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Approach to limping child


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by dr. hardik pawar

Published in: Education
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Approach to limping child

  1. 1. Approach to limping child BY DR. HARDIK PAWAR CARE HOSPITAL
  2. 2. 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.
  3. 3. Some Abnormal Gaits• An antalgic gait 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.• A Trendelenburg gait 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• A steppage (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.• A vaulting gait 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.• A stooped gait is characterized by walking with bilaterally increased hip flexion A stooped gait is common in children with pelvic or lower abdominal pain.• A scissors gait caused due to cerebral palsy , legs cross while walking• A waddling gait seen in bilateral hip involvement
  4. 4. Differential DiagnosisAge Painful limp Painless limp1-3yr 1- Infection 1- Developmental Septic arthritis / dyplasia of the hip osteomyelitis/ 2- Neuromuscular cellulitis / synovitis disease 2- Trauma -Cerebral palsy 3- 1ry or metastatic -Muscular dystrophy neoplasm 3- lower limb length inequality
  5. 5. Differential Diagnosis Age Painful limp Painless limp4 - 10yr 1-Infection 1-Developmental dyplasia 2- inflammatory JRA, SLE of the hip 3- Trauma 2- NMD 4- 1ry or metastatic tumor 3- Lower limb length 5- hematological disease inequality 4 –hereditary motor Hemophilia, SCA, leokemia sensory neuropathy charcot’s marrie tooth 6-Legg-Calve-Perthes disease Disease , Kohler’s (AVN)
  6. 6. Differential Diagnosis Age Painful limp Painless limp11- 18yr 1-Infection 1- Developmental dyplasia of 2- inflammatory :JRA, SLE the hip 3- Trauma 2- Neuromuscular disease 4-1ry or metastatic tumor Cerebral palsy 5-hematological disease Muscular dystrophy Hemophilia, SCA, leukemia 3- lower limb length inequality 6-Legg-Calve-Perthes Disease 4- chronic slipped upper (AVN of femoral head) femoral epiphysis 7-acute slipped upper femoral epiphysis*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
  7. 7. 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
  8. 8. Approach• History• Examination• Investigation• Management
  9. 9. History• Age• Sex• Onset• Painful or painless? ( analysis…)• Acute or chronic• History of trauma• Association : Night pain, arthralgia, swelling, morning stiffness, backache
  10. 10. History• Systemic review – Recent illness : URTI – Weight loss, anorexia – Fever, chills – Unexplained rash or bruising – Voiding problem
  11. 11. History• Past history – Medical : chronic illness – Drugs : steroids, antibiotic – Allergies – Developmental – Nutritional – Vaccination ( site, MMR vaccine)• Family history – Hemoglobinopathy, CTD, IBD, NMD• Social history
  12. 12. Examination• General inspection + Gait• Vital signs & anthropometric measurements• Musculoskeletal examination +Back exam• Neurological examination• Evaluate leg lengths- anterior iliac spine to medial mallelous
  13. 13. Investigations• CBC• ESR, CRP• Blood culture• Sickle test• Coagulation test• Peripheral smear• Immunological : RF, ANA, etc
  14. 14. Investigations• Imaging studies – Plain x ray – U/S – CT – MRI – Radionuclide studies – Bone scan
  15. 15. Investigations normal traumatic JRA Septic• Synovial Arthritis fluid appearance Clear to yellow Bloody to straw colored Cloudy yellow Purulent aspiration WBC <200 <5,000 5,000- 80,000 50,000- 200,000 Polymorphs <25% <25% 50-75% 75-100% other High RBC Bacterial count culture positive Low glucose High protien
  16. 16. Thank you!