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Lecture 4: 12/02/23 Presented by: Callum Cutinha Upper and Lower Limb Examination SURGICAL SOCIETY JUNIOR ANATOMY SERIES | CPA LECTURE SERIESContents 1. Structure of the limb examinations 2. Pathological findings upon examination 3. Spinal MRIs and Disc Herniation 4. Practice Questions S U R G S O C J A S | C P A L E C T U R E S E R I E S Structure of the Limb Examinations 1. Tone 2. Power 3. Reflexes 4. Sensation 5. Follow-Up Questions S U R G S O C J A S | C P A L E C T U R E S E R I E S Introduction PPE and wash hands Introduce yourself Check patient details Exposure (bare shoulders/ wearing Gain consent Patient comfort shorts) and positioning (45˚) S U R G S O C J A S | C P A L E C T U R E S E R I E ST one Muscles are in a constant state of partial contraction,even at rest. This creates tension in the muscle which is referred to as tone. In order to assess tone, you need to passively move the patient. Ask the patient to completely relax and allow you to fully control movement in their arms/legs. Throughout the exam you should be comparing each side with each other. S U R G S O C J A S | C P A L E C T U R E S E R I E ST one • Shoulder: move in a circular motion Upper Limb • Elbow: flexion and extension • Wrist: flexion, extension, pronation and supination If there is an increase in tone, then the joints will feel stiffer and harder to move. If there is decreased tone, then the joints will move much more freely with very little resistance. S U R G S O C J A S | C P A L E C T U R E S E R I E ST one HIP (leg roll) • foot should move independently. Lower limb • If there is increased tone, then the foot will move more rigidly. • If decreased tone, then the foot will move much more freely. KNEE • pull knee up briskly – the heel should remain in contact with the bed. • If there is increased tone, then the heel will come off the bed. S U R G S O C J A S | C P A L E C T U R E S E R I E S ANKLE T one • move in circular motion – Lower limb • greater range of movement in hypotonia • decreased range of movement in hypertonia. ABNORMAL ANKLE CLONUS • move in circular motion and stop suddenly • if there is a clonus then the foot will spontaneously move up and down when you stop. S U R G S O C J A S | C P A L E C T U R E S E R I E S T one - findings HYPOTONIA is caused by HYPERTONIA is caused by ABNORMAL ANKLE lower motor neuron lesions. upper motor neuron lesions. CLONUS is caused by upper (loss of tension from LMN (loss of inhibitory effect on motor neuron lesions of the causing muscles to be more LMN causing muscles to be descending motor pathways. relaxed) stiffer) S U R G S O C J A S | C P A L E C T U R E S E R I E S What type of lesion will cause a high degree of flexibility in the elbows? Lower motor neuron lesion What would cause a clonus to be present? Upper motor neuron lesion S U R G S O C J A S | C P A L E C T U R E S E R I E SPower • Ask the patient to move their own limbs against some Score Description resistance. 0 No contraction • It is important to stabilize the 1 Flicker/very little contraction joints and ensure that the patient 2 Active movement (not against gravity) is only using the muscles that you 3 Active movement against gravity (but are assessing. not against applied resistance) • Compare both sides after each 4 Active movement against some resistance movement to test for any unilateral power loss. 5 Normal power S U R G S O C J A S | C P A L E C T U R E S E R I E SPower SHOULDER ABDUCTION Upper Limb • ‘put your arms up like a chicken and don’t let me push them down’ • Axillary nerve (C5) SHOULDER ADDUCTION • ‘keep your arms out like a chicken but now push down against me’ • Thoracodorsal nerve (C6/C7) S U R G S O C J A S | C P A L E C T U R E S E R I E S ELBOW FLEXION Power • ‘Put your arms in front of you like a boxer and pull me Upper Limb towards you’ • Musculocutaneous and radial nerves (C5/C6) ELBOW EXTENSION • ‘push me away from you’ • Radial nerve (C7) Make sure they are only moving their forearms and not their arms otherwise this is not assessing the biceps/triceps. S U R G S O C J A S | C P A L E C T U R E S E R I E S WRIST FLEXION Power Upper Limb • ‘make a fist with your palms facing upwards and don’t let me push down’ • Median nerve (C6/C7) S U R G S O C J A S | C P A L E C T U R E S E R I E SPower HIP FLEXION • ‘keep your leg straight and push up against me’ Lower limb • Iliofemoral nerve (L1/L2) HIP EXTENSION • ‘keep your leg up and push down against me’ • Inferior gluteal nerve (L5/S1/S2) Place your hands