Module 6: Extremity Syndromes Flashcards
Antalgic gate can be indicative off? ddx
Trendelenburg gait can be indicative off? ddx
Antalgic gate- generally due to congenital, developmental, or muscular disorders
Trendelenburg gaits are generally due to congenital developmental, or muscular disorders
Trendelenburg’s gait should be differentiated from antalgic gait (due to pain) and short-leg gait (due to differences in leg length).
Antalgic gait is due to pain in the lower extremities that results in a limp that is associated with a shortened stance phase relative to the swing phase.
DDX
CONGENITAL:
-Tarsal coalition
Aquired:
SCFE (slipped capital femoral epiphysis)
Trauma- Sprains, strains, contusions
Fractures: Occult, toddlers fracture
Subluxation
Rheumatologic:
Neoplasia:
-benign (osteoid sosteoma) bone cyst
Malignant: osteogenic sarcoma, ewings sarcoma, leukemia, spinał cord tumours
Infection: septic arthritis
Osteomyelitis: Acite, subacute
Diskitis
TRENDELENBURG GAIT
ddx
Developmental: DDH, Leg length discrepancy
Neuormuscular: Muscular dystrophies, cerebral palsy, subluxation.
Management of the limping child- what should we do?
- It is appropriate to x-ray any child who presents with a limp – failure to x-ray often results in missed pathology
- Toddlers and pre-schoolers may need to have both legs x-rayed from the waist down as it is often difficult to localise the cause of the limp
- History of trauma is often uncertain as onset of limp is often not observed
- With history of trauma >90% of pathologies are below the knee so initial investigation limited to knee joint and below is often appropriate with later x-ray of pelvis and hips if needed – this reduces pelvic radiation
- Further investigation such as ultasound, CT, MRI, bloods is often needed to establish diagnosis – this process may take a number of months
Torsional variations
—in-toeing and out-toeing—are the most common gait disturbances that cause parents to seek advice.
Many do not require treatment because they are physiologic in origin and improve and resolve with normal growth and development.
DIFFERENTIAL DX
In-Toeing
* Internal femoral torsion
* Internal tibial torsion
* Metatarsus adductus
* Talipes equinovarus (clubfoot) - fixed
* Subluxation
Out-Toeing
* External femoral torsion
* External tibial torsion
* Calcaneovalgus feet - flexible
* Hypermobile pes planus * Subluxation
FEMORAL ante version
What does it present as and what should our management be?
-Increased medial rotation (prone) moving foot around
-child moves with patella medially rotated + running characterised by medial rotation of thighs
Management:
-advise child avoids sitting in W position
-monitor ROM, should grow out of it/ improve slowly as they grow.
Operative Indications:
Procedure should only be performed at 8-10 years of age for persistent deformity. >50 ante version
Internal Tibial torsion:
How should you examine it?
How to treat it?
Hip and thigh and knee are normal but Lower leg is turned inward - results in - intoe ing which may cause kid to trip.
Lateral malleolus positioned anterior to medial malleolus.
ExaminatioN:
Patella is correctly aligned facing forward
Alignment of tibal tuberosity at the knee joint
maybe altered
Assess orientation of ankle mortise – line from medial distal tibia to lateral distal fibula should be in coronal plane – will be oblique with tibial torsion
Will be associated with subluxation of the tibia and/or fibula at the knee joint as well as often at the distal tibio-fibular joint.
Treatment: Most can be managed conservatively
* Correctanysubluxationsofthe tibia, fibular, pelvis, lumbar spine and cervical spine
Metatarsus adductus
what causes it?
Management:
-Mainly caused by inutero constraint
-Is associated with muscular torticollus
-Ensure you can manually straighten forefoot and procedure good alignment, if unable to straighten forefoot need to refer for ortho assessment.
-if there is a medial arch crease refer for orthopaedic assessment.
Management:
Refer for orthopaedic assessment.
1. Refer for orthopaedic assessment if
You are unable to manually straighten the forefoot producing good alignment
2. If there is a crease present across the medial arch of the foot
Most cases will resolve without treatment once child is weight bearing (1-2 year period)
Placing shoes on opposite feet is no longer recommended.
Toe Walking
Give DDX for Unilateral and Bilateral Toe walking
Whats the management
Toe walking or equines gait is a less common cause of gait disturbance
It can be a normal finding in children up to 3 yrs of age >3= abnormal
Persistent toe walking thereafter or acquired toe walking at a later age is considered abnormal and requires careful evaluation.
