Clin skills - Gait and Limp Flashcards
What is the limp
Abnormal gait
Examples of abnormal gait
Antalgic Short leg Trendelenburg Stiff knee Spastic
Things to note in the HPC of the limping child
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
Things to ask in the PMH of a limping child
Incl perinatal hx
- DDH risk factors – breech, oligohydramnios
- Birth complications
- SCBU
Things to ask in the developmental history of a limping child
Milestones - how long walking
Things to ask in the family history of a limping child
DDH
Infl arthritides
Autoimmune condns
General examination of a limping child
Well or unwell?
Comfortable at rest?
Temp
Pulse
Well presented?
Rashes
Bruises/ bites/ burns …
ENT
Apley’s examination - look
Posture of limb Joints held flexed? External signs of injury? Joints swollen Limb length discrepancy Gait
Apley’s examination - feel
Erythema
Tenderness
Joint effusion
Tone of muscles
Apley’s examination - move
Active/ passive ROM
Neurological/ developmental examination
Investigations done for a limping child
FBC
Infl markers
Autoimmune markers
Blood cultures
Imaging for limping children
Plain radiographs
Ultrasound
MRI
Radiographs for limping children
Fractures and dislocations
Bony pathology
Ultrasound for limping children
Good for looking for effusions
MRI for limping children
Gold standard
Detailed imaging of joint, soft tissues
Difficult for kids <5yrs
The ‘irritable hip’
Painful hip
Joint stiffness
Limp
Ddx for irritable hip
Infection Transient synovitis JIA Perthes Tumour
Main ddx of septic arthritis
Transient synovitis
Septic arthritis in children
Infection within joint space
ROM reduced
Effusion
Erythema
OM in children
Infection within the bone
Hx of trauma
ROM usually less affected
Localised tenderness
Key Kocher criteria for infection or transient synovitis
Refusal to WB
Fever > 38.5
Key Caird criteria for infection or transient synovitis
T > 38.5
Refusal to WB
When does OM require surgery
Subperiosteal abscess
Large intraosseous collection (>2cm)
PVL staph
Spectrum of abnormality for DDH
Dysplasia
Sublaxation
Dislocation
Instability
Barlow exam for DDH
Test of instability
Common in new-borns
Ortolani exam for DDH
Reduction if dislocated hip
Clunk v click
Further exams for DDH
Allis test
Galleazi test
Restriction in ROM
Gait abnormalities
USS screening for DDH if
Breech
First degree family hx
Abnormal clinical exam
Px of late presentation of DDH
Painless limping (if walking) Leg length discrepancy
O/E of late presentation of DDH
Restricted ROM LLD Asymmetric skin creases Especially abduction of the flexed hip Abnormal gait
Treatment for DDH
Determined by age
- Pavlik harness
- Closed reduction (GA)
- Open reduction of the hip (GA)
- Open reduction with femoral/ pelvic osteotomies (GA)
Possible causes of Perthes
Clotting disorders
Passive smoking
Genetic
Environmental
Perthes px
Stiff hip – particularly abduction
Pain
Limp
Leg length discrepancy
Stages of Perthes disease
Initial/ sclerotic
Fragmentation
Healing
Remodelling
Therapeutics for Perthes
Bisphosphonates
Epidemiology of SCFE/ SUFE
2/100,000 M:F 3:2 Assocn with obesity 25% bilateral Endocrine assocn (HypoTh, Hypopit, CRF)
AP views of pelvis in SCFE/ SUFE
Physeal widening
Trethowan’s sign
Reduced epiphyseal ht
Frog laterals required too
Classification of SUFE
Temporal
Stability
Severity of slip
SUFE - Temporal
Acute (<3/52) – higher rate AVN
Chronic
SUFE - stability
Stability (can weight bear - 0% AVN)
Unstable (cannot weight bear at all – 47% AVN)
SUFE - severity of slip
Mild, moderate or severe
Worse deformity, worse the later function
Treatment simpler and outcome better for lesser grade
Why do we not attempt closed reduction for SUFE
AVN risk
Pre-requisites for gait
Stability in stance Sufficient foot clearance Appropriate pre-positioning of foot in swing Adequate step length Energy conservation
STRAWS - abnormal gait
Short Trendelenburg Rigid Antalgic Weak Supratenorial
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”
Vaulting gait
Elevate pelvis and PF stance leg
Allows longer leg to swing through
Trendelenburg gait
Excessive lateral trunk flexion
Weight shifting over the stance leg
Cause of Trendelenburg gait
Weakness of abductor mechanisms
- Joint – subluxed/ dislocated hip
- Bone – shortening of femoral neck
- Muscle - abductor weakness
Types of rigid gait
Hip
Knee
Ankle
Rigid gait - hip
Head and torso sways front to back in sagittal plane
Decreased hip flexion on wing phase and lumbar motion (AP sway)
Rigid gait - knee
Hip circumducts
Little flexion/ extension through stance
Rigid gait - ankle
May turn foot out to use STJ
Limitation F/E in sagittal plane
Antalgic gait
Shortened stance phase
Avoids weightbearing on that side
Avoids heel strike
Antalgic gait - hip
Lurches over the painful side to reduce lever arm and then JRF (joint reaction force)
