APPROACH TO CHILD WITH LOWER LIMB WEAKNESS.pptx

1. APPROACH TO CHILD WITH
LOWER LIMB WEAKNESS
PRESENTED BY: DR. ANUM GUL

2. Contents
 Introduction
 Classification
 Difference of UMN & LMN Lesion
 Where is Lesion ?
 History
 Examination
 Investigation
 Management

3. Introduction
 Paraparesis
 Weakness or partial paralysis
 Paraplegia
 Complete paralysis
 Paraplegia is impairment in motor function of lower
extremities with or without involvement of sensory system.

4. Classification
Spastic
It occurs in upper motor neuron
disease.
Flaccid
It occurs in lower motor neuron
disease.
Based on the nervous system involved and tone paraplegia can be of two types

5. Lateral Corticospinal Tract

6. Comparison of UMN and LMN Lesions
UPPER MOTOR NEURON
• There is no wasting
• Tone is increased
• Tendon jerks are brisk
• Plantar is up going
• Fasciculation absent
LOWER MOTOR NEURON
• There is marked wasting
• Tone is decreased
• Tendon jerks are diminished
• Plantar is down going
• May be present

7. Site of
Lesion
Cerebrum
Muscles
PeripheralNerves Spinal
Brain Stem
Neuromuscular
Junction

8. Cerebral
1. Traumatic
 Depressed fracture of the vault of skull
 Subdural hematoma
2. Vascular
 Superior sagittal sinus thrombosis
3. Inflammatory
 Meningo encephalitis
4. Neoplastic
 Parasagittal meningioma
5. Degenerative
 Cerebral palsy

9. Brain Stem
 Syringo bulbia and midline tumours
 These lesions arise in the midline
 Involves the inner most fibers
 Which supplies lower limbs

10. SPINAL
 Tumours ( meningioma glioma astrocytoma)
 Poliomyelitis
 Syringomyelia
 Vertebral
 Fracture or dislocation of vertebra or disc
 Infective-pott’s disease
 Congenital-spina bifida
 Neoplastic-primary/metastatic
 Paravertebral
 Abscess/hematoma/aortic aneurysm
 Transverse myelitis
 Multiple sclerosis

11. Peripheral nerves
 Guillian barre syndrome
 Nerve toxins
 Acute intermittent porphyria

12. Neuromuscular Junction
 Botulism
 Myasthenia gravis
 Organo phosphorus poisoning
 Neurotoxic snake venom
 Tick paralysis

13. Muscles
 Mascular dystrophy
 Rhabdomyolysis
 Congenital myopathy
 Electrolyte disturbances

14. History
Onset
Sudden
Trauma
Infection
Vascular
Tranverse myelitis
Gradual
Neoplastic

15. History
 Duration of symptom
 Short duration - Traumatic/infective causes
 Long duration
 Neoplastic/hereditary/ congenital/demyelinating causes
 Sensory
 Ask about pattern of sensory loss
 Radicular (root) pain indicates an extradural lesion

16. History
 Motor
 Limb involvement – Symmetrical/Asymmetrical
 Weakness - Proximal /distal muscles
 Weakness - Progressive/Static
 Associated symptoms
 Fever/Seizures/Delayed milestones
 Specific systemic symptoms e.g. vitamin deficiency
 Any preceding illness/Specific trauma/Prior vaccination / Involuntary
movements

17. Physical Examination
Inspection
 General inspection
 Position of extremities
 Pronation drift
 Gait
 Muscle bulk, fasciculation, contractures

18. Physical Examination
 Tone
 Increased in upper motor neuron disease
 Decreased in lower motor neuron disease
 DTR
 Exaggerated in UMN diseases
 Absent in LMN diseases and spinal shock
 SPINE
 Check for spinal tenderness
 Rectal
 Check for rectal tone. It is affected in spinal cord lesions

19. Physical Examination
 Sensory Examinations
 To access sensory level
 To find the extent of
sensory loss

20. Investigations
 Routine blood tests (CBC, PS, CRP & C/S)
 Blood chemistry (blood urea, creatinine, electrolytes etc.)
 Routine urine exam, urine for culture and sensitivity
 Plain X-ray Spine (Lateral and oblique view)
 CSF Analysis
 To R/O infection-bacterial/tubercular/viral meningitis
 CSF culture and sensitivity testing
 C.S.F.-Electrophoresis to show oligoclonal bands of multiple sclerosis
 CT Cranium/Brain

21. Investigations
 MRI brain is more informative than CT
 It helps in diagnosing
 Degenerative/neoplastic/vascular/infective lesions
 Spinal MRI
 Sagittal views - differentiates
 Syringomyelia from intramedullary tumours/transverse myelitis
 It also shows cord compression whether internal or external
 Myelogram

22. Management of Paraplegia
1. General
 Frequent change of posture to guard against bedsores
 Care of skin
 Frequent washing with alcohol and
 Applying talc powder
 Care of the bladder
 If there is retention,
 Use parasympathomimetic drugs
 If this fails, use a catheter to evacuate the bladder

23. Management of Paraplegia
 In case of urinary incontinence
 Frequent change of bed-sheets
2. Physiotherapy
3. Symptomatic Treatment
 Analgesics and sedatives for pain
 Muscle relaxants for the spasticity
 Vitamins and mineral supplementation

24. Management of Paraplegia
4. Specific Treatment (treatment of the cause)
 ATT + supportive measures in Pott's disease
 Drainage of paraspinal abscess
 Traumatic spine stabilisation
 Surgical management of some tumors
5. Rehabilitation
 Management of complications
 Occupational therapy
 Gait retaining
 Community re- integration