approach to child with a limp
TRANSCRIPT
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LIMPING GAITbyDr. Rabyah khan
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Case scenario• 5 year old boy brought to ER with walking difficulty and
difficulty in bearing weight on right leg.. O/E he is febrile, unwell looking, swelling of right knee with restricted movements.
• Lab: TLC 26000 . Neu 78%• CRP 89• ESR 112• How to evaluate and treat the child?
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Case 2• 8 years old boy presented with sudden onset of pain in left
leg and walking difficulty. • Examination unremarkable
• TLC 58000• Lymphocytes predominently• Periphral film : blast cells
• Wht you suspect and how to evaluate
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Definition• Limp is defined by a deviation from the normal gait pattern
expected for a child's age
• Incidence :180 cases per 100,000• males > females• Median age 4.4 years• Right> left
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The Normal Gait Cycle
• Begins to walk at 12 to 14 months• Mature adult gait pattern : 3 years• Infant gait: Wide based externally rotated gait • Mature adult gait :
60% of the time in the stance phase (from heel strike to toe off)
40% of the time in the swing phase (from toe off to the next heel strike).
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Causes of limp• Pain (Antalgic gait):
( traumatic, infectious, inflammatory, or neoplastic)
• Structural Abnormalities: (limb length discrepancies, angular limb deformities)
• Neuromuscular problems(ataxia, muscle injury)
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Etiology• Toddler: 1-3 Years Old• □ Toddlers’ Fracture• □ Transient Synovitis• □ Septic Arthritis• □ Developmental Dysplasia of the Hip• □ Leg-length discrepancy
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Etiology• Child: 4-10 Years Old• □ Viral Transient Synovitis• □ Juvenile idiopathic arthritis• □ Legg-Calve-Perthes disease
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Etiology• Adolescent: 11-16 Years Old• □ Slipped capital femoral epiphysis• □ Avascular necrosis of femoral head• □ Chondromalacia• □ Neoplasm• □ Gonococcal septic arthritis
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Key to evaluation
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Questions to ask• Onset, Duration and Progression • History of Trauma• Constitutional symptoms • Diurnal variation of pain• Family history • Nutritional history• Daily activity level
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Examination• Inspection• proper exposure • Look for muscle bulk• Swelling & erythema• Deformities• Asymmetries of the trunk, hips, and lower extremities• Gait • Measure Leg Lengths• Assess the spine
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• Antalgic Gait: less time spent in stance phase of the affected limb
• Trendelenburg Gait: the pelvis tilts away from the pathologic hip during stance on the ipsilateral side
• Steppage Gait: foot drop due to injury to the peroneal nerve or weakness of the tibialis anterior muscle
.• Toe-walking gait: leg length discrepancy,short Achilles
tendons, behavioral phenomenon.
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Approach to antalgic gait• Painful limp• Trauma1. Abnormal radiographs
(fracture, slipped capital femoral epiphysis)2. Normal radiographs
contusion, sprain, muscle injury
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Antalgic gait• Painful limp, no trauma, fever ,ill child
• Raised inflammatory markers, radiological findings (osteomyelitis, septic arthritis, rheumatic disease)
• Normal results (transient synovitis)
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Antalgic gait• Painful limp, no trauma, no fever
1. Transient synovitis2. Avascular necrosis3. Slipped capital femoral epiphysis4. Discitis5. Non accidental trauma6. Over use injuries
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Painless limp• Early detection , normal neurological examination (DDH,
leg length inequality , talipes equinus• • Early detection , Abnormal neurological (cerebral palsy, neuromuscular diseases, spinal dysraphism)
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Laboratory studies
• Complete blood count (CBC)• Differential white blood cell (WBC) count• Erythrocyte sedimentation rate (ESR)• C-reactive protein (CRP)
infectious, inflammatory, or neoplastic etiology
• Blood cultures high for septic arthritis or osteomyelitis
• Synovial fluid examination
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Laboratory studies• calcium• sickle cell tests• Lyme disease titers• lupus antibodies• Anti–double stranded DNA• Rheumatoid factor• Creatine kinase
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Imaging modalities• X-rays• Ultrasound• MRI• Bone scan
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imaging• Begin with standard radiographs • Children too young to localize pain or give a reliable
history, the entire lower legs should be imaged• Initial radiographs may be normal in children with stress
fractures, toddler’s fracture, Legg disease, osteomyelitis, or septic arthritis.
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imaging
• Frog-leg lateral radiograph of a patient with slipped capital femoral epiphysis. Note the slip in the patient’s right hip (arrow) compared with the normal left hip.
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Ultrasound• Sensitive for detecting effusion in the hip joint• Ultrasound-guided aspiration • Hip dislocation in neonatal period
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Magnetic resonance imaging • Excellent visualization of joints, soft tissues, cartilage, and
medullary bone
Sensitivity and specificityOsteomyelitis, malignancies, identifying stress fractures,
slipped capital femoral
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Nuclear imaging• Tech.99 bone scan• Septic arthritis.• Neoplasms
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Prehospital Care
• Splinting and transportation make up the majority of services that prehospital personnel render to a limping patient.
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Emergency care • Relief of acute pain• Identification of the cause• Referral to the appropriate health care professional • Reduction of dislocations and displaced fractures• Suspected osteomyelitis, diskitis, or septic joint,
intravenous antibiotics • Immobilization
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consultation • Orthopedic surgeon• Infectious diseases specialist• Neurologist or rheumatologist• Neurosurgeon• Child protective services
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Further Outpatient Care
• All children with a limp should have close follow-up visits with their pediatrician or primary care physician within 24 hours of their visit. Any persistence of a limp without cause should be investigated further.
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Complications
• Left untreated, a slipped capital femoral epiphysis can result in permanent gait abnormalities
• Necrosis of femoral head• Early treatment of several disorders that may cause
limping can result in resolution or at least limit the extent of the injury
• Prognosis depends on underlying cause
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Thank u