Unilateral
* Neuromuscular disorder
* Cerebral palsy (hemiplegia) * Leg length discrepancy
* Hip dislocation (DDH)
* Subluxation
Bilateral
* Neuromuscular disorder
* Cerebral palsy (diplegia)
* Duchenne muscular dystrophy
* Congenital tendo-Achilles contracture
* Habitual
* Subluxation
- Ensure the is adequate ankle dorsiflexion – if there is not then calf muscle stretching is needed
- Assess for persistence of Plantar grasp reflex and associated increased foot skin sensitivity (increased withdrawal response)
- Assess and correct any foot, ankle, knee, lumbo-pelvic and cervical spine subluxations
- Most common issue is upper cervical spine subluxation which may affect vestibular nucleus (involved in muscle tone setting) and maybe associated with persistence of the Plantar grasp reflex
- Correct plantar skin hypersensitivity by having parents provide repetitive light stimulation to skin with various textures
- If habitual or poorly responsive to chiropractic management refer to podiatrist for special orthosis to assist restricting toe walking – ensure you work with a podiatrist familiar with preschoolers
What is this?
What are some possible causes?
How do we examine it?
HOW DO we manage it?
Genu varum
- Physiologic
Asymmetric growth
Focal fibrocartinaginous dysplasia Trauma
Infection
Physeal injury
Tumour - Metabolic disorders
1. Vitamin D deficiency
2. Vitamin D resistant rickets
3. Hypophosphatasia - Skeletal dysplasia
1. Metaphyseal dysplasia
2. Achondroplasia
3. Enchondromatosis
EXAMINATION
* Measure distance between knees when supine and standing
* If standing measurement is significantly greater assess for global ligament laxity
* If there is a noticeable angulation at the knee arrange x-ray to assess for Blount’s Disease
CHECK FOR GLOBAL LIGAMENT LAXITY
Assess knee joint, elbow joint, wrist and thumb
Associated with genetic conditions such as Marfans
Ehlers-Danlos
Morquois
Osteogenesis imperfecta
- Natural history in the toddler is for mild to moderate genu varum (<6cm) to decrease from 12 moa to 0cm at 2.5 years of age.
- If the genu varum is within normal limits monitor and measure every three to six months
- If the genu varum is outside normal limits for age then arrange x-ray of lower extremity; including distal half of femur as well as the full length of the tibia and fibula
- Most cases only require measurement, monitoring and reassurance of the parents that it will correct with time
What genetic conditions can it be associated with?
How do we examine it?
How do we manage it?
Genu valgum
Genetic conditions
1. Benign joint hypermobility syndrome 2. Marfan syndrome
3. Ehlers-Danlos syndromes
4. Stickler syndrome
5. Homocystinuria
6. Osteogenesis imperfecta 7. Williams Syndrome
8. Downs syndrome
Examination
* Measure distance between ankles when supine and standing
* If standing measurement is significantly greater assess for global ligament laxity
* Assess feet for increased pronation - often associated
* If there is a noticeable angulation at the knee arrange x-ray to assess for Blount’s Disease
Management:
* If 6 cm or less between ankles then within normal limits
* If 10cm or less between ankles chiropractic management with monthly remeasure to monitor valgus development
* If more than10cm between ankles refer for orthopaedic opinion as well as chiropractic management
* If significant pronation assess footwear, usefoot strengthening exercises and consider podiatrist referral – ensure you work with a podiatrist familiar with pre-schoolers and preference is for soft orthotics
What are the 6 Selected conditions associated with hypermobility
Marfan Syndrome
Homocystinuria
Stickler Syndrome
Ehlers-Danlos Syndromes
Williams Syndrome
Down Syndrome (Trisomy 21)
Marfan syndrome is an inherited disorder that affects connective tissue — the fibers that support and anchor your organs and other structures in your body. Marfan syndrome most commonly affects the heart, eyes, blood vessels and skeleton.
People with Marfan syndrome are usually tall and thin with unusually long arms, legs, fingers and toes. The damage caused by Marfan syndrome can be mild or severe. If your aorta — the large blood vessel that carries blood from your heart to the rest of your body — is affected, the condition can become life-threatening.
Treatment usually includes medications to keep your blood pressure low to reduce the strain on your aorta. Regular monitoring to check for damage progression is vital. Many people with Marfan syndrome eventually require preventive surgery to repair the aorta.