just above the knee but not below so that you isolate the hip flexors/extensors. S U R G S O C J A S | C P A L E C T U R E S E R I E S KNEE FLEXION Power • ‘bend you knees and don’t let me straighten Lower limb them’ • Place hands on the back of the thigh to feel for hamstring contraction and prevent them from using hip extension to compensate. • Sciatic nerve (L5/S1/S2) KNEE EXTENSION • ‘kick your legs out against me’ • Place hands on top of thigh to feel for quadricep contraction. • Femoral nerve (L2/L3/L4) S U R G S O C J A S | C P A L E C T U R E S E R I E S ANKLE DORSIFLEXION Power • ‘move your foot up against my hand’ Lower limb • Deep peroneal nerve (L4/L5) ANKLE PLANTARFLEXION • ‘push your foot down into my hand’ • Tibial nerve (S1/S2) Make sure they are only moving the foot and not their whole leg. S U R G S O C J A S | C P A L E C T U R E S E R I E S Power - Pathology Upper and lower motor neuron Upper motor neuron lesions Lower motor neuron lesions lesions both present with typically have a ‘pyramidal’ have a focal pattern of weakness. pattern of weakness: weakness with only the affected muscles only being Upper limb extensors being those that are directly weaker than flexors. Lower limb flexors weaker than extensors. innervated. S U R G S O C J A S | C P A L E C T U R E S E R I E S What nerve is tested when you assess shoulder abduction? Axillary (C5) Where should you place your hand when assessing hip flexion? On the quadriceps What nerve is tested when you assess ankle dorsiflexion? Deep peroneal nerve (L4/L5) S U R G S O C J A S | C P A L E C T U R E S E R I E SReflexes • Explain to the patient that you are going to be tapping on their arms/legs with a tendon hammer and that they need to be fully relaxed. • Make sure you hold the tendon hammer at the end and use gravity to produce a good swing. • It may be necessary to ask the patient to perform a reinforcement manoeuvre to allow you to elicit the reflex. Ask the patient to clench their jaw on a count of 3 as you tap the tendon. S U R G S O C J A S | C P A L E C T U R E S E R I E S • Biceps (C5/C6) Reflexes Upper Limb • Ask the patient to put their arm across their body so that it is relaxed. • Locate the biceps tendon and place your thumb over it. • Tap your thumb with the tendon hammer and observe for the reflex. S U R G S O C J A S | C P A L E C T U R E S E R I E S • Triceps (C7/C8) Reflexes Upper Limb • Hold the patient’s arm out at 90˚ • Locate the triceps tendon and tap it with the tendon hammer as you observe for a contraction S U R G S O C J A S | C P A L E C T U R E S E R I E S • Supinator (C6) Reflexes Upper Limb • Locate the brachioradialis tendon which can be found on the lateral side of the forearm (a few inches below the base of the thumb). • Place two fingers over this tendon and tap it with the tendon hammer as you observe for a contraction S U R G S O C J A S | C P A L E C T U R E S E R I E S • Patellar (L2/L3/L4) Reflexes Lower limb • Ask the patient to sit at the end of the bed with their legs dangling freely • Locate the patellar tendon just below the knee and tap it with the tendon hammer S U R G S O C J A S | C P A L E C T U R E S E R I E S • Achilles (S1/S2) Reflexes Lower limb • With the patient sitting on the bed, put both their knee at a right angle and dorsiflex the foot to straighten the Achille’s tendon • With your hand on the sole of their foot, tap the Achille’s tendon and you should feel the foot plantarflex S U R G S O C J A S | C P A L E C T U R E S E R I E S Reflexes - Pathology Hyporeflexia/areflexia – Hyperreflexia – upper motor lower motor neuron lesion – neuron lesion – loss of LMN needed in order to form inhibitory signal causing more the reflex arc exaggerated reflexes S U R G S O C J A S | C P A L E C T U R E S E R I E S Which tendon do you tap when eliciting the supinator reflex? Brachioradialis What nerve roots are assessed when you elicit the patellar reflex? L2-L4 What type of lesion would cause more exaggerated reflexes? Upper motor neuron lesion S U R G S O C J A S | C P A L E C T U R E S E R I E SSensation • By assessing the sensation of the limbs, it allows you to assess the dermatomes individually which allows you to understand if there is a particular nerve which has been affected. • You will be using cotton wool to assess light sensation. S U R G S O C J A S | C P A L E C T U R E S E R I E SSensation • Demonstrate normal sensation by letting the patient know what it will feel like by touching their sternum before you begin. • Then ask the patient to close their eyes