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NEUROLOGICAL EXAMINATION AN ANATOMICAL GUIDE an Yücel M.D., Ph.D. 22.March.2012 Thursday MOTOR & SENSORY FUNCTION

22.March.2012 Thursday. History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function

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Page 1: 22.March.2012 Thursday. History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function

NEUROLOGICAL EXAMINATION

AN ANATOMICAL GUIDE

Kaan Yücel M.D., Ph.D. 22.March.2012 Thursday

MOTOR & SENSORY FUNCTION

Page 3: 22.March.2012 Thursday. History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function

TESTING THE MUSCLES

Page 4: 22.March.2012 Thursday. History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function

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

Page 5: 22.March.2012 Thursday. History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function

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.

Page 6: 22.March.2012 Thursday. History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function

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

Page 7: 22.March.2012 Thursday. History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function

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

Page 8: 22.March.2012 Thursday. History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function

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

Page 9: 22.March.2012 Thursday. History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function

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

Page 10: 22.March.2012 Thursday. History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function

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

Page 11: 22.March.2012 Thursday. History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function

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

Page 12: 22.March.2012 Thursday. History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function

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

Page 13: 22.March.2012 Thursday. History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function

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

Page 14: 22.March.2012 Thursday. History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function

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

Page 15: 22.March.2012 Thursday. History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function

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

Page 16: 22.March.2012 Thursday. History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function

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.

Page 17: 22.March.2012 Thursday. History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function

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.

Page 18: 22.March.2012 Thursday. History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function

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

Page 19: 22.March.2012 Thursday. History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function

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

Page 20: 22.March.2012 Thursday. History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function

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

Page 21: 22.March.2012 Thursday. History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function

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.

Page 22: 22.March.2012 Thursday. History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function

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

Page 23: 22.March.2012 Thursday. History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function

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

Page 24: 22.March.2012 Thursday. History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function

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

Page 25: 22.March.2012 Thursday. History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function

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.

Page 26: 22.March.2012 Thursday. History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function

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”).

Page 27: 22.March.2012 Thursday. History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function

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.

Page 28: 22.March.2012 Thursday. History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function

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)

Page 29: 22.March.2012 Thursday. History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function

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

Page 30: 22.March.2012 Thursday. History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function

SUPERFICIAL MUSCLES OF BACK

Rhomboids

The arm is abducted 90° and then adducted against resistance provided by the examiner.

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

If the muscle is normal, the anterior border of the muscle can be seen and easily palpated in the posterior axillary fold.

Page 31: 22.March.2012 Thursday. History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function

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)

Page 32: 22.March.2012 Thursday. History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function

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

Page 33: 22.March.2012 Thursday. History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function

THIGH & POPLITEAL FOSSA

Quadriceps femoris

Performed with the person in the supine position with the knee partly flexed.

Person extends knee against resistance.

Great extensor of the legFemoral nerve

Page 34: 22.March.2012 Thursday. History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function

THIGH & POPLITEAL FOSSA

Hamstring muscles

Person flexes his leg against resistance.

Normally, these muscles—especially their tendons on each side of the popliteal fossa—should be prominent as they bend the knee.

Extension @ hip joint Flexion @ knee jointTibial nerve

Page 35: 22.March.2012 Thursday. History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function

LEG

Tibialis anterior

The person is asked to stand on the heels or dorsiflex the foot against resistance.

If normal, its tendon can be seen and palpated.

Dorsiflexes ankle & inverts footDeep fibular nerve

Page 36: 22.March.2012 Thursday. History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function

LEG

Extensor hallucis longus

Great toe dorsiflexed against resistance.

If acting normally, its entire tendon can be seen and palpated.

Extensor digitorum longus

Lateral four toes dorsiflexed against resistance.

If acting normally, the tendons can be seen and palpated.

Extends great toe & dorsiflexes ankleDeep fibular nerve

Extends the toes & dorsiflexes foot at the ankle joint Deep fibular nerve

Page 37: 22.March.2012 Thursday. History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function

LEGFibularis longus and brevis

The foot is everted strongly against resistance.

If acting normally, the muscle tendons can be seen and palpated inferior to the lateral malleolus.

