Phys · general-medicine
Neurological Examination of the Upper Limbs — The DCE Short-Case Routine
Also known as upper limb neurological examination · upper limb neurological exam · neurological examination upper limbs · examine this patient upper limbs neurologically · DCE short case upper limb neurology · PACES neurological station upper limb · motor examination upper limb · myotome examination · dermatome examination upper limb · tone power reflexes coordination sensory · UMN versus LMN · finger-nose test · pronator drift · Hoffman sign · MRC power grading · dysdiadochokinesia · cogwheel rigidity · lead-pipe rigidity · inverted supinator sign
Consultant-physician-depth guide to the systematic neurological examination of the upper limbs for the FRACP DCE short case and the MRCP PACES neurological station. Covers the eight-step routine — inspection, tone, power by myotome, reflexes, coordination, sensory, cortical sensory, and functional testing — the interpretation of each sign, the UMN versus LMN framework, the presentation template the candidate delivers aloud, and the examiner discussion questions by finding. Addresses muscle wasting patterns (dorsal interossei in MND, thenar eminence in median nerve, hypothenar in ulnar nerve), tremor classification, tone abnormalities (spastic, lead-pipe, cogwheel, hypotonic), the MRC power grading, reflex levels and the inverted supinator sign, the finger-nose test and dysdiadochokinesia, the spinothalamic and dorsal column sensory pathways, stereognosis and graphesthesia, and the common examination traps. Structured for FRACP DCE and MRCP PACES preparation.
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Red flags
- Acute onset of upper limb weakness with UMN signs (increased tone, hyperreflexia, pronator drift) may represent an acute stroke or spinal cord lesion — this is a neurological emergency requiring immediate imaging and time-critical management
- Asymmetric weakness with rapidly progressive fasciculations and mixed UMN and LMN signs across multiple body regions is motor neuron disease until proven otherwise — the combination of wasted fasciculating muscles with brisk reflexes is pathognomonic
- Acute bilateral upper limb weakness with sensory level suggests a cervical spinal cord lesion (compression, infarction, transverse myelitis) — this is a surgical emergency if the cord is compressed
- A positive Hoffman sign with hyperreflexia and any gait disturbance or lower limb signs raises cervical myelopathy until MRI excludes cord compression — a missed cervical myelopathy that progresses to paraplegia is a catastrophic failure
- Weakness that fatigues with repeated activity and improves with rest, with normal reflexes and sensation, is myasthenia gravis — ptosis and diplopia should be sought to confirm
Meet the patient
Mr Chen, sixty-four, holds out his hands for the short case. The first dorsal interosseus on the right is guttered and flickering with fasciculations; the thenar eminence is flattening. When you test tone the wrist feels a little stiff, and when you strike the right supinator the triceps and finger jerk fire briskly. He walks in with a foot drop. The examiner is watching to see whether you notice that the wasted, fasciculating limb also has brisk reflexes.[1]
This is the station where structure beats signs. The two questions that decide Mr Chen's case decide every upper-limb neurological short case: is the lesion upper motor neuron or lower motor neuron? and where in the neuraxis does it sit — cortex, cord, root, nerve, or muscle? The combination of wasted fasciculating muscles (LMN) with brisk reflexes (UMN) in the same patient is the clinical signature of motor neuron disease — and it is diagnosis candidate must not miss.[1]
References4ShowHide
- [1]Brooks BR, Miller RG, Swash M, Munsat TL; World Federation of Neurology Research Group on Motor Neuron Diseases El Escorial revisited: revised criteria for the diagnosis of amyotrophic lateral sclerosis Amyotroph Lateral Scler Other Motor Neuron Disord, 2000.PMID 11464847
- [2]Hannaford A, Pavey N, van den Bos M, Geevasinga N, Menon P, Shefner JM, Kiernan MC, Vucic S Diagnostic Utility of Gold Coast Criteria in Amyotrophic Lateral Sclerosis Ann Neurol, 2021.PMID 33565111
- [3]Cook CE, Wilhelm M, Cook AE, et al. Clinical tests for screening and diagnosis of cervical spine myelopathy: a systematic review J Manipulative Physiol Ther, 2011.PMID 21899892
- [4]Postuma RB, Berg D, Stern M, Poewe W, Olanow CW, Oertel W, Obeso J, Marek K, Litvan I, Lang AE, Halliday G, Goetz CG, Gasser T, Dubois B, Chan P, Bloem BR, Adler CH, Deuschl G MDS clinical diagnostic criteria for Parkinson's disease Mov Disord, 2015.PMID 26474316