Gait and limp- Clinical Medicine Flashcards
What must you ask about in the past medical history regarding a child with a limp?
Include perinatal history
- Differential diagnosis risk factors - breech, oligohydamnios
- Birth complications
- Special care baby unit (SBCU)
Include developmental hsitory
- Milestones - how long walking
What must you ask about in family history regarding a child with a limp?
- Developmental dysplasia of the hip - DDH
- Inflammatory arthritides
- Autoimmune conditions
What must you ask about in the social history regarding a child with a limp?
- Other members of family at home
- Other carers
- Safeguarding concerns
What must you take note of in a general examination of a child with a limp?
- Well or unwell
- Comfortable at rest?
- Temeperature
- Pulse
- Well presented (do they look cared for)?
- Rashes
- Bruies/bites/burns
- ENT
What investigations must be done when presented with a child with a limp?
- FBC
- Inflammatory marks - CRP, ESR
- Autoimmune markers e.g., RF, anti-CCP
- Blood cultures (if thinking infection)
What imagaging must be taken when presented with a child with a limp
- Plain radiographs - fractures and dislocations, bony pathology
- Ultrasound - good for looking for effusions in septic arthritis, transient synovitis, Perthes disease (early)
- MRI - gold standard, detailed imaging of joint, soft tissues, difficult for kids <5yrs (cannot stay still)
List the possible differential diagnosis of a child with a limp
- Septic arthritis
- Irratible hip
- Slipped upper femoral epiphysis (SUFE)
- Developmental dysplasia of the hi (DDH)
- Perthes disease
- Osteomyeleitis
- Occult trauma
- Nueromuscular causes
- Juvenile idiopathis arthritis
- Malignacy
- Infection
a) List 3 clinical features of an “irritable hip”
b) List 5 causes
a)
- Painful hip
- Joint stiffness
- Limp
b)
- Infection
- Transient synovitis
- JIA
- Perthes
- Tumour
List 3 pathology relating to a limp can occur in all ages
- Infection
- Juvenile idiopathic arthritis (JIA)
- Non accidental DDH
List 4 pathology relating to a limp that can occur in infants (1-3 years)
- (Late-presenting) DDH
- Irritable hip
- Neuromuscular
- Occult trauma(including NAI)
List 5 pathology that can ouccur in childhood (3-11 years)
- Perthes disease (3-7 year olds)
- Irritable hip
- Neuromuscular
- SUFE
- NAI
List 2 pathology relating to a limp that occur in adolescene (12-16 years)
- SUFE
- Infection
Age relates to potential patholofy. Fill out the boxes with the options: Perthes, SCFE, DDH
a) What is transient synovitis?
b) What is there usually a history of if a patient has transient synovitus?
c) Describe the epidemiology
d) Describe the managment
e) What is the main differential diagnosis
a) Reactive inflammation of synovium
b) Often history preceding viral illness e.g., URTI
c) 70% boys and age 2-10 years
d) Milder symptoms, resolves sponatenously, NSAIDs
e) Septic arthritis
What is the difference between osteomyelitis and septic arthritis? include difference in clinical features
Osteomyelities
- Infection within the bone
- Clinical features: ROM usually less affected, localised tenderness
Septic arthritis
- Infection within the joint spae
- Clinical features: ROM reduced, effusion, erythema
a) Describe the clinical features of septic arthritis
b) What are the most common pathogens causing septic arthritis?
c) What investigations should be undertaken?
d) Why should you keep a patient with septic arthritis nil by mouth?
a)
- Unwell and uncomfortable
- Fever
- Very limited ROM in joint
- Effusion
- Erythema
b) Staph Aureus and streptococcs
c)
- Bloods - CRP, ESR, WBC, cultures
- Serum lactate
- Urine output
- Plain x-rays
d) Keep Nil by mouth (NBM) as may want to wash joints out and off antibiotics
a) Does septic arthrits require surgey?
b) Does osteomyelitis require surgery?
