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Paeds > Abnormal gait > Flashcards

Abnormal gait Flashcards

1
Q

Common diagnoses (by age) in a child who is limping or non-weight bearing

A

Toddler (1-4 years)

  • Developmental dysplasia of the hip (DDH)
  • Toddlers fracture
  • Transient synovitis of the hip (Irritable hip)
  • Child abuse

Child (4-10 years)

  • Transient synovitis of the hip
  • Perthes Disease

Adolescent (>10 years)

  • Slipped upper femoral epiphysis (SUFE)
  • Overuse syndromes / stress fractures
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2
Q

Common diagnoses in a child who is limping or non-weightbearing (any age group)

A

All ages:

  • Infections: Osteomyelitis / Septic Arthritis, discitis, soft tissue, viral myositis
  • Trauma (see Fractures)
  • Non accidental or inflicted injury (see Child abuse guideline) - fracture, sprain, haematoma
  • Malignancy - Acute lymphoblastic leukaemia, bone tumours, eg: spine or long bone
  • Rheumatological disorders and reactive arthritis
  • Intra-abdominal pathology, eg: appendicitis
  • Inguinoscrotal disorders, eg: testicular torsion
  • Vasculitis, serum sickness
  • Functional limp
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3
Q

Important history questions in a child who is limping/non-weight bearing

A
  • Duration of symptoms
  • Complete refusal to weight bear
  • Trauma - there is often a coincidental history of trauma in a non-traumatic condition or there may be no history of trauma and the child may have a significant injury.
  • Preceding illness - there is often a history of a simple viral infection preceding a transient synovitis or reactive arthritis
  • Fever or systemic symptoms - suggests infective or inflammatory causes
  • Pain - site and severity. Pain on changing the nappy, causing back flexion, may be present in discitis
  • Morning stiffness
  • Previous injuries or child protection concerns
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4
Q

Things to examine in child who is limping/non-weight bearing

A
  • General appearance, temp
  • Gait - running may exaggerate a limp
  • Neurological examination - look for ataxia, weakness
  • Generalised lymphadenopathy (viral infection / haematological cause)
  • Excessive bruising or bruising in unusual places (NAI, haematological)
  • Abdomen, scrotum and inguinal area (masses)
  • Bony tenderness
  • All joints
    • knee pain can be referred from the hip, and thigh pain can be referred from the spine
    • Include sacro-iliac joints and spine in joint assessment - look for pain on flexion and/or midline tenderness which may be present in discitis
    • Exaggerated lordosis (discitis)
    • Hip abduction and internal rotation are often the most restricted movements in hip pathology
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5
Q

Investigations for child who is limping

A

Unless suspecting a specific diagnosis, investigations are usually not required in children with limp <3 days duration.

Discuss with senior staff, then consider:

  • Bloods:
  • FBE, CRP, ESR, blood culture

Imaging:

  • plain films
  • Further imaging should be discussed with senior staff:

PLAIN XRAY

  • Perthes / SUFE
  • Chronic osteomyelitis (bony changes only evident after 14 - 21 days)
  • Tumours
  • Developmental dysplasia of hips (> 6 months of age)

USS

  • septic hip

Bone scan

  • Osteomyelitis
  • Discitis
  • Perthes
  • Occult fracture

CT/MRI

  • Only after orthopaedic consultation
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6
Q

What is Perthes disease

A

Perthes disease

  • Avascular necrosis of the capital femoral epiphysis.
  • Age range 2-12 years (majority 4-8yrs)
  • 20% bilateral
  • Present with pain and limp
  • Restricted hip motion on examination
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7
Q

What is Slipped Upper Femoral Epiphysis?

A

Slipped Upper Femoral Epiphysis

  • Late childhood/early adolescence.
  • Weight often > 90th centile.
  • Presents with pain in hip or knee and associated limp.
  • The hip appears externally rotated and shortened.
  • There is decreased hip movement - especially internal rotation.
  • May be bilateral.
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8
Q

When to consider outpatient rheumatology referral in a child with acutely swollen joint?

A

Consider outpatient referral to Rheumatology if:

  • Symptoms for >4 weeks
  • A significant joint effusion
  • Significant limitation of activity
  • Multiple joint involvement
  • Evidence of joint contractures
  • Vasculitis other than HSP
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9
Q

Outline approach to hsitory taking in a child with acutely swollen joint

A
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10
Q

Outline the difference in presentation between septic arthritis and osteomyelitis

A

Septic arthritis

  • Acute onset of limp / non-weight bearing / refusal to use limb
  • Pain on movement and at rest
  • Limited range / loss of movement
  • Soft tissue redness / swelling often present
  • Fever

Osteomyelitis

  • Subacute onset of limp / non-weight bearing / refusal to use limb
  • Localised pain and pain on movement
  • Tenderness
  • Soft tissue redness / swelling may not be present & may appear late
  • +/- Fever
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11
Q

Common causative organisms of septic arthritis/osteomyelitis

A

Both are most commonly caused by

  • Staphylococcus aureus
  • can be caused by group A b -haemolytic streptococci and Haemophilus influenzae
  • Children with sickle cell anaemia are prone to infection by salmonellae.
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12
Q

Management of osteomyelitis/septic arthritis

A

Management

  • Refer to Orthopaedics if osteomyelitis/septic arthritis suspected or confirmed
  • Septic arthritis requires urgent aspiration +/- arthrotomy and washout* Flucloxacillin 50mg/kg (max 2g) 6 hourly IV
  • Elevate and immobilise limb
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13
Q

Investigations for osteomyelitis/septic arthritis

A
  • FBC
  • ESR (may be useful for monitoring progress)
  • blood culture
  • xray (often normal, but may exclude trauma, etc)
  • Bone Scan.
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14
Q

What is juvenile idiopathic arthritis? What are the classifications?

