NEUROLOGICAL EXAMINATION

AN ANATOMICAL GUIDE

Kaan Yücel M.D., Ph.D. 14.February.2013 Thursday

MOTOR & SENSORY FUNCTION

UPPER LIMB

HistoryCerebral function (mental status)Cranial nerve functionMotor functionSensory functionCerebellar functionReflex functionGait and stance

Neurologic ExamSusan R. Winkler, Pharm.D. BCPSSpring 1998

Basic Components of the Neurologic Examination

TESTING THE MUSCLES

SHOULDERDeltoid

The arm is abducted, starting from approximately 15°, against resistance. If acting normally, the deltoid can easily be seen and palpated.

Shoulder abductionAxillary nerve

SHOULDERSupraspinatus

Initiates abduction of the armSuprascapular nerve

Infraspinatus Laterally rotates the humerusSuprascapular nerve

Abduction of the arm fromfully adducted position against resistance.Palpated superior to scapular spine.

Supraspinatus & middle deltoid tested together.

The person flexes the elbow and adducts the arm. The arm then laterally rotated against resistance. Infraspinatus & teres minor tested together.

Palpated inferior to scapular spine.

SHOULDERDegenerative 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 supraspinatus part) is diseased and/or torn

ANTERIOR ARM

Biceps brachiiElbow 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.

Forearm flexor & supinatorMusculocutaneous nerve

ANTERIOR ARM

Brachialis

Forearm is semipronated and flexed against resistance. If acting normally, the contracted muscle can be seen and palpated.

Main flexor of the forearmMusculocutaneous nerve

POSTERIOR ARM

Triceps brachii

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.

Forearm extensionRadial nerve

ANTERIOR FOREARM

Flexor carpi ulnaris

Flexor carpi radialis

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.

The person is asked to flex the wrist against resistance. If acting normally, its tendon can be easily seen and palpated.

Flexor & adductor of the wristUlnar nerve

Flexor & abductor of the wristRadial nerve

ANTERIOR FOREARM

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.

Accessory flexor of the wrist, opposes shearing forces on the skin of the palm during grippingMedian nerve

ANTERIOR FOREARM

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.

Rotates radius over ulna during pronationMedian nerve

ANTERIOR FOREARM

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.

Flexes the metacarpophalangeal joint and proximal interphalangeal joint of each finger; also flexes the wrist joint.Median nerve

ANTERIOR FOREARM

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.

Flexes the distal phalanges of the medial four fingersLateral half median nerveMedial half ulnar nerve

ANTERIOR FOREARM

Flexor pollicis longus

The proximal phalanx of the thumb is held and the distal phalanx is flexed against resistance.

Flexes the thumb Median nerve

POSTERIOR FOREARM & HAND

Brachioradialis

Relatively weak flexion of forearm; maximal when forearm is in midpronated positionRadial nerve

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.

POSTERIOR FOREARM & HAND

Extensor carpi radialis longus

Extend & abduct hand @ wristRadial nerve

Wrist is extended & abducted with forearm pronated.

Its tendon can be palpated proximal to the wrist.

POSTERIOR FOREARM & HAND

Extensor digitorum

Extends medial four digits primarily @ metacarpophalangeal joints, secondarily @ interphalangeal jointsDeep branch of radial nerve

Forearm is pronated and the fingers are extended.

The person attempts to keep the digits extended @ metacarpophalangeal joints as the examiner exerts pressure on the proximal phalanges by attempting to flex them. Tendons on the dorsum of the hand

POSTERIOR FOREARM & HAND

Extensor carpi ulnaris

Extends and adducts hand @ wrist Deep branch of radial nerve

Forearm pronated & fingers are extended Extended wrist is then adducted against resistance. Muscle seen and palpated proximal part of the forearm & tendon felt proximal to ulnar head

POSTERIOR FOREARM & HAND

Extensor digiti minimi

Extends 5th digit primarily @metacarpophalangeal joint, secondarily @ interphalangeal jointDeep branch of radial nerve

Little finger is extended against resistance while holding digits 2-4 flexed @ metacarpophalangeal joints

POSTERIOR FOREARM & HAND

Abductor pollicis longus

Abducts thumb and extends it @ carpometacarpal jointPosterior interosseous nerve

Thumb is abducted against resistance at the metacarpophalangeal joint.

Tendon seen and palpated at the lateral side of the anatomical snuff box and on the lateral side of the adjacent extensor pollicis brevis tendon.

