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PBL Week 15 > Limp in adults & children profoma > Flashcards

Limp in adults & children profoma Flashcards

1
Q

What should you ask in a history where a child presents with a limp?

A

Age- this affects what they could have

Gender

Onset- gradual or sudden

previous episodes

Pain levels

Systemic symptoms- suggests infection or JIA

Joint swelling

Hx of trauma

Birth history -breach or oligohydramnios (lack of amniotic fluid)

Developmental histroy - when did they start walking?

Family history of DDH, SUFE, Perthes, inflammatory diseases or autoimmune conditions.

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2
Q

What are some differentials for limping in children?

A

Septic arthritis

Irritable hip - transient synovitis - common in boys aged 4-8 & symptoms usually settle w/in 2 weeks.

Reactive arthritis

Trauma & fracture e.g. Toddlers fracture (subtle un-displaced spiral fracture of the tibia, usually in preschool child).

Slipped upper femoral epiphysis (SUFE)

Developmental Dysplasia of the hip (DDH)

Perthes disease

Osteomyelitis

Occult trauma - trauma not apparent on initial presentation. Including NAI

Juvenile idiopathic arthritis (JIA)

Malignancy e.g. osteosarcoma, Ewing sarcoma.

Osgood-Schlatter disease - pain & swelling of tibial tuberosity & patella tendon.

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3
Q

Differentials for limping categorised by age?

A

All ages:
- infection
- JIA
- NAI

Infants (1-3y)
- Late presenting DDH
- Irritable hip
- NAI or occult trauma

Childhood (3-11y)
- Perthes disease (p= primary so 3-10)
- irritable hip
- SUFE (s= secondary so 11-14 y)
- NAI

Adolescence
- NAI
- SUFE
- Infection

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4
Q

Presentation of limp in children

A

Rapid onset of pain:
- trauma or infection

Gradual onset of pain:
- Perthes

Weeks of knee/hip pain then sudden increase in pain
- SUFE

Pain in groin mimicking septic arthritis
- Transient synovitis of the hip

Night pain gradually getting worse with analgesics not helping
- Malignancy

Limp & leg length difference with no pain
- DDH

Muscle imbalance or wasting with painless limp
- Neuromuscular disorder e.g. cerebral palsy

Systemically unwell e.g. fever, drowsy, irritibility, not eating…
- JIA or infection

Recent infection e.g. UTI, otitis media…
- Transient syntovitis

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5
Q

Investigations for limping in children

A

Always exclude septic arthritis first

Blood tests:
- Septic arthritis- high WCC, ESR & CRP
– JIA or transient synovitis - mildly increased WCC, ESR & CRP.
- Muscular dystrophy - high creatinine kinase.

Kocher criteria- differentiates between transient synovitis from septic arthritis, since both cause hip pain.
- 1-4 score. 5= higher change of septic arthritis
1. WCC > 12,000 cells/mm⁻³
2. Inability to bear weight
3. Fever > 38.5°C
4. ESR > 40 mm/h

X-rays:
- Subluxation in DDH
- Damaged femoral head & acetabulum in Perthes’ disease.
- SUFE
- Evidence of infection - they are initially normal.
- Fracture
- Hip = AP & frog leg lateral views; Knee = AP & lateral views.

Ultrasound:
- can identify swelling from inflammatory diseases, septic arthritis, transient synovitis & early Perthes disease. -

MRI
- can identify inflammation, osteomyelitis & tumours.
- Rarely performed.

Urinalysis - looks for infection.

Blood culture - excludes septic arthritis.

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6
Q

Presentation of limping in adults

A

NOTE: we don’t get a normal gait until age 3-4 yrs.

Look for STRAWS
- S-hort leg gait
- T-rendelenberg gait
- R-igid: do the limbs move flexibly?
- A-ntalgic Gait
- W-eakness
- S-upratentorial gait - split into 2 types (hemiplegic & diplegic)

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7
Q

Describe a Hemiplegic gait

A
  • Unilateral weakness & spasticity
  • Arm - flexed, adducted & internally rotated.
  • Leg - extended, foot plantar flexed
  • Circumduction - circular motion.
  • e.g. Spinal cord lesion or post stroke.

NOTE: view image on notes!

