Neurology Upper Limb Examination | Kaithlyn Goh

Conditions

Inspection

Tone

Power

Reflexes

Sensation

Co-ordination

Gait

UMN
- Stroke

Muscle wasting only if

disuse in stroke

Spastic (Clasp knife)
Clonus

Pyramidal: Flexors >

Extensors

Brisk
+ve Hoffmans sign

Normal to dull, sharp,

vibration & proprioception
Numbness, loss of sensation
in stroke

Hemiplegic
- Abducted leg
- Swing in lateral arc

LMN

Fasciculation
Muscle wasting

Normal/

Reduced

Normal to dull, sharp,

vibration & proprioception

Normal

Normal

MND
Syringomyelia
- LMN in arms
- UMN in legs

Fasciculation
Muscle wasting
- Hyperextension at MCP
- Flexion at IP
- Claw hands (advanced)
Dysarthria
Horners syndrome in
syringomyelia

Spastic (Clasp knife)

Distal proximal weakness

Unilateral Bilateral
Difficulty of fine hand
movements

Brisk
+ve Hoffmans sign

Normal to dull, sharp,

vibration & proprioception
Dissociated sensory loss
(Loss of pain & temp;
Vibration, proprioception
preserved) in syringomyelia

Normal

High-stepped
- Due to foot drop
- Allow toes to clear ground

Parkinsons
(Extrapyramidal)

Face: Hypomimia, +ve

glabellar tap test
Speech: Hypophonia,
monotonous, slow
Drooling saliva
Blepharoclonus
Tremor of eyelids when
gently closed
Asymmetrical, resting pill
rolling tremor

(Lead pipe) - Elbow
Cogwheel rigidity - Wrist

Bradykinesia

Normal
+ve Postural instability
pull test

Normal to dull, sharp,

vibration & proprioception

Simian posture
- Stooped posture
- Lowered head
- Flexed knees & elbows
Shuffling, narrow-based
gait
Reduced arm swing

Cerebellar
- Ipsilateral

Slurred, staccato speech

Nystagmus
(Fast towards affected side)
Hypermetric saccades

Normal
Rebound phenomenon

Normal

Normal to dull, sharp,

vibration & proprioception

Truncal ataxia
(Vermis lesion)
Broad-based gait
- Looking ahead
(Differentiate from sensory
ataxia looking at feet)
Impaired heel to toe
-ve Rhombergs test

CMT

Lower limb affected first

Bilateral claw hands
Wasting of small muscles
of hands
Fasciculations
Postural tremor
Tremor when holding
against gravity

Normal
Palpable ulnar nerve

Symmetrical distal
weakness

Absent

Bilateral symmetrical glove

distribution loss
Vibration &
proprioception
Normal to pain and
temperature

Normal

Dysdiadochokinesis
Intention tremor
Past pointing

High-stepped
- Due to foot drop
- Allow toes to clear ground
+ve Rhombergs test

Neurology Upper Limb Examination | Kaithlyn Goh

Sensory
neuropathy

Skin changes
- Legs > Hands
- Dry, thin, loss of hair

Normal

Normal

Normal

Bilateral symmetrical glove

distribution loss
Not all sensory modalities
lost

Normal

High-stepped
- Proprioception loss at
ankles
+ve Rhombergs test
Wide-based gait
- Sensory ataxia
- Looking at feet

Motor
neuropathy

Skin changes
- Legs > Hands
- Dry, thin, loss of hair

Distal muscle wasting

Length-dependent
weakness
Starts when weakness
reaches knees

Reduced/ Absent
Distal Proximal

Normal

Normal

High-stepped
- Due to foot drop
- Allow toes to clear ground

Ulnar nerve
palsy

Muscle wasting
- Hypothenar eminence
- Thenar eminence spared
th
th
Claw hand at 4 , 5 finger
th
Ulnar deviation of 5 finger

Normal

Weakness of finger
ABduction and ADduction
Weakness of thumb
ADduction
th
Weakness of flexion of 4
th
and 5 finger
+ve Froments sign
Weakness of wrist flexion if
elbow lesion

Normal

Loss at 5 finger, adjacent

th
medial half of 4 finger,
dorsal and palmar surface
of medial hand
th
Normal on lateral 4 finger
- If abnormal, C8 lesion

th

Normal

Normal

Radial nerve
palsy

Normal
Tricep muscles intact

Wrist drop

Weakness of elbow, wrist

extension
Weakness of finger
extension
- Due to weak MCP joints
extensor
Intact extension at IP joints
Weakness of supination
and elbow flexion

Tricep jerk intact

- If absent, lesion at/above
upper third of humerus

Loss at 1 dorsal
interosseous space, dorsum
of thumb, index finger

st

Normal

Normal

Median nerve
palsy

Muscle wasting
- Thenar eminence
- Hypothenar eminence
spared
Ape-hand appearance

Normal
+ve Tinels and Phalens
sign

Weakness of thumb
ABduction, flexion,
opposition

Normal

Sensory loss over palmar

aspect of first three and a
half fingers
Sensation over thenar
eminence spared

Normal

Normal

C7 lesion

Triceps muscle wasting

Normal

Weakness of elbow, wrist,

finger extension

Tricep jerk absent

Sensory loss over middle

finger

Normal

Normal

GBS

Facial weakness
Dysphasia
Dysarthria

Hypotonia

Bilateral symmetrical glove

distribution weakness

Reduced/ Absent

Bilateral symmetrical glove

distribution loss
Paraesthesia

Normal

Gait disturbance due to

weakness