NEUROLOGICAL EXAMINATIONUPPER LIMB

14. 2. 2013

Kaan Yücel

M.D., Ph.D.

http://yeditepeanatomy1.org

A TOTAL OF XXFIGURES IN THE TEXT

. Dr. Kaan Yücel http://yeditepeanatomy1.org Neurological examination-Upper limb

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Dr. Kaan Yücel http://yeditepeanatomy1.org Neurological examination-Upper limb

SHOULDERTo test the deltoid (or the function of the axillary nerve that supplies it), the arm is abducted, starting

from approximately 15°, against resistance. If acting normally, the deltoid can easily be seen and palpated. The influence of gravity is avoided when the person is supine.

To test the supraspinatus, abduction of the arm is attempted from the fully adducted position against resistance, while the muscle is palpated superior to the spine of the scapula. The supraspinatus and the middle deltoid muscles are tested together.

To test the infraspinatus, the person flexes the elbow and adducts the arm. The arm is then laterally rotated against resistance. If acting normally, the muscle can be palpated inferior to the scapular spine. To test the function of the suprascapular nerve, which supplies the supraspinatus and infraspinatus, both muscles must be tested as described. The two lateral rotator muscles; the infraspinatus and teres minör are tested together.

To test for degenerative tendonitis of the rotator cuff, the person is asked to lower the fully abducted limb slowly and smoothly. From approximately 90° abduction, the limb will suddenly drop to the side in an uncontrolled manner if the rotator cuff (especially the supraspinatus part) is diseased and/or torn.

ARMTo test the biceps brachii, the elbow joint is flexed against resistance when the forearm is supinated. If

acting normally, the muscle forms a prominent bulge on the anterior aspect of the arm that is easily palpated.To test the brachialis, the forearm is semipronated and flexed against resistance. If acting normally, the

contracted muscle can be seen and palpated.To test the triceps (or to determine the level of a radial nerve lesion), the arm is abducted 90° and then

the flexed forearm is extended against resistance provided by the examiner. If acting normally, the triceps can be seen and palpated. Its strength should be comparable with the contralateral muscle, given consideration for lateral dominance (right or left handedness).

ANTERIOR COMPARTMENT OF THE FOREARMTo test the flexor carpi ulnaris, the person puts the posterior aspect of the forearm and hand on a flat

table and is then asked to flex the wrist against resistance while the examiner palpates the muscle and its tendon.To test the palmaris longus, the wrist is flexed and the pads of the little finger and thumb are tightly

pinched together. If present and acting normally, the tendon can be easily seen and palpated.To test the flexor carpi radialis, the person is asked to flex the wrist against resistance. If acting

normally, its tendon can be easily seen and palpated.To test the pronator teres, the person's forearm is flexed at the elbow and pronated from the supine

position against resistance provided by the examiner. If acting normally, the muscle is prominent and can be palpated at the medial margin of the cubital fossa.

To test the flexor digitorum superficialis, one finger is flexed at the proximal interphalangeal joint against resistance and the other three fingers are held in an extended position to inactivate the flexor digitorum profundus.

To test the flexor digitorum profundus, the proximal interphalangeal joint is held in the extended position while the person attempts to flex the distal interphalangeal joint. The integrity of the median nerve in the proximal forearm can be tested by performing this test using the index finger, and that of the ulnar nerve can be assessed by using the little finger.

To test the flexor pollicis longus, the proximal phalanx of the thumb is held and the distal phalanx is flexed against resistance.

POSTERIOR COMPARTMENT OF THE FOREARM & HANDTo test the brachioradialis, the elbow joint is flexed against resistance with the forearm in the midprone

position. If the brachioradialis is acting normally, the muscle can be seen and palpated.To test the extensor carpi radialis longus, the wrist is extended and abducted with the forearm pronated.

If acting normally, the muscle can be palpated inferoposterior to the lateral side of the elbow. Its tendon can be palpated proximal to the wrist.

