Upper Limb Neurological Examination OSCE — Complete Mark Scheme Guide

Why Upper Limb Neurological Examination Is a Core OSCE Station

Upper limb neurological examination tests systematic clinical methodology and pattern recognition. Examiners expect candidates to demonstrate a practised, fluent routine and then synthesise findings into a localisation (cortex, internal capsule, spinal cord, nerve root, peripheral nerve, neuromuscular junction, muscle). It appears as both a standalone station and embedded within a respiratory or cardiovascular examination (looking for wasting, fasciculation, or tremor).

Setting Up

Expose both upper limbs fully. Ensure the patient is seated comfortably. Introduce each component before performing it. Compare each finding between right and left. Work in the sequence: inspection → tone → power → reflexes → coordination → sensation.

Inspection

Before touching the patient, observe systematically:

• Wasting: generalised (myopathy) vs. focal (nerve lesion — e.g., small muscles of hand in T1 root or ulnar nerve lesion)
• Fasciculations: visible muscle twitching at rest — lower motor neurone disease (motor neurone disease, radiculopathy)
• Posture: flexed arm in hemiplegia (UMN); flail arm, dropped wrist, clawed hand (LMN/peripheral nerve)
• Tremor: resting (Parkinson's), intention (cerebellar), postural (essential tremor)
• Skin: Raynaud's, scars, needle marks, rash (dermatomyositis — Gottron's papules)

Tone

Ask the patient to "let their arm go completely floppy." Test at the wrist (pronate/supinate and flex/extend the forearm), elbow (flex/extend), and shoulder (rotate). Assess for:

Power — MRC Scale

Test each major muscle group bilaterally, stating the nerve root and peripheral nerve:

MRC Power Scale:

• 0: No movement
• 1: Flicker of movement
• 2: Movement with gravity eliminated
• 3: Movement against gravity, not resistance
• 4: Movement against some resistance (subdivide: 4−, 4, 4+)
• 5: Normal power

Reflexes

Test with a tendon hammer using a loose wrist, hitting the tendon (not the muscle). Reinforce if absent using Jendrassik — ask the patient to clench their teeth or hook fingers together and pull.

Grade reflexes: absent (0), present only with reinforcement (+), reduced (+), normal (++), brisk (+++), clonus (++++) — though clonus is less applicable in upper limb.

Coordination

Finger-Nose Test

Ask the patient to alternately touch their own nose and then your finger, held at arm's length. Move your finger between attempts. Look for:

• Dysmetria: past-pointing (missing your finger)
• Intention tremor: tremor worsening as the finger approaches the target (cerebellar)

Dysdiadochokinesia

Ask the patient to tap the palm of one hand alternately with the front and back of the other hand as fast as possible. Slowed, irregular, poorly rhythmic movement indicates cerebellar dysfunction (ipsilateral).

Sensation

Test in a dermatomal distribution:

• Light touch: use a wisp of cotton wool — compare left to right, proximal to distal
• Pin-prick: neurological pin — test dermatomes C4 (shoulder), C5 (lateral arm), C6 (thumb), C7 (middle finger), C8 (little finger), T1 (medial forearm)
• Vibration: 128 Hz tuning fork — apply to bony prominences (DIP joints → wrist → elbow → shoulder)
• Proprioception: hold the distal phalanx by the sides — demonstrate up/down with eyes open; test with eyes closed

UMN vs. LMN Pattern

Closing and Presenting Findings

Present in a structured, confident manner: "On examination of the upper limbs, I found [X] with [Y] and [Z], consistent with a [UMN/LMN/cerebellar] pattern, most likely due to [diagnosis]. I would like to examine the lower limbs, test cranial nerves, and review an MRI brain/spine to complete my assessment."

Frequently Asked Questions

"What is the correct order for upper limb neurological examination in an OSCE?"

The standard order is: inspection → tone → power → reflexes → coordination → sensation → presentation of findings. Starting with inspection scores marks for professionalism and allows you to form an early hypothesis before you touch the patient. Tone before power prevents you from interpreting increased tone as weakness. Reflexes after power allows correlation (brisk reflexes with weakness = UMN; absent reflexes with weakness = LMN). Coordination is tested after power as cerebellar signs can be confounded by weakness. Sensation is last because it is time-consuming and less discriminating. Always state "I would now examine the lower limbs and perform a full neurological examination" at the end to show you understand the systematic approach.

