Week 14 - gait and limp Flashcards
What are the two phases of a normal gait? (LO1)
- Stance - 60% of walking.
- Swing - 40% of walking.
What are the four parts of the stance phase in normal gait? (LO1)
- Heel strike to foot flat.
- Foot flat to midstance.
- Midstance to heel off.
- Heel off to toe off.
What are the two parts of the swing phase in normal gait? (LO1)
- Acceleration to midswing.
2. Midswing deceleration.
Describe antalgic gait. (LO1)
- Another name for limp.
- Shortening in stance phase relative to swing phase.
- Prevents an area that is painful from being put under too much pressure.
- Reason for this could be traumatic, infectious, inflammatory, vascular or neoplastic.
- The likelihood of developing antalgic gait increases with age.
- More than 60% of people >80 are affected.
- Treatment and management will depend on diagnosis as fixing the underlying issue is key. Refer to the appropriate specialist.
How do we diagnose the cause of an antalgic gait? (LO1)
- Comprehensive history.
- Examination of the lower limb, hip and spine.
List the differential diagnoses for antalgic gait. (LO1)
Traumatic:
- Fracture or sprain of the lower extremity.
- Vertebral body fracture.
- Hip fracture.
Infectious:
- Epidural abscess.
- Osteomyelitis.
- Discitis.
- Septic arthritis.
Inflammatory:
- Gout.
- Lumbar radiculopathy.
- Sciatica.
- Bursitis of the hip or knee.
- Rheumatoid arthritis.
- Osteoarthritis.
- Plantar fasciitis.
- Neuropathy.
- Pelvic girdle pain in pregnancy.
- Chronic anterior pelvic ring instability.
Vascular:
- Vascular disease.
- Claudication.
- Deep vein thrombosis (DVT).
Neoplastic:
- Tumour.
- Pathological fracture.
List the investigations for antalgic gait. (LO1)
Depends on the suspected underlying issue and will therefore be subject to the history and examination.
- X-rays.
- MRI.
- CT scan.
- Ultrasound.
- Lab tests (e.g. blood or urine samples) - may be taken to help diagnose viral or bacterial infections. In children, lab tests may help identify juvenile rheumatoid arthritis.
Describe the gait pattern in toddlers and young children. (LO1)
- Immature gait pattern.
- Characterised by broad-based, increased flexion of the hips and knees.
- Arms beside the body with the elbow extended.
- Also cannot increase the size of their steps and so increase the pace of their steps to move faster - due to lack of neuromuscular maturity.
List the potential causes of limping in children. (LO1)
- Transient synovitis - usually in the hip secondary to viral infection.
- Septic arthritis - aspirate to eliminate this option if unclear.
- Juvenile rheumatoid arthritis.
- Cerebral palsy.
- Muscular dystrophy.
- Developmental dysplasia of the hip.
- Osteoid sarcoma.
- Leukaemia.
Describe juvenile rheumatoid arthritis as a cause of limping in children. (LO1)
- Mild and insidious pain in the legs at the start of walking.
- More common in girls.
- Knees and ankles most commonly affected.
- Presentation: swelling, warmth, decreased range of movement.
- Investigations: WBC, ESR, RF, ANA. These may be normal and should not rule out diagnosis if they are.
When do most children start walking? (LO1)
- First steps at around 12 months.
- Walking without assistance at around 18 months.
Delay in walking may indicate a neurological disorder.
What is cerebral palsy? (LO1)
- Neurological disorder.
- Leads to claudication when walking, which may go unnoticed before the child’s first steps.
What is muscular dystrophy and how does it differ from cerebral palsy? (LO1)
Delay in the beginning of walking accompanied by:
- Repeated stumbling.
- Frequent falls.
- Difficulty climbing stairs due to weakness of muscles proximal to the root of the limb - gluteus maximus, medius and quadriceps.
- The calf exhibits false hypertrophy and a positive Gower’s sign.
What is Gower’s sign? (LO1)
The child is placed in prone position and asked to get up. If they seem to be “climbing over themself”, this is a positive Gower’s sign.
Describe the investigations and prognosis of muscular dystrophy. (LO1)
- Serum CPK - may be 200-300 times the normal level.
- In general, the patient is taken to the doctor at around 3-6 years of age.
- May be a positive family history where boys are almost exclusively affected, as it is X-linked recessive.
- Disease is progressive and evolves slowly.
- Patients usually die in their 20s/30s from respiratory failure or cardiac arrest.
What are two neoplastic disorders that can cause limping gait in children? (LO1)
Osteoid osteoma:
- > 5 year olds.
- Claudication pain - mainly at night.
- May pass undetected on radiographs.
- Unremarkable clinical examination.
- Usually no pain on palpation.
- Significant improvement with aspirin - may increase suspicion.
- Scintigraphy - highly sensitive in aiding diagnosis.
- Diagnosis is a challenge, especially, at the start of walking age.
Leukaemia:
- 2-5 year olds.
- Claudication pain - even in their first steps.
- Bone pain, fever and lethargy - similar to arthritis and osteomyelitis.
- Normal x-ray.
- Scintigraphy may be unsuccessful.
- Lab tests at initial stage can also create doubts.
- Non-specific elevation of ESR and peripheral leukocyte count.
- Refer to haematologist for bone marrow evaluation.
List the types of abnormal gait. (LO2)
- Antalgic.
- Short leg.
- Trendelenburg - weak hip adductors.
- Stiff knee.
- Spastic.
Which differentials can short leg gait indicate? (LO2)
- Slipped upper femoral epiphysis (SUFE).
- Proximal focal femoral deficiency (PFFD).
- Developmental dysplasia of the hip (DDH).
What is the surgical sieve? (LO2)
A surgical sieve is an approach to differential diagnosis that encourages you to consider various types of pathologies systematically.
What is the surgical sieve mnemonic for musculoskeletal deformities? (LO2)
VITAMIN CDEF:
- Vascular.
- Infective/inflammatory.
- Trauma.
- Autoimmune.
- Metabolic.
- Iatrogenic/idiopathic.
- Neoplastic.
- Congenital.
- Developmental/degenerative.
- Endocrine.
- Functional.
Which of the broad categories of the surgical sieve of musculoskeletal deformities are relevant in children? (LO2)
- Vascular.
- Infective/inflammatory.
- Trauma.
- Autoimmune.
- Neoplastic.
- Congenital.
- Developmental.
- Functional.
For a limping child, what do we want to know about the history of the presenting complaint? (LO2)
- Acute/chronic?
- SOCRATES.
- Trauma.
- Systemic symptoms - i.e., fever, malaise, anorexia.
- Joint swelling (NOT HIP).
- Any previous episodes.
- Recent infections.
For a limping child, what do we want to know about the past medical history? (LO2)
Perinatal history:
- DDH risk?
- Birth complications.
- Special care baby unit (SCBU).
Developmental:
- Milestones - especially gross motor, e.g., walking.
For a limping child, what do we want to know about the family history? (LO2)
- DDH.
- Inflammatory arthritis.
- Autoimmune conditions.