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Evaluating Gait in Children; A Rational Approach

Pediatric Orthopedics & Scoliosis Texas Children’s Hospital Professor, Orthopedics & Pediatrics Baylor College of Medicine

William A. Phillips, MD, FAAP, FACS

Disclosure •  I receive royalties from Up to Date as

section editor for pediatric orthopaedics •  I have no relevant financial relationship

with any commercial product or service discussed in this CME activity.

•  I do not intend to discuss any unapproved or investigative use of a commercial product or device in my presentation.

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Practice Changes I Hope You Make

1.  Never order a single hip film, always order radiographs of the pelvis

2.  Consider SCFE for any adolescent with groin, thigh or knee pain

3.  Consider osteoarticular infection for all children with limp plus fever

•  “She’s not walking right” •  “He just started to walk funny” •  “We just noticed it” •  “Ever since last Thursday when she fell...”

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“My mother-in-law said none of her kids EVER walked like this”

Normal Gait •  Smooth •  Rhythmic

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Abnormal Gait

•  Irregular •  Less efficient •  Slower

Limping Alteration in normal gait cycle

Toddlers won’t have a “normal gait” until age 3 to 4 years

Feet wide apart

Feet externally

rotated

Arms high for balance

Lands on toes, not

heel

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Limping in Children

A common complaint Many possible causes (a partial list?!)

68 etiologies/20 minutes= 18 seconds per topic!

Lecture Goals

After this presentation, participants will be better able to: •  Efficiently assess a limping child •  Rule out catastrophic causes of limping •  Recognize some subtle causes of limping

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Limp

•  What to ask •  What to look for •  What tests to

consider •  What to tell

parents

Assessment of the Limping Child

First priority – rule out catastrophes

Q: “Why get a consultant?”

A: “It’s nice to have co-defendants.”

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Limp – Potential Catastrophes •  Fractures- acute, stress,

pathologic •  Infections- bone, joint, spine

•  Slipped capital femoral epiphysis (SCFE)

•  Tumors •  Developmental dysplasia of hip

(DDH)

What to Ask •  Acuity- how long has she been limping?

•  Illness- has he had a recent fever or infection?

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What to Ask

Does he limp all the time?

Trendelenberg Gait

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What to Ask •  Severity- what can’t he do that he normally

does? •  Stopped sports? •  Missed gym class? •  Missed school?

What to Ask Potential Catastrophes

•  Fractures- pain increases with walking, relieved with rest

•  Infections- recent illness, fever •  Toddlers may refuse to walk at all with

fracture or infection

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What to Ask Potential Catastrophes

SCFE- hip, groin, thigh, knee pain or no pain

SCFE Delayed Diagnosis SCFE is more likely to be missed at the initial visit if hip pain is absent or if thigh pain is present.

(Ledwirth, 1992) Isolated distal thigh or knee pain or both is a common presentation of SCFE

(Matyava, 1999)

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What to Ask Potential Catastrophes

Tumors •  Pain at rest (night pain), may cause

pathologic fracture •  Any systemic complaints- weight loss,

malaise

DDH in Walkers •  No gross motor delay

•  Pathologic changes worsen with walking

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DDH Lightning can strike twice

•  65% left •  10% right •  25% bilateral*

* Often not detected until walking

DDH Gait in Walkers

Unilateral – Trendelenberg gait

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DDH Gait in Walkers

Bilateral - waddling, hyperlordotic “drunken sailor” gait

What to Look for Gait Evaluation

•  Disrobed, barefoot child

•  In shorts or gown above knees

Knee cap straight ahead

Foot externally rotated

Dx: external tibial torsion

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Gait Evaluation •  Long hallway, not in room •  Get rid of “clinic walk” •  Walk child back and forth, tire them out •  Ask parent to point out area of concern

Gait Evaluation •  Walk on tiptoes, heels •  *Hop on each leg* •  Rise from floor

(Gower’s) •  Run

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Types of Limp

•  Antalgic •  Mechanical •  Neuromuscular

Antalgic (Painful) Limp

•  Minimum single limb support time on affected side

•  Shortened, quick stride by opposite side

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Mechanical Limp

•  Altered joint motion •  Limb length inequality •  Angular and torsional

abnormalities

Neuromuscular Limp

•  Decreased balance and coordination

•  Decreased strength •  Inappropriate firing of

muscles

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Physical Examination •  Swelling, tenderness, redness •  Range of motion •  Limb length, limb contour •  Neurologic exam •  Special maneuvers

Potential Catastrophes

•  Fractures- usually swollen and tender to palpation

•  Infections- tender to palpation, +/- limited joint motion

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Potential Catastrophes

•  SCFE- limited, painful hip internal rotation

•  Tumors- tender, firm mass, or neurologic abnormalities

SCFE Loss of internal rotation

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SCFE Loss of internal rotation

