LIMPING GAITbyDr. Rabyah khan

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?

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

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

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).

Causes of limp• Pain (Antalgic gait):

( traumatic, infectious, inflammatory, or neoplastic)

• Structural Abnormalities: (limb length discrepancies, angular limb deformities)

• Neuromuscular problems(ataxia, muscle injury)

Etiology• Toddler: 1-3 Years Old• □   Toddlers’ Fracture• □   Transient Synovitis• □   Septic Arthritis• □   Developmental Dysplasia of the Hip• □   Leg-length discrepancy

Etiology• Child: 4-10 Years Old• □   Viral Transient Synovitis• □   Juvenile idiopathic arthritis• □   Legg-Calve-Perthes disease

Etiology• Adolescent: 11-16 Years Old• □   Slipped capital femoral epiphysis• □   Avascular necrosis of femoral head• □   Chondromalacia• □   Neoplasm• □   Gonococcal septic arthritis

Key to evaluation

Questions to ask• Onset, Duration and Progression • History of Trauma• Constitutional symptoms • Diurnal variation of pain• Family history • Nutritional history• Daily activity level

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

• 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.

Approach to antalgic gait• Painful limp• Trauma1. Abnormal radiographs

(fracture, slipped capital femoral epiphysis)2. Normal radiographs

contusion, sprain, muscle injury

Antalgic gait• Painful limp, no trauma, fever ,ill child

• Raised inflammatory markers, radiological findings (osteomyelitis, septic arthritis, rheumatic disease)

• Normal results (transient synovitis)

Antalgic gait• Painful limp, no trauma, no fever

1. Transient synovitis2. Avascular necrosis3. Slipped capital femoral epiphysis4. Discitis5. Non accidental trauma6. Over use injuries

Painless limp• Early detection , normal neurological examination (DDH,

leg length inequality , talipes equinus• • Early detection , Abnormal neurological (cerebral palsy, neuromuscular diseases, spinal dysraphism)

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

Laboratory studies• calcium• sickle cell tests• Lyme disease titers• lupus antibodies• Anti–double stranded DNA• Rheumatoid factor• Creatine kinase

Imaging modalities• X-rays• Ultrasound• MRI• Bone scan

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.

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.

Ultrasound• Sensitive for detecting effusion in the hip joint• Ultrasound-guided aspiration • Hip dislocation in neonatal period

Magnetic resonance imaging • Excellent visualization of joints, soft tissues, cartilage, and

medullary bone

Sensitivity and specificityOsteomyelitis, malignancies, identifying stress fractures,

slipped capital femoral

Nuclear imaging• Tech.99 bone scan• Septic arthritis.• Neoplasms

Prehospital Care

• Splinting and transportation make up the majority of services that prehospital personnel render to a limping patient.

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

consultation • Orthopedic surgeon• Infectious diseases specialist• Neurologist or rheumatologist• Neurosurgeon• Child protective services

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.

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

Thank u