Limp in adults & children profoma Flashcards
(39 cards)
What should you ask in a history where a child presents with a limp?
Age- this affects what they could have
Gender
Onset- gradual or sudden
previous episodes
Pain levels
Systemic symptoms- suggests infection or JIA
Joint swelling
Hx of trauma
Birth history -breach or oligohydramnios (lack of amniotic fluid)
Developmental histroy - when did they start walking?
Family history of DDH, SUFE, Perthes, inflammatory diseases or autoimmune conditions.
What are some differentials for limping in children?
Septic arthritis
Irritable hip - transient synovitis - common in boys aged 4-8 & symptoms usually settle w/in 2 weeks.
Reactive arthritis
Trauma & fracture e.g. Toddlers fracture (subtle un-displaced spiral fracture of the tibia, usually in preschool child).
Slipped upper femoral epiphysis (SUFE)
Developmental Dysplasia of the hip (DDH)
Perthes disease
Osteomyelitis
Occult trauma - trauma not apparent on initial presentation. Including NAI
Juvenile idiopathic arthritis (JIA)
Malignancy e.g. osteosarcoma, Ewing sarcoma.
Osgood-Schlatter disease - pain & swelling of tibial tuberosity & patella tendon.
Differentials for limping categorised by age?
All ages:
- infection
- JIA
- NAI
Infants (1-3y)
- Late presenting DDH
- Irritable hip
- NAI or occult trauma
Childhood (3-11y)
- Perthes disease (p= primary so 3-10)
- irritable hip
- SUFE (s= secondary so 11-14 y)
- NAI
Adolescence
- NAI
- SUFE
- Infection
Presentation of limp in children
Rapid onset of pain:
- trauma or infection
Gradual onset of pain:
- Perthes
Weeks of knee/hip pain then sudden increase in pain
- SUFE
Pain in groin mimicking septic arthritis
- Transient synovitis of the hip
Night pain gradually getting worse with analgesics not helping
- Malignancy
Limp & leg length difference with no pain
- DDH
Muscle imbalance or wasting with painless limp
- Neuromuscular disorder e.g. cerebral palsy
Systemically unwell e.g. fever, drowsy, irritibility, not eating…
- JIA or infection
Recent infection e.g. UTI, otitis media…
- Transient syntovitis
Investigations for limping in children
Always exclude septic arthritis first
Blood tests:
- Septic arthritis- high WCC, ESR & CRP
– JIA or transient synovitis - mildly increased WCC, ESR & CRP.
- Muscular dystrophy - high creatinine kinase.
Kocher criteria- differentiates between transient synovitis from septic arthritis, since both cause hip pain.
- 1-4 score. 5= higher change of septic arthritis
1. WCC > 12,000 cells/mm⁻³
2. Inability to bear weight
3. Fever > 38.5°C
4. ESR > 40 mm/h
X-rays:
- Subluxation in DDH
- Damaged femoral head & acetabulum in Perthes’ disease.
- SUFE
- Evidence of infection - they are initially normal.
- Fracture
- Hip = AP & frog leg lateral views; Knee = AP & lateral views.
Ultrasound:
- can identify swelling from inflammatory diseases, septic arthritis, transient synovitis & early Perthes disease. -
MRI
- can identify inflammation, osteomyelitis & tumours.
- Rarely performed.
Urinalysis - looks for infection.
Blood culture - excludes septic arthritis.
Presentation of limping in adults
NOTE: we don’t get a normal gait until age 3-4 yrs.
Look for STRAWS
- S-hort leg gait
- T-rendelenberg gait
- R-igid: do the limbs move flexibly?
- A-ntalgic Gait
- W-eakness
- S-upratentorial gait - split into 2 types (hemiplegic & diplegic)
Describe a Hemiplegic gait
- Unilateral weakness & spasticity
- Arm - flexed, adducted & internally rotated.
- Leg - extended, foot plantar flexed
- Circumduction - circular motion.
- e.g. Spinal cord lesion or post stroke.
NOTE: view image on notes!
Describe a diplegic gait
- Bilateral weakness & spasticity.
- Hips& knees-flexed&abducted.
- Ankles-extended &internally rotated
- The knees are forced together due to spasticity in the adductor muscles resulting inleg overlapwhen walking (a.k.a. scissoring gait).
- In an attempt to overcome this adduction, the patientcircumducts both legduring the swing phase.