a) No, it needs washout asap & IV antibiotics, oxygen, fluids
b) usually doesn’t need surgery - just antibiotics
Unless:
- Subperiosteal abscess (pus between periosteum and bone itself)
- Phanton valentine leukcocidin (PVL) staph - PVL is a a toxinproduced bycertain types of staph aureus
a) What is developmental dysplasia (DDH)
b) Describe the epidemiology?
c) What are the risk factors?
a) A condition where the “ball and socket” joint of the hip does not properly form in babies and young children
b) 1/1000, more common in females
c)
- Breech
- 1st degree family history
- Female
- First born
- Oligohyrdamnios (too little amnitoic fluid)
- Packaging disoders (occurs during pregnancy when foetus is squished/packaged too tightly within the uterus)
a) Describe the two main clinical examinations for developmental dysplasia of the hip (DDH) including what they are testing for
b) What issue arise from these tests?
c) Describe the 4 others examintions you can do t test for DDH
a) Barlow
- Test of instability
- Common in new-borns
Ortolani
- Reduction of ths dislocated hip
- Clunk v click
b) They are negative after 3 months in many cases so are far from 100% sensitivity
c)
- Gait abnormalities
- Allis test - skin fold symmetry (low sensitivity and specificity)
- Galleazi - leg legnth discrepnancy (not a normal vraiant)
- Restriction of ROM - easy adduction of the flexed hips & ask about changing nappies
Every baby is clinically screen at birth, 6-8/52 weeks. What circumstances relating to an increase chance of DDH means an ultrasound screening is required?
- Breech
- First degree family history
- Abnormal clinical examination: barlow/ortolani/allis/galleazi/restrcition of ROM/gait abnormalities
a) Why does late presentation of DDH occur?
b) What is the clinical presentation of late DDH?
c) What will be found one examination of late DDH?
a) It occurs if there is a failure of clinical screening
b) Painless limpig (if walking), leg lenth discrepnancy
c)
- Restricted ROM
- Leg length discrepancy
- Asymmetric skin crease
- Loss of abduction and flexion of hip
- Abnormal gait
a) Age determines treatment of DDH. what is the treatment if DDH is found:
i) Before 3 months
ii) After 3 months
iii) Over the age of 1
iiii) Over 18 months
b) What is an increasing age of diagnosis of DDH associated with, relating to the treatment?
a) i) Pavlik harness
ii) Clsed reduction (GA)
iii) Open reduction of the hip (GA)
iiii) Open reduction with femorl/pelvic osteotomies (GA)
b) Associated with an inrease invasivness, complexity and complication of treatment. Also increased parental stress
a) What is Perthes?
b) Describe the epidemiology
c) What are the causes?
a) Idiopathic avascular necrosis of femoral head
b)
- 3/100,000
- 4-9 year olds (older children do badly if thye get it)
- M:F = 6:1 = male predominates (femaled do badly if they get it)
- In skinny, hyperactive children (but obese do badly if they get it)
- 25% bilateral
c) Causes are uknown but found to relate to:
- Clotting disorders
- Passive smoking
- Genetic
- Environmental
List 4 signs/clinical presentation of perthes disease
- Stiff hip - particulary abduction
- Limp
- Pain
- Leg lenth discrepancy
In Perthes disease children will have a stiff hip. Which movement is particulary affected in Perthes disease?
Abduction
a) What is herrings classification?
b) Describe the 3 groups of herrings classification
a) Classification based on how much lateral pillar of the femoral head has lost its height
b) Group A - no height lost
Group B -oevr 50% present
Group C - Under 50% present
a) What are the main principles of management of Perthes?
b) Describe the managment of Perthes
a)
- Try to keep ball and socket together to keep the congruent
- The less congruent the joint, the greater the chances of OA later in life
b)
- Physiotherapy for ROM
- Brace/plaster
- Surgical -femoral osteomy/ pelvic osteomy/ hipdistraction
- Wheel chir
- Bisphosphonates
a) What is slipped upper/capital femoral epiphysis (SUFE/SCFE)
b) Why must always SUFE be ruled out?
