abnormal gait

Question 1

Causes of abnormal gait

Answer 1

Septic arthritis
Osteomyelitis
Rheumatic fever
Transient synovitis
Trauma - accidental and non accidental
Malignancies
Neuro - Guillain Barre syndrome, Cerebral palsy, CV accident
Development dysphasia of hip
Perthe's disease
Slipped upper femoral epiphysis
Duchenne's muscular dystrophy
Talipes equinovarus, toe walking, genuine Valgum/Varum, pets plannus, in toeing.

Question 2

How do disorders of the hip usually present and what are the DDX

Answer 2

Pain which can sometimes be to the knee
Limp
DDX
Developmental dysphasia of hip
Perthe's disease
Slipper upper femoral epiphysis
Transient synovitis

Question 3

DDX for leg pain and limp

Answer 3

Growing pain
Transient synovitis
Septic arthritis
Trauma
Osteomyelitis
Legg- Perthes disease
Slipped capital femoral epiphysis
Neoplastic disease - red flag

Question 4

Growing pains

Answer 4

Occur in preschool children
Pain at night with no limp by day
Often bilateral 
Shins or thighs
Prominently muscular not bone
Otherwise health child
Doesn't stop them functioning in activities
If refusal to walk, pressure of a limp, warm, tenderness, swelling or constitutional symptoms then look for other diagnosis

Question 5

Transient synovitis

Answer 5

Benign and common in boys aged 2-8
Sudden onset limp
Otherwise well
Often preceded by URTI
All Ix come back normal

Question 6

Septic arthritis

Answer 6

Common in infant and toddler
Child looks septic
Swollen hot joint - can't see in hip
May be Febrile
Emergency
Ix high WCC and CRP. X-ray shows widening of joint space. Joint aspiration show purulent joint fluid.

Question 7

Osteomyelitis

Answer 7

Fever
Swelling, erythema, tenderness with decreased movement of limb
Ix - High CRP, WCC and Dx on X-ray, CT or MRI

Question 8

Legg-Perthes disease

Answer 8

Defined as Osteochondritis leading to a vascular necrosis of femoral head.
4:1 male to female ratio, 4-11yrs with peak at 4-7 years
Presentation - May follow transient synovitis, initially painless. Pain and limp when fracture occurs
Dx by X-ray or MRI

Question 9

Slipped capital femoral epiphysis

Answer 9

Occurs in overweight teenage boys
Presentation - gradual onset of pain in groin or knee
Dx by X-ray

Question 10

Neo plastic disease

Answer 10

Presentation - pain, tenderness and mass
Gnawing pain in leukaemia
Ix - Xray - destructive mass on X-ray

Question 11

Causes of acute limp

Answer 11

ARF
Slipped capital femoral epiphysis
Malignancy
Accidental and non accidental injury
Infection

Question 12

Talipes Equinovarus

Answer 12

Common in newborns as a transient postural deformity
Rarely more fixed deformity
Needs physiotherapist and surgery if persistent

Question 13

Common causes of abnormal gait in toddler 1-4 yr

Answer 13

Developmental dysphasia of the hip
Toddlers fracture
Transient synovitis of the hip - irritable hip
Child abuse

Question 14

Common causes of abnormal gait in 4-10 yr olds

Answer 14

Transient synovitis of the hip

Perthes disease

Question 15

Common cause of abnormal gait in adolescent greater then 10yr

Answer 15

Slipped upper femoral epiphysis

Overuse syndromes/stress fracture.

Question 16

Hx question for a child with abnormal gait

Answer 16

Duration
Complete refusal to wt bear
Trauma -
Preceding illness eg viral infection before transient synovitis or reactive arthritis
Fever or systemic symptoms suggests infective or inflammatory causes
Pain - site and severity.
Morning stiffness
Previous injuries or child protection concerns

Question 17

What to examine with a child with abnormal gait

Answer 17

GI
Vital
Gait eg running may exaggerate a limp
Neurological examination for ataxia and weakness
Generalised lymphadenopathy - viral infection/haematological cause
Excessive bruising or bruising in unusually places - NAI or haematological cause
Abdomen, scrotum and inguinal area - masses
Bony tenderness
All joint - pain, sacroiliac joints and spine - flex ion and midline tenderness may be discitis. Exaggerated lordosis in discitis. Hip abduction and internal rotation.