Antalgic gait - knee
Held slightly flexed
Weak gait - hip
Trendelenburg
Weak gait - knee
Weak quadriceps
Back – knee (to control flexion of the ground reaction force)
Weak gait - ankle
High stepping gait
Hip/ knees flexed excessively to lift foot
Foot slap on initial contact
Types of supratenorial gait
Spastic diplegia
Spastic hemplegia
Spastic diplegia
Equinus gait
Jump gait
Crouch gait
Scissoring gait
Equinas gait
Nil heel strike in rocker phases
Jump gait
Ankle equinas, knee flexion
Crouch gait
Ankle/ knee + hip flexion
Spastic hemiplegia
Unilateral loss heel strike
Knee held flexed
Nil movement of arm in swing
When do we develop normal gait
3/4 yrs
Management for abnormal gait
Treat underlying cause e.g. wt reduction, physio or orthotics & aids
Surgery
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
Further examination for suspected NAI
Skeletal survey
CT brain
Ophthalmology
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
Why do skeletal surveys incl follow up x-rays
To identify occult fresh fractures not visible on initial survey
Ophthalmology for suspected NAI
Identify any external trauma e.g. bruising or subconjunctival haemorrhage
Mostly identifying retinal haemorrhages
Why do we look for retinal haemorrhages in suspected NAI
When seen alongside subdural haemorrhage and encephalopathy indicates high likelihood of abusive head trauma
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.
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
Factors associated with abuse
Domestic violence
Parental substance abuse
Parental mental illness
Social factors associated with abuse
Poverty
Young parents
Social isolation
3 children or more under 5 years
Factors related to the child associated with abuse
Disability
Preterm delivery
Multiple pregnancy
Factors related to the parent associated with abuse
Learning difficulties
Bad experiences of parenting, personal hx of abuse
Common accidental sites of bruising
Commonly impact during falls
Lower legs
Lower back
Forehead
Chin
NAI causing fractures more likely if
Absence of credible hx
Younger child
Multiple fractures
Metaphyseal
Common “accidental” fractures
Supracondylar
Toddler fractures
Wrist
Spotting child abuse - hx
Delay in presentation
Story not credible
Changeable story
Spotting child abuse - exam
Injuries don’t fit story
Injuries not compatible with development
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
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
How child abuse is managed
Good record keeping
Pictures or photographs
Share concerns with a colleague or supervisor
Report the case to children services
Interagency communication for NAI
Liaison and communication between health, education, police and social services
Gait
Pattern of movement of limbs during human (and animal) locomotion over solid ground
Steps in stance phase of gait
Heel strike to foot flat
Foot flat through midstance
Midstance to Heel off
Heel off to Toe off
Steps in swing phase of gait
Acceleration to midswing
Midswing to deceleration
Traction for <6 months
Pavlik or Gallows
Traction for 6 months to 5 yrs
Hip spica
Traction for 5yrs to 10 yrs
Flexible nails*
Exfix
Plate
Traction for >10 yrs
Rigid nail*
Plate
Exfix
Flexi nails
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
Cause of supracondylar fractures
FOOSH
Hyperextension
Gartland classification for supracondylar fractures
Type 1 - undisplaced
Type 2 - angulated
Type 3 - off-ended
Off-ended supracondylar fractures
Limb threatening injury
Splint as is, do not try to reduce
Analgesia & IV access
Call ortho urgently
Club foot
Congenital talipes equinovarus (CTEV)
Can be postural, typical or atypical
Treat w/ Ponseti method
Causes of a limp
Acute or chronic conditions Bone fracture Sprain Strains Arthritis Congenital malformations CNS damage
Pattern of bruises indicating NAI
Non-bony parts of the body
Face or ears
Multiple bruises
Clustered bruises
When are lacerations/ abrasions suspicious
Non-mobile children
Symmetrically
Around the face
Around the wrists or ankles
Thermal injuries indicative of NAI
Areas not expected to encounter a hot object incl
Soles of feet
Buttocks/back
Backs of hands
Risk factors for NAI
Hx of intimate partner violence and abuse
Substance abuse or mental health conditions
Excessive crying
Unintended pregnancy
Developmental problems
Podiatrist
Healthcare professionals who have been trained to diagnose and treat abnormal conditions of the feet and lower limbs
What do podiatrists assess
Overall anatomical alignment and posture whilst considering the position of your spine, pelvis, knees, ankles and feet.
Gait analysis and biomechanical assessment done by podiatrists
Hallway assessment
Video analysis - multiple camera angles
Infrared pressure analysis to find inefficiencies in walking pattern
