Acute Limping Child

Definition Any asymmetric deviation from the normal gait pattern as expected. It maybe be caused by pain,

weakness, neuromuscular imbalance or a skeletal deformity

Normal Gait Can be divided into swing phase and stance phase. Swing phase forms 40% of the gait cycle and stance phase foms 60% of the gait cycle. The most common form of limp is antalgic gait.Abnormal gait Antalgic Gait Steppage Gait Trendelburg Gait Circumduction Gait Tip-toe gait Charlie Chaplin like Gait

Antalgic (Painful) Gait

The patient attempts to avoid putting weight on one leg due to pain.Causes Trauma to hip, knee, ankle, leg, or foot Diabetic foot or peripheral neuropathy Arthritis or gout Joint or limb deformity Stress fracture Bone infection Tumor Blisters Painful calluses Ingrown toenail Foreign body

Steppage Gait

Characterized by foot drop due to loss of dorsiflexion. The foot hangs with the toes pointing down, causing the toes to scrape the ground while walking, requiring someone to lift the leg higher than normal when walkingCauses

Guillain-Barre syndrome Herniated lumbar disk Multiple sclerosis Peroneal muscle atrophy Peroneal nerve trauma

Trendelburg Gait (gluteus medius lurch)

Associated with a weakness of the gluteus medius. It is characterized by the dropping of the pelvis on the unaffected side of the body at

the moment of heelstrike on the affected side. In this deviation the pelvic drop during the walking cycle lasts until heel strike on the unaffected side and is accompanied by an apparent lateral protrusion of the affected hip.

The person with a Trendelenburg gait also shortens the step on the unaffected side and displays a lateral deviation of the entire trunk and the affected side during the stance phase of the affected lower limb.

Circumduction Gait

The patient stands with unilateral weakness on the affected side, arm flexed, adducted and internally rotated. Leg on same side is in extension with plantar flexion of the foot and toes. When walking, the patient will hold his or her arm to one side and drags his or her affected leg in a semicircle (circumduction) due to weakness of distal muscles (foot drop) and extensor hypertonia in lower limb.

This is most commonly seen in stroke. With mild hemiparesis, loss of normal arm swing and slight circumduction may be

the only abnormalities. Tip-toe gait

Toe walking is sometimes the result of cerebral palsy, muscular dystrophy or another generalized disease of nerve and muscle.

Children with autism also may walk on their toes or the balls of their feet, but many do not.

Charlie Chaplin like Gait

A gait seen in bilateral external torsion of tibia, caused by faulty sitting or sleeping, as in prolonged maintenance of ‘spread-eagle’ or frogleg position

Causes of Limping Child Congenital (DDH, Club foot ) Developmental (legg-Calve’s Perthes dis., SCFE) Infection (septic arthritis) Inflammation (transient synovitis, Juvenile rheumatoid arthritis) Neoplasia (leukemia, osteosarcma, Ewing’s sarcoma) Trauma (fractures, muscle bruising, contusion) Neuromuscular (cerebral palsy)

Classification of Limping Child According to Age1-3 years old : Septic hip Soft tissue injury Occult fracture DDH (most common) LLD – ask 5 questions

- True or false LLD- If false what is the cause? (pelvic tilt, equinos in foot, hip dislocation)- If true what is the cause ? (femoral/tibial)- If femoral, is it supratrochanteric or infratrochanteric)- If supratrochanteric, is the hip dicocated?

3 to 10 years : Legg – Calve’s Perthes disease

- Degenerative disease of the head of femur which results in bone loss and deformity. It is an idiopathic avascular necrosis of the femoral head

Transient Synovitis Septic Arthritis

10 to 14 years Slipped Capital Femoral Epiphysis (SCFE)

- A condition where the growth plate of the head of the femur slips over the underlying bone)

Diagnostic ApproachMade based on: History ( any history of abuse, in younger patient ask the care taker, onset, course, duration) Physical exam findings (gait,cavus deformities, deep tendon reflexes, ROM of knee and hip, Faber

test, Galeazzi test) Investigations

InvestigationsPhysical TestTrendelenburg test Used to identify conditions that cause weakness in the hip abductors. The child stands on the affected limb and lifts the unaffected limb from the floor. In a positive test, the pelvis fails to stay level and drops down toward the unaffected side.The Galeazzi sign Can signal conditions that cause a leg-length discrepancy. The child should lie in the supine position with the hips and knees flexed. The test is positive if the knee on the affected side is lower than that on the normal side

The Patrick test (the FABER test) can indicate pathology of the sacroiliac joint. With the child in the supine position, the examiner flexes, abducts, and

externally rotates the hip joint. In a positive test, pain occurs in the sacroiliac joint.

The pelvic compression test Indicate the presence of sacroiliac joint pathology. With the child in the

supine position, the examiner compresses the iliac wings toward each other. Pain with this maneuver indicates sacroiliac joint pathology.

The psoas sign Can signal a psoas abscess or appendicitis. With the child lying on his or her side, the hip is

passively extended. Pain with hip extension indicates a positive test.*Special attention should be paid to performing a thorough spinal, pelvic, neurologic, abdominal, and genitourinary examination. Conditions affecting these systems are associated with limping Laboratory test CBC ESR,CRP ( elevated in infectious process) Joint aspiration Plain x-ray (pelvic film, lower limb x-ray)Imaging Xray Ultrasound CT scan MRI Bone scintigraphy

Diagnosis

Treatment Treatment of the underlying cause Physical therapy – to strengthen muscle and to correct gait Devices – Walking aids