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Podopediatrics > 5) The Limping Child > Flashcards

5) The Limping Child Flashcards

1
Q

Limping

A
  • Any deviation from normal, rhythmic gait
  • Never normal
  • Many possible etiologies
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2
Q

Antalgic

A
  • Painful limping
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3
Q

Center of gravity

A
  • Located 2 cm anterior to S – 2

- Moves in spiral 5 cm diameter during normal gait

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4
Q

Six determinants of gait

A
  • Pelvic rotation
  • Pelvic tilt
  • Lateral pelvic motion
  • Knee flexion at heel contact
  • Knee motion
  • Foot and ankle motion
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5
Q

ROM required for normal gait

A
  • Hip: 10 degrees of extension to 30 degrees of flexion
  • Knee: 180 degrees extension to 60 degrees of flexion
  • Ankle: 10 degrees dorsiflexion to 20 degrees plantarflexion (more than during running)
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6
Q

Muscle function during gait

A
  • Eccentric vs. concentric contraction
  • Hip flexors: initiate gait
  • Spasticity: Velocity dependent movement
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7
Q

Six anatomic locations to clinically examine limping

A
  • Spine
  • Pelvis
  • Hip
  • Knee
  • Ankle
  • Foot
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8
Q

Limping disease categories

A
  • Pain
  • Neuromuscular imbalance
  • Limb length inequality
  • Joint restriction
  • Limb deformity
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9
Q

Potential etiologies of limping

A
  • Biomechanical
  • Circulatory
  • Congenital
  • Dermatologic
  • Infection
  • Inflammation
  • Neoplastic
  • Neuromuscular
  • Metabolic
  • Traumatic
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10
Q

Limping diagnosis considerations

A
  • Patient age
  • Antalgic vs. non-antalgic
  • Potential etiologies
  • Anatomic location (level of the deformity)
  • Disease categories
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11
Q

Congenital limping diagnosis (ex. clubfoot)

A
  • Painless
  • Any age
  • Limb length discrepancy
  • Deformity
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12
Q

Traumatic limping diagnosis (ex. ankle sprain)

A
  • Any age
  • Antalgic
  • Joint restriction
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13
Q

Limping infectious diagnosis (ex. osteomyelitis)

A
  • Usually < 5 yrs of age
  • Antalgic
  • Physical examination
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14
Q

Inflammatory limping diagnosis (ex. sever’s disease)

A
  • Ages 7 – 13 yrs
  • Antalgic
  • Joint restriction (equinus)
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15
Q

Metabolic limping diagnosis (ex. ricket’s)

A
  • Usually < 5 yrs of age
  • Painless
  • Limb deformity
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16
Q

Circulatory limping diagnosis (ex. Kholer’s disease)

A
  • Usually ages 2 – 6
  • Antalgic
  • Physical examination (midfoot pain)
17
Q

Toe walking (uncompensated ankle equinus)

A
  • The etiology may vary
  • STJ supination only
  • When sustained, it is never normal
18
Q

Characteristics of “normal” toe walking

A
  • No significant PMH
  • Occurs early on
  • Occurs intermittently (not constant)
  • Child < seven (7) years of age
  • Normal physical examination
19
Q

Characteristics of abnormal toe walking

A
  • Associated abnormalities
  • Occurs later, following a period of normal gait
  • Is fairly constant
20
Q

Toe walking physical examination

A
  • Neurological examination: Spasticity, clonus, pathological reflexes ?
  • Biomechanical examination: Equinus, limb length discrepancy, CDH ?
21
Q

Potential toe walking etiologies

A
  • Biomechanical: Equinus (congenital or acquired)
  • Neuromuscular: Cerebral palsy, Duchenne muscular dystrophy, etc.
  • Idiopathic (ITW) Most common etiology
22
Q

Toe walking neurological etiologies

A
  • Cerebral Palsy
  • Duchenne muscular dystrophy
  • Peroneal muscular atrophy (CMT)
  • Dystonia musculorum deformans
  • Tethered cord syndrome
  • Spinal cord tumor
  • Acute myopathy
23
Q

Toe walking diagnosis considerations

A
  • History
  • Neurological examination
  • Biomechanical examination
  • Gait analysis
  • Electromyography / kinematic analysis
  • Laboratory testing
24
Q

Diagnostic testing for toe walking

A
  • A thorough perinatal and family history !
  • CPK screening
  • MRI
25
Q

Congenital ankle equinus management

A
  • AFO with heel lift
  • Ankle fusion at 90 degrees
  • Ankle implant: Consider patient age and stability of the knee
26
Q

Idiopathic toe walking (ITW): most common

A
  • Early onset toe walking without significant physical findings and all other diagnosis have been excluded
27
Q

The ITW child

A
  • Consistent toe walking
  • Ankle equinus (dorsiflexion is available)
  • Normal neurological exam and EMG
  • Learning / communication / other disorder
  • Autism
  • A diagnosis of “exclusion”
28
Q

ITW history

A
  • Learning disability
  • Communication disorder
  • Autism
  • Mental retardation
  • Developmental disability
29
Q

Management of idiopathic toe walking (ITW)

A
  • Determine etiology
  • Achilles stretching
  • Heel lift
  • Serial casting
  • AFO with plantarflexion stop
  • Botulism toxin (Botox)
  • Surgical achilles lengthening

Podopediatrics (6 decks)

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