Question 18

Ix for child with joint pain

Answer 18

In less then 3 days = nothing
Discuss with senior staff
Blood - FBC, CRP, ESR and BC.
Imaging
Xray for Perthes/SUFE, Chronic osteomyelitis, tumours, developmental dysphasia of hips ( more then 6 m)
USS - Septic hip
Bone scan - osteomyelitis, discitis, Perthes, occult fracture
CT/MRI - Only after orthopaedic consultation.

Question 19

Common organism that causes Osteomyelitis and septic arthritis

Answer 19

Staph aureus, GAS and Haemophilus influenza

Question 20

How to differentiate between osteomyelitis and septic arthritis

Answer 20

Both
Not using that limb and may have redness over effected area.
Osteomyelitis - Subacute onset of limp/non wt bearing and refusal to use limb. Localised pain and pain on movement, tenderness, soft tissue redness/swelling may not be present and may appear late. May or may not have fever.
Septic arthritis - Acute onset of limp/non wt bearing/refusal to use limb. Pain on movement and at rest. Limited range/loss of movement. Soft tissue redness/swelling often present. Fever.

Question 21

Ix for osteomyelitis and septic arthritis

Answer 21

FBC, ESR, BC, Xray and bone scan (don’t delay Tx for this)

Question 22

Mx for septic arthritis and osteomyelitis

Answer 22

Surgical emergency - clean out joint
Refer to orthopaedics when suspected
Urgent aspiration, arthroscopy and washout with ABx Flucloxacillin

Question 23

Define cerebral palsy

Answer 23

Unchanging disorder of movement and posture due to defect or lesion of the developing brain. It is non progressive

Question 24

Has does cerebral palsy present

Answer 24

Delayed motor milestones - learning to site, stand and walk
Asymmetric movement patterns eg strong hand preference early in life
Abnormalities of muscle tone particularly spasticity or hypotonia
Difficult mx as there is severe feeding difficulties and unexplained irritability.

Question 25

Associated disorders of cerebral palsy

Answer 25

Visual problems eg strabismus, reflective errors, visual field defects and cortical visual impairment
hearing deficits
Speech and language problems
Epilepsy about 50%
Cognitive impairments. Intellectual disability, learning problems and perceptual difficulties are common

Question 26

Mx principles of cerebral palsy

Answer 26

1 accurate Dx and genetic counselling by clear Hx of pregnancy, birth and neonatal period. May need Ix such as urine/plasm metabolic screen, congenital infections, chromosomal analysis, radiological investigation - MRI - vascular lesion, malformation, periventricular leucomalacia
2 Mx of associated disabilities, health problems and consequences of the motor disorder
3 Assessment of the child’s capabilites and referral to appropriate services for the child and family
4 Common presentations to the ED - Pneumonia or other Resp disease, Uncontrolled seizure/status epileptic us, irritability consider acute infections, Oesophagitis, dental disease hip subluxation, pathological fracture. Review medication

Question 27

Developmental dysphasia of the hip

Answer 27

Presentation - stiff hip joint, Clicky hips, legs are different length, lean on affected side when standing, leg may turn outward on the affected side, skin folds may be uneven on affected side, Leg length discrepancy.
RF - breach, first born, girls, FmHx of DDH
Tx - splints, Closed reduction procedure, Open reduction surgery, Hip spices, Osteotomy

Question 28

Disorder of the hip that present with pain and limp. Sometimes knee pain.

Answer 28

Developmental dysphasia of the hip
Perthe’s disease
Slipper upper femoral epiphysis
Transient synovitis

Question 29

Signs of serious joint disease

Answer 29

Pain, swelling, warmth and redness

Question 30

Mx of ARF Joint swelling

Answer 30

Admit
Echo
Pain relief Aspirin or ibuprofen once Dx is confirmed otherwise just paracetamol.
Single dose of IM Benzathine penicillin
Secondary prophylaxis
Education and counselling for pt and family
Registered in centralised and local ARF/RHD registers
Promote good dental hygiene