Limping Flashcards
Antalgic
- Painful
- Involved leg is shorter
Trendelenburg
- Normal standing
- Imbalance (front and back)
Duck gait
Bilateral gluteus weakness
Toe walking
- Kids that recently started walking
- Habit, Neuromuscular, Short achilles
- Checked in older than 3yr olds
Approach (Sudden or chronic)
Sudden:
- Infection
- Trauma
- Better prognosis
Chronic:
- Neuromuscular, Metabolic
- Malignancy, Leukemia, Neuroblastoma
Common in kids
- Trauma
- Immune complex arthritis after infection (Henoch, Rheumatic Fever, EBV)
- Transient Synovitis of hip
- Arthritis, Arthralgia, Serum sickness (after cephalosporines) are mostly systemic
Other complaints
- Fever & weight loss: Malignancy, infection
Osteomyelitis & Septic arthritis are emergencies - Long fevers: Malignancy
- Specific lesions: Dermatomyositis, JRA, Lupus
Limping secondary to pain
Pain is in:
Organs, stomach, hip, hip joint
Painful limping (1-3yr old)
- Septic arthritis
- Osteomyelitis
- Transient Synovitis
- Hidden trauma
- Disc inflammation
- Malignancy
Painless limping (1-3yrs)
- Hip dysplasia (DDH)
- Neuromuscular disorder
- Cerebral palsy
- Short steps (pressure off the involved leg)
Painful limping (3-10yrs)
1-3yrs
+
- Myositis
- Rheumatic disorders
- JRA
Painless limping (3-10yrs)
1-3yrs
+
- Legg-Calvé-Perthes (Avascular femur head necrosis)
- Duchenne muscular dystrophy
Painful (>11)
- Septic arthritis
- Osteomyelitis
- Myositis
- Trauma
- Malignancy
- Rheumatic disorders
- Slipped capital femoral epiphysis (SCFE)
acute & unstable
Painless (>11)
- Slipped capital femoral epiphysis (SCFE)
chronic & stable - Hip dysplasia (DDH)
- Acetabulum dysplasia
- Short steps
DDx
- Infectious
- Orthopedic
- Inflammatory
- Neoplasm
- Neuromuscular
- Other
Infectious ddx
- Disc inflammation
- Osteomyelitis, Septic arthritis
- Myositis
- Cellulitis, arthralgia or arthritis after infection
Orthopedic ddx
- SCFE
- DDH
- Avascular necrosis
Inflammatory ddx
- Transient Myositis
- SLE, JRA, Dermatomyositis, Henoch
Neoplasm ddx
- Benign Osteochondroma, Osteoma
- Osteogenic sarcoma
- Leukemia, Neuroblastoma (Fatigue, weight loss, fever)
- Metastasis
Neuromuscular ddx
- Duchenne (Gowers’s sign)
- Guillain-barré
- Tick borne paralysis
- Weak cerebral palsy
Reactive arthritis
- Aseptic
- Infection in another place
- Acute Polyarthritis/Tenosynovitis
- Immune complex
Causes of reactive arthritis
- Meningococcemia
- Gonococcemia
- Hepatitis
Immune-complex-causing infections:
Yersinia, Salmonella, Campylobacter, Shigella, Ureoplasma, Mycoplasma, Chlamydia
Reiter syndrome triad
1- Non-gonococcal Urethritis
2- Conjunctivitis
3- Reactive arthritis
Joint swelling
- Hematogen: 3 days, microbial
- Immune reaction: 1w, no microbes
- Hip IAP: Avascular epiphysis & femor head necrosis, EMERGENCY
Gonococcal Septic arthritis
- With DGI, most common cause of poly/single arthritis in teens
- Following bacteremia (Fever, chills, Migrating Polyarthritis)
- DGI women 4×, period, 2nd&3rd trimester
- Reiter can mimic DGI
- Reiter doesn’t respond to antibiotics
Septic arthritis treatment duration
- S. Aureus: 4-6w
- H. Influenza B, Strep A, Pneumococcus: 2-3w, 10-14d
- Gonococcus: 7-10d
- Joint Aspiration beginning or 3-5d later
Septic arthritis surgery indications
1- Fluid more than 7d
2- Any hip septic arthritis
3- Most shoulder arthritis
Good prognosis (Septic arthritis)
- Systemic Ab against Staph & Haemophilus
- Rest, Immobilization, Not putting weight
- Recovery after 72h if quick diagnosis
Bad prognosis
- Under 6m old
- S. Aureus, Gr -, Fungus
- Hip involvement
- Osteomyelitis & Epiphysis destruction
- Late treatment (5-7d)
- If fast diagnosis no disability
Other limping ddx
1- Stomach, substernal, testicular pain
2- Sickle cell
3- Femur head avascular necrosis
4- Hemophilia (Hemarthrosis)
