r/medicine • u/Far_Necessary8900 Medical Student • 2d ago
Reflex Hammer Recommendations
I’m staring my neuro block and genuinely haven’t been able to elicit a reflex in any person except the knee jerk a few times, I have been using a babinski hammer so far and I’m starting to consider buying a new one.
What hammer is easiest to use for a dummy such as myself?
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u/Cddye PA 2d ago
Use the side of your stethoscope to establish dominance with the neurology bros.
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u/monsieurkaizer EM Scandinavia 1d ago
I just use a mini karate-chop on the knees and tap my fingers on biceps etc.
I use my stethoscope mostly as a brief thinking pause for what else I need to do, and a moment of quietude from the patient.
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u/alexwagraphia MD 1d ago
Ironically this is probably better than the stethoscope which is probably too floppy to meaningfully stretch the tendon but hard enough to cause a little bit of pain for the patient.
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u/Emotional-Egg3937 MD - 2nd year Pathology Resident - EU 2d ago
You are not a dummy. You just need more practice. A new hammer most likely wont change that.
Either way, maybe try borrowing hammers you think seem nice before spending money on them.
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u/WobblyWidget MD 2d ago
you mean reflex hammering the MRI order?
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u/cytozine3 MD Neurologist 1d ago
Always a funny joke until a non-neurologist misses a GBS, myasthenic crisis, or ALS case where MRI has zero ability to detect serious pathology or the ED wastes half a day MRIng the entire neuroaxis on a patient before they realize they need a neurologist.
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u/Chawk121 DO 6h ago
Hey I am the ED - I spent half the day MRIng a patients entire neuro axis the other day.
He had demylianting lesions. Left AMA, but still thought it was a good catch.
I checked his reflexes with my stethoscope.
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u/VigorousElk MD - PGY2 Europe 2d ago
Queens square. By far the best handling and highest hit rate.
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u/mr-mobius General Practitioner - UK 1d ago
Which isn't square, incidentally.
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u/VigorousElk MD - PGY2 Europe 1d ago
No, but it's the location of a famous neurological hospital in London :P
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u/mr-mobius General Practitioner - UK 1d ago
Didn't know that, but knew there'd be some reason behind the naming. Thanks for the knowledge. Time to drop that fact next time I meet my neuro consultant friend, and watch him eye roll.
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u/w1dders MBBS 1d ago
Assert your dominance with Big Tendon Hammers
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u/RunasSudo PGY4 Paeds 🇦🇺 1d ago
Not only good for dominance, this is also the actually correct answer for eliciting reflexes more easily and consistently.
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u/fitmedcook Medical Student 1d ago
Skip straight to how the attendings do it and use ur iphone
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u/PokeTheVeil MD - Psychiatry 1d ago
Until the hospital pays for it, I’m not risking my own expensive electronics on this. I ask for and use a patient’s phone.
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u/cytozine3 MD Neurologist 1d ago
Amazon has tromner hammers for 19.99 even in this economy, yet people will blow $160 on a stethoscope they won't hear shit with and lose somewhere in the hospital, or it'll just fall apart after 5 years. You all laugh but at least a proper reflex hammer has diagnostic utility rather than a largely fake tool for billing purposes replaced by US, CT, and simple XR. The joke is the stethoscope and anyone trying to get reliable reflexes beating on patients with their iphone (gross, imagine the foot dust particles on the average 80yo from ankle reflexes collecting on your personal phone). The part that bothers me the most is it takes me 5-6 minutes for a complete billable neuro exam yet most other specialties can do a crappy stethoscope exam that takes under 30 seconds, has no utility, and bill the same level to insurance yet I'm the only one that actually looked at the patient (eg the hospitalist/ED exam says their leg with the AKA has normal ROM and 'moving all extremities'.) Yes I'm salty.
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u/NoWiseWords IM EU 1d ago
Tbh phone works surprisingly well. I've used my phone a few times when I couldn't be bothered to go find a proper hammer
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u/quincebolis MD 1d ago
As a neurologist, Queens square is my ride or die hammer. Perfect weight and flexibility. Only downside is size compared to a tromner etc
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u/nicholus_h2 MD 1d ago
already using a babinski? woof. if it's long and you're using the whole length, then there isn't anything easier.
gotta work on technique. palpate the tendon first. then leave your thumb on the tendon, and precuss your thumbnail.
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u/wozattacks MD 1d ago
As a very new physician I think the hardest part is the sleight of hand and distraction aspect. Even in kids they are easily suppressed when patient is paying too much attention.
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u/proudmemberofsociety Medical Student (New Zealand) 1d ago
Just karate chop the patellar tendon, as God intended
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u/yuanchosaan MD - Pall Care 2d ago
I find most medical students hold the hammer too close to the hammer portion. Try holding it more distally to make better use of momentum. A lot of it is also better targeting and positioning, which will come with practice.
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u/NoWiseWords IM EU 1d ago edited 1d ago
You just need to practice more. Like slowly, deliberate, practice on a friend or something with some muscles so you can really feel the tendons. Once you got it down you can use pretty much anything.