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. Dr. Kaan Yücel http://yeditepeanatomy1.org Neurological examination-Upper limb

To test the extensor digitorum, the forearm is pronated and the fingers are extended. The person attempts to keep the digits extended at the metacarpophalangeal joints as the examiner exerts pressure on the proximal phalanges by attempting to flex them. If acting normally, the extensor digitorum can be palpated in the forearm, and its tendons can be seen and palpated on the dorsum of the hand.

To test the extensor carpi ulnaris, the forearm is pronated and the fingers are extended. The extended wrist is then adducted against resistance. If acting normally, the muscle can be seen and palpated in the proximal part of the forearm and its tendon can be felt proximal to the head of the ulna.

To test the extensor digiti minimi, the little finger is extended against resistance while holding digits 2-4 flexed at the metacarpophalangeal joints.

To test the abductor pollicis longus, the thumb is abducted against resistance at the metacarpophalangeal joint. If acting normally, the tendon of the muscle can be seen and palpated at the lateral side of the anatomical snuff box and on the lateral side of the adjacent extensor pollicis brevis tendon.

To test the extensor pollicis brevis, the thumb is extended against resistance at the metacarpophalangeal joint. If the extensor pollicis brevis is acting normally, the tendon of the muscle can be seen and palpated at the lateral side of the anatomical snuff box and on the medial side of the adjacent abductor pollicis longus tendon.

To test the extensor pollicis longus, the thumb is extended against resistance at the interphalangeal joint. If the extensor pollicis longus is acting normally, the tendon of the muscle can be seen and palpated on the medial side of the anatomical snuff box.

To test the abductor pollicis brevis, abduct the thumb against resistance. If acting normally, the muscle can be seen and palpated.

To test the flexor pollicis brevis, flex the thumb against resistance. If acting normally, the muscle can be seen and palpated; however, keep in mind that the flexor pollicis longus also flexes the thumb.

To test the lumbrical muscles, with the palm facing superiorly the patient is asked to flex the metacarpophalangeal (MP) joints while keeping the interphalangeal joints extended. The examiner uses one finger to apply resistance along the palmar surface of the proximal phalanx of digits 2-5 individually. Resistance may also be applied separately on the dorsal surface of the middle and distal phalanges of digits 2-5 to test extension of the interphalangeal joints, also while flexion of the MP joints is maintained.

To test the dorsal interossei, the examiner holds adjacent extended and adducted fingers between thumb and middle finger, providing resistance as the individual attempts to abduct the fingers (the person is asked to “spread the fingers apart”). To test the palmar interossei, a sheet of paper is placed between adjacent fingers. The individual is asked to “keep the fingers together” to prevent the paper from being pulled away by the examiner.

SUPERFICIAL MUSCLES OF THE BACKTo test the trapezius (or the function of the spinal accessory nerve [CN XI] that supplies it), the shoulder

is shruggedx against resistance (the person attempts to raise the shoulders as the examiner presses down on them). If the muscle is acting normally, the superior border of the muscle can be easily seen and palpated.

To test the latissimus dorsi (or the function of the thoracodorsal nerve that supplies it), the arm is abducted 90° and then adducted against resistance provided by the examiner. If the muscle is normal, the anterior border of the muscle can be seen and easily palpated in the posterior axillary fold.

To test the rhomboids (or the function of the dorsal scapular nerve that supplies them), the individual places his or her hands posteriorly on the hips and pushes the elbows posteriorly against resistance provided by the examiner. If the rhomboids are acting normally, they can be palpated along the medial borders of the scapulae; because they lie deep to the trapezius, they are unlikely to be visible during testing.

PECTORAL REGION & MAMMARY GLANDSTo test the clavicular head of pectoralis major, the arm is abducted 90°; the individual then moves the

arm anteriorly against resistance. If acting normally, the clavicular head can be seen and palpated.To test the sternocostal head of the pectoralis major, the arm is abducted 60° and then adducted

against resistance. If acting normally, the sternocostal head can be seen and palpated.To test the serratus anterior (or the function of the long thoracic nerve that supplies it), the hand of the

outstretched limb is pushed against a wall. If the muscle is acting normally, several digitations of the muscle can be seen and palpated.

