ped limp

Question 1

mature gait develops

Answer 1

around age 3, finally developed around 7

Question 2

nonantalgic gait

Answer 2

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

Question 3

antalgic gait

Answer 3

shortening of stance phase, compensatory to prev. pain (hip, knee, ankle pain)
if intense, may not bear weight on limb

Question 4

what else to ask

Answer 4

hx: birth, dev, immunization

interview sep. if suspect abuse

Question 5

ddx

Answer 5

benign, cong/dev, *infection, *malignant, osteonecrosis, overuse, *trauma, limb length

Question 6

5 most common

Answer 6

• 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

Question 7

intra-abdominal causes

Answer 7

appendicitis

neuroblastoma, posas abscess

Question 8

intra-articular

Answer 8

cong., hemoarthrosis, inf, inflammation, trauma

Question 9

neuromuscular

Answer 9

cerebral palsy, meningitis, musc. dystrophy, myelomeningocele (MS)

Question 10

ST conditions

Answer 10

cong, inf, overuse, trauma

Question 11

spine

Answer 11

vertebral osteomyelitis, spinal cord tumors, diskitis

Question 12

steppage gait

Answer 12

neurologic, can’t dorsiflex foot

Question 13

tredelenburg gait

Answer 13

DDH, abn. in hip abduction

Question 14

circumduction gait

Answer 14

neurologic, mechanical (stiffness in knee, ankle), + Galeazzi sign? : limb length discrepancy, disloc. fem head, knees diff. heights

Question 15

equinus gait

Answer 15

on toes

CTEV, cerebral palsy, idio. tight Achilles tendon, calcaneal fx, foreign body in foot, limb length discrepancy

Question 16

septic arthritis

Answer 16

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!

Question 17

transient synovitis

Answer 17

viral inf. in joint, somewhat self-limiting

Question 18

to det. if painful joint more serious, add this to aspiration

Answer 18

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)

Question 19

what to ask

Answer 19

is pain med. controlling pain?

-serious if giving ibuprofen regularly

Question 20

leg limp: toddler

Answer 20

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

Question 21

leg limp: child 3-10 yrs

Answer 21

*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.

Question 22

leg limp: adolescent >10

Answer 22

*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

Question 23

test which limb 1st?

Answer 23

unaffected, gain trust

Question 24

tests

Answer 24

Trendelenburg
Galeazzi sign
Patrick test (FABER)
Pelvic compression test
Psoas sign

Question 25

Patrick tests (FABER)

Answer 25

“figure 4”

SI joint pathology if positive

Question 26

pelvic compression test

Answer 26

SI joint pathology

Question 27

psoas sign

Answer 27

have pt raise leg, physician resists

+ if pain: appendicitis, psoas abscess

Question 28

physical exam signs to look for

Answer 28

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

Question 29

more physical exam

Answer 29

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

Question 30

even more PE

Answer 30

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

Question 31

blood work to do

Answer 31

CBC
ESR
CRP
Joint fluid (aspiration) for Gs if septic arthritis 
Blood/bone Cx

Question 32

imaging

Answer 32

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

Question 33

what to do if abuse

Answer 33

call ambulance–>send to ED–>more support/resources, sep from parents, social work

Question 34

emergent situations

Answer 34

• 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