- Narrow base, drags legs w/ toe walking
- e.g. Cerebral palsy
NOTE: view image on notes
Describe a trendelenburg gait (waddling/ myopathic)
- Caused by unilateral weakness of hip abductor muscle.
- Patient is unable to weight bear on that side.
- Pelvic drop when walking.
- Waddling
Possible causes:
- Short femoral neck
- Gluteal nerve damage
- Hip replacement surgery
- Hip fracture
NOTE: view image on notes
Describe an antalgic gait
- Short stance phase
- Long swing phase on the painful leg/foot
- Avoids heel strike
- Avoids weight-bearing on the painful side.
Describe a Parkinsonian gait
- Small steps, shuffling
- Bradykinesia- slowness of movement
- Rigidity
- Tremor
- Stooped head
- Freezing & difficulty initiating steps
NOTE: view image on notes
Describe an Ataxic gait
- Clumsy, staggering movements
- Alcohol intoxication mimics this.
- Wide base
- Body may sway when standing still
- Cannot heal-toe walk
- e.g. Cerebellar issues
NOTE: view image on notes
Describe a Neuropathic gait
- Foot drop
- High stepping gait - lift knee high enough not to drag foot on floor.
- Unilateral causes - L5 radiculopathy or Peroneal nerve palsy.
- Bilateral causes - peripheral neuropathies e.g. diabetic neuropathy, Charcot-Marie-Tooth disease & Amyotrophic Lateral Sclerosis (ALS).
NOTE: view image on notes
Differential diagnosis for limping in adults
Ligament tear:
- PCL
- ACL
Tendinopathy:
- Patella tendon
- achilles tending
- hamstring tendon
Nerve entrapment:
- Sicatica
- L5-S1 entrapment
Malignancy
Infection
- septic arthritis
- osteomyelitis
Backpain:
- spinal stenosis
- Herniated disc
- disciitis
Muscle weakness
- trendelenburg
Inflammatory:
- RA
- Reactive arthritis
- psoriatic arthritis
- ankylosing spondylitis
OA
Parkinsons
Fractures & dislocations
Management of limping in adults
- Pain relief e.g. NSAIDs
- Weight reduction
- Physiotherapy
- Orthotics & aids- walking stick in contralateral hand.
- Surgical - Joint replacement or osteotomy.
Risk factors for Developmental Dysplasia of Hip (DDH)
- Breech delivery
- First degree family history
- Oligohydramnios - too little amniotic fluid.
- Packaging disorders in the womb
- First born
More common in girls
Presentation of DDH
Late presentation if not found on screening:
- Painless limp & abnormal gait
- Leg length discrepancy
- Restricted range of movement- loss of abduction.
- Asymmetric skin creases
- Subluxation or dislocation of hip
Examination & Investigation for DDH
Barlow test- test of instability. Involves dislocating the babies hip. The test is positive if you are able to dislocate the hip.
Ortolani test- reduction of the dislocated hip. “Clunk, click”.
Common in new borns but negative after 3 months in many cases.
Ultrasound better on babies btw 0-6 months because the femoral head is cartilage so won’t show on x-rays
NOTE: view image on notes
Management for DDH
Pavlik harness- if severe- prevents hip abduction & extension)
Closed reduction - involves being in a cast for 6 weeks
Open reduction of the hip - at 18 months.
Open reduction with femoral or pelvic osteotamies
What is SUFE?
the growth plate at the top of humerus is fractured, & femoral head slips out of position.
Risk factors for Slipped Upper femoral epiphysis (SUFE)
- Male
- Obesity
- Endocrine association - Hypothyroidism, Hypopituitarism…
Aged 8-15 most common
Presentation of SUFE
Previous history of gradual thigh, knee or hip pain w/ sudden worsening of pain
Pain worse on activity
Subtle painful limp - antalgic gait.
Externally rotated - femoral head is displaced posteriorly & inferiorly.
Loss of internal rotation of leg in flexion
Note: view notes for diagram
Investigation from SUFE
X-ray - need AP & frog leg views. Frog leg views are more helpful.
- dislocation of femoral head is postero-inferiorly
X-ray:
- melting ice cream cone appearance visible through line of Klein)
Frog view:
- straight line through femoral neck anterior to epiphysis
NOTE: view x-ray of notes!-very important
Management for SUFE
Surgical fixation w/ screws- mild to moderate.
Open reduction w/ osteotomy - for severe.
This is an emergency because avascular necrosis of the femoral head can occur.
Under 10, endocrine problems or if you don’t think they’ll come back - then prophylactically pin the other side, too.
