Clin skills - Gait and Limp Flashcards

1
Q

What is the limp

A

Abnormal gait

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2
Q

Examples of abnormal gait

A
Antalgic 
Short leg 
Trendelenburg
Stiff knee 
Spastic
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3
Q

Things to note in the HPC of the limping child

A

Acute/chronic
Pain – SOCRATES, beware knee/ thigh pain
Trauma
Systemic symptoms – fever, malaise, anorexia
Joint swelling(s) (not hip!)
Any previous episodes
Recent viral/ bacterial infections

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4
Q

Things to ask in the PMH of a limping child

A

Incl perinatal hx

  • DDH risk factors – breech, oligohydramnios
  • Birth complications
  • SCBU
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5
Q

Things to ask in the developmental history of a limping child

A

Milestones - how long walking

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6
Q

Things to ask in the family history of a limping child

A

DDH
Infl arthritides
Autoimmune condns

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7
Q

General examination of a limping child

A

Well or unwell?
Comfortable at rest?
Temp
Pulse

Well presented?
Rashes
Bruises/ bites/ burns …

ENT

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8
Q

Apley’s examination - look

A
Posture of limb 
Joints held flexed?
External signs of injury?
Joints swollen
Limb length discrepancy  
Gait
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9
Q

Apley’s examination - feel

A

Erythema
Tenderness
Joint effusion
Tone of muscles

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10
Q

Apley’s examination - move

A

Active/ passive ROM

Neurological/ developmental examination

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11
Q

Investigations done for a limping child

A

FBC
Infl markers
Autoimmune markers
Blood cultures

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12
Q

Imaging for limping children

A

Plain radiographs
Ultrasound
MRI

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13
Q

Radiographs for limping children

A

Fractures and dislocations

Bony pathology

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14
Q

Ultrasound for limping children

A

Good for looking for effusions

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15
Q

MRI for limping children

A

Gold standard
Detailed imaging of joint, soft tissues
Difficult for kids <5yrs

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16
Q

The ‘irritable hip’

A

Painful hip
Joint stiffness
Limp

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17
Q

Ddx for irritable hip

A
Infection 
Transient synovitis 
JIA 
Perthes 
Tumour
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18
Q

Main ddx of septic arthritis

A

Transient synovitis

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19
Q

Septic arthritis in children

A

Infection within joint space
ROM reduced
Effusion
Erythema

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20
Q

OM in children

A

Infection within the bone
Hx of trauma
ROM usually less affected
Localised tenderness