Everts foot and weakly plantarflexes ankleSuperficial fibular nerve

Initial PositionPatient plantar flexes and everts foot

Final PositionExaminer forces the foot into inversion

Page 38: 22.March.2012 Thursday. History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function

LEG

Triceps surae

The foot is plantarflexed against resistance (e.g., by “standing on the toes,” in which case body weight [gravity] provides resistance).

If normal, the calcaneal tendon and triceps surae can be seen and palpated.

Plantarflexes ankle; raises heel during walking; flexes leg at knee joint (soleus; steadies leg on foot)Tibial nerve

Page 39: 22.March.2012 Thursday. History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function

LEG

Flexor hallucis longus

The distal phalanx of the great toe is flexed against resistance.

If normal, the tendon can be seen and palpated on the plantar aspect of the great toe as it crosses the joints of the toe.

Flexes great toe at all joints; weakly plantarflexes ankle; supports medial longitudinal arch Tibial nerve

Page 40: 22.March.2012 Thursday. History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function

LEG

Flexor digitorum longus

The distal phalanges of the lateral four toes are flexed against resistance.

If they are acting normally, the tendons of the toes can be seen and palpated.

Flexes lateral four digits; plantarflexes ankle; supports longitudinal arches of footTibial nerve

Page 41: 22.March.2012 Thursday. History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function

LEG

Tibialis posterior

. The foot is inverted against resistance with foot in slight plantarflexion.

If normal, the tendon can be seen and palpated posterior to the medial malleolus

Plantarflexes ankle; inverts footTibial nerve

Page 42: 22.March.2012 Thursday. History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function

regIONS&

SENSORy INNERVATION

Page 43: 22.March.2012 Thursday. History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function

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

Page 44: 22.March.2012 Thursday. History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function

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

Page 45: 22.March.2012 Thursday. History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function

Superior clunial nerves L1-L3 posterior rami Skin overlying superior and central parts of buttockMedial clunial nerves S1-S3 posterior ramiSkin of medial buttock and intergluteal cleftInferior clunial nervesPosterior cutaneous nerve of thigh (S2-S3)Skin of inferior buttock (overlying gluteal fold

Upper lateral quadrant lateral branches of the iliohypogastric (L1) and 12th thoracic nerves (anterior rami)

Page 46: 22.March.2012 Thursday. History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function

Obturator nerve Superior medial thigh

Genitofemoral nerve Middle anterior thigh

Posterior cutaneous nerve of the thigh Posterior aspect of the thigh

Intermediate cutaneous nerve of the thigh (femoral nerve) Variable area on the medial aspect of the thigh Medial cutaneous nerve of the thigh (femoral nerve) Medial aspect of the thigh

Page 47: 22.March.2012 Thursday. History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function

Saphenous nerve (femoral nerve) Medial aspect of leg

Posterior cutaneous nerve of the thigh Upper part of the leg

Superficial fibular nerve Anterolateral leg

Sural nerve Posterolateral leg

Page 48: 22.March.2012 Thursday. History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function

Medially saphenous nerve, which extends distally to the head of 1st metatarsal

Superiorly (dorsum of foot) superficial (primarily) and deep fibular nerves

Inferiorly (sole of foot) medial and lateral plantar nerves; Common border of their distribution along the 4th metacarpal toe or digit

Laterally sural nerve, including part of the heel.

Posteriorly (heel) medial and lateral calcaneal branches of the tibial and sural nerves, respectively

Page 49: 22.March.2012 Thursday. History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function

DERMATOMES

Page 50: 22.March.2012 Thursday. History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function

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

Page 51: 22.March.2012 Thursday. History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function

reflexes

Page 52: 22.March.2012 Thursday. History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function

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

Patellar Reflex L3 & 4A tap with a tendon hammer on the patellar ligament Calcaneal Tendon Reflex S1 & 2Person's legs are dangling over the side of the examining table. The calcaneal tendon is struck briskly with a reflex hammer just proximal to the calcaneus. The normal result is plantarflexion of the ankle joint.

Page 53: 22.March.2012 Thursday. History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function
Page 54: 22.March.2012 Thursday. History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function

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