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.
For a limping child, what do we want to know about the social history? (LO2)
- Other family members at home.
- Other carers.
- Safeguarding concerns.
Describe what you are looking for in a general examination of a limping child. (LO2)
- Well or unwell?
- Comfortable at rest?
- Temperature.
- Pulse.
- Rashes.
- Bruises/bites/burns.
- ENT.
Describe what you are looking for in the LOOK part of a joint examination of a limping child. (LO2)
- Posture of the limb.
- Fixed flexion deformities.
- External signs of injury.
- Swollen joints.
- Limb length discrepancy.
- Gait.
- Erythema.
Describe what you are looking for in the FEEL part of a joint examination of a limping child. (LO2)
- Tenderness.
- Joint effusion.
- Muscle tone.
Describe what you are looking for in the MOVE part of a joint examination of a limping child. (LO2)
- Active and passive range of motion.
- Neurological/developmental examination.
Describe the investigation for a limping child. (LO2)
Blood tests:
- FBC - raised WCC for infections.
- Inflammatory markers - CRP, ESR, raised in infection, inflammation.
- Autoimmune markers.
- Blood cultures.
Imaging:
- Plain radiographs - fractures and dislocations _ bony pathology.
- Ultrasound - effusions.
- MRI - bony and soft tissue detail, difficult in <5 year olds as they cannot sit still.
At what ages are the common causes of limp present? (LO2)
- Infection/transient synovitis can occur at ANY AGE.
- DDH - toddlers - 2-3 years old.
- Perthes - 4-9 years of age.
- SUFE - 9-12 years of age.
Describe transient synovitis as a cause of limp in children. (LO2)
- Involves a preceding viral illness.
- 70% boys.
- 3-10 years old.
- Milder symptoms.
- Bloods - normal to mildly increased inflammatory markers.
- Normal imaging.
- No treatment required, recovers spontaneously.
- Can sometimes prescribe analgesia, e.g., NSAIDs.
- Main DDx: septic arthritis - MUST RULE OUT.
Describe osteomyelitis as a cause of limp in children. (LO2)
Infection within the bone:
- History of trauma.
- Range of motion usually less affected.
- Localised tenderness.
Surgery not usually indicated:
- Subperiosteal abscess.
- Intraosseous collection.
Describe septic arthritis as a cause of limp in children. (LO2)
- Infection within the joint space.
- Range of motion reduced.
- Effusion.
- Erythema.
- Bacterial products and inflammatory mediators destroy cartilage.
- Washout required urgently.
- Might have a preceding infection elsewhere.
- FEVER, UNWELL.
- Most commonly Staph aureus and Strep.
List the essential investigations for bony infection (limp in children). (LO2)
Bloods:
- CRP.
- ESR.
- White cell count.
- Cultures.
Plain film radiograph:
- X-ray.
Treat with NSAIDs if no contraindications.
What are the indications for surgery in a child with osteomyelitis? (LO2)
- Subperiosteal abscess.
- Large interosseous collection - PVL Staph.
What is DDH? (LO2)
- Developmental dysplasia of the hip.
- 1/1000 incidence.
- Spectrum: dysplasia > subluxation > dislocation > instability.
List the risk factors for DDH. (LO2)
- Female.
- First born.
- Breech.
- 1st degree relative family history - parents, siblings, etc.
- Oligohydramnios - low amniotic fluid during pregnancy.
- Packing disorders, e.g., torticollis (abnormal muscles of the neck meaning head tilts downwards), metatarsus adductus (metatarsal bones turned inwards towards the body).
What are the two main tests for DDH? (LO2)
Barlow’s test:
- Test of instability.
- Dislocate the hip from the acetabulum.
Ortolani’s test:
- Reduce the dislocated hip.
- Clunk vs. click.
These are performed during neonatal examination. If these are positive or if risk factors present, then ultrasound of the hip at 6-8 weeks.
List the other examinations for DDH. (LO2)
- Allis test - skinfold symmetry.
- Galeazzi test - leg length discrepancy.
- Espy abduction of the flexed hip.
- Gait abnormalities.
Describe the presentation of DDH. (LO2)
- Painless limp (if walking).
- Leg length discrepancy.
On examination:
- Restricted range of motion - especially abduction of flexed hip.
- Leg length discrepancy.
- Asymmetric skin creases.
- Abnormal gait.
What is the treatment for DDH? (LO2)
Usually determined by age. In order of increasing complexity:
- Pavlik harness.
- Closed reduction (under general anaesthesia).
- Open reduction (under general anaesthesia).
- Open reduction with femoral/pelvic osteotomies (under general anaesthetic).
