Examination of the Upper Limb

(1)

Department of Neurosurgery, University of Wisconsin, Madison, WI, USA

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23.1 Motor Examination

Muscles are tested and graded using the MRC system: 0: no function, 1: flicker, 2: movement with gravity eliminated, 3: movement against gravity, 4: movement against some resistance, and 5: normal. Detailed testing can be done using a hydraulic hand dynamometer. Range of motion can be tested with a goniometer.

Fig. 23.1

Trapezius (spinal accessory n). Ask the patient to shrug the shoulders (A), then against resistance (B)

Fig. 23.2

Rhomboids (dorsal scapular n). Ask the patient to retract the shoulder blades towards the midline as in a military position

Fig. 23.3

Latissimus dorsi (thoracodorsal n). (A) Ask the patient to cough while palpating the posterior axillary fold to assess for muscle contraction. (B) Ask the patient to adduct the shoulder against resistance from a 90° position with the elbow flexed

Fig. 23.4

Teres major (lower subscapular n). Ask the patient to adduct the shoulder against resistance from a 90° position with the elbow fully extended

Fig. 23.5

Teres minor (axillary n). Shoulder external rotation is tested by asking the patient to push backwards with his hand against resistance while the shoulder and elbow are at 90°

Fig. 23.6

Subscapularis (upper and lower subscapular nn). (A) Shoulder internal rotation is tested by asking the patient to push backwards with the hand against resistance while the shoulder and elbow are at 90°. (B) Gerber’s lift-off test [1]: ask the patient to lift the hand off his back against resistance

Fig. 23.7

Test for scapular winging. Ask the patient to push on the wall first with the elbows extended (A) This tests for serratus anterior (long arms = long thoracic n). Ask the patient to take a step forward and push again with the elbows flexed (B) This tests for the trapezius. (A, B) No scapular winging. (C) Right scapular winging due to long thoracic neuropathy

Fig. 23.8

Shoulder abduction: (A) Initiation, especially in internal rotation (thumbs towards the floor), supraspinatus (suprascapular n). (B) Up to 90°, deltoid (middle fibers, axillary n). (C) Up to 180°, coupling of serratus anterior and trapezius. This movement is between the scapula and the chest wall

Fig. 23.9

Posterior fibers of the deltoid (arrow). The patient is asked to push back while the shoulder is abducted at 90° and the elbow fully extended

Fig. 23.10

Eyes need to be checked for the presence of Horner’s syndrome. (A) Normal. (B) Right Horner’s syndrome in a patient with right brachial plexus avulsion (preganglionic) injury. Note right ptosis and miosis

Fig. 23.11

Sternocleidomastoid (spinal accessory n). The patient is asked to push with his chin to the contralateral side against the examiner’s hand. The sternocleidomastoid (arrow) is observed contracting

Fig. 23.12

Anterior fibers of the deltoid

Fig. 23.13

Pectoralis major. (A) Sternal head. The patient is asked to adduct the shoulder against resistance; the sternal head of pectoralis major (arrow) is felt contracting along the anterior axillary fold. (B) Clavicular head. The patient is asked to protract (push forwards) the shoulder against resistance while the shoulder and elbow are at 90°. The clavicular head of pectoralis major (arrow) can be seen and felt contracting

Fig. 23.14

Infraspinatus (suprascapular n). Shoulder external rotation is tested by asking the patient to push outwards against the examiner’s hand while the elbow is flexed 90°

Fig. 23.15

Subscapularis. Shoulder internal rotation is tested by asking the patient to push inwards against the examiner’s hand while the elbow is flexed 90°

Fig. 23.16

Elbow flexion [1]. (A) With the forearm supinated: Biceps brachii (arrow) and brachialis (Musculocutaneous n). (B) In semi-prone position: brachioradialis (arrow) (radial n). (C) With the forearm pronated: Brachialis and brachioradialis (arrow)