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8
Q

Describe a diplegic gait

A
  • Bilateral weakness & spasticity.
  • Hips& knees-flexed&abducted.
  • Ankles-extended &internally rotated
  • The knees are forced together due to spasticity in the adductor muscles resulting inleg overlapwhen walking (a.k.a. scissoring gait).
  • In an attempt to overcome this adduction, the patientcircumducts both legduring the swing phase.
  • Narrow base, drags legs w/ toe walking
  • e.g. Cerebral palsy

NOTE: view image on notes

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9
Q

Describe a trendelenburg gait (waddling/ myopathic)

A
  • Caused by unilateral weakness of hip abductor muscle.
  • Patient is unable to weight bear on that side.
  • Pelvic drop when walking.
  • Waddling

Possible causes:
- Short femoral neck
- Gluteal nerve damage
- Hip replacement surgery
- Hip fracture

NOTE: view image on notes

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10
Q

Describe an antalgic gait

A
  • Short stance phase
  • Long swing phase on the painful leg/foot
  • Avoids heel strike
  • Avoids weight-bearing on the painful side.
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11
Q

Describe a Parkinsonian gait

A
  • Small steps, shuffling
  • Bradykinesia- slowness of movement
  • Rigidity
  • Tremor
  • Stooped head
  • Freezing & difficulty initiating steps

NOTE: view image on notes

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12
Q

Describe an Ataxic gait

A
  • Clumsy, staggering movements
  • Alcohol intoxication mimics this.
  • Wide base
  • Body may sway when standing still
  • Cannot heal-toe walk
  • e.g. Cerebellar issues

NOTE: view image on notes

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13
Q

Describe a Neuropathic gait

A
  • Foot drop
  • High stepping gait - lift knee high enough not to drag foot on floor.
  • Unilateral causes - L5 radiculopathy or Peroneal nerve palsy.
  • Bilateral causes - peripheral neuropathies e.g. diabetic neuropathy, Charcot-Marie-Tooth disease & Amyotrophic Lateral Sclerosis (ALS).

NOTE: view image on notes

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14
Q

Differential diagnosis for limping in adults

A

Ligament tear:
- PCL
- ACL

Tendinopathy:
- Patella tendon
- achilles tending
- hamstring tendon

Nerve entrapment:
- Sicatica
- L5-S1 entrapment

Malignancy

Infection
- septic arthritis
- osteomyelitis

Backpain:
- spinal stenosis
- Herniated disc
- disciitis

Muscle weakness
- trendelenburg

Inflammatory:
- RA
- Reactive arthritis
- psoriatic arthritis
- ankylosing spondylitis

OA

Parkinsons

Fractures & dislocations

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15
Q

Management of limping in adults

A
  1. Pain relief e.g. NSAIDs
  2. Weight reduction
  3. Physiotherapy
  4. Orthotics & aids- walking stick in contralateral hand.
  5. Surgical - Joint replacement or osteotomy.
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16
Q

Risk factors for Developmental Dysplasia of Hip (DDH)

A
  • Breech delivery
  • First degree family history
  • Oligohydramnios - too little amniotic fluid.
  • Packaging disorders in the womb
  • First born

More common in girls

17
Q

Presentation of DDH

A

Late presentation if not found on screening:
- Painless limp & abnormal gait
- Leg length discrepancy
- Restricted range of movement- loss of abduction.
- Asymmetric skin creases
- Subluxation or dislocation of hip

18
Q

Examination & Investigation for DDH

A

Barlow test- test of instability. Involves dislocating the babies hip. The test is positive if you are able to dislocate the hip.

Ortolani test- reduction of the dislocated hip. “Clunk, click”.

Common in new borns but negative after 3 months in many cases.

Ultrasound better on babies btw 0-6 months because the femoral head is cartilage so won’t show on x-rays

NOTE: view image on notes

19
Q

Management for DDH

A

Pavlik harness- if severe- prevents hip abduction & extension)

Closed reduction - involves being in a cast for 6 weeks

Open reduction of the hip - at 18 months.

Open reduction with femoral or pelvic osteotamies

20
Q

What is SUFE?

A

the growth plate at the top of humerus is fractured, & femoral head slips out of position.

21
Q

Risk factors for Slipped Upper femoral epiphysis (SUFE)

A
  • Male
  • Obesity
  • Endocrine association - Hypothyroidism, Hypopituitarism…

Aged 8-15 most common

22
Q

Presentation of SUFE

A

Previous history of gradual thigh, knee or hip pain w/ sudden worsening of pain

Pain worse on activity

Subtle painful limp - antalgic gait.