Homocystinuria is an inherited disorder in which the body is unable to process certain building blocks of proteins (amino acids) properly. There are multiple forms of homocystinuria, which are distinguished by their signs and symptoms and genetic cause. The most common form of homocystinuria is characterized by nearsightedness (myopia), dislocation of the lens at the front of the eye, an increased risk of abnormal blood clotting, and brittle bones that are prone to fracture (osteoporosis) or other skeletal abnormalities. So
Stickler syndrome is a group of hereditary conditions characterized by a distinctive facial appearance, eye abnormalities, hearing loss, and joint problems. T
What are some signs in older children that they have an undiagnosed DDH
How do we radiographically assess a kid with suspected DDH
In older or walking children, complaints of
1. limping,
2. waddling,
3. increased lumbar lordosis,
4. toe walking, and
5. leg length discrepancy
may indicate an unrecognized DDH.
* Hipstabilityaswellasacetabulardevelopmentmay be assessed accurately in neonates and young infants by dynamic ultrasonography.
Radiographicevaluationinolderinfantsandchildren includes anteroposterior and Lauenstein (frog) lateral radiographs of the pelvis.
- Theossificnucleusofthefemoralheaddoesnot appear until 3–7 mo of age, and it may be further delayed in DDH.
- Linemeasurementsareusuallymadetodetermine the relationship of the femoral head to the acetabulum (acetabular index, quadrant assessment, Shenton’s line, and the center edge angle of Wiberg)
What is the treatment of DDH for kids at various ages
Birth
1-6 months
6–18 Months.
18 Months–8 Years.
Birth
When an unstable hip is recognized at birth, maintenance of the hip in the position of flexion and abduction (“human” position) for 1–2 mo is usually sufficient.
1-6 months
During this age, a true dislocation may develop. As a consequence, treatment is directed toward reduction of the femoral head into the acetabulum. Pavlik harness is the treatment of choice in this age group.
6–18 Months.
Spika if they have surgery - put in cast 6-18 month.
In the older infant, surgical closed reduction is the major method of treatment.
18 Months–8 Years.
After 18 mo of age, the progressive deformities are so severe that open reduction followed by pelvic (innominate) osteotomy or femoral osteotomy, or both, are necessary to realign the hip.
All infants seen by chiropractors should be assessed for DDH and dislocation at every appointment during the first year of life
How should we check kids at these ages?
0-2 weeks
4-8 weeks
8 weeks +
0-2 weeks of age
Most clicking hips (positive Barlow) will resolve without treatment (799 out of 800) – only severe cases will need a harness.
Positive Ortolani on its own would be more clinically significant
4-8 weeks of age
Ortolani test are clinically useful during this age range
8 weeks plus
Ortolani no longer clinically useful, don’t look for clicks
anymore, look for limited abduction of hip joint and uneven knees.
Transient synovitis
What is it?
How does it present?
What needs to be ruled out?
Treatment
Transient synovitis is an inflammation in the hip joint that causes pain, limp and sometimes refusal to bear weight. This occurs in pre-pubescent children and is the most common cause of hip pain. It occurs when a viral infection, such as an upper respiratory infection, moves to and settles in the hip joint.
*
Transient synovitis of the hip is one of the more common causes of limping in a normal child.
It is characterized by
acute onset of pain,
limp,and
mild restriction of motion, especially abduction and internal rotation.
Septic arthritis and osteomyelitis of the hip must be excluded before this diagnosis can be confirmed.
Causes
* The cause remains uncertain, but possibilities include
(1)active or recent systemic viral syndrome, (2)trauma, and
(3)allergic hypersensitivity.
* Biopsy specimens from the hip joint have demonstrated synovial hypertrophy secondary to nonspecific inflammatory reaction.
Presentation:
* Transient monoarticular synovitis can occur in all age groups, but the mean age of onset is 6 yr; it occurs predominantly in the 3–8 yr age group.
* Approximately 70% of affected children have had a nonspecific upper respiratory tract infection 7–14 days before the onset of symptoms.
* There is usually an acute onset of symptoms with pain felt in the groin, anterior thigh, or knee; nontraumatic anterior thigh or knee pain may be referred from the hip.
* Are usually ambulatory, and the hip is not held flexed, abducted, and laterally rotated unless a significant effusion is present.
* Walkwithapainful,limpinggait.
* Are usually afebrile or have a low-grade fever (temperature less than 38°C).
Treatment:
* Treatment for monoarticular synovitis of the hip is conservative.
* Bed rest and non–weight-bearing until the pain resolves, followed by limited activities thereafter are the treatments of choice.
* Most children are maintained on bed rest for less than 1 wk. They are then maintained on limited activities for 1–2 additional wk.
* Chiropractic adjustments
What is this?
