abnormal gaits clarified by videos

1. APPROACH TO LIMPING
IN PEDIATRICS
BY
N O R A D E E N H U S S E I N & Z A I D R A S H E E D
University of duhok
College of medicine

2. OUTLINES
• What's liming ?!
• Normal gait
• Approach to limping
• Ddx
Some of the pathologies causing limping

3. GAIT:: MANNER OF MOVEMENT BY
USING LIMBS = LEGS (WALKING )
•Gait Cycle: sequence of each limb action during
walking:
1. period of weight-bearing (stance) = 60%
2. period of non weight-bearing(swing) = 40%

4. GAIT CYCLE
I. Swing phase:
1. Acceleration phase
2. Mid-swing phase
3. Deceleration phase
I. Stance
phase:
1. Heel contact
2. Foot flat
3. Heal off

5. LIMPING
It’s uneven jerky ,or labourious gait due
to the :
•PAIN
•WEAKNESS
•STRUCTURAL OR MECHANICAL
ABNORMALITIES:.

6. HOW THE CHILD WILL PRESENT TO THE
CASUALTY ?!
•Baby refuse to walk
• Crying whenever mother
changing the dipper
• school age children with
hx 2 days hx of limbing

7. NORMAL VARIATION OF GAIT IN
CHILDREN:
• Toe walking is common up
to 3 years .
• In-toeing most common
between 3-8 years (due to
persistent femoral
anteversion ).

8. • Flat feet are common and
usually resolve by age of
6 years.
• Crooked toes most
resolve with weight
bearing .
Adult pattern of gait develops between 3 -5 years of age
.

9. APPROACH TO LIMPING:
History.
Physical Examination.
Investigations .

10. HISTORY:
1. Age.children <3 years (septic arthritis more common in this age
group)
2. Sex( DDH is more common in female)
3. Duration, progression , improves or aggravate with activity.
4. At which time it became worse ?! For example:
●if in the early morning with stiffness 》》》》 JIA.
●nocturnal with pain 》》》》osteoid osteoma or other bone
neoplasm.
5. Painful or painless , and location of pain.
6. History of trauma , new or increasing sport activity.

11. 7. Associated symptoms :
●Fever .
●weight loss.
●Anorexia.
●Voiding problems.
8. Hx. Of recent dysentery 》》》Reiters syndrome.
9. Hx. Of recent viral infections or streptococcal infections 》》》Post
infectious arthritis.
10.Hx. Of URTI. 》》》 may suggest Transient synovitis.

12. 11.Recent intramuscular injection. 》》》can cause muscle
inflammation or sterile abscess.
12. Past medical and surgical Hx.
13. Immunization.
14. Developmental history.
15.Family history of rhumatologic, neuromuscular
disease, connective tissue disorder, DDH.

13. RED FLAGS IN HX.
☆ children <3 years (septic arthritis more common in this age
group) .
☆Inability to bear weight.
☆Fever or systemic illness.
☆ >9 years with hip pain or restricted hip movements (SCFE).

14. ANTALGIC GAIT IS A PAINFUL
GAIT. A PATIENT DOES NOT
WANT TO SPEND TIME ON
THE AFFECTED LEG DUE TO
PAIN
SHORT STANCE PHASE .
•Antalgic gait: stance phase 40%,
swing phase less than 60%.
Ddx. Trauma , infection, neoplasm
Rhumatologic disease,.
Abnormal gait

16. During the stance phase, the
gluteus medius work to maintain
both hips at the same level.
The patient cannot abduct the
affected hip due weakness of the
abductor muscles on the affected
side.
Trendelenbu
rg Gait

18. HIGH STEPPAGE GAIT

19. HEMIPLEGIC GAIT

21. equinus refers to a gait characterized by plantarflexion
of the foot and ankle

23. APPROACH TO LIMPING PATIENT
( DIAGNOSIS )
 On Examination:
• Look:
– Observe the gait & record it for analysis to decide the type of abnormal gait
– Skin color changes
– Skin lesions as abrasion, wound , scar, ….
– Shape
– Alignment
• Feel:
– Skin temperature
– Bone tenderness
– Soft tissue tenderness

24. APPROACH TO LIMPING PATIENT
( DIAGNOSIS )
• Move :
– For any limitation of joints movements
• Assessment of neurological state of the limb:
• Limb length measurement:
– Visual method
– Using tape measure method
• Apparent length
• Real length

28. INVESTIGATIONS:
• CBC , ESR , CRP .
• Blood culture (septic arthritis, OM)
• Peripheral blood smear ( leukaemia)
• Mantox test and PCR (TB)
• Coagulation profiles (Hemarthrosis)
• Immunological (RF , ANA , JIA , SLE).
• Renal function test & Endocrine screening (SCFE).
• Synovial fluid analysis.
• Imaging ( Xray , U/S , CT , MRI , Nucleotide scan )

31. TODDLERS FRACTURE
• This is oblique fracture of the distal tibia
without a fibula fracture , there is often
no significant trauma . Patients are
usually 1 to 3 years old , but can be as
old as 6 and present with limping and
pain
DX :
• History
• Examination
• Imaging studies
Treatment
• Splint/cast

32. SLIPPED CAPITAL
FEMORAL EPIPHYSIS
• Is an adolescent hip disorder where the femoral
neck and shaft displace relative to the epiphysis
,Present with pain in the groin , the part of the thigh
, knee , limping , and the leg be short and externally
rotated.
• Risk factors : obesity , age 10-16 , endocrine
disorders
• Dx : history , examination , X-ray
• Treatment : screw
• Complications : chondrolysis , avascular necrosis

37. OSTEOMYELITIS
• Acute osteomyelitis is an infection in the
bone, is more common in the long bones
of the arms and legs, can happen in
children of any age.
• Osteomyelitis happens when a bacterial
infection from another part of the body
spreads to the bone. In children, an
infection in the blood is a common cause
of osteomyelitis.
• DX:Blood culture &test , Imaging test,
bone biopsy
• Tx: IV AB

40. DDH
• Developmental dysplasia of the hip .
• Abnormal formation or developmental malalignment of the hip.
• Compromise a spectrum of disorders including acetabular dysplasia without
displacement , subluxation ,and dislocation .
• More common in the left side , more common in females .
Etiology :
• Genetic .
• Hormonal .
• Intrauterine .
• Postnatal.