GAIT
- The pattern of how a person walks
- A dynamic & repetitive performance
- Occurs with a definite rhythmic sequence of events that takes during a gait cycle
- Normal walking is relatively effortless, performed with minimum expenditure of energy
GAIT CYCLE
- The walking sequence requires that the non weight bearing leg moves forward while weight is shifted smoothly from one leg to another
- The period of time from one heel-ground contact to the next heel-ground contact of the same foot is one gait cycle
- 2 phases
- Stance phase
- Swing phase
STANCE PHASE
- Normal gait begins with the stance phase
- The foot is in contact with the floor & the lower limb is bearing all or part of body weight.
- Begins when the heel strikes the floor & when the toes rise off the floor
- Occupies 60% of the duration of the cycle
SWING PHASE
- The foot is not touching the floor & body weight is borne by the opposite limb
- Begins immediately the toe leaves the ground until the heel contacts ground
- Occupies 40% of the gait cycle
LIMP
- Any deviation from a normal gait pattern for the child’s age
- Any asymmetric deviation from a normal gait pattern
- It is a common complaint in childhood, accounting for 4 per 1000 visits in one pediatric emergency department (literature review -August 2007- Mark C Clark)
POINTS TO CONSIDER
- Children complain of pain frequently, but limping is almost always in the context of true organicity
- The cause of a limp can range from a life-threatening bone tumor to a pebble in a shoe
- Plain radiographic assessment should be the initial study as 20% of children have unsuspected fractures
ORIGIN OF A LIMP
- CNS
- Spine
- Hip
- Knee
- Ankle
- Foot
- Mechanical defects affecting the pelvis, hips, or legs
- Pain in pelvis, any of the bones, joints, muscles, or other structures of the lower limbs
- Disorders of the pyramidal or peripheral nervous systems or muscle
- Disorders of the vestibular structures e.g. vertigo
- Psychological disturbances
- Miscellaneous
- Foot conditions-plantar warts, pressure ulcers
- Toxic reactions – alcohol, drug,
- Neoplasms
CAUSES OF LIMP
- Trauma
- Fracture
- Stress fracture
- Toddler’s fracture (minimally displaced spiral fracture of the tibia)
- Soft tissue
- Contusion
- Ankle sprain
- Child abuse
- Tumor
- Spinal cord tumors
- Tumors of bone
Benign: osteoid osteoma, osteoblastoma
Malignant: osteosarcoma, Ewing’s sarcoma - Lymphoma
- Leukemia
- Inflammatory
- Juvenile rheumatoid arthritis
- Transient synovitis
- Systemic lupus erythematosus
- Congenital
- Developmental dysplasia of the hip
- Sickle cell
- Congenitally short femur
- Clubfoot
- Developmental
- Legg-Calvé-Perthes disease
- Slipped capital femoral epiphysis
- Tarsal coalitions
- Osteochondritis dissecans (knee, talus)
- Neurologic
- Cerebral palsy
- Hemiparesis
- Hereditary sensory motor neuropathies
HISTORY TAKING
- Age of Onset
- Developmental dysplasia of the hip and congenital limb length discrepancy – children younger than 3 years
- Toxic synovitis and Legg-Calvé- Perthes disease – 4 to 10 years of age
- Adolescence – slipped capital femoral epiphysis
CAUSES OF LIMP IN CHILDREN AT DIFFERENT AGES
- Birth to 3 years
- Septic arthritis
- Osteomyelitis
- Fractures
- Developmental dysplasia of the hip
- Congenital limb length discrepancy
- Ages 4 to 10 years
- Septic arthritis
- Osteomyelitis
- Transient synovitis
- Fractures
- Legg-Calvé-Perthes disease
- Juvenile rheumatoid arthritis
- Leukemia
- Ages 11 to 18 years
- Slipped capital femoral epiphysis
- Avascular necrosis of femoral head
- Overuse syndromes
- Tarsal coalitions
- Gonococcal septic arthritis
- Sex
- Developmental dysplasia of the hip -common in girls
- Legg-Calvé- Perthes disease and slipped capital femoral epiphysis – common in boys
- Onset of the Limp
- An acute onset – trauma or infection.
