abnormal gait Flashcards
Causes of abnormal gait
Septic arthritis Osteomyelitis Rheumatic fever Transient synovitis Trauma - accidental and non accidental Malignancies Neuro - Guillain Barre syndrome, Cerebral palsy, CV accident Development dysphasia of hip Perthe's disease Slipped upper femoral epiphysis Duchenne's muscular dystrophy Talipes equinovarus, toe walking, genuine Valgum/Varum, pets plannus, in toeing.
How do disorders of the hip usually present and what are the DDX
Pain which can sometimes be to the knee Limp DDX Developmental dysphasia of hip Perthe's disease Slipper upper femoral epiphysis Transient synovitis
DDX for leg pain and limp
Growing pain Transient synovitis Septic arthritis Trauma Osteomyelitis Legg- Perthes disease Slipped capital femoral epiphysis Neoplastic disease - red flag
Growing pains
Occur in preschool children Pain at night with no limp by day Often bilateral Shins or thighs Prominently muscular not bone Otherwise health child Doesn't stop them functioning in activities If refusal to walk, pressure of a limp, warm, tenderness, swelling or constitutional symptoms then look for other diagnosis
Transient synovitis
Benign and common in boys aged 2-8 Sudden onset limp Otherwise well Often preceded by URTI All Ix come back normal
Septic arthritis
Common in infant and toddler Child looks septic Swollen hot joint - can't see in hip May be Febrile Emergency Ix high WCC and CRP. X-ray shows widening of joint space. Joint aspiration show purulent joint fluid.
Osteomyelitis
Fever
Swelling, erythema, tenderness with decreased movement of limb
Ix - High CRP, WCC and Dx on X-ray, CT or MRI
Legg-Perthes disease
Defined as Osteochondritis leading to a vascular necrosis of femoral head.
4:1 male to female ratio, 4-11yrs with peak at 4-7 years
Presentation - May follow transient synovitis, initially painless. Pain and limp when fracture occurs
Dx by X-ray or MRI
Slipped capital femoral epiphysis
Occurs in overweight teenage boys
Presentation - gradual onset of pain in groin or knee
Dx by X-ray
Neo plastic disease
Presentation - pain, tenderness and mass
Gnawing pain in leukaemia
Ix - Xray - destructive mass on X-ray
Causes of acute limp
ARF Slipped capital femoral epiphysis Malignancy Accidental and non accidental injury Infection
Talipes Equinovarus
Common in newborns as a transient postural deformity
Rarely more fixed deformity
Needs physiotherapist and surgery if persistent
Common causes of abnormal gait in toddler 1-4 yr
Developmental dysphasia of the hip
Toddlers fracture
Transient synovitis of the hip - irritable hip
Child abuse
Common causes of abnormal gait in 4-10 yr olds
Transient synovitis of the hip
Perthes disease
Common cause of abnormal gait in adolescent greater then 10yr
Slipped upper femoral epiphysis
Overuse syndromes/stress fracture.
Hx question for a child with abnormal gait
Duration
Complete refusal to wt bear
Trauma -
Preceding illness eg viral infection before transient synovitis or reactive arthritis
Fever or systemic symptoms suggests infective or inflammatory causes
Pain - site and severity.
Morning stiffness
Previous injuries or child protection concerns
What to examine with a child with abnormal gait
GI
Vital
Gait eg running may exaggerate a limp
Neurological examination for ataxia and weakness
Generalised lymphadenopathy - viral infection/haematological cause
Excessive bruising or bruising in unusually places - NAI or haematological cause
Abdomen, scrotum and inguinal area - masses
Bony tenderness
All joint - pain, sacroiliac joints and spine - flex ion and midline tenderness may be discitis. Exaggerated lordosis in discitis. Hip abduction and internal rotation.
Ix for child with joint pain
In less then 3 days = nothing
Discuss with senior staff
Blood - FBC, CRP, ESR and BC.
Imaging
Xray for Perthes/SUFE, Chronic osteomyelitis, tumours, developmental dysphasia of hips ( more then 6 m)
USS - Septic hip
Bone scan - osteomyelitis, discitis, Perthes, occult fracture
CT/MRI - Only after orthopaedic consultation.
Common organism that causes Osteomyelitis and septic arthritis
Staph aureus, GAS and Haemophilus influenza
How to differentiate between osteomyelitis and septic arthritis
Both
Not using that limb and may have redness over effected area.
Osteomyelitis - Subacute onset of limp/non wt bearing and refusal to use limb. Localised pain and pain on movement, tenderness, soft tissue redness/swelling may not be present and may appear late. May or may not have fever.
Septic arthritis - Acute onset of limp/non wt bearing/refusal to use limb. Pain on movement and at rest. Limited range/loss of movement. Soft tissue redness/swelling often present. Fever.
Ix for osteomyelitis and septic arthritis
FBC, ESR, BC, Xray and bone scan (don’t delay Tx for this)
Mx for septic arthritis and osteomyelitis
Surgical emergency - clean out joint
Refer to orthopaedics when suspected
Urgent aspiration, arthroscopy and washout with ABx Flucloxacillin
Define cerebral palsy
Unchanging disorder of movement and posture due to defect or lesion of the developing brain. It is non progressive
Has does cerebral palsy present
Delayed motor milestones - learning to site, stand and walk
Asymmetric movement patterns eg strong hand preference early in life
Abnormalities of muscle tone particularly spasticity or hypotonia
Difficult mx as there is severe feeding difficulties and unexplained irritability.