c) Describe the epidemiolgy
d) What are the associtations/risk factors?
a) The femoral neck slips in relation to the epiphysis (leaving head posterior and inferior)
b) It is usually completely atraumatic and easily missed out, unless you’re looking for it
c)
- M:F = 3:2 = predominance in boys
- 25% bilateral
- 2/100,000
d)
- Obesity
- Endocrine association (hypothyroidism, hypopituitarism, chronic renail failure)
Describe the clinical features of slipped upper femoral epiphysis (SUFE)
Pain
- Pain on activity
- Painful hip
- Pain felt on thigh or knee
Limp
- Antalgic
- Externally rotated (and flexed) limb - foot points outwards
Why should you always examine the hip in a child with thigh/knee pain?
Because hip pain could be referred to thigh/knee
What are the radiological features seen on an x-ray: AP pelvis of child with Perthes?
- Physeal widening
- Trethowan’s sign
- Reduced epiphyseal height
What views on aplain film radiograph must you get when ruling out SUFE
- AP pelvis
- Frog-lateral
Except from an AP pelvis what other views must you get in any child with a limp? What is it important in ruling out?
You must get a frog-lateral view on plain film radiograph. This because the features can bo ccult (hidden) on AP x-ray. It also picks up minor degree of subluxation
It is important in ruling out SUFE
Describe the 3 classifcations used to classify slipped upper femoral epiphysis (SUFE)
Temporal
- Acute - higher rate of avascular necrosis (AVN)
- Chronic
Stability
- Stable (can weight bear - 0% AVN)
- Unsstable (cannot weight bear at all - 47% AVN)
Severity of slip
- Mild. moderate or severe
a) Describe the management for SUFE
b) Why must you not attempt closed reduction?
a)
- Pin in situ is mainstay (internal pinning ad fixation) for mild to moderate
- Femoral osteotmy to re-shape the femur early or late
- Open reduction and osteomy if severe (AVN risk)
b) Avascular necrosis risk
What general clinical observations should be noted in an exmaniation of a child?
- Thriving or not - height and weight
- Well cared for or not - clean, dressed apropriately?
- Is child secure and stable with parent of fearful?
- Development - appropriate or not?
- Attachment - does child seek security from parent?
What specific clinical observations should be noted in an exmaniation of a child?
- Age - abuse more likely in younger children
- Bruising - face, ear, head, back, buttoks, soft tissue areas
- Slaps, pinches, bites
- Burns, brands, cigarette marks
- Fractures
- Injuries to the mouth
What examinations must be done when suspecting NAI?
A full head to toe examination
What further investigations are required when NAI is indicated?
- Skeletal survey
- CT brain (part of skeletal survery for any infant < 12 months)
- Ophthalmology
What is a skeletal survery?
- Series of x-rays covering all bones i boy
- 20 individual x-rays of chest and long bones 10-14 days later to identify occult fresh fractures not visible on intial survey
Why is an opthalamology as part of further investigation when NAI is indicated done?
- The purpose is to identify an external trauma e.g.,bruising or subconjunctivalhaemorrhage
- But mostly for identifying retinal haemorrhages as when seen alongside subdural haemorrhage and encephalopathy (indicates high likelihood of abusive head trauma)
What is your duty as a doctor when it comes to NAI?
- Duty to primarily report concerns to appropriate agent - children services
- They will share this with police so unneccessary to contact police unless concerns about immediate safety, staff or parents/carer OR you feel there’s important evidence to be gathered urgently as a matter of public safety
What are red flags isuggesting NAI?
- Injuries in non-ambulant (unable to walk about) baboes
- Fractures in infants - especially ribs
- Subdural bleeding, especially encephalopathy (damage or disease that affects the brain and retinal haemorrhage
- Peri-oral or facial brusing
- Delay in presentation
- Story not credible
- Changeable story
- Injuries do not fit story
- Injuries not compatibe with development
What factors are associated with abuse including the social, the child and parental factors
- Domestic violence
- Parental substance abuse
- Social factors: poverty, young children, social isolation, 3+ children under 5 years
- Child: disability, preterm delivery, multiple prgnancy
- Parental: learning difficulties, bad experience of parenting, personal history of abuse
Why do we miss/fail to act to NAI?