- A gradual onset with progression of the limp – neuromuscular disorder, Legg-Calvé-Perthes disease, slipped capital femoral epiphysis, rheumatic disease, or malignancy.
- A chronic limp – mechanical or psychogenic in nature.
- Recent Trauma or Strenuous Exercise
- May be difficult to obtain in very young children
- Obvious trauma in the absence of a consistent history raises the question of child abuse
- Limping after strenuous activity suggests a musculoskeletal etiology
- Associated Symptoms- PAIN
- Exact location and character; severity;localized – fractures, dislocations, osteomyelitis, and septic arthritis
- Referred pain -hip pathology may present as knee pain and pain from the lower back can be referred to the lateral thigh
- A painful limp without localization or with migratory bone pain – sickle cell disease or leukemia
- Limping with bilateral leg pain localized to the calf muscles – myositis
- Associated Symptoms
- Severe pain out of proportion to the history of injury – reflex sympathetic dystrophy
- Painless limp- limb length discrepancy, developmental dysplasia of the hip, or a neuromuscular disease.
- Muscle pain – more aching in nature
- Nerve pain – burning or tingling in nature
- Increasing pain with joint motion – joint problem
-
- Fever – infection or inflammation
- Recurrent fever, rash and joint pain- juvenile rheumatoid arthritis
- Low grade fever, weight loss, and malaise- with occult malignancy
- Unexplained bruising in the lower extremities, joint pain, and abdominal pain – Henoch-Schönlein purpura
- A deterioration of gait or loss of acquired motor skills is suggestive of a neuromuscular disease
- Precipitating or Relieving Factors
- Worse in the morning & morning stiffness -juvenile rheumatoid arthritis
- Worsens with activity – soft tissue strain, stress fracture, overuse injury
- Relieved by aspirin- osteoid osteoma
- Pain that worsens throughout the day is typical of muscle fatigue
- Past History
- juvenile rheumatoid arthritis,leukemia,TB
- Family History
- hemophilia ,sickle cell disease
- Birth history
- Prematurity & birth complications-hypoxic brain damage- cerebral palsy
- Neurological impairment present since birth or early infancy-non progressive cerebral palsy
Type of Gait
- Dragging of foot- Hemiplegia, foot drop
- Dragging of both feet & scissor like gait-Cerebral diplegia
EXAMINATION
- Observation of gait
- Without shoes or socks
- Walk along a straight line
- Walking on the balls of the feet, flat footed, or the heels & relative stability of pelvis
- Associated movements of arms & hand-fingers & hands may flex associated with infolding of the thumbs—corticospinal tract dysfuction
- General examination
- weight
- Height
- vital signs
- Poor growth -chronic disorder, neuromuscular disorder or rheumatic disease
- Fever – infection or inflammation
- Examination of shoes- for unusual wear, asymmetry, and point of initial foot strike
- Examination of foot for foreign bodies and calluses
- Ecchymosis and puncture –trauma
- Pallor, fever, an appearance of being ill, generalized lymphadenopathy, and hepatosplenomegaly -malignancy, chronic infection, or rheumatic disease
- A photosensitive rash – systemic lupus erythematosus or juvenile dermatomyositis
- Musculoskeletal Examination
- Gait pattern
- Skin- color, warmth, tenderness
- Joint-Soft tissue/joint swelling, joint laxity, muscle strength, range of motion and symmetry: Hyperextensibile -benign hypermobility syndrome, Stiff- chronic joint inflammation
- Measurement of limb lengths – from the patient’s anterior superior iliac spine to the medial malleolus
- Point tenderness over a bone may indicate a fracture or osteomyelitis
- Muscle atrophy suggests a neuromuscular disorder
- A stiff, tender spine suggests diskitis
- A positive FABER test-signifies sacroiliac joint pathology
NEUROLOGICAL EXAMINATION
