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MBBS - Year 1 > Clin skills - Gait and Limp > Flashcards

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
Q

Barlow exam for DDH

A

Test of instability

Common in new-borns

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26
Q

Ortolani exam for DDH

A

Reduction if dislocated hip

Clunk v click

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27
Q

Further exams for DDH

A

Allis test
Galleazi test
Restriction in ROM
Gait abnormalities

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28
Q

USS screening for DDH if

A

Breech
First degree family hx
Abnormal clinical exam

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29
Q

Px of late presentation of DDH

A 
Painless limping (if walking)
Leg length discrepancy
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30
Q

O/E of late presentation of DDH

A 
Restricted ROM 
LLD 
Asymmetric skin creases 
Especially abduction of the flexed hip
Abnormal gait
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31
Q

Treatment for DDH

A

Determined by age

  • Pavlik harness
  • Closed reduction (GA)
  • Open reduction of the hip (GA)
  • Open reduction with femoral/ pelvic osteotomies (GA)
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32
Q

Possible causes of Perthes

A

Clotting disorders
Passive smoking
Genetic
Environmental

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33
Q

Perthes px

A

Stiff hip – particularly abduction
Pain
Limp
Leg length discrepancy

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34
Q

Stages of Perthes disease

A

Initial/ sclerotic
Fragmentation
Healing
Remodelling

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35
Q

Therapeutics for Perthes

A

Bisphosphonates

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36
Q

Epidemiology of SCFE/ SUFE

A 
2/100,000
M:F 3:2
Assocn with obesity 
25% bilateral 
Endocrine assocn (HypoTh, Hypopit, CRF)
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37
Q

AP views of pelvis in SCFE/ SUFE

A

Physeal widening
Trethowan’s sign
Reduced epiphyseal ht

Frog laterals required too

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38
Q

Classification of SUFE

A

Temporal
Stability
Severity of slip

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39
Q

SUFE - Temporal

A

Acute (<3/52) – higher rate AVN

Chronic

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40
Q

SUFE - stability

A

Stability (can weight bear - 0% AVN)

Unstable (cannot weight bear at all – 47% AVN)

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41
Q

SUFE - severity of slip

A

Mild, moderate or severe
Worse deformity, worse the later function
Treatment simpler and outcome better for lesser grade

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42
Q

Why do we not attempt closed reduction for SUFE

A

AVN risk

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43
Q

Pre-requisites for gait

A 
Stability in stance 
Sufficient foot clearance 
Appropriate pre-positioning of foot in swing 
Adequate step length 
Energy conservation
44
Q

STRAWS - abnormal gait

A 
Short 
Trendelenburg 
Rigid
Antalgic
Weak 
Supratenorial
45
Q

Short leg gait

A

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
Q

Vaulting gait

A

Elevate pelvis and PF stance leg

Allows longer leg to swing through

47
Q

Trendelenburg gait

A

Excessive lateral trunk flexion

Weight shifting over the stance leg

48
Q

Cause of Trendelenburg gait

A

Weakness of abductor mechanisms

  • Joint – subluxed/ dislocated hip
  • Bone – shortening of femoral neck
  • Muscle - abductor weakness
49
Q

Types of rigid gait

A

Hip
Knee
Ankle

50
Q

Rigid gait - hip

A

Head and torso sways front to back in sagittal plane

Decreased hip flexion on wing phase and lumbar motion (AP sway)

51
Q

Rigid gait - knee

A

Hip circumducts

Little flexion/ extension through stance

52
Q

Rigid gait - ankle

A

May turn foot out to use STJ

Limitation F/E in sagittal plane

53
Q

Antalgic gait

A

Shortened stance phase
Avoids weightbearing on that side
Avoids heel strike

54
Q

Antalgic gait - hip

A

Lurches over the painful side to reduce lever arm and then JRF (joint reaction force)

55
Q

Antalgic gait - knee

A

Held slightly flexed

56
Q

Weak gait - hip

A

Trendelenburg

57
Q

Weak gait - knee

A

Weak quadriceps

Back – knee (to control flexion of the ground reaction force)

58
Q

Weak gait - ankle

A

High stepping gait
Hip/ knees flexed excessively to lift foot
Foot slap on initial contact

59
Q

Types of supratenorial gait

A

Spastic diplegia

Spastic hemplegia

60
Q

Spastic diplegia

A

Equinus gait
Jump gait
Crouch gait
Scissoring gait

61
Q

Equinas gait

A

Nil heel strike in rocker phases

62
Q

Jump gait

A

Ankle equinas, knee flexion

63
Q

Crouch gait

A

Ankle/ knee + hip flexion

64
Q

Spastic hemiplegia

A

Unilateral loss heel strike
Knee held flexed
Nil movement of arm in swing

65
Q

When do we develop normal gait

A

3/4 yrs

66
Q

Management for abnormal gait

A

Treat underlying cause e.g. wt reduction, physio or orthotics & aids
Surgery

67
Q

Surgery for abnormal gait

A

Joint replacement
“Re-shape” bone (osteotomy)
Lengthen/ divide/ transfer muscles – but this weakens muscles and we cannot make weak muscles stronger

