his finger
approaches its target
Sensory ataxia: in case of deficit of
joint position sense, the original
movements are accurate but when
repeated with the eyes closed are
substantially worse
Dysdiadochokinesia: disorganization
of the movement cerebellar sign
Dysrhythmia: inability to keep a
rhythm - cerebellar sign

Rapid alternate movements: tell the patient repeatedly

tap the palm of one hand alternately with the palm and


then the back of the other hand as quickly as possible
(demonstrate).
Alternatively, tell the patient Twist your hand as if
opening a door or unscrewing a light bulb (demonstrate
by flexing your elbows at right angles and then pronating
and supinating your forearms as rapidly as possible).
Always compare right with left. Expect the right side to
be slightly better in right handed persons
3. Rapid repeated movements: tell the patient rapidly

Bradykinesia (slowed movements or
bring thumb and index finger together (demonstrate).
break up easily extrapyramidal sign)
Alternatively, tell the patient rapidly touch the thumb
with each finger in turn (demonstrate). Compare right
with left. Expect the right side to be slightly better in
right handed persons
N.B. do not assess coordination if power < 3 (inability to move against gravity), and tell the examiner that
coordination cannot be assessed due to weakness
See theoretical notes for types of ataxia and causes of ataxia
2.

Pearls in PACES- CNS (Upper Limb)

Adel Hasanin
(8) SENSATION
Steps
Possible findings

Reduced sensation over the
Pin prick:

Demonstrate the stimuli to the patient by testing on the
first dorsal interosseous
sternum (use each end of the hat pin): explain to the patient
radial nerve or C6 lesion
this is sharpand this is bluntnow Im going to test the

Reduced sensation over
sensation in your legs and I want you to close your eyes and
palmar surface of distal
say Sharp if it feels sharp, and blunt if it feels blunt.
phalanx of index finger

Start distally and move proximally testing over each
median nerve or C6 lesion
dermatome (and each main nerve): Skin over the first dorsal

Reduced sensation over
interosseous Palmar surface of distal phalanx of index
Palmar surface of distal
finger Palmar surface of distal phalanx of middle finger
phalanx of middle finger
Palmar surface of distal phalanx of little finger Inner
median nerve or C7 lesion
aspect of forearm Outer aspect of forearm Outer aspect
Reduced sensation over
of proximal part of upper arm Inner aspect of proximal
palmar surface of distal
part of upper arm. Repeat in the other side then compare
phalanx of little finger
right with left.
ulnar nerve or C8 lesion

Map out the boundaries of any area of reduced, absent or

Reduced sensation over inner
increased sensation; starting from the area of altered
aspect of forearm T1
sensation and moving towards normal to find the edges,
lesion
noting any difference between the two sides.

Reduced sensation over outer

If a stocking sensory loss is present, demonstrate that the
aspect of forearm C6
sensory loss is present right round the limb.
lesion

If compression of the cord is suspected, then demonstrate a

Reduced sensation over outer
sensory level.
aspect of proximal part of
upper arm C5 lesion
2. Light touch:

Demonstrate I am going to touch you with this piece of
Reduced sensation over inner
aspect of proximal part of
cotton wool and I want you to close your eyes and say (Yes)
upper arm T2 lesion
every time you feel it. Avoid dragging it across the skin or
tickling the patient. Time the stimuli irregularly to check the
See theoretical notes for
sensory root values
patient reliability.
(dermatomes) in the upper

Start distally and move proximally testing the upper limb
limb
in the same sequence as for pin prick
3. Joint position sense:

Demonstrate: fix the proximal phalanx of the patients
index finger with one of your hands. Hold the lateral aspects
of the distal phalanx of the patients index finger between the
thumb and index finger of your other hand. Ensure that your
thumb and index finger are at 90 degrees to the intended
direction of movement. Tell the patient Im going to move
your finger up and down; this is up (move finger up), and
this is down (move finger down)now close your eyes and
tell me whether I am moving your finger up or down.

Start with the DIP joint of the index finger. If impaired,
move to more proximal joints (DIP PIP MCP wrist
elbow shoulder).
N.B. vibration sense is commonly
4. Vibration sense:

Demonstrate: use a 128 Hz tuning fork. Make the fork reduced or absent in elderly
vibrate and place it on the sternum. Ask the patient Do you patients
feel it vibrating (buzzing)?

Tell the patient Close your eyes. Make the fork vibrate
silently and place it on the the DIP joint of the index finger
and ask the patient Can you feel it now? If patient cannot
feel the vibration, move to more proximal joints (DIP PIP
MCP radial styloid olecranon acromion).
See theoretical notes for modalities and tracts of sensation, patterns, causes and approach to sensory loss
1.