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21
Q

Key Kocher criteria for infection or transient synovitis

A

Refusal to WB

Fever > 38.5

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22
Q

Key Caird criteria for infection or transient synovitis

A

T > 38.5

Refusal to WB

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23
Q

When does OM require surgery

A

Subperiosteal abscess
Large intraosseous collection (>2cm)
PVL staph

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24
Q

Spectrum of abnormality for DDH

A

Dysplasia
Sublaxation
Dislocation
Instability

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25
Barlow exam for DDH
Test of instability | Common in new-borns
26
Ortolani exam for DDH
Reduction if dislocated hip | Clunk v click
27
Further exams for DDH
Allis test Galleazi test Restriction in ROM Gait abnormalities
28
USS screening for DDH if
Breech First degree family hx Abnormal clinical exam
29
Px of late presentation of DDH
``` Painless limping (if walking) Leg length discrepancy ```
30
O/E of late presentation of DDH
``` Restricted ROM LLD Asymmetric skin creases Especially abduction of the flexed hip Abnormal gait ```
31
Treatment for DDH
Determined by age - Pavlik harness - Closed reduction (GA) - Open reduction of the hip (GA) - Open reduction with femoral/ pelvic osteotomies (GA)
32
Possible causes of Perthes
Clotting disorders Passive smoking Genetic Environmental
33
Perthes px
Stiff hip – particularly abduction Pain Limp Leg length discrepancy
34
Stages of Perthes disease
Initial/ sclerotic Fragmentation Healing Remodelling
35
Therapeutics for Perthes
Bisphosphonates
36
Epidemiology of SCFE/ SUFE
``` 2/100,000 M:F 3:2 Assocn with obesity 25% bilateral Endocrine assocn (HypoTh, Hypopit, CRF) ```
37
AP views of pelvis in SCFE/ SUFE
Physeal widening Trethowan’s sign Reduced epiphyseal ht Frog laterals required too
38
Classification of SUFE
Temporal Stability Severity of slip
39
SUFE - Temporal
Acute (<3/52) – higher rate AVN | Chronic
40
SUFE - stability
Stability (can weight bear - 0% AVN) | Unstable (cannot weight bear at all – 47% AVN)
41
SUFE - severity of slip
Mild, moderate or severe Worse deformity, worse the later function Treatment simpler and outcome better for lesser grade
42
Why do we not attempt closed reduction for SUFE
AVN risk
43
Pre-requisites for gait
``` Stability in stance Sufficient foot clearance Appropriate pre-positioning of foot in swing Adequate step length Energy conservation ```
44
STRAWS - abnormal gait
``` Short Trendelenburg Rigid Antalgic Weak Supratenorial ```
45
Short leg gait
Head and shoulder drop as pt steps onto short limb (bobbing up & down in sagittal plane) Pelvis drops on affected side with heel strike “Vaulting gait”
46
Vaulting gait
Elevate pelvis and PF stance leg | Allows longer leg to swing through
47
Trendelenburg gait
Excessive lateral trunk flexion | Weight shifting over the stance leg
48
Cause of Trendelenburg gait
Weakness of abductor mechanisms - Joint – subluxed/ dislocated hip - Bone – shortening of femoral neck - Muscle - abductor weakness
49
Types of rigid gait
Hip Knee Ankle
50
Rigid gait - hip
Head and torso sways front to back in sagittal plane | Decreased hip flexion on wing phase and lumbar motion (AP sway)
51
Rigid gait - knee
Hip circumducts | Little flexion/ extension through stance
52
Rigid gait - ankle
May turn foot out to use STJ | Limitation F/E in sagittal plane
53
Antalgic gait
Shortened stance phase Avoids weightbearing on that side Avoids heel strike
54
Antalgic gait - hip
Lurches over the painful side to reduce lever arm and then JRF (joint reaction force)
55
Antalgic gait - knee
Held slightly flexed
56
Weak gait - hip
Trendelenburg
57
Weak gait - knee
Weak quadriceps | Back – knee (to control flexion of the ground reaction force)
58
Weak gait - ankle
High stepping gait Hip/ knees flexed excessively to lift foot Foot slap on initial contact
59
Types of supratenorial gait
Spastic diplegia | Spastic hemplegia
60
Spastic diplegia
Equinus gait Jump gait Crouch gait Scissoring gait
61
Equinas gait
Nil heel strike in rocker phases
62
Jump gait
Ankle equinas, knee flexion
63
Crouch gait
Ankle/ knee + hip flexion
64
Spastic hemiplegia
Unilateral loss heel strike Knee held flexed Nil movement of arm in swing
65
When do we develop normal gait
3/4 yrs
66
Management for abnormal gait
Treat underlying cause e.g. wt reduction, physio or orthotics & aids Surgery
67
Surgery for abnormal gait
Joint replacement “Re-shape” bone (osteotomy) Lengthen/ divide/ transfer muscles – but this weakens muscles and we cannot make weak muscles stronger
68
Further examination for suspected NAI
Skeletal survey CT brain Ophthalmology
69
Skeletal survey
Series of x-rays covering all bones in body 20 individual x-rays – incl follow-up X-rays of chest and long bones 10-14 days later Quite traumatic and should only be done if indicated
