1. Approach to limping child
Done by
Group A1

2. Case Scenario
A 14 month old boy is brought to the office because the parents noticed a limp this morning when the child got out of bed…

3. 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.

4. 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.

5. Differential Diagnosis
Painless limp
Painful limp
Age
1- Developmental dyplasia of the hip
2- Neuromuscular disease
-Cerebral palsy
-Muscular dystrophy
3- lower limb length inequality
1- Infection
Septic arthritis / osteomyelitis/ cellulitis / synovitis
2- Trauma
3- 1ry or metastatic neoplasm
1-3yr

6. Differential Diagnosis
Painless limp
Painful limp
Age
1-Developmental dyplasia of the hip
2- NMD
3- Lower limb length inequality
1-Infection
2- inflammatory JRA, SLE
3- Trauma
4- 1ry or metastatic tumor
5- hematological disease
Hemophilia, SCA, leokemia
6-Legg-Calve-Perthes Disease , Kohler’s (AVN)
4 - 10yr

7. Differential Diagnosis
Painless limp
Painful limp
Age
1- Developmental dyplasia of the hip
2- Neuromuscular disease
Cerebral palsy
Muscular dystrophy
3- lower limb length inequality
4- chronic slipped upper femoral epiphysis
1-Infection
2- inflammatory :JRA, SLE
3- Trauma
4-1ry or metastatic tumor
5-hematological disease
Hemophilia, SCA, leukemia
6-Legg-Calve-Perthes Disease (AVN of femoral head)
7-acute slipped upper femoral epiphysis*
11- 18yr
*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

8. 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

9. Approach
History
Examination
Investigation
Management

10. History Age Sex Onset Painful or painless? ( analysis…)
Acute or chronic
History of trauma
Association : Night pain, arthralgia, swelling, morning stiffness, backache

11. History Systemic review Recent illness : URTI Weight loss, anorexia
Fever, chills
Unexplained rash or bruising
Voiding problem

12. History Past history Family history Social history
Medical : chronic illness
Drugs : steroids, antibiotic
Allergies
Developmental
Nutritional
Vaccination ( site, MMR vaccine)
Family history
Hemoglobinopathy, CTD, IBD, NMD
Social history

13. Examination General inspection + Gait
Vital signs & anthropometric measurements
Musculoskeletal examination +Back exam
Neurological examination
Evaluate leg lengths- anterior iliac spine to medial mallelous

14. Investigations CBC ESR, CRP Blood culture Sickle test Coagulation test
Peripheral smear
Immunological : RF, ANA, etc

15. Investigations Imaging studies Plain x ray U/S CT MRI
Radionuclide studies
Bone scan

16. Investigations Synovial fluid aspiration Septic Arthritis JRA
traumatic
normal
Purulent
Cloudy yellow
Bloody to straw colored
Clear to yellow
appearance
50, ,000
5, ,000
<5,000
<200
WBC
75-100%
50-75%
<25%
Polymorphs
Bacterial culture positive
Low glucose
High protien
High RBC count
other
Synovial
fluid
aspiration

17. Thank you! Done by Al Motasim Rammal Amin Zagzoog
Bandar Al Hubaishi Ayman Bukhary
Mazen Badawi Mohammed Yosef