- Not considering NAI in the differential diagnosis
- Concern about missing a treatable disorder
- Fear of losing a positive relationship with family
- Discomfort fof disbelieveing/suspecting/wrongly blaming
- Divided loyalties between adult and child and breaching confidentiality
- Understandng why the maltreatment ocurred and that it wasn’t intentional
- Stress/time pressures
- Personal safety
- Fear of complaints
a) List the common accidental sites of bruising in a child
b) List uncommon sites of bruising
a)
- Lower legs
- Lower back
- Forehead
- Chin
b) Soft tissue areas e.g., abdomen and pubic area
a) List the common accidental fractures in a child
b) List uncommon fractures
a)
- Supraondylarof humerus
- Toddler fractures
- Wrist
b)
- Multiple fractures
- Metaphyeal fractures
How is child abuse managed?
- Good record keeping
- Pictures or photographs
- Share concerns with a colleague or supervisor
- Report the case to children services
- Fracturetreated the usual way
- The child should be admitted for protection when NAI is strong suspected
- Report to child services if NAI suspected
How should you react when you suspected NAI? and why?
Professional response for suspected abuse should be objectivity and treating parents/carers with politeness and respect
This is because you may be confident that abusive trauma is the case, but we aren’t able to tell who perpetrator is and future medical care may require engagement with 1 or both carers
Describe interagency communication regarding NAI?
- Liason and communication between agencies take place in strategy meeting
- Decisions about whether abuse has ocurred ismade during case conferences
- Agencies disscus how children can be protected
A mother brings her eight week old baby boy to see you. The mother says he rolled off the changing table onto carpeted floor. He has a 3 cm x 4 cm boggy swelling on the left side of his head but is otherwise well.
Discuss what you should do.
Refer to an on call hospital paediatrician immediately, as the boggy swelling could be due to an underlying fracture. If there was a fracture with an underlying intracranial bleed, then the child’s condition could deteriorate. Since it is unlikely that a six week old baby could roll yet, you should have concerns about how the injury occurred. You will need to consult with the hospital paediatrician and agree which of you will contact Children’s Social Care. Check patient arrived at hospital.
Baby brought in for routine 6 week check. You note 2 small bruises on anterior chest wall. Baby of this age shouldn’t have any bruising.
Discuss what you should do.
This could be part of shaken baby syndrome as above need to consult with on call hospital immediately for further assessment of other possible injuries (e.g., intracranial bleeds or fractures) and ensure child arrives at the hospital
Toddler brought in for eczema. You note multiple bruises of various ages on knees, shins, and a couple on the forehead.
Discuss what you should do.
Common places for bruising in a child learning to walk. Not of concern as long as there are no other indicators.
You receive a letter from A&E about a 5yo with a fractured finger. You notice this is the 6th letter from A&E about this child. Need to look at all previous A&E letters and GP notes.
Discuss what you should do.
What are the reasons for attendance? Are there good explanations? Ask other professionals if they have concerns e.g., school and health visitor. Health visitor or GP should review the child face to face if any concerns (e.g., different injuries especially with inadequate explanations) and then discuss with and refer to child safeguarding team.
Mum books emergency appointment as 5yo son is unwell. You note he looks pale and has extensive bruising over all areas of his body.
Discuss what you should do.
Could be a medical emergency here – careful history and examination. Needs urgent FBC (full blood count) either at surgery or at hospital depending on clinical situation? Leukaemia etc. However, if FBC normal consider physical abuse and neglect.