SCFE Imaging

•  Never order a hip x-ray

•  Always get a pelvis x-ray to compare

Kline’s line

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Early SCFE (pre-slip)

Note widening of physis

Wednesday- “groin strain”

Friday- acute SCFE, angry parents

SCFE Diagnosis

Can be bilateral “Fallen ice cream” sign on x-ray

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SCFE Management •  Emergent referral •  Crutches or wheel chair

6/24 Four days later…

What Tests to Order

•  Imaging •  Laboratory

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Radiographic Assessment of the Limping Child

•  At least two perpendicular views, may need obliques

•  View entire bone and adjacent joints

Potential Catastrophes Fractures

Usually visible on at least one view

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Childhood Fracture Caveats

Ligaments are stronger than bone, so sprains are uncommon in children under 10 years old

Childhood Fracture Caveats

Acute epiphyseal fractures can have minimum x-ray findings

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Toddlers Fracture

•  Undisplaced hairline crack

•  May be very subtle

•  Distal half tibia

Toddlers Fracture

•  Undisplaced hairline crack

•  May be very subtle

•  Distal half tibia

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Stress Fractures

•  Not always in organized sports

•  Early-normal x-ray •  Hot on bone scan

or MRI

Orthopaedic Infection Imaging

•  Early osteomyelitis, normal bone X-ray

•  Soft tissue edema apparent early

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Orthopaedic Infection Imaging

•  Early osteomyelitis, normal bone X-ray

•  Soft tissue edema apparent early

Orthopaedic Infection Imaging

Ultrasound may show joint effusion or sub-periosteal pus

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Orthopaedic Infection Lab Studies

•  Elevated white blood cell count •  Elevated sedimentation rate,

C-reactive protein •  Blood cultures- positive in 50% of patients

Septic Arthritis Capsular distention causes decreased, painful joint motion

Log roll- gently tests hip motion

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Septic Arthritis of Hip A Surgical Emergency

Intracapsular blood supply easily occluded by increased pressure of joint effusion

Joint capsule

No blood vessels cross physis (growth plate)

Septic Arthritis of Hip

•  If pus obtained – drain surgically ASAP!

•  DO NOT just give antibiotics

•  DO NOT attempt repeat aspirations

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Regional Assessment by Age

Toddlers 1-3 years Children 4-10 years Adolescents 11-16 years

Toddlers (1 to 3 Years)

Sometimes hard to tell normal gait from abnormal

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Toddlers (1 to 3 Years)

•  Anxious parents - First child

Not standard equipment L

Limping in Toddlers

Angular and rotational variants are common Beware unilateral problems

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Antalgic Gait in Toddlers

•  Discitis •  Infection •  Foreign body

in foot or knee

Limping in Toddlers •  Hip- DDH, coxa vara •  Knee- juvenile idiopathic arthritis

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Limping in Toddlers

Foot-toe walking: idiopathic, cerebral palsy, leg length inequality

Children (4 to 10 Years)

•  Walk and run well •  Little secondary gain

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Limping in Children •  Hip- DDH, Perthes disease •  Foot- toe walking, leg length inequality

Adolescents (11 to 16 Years)

•  Complaints minimized or exaggerated •  Septic arthritis – gonorrhea

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Limping in Adolescents •  Hip - SCFE, hip dysplasia •  Knee - patellar tracking disorders

(chondromalacia), osteochondritis dissecans, tumors

•  Foot - tarsal coalition (peroneal spastic flat foot)

Painless Limp

•  Do careful neurologic exam

•  DDH possible in younger children

•  SCFE possible in older children

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Painful Limp •  Work up appropriate extremity •  Generalized - rule out discitis

Will you be able to determine the cause of limping in every child?

Probably not!

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What to Tell Parents

Ruling out catastrophes is often reassuring

What to Tell Parents Possible Outcomes

1.  Things get better- who cares what it was?

2.  Things get worse- makes it easier to figure out what’s wrong

3.  Things stay the same- rarely happens

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Summary Limp-potential Catastrophes

•  Fractures- acute, stress, pathologic •  Infections- bone, joint, spine •  Slipped capital femoral epiphysis (SCFE) •  Tumors •  Developmental dysplasia of hip (DDH)

Limp Assessment •  History •  Physical exam •  Plain radiographs •  Simple lab tests

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Practice Changes I Hope You Make

1.  Never order a single hip film, always order radiographs of the pelvis

2.  Consider SCFE for any adolescent with groin, thigh or knee pain

3.  Consider osteoarticular infection for all children with limp plus fever

Thank you very much

waphilli@texaschildrens.org

Enjoy the rest of your weekend