and ask them to tell you when they feel the cotton wool and if it felt the same on both sides. S U R G S O C J A S | C P A L E C T U R E S E R I E S • C5 (Lateral aspect of the arm) Sensation Upper Limb • C6 (Lateral aspect of forearm) • C7 (Middle finger) • C8 (Little finger) • T1 (Medial aspect of forearm) • T2 (Axilla) S U R G S O C J A S | C P A L E C T U R E S E R I E S • L2 (Lateral aspect of thigh) Reflexes • L3 (Lower medial aspect of thigh) Lower limb • L4 (Medial aspect of leg/foot and great toe) • L5 (Lateral side of leg and middle three toes) • S1 (Little toe, lateral foot and sole of foot) • S2 (Back of upper leg and thigh) S U R G S O C J A S | C P A L E C T U R E S E R I E SS U R G S O C J A S | C P A L E C T U R E S E R I E S What nerve root is assessed when you touch the lateral aspect of the forearm? C6 Where do you touch to assess the S2 nerve root? Back of the upper leg or thigh Which nerve root is assessed when you touch the hallux? L4 S U R G S O C J A S | C P A L E C T U R E S E R I E SLesions Upper Motor Lower Motor Neuron Lesions Neuron Lesions • Stroke • Motor neuron disease • Multiple sclerosis • Peripheral neuropathy • Traumatic brain/ spinal • Poliomyelitis injury • Nerve root compression • Cerebral palsy • Amyotrophic lateral sclerosis S U R G S O C J A S | C P A L E R I E S E S ESummary Upper Motor Neurone Lower Motor Neurone Lesions Lesions Inspection No fasciculations or muscle Fasciculations and muscle wasting wasting Tone Increased tone Reduced tone Power Reduced power (UL Reduced power (local muscle extensors weaker, LL flexors weakness) weaker) Reflexes Hyperreflexia Hyporeflexia/absent reflexes Other Babinski sign Pronator drift S U R G S O C J A S | C P A R I E S U R E S ECT vs MRI Is this CT or MRI? S U R G S O C J A S | C P A L E C T U R E S E R I E SCT vs MRI • Bone appears darker on MRI • Fluid appears lighter on MRI • MRI is much more detailed than CT (e.g. can see intervertebral discs) CT MRI S U R G S O C J A S | C P A L E C T U R E S E R I E SGuide to Reading an MRI Alignment Bone Cord Discs S U R G S O C J A S | C P A L E C T U R E S E R I E S What pathology is shown? Disc herniation S U R G S O C J A S | C P A L E C T U R E S E R I E S Where is the lesion? C6/C7 S U R G S O C J A S | C P A L E C T U R E S E R I E S Will this patient have upper or lower motor neuron lesion symptoms? Both: LMN lesion in the upper limb and UMN in the lower limb S U R G S O C J A S | C P A L E C T U R E S E R I E S There are 3 types of disc herniation: Disc Herniation • Disc prolapse – the nucleus the annulus fibrous remains intact. • Disc extrusion – the nucleus pulposus breaks through the the disc.ibrous but remains within • Disc sequestration – the nucleus annulus fibrous and separates from the disc allowing it to enter the spinal canal. S U R G S O C J A S | C P A L E C T U R E S E R I E S • Degenerative – normal wear and tear which Disc Herniation causes the annulus fibrous to weaken which allows the nucleus pulposus to herniate. • Injury – a sudden strain on the spine which allows the nucleus pulposus to break through the annulus fibrous (e.g. car crash, lifting heavy objects). • Both – degeneration which weakens the annulus fibrous allowing the nucleus pulposus to herniate through without needing much strain (e.g. triggered by sneezing) S U R G S O C J A S | C P A L E C T U R E S E R I E S What muscles are tested when you assess elbow flexion? Biceps brachii, coracobrachialis and brachialis S U R G S O C J A S | C P A L E C T U R E S E R I E S State two positive signs that you would find if you did an upper limb examination on a patient that has Parkinson’s disease Tremor at rest, increased tone/rigidity, hyperreflexia, weakness S U R G S O C J A S | C P A L E C T U R E S E R I E S State 3 possible causes of an ankle clonus Stroke, multiple sclerosis, cerebral palsy S U R G S O C J A S | C P A L E C T U R E S E R I E S What is your diagnosis? Extradural haemorrhage What would be the associated symptoms? Left sided weakness, hypertonia and hyperreflexia S U R G S O C J A S | C P A L E C T U R E S E R I E S Which of the following signs would be seen in a patient with this MRI? Hypertonia in the arms Hyporeflexia in the legs Muscle weakness in the arms Fasciculations in the legs Hyporeflexia in the arms S U R G S O C J A S | C P A L E C T U R E S E R I E S Callum Cutinha callum.cutinha19@imperial.ac.uk JAS Leads CPA Lead: Mohamad Abou-Eid (ma2219@ic.ac.uk) Phase 1a Lead: Sree Kanakala (sk1821@ic.ac.uk) Phase 1b Lead: Ananya Jain (aj620@ic.ac.uk) Feedback