Dad brings in 6yo daughter. She is able to tell you clearly that 2 days ago she was jumping on the trampoline and fell off onto her outstretched hand. Dad reports she cried instantly but then seemed to improve. She complains of pain in her right forearm which looks swollen on the radial aspect. It is tender to palpate. She is able to move her fingers and make a fist which is why her parents don’t think it is broken. You arrange an on the day X-ray. You check the report later – a greenstick fracture of the radius. The radiology department have already referred her to orthopaedics.
Discuss what you should do.
This is a common injury consistent with the history and low association for non-accidental injury. However, there was a delay in reporting the injury. This is reasonable as parents felt her arm unlikely to be broken as able to move fingers and hand. The girl is of an age where she is able to give a good account. Did she do this naturally? Were there any concerning dynamics between father and daughter? Review her notes: any history of other injuries, missed appointments etc. Unless any concerns no other safeguarding issues apart from discussion re safety of trampoline. Did it have a net? Was she properly supervised etc?
What are the pre-requisites for gait?
- Stabilityin stance
- Sufficient foot clearance
- Appropriate pre-postitioning offoot in swing
- Adequate step length
- Energy conservation
List 4 things that affects gait
- Joint - arthritis
- Bone - deformity
- Muscle - muscular dystrophy, spasticity
- Nerve - trauma
List the 6 types of gait
Short
Trendelenburg
Rigid
Antalgic
Weak
Supratentorial
Describe short leg gait
- Head and shoulder drop as patient steps onto short limb (bobbing up and down of head and shoulder in sagittal plane)
- Pelvis drops on affected side with heel strike
- “Vaulting gait” - elevate pelvis and PF stance leg which allows longer lleg to swing through
- Flexion knee, equinus ankle of longer leg
Describe the tredelenburg gait including what it’s caused by
- Excessive lateral trunk flexion
- Weight shiftng over the stance leg
- Weakness of abductor muscles
Describe the rigid gait and how it affects the hip, knee and ankle
Hip
- Head and torso sway front to back in sagittal plane
- Decreased hip flexion on swing phase and lumbar motion (AP sway)
knee
- Hip circumducts
- Little flexion/extension through stance
Ankle
- May turn foot out to use sub-talar joint
- Limitation in flexion/extension in sagittal plane
Describe the antalgic gait including what paients avoid doing if they have an antalgic gait
- Shortened stance phase
- Hip - lurches over painful side to reduce lever arm and then joint reaction force (JRF)
- Knee - held slighrly flexed
- Avoids weightbearing on painful side
- Avoids heel strike
Describe the weak gait and how it affects the hip, knee and ankle
Hip
- Tredelenburg
Knee
- Weak quadriceps
- Back - knee ( to controlflexion of the ground reaction force0
Ankle
- High stepping gait
- Hip/knees flexed exessively to lift foot
- Foot slap on initial contact
Describe supratentorial gait can be spastic diplegia or spastic hemiplegia. Describe these two gait s
Spastic dipelgia
- Equinus gait - no heel strike in rocker phases
- Jump gait - ankle equinus, knee flexion
- Crouch gait - ankle/knee + hip flexion
- Scissoring gait
Spastic hemipelgia
- Unilateral loss heel strike
- Knee held flexed
- No movement of arm in swing
Describe how to manage abnormal gait
- History - congenital vs acquired
- Examinations
- Investigations
- Treat underlying cause: weight reduction, physio, orthotics and aids
- Surgery: joint replacement, Osteomy (“re-shape” bone), lengthen/dvide/transfer muscles
Why do you not need to be overly concerned about abnormal gait in a child less than 3 year old, unless indicated?
We do not develop normal gait until we’re 3/4 years old
Define the two phases of gait and the percentage that each phase makes up the total gait cycle
- Stance - defined as the interval on which foot is on the ground (60% of gait cycle)
- Swing - defined as the interval on which the foot is not in contact with the ground (40% of gait cycle )
What are 4 stages of the stance phase in the gait cycle?
- Heel strike to foot flat
- Foot flat through midstance
- Midstance to heel off
- Heel off to toe off
What are 2 stages of the swing phase?
- Acceleration to midswing
- Midswing to deceleration