70
Why do skeletal surveys incl follow up x-rays
To identify occult fresh fractures not visible on initial survey
71
Ophthalmology for suspected NAI
Identify any external trauma e.g. bruising or subconjunctival haemorrhage Mostly identifying retinal haemorrhages
72
Why do we look for retinal haemorrhages in suspected NAI
When seen alongside subdural haemorrhage and encephalopathy indicates high likelihood of abusive head trauma
73
When do you alert police of suspected NAI
Concerns about immediate safety, staff or parents/ carer | There’s important evidence to be gathered urgently as a matter of public safety.
74
Injuries suggesting non-accidental cause – red flags
Injuries in non-ambulant babies Fractures in infants – esp ribs Subdural bleeding, esp with encephalopathy and retinal haemorrhage Peri-oral or facial bruising
75
Factors associated with abuse
Domestic violence Parental substance abuse Parental mental illness
76
Social factors associated with abuse
Poverty Young parents Social isolation 3 children or more under 5 years
77
Factors related to the child associated with abuse
Disability Preterm delivery Multiple pregnancy
78
Factors related to the parent associated with abuse
Learning difficulties | Bad experiences of parenting, personal hx of abuse
79
Common accidental sites of bruising
Commonly impact during falls Lower legs Lower back Forehead Chin
80
NAI causing fractures more likely if
Absence of credible hx Younger child Multiple fractures Metaphyseal
81
Common “accidental” fractures
Supracondylar Toddler fractures Wrist
82
Spotting child abuse - hx
Delay in presentation Story not credible Changeable story
83
Spotting child abuse - exam
Injuries don’t fit story | Injuries not compatible with development
84
Clinical observations that should be noted in examinations – general
Thriving or not – height and weight Well cared for or not – clean, dressed appropriately Is child secure and stable with parent or fearful Development – appropriate or not Attachment – does child seek security from parent
85
Clinical observations that should be noted in examinations – spp
Age – abuse more likely in younger children Bruising – face, ear, head, back, buttocks, soft tissue areas Slaps, pinches, bites Burns, brands, cigarette marks Fractures Injuries to the mouth
86
How child abuse is managed
Good record keeping Pictures or photographs Share concerns with a colleague or supervisor Report the case to children services
87
Interagency communication for NAI
Liaison and communication between health, education, police and social services
88
Gait
Pattern of movement of limbs during human (and animal) locomotion over solid ground
89
Steps in stance phase of gait
Heel strike to foot flat Foot flat through midstance Midstance to Heel off Heel off to Toe off
90
Steps in swing phase of gait
Acceleration to midswing | Midswing to deceleration
91
Traction for <6 months
Pavlik or Gallows
92
Traction for 6 months to 5 yrs
Hip spica
93
Traction for 5yrs to 10 yrs
Flexible nails* Exfix Plate
94
Traction for >10 yrs
Rigid nail* Plate Exfix Flexi nails
95
Epidemiology of humeral shaft fractures
Rare 1-3/ 10,000 2-5% of all kids fractures Bimodal - <3 and >12 Consider NAI - 60% of newly diagnosed injuries and 12% of all fractures in abuse
96
Cause of supracondylar fractures
FOOSH | Hyperextension
97
Gartland classification for supracondylar fractures
Type 1 - undisplaced Type 2 - angulated Type 3 - off-ended
98
Off-ended supracondylar fractures
Limb threatening injury Splint as is, do not try to reduce Analgesia & IV access Call ortho urgently
99
Club foot
Congenital talipes equinovarus (CTEV) Can be postural, typical or atypical Treat w/ Ponseti method
100
Causes of a limp
``` Acute or chronic conditions Bone fracture Sprain Strains Arthritis Congenital malformations CNS damage ```
101
Pattern of bruises indicating NAI
Non-bony parts of the body Face or ears Multiple bruises Clustered bruises
102
When are lacerations/ abrasions suspicious
Non-mobile children Symmetrically Around the face Around the wrists or ankles
103
Thermal injuries indicative of NAI
Areas not expected to encounter a hot object incl Soles of feet Buttocks/back Backs of hands
104
Risk factors for NAI
Hx of intimate partner violence and abuse Substance abuse or mental health conditions Excessive crying Unintended pregnancy Developmental problems
105
Podiatrist
Healthcare professionals who have been trained to diagnose and treat abnormal conditions of the feet and lower limbs
106
What do podiatrists assess
Overall anatomical alignment and posture whilst considering the position of your spine, pelvis, knees, ankles and feet.
107
Gait analysis and biomechanical assessment done by podiatrists
Hallway assessment Video analysis - multiple camera angles Infrared pressure analysis to find inefficiencies in walking pattern