68
Q

Further examination for suspected NAI

A

Skeletal survey
CT brain
Ophthalmology

69
Q

Skeletal survey

A

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
Q

Why do skeletal surveys incl follow up x-rays

A

To identify occult fresh fractures not visible on initial survey

71
Q

Ophthalmology for suspected NAI

A

Identify any external trauma e.g. bruising or subconjunctival haemorrhage
Mostly identifying retinal haemorrhages

72
Q

Why do we look for retinal haemorrhages in suspected NAI

A

When seen alongside subdural haemorrhage and encephalopathy indicates high likelihood of abusive head trauma

73
Q

When do you alert police of suspected NAI

A

Concerns about immediate safety, staff or parents/ carer

There’s important evidence to be gathered urgently as a matter of public safety.

74
Q

Injuries suggesting non-accidental cause – red flags

A

Injuries in non-ambulant babies
Fractures in infants – esp ribs
Subdural bleeding, esp with encephalopathy and retinal haemorrhage
Peri-oral or facial bruising

75
Q

Factors associated with abuse

A

Domestic violence
Parental substance abuse
Parental mental illness

76
Q

Social factors associated with abuse

A

Poverty
Young parents
Social isolation
3 children or more under 5 years

77
Q

Factors related to the child associated with abuse

A

Disability
Preterm delivery
Multiple pregnancy

78
Q

Factors related to the parent associated with abuse

A

Learning difficulties

Bad experiences of parenting, personal hx of abuse

79
Q

Common accidental sites of bruising

A

Commonly impact during falls

Lower legs
Lower back
Forehead
Chin

80
Q

NAI causing fractures more likely if

A

Absence of credible hx
Younger child
Multiple fractures
Metaphyseal

81
Q

Common “accidental” fractures

A

Supracondylar
Toddler fractures
Wrist

82
Q

Spotting child abuse - hx

A

Delay in presentation
Story not credible
Changeable story

83
Q

Spotting child abuse - exam

A

Injuries don’t fit story

Injuries not compatible with development

84
Q

Clinical observations that should be noted in examinations – general

A

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
Q

Clinical observations that should be noted in examinations – spp

A

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
Q

How child abuse is managed

A

Good record keeping
Pictures or photographs
Share concerns with a colleague or supervisor
Report the case to children services

87
Q

Interagency communication for NAI

A

Liaison and communication between health, education, police and social services

88
Q

Gait

A

Pattern of movement of limbs during human (and animal) locomotion over solid ground

89
Q

Steps in stance phase of gait

A

Heel strike to foot flat
Foot flat through midstance
Midstance to Heel off
Heel off to Toe off

90
Q

Steps in swing phase of gait

A

Acceleration to midswing

Midswing to deceleration

91
Q

Traction for <6 months

A

Pavlik or Gallows

92
Q

Traction for 6 months to 5 yrs

A

Hip spica

93
Q

Traction for 5yrs to 10 yrs

A

Flexible nails*
Exfix
Plate

94
Q

Traction for >10 yrs

A

Rigid nail*
Plate
Exfix
Flexi nails

95
Q

Epidemiology of humeral shaft fractures

A

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
Q

Cause of supracondylar fractures

A

FOOSH

Hyperextension

97
Q

Gartland classification for supracondylar fractures

A

Type 1 - undisplaced
Type 2 - angulated
Type 3 - off-ended

98
Q

Off-ended supracondylar fractures

A

Limb threatening injury
Splint as is, do not try to reduce
Analgesia & IV access
Call ortho urgently

99
Q

Club foot

A

Congenital talipes equinovarus (CTEV)
Can be postural, typical or atypical
Treat w/ Ponseti method

100
Q

Causes of a limp

A 
Acute or chronic conditions 
Bone fracture 
Sprain 
Strains 
Arthritis 
Congenital malformations
CNS damage
101
Q

Pattern of bruises indicating NAI

A

Non-bony parts of the body
Face or ears
Multiple bruises
Clustered bruises

102
Q

When are lacerations/ abrasions suspicious

A

Non-mobile children
Symmetrically
Around the face
Around the wrists or ankles

103
Q

Thermal injuries indicative of NAI

A

Areas not expected to encounter a hot object incl
Soles of feet
Buttocks/back
Backs of hands

104
Q

Risk factors for NAI

A

Hx of intimate partner violence and abuse
Substance abuse or mental health conditions
Excessive crying
Unintended pregnancy
Developmental problems

105
Q

Podiatrist

A

Healthcare professionals who have been trained to diagnose and treat abnormal conditions of the feet and lower limbs

106
Q

What do podiatrists assess

A

Overall anatomical alignment and posture whilst considering the position of your spine, pelvis, knees, ankles and feet.

107
Q

Gait analysis and biomechanical assessment done by podiatrists

A

Hallway assessment
Video analysis - multiple camera angles
Infrared pressure analysis to find inefficiencies in walking pattern

MBBS - Year 1 (93 decks)

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