"How do I use the MRC power scale accurately in an OSCE?"

The MRC (Medical Research Council) power scale grades muscle strength from 0 (no movement) to 5 (normal). The critical grades to demonstrate in an OSCE are: grade 3 — the patient can move the limb against gravity but not against examiner resistance (demonstrate this by first supporting the limb, then asking them to move it without support and adding resistance); grade 4 — movement against resistance that is less than normal (subdivided as 4−, 4, or 4+ in clinical practice). Always test the same movement bilaterally before recording the grade. State the root and nerve when announcing each result: "Elbow flexion is MRC grade 4 bilaterally, C5/C6, musculocutaneous nerve." This demonstrates anatomical knowledge and is expected at senior medical student level.

"What is the inverted supinator reflex and what does it indicate?"

The inverted supinator reflex occurs at the C5/C6 spinal cord level. When you tap the brachioradialis tendon (supinator reflex), instead of the normal response (elbow flexion and forearm supination), you get finger flexion instead — the supinator response is absent (C5/C6 arc is damaged at cord level) but the finger jerk (C8 arc, below the lesion, now disinhibited) is exaggerated. This combination indicates a C5/C6 spinal cord lesion with UMN involvement below (exaggerated lower reflexes) and LMN involvement at the level of the lesion (absent C5/C6 reflex arc). It is classic for cervical spondylotic myelopathy at C5/C6. Examiners frequently ask about this in a viva or a "what does this finding mean?" question.

"How do I differentiate a radial nerve palsy from a C7 root lesion in the upper limb examination?"

Both radial nerve palsy and C7 root lesion can cause weakness of wrist and finger extension and reduced triceps reflex. The key differentiator is the distribution of sensory loss and the muscles affected. Radial nerve palsy (e.g., from a spiral fracture of the humerus or Saturday night palsy) causes sensory loss confined to a small patch on the dorsum of the thumb and first web space. C7 root lesion causes sensory loss in the C7 dermatomal distribution (middle finger, dorsum of hand). Radial nerve palsy also spares triceps if the lesion is at the spiral groove (triceps is supplied by branches arising proximal to the spiral groove). C7 root lesion additionally affects C7-innervated muscles not supplied by the radial nerve, such as pronator teres (median nerve, C6/C7). Examination of sensation distribution is the critical step.

"What are the signs of an ulnar nerve lesion and where is the most common site of injury?"

An ulnar nerve lesion at the elbow (the most common site, at the cubital tunnel or medial epicondyle) causes: wasting and weakness of intrinsic hand muscles (interossei and medial two lumbricals) → weakness of finger abduction/adduction; weak grip; ulnar claw hand (clawing of ring and little fingers due to loss of lumbrical action, unopposed long flexors); weakness of wrist flexion (flexor carpi ulnaris); sensory loss over the little finger, medial half of ring finger, and medial hypothenar eminence; weakness of adductor pollicis (positive Froment's sign: compensatory IP joint flexion using FPL when gripping paper). Note that clawing is paradoxically worse with a distal lesion (ulnar paradox) because the long finger flexors (supplied above the lesion) are intact and pull the ring/little fingers into clawing without the lumbricals to oppose them.

"How do I distinguish cerebellar from sensory ataxia in the coordination component of the examination?"

Cerebellar ataxia produces incoordination that is present with eyes open and does not significantly worsen with eyes closed. On finger-nose testing there is intention tremor (worsening as the finger approaches the target) and past-pointing. There may be associated dysdiadochokinesia, nystagmus (fast phase towards the side of the lesion), dysarthria (scanning/explosive speech), and hypotonia. Signs are ipsilateral to the affected cerebellar hemisphere. Sensory ataxia results from loss of proprioception — coordination worsens dramatically with eyes closed (positive Romberg's test). Finger-nose test shows past-pointing that improves when the patient watches their hand carefully. There is no intention tremor. Associated findings include loss of vibration sense and proprioception in a glove-and-stocking distribution (peripheral neuropathy) or a dorsal column pattern (vitamin B12 deficiency, MS, tabes dorsalis).

Related guides: Neurological Examination OSCE · Cerebellar Examination OSCE · Cranial Nerve Examination OSCE · Neurological History OSCE · Stroke and TIA Assessment OSCE