Approach to limping child Done by Group A1
Case Scenario • A 14 month old boy is brought to the office because the parents noticed a limp this morning when the child got out of bed…
Pathophysiology • Three major factors cause a child to limp: pain, weakness, and structural or mechanical abnormalities of the spine, pelvis, and lower extremities (Clark, 1997; deBoeck & Vorlat, 2003; Lawrence, 1998). • A normal gait is composed of symmetrical, alternating, rhythmical motions involving two phases: stance and swing. The stance phase normally encompasses 60% of the gait cycle. The type of gait may be helpful in identifying the etiology of the limp.
Some Abnormal Gaits • Anantalgicgait results from pain in one extremity that causes the patient to shorten the stance phase on that side with a resultant increase in the swing phase. The most common causes of an antalgic gait are trauma or infection. • ATrendelenburggait is a downward pelvic tilt away from the affected hip during the swing phase as a result of weakness of the contralateral gluteus medius muscle .The gait disturbance is commonly observed in children with developmental dysplasia of the hip, Legg-Calves-Perthes disease, or slipped capital femoral epiphysis. If the involvement is bilateral, a waddling gait results • Asteppage (equinus) gait is a result of the inability to actively dorsiflex the foot, with exaggerated hip and knee flexion during the swing phase. A steppage gait is seen in children with neuromuscular diseases (eg, cerebral palsy) that cause impairment of dorsiflexion of the ankle. • Avaultinggait occurs when the knee is hyperextended and locked at the end of the stance phase and the child vaults over the extremity .A vaulting gait is seen in children with limb length discrepancy or abnormal knee mobility. • Astoopedgait is characterized by walking with bilaterally increased hip flexion A stooped gait is common in children with pelvic or lower abdominal pain.
Differential Diagnosis *very tall and/or obese. Limp and pain in the hip. Leg is held in an extemal rotation position. Often painful on internal rotation of the hip. Association with hypothyroidism
Differential Diagonsis • Others: don’t forget to consider: • Appendicitis with psoas muscle irritation • Neoplasms- either cause pain or pathological fractures • Retroperitoneal neoplasms or infection • Neuromusculature disorders
Approach • History • Examination • Investigation • Management
History • Age • Sex • Onset • Painful or painless? ( analysis…) • Acute or chronic • History of trauma • Association : Night pain, arthralgia, swelling, morning stiffness, backache
History • Systemic review • Recent illness : URTI • Weight loss, anorexia • Fever, chills • Unexplained rash or bruising • Voiding problem
History • Past history • Medical : chronic illness • Drugs : steroids, antibiotic • Allergies • Developmental • Nutritional • Vaccination ( site, MMR vaccine) • Family history • Hemoglobinopathy, CTD, IBD, NMD • Social history
Examination • General inspection + Gait • Vital signs & anthropometric measurements • Musculoskeletal examination +Back exam • Neurological examination • Evaluate leg lengths- anterior iliac spine to medial mallelous
Investigations • CBC • ESR, CRP • Blood culture • Sickle test • Coagulation test • Peripheral smear • Immunological : RF, ANA, etc
Investigations • Imaging studies • Plain x ray • U/S • CT • MRI • Radionuclide studies • Bone scan
Investigations • Synovial fluid aspiration
Thank you! Done by Al Motasim Rammal Amin Zagzoog Bandar Al Hubaishi Ayman Bukhary Mazen Badawi Mohammed Yosef