NEUROLOGICAL EXAMINATION
UPPER LIMB
09.04.2014
Kaan Yücel
M.D., Ph.D.
http://yeditepeanatomy1.org
. Dr. Kaan Yücel
http://yeditepeanatomy1.org
Neurological examination-Upper limb
To test the deltoid , the arm is abducted, starting from approximately 15°, against resistance.
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.
To test the infraspinatus, the person flexes the elbow and adducts the arm. The arm is then laterally rotated against
resistance. 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 minor 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.To test the biceps brachii, the elbow joint is
flexed against resistance when the forearm is supinated. To test the brachialis, the forearm is semipronated and flexed
against resistance.
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.
To 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.
To test the palmaris longus, the wrist is flexed and the pads of the little finger and thumb are tightly pinched together.
To test the flexor carpi radialis, the person is asked to flex the wrist against resistance.
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.
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.
To test the brachioradialis, the elbow joint is flexed against resistance with the forearm in the midprone
position.Totest the extensor carpi radialis longus, the wrist is extended and abducted with the forearm pronated.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.
To test the extensor carpi ulnaris, the forearm is pronated and the fingers are extended. The extended wrist is then
adducted against resistance. 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. To test
the extensor pollicis brevis, the thumb is extended against resistance at the metacarpophalangeal joint. 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. To test the flexor pollicis brevis, flex the
thumb against resistance.
To test the lumbrical muscles, with the palm facing superiorly the patient is asked to flex the metacarpophalangeal
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.
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.
To test the trapezius, the shoulder is shrugged against resistance. To test the latissimus dorsi, the arm is abducted 90°
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and then adducted against resistance provided by the examiner. To test the rhomboids, the individual places his or her
hands posteriorly on the hips and pushes the elbows posteriorly against resistance provided by the examiner.
Dr. Kaan Yücel
http://yeditepeanatomy1.org
Neurological examination-Upper limb
SHOULDER
To 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.
ARM
To 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 FOREARM
To 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 & HAND
To 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.
3
. 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 BACK
To 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 GLANDS
To 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
Anterior arm: Coracobrachialis
Function
flexion- adduction arm
http://yeditepeanatomy1.org
Neurological examination-Upper limb
RegIons & MUSCLES
Brachialis
main flexor of forearm
Biceps brachii
flexor of the forearm @ elbow joint
supinator of forearm when elbow flexed
Posterior arm: Triceps brachii
Function
forearm extension
Anterior forearm sprfcl: Flexor carpi ulnaris Palmaris longus Flexor carpi radialis
Pronator teres
Function
flexor and adductor of wrist
flexor of wrist
flexor,abductor of wrist rotates radius over ulna
Anterior forearm intermediate: Flexor digitorum superficialis
Function
flexes metacarpophalangeal joint- proximal interphalangeal joint , flexes wrist
Anterior forearm deep: Flexor digitorum profundus Flexor pollicis longus
Pronator quadratus
Function
flexes the distal phalanges
flexes thumb
prime mover for pronation
Posterior foreposarm sprfcl: Brachioradialis Extensor carpi radialis longus Extensor carpi radialis brevis
Extensor digitorum Extensor digiti minimi Extensor carpi ulnaris Anconeus
Function 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 indicis
Function Supinator: supination of forearm, abduction of thumb, extension of proximal (EPB) and distal (EPL) phalanges
Hand: 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
joints
Shoulder: Trapezius
Function rotates the lateral aspect of the scapula upward
Latissimus dors
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 arm
Back: Serratus posterior superior
Serratus posterior inferior
Function
elevate and depress the ribs
Pectoral region: Pectoralis major
Pectoralis minor Subclavius
Serratus anterior
Function 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
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. Dr. Kaan Yücel
http://yeditepeanatomy1.org
Neurological examination-Upper limb
REGIONS & Nerves (Motor INNERVATION ONLY)
Anterior arm: Musculocutaneous nerve
Posterior arm: Radial nerve
Anterior forearm: Median nerve & ulnar nerve (flexor carpi ulnaris, medial half of flexor
digitorum profundus)
Posterior forearm: Radial nerve
Hand: 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 (and the palmaris
brevis innervated by the superficial branch of the ulnar nerve), which are innervated by the
median nerve.
Shoulder: Axillary nerve, Suprascapular nerve, Sup. & Inf. subscapular nerves, Accessory
nerve [XI], Thoracodorsal nerve, Dorsal scapular nerve
Back: Accessory nerve [XI], Thoracodorsal nerve, Dorsal scapular nerve, Intercostal nerves,
the superior by the first four intercostals and the inferior by the last four
Pectoral region: Lateral and Medial pectoral nerves, Nerve to subclavius, Long thoracic nerve
REGIONS & sensory INNERVATION
Shoulder: 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 forearm
Posterior 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 arm
Hand:
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 1/3 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 digits
median 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 (2/3) side of the palm and
middle of the wrist
REGIONS & DERMATOMES
A 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.
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Dr. Kaan Yücel
http://yeditepeanatomy1.org
Neurological examination-Upper limb
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.
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.
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)
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. Dr. Kaan Yücel
http://yeditepeanatomy1.org
Neurological examination-Upper limb
 Brachioradialis tendon reflex: C5, 6, and 7 (supination of the radioulnar joints by tapping the insertion of
the brachioradialis tendon)
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.
NEUROLOGICAL EXAM
Online resources
NeuroLogic Examination Videos and Descriptions...an Anatomical Approach
http://library.med.utah.edu/neurologicexam/html/home_exam.html
The Precise Neurological Exam
http://cloud.med.nyu.edu/modules/pub/neurosurgery/
Neuroexam
http://www.neuroexam.com/neuroexam/
Neurologic Examination
http://medinfo.ufl.edu/year1/bcs/clist/neuro.html
The Neurological Examination
http://www.aan.com/familypractice/pdf/FINAL%20THE%20NEUROLOGIC%20EXAMINATION.pdf
What is a Neurological Exam?
http://peripheralneuropathycenter.uchicago.edu/learnaboutpn/evaluation/neuroexam/index.shtml
The Neurological Examination
http://meded.ucsd.edu/clinicalmed/neuro2.htm
Neurologic Exam
http://www.uic.edu/classes/pmpr/pmpr652/Final/Winkler/NEUROEXM.html
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