Pearls in PACES- CNS (Upper Limb)

Adel Hasanin
(9) Additional signs: according to diagnosis, e.g.
Look for cataract and scar for pacemaker, palpate for local spinal tenderness, and examine for sensory
level
Tell the examiner that you would normally extend your examination to examine the lower limb and
cranial nerves and woud ask about swallowing (Dystrophia myotonica), bladder symptoms, test the
anal tone (spinal cord syndrome), and to dipstick urine for DM.
(10) Thank the patient and cover him (her)

Pearls in PACES- CNS (Upper Limb)

Adel Hasanin
THEORETICAL NOTES
DESCRIPTION, TYPES, FEATURES AND CAUSES OF ABNORMAL MOVEMENTS: See Ch. 6
CNS Lower Limb
ABNORMALITIES OF THE TONE: See Ch. 6 CNS Lower Limb
THE MEDICAL RESEARCH COUNCIL (MRC) SCALE FOR POWER GRADING: See Ch. 6 CNS
Lower Limb
FEATURES AND CAUSES OF THE DIFFERENT PATTERNS OF WEAKNESS: See Ch. 6 CNS
Lower Limb
CLINICAL APPROACH TO WEAKNESS: See Ch. 6 CNS Lower Limb
MOTOR ROOT VALUES IN THE UPPER LIMB
Root value
Muscle action
C5
Shoulder abduction
C5,6,7
Shoulder adduction
C5,6
Elbow flexion
C7,8
Elbow extension
C6
Pronation, supination
C7
Wrist flexion and extension, finger flexion and extension
T1
Thumb opposition and splaying of fingers
N.B. all muscles on the back of upper limb (triceps, wrist and finger extensors) are innervated by C7

Pearls in PACES- CNS (Upper Limb)

Adel Hasanin
EXAMPLES OF MONONEUROPATHIES AND RADICULOPATHIES IN THE UPPER LIMB
Lesion
Features

Wasting of the thenar eminence
Median nerve

Weakness of opposition, abduction and flexion of the thumb
palsy

Sensory loss over the palmar aspect of the lateral 3 fingers


Generalized muscle wasting and weakness sparing the LOAF ( wasting of
Ulnar nerve palsy
the hypothenar eminence and first dorsal interosseous, and guttering of the
dorsum of the hand)

Ulnar claw hand (hyperextension at the MCP joints with flexion of the IP joints
in the fourth and fifth fingers)

Sensory loss over the medial 1 fingers

Wasting of all small muscles of the hand.
T1 root lesion

Sensory changes are confined to the medial forearm
Radial nerve palsy
Weakness of fingers and wrist extension and probably brachioradialis &
supinator (if damage occurs at the middle third of humerus). Paralysis may
involve the triceps (if damage occurs at the axilla) loss of elbow extension.

If the wrist is passively extended the patient is able to straighten his fingers at
the IP joints due to the action of interossei and lumbricals, but is unable to
extend the MCP joints

There appears to be a weakness in abduction and adduction of the fingers, but
this is not present when the hand is kept flat on a table and the fingers are
extended

Wrist-drop, and weak grip (due to missing synergistic effect of an extended
wrist)

Sensory loss over the first dorsal interosseous (at the anatomical snuff box)

Loss of supinator reflex (triceps reflex may also be lost if lesion above spiral
groove).

If there is no sensory loss whatsoever, in a patient with symptoms of
progressive radial nerve palsy, then a lesion of the posterior interosseous nerve
(the main, purely motor, branch of the radial nerve) may be suspected and
surgical exploration is considered.
Bilateral wasting of
With distal sensory loss peripheral neuropathy

Without sensory loss MND
small muscles of
the hand

Weakness of shoulder abduction and external rotation and elbow flexion
C5 root lesion

Loss of biceps reflex

Sensory loss over the outer aspect of upper arm

Weakness of elbow flexion, Pronation
C6 root lesion

Loss of supinator reflex

Sensory loss over the lateral aspect of forearm and thumb

Weakness of elbow and wrist extension
C7 root lesion
(compare to radial
Loss of triceps reflex

Sensory loss over the middle finger
nerve)