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Dr. Kaan Yücel http://yeditepeanatomy1.org Neurological examination-Upper limb

RegIons & MUSCLESAnterior arm: C oracobrachialis Brachialis Biceps brachii Function flexion- adduction arm main flexor of forearm flexor of the forearm @ elbow joint supinator of forearm when elbow flexed Posterior arm: Triceps brachiiFunction forearm extensionAnterior forearm sprfcl: Flexor carpi ulnaris Palmaris longus Flexor carpi radialis Pronator teresFunction flexor and adductor of wrist flexor of wrist flexor,abductor of wrist rotates radius over ulna Anterior forearm intermediate: Flexor digitorum superficialisFunction flexes metacarpophalangeal joint- proximal interphalangeal joint , flexes wrist Anterior forearm deep: Flexor digitorum profundus Flexor pollicis longus Pronator quadratusFunction flexes the distal phalanges flexes thumb prime mover for pronationPosterior forearm sprfcl: Brachioradialis Extensor carpi radialis longus Extensor carpi radialis brevis Extensor digitorum Extensor digiti minimi Extensor carpi ulnaris AnconeusFunction Brachioradialis flexion of forearm; maximal when forearm in midpronated position, others extending the hand (…radialis abducting the hand, …ulnaris adducting the hand)Posterior forearm deep: Supinator Abductor pollicis longus Extensor pollicis brevis Extensor pollicis longus Extensor indicisFunction Supinator: supination of forearm, abduction of thumb, extension of proximal (EPB) and distal (EPL) phalangesHand: Palmaris brevis Adductor pollicis Thenar Hypothenar Function adductor of the thumb opposition,flexion,abduction Lumbricals Interossei Function flex metacarpophalangeal joints & extendi interphalangeal joints palmar:adduction of fingers, dorsal: abduction @ metacarpophalangeal jointsShoulder: Trapezius Latissimus dors Function rotates the lateral aspect of the scapula upward adductor of the humerus; downward rotation of the scapula Levator scapulae Rhomboids Function elevates scapula, or fix it retract & rotate scapula; assist the serratus anterior in holding the scapula against the thoracic wall Deltoid Subscapularis Supraspinatus Function abduction of the arm beyond the initial 15° Medially rotates arm initiates & assists deltoid in abduction of arm İnfraspinatus Teres minor Teres major Function laterally rotates arm adducts and medially rotates armBack: Serratus posterior superior Serratus posterior inferiorFunction elevate and depress the ribsPectoral region: Pectoralis major Pectoralis minor Subclavius Serratus anteriorFunction adduction & medial rotation of the arm pull the tip of the shoulder inferiorly rotates the scapula, elevating its glenoid cavity so the arm can be raised above the shoulder

REGIONS & Nerves (Motor INNERVATION ONLY)5

. Dr. Kaan Yücel http://yeditepeanatomy1.org Neurological examination-Upper limb

Anterior arm: Musculocutaneous nervePosterior arm: Radial nerveAnterior forearm: Median nerve & ulnar nerve (flexor carpi ulnaris, medial half of flexor digitorum profundus)Posterior forearm: Radial nerveHand: All of the intrinsic muscles of the hand are innervated by the deep branch of the ulnar nerve except for the three thenar and two lateral lumbrical muscles, which are innervated by the median nerve. Shoulder: Axillary nerve, Suprascapular nerve, Sup. & Inf. subscapular nerves, Accessory nerve [XI], Thoracodorsal nerve, Dorsal scapular nerveBack: Accessory nerve [XI], Thoracodorsal nerve, Dorsal scapular nerve, Intercostal nerves, the superior by the first four intercostals and the inferior by the last fourPectoral region: Lateral and Medial pectoral nerves, Nerve to subclavius, Long thoracic nerve

