Upper limb examination for PACES

1) Look 
  • ? wasting, position, fasciculation or tremor
  • hold arms out with palms up. Close eyes.
    • ? slow drop - UMN weakness or fatiguability
    • ? pronator drift - suggests contra-lateral pyramidal tract lesion (UMN)
    • ? cerebellar lesion - push down and suddenly release; oscillates before returning to position

2) Tone - ? rigidity suggesting UMN lesion or extrapyramidal stiffness

3) Power
  • "Can you make chicken wings and stop me pushing you down" = shoulder abduction
  • "And stop me moving them up" = shoulder adduction
  • "Bend your elbows and don't let me straighten them" = elbow flexion
  • "And straighten them out" = elbow extension
  • "Bend your wrist and don't let me straighten it" = wrist flexion
  • "And try and straighten it out" = wrist extension
  • "Now grip my finger" = finger flexion
  • "Straighten your fingers and don't let me push them down" = finger extension
  • "Try and spread your fingers out" = finger abduction
  • "Keep this piece of paper between your fingers" = finger adduction
  • "Move your thumb up" = thumb abduction
  • "Hold this piece of paper between your thumbs and index fingers" = thumb adduction
Summary of nerve roots, nerves and muscles involved: (click on imagine for larger version)

4)  Co-ordination - finger to nose

5) Sensation
Click here to view dermatomes
Click here to view areas innervated by nerve

6) Reflexes
  • Suppinator = brachioradialis contraction = C5 and C6; mainly C6
  • Biceps = C5 and C6; mainly C5
  • Triceps = C7


Think about:
Median nerve palsy
Ulnar nerve palsy
Radial nerve palsy


Small print gem: Froment's sign = if adductor of thumb is paralysed, it flexes at the interphalangeal joint when testing thumb adduction with the paper between thumb and index finger test.

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