Neuro check: triple flex vs withdrawal

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I'm still new to my ICU and was wondering the specific difference between triple flex and withdrawal of the lower extremities? I know triple flex is flexion of the ankle, knee, and hip but it seems like our neuro MDs frequently have triple flex charted when I have withdrawal. Is there any key differences between these? One nurse told me that true withdrawal would have the patient continuously moving their foot back to their body vs. triple flex where the foot would flex and stop after about 6 inches.

Also, is it always necessary to do noxious stimuli (pinch nailbed) every 2hours? We have a lot of patients that have bruises or open wounds on most nailbeds from clamping down frequently.



Hi mcmurray - sorry this is a late response, hopefully it can still help you.

the nurse your spoke with is correct - sort of. A withdrawal IS a continual motion - meaning the patient will continue to withdraw his or her limb for the duration of the painful stimulus, because they are consciously withdrawing from the pain. A true triple flex is different. A TF will LOOK like a withdrawal, but the way to tell the difference is to see the patient relax while the painful stimulus is being held.

Example: if you apply nailbed pressure for 10 seconds (ouch!), a patient who is truly withdrawing will withdraw for the whole 10 seconds, while the patient who is triple flexing will withdraw for a few seconds and then relax again, even though you are still holding nailbed pressure.

hope this helps!

Esme12, ASN, BSN, RN

4 Articles; 20,908 Posts

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 43 years experience.

withdrawl is clearly a response to the stimuli and purposeful. If the staff is pressing hard enough to cause open wounds that patient is pretty deep neurologically. I have been a critical care nurse for 35 years and I have had some pretty impaired neurological patients and I haven't seen open wounds from a neurological assessment.


150 Posts

I think triple flex is a spinal reflex and is not a true indication of brain function, withdrawal would be a better sign. At least that is what I heard a group of neurosurgeons saying the other day. And I hope you are pinching your pts every 2 hours!

Specializes in SICU, trauma, neuro. Has 16 years experience.

I like to roll a bit of foam tape around both sides of a Kelly clamp. That way you can squeeze hard if you need to, but you've eliminated the sharp edges which can break the skin

Specializes in Critical Care.
iluvgusgus said:
I think triple flex is a spinal reflex and is not a true indication of brain function, withdrawal would be a better sign. At least that is what I heard a group of neurosurgeons saying the other day. And I hope you are pinching your pts every 2 hours!

I pinch them every hour.


12 Posts

Here's how I think of withdrawal. 5 on the Glascow Coma Scale. If the persone is intubated and you suction, that person will grab the ETT and yank it out (o attempt to do so); the person may do what I call a head to hand maneuver because of restraints--sit up to get ETT close to the hand to yank it out; the patient may also try to push you away. The hallmark is that this movement has a purpose--remove noxious stimuli. 4 on the Glascow Coma Scale: Patient will start to raise arm to ETT but not complete the movement--as though too sleepy to do it. The hallmark of 4 is that it is semi-purposeful movement--either attempting to remove or get away from noxious stimuli--but it is typically elicited slower and the movement is not as vigorous as 5. 3 is flexion withdrawal: now the patient is posturing (decorticate)--to noxious stimuli--elbows flex, wrists flex, legs extend, feet plantar flex (look extended) and turn inward. This means that the corticospinal tract is interrupted at the level of the red nucleus. This movement is a reflex, it is not purposeful. Triple Flex Reflex is s spinal cord reflex. Patients may exhibit this reflex when brain dead. Flexion withdrawal, the red nucleus is responsible for the upper arm movements and the leg movements are a due to activity in the lateral corticospinal tract of the spinal cord. The motor assessment number of the Glascow Coma Scale is inversely related to prognosis with 3,2, and 1 having a grim prognosis. Triple Flex Reflex can occur with stimuli like air moving across the patient--the hips, knees flex and feet dorsiflex. Hope this helps. There are some good youTube videos on neuro stuff. There is a cranial nerve music video that is very helpful to remember cranial nerves.


12 Posts

Has 13 years experience.

This is an ancient thread, but still great conversation. :)

I have a hunch that the docs are charting triple flexion because they're not convinced the movement is anything more than a spinal reflex that can be stimulated in even brain dead patients. I see charting like that in my Neuro ICU as well. I'm in a Critical Care Consortium right now, and in the neuro lecture, the educator told us to not use the lower extremities when using painful stimuli to determine the motor score. He referenced the American College of Surgeons' Trauma Quality Improvement Program (TQUIP). So I looked it up....

In the section entitled Management of Traumatic Brain Injury, it mentions:

"The location of the stimulus (central or peripheral) should be standardized and used consistently. To describe the motor response, only the reaction of the arms should be observed, not the legs."

I think if you actually scored true triple flexion, it would get a +1, because it does not reflect any cerebral function at all. I see nurses pretty routinely crank on a toenail bed, and when the patient moves the extremity, they say, "She's withdrawing from pain" and score it a +4.

Unfortunately, in my neuro training (which was pretty recent), the pain reflex, spinal reflex, withdrawal reflex or whatever you want to call it, is something that was never discussed. But it seems pretty important to know.

I'm attaching an interesting conversation on Reddit about the topic. The highlights are mine.

Triple flexion.jpg