A
  • a group of conditions that present in childhood with joint inflammation lasting 6 weeks for which no other cause is found
  • Up to 1 in 1000 children may be affected during childhood
  • classification depends on the presentation, but may not be reliably assigned for 6 months
  • Treatment = aimed at treating the pain and inflammation and maintaining good joint mobility
  • In the majority there is resolution during childhood
  • A multidisciplinary approach is needed

CLASSIFICATIONS

  • Systemic (Still’s disease): 9%
  • Polyarticular: 19%
  • Pauciarticular ( ≤4 joints): 49%
  • Spondyloarthropathies (HLA B27): 7%
  • Juvenile psoriatic arthritis: 7%
  • Other
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15
Q

Outline the presentation, features, and prognosis of Still’s disease

A

Presentation
• Spiking fever, severe malaise
• Salmon-pink rash
• Anaemia, weight loss
• Hepatosplenomegaly, pericarditis
• Arthralgia and myalgia but may have minimal joint
symptoms
• May resemble malignancy

Features
• Both large and small joints affected
• 25% have severe arthritis
• Rheumatoid factor negative
• Associated with HLA-DR4

Prognosis
• In 25%, arthritis persists into adulthood
• Long term prognosis improved with introduction of
biological therapies

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16
Q

Outline the presentation, features, and prognosis of polyarticular arthritis in children

A

Polyarticular = >4 joints

Presentation
• Symmetrical involvement of large and small joints
• There may be poor weight gain and mild anaemia
• Morning stiffness
• Irritability in young children

Features and prognosis
• Rheumatoid factor negative in 97%, ANA may be positive
• Low risk of eye involvement
• 12% develop severe arthritis but prognosis is generally good
Polyarticular (more than four joints)
• Temporomandibular joint may be involved, causing
micrognathia

17
Q

Outline the presentation, features, and prognosis of Pauciarticular arthritis in children

A

Pauciarticular = <4 joints

Presentation
• Most common form of JIA
• Usually affects large joints (knees, ankles, elbows)
• Commonly affects girls under the age of 4 years
• Minimal systemic symptoms

Features and prognosis
• Rheumatoid factor negative, antinuclear antibody
(ANA) may be positive
• High risk of chronic uveitis (inflammation of
anterior eye structures), especially if ANA +ve.
Needs regular slit-lamp examination to screen
for this
• Arthritis resolves completely in 80%

18
Q

What is Developmental dysplasia of the hip (DDH)?

A
  • abnormal development of the hip joint
  • The ball at the top of the thighbone (called the femoral head) is not stable within the socket (called the acetabulum)
  • The ligaments of the hip joint which hold it all together may also be stretched and loos
  • Sometimes, the hips dislocate after birth and this may not be noticed until your child starts to walk.
19
Q

Signs + symptoms of DDH?

A

Signs and symptoms

  • a stiff hip joint
  • the legs are different lengths
  • your child may lean to the affected side when standing
  • your child’s leg may turn outward on the affected side
  • the skin folds may be uneven on their bottom
20
Q

What causes DDH?

A
  • Pregnant women secrete hormones in their bloodstream which allows their ligaments to relax
  • These hormones help the delivery of the baby through the mother’s pelvis
  • Some of these hormones enter the baby’s blood and can make the baby’s ligaments relaxed as well
  • This can make the hip joint loose in the socket
  • The way the baby lies in the uterus can also cause the hip joint to become loose or dislocate.
  • DDH is more common in girls, firstborn children, babies born in the breech position (i.e. bottom first) and in families where a parent has had a dislocated hip joint. DDH can be in one or both hip joints.
21
Q

What is the treatment for DDH?

A
  • splints
    • holds the hip joint in the correct position so that the ligaments tighten
    • child may need to wear the splint for several months, until the hip is stable or X-rays are normal
    • 1 commonly used splint is called a ‘Pavlik Harness’.
  • closed reduction procedure
    • The hip joint is moved into the correct position while child is under anaesthetic
    • Children then need to wear a ‘hip spica’ plaster
  • open reduction surgery
    • The hip joint is moved into the correct position while child is under anaesthetic
    • The hip joint is made more stable by surgery to the surrounding tendons. This is done through a small cut in the groin.
    • Children then need to wear a ‘hip spica’
  • hip spicas
    • a plaster cast that covers your child’s body from the knees to the waist
    • may need to be worn for a number of months
    • Children may then need to wear different splints or braces to make sure the hip joint remains stable and in the right position.
  • osteotomy
    • when DDH is diagnosed late, more surgery to the thigh or pelvic bones may need to be done to make sure the hip joint stays in place
22
Q

Risk factors for developmental dysplasia of the hip

A
  • First born
  • Female
  • Breech
  • FmHx

Paeds (29 decks)

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