ped limp Flashcards
mature gait develops
around age 3, finally developed around 7
nonantalgic gait
There likely is no pain because of gait compensation
Stance phase is not shortened
Ex: toe walking from tight heel cord, clubfoot, limb length discrepancy, cerebral palsy
antalgic gait
shortening of stance phase, compensatory to prev. pain (hip, knee, ankle pain)
if intense, may not bear weight on limb
what else to ask
hx: birth, dev, immunization
interview sep. if suspect abuse
ddx
benign, cong/dev, *infection, *malignant, osteonecrosis, overuse, *trauma, limb length
5 most common
- limb length discrepancy
- transient synovitis (inflam. in joint)
- legg-calve-perthes (avasc. necr. of fem hd, thickening, sclerosis)
- fracture: toddler: 1 cortex to other (spiral/oblique): cast if suspect, initial XR might not show
- septic arthritis
intra-abdominal causes
appendicitis
neuroblastoma, posas abscess
intra-articular
cong., hemoarthrosis, inf, inflammation, trauma
neuromuscular
cerebral palsy, meningitis, musc. dystrophy, myelomeningocele (MS)
ST conditions
cong, inf, overuse, trauma
spine
vertebral osteomyelitis, spinal cord tumors, diskitis
steppage gait
neurologic, can’t dorsiflex foot
tredelenburg gait
DDH, abn. in hip abduction
circumduction gait
neurologic, mechanical (stiffness in knee, ankle), + Galeazzi sign? : limb length discrepancy, disloc. fem head, knees diff. heights
equinus gait
on toes
CTEV, cerebral palsy, idio. tight Achilles tendon, calcaneal fx, foreign body in foot, limb length discrepancy
septic arthritis
pain in joint; infection (case: OM–>travel via blood to hip joint), look @ onset timeframe: septic: quick vs. rheumatoid: slow
-typ. one joint
aspirate joint, Gs/Cx to ID
*deal with now!
transient synovitis
viral inf. in joint, somewhat self-limiting
to det. if painful joint more serious, add this to aspiration
CBC, (left shift-infection)
ESR (sed rate >40–> more serious: bac inf) (vs virus)
CRP (>2.5, serious bac)
temp. >101
WBC >12000
*for septic arthritis, bacterial (dx from synovitis)
what to ask
is pain med. controlling pain?
-serious if giving ibuprofen regularly
leg limp: toddler
dev. dysplasia of hip, cong limb, neuromus. abn, painful gait, foreign body *fx: spiral or oblique, thru both cortices, think abuse* septic/reactive arthritis transient synovitis osteomyelitis
leg limp: child 3-10 yrs
*legg-calve-perthes: avasc. necrosis in fem head stress fx tumors osteochondritis kohler dis: navicular bone in foot loses blood supply osteochondritis osgood-schlatter transient synovitis osteomyelitis leg length discrp.
leg limp: adolescent >10
*SCFE (slip cap fem epi): unstable is emergency: dec. blood supply-->avascular necrosis LCP juv. idiop. arthritis (slow) overuse osteochondrosis tumor osteochondritis stress fx tarsal coalition (should sep but don't) discoid meniscus: lateral meniniscus is thick, impinges blood supply
test which limb 1st?
unaffected, gain trust
tests
Trendelenburg Galeazzi sign Patrick test (FABER) Pelvic compression test Psoas sign
Patrick tests (FABER)
“figure 4”
SI joint pathology if positive
pelvic compression test
SI joint pathology
psoas sign
have pt raise leg, physician resists
+ if pain: appendicitis, psoas abscess
physical exam signs to look for
Abdominal mass
Abdominal tender
Asymmetrical gluteal/thigh skin folds
Calf hypertrophy
Conjuctivitis, enthesitis (*inflam. where tendon and bone meet), oligoarthritis (mult. its involved), urethritis
Erythema chronicum migrans (Lyme disease)
Erythema marginatum (red patches: trunk, legs; rheumatic fever, SJS)
External hip rotation with hip flexion
Galeazzi sign
Hepatomegaly, lympadenopathy, splenomegaly
more physical exam
Hip joint flexed, abd, ER Joint swelling Localized bony tenderness Loss of hip abduction Loss of hip internal rotation Malar rash Muscular arthropathy Neck pain & stiffness, +brudzinski and kernig Non-weight bearing, pain ROM
even more PE
Obesity Overlying warmth or erythema Painless, non-pruritic maculopapular/vesicular rash with polyarthritis, tenosynovitis Palpable bony mass Positive Patrick test Positive Pelvic compression test Positive Trendelenburg test Psoas sign
blood work to do
CBC ESR CRP Joint fluid (aspiration) for Gs if septic arthritis Blood/bone Cx
imaging
XR: complete skeletal exam (if abuse: see old and new fx) U/S-fluid in joint bone scintigraphy CT-not used often MRI-U/S first
what to do if abuse
call ambulance–>send to ED–>more support/resources, sep from parents, social work
emergent situations
- septic arthritis (can become septic!): go to OR, open jt to clean out joint, IV abx
- compartment syndrome: infection–>swelling, inc. pressure, pain in fascial compartment (can become gangrenous–>sepsis)
- vascular compromise: avascular necrosis: begin to kill off joint, sev. pain/inf–>limb loss
- open fx
- unstable slipped capital femoral epiphysis (SCFE)–>avascular necrosis