POSTERIOR FOREARM & HAND Extends proximal phalanx of thumb @ metacarpophalangeal joint; extends carpometacarpal jointPosterior interosseous nerve

Extensor pollicis brevis

Thumb is extended against resistance at the metacarpophalangeal joint.

Tendon @ lateral side of the anatomical snuff box and on the medial side of the adjacent abductor pollicis longus tendon

POSTERIOR FOREARM & HAND

Extensor pollicis longus

Extends distal phalanx of thumb @ interphalangeal joint; extends metacarpophalangeal & carpometacarpal jointsPosterior interosseous nerve

Thumb is extended against resistance at the interphalangeal joint.

Tendon on the medial side of the anatomical snuff box

POSTERIOR FOREARM & HAND

Abductor pollicis brevis

Abducts the thumb, principally @ metacarpophalangeal jointMedian nerve

Flexor pollicis brevis Flexes metacarpophalangeal joint of the thumbMedian nerve

Abduct the thumb against resistance

Flex the thumb against resistance

POSTERIOR FOREARM & HAND

Lumbricals

Participate in flexing metacarpophalangeal joints & extending the interphalangeal jointsMedial 2 ulnar nerveLateral 2 median nerveWith the palm facing

superiorly 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.

POSTERIOR FOREARM & HAND

Dorsal interossei

Major abductors of the index, middle, and ring fingers @ metacarpophalangeal jointsUlnar nerve

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”).

POSTERIOR FOREARM & HAND

Palmar interossei

Addduct thumb, index, ring, and little fingers @ metacarpophalangeal jointsUlnar nerve

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 BACK

Trapezius

The shoulder is shrugged 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.

Superior fibers elevate scapulaMiddle fibers retract scapulaInferior fibers depress scapula and lower the shoulder.The superior and inferior fibers work together to rotate the lateral aspect of the scapula upward, which needs to occur when raising the upper limb above the head. Spìnal accessory nerve (CN XI)

SUPERFICIAL MUSCLES OF BACK

Latissimus dorsi

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.

Adductor of the humerusExtension, adduction, and medial rotation of the upper limb. Depresses the shoulder, preventing its upward movement.Thoracodorsal nerve

SUPERFICIAL MUSCLES OF BACK

Rhomboids

Individual places the hands posteriorly on the hips and pushes the elbows posteriorly against resistance provided by the examiner.

Palpated along the medial borders of the scapulae; because they lie deep to the trapezius, they are unlikely to be visible during testing.

Retract and rotate the scapula, depressing its glenoid cavity. Assist the serratus anterior in holding the scapula against the thoracic wall.Dorsal scapular nerve

PECTORAL REGION

Pectoralis major

Clavicular head 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.

Sternocostal headThe arm is abducted 60° and then adducted against resistance. If acting normally, the sternocostal head can be seen and palpated.

Adduction and medial rotation of the arm Clavicular head flexes humerus Sternocostal head extends it back

Lateral and medial pectoral nerves clavicular head (C5, C6), sternocostal head (C7, C8, T1)

PECTORAL REGION

Serratus anterior

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.

Protracts scapula and holds it against thoracic wall; rotates scapulaLong thoracic nerve

regIONS&

SENSORy INNERVATION

Inferior lateral cutaneous nerve of arm Lateral & anterior aspects of the lower part of the armMedial cutaneous nerve of forearm Medial surface of the forearm down to the wrist

Posterior cutaneous nerve of forearmPosterior aspect of the arm and forearm

Medial cutaneous nerve of arm Medial side of the distal third of the arm

Lateral cutaneous nerve of forearmLateral half of the anterior aspect forearm

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

Superficial branch of the radial nerve Dorsolateral aspect of the palm Dorsal aspects of the lateral 3 ½ digits distally to approximately the terminal interphalangeal joints

Ulnar nerve Medial side of the palmMedial half of the dorsum of the hand5th finger & medial half of the 4th fingerAnterior surfaces of the medial 1 ½ digits

Median nerve Thumb,index,middle fingersLateral side of the ring [distal parts on the dorsum of the hand]Palmar surface of the lateral 3 ½ digits Lateral side of the palm & middle of the wrist

DERMATOMES

The dermatomes for the upper cervical segments C3 to 6 are located along the lateral margin of the upper limb

C7 dermatome is situated on the middle finger

C8, T1, and T2 along the medial margin of the limb

reflexes

Biceps brachii tendon reflex C5 & 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

NEUROLOGICAL EXAMOnline resources

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