- Sensation
- Deep tendon reflexes
- Tone
- Hyperreflexia and spasticity – cerebral palsy
- Tightness of the hamstring muscles with a limited straight-leg raise – spinal problem
INVESTIGATIONS
- TLC,DLC ,ESR, Platelet (Platelet count may be low, or the white cell count elevated in the child with leukemia)
- CRP (elevated earlier than the ESR and is considered more sensitive for an infectious process; a baseline ESR and CRP helps monitor clinical improvement during antibiotic treatment)
- Peripheral blood film
- Blood cultures
- RA factor, ANA, HLA typing
- When examined together, the combination of an ESR greater than 20 and a temperature above 37.5°C (99.5°F) identified septic arthritis of the hip in 97 percent of patients presenting with a limp (Del Beccaro MA, Champoux AN, Bockers T, Mendelman PM. Septic arthritis versus transient synovitis of the hip: the value of screening laboratory tests. Ann Emerg Med 1992;21:1418-22)
- Septic Arthritis- joint aspirate
- White cell count
- Gram stain
- Anaerobic and aerobic cultures
- Protein and glucose analyses
- Significant overlap of synovial white cell counts in infection and inflammatory conditions, a white blood cell count above 50,000 per mm3 (50 3 109 per L) should be presumed to be an infection.
- A septic joint partially treated with antibiotics may have a lower-than-expected white cell count
- A negative culture does not rule out a septic joint, in about 33 percent of cases, the joint aspirate does not recover an organism (Herndon WA, Knauer S, Sullivan JA, Gross RH. Management of septic arthritis in children. J Pediatr Orthop 1986;6:576-8)
- If the joint in question is the knee in a sexually active patient, the fluid should be cultured for gonorrhea (Renshaw TS. The child who has a limp. Pediatr Rev 1995;16:458-65)
RADIOGRAPHIC ANALYSIS
- Plain films of the affected area
- In the nonverbal patient, presenting with a limp- a screening of antero-posterior film from hips to feet identifies a fracture in one fifth of patients (Oudjhane K, Newman B, Oh KS, Young LW, Girdany BR. Occult fractures in preschool children. J Trauma 1998;28:858-60)
IMAGING
- Plain X-rays
- At least 2 views
- Oblique, AP, Lateral views for minimally displaced tibial (Toddler’s) fracture
- AP & frog lateral view of the pelvis for hip patholgy
- USG
- Joint effusion or abscess
- developmental dysplasia of the hip
- more sensitive than plain films- identify an effusion in two thirds of a series of 500 children with normal plain films (Miralles M, Gonzalez G, Pulpeiro JR, Millan JM, Gordillo I, Serrano C, et al. Sonography of the painful hip in children: 500 consecutive cases. AJR Am J Roentgenol 1989;152:579-82)
- Radioisotope uptake scan
- When the cause of a child’s limp cannot be localized by history or physical examination, a bone scan is an excellent way to help localize pathology (Aronson J, Garvin K, Seibert J, Glasier C, Tursky EA. Efficiency of bone scan for occult limping toddlers. J Pediatr Orthop 1992;12:38-44)
- Perthe’s disease, septic arthritis & osteomyelitis, chronic recurrent multifocal osteomyelitis, stress fracture & osteoid osteoma
- CT
- Bone – to demonstrate tarsal coalition, spondylolisthesis/ spondylolisis & osteoid osteoma
- MRI
- If soft tissue malignancy or infection is suspected
- Spinal cord
- Early diagnosis of Perthe’s disease
- CT best delineates bone structure, whereas MRI best highlights areas of pathology in the soft tissues, as well as inflammation of bone If soft tissue malignancy or infection is suspected
- Spinal cord
- Early diagnosis of Perthe’s disease
- CT best delineates bone structure, whereas MRI best highlights areas of pathology in the soft tissues, as well as inflammation
MANAGEMENT
- Depends on the specific cause
- Besides medical & surgical management, acute & long term rehabilitation are also important.