REGIONS & sensory INNERVATIONShoulder: supraclavicular nerves (medial,intermediate,lateral) the skin as far as the middle line, the skin over the pectoralis major and deltoideus, the skin of the upper and posterior parts of the shoulder,inferior part of the deltoid muscle (axillary nerve)Anterior arm: inferior lateral cutaneous nerve of the arm (radial nerve) lateral and anterior aspects of the lower part of the arm medial cutaneous nerve of arm back of the lower third of the arm, extending as far as the elbow superior lateral cutaneous nerve of arm (axillary nerve) the skin over the lower two-thirds of the posterior part of the deltoid muscle, as well as that covering the long head of the triceps brachii Anterior forearm: medial cutaneous nerve of forearm medial surface of the forearm down to the wrist lateral cutaneous nerve of forearm (continuation of musculocutaneous nerve) lateral half of the anterior aspect of the forearmPosterior arm & forearm: radial nerve posterior aspect of the arm and forearm (posterior cutaneous nerve of forearm), lower lateral surface of the arm, medial cutaneous nerve of arm medial side of the distal third of the armHand: superficial branch of the radial nerve dorsolateral aspect of the palm and the dorsal aspects of the lateral three and one-half digits distally to approximately the terminal interphalangeal joints ulnar nerve medial side of the palm, medial half of the dorsum of the hand, the 5th finger, and the medial half of the 4th finger, anterior surfaces of the medial one and a half digitsmedian nerve thumb,index,middle fingers,lateral side of the ring [distal parts on the dorsum of the hand], palmar surface of the lateral three and one-half digits and over the lateral side of the palm and middle of the wrist

REGIONS & DERMATOMESA dermatome is an area of skin that is mainly supplied by a single spinal nerve. The areas of skin

supplied by the individual spinal nerves, including those contributing to the plexuses, are called dermatomes. There are eight cervical nerves (C1 being an exception with no dermatome), twelve thoracic nerves, five lumbar nerves and five sacral nerves. Each of these nerves relays sensation (including pain) from a particular region of skin to the brain. The nerve fibers from a particular segment of the spinal cord, although they exit from the cord in a spinal nerve of the same segment, pass to the skin in two or more different cutaneous nerves.

The dermatomal (segmental) pattern of skin innervation is retained throughout life but is distorted by limb lengthening and the torsion of the limb that occurs during development.

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Dr. Kaan Yücel http://yeditepeanatomy1.org Neurological examination-Upper limb

reflexes

Tendon Reflexes and the Segmental Innervation of Muscles of the Upper Limb

The skeletal muscle receives a segmental innervation. Most muscles are innervated by several spinal nerves and therefore by several segments of the spinal cord. A physician should know the segmental innervation of the following muscles because it is possible to test them by eliciting simple muscle reflexes in the patient: Biceps brachii tendon reflex: C5 and 6 (flexion of the elbow joint by tapping the biceps tendon) Triceps tendon reflex: C6, 7, and 8 (extension of the elbow joint by tapping the triceps tendon) Brachioradialis tendon reflex: C5, 6, and 7 (supination of the radioulnar joints by tapping the insertion of

the brachioradialis tendon)

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The dermatomes for the upper cervical segments C3 to 6 are located along the lateral margin of the upper limb; the C7 dermatome is situated on the middle finger; and the dermatomes for C8, T1, and T2 are along the medial margin of the limb.

The skin over the point of the shoulder and halfway down the lateral surface of the deltoid muscle is supplied by the supraclavicular nerves (C3 and 4). Pain may be referred to this region as a result of inflammatory lesions involving the diaphragmatic pleura or peritoneum. The afferent stimuli reach the spinal cord via the phrenic nerves (C3, 4, and 5). Pleurisy, peritonitis, subphrenic abscess, or gallbladder disease may therefore be responsible for shoulder pain.

. Dr. Kaan Yücel http://yeditepeanatomy1.org Neurological examination-Upper limb

A tap on the tendon of biceps brachii at the elbow is used to test predominantly spinal cord segment C6. A tap on the tendon of triceps brachii tests predominantly spinal cord segment C7.

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