Examination of the Upper Limbs
				sidered a pyramidal tract sign: forceful passive flexion of
		a	b	the middle finger at the metacarpophalangeal joint is
				normally followed by reflex adduction of the metacarpal
				bone of the thumb (Fig. 3.27), but not if there is a lesion
				in the pyramidal pathway. Another pyramidal tract sign
				is flexion and opposition of the thumb when the ex-
				aminer forcefully pulls on an actively flexed finger.
				Sensation
				Sensory testing takes time, patience, and good coopera-
				tion from the patient. Its general purpose is to identify
				any sensory deficit that may be present, delimit its site
				and extent precisely, and determine which sensory
				modalities are affected. The pattern of findings obtained
				in this way usually permits classification of the causa-
				tive lesion as central, radicular, or peripheral. During the
				examination, the clinician must keep in mind what he
				or she is looking for with each examining technique in
				each part of the body where it is being applied.
			c	The sense of touch (esthesia) is tested with the patient’s
				eyes closed. The examiner lightly touches various sites
				on the patient’s body with a finger, a feather, a piece of
	Fig. 3.26 Facilitation maneuvers make the intrinsic muscle reflexes			tissue paper, or the like. Precise quantitative testing can
				be performed with graded instruments, such as von Frey
	more intense and easier to elicit. a Jendrassik hand grip. b Same ef-
	fect with active, strong raising of the head off the headrest. c Active			hairs or an adjustable Wartenberg pinwheel, but is not
	plantar flexion of the foot.			necessary in routine practice. (Sharp pinwheels can also
				transmit infectious diseases such as hepatitis and AIDS;
				sterilization before each use is mandatory!) It generally
				suffices to describe a deficit as either a deficient sense of
				touch (hypesthesia) or an absent sense of touch (an-
				esthesia). Depending on the clinical situation, the ex-
				aminer may want to measure sensation quantitatively
				in a particular dermatome or in the distribution of a par-
				ticular peripheral nerve, or to compare sensation on
				mirror-image sites on the body.
				Two-point discrimination, stereognosis. The epicritic
				component of the sense of touch (ultimately derived
				from Greek krites, “judge”) is tested on the pads of the
				fingers, e. g., by determining the patient’s ability to dis-
				criminate two simultaneous stimuli located close to-
	Fig. 3.27 The Mayer reflex of the metacarpophalangeal joint is			gether. This can be done with a pair of calipers or simply
				with the two points of an unfolded paper clip. The two
	elicited by forceful passive flexion of the middle finger. Involuntary			pointed ends are placed on the skin simultaneously, ini-
	adduction of the thumb normally follows; absence of the reflex sug-			tially very close together, and then at increasing dis-
	gests a lesion of the pyramidal pathway.
				tances until the patient reports feeling two separate
				stimuli. The threshold distance is usually larger when
				the stimuli are simultaneous than when they are suc-
				cessively applied; on the fingertips, it should be no more
	lower limb, because there are no “classic pyramidal tract			than 5 mm. Epicritic sensation can also be tested by
	signs” for the upper limb, as there are for the lower (cf.			having the patient identify a coin by touch, or “read” a
	p. 38). One important clue is exaggeration of the physio-			number written on the patient’s fingertip. Normal per-
	logical intrinsic muscle reflexes, especially if asym-			formance on these tests also requires intact stereogno-
	metric. Two others are spreading of the reflex zones and			sis.
	unusual briskness of certain intrinsic reflexes that,			Vibration and position sense. Vibration sense (pal-
	under normal circumstances, are only barely elicitable,
	or not at all, e. g., the trapezius and pectoralis reflexes			lesthesia) is tested with a vibrating 64or 124-Hz tuning
	(cf. Table 3.5). The Trömner reflex and Hoffmann sign			fork solidly placed on various bony prominences of the
	can also be of pathological significance if abnormally			body, i. e., sites where the bone is covered only by skin.
	brisk or unilaterally exaggerated. Absence of the Mayer			The intensity of vibration can be graduated, if desired,
	reflex of the metacarpophalangeal joint is also con-			with the aid of special adjustable tuning forks, such as
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35

3

The Neurological Examination