Weakness of finger flexion
C8 root lesion

Loss of finger reflex

Sensory loss over the medial aspect of forearm

Weakness of shoulder abduction (deltoid)
Axillary nerve

Sensory loss over small patch on lateral part of shoulder
palsy
REFLEXES GRADING: See Ch. 6 CNS Lower Limb
ABNORMAL TENDON REFLEXES: See Ch. 6 CNS Lower Limb
THE ROOT VALUES FOR REFLEXES: See Ch. 6 CNS Lower Limb
TYPES AND CAUSES OF ATAXIA: See Ch. 6 CNS Lower Limb
MODALITIES AND TRACTS OF SENSATION: See Ch. 6 CNS Lower Limb
PATTERNS AND CAUSES OF SENSORY LOSS: See Ch. 6 CNS Lower Limb

Pearls in PACES- CNS (Upper Limb)

Adel Hasanin
CLINICAL APPROACH TO SENSORY LOSS: See Ch. 6 CNS Lower Limb
THE SENSORY ROOT VALUES (DERMATOMES) IN THE UPPER LIMB
Root value
Dermatome
The root of neck
C3
Tip of shoulder
C4
Lateral aspect of upper arm
C5
Lateral aspect of forearm and hand including the thumb
C6
Middle finger
C7
Medial aspect of the hand including the little finger
C8
Medial aspect of forearm
T1
Medial aspect of the upper arm
T2
Axilla
T3
BRACHIAL PLEXUS (C5,6,7,8,T1): Gives rise to 3 cords (posterior, medial, and lateral), which give rise
to the 3 main nerves of the upper limb (radial, ulnar, and median)
RADIAL NERVE (C5,6,7,8):
 Radial nerve is the main continuation of the posterior cord supplies the extensors in the back of
upper limb
 Motor to the BEST extensors of the upper limb (Brachioradialis, Extensors of wrist and fingers,
Supinator, Triceps)
 The axillary nerve (C5,6) is the smaller terminal branch, and supplies both the deltoid and teres major
muscle
 The radial nerve gives off two branches at the elbow:
 Superficial radial (entirely sensory)
 Posterior interosseous (entirely muscular)
 In contrast to median and ulnar nerves: the radial nerve has C5 root and has no Thoracic roots,
supplies no muscles in the hand, and no complete finger; whereas ulnar and median nerves supply no
muscles in the upper arm
 Radial nerve palsy:

Weakness of fingers and wrist extension and probably brachioradialis & supinator (if damage
occurs at the middle third of humerus). Paralysis may involve the triceps (if damage occurs at the
axilla) loss of elbow extension.

If the wrist is passively extended the patient is able to straighten his fingers at the IP joints due to
the action of interossei and lumbricals, but is unable to extend the MCP joints

There appears to be a weakness in abduction and adduction of the fingers, but this is not present
when the hand is kept flat on a table and the fingers are extended

wrist-drop, and weak grip (due to missing synergistic effect of an extended wrist)

Sensory loss over the first dorsal interosseous (the anatomical snuff box)

Loss of supinator reflex (triceps reflex may also be lost if lesion above spiral groove).

If there is no sensory loss whatsoever, in a patient with symptoms of progressive radial nerve
palsy, then a lesion of the posterior interosseous nerve (the main, purely motor, branch of the
radial nerve) may be suspected and surgical exploration is considered.
MEDIAN NERVE (C6,7,8,T1):
 Median nerve arises from the lateral and medial cords supplies lateral 2 lumbricals and lateral 3
fingers
 Motor to LOAF: Lateral 2 lumbricals, Opponens pollicis, Abductor pollicis, Flexor pollicis brevis
& Forearm flexors except flexor carpi ulnaris & ulnar of flexor digitorum profundus
 Median nerve palsy:

wasting of the thenar eminence

weakness of opposition, abduction and flexion of the thumb

sensory loss over the palmar aspect of the lateral 3 fingers

10

Pearls in PACES- CNS (Upper Limb)

Adel Hasanin
ULNAR NERVE (C7,8,T1):
 Ulnar nerve is the main continuation of the medial cord supplies medial 2 lumbricals and
medial 1 fingers
 Motor to MAFIA: Medial 2 lumbricals, Adductor pollicis, Flexor carpi ulnaris & ulnar of
Flexor digitorum profundus, Interossei, Abductor & flexor digiti minimi
 Ulnar nerve palsy:

Generalized wasting and weakness of the muscle of the hand sparing the thenar eminence
(i.e. wasting of the hypothenar eminence and first dorsal interosseous, and guttering of the
dorsum of the hand)

Ulnar claw hand (hyperextension at the MCP joints with flexion of the IP joints in the fourth
and fifth fingers)

Sensory loss over the medial 1 fingers

11