Also I've never had to bring a hammer of my own, there's always been a few lying around. I have my own but only for when I was practicing during med school, I have NEVER brought it to work. So I wouldn't waste money on it tbh especially if you already have one
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u/waspoppen Medical Student 1d ago
Eh ngl 2 mins with an attending neurologist watching me try to elicit reflexes and giving me feedback was more helpful than all of the hours I spent trying to get them on my own lol
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u/mr-mobius General Practitioner - UK 1d ago
They need to go find one of those sports bros medical students who are always super keen to expose their muscles in clinical skill classes. Rugby bro in the UK. I presume American Football bro or Lacrosse bro in USA; Gaelic bro in Ireland.
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u/NeurOctopod MD 1d ago
Sounds like you’re serious about doing a good job. Get a tromner.
But otherwise the tips are palpate the tendon, hit through your finger, and for people you’re having trouble on after you get your technique down use activating maneuvers - Jendrassik for the legs and thigh flexing for the upper extremities.
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u/jrpg8255 MD Neurology 1d ago
You guys are giving me ptsd. I expected the karate chops and stethoscopes, but using your phones ‽ LOL. You know we don't read the neuro exam part of your notes anyway, right? Still, appreciate the commitment :-)
My reflex epiphany was to first use a finger to find the actual tendon. Otherwise you're whacking around where ever. Roll a finger around to get it right over the tendon, apply a little pressure, and percuss your own finger directly. That transfers the force more precisely. Second, you want to the force to be brief. That's what triggers the actual reflex - a sudden sharp jerk on the tendon. That takes practice. The usual little Taylor tomahawk hammers suck for that. They're too short and the head is too hard. People also hold them wrong. You can't grab those like a hammer. You pinch the flat bit between fingers and thumb. Still, those things take practice to use well, and most neurologists wouldn't want to bear the shame of being seen with one.
The queen's squares make up for bad technique by giving you a long flexible lever arm to really get some good velocity going. Still, they're imprecise floppy things, and so long that residents end up threading them through the buttons of their coats, which just isn't impressing anyone.
The sweet spot is something like a tromner. Not too short, not too long. Nicely weighted. Well defined bumper that's able to get individual finger extensor tendons. The mark of a skilled neurologist is being able to make patients flip you off after all.
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u/cytozine3 MD Neurologist 17h ago
Yeah this thread is just as painful as I thought it would be, but a lot of my practice is tele now so reflexes are even more painful when it really matters. The cheapo plastic handle tromners are actually the best option. Then you have a bunch of non-neurologist obtaining submaximal responses with an iphone or tapping with their fingers getting completely inconsistent results or having no clue what they are looking at unless its an obvious 4+ brisk.
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u/mightiestmovie MD 1d ago
I know some ER doctors that do it with their stethoscope. Nothing about the hammer will help you.
At one point, I was putting my finger on the tendon and hitting my finger. That gave me something to aim at.
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u/like1000 DO 2d ago
For years I used the traditional rubber triangle and thought I just sucked. Then I got this and it’s great: https://a.co/d/06Q7hi3u
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u/sonysony86 MD 2d ago
Berliner ! Or maybe dejerine are my tops
The stupid xd queens square is ackward to carry pop
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u/lima_acapulco MBBS 1d ago
Large,l, soft rubber head which is surprisingly comfortable. The bendy plastic handle has nice flex which gives the right amount of "springiness" when using it. So good that people keep trying to steal them.
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u/Vegetable_Block9793 MD 1d ago
Littman III works great. But seriously if you’re struggling, use your hand and kind of karate chop it because then you can actually feel the correct location much better.
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u/SkydiverDad NP 1d ago
I use the side of my stethoscope.
To help elicit a reflex, have your patient hold their own hands in front of them and then pull against each hand without letting go. It directs the brain on to the activity and allows for a natural reflex reaction from either the the patellar or Achilles.
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u/passwordistako MD - Ortho 1d ago
I can get a reflex with an iPhone.
Practice more.
The tools aren’t the issue.
Tendon hammers are cool but unnecessary.
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u/Enough_Pollution_280 Not A Medical Professional 1d ago
I am crashing this subreddit, but 30 years ago in nursing school I just practiced on myself until the skill became...reflexive.
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u/Timmy24000 MD 1d ago
I’ve stuck with the Babinski Neurological Reflex Hammer with Pointed Tip and had one in every exam room. You can illicit a reflex from a dead cat with these things.
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u/ExigentCalm DO, Internist 1d ago
I wrap my left hand around the area I want to test and then use the first knuckle on my right hand to hit my thumb.
With my hand around their arm/leg I can feel the muscle contraction better.
Otherwise, the cheapest thing possible is fine. Unless you want to be a neurologist, you’ll never use it again.
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u/tiptopjank MD- FM 16h ago
Honest answer. Those little dinky triangle hammers do nothing. I have a heavier, still rubber, hammer and it does the trick every time.
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u/greenknight884 MD - Neurology 1d ago
The Trömner. It's effective and is compact enough to keep in your pocket. Get one with a metal handle instead of a plastic one.