The acute limping child Flashcards
How would a medical professional define a limp?
A shorter stance phase (weight bearing) on the affected limb + abnormal gait commonly due to pain, weakness or deformity.
Why might a child have an abnormal gait? (6)
- Pain - antalgic gait is a limp associated with pain - this is the classical limp seen in a child
- Weakness in muscles - trendelenberg gait - https://www.youtube.com/watch?v=ZUPQp5oxXj8
- Short limb - toe walk on one side
- Stiff joint
- Spasticity
- Poor balance
What is Trendelenburg gait?
- Trendelenburg gait is an abnormal gait seen in those with weak hip abductor muscles.
- Hip abduction is the movement of the leg away from the midline of the body.
Name some common causes of limp in children (6)
- Toxic/transient synovitis
- Septic arthritis
- Trauma
- Osteomyelitis
- Viral syndrome
- Perthes disease
When a child presents to the GP or A&E with a limp there are specific causes that may be more likely. What are these causes dependent on?
Age
- Pre-primary school - 0-5 years
- Primary school - 5-10
- Secondary school - 10-15
Common causes of limp in a 0-5 year old child
- ‘Normal variant’ - CNS is still developing, may sort itself out
- Trauma
- Transient synovitis - inflammatory condition - often the limp comes on after a viral (and sometimes bacterial) infection elsewhere
- Osteomyelitis
- Septic arthritis
- DDH
- JIA - juvenile idiopathic arthritis
Common causes of limp in a 5-10 year old child (5)
- Trauma
- Transient synovitis
- Osteomyelitis
- Septic arthritis
- Perthes disease
Common causes of limp in a 10-15 year old child (6)
- Trauma
- Osteomyelitis
- Septic arthritis
- SUFE - slipped upper femoral epiphysis
- Chondromalacia
- Neoplasm
Why is pain really important in finding the diagnosis of a limp in a child?
Details about pain like how severe it is, where the patient feels it, when they feel it (morning/night) and whether it is constant or intermittent are very important when working out a diagnosis.
- Infective problems and tumours tend to cause constant pain
- Transient synovitis causes intermittent issues
- Morning pain/stiffness suggests inflammatory component
- Bilateral problems might suggest an underlying skeletal dysplasia or an inflammatory cause
- Are they systemically unwell and sore? - need to exclude infection in this case
What important information do you want to find out from the history about the child and their limp?
- Duration and progression of limp?
- Any recent trauma and the mechanism of that trauma – does it fit with presentation?
- Associated pain and its characteristics?
- Accompanying weakness?
- Time of day when limp is worse?
- Can the child walk or bear weight?
- Has the limp interfered with normal activities? Still able to do sport etc?
- Presence of systemic symptoms like fever, weight loss?
- Medical history, —birth history, immunisation history, nutritional history, and developmental history
Give a rough description of what is involved in the examination of a child with a limp
- Inspection
- Palpation
- Range of movement
- Neurological examination
- Special tests as required
- Examine related areas! i.e referred pain from the back can cause hip pain so need to examine the back.
What is Gower’s manoeuvre?
It is a clinical test for muscular dystrophy - it indicates weakness of the proximal muscles
The test gets a child to stand up from sitting or lying down. A positive sign will show the child using their hands and arms to “walk” up their own body from a squatting position due to lack of hip and thigh muscle strength.
How do you differentiate between…
- Septic arthritis
- Osteomyelitis
- Transient synovitis
- Septic arthits - painful, child is unwell (pyrexic), general malaise/ loss of appetite/ listless. SA will rapidly damage the joint and needs emergency drainage + immediate antibiotics.
- Osteomyelitis - painful, child is unwell (pyrexic), general malaise/ loss of appetite/ listless, doesn’t need emergency intervention but does require IV antibiotics
- Transient synovitis - post viral inflammation of the joints i.e URTI or ear infection – only needs symptomatic treatment
What is pseudoparalysis?
- It is an apparent lack or loss of muscular power but with no real paralysis
- A child will not move the joint in this case
If a child refuses to weight bear what does this suggest?
It suggests there might be an infection, tumour or fracture.
How does the infection get into the joint in septic arthritis? (5)
- Haematogenous spread - an infection elsewhere in the body gets into the blood stream and moves into the joint i.e dirty cut or infected tooth
- Dissemination from osteomyelitis – the growth plate is the area with the biggest blood supply around the joint and often infection lodges there and then bursts through the periosteum into the joint. (Growth plate is an intra articular structure)
- It can spread from a nearby soft tissue infection i.e cellulitis
- Diagnostic or therapeutic measures i.e injection into the joint can cause infection
- Penetrating trauma – this is rare but might be caused by deep splinter, stick etc
