Peripheral Nerve Examination

Exposure: Expose both UL fully with patient hands on pillow

1) Look from proximal to distal

2) Screening for the 3 nerves
3) Test each individual nerve

1) Look
- Deformity ( eg. claw hand - ulnar, finger-pointing hand - median, elbow
deformity - ulnar)
- Skin changes
- Muscle wasting (if triceps involved, most probably radial nerve. if flexor in the
forearm involved, either median or ulnar nerve)
* If patient seems to have claw hand, ask patient to open and close the fingers
to determine if this is true claw hand

2) Screen
- Open & close fingers - for ulnar nerve
- Do the 'O' sign - for median nerve
- Do wrist extension - for radial nerve

3) Testing each individual nerve

a) Radial nerve
- Look for any deformity, skin changes, muscle wasting, wrist drop, fingers
drop
- To test the nerve (All active movement followed by against resistance. If no
active movement, proceed to passive movement)
Triceps (extend the forearm)
Brachioradialis (flex the forearm)
Supinator (supinates the forearm) - this must be done with elbow fully
extended
Wrist extension
Finger extension
Sensation (first webspace on the dorsum aspect of hand)

b) Median nerve
- Look for any deformity, skin changes, muscle wasting ( look carefully for
thenar wasting)
- To test the nerve (All active movement followed by against resistance. If no
active movement, proceed to passive movement)
Pronation
Wrist flexion (radial deviate the wrist then flex)
Thumb movement (abduction for APB, flexion of interphalangeal joint
of thumb for FPL, flexion for FPB)
Flexion of the distal interphalangeal joint of the second finger (FDP)
Sensation (lateral side of the 2nd finger)
Any finger-pointing sign
Carpal tunnel syndrome
Symptoms: shooting sensation numbness and pain which is usually
worse at night
Phalen's test - do this for 1 minute
 Tinel test - tap the median nerve
Median nerve compression - press on the median nerve when
patient makes a fist and flexes the wrist
Sensation on index finger ( this will be done, but the sensation over
the palmar triangle may be spared due to the palmar cutaneous
branch of the median nerve which arises before the median nerve
transverses under the flexor retinaculum)
Note: Double crush syndrome = carpal tunnel syndrome + cervical
spondyosis. In this situation, carpal tunnel release may not totally
resolve patient's symptoms.

c) Ulna nerve
- Look for any elbow deformity, scars in wrist region, guttering over dorsum
of hand, muscle wasting of hypothenar muscle, claw hand, and skin
changes
- To test the nerve (All active movement followed by against resistance. If no
active movement, proceed to passive movement)
Wrist flexion (ulna deviate the wrist then flex)
Flexion of the distal interphalangeal joint of the fifth finger (FDP)
Dorsal and palmar interossei (abduct and adduct the fingers)
Froment's sign (to test for adductor pollicis) - if the muscle is weak,
patient will compensate by flexing the interphalangeal joint of the
thumb due to the intact flexor pollicis longus which is innervated by
the median nerve
Sensation (medial aspect of little finger)