What is Perthes disease? (LO2)
- Idiopathic avascular necrosis of the femoral head.
- 3/100,000
- 4-9 year olds (older children have worse prognosis).
- Males 6:1 females.
- Females have worse prognosis.
- Typically, skinny, hyperactive children.
- Obesity = worse prognosis.
- 25% bilateral.
List the potential causes for Perthes disease. (LO2)
- Clotting disorder.
- Passive smoking.
- Genetic.
- Environmental.
List the signs of Perthes disease. (LO2)
- Stiff hip - particularly abduction.
- Pain.
- Limp.
- Leg length discrepancy.
What are the four stages of Perthes disease? (LO2)
- Initial/sclerotic.
- Fragmentation.
- Healing.
- Remodelling.
Classified using the Herring classification.
Describe the management of Perthes disease. (LO2)
Main principle is hip containment:
- Try to keep ball and socket together to keep them congruent.
- Less congruent the joint, greater the chances of OA later in life.
Methods:
- Physio for range of motion increase.
- Brace/plasters.
- Wheelchair?
- Bisphosphonates.
- Surgical:
1. Femoral osteotomy.
2. Pelvic osteotomy.
3. Hip distraction.
What is SUFE? (LO2)
- Slipped upper femoral epiphysis.
- Femoral head is left POSTERIOR AND INFERIOR.
- Atraumatic.
- Usually in OBESE male children.
- 25% bilateral.
- Endocrine association - hypothyroid, hypopituitary, CRF (chronic renal failure).
List the symptoms of SUFE. (LO2)
Pain:
- Activity-related.
- Hip.
- Could be thigh or knee - always examine the hip of a child with knee pain.
Limp:
- Antalgic.
- Externally rotated hip.
Describe the findings on an x-ray of a SUFE. (LO2)
MUST be frog leg x-ray of the pelvis.
- Physeal widening.
- Trethowan’s sign.
- Reduced epiphyseal hypertrophic zone.
By which three properties are SUFEs classed? (LO2)
- Temporal (onset).
- Stability.
- Severity of slip.
What are the two classes of SUFEs according to the onset? (LO2)
- Acute (less than 3 weeks) - higher rate of avascular necrosis.
- Chronic.
What are the two classes of SUFEs according to the stability? (LO2)
- Stable - weight-bearing.
- Unstable - non-weight bearing - 50% have avascular necrosis.
What are the three classes of SUFEs according to the severity of the slip? (LO2)
- Mild.
- Moderate.
- Severe.
Worse deformity = worse function later in life.
Describe the management for SUFE. (LO2)
- Pin in situ for mild/moderate.
- DON’T ATTEMPT REDUCTION - risk of avascular necrosis.
- Femoral osteotomy to re-shape the femur - early or late.
- If severe - open reduction and osteotomy - avascular necrosis risk.
Describe the flowchart used in diagnosing limp in children. (LO2)
- Pain?
- No - DDH, LLD, hemiplegia.
- Yes - question 2. - Acute?
- No - Perthes, SUFE, tumour, JIA (juvenile idiopathic arthritis).
- Yes - question 3. - Trauma?
- No - question 4.
- Yes - Injury, fracture. - Systemic upset?
- No - Perthes, SUFE, tumour, JIA (juvenile idiopathic arthritis).
- Yes - Infection, irritable hip, JIA, acute lymphoblastic leukaemia.
Which muscles are involved in the heel-strike part of gait? (LO2)
The foot must be dorsiflexed so:
- Tibialis anterior.
- Gluteus maximus and posterior capsule.
Which muscle is involved in the loading response (foot flat after heel-strike)? (LO2)
Quadriceps femoris.
Which muscle are involved in the mid-stance (foot flat after heel-strike and other foot leaves floor)? (LO2)
- Triceps surae (gastrocnemius x2 and soleus).
- This moves into the terminal stance/heel off which involves plantarflexion.
Which muscles are involved in the toe-off part of gait? (LO2)
- Deep plantar flexors.
- Flexors of the toes.
- Intrinsic foot muscles.
- Rectus femoris.
Which muscles are involed in the initial and mid-swing part of gait? (LO2)
- Contralateral abductors of the hip.
- Iliopsoas.
- Rectus femoris.
Which muscles are involved in the terminal swing part of gait (foot about to be planted but still swinging)? (LO2)
- Quadriceps femoris.
- Tibialis anterior.
- Hamstrings.
What are the pre-requisites for gait? (LO2)
- Stability in stance.
- Sufficient foot clearance in swing.
- Appropriate pre-positioning of the foot in swing.
- Adequate step length.
- Energy conservation.