Externally rotated - femoral head is displaced posteriorly & inferiorly.

Loss of internal rotation of leg in flexion

Note: view notes for diagram

23
Q

Investigation from SUFE

A

X-ray - need AP & frog leg views. Frog leg views are more helpful.
- dislocation of femoral head is postero-inferiorly

X-ray:
- melting ice cream cone appearance visible through line of Klein)

Frog view:
- straight line through femoral neck anterior to epiphysis
NOTE: view x-ray of notes!-very important

24
Q

Management for SUFE

A

Surgical fixation w/ screws- mild to moderate.

Open reduction w/ osteotomy - for severe.

This is an emergency because avascular necrosis of the femoral head can occur.

Under 10, endocrine problems or if you don’t think they’ll come back - then prophylactically pin the other side, too.

25
Q

What is Perthes disease?

A

Degenerative condition affect hip joints of children

Due to avascular necrosis of femoral head

26
Q

Risk factors for Perthes disease

A
  • Male
  • Skinny hyperactive children (but obese children do badly)
  • Possible causes: clotting disorders, passive smoking, genetic, environmental.
  • 4-10y (older children do badly)
27
Q

Presentation of Perthes Disease

A
  • Gradual onset of hip pain
  • Reduced range of movement - particularly abduction.
  • Painful limp
  • Leg length discrepancy
  • Stiffness
28
Q

Investigations for Perthes

A

x-ray

early changes:
- widening of joint space

Later changes:
- decrease femoral head size (flattening)

29
Q

Management for Perthes disease

A
  • Usually no treatment required as disease self-limiting.
  • Physio for ROM
  • Hip containment - try to keep the ball & socket congruent so there is less chance of OA in later life.
30
Q

Presentation of cerebral palsy

A

Painless limp

31
Q

Presentation of JIA

A
  • Last more than 3 weeks
  • Patient younger than 16
  • 4 or less joints affected- usually medium sized joints e.g.g knees, ankle, elbows- pain + swelling
  • Signs of joint inflammation
  • limp
  • Pain or irritable & reluctant to mobilise
  • Fatigue, malaise & other systemic symptoms
  • ANA may be positive- associated w/ uveitis
32
Q

Epidemiology of transient synovitis

A
  • 70% boys
  • Age 3-10 yrs

MOST common cause of hip pain in children

Associated w/ viral infection

33
Q

Management of transient synovitis

A
  • Resolves on own.
  • Give NSAIDs
  • Can mimic septic arthritis so send to hospital to exclude this diagnosis.
34
Q

Presentation of transient synovitis

A
  • Reactive inflammation of synovium
    • Often after viral illness- 1-2 weeks
  • often unilateral in hip, thigh, groin or knee
  • may be asymptomatic
  • tenderness/pain during passive movement - limited abduction + internal rotation
  • antalgic gait (avoids weight bearing)
  • may have low grade fever
35
Q

Epidemiology of Osgood-Schlatter

A
  • occurs due to overuse (particularly in adolescents)
  • seen in active kids between 10-15 years old
  • more common in men
36
Q

Pathophysiology of Osgood-Schlatter

A

Inflammation of the insertion point of the patella tendon at the tibial tuberosity

  • overuse injury, repetitive quadriceps contraction creates traction on tibial tuberosity leading to micro avulsion fractures creating tendinous inflammation
  • severe cases may suffer a complete tibial tubercle avulsion fracture
37
Q

Presentation of Osgood-Schlatter

A
  • anterior knee pain exacerbated by movement, relieved by rest
  • pain, tenderness + visible swelling over tibial tubercle
  • limping
  • tends to be asymmetrical but can be bilateral
  • initially bump is tender due to inflammation, however as bone heals the lump will become hard + non-tender
38
Q

Management for Osgood-Schlatter

A
  • short term analgesia + NSAID use
  • rest
  • modification of activities/physio
  • If all else fails surgical ossicle resection, excision of tibial tuberosity
39
Q

Investigations of Osgood-Schlatter

A

mainly clinical- examination

On X-ray may see:
- elevation of tibial tubercle
- fragmentation of tibial tubercle
- soft tissue swelling
- calcification/thickening of patellar tendon

PBL Week 15 (8 decks)

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