Which anatomical structures can affect gait? (LO2)
- Joints, e.g., arthritis.
- Bones, e.g., deformities.
- Muscles, e.g., muscular dystrophy and spasticity.
- Nerves, e.g., trauma.
List the types of abnormal gait (Mnemonic: STRAWS). (LO2)
- Short leg.
- Trendelenburg.
- Rigid.
- Antalgic.
- Weak.
- Supratentorial.
List the potential causes of short leg gait. (LO2)
- Bowing at the femur - valgus deformity.
- Leg length discrepancy.
- Shorter left femur - diagnosis: Proximal focal femoral deficiency (PFFD).
- Shorter femoral neck - diagnosis: Perthes.
Describe how we can identify short leg gait. (LO2)
- Head and shoulder drop as the patient steps onto short limb (head bobs in sagittal plain).
- Pelvis drops on affected side during heel strike.
- Vaulting gait - elevate pelvis and proximal femur of stance leg, allows for longer leg to swing through.
- Flexion of the knee, equinus ankle of longer leg (limited dorsiflexion).
Describe how we can identify Trendelenburg gait. (LO2)
- Excessive lateral trunk flexion.
- Weight shifting over the stance leg.
- Positive Trendelenburg test.
- Possibly due to hemiarthroplasty.
Weakness of abductor mechanism:
- Joint: subluxed, dislocated hip.
- Bone - shortening of femoral neck.
- Muscle - abductor weakness.
- Pain.
Describe how we can identify rigid gait. What would you see if the abnormality causing this gait was in different joints of the lower limb? (LO2)
Hip abnormality:
- Head and torso sways from the front to back in sagittal plan while walking.
- Decreased hip flexion on swing phase and lumbar motion increases.
Knee abnormality:
- Hip circumducts.
- Little flexion/extension through stance.
Ankle abnormality:
- May turn foot our to use subtalar joint (STJ).
- Limitation flexion/extension in sagittal plan.
Describe how we can identify antalgic gait. (LO2)
- Shortened stance phase.
- Avoids weightbearing on that side.
- Avoids heel-strike.
What happens at the hip?:
- Lurches over the painful side to reduce lever arm and hence joint reaction force (JRF).
What happens in the knee?:
- Held slightly flexed.
This is one person and these are the features you would see on the patient simultaneously.
What is joint reaction force (hip)? (LO2)
- Joint reaction force is defined as the force generated within a joint in response to forces acting on the joint.
- In the hip, it is the result of the need to balance the moment arms of the body weight and abductor tension. You work to lower the joint reaction force when in pain.
(- A moment arm is simply the length between a joint axis and the line of force acting on that joint.)
How does the body work to lower the JRF at the hip? (LO2)
- The abductors work to take some of the pressure off your joints.
- The same can be done with a stick.
What happens to the knee joint when you put your full body weight on it? (LO2)
By doing this, you force the knee into hyperextension.
Describe how we can identify weak gait. What would you see if the abnormality causing this gait was in different joints of the lower limb? (LO2)
Hip abnormality:
- Trendelenburg.
Knee abnormality:
- Weak quadriceps.
- Back-knee.
Ankle abnormality:
- High-stepping gait (usually due to foot drop/common peroneal nerve injury).
- Hip/knee flexed excessively to lift foot.
- Foot slap on initial contact.
Describe how we could identify spastic gait. (LO2)
- No heel-strike on the right foot.
- Right leg adducted and internally rotated.
What are hemiplegia and diplegia? (LO2)
- Brain injury resulting in varying degrees of weakness, (stiffness) spasticity and lack of control.
- Hemiplegia = affecting one side of the body.
- Diplegia = affecting both sides of the body.
Diplegia can be asymmetrical so if one side is more affected than the other, it can look like hemiplegia (only one side affected).
What are the two causes of supratentorial (neuromuscular) gait? (LO2)
- Spastic hemiplegia.
- Spastic diplegia.
Describe how we can identify supratentorial gait caused by spastic HEMIplegia. (LO2)
- Unilateral loss of heel strike.
- Knee held flexed.
- Nil movement of arm in swing.
What are the four types of gait which can be seen in spastic DIplegia? Describe them. (LO2)
- Equinus gait - nil heel strike in rocker phases.
- Jump gait - ankle equinus (lack of dorsiflexion), knee flexion.
- Crouch gait - ankle/knee + hip flexion.
- Scissoring gait.
Describe the management of abnormal gait. (LO2)
- History.
- Examination.
- Investigations.
- Treat the underlying cause - weight reduction, physio, orthotics and aids, e.g., walking sticks.
- Surgery.