Paeds > Gait Abnormality > Flashcards

Gait Abnormality Flashcards

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1
Q

Types of Gait Disturbance

A
  1. Hemiplegia
    • The leg is rigid and describes a semi-circle when walks with toe scraping the floor (as foot is planter flexed). The arm is adducted and internal rotated and the forearm is pronated and flexed at elbow. Swinging is decreased when walking = circumduction gait.
  2. Paraplegia
    • ‘Scissors gait’
    • Patient walks with narrow base, dragging his feet along as if they are glued to the floor = tip-toeing
  3. Cerebellar
    • Walks with wide based gait, arm held wide and ataxia staggering towards the side of lesion
  4. Sensory
    • ‘Stepping and stamping gait’
    • Ataxia walks on wide base, looking at the ground and foot raised high above ground and stamps on it.
  5. Steppage
    • Due to absent dorsiflexion of foot
    • Affected legs raised high above ground to avoid scraping the toe.
  6. Walddling
    • As one walks, body swings from side to side and pelvis drops on each side in turn as leg leaves off the ground.
  7. Shuffling
    • One walks with small stride, foot appears sticking to the ground
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2
Q

Steps in examination of child’s gait

A
  1. Ask child to walk with bare foot (if possible)
  2. Look at UL first
    • Stretch out UL –> Ataxic gait and unsteady
    • Decreased movement at one side –> Hemiplegic gait
    • Normal –> Look at Lower Limb
3. Look at LL next
•  Ataxic gait - wide based
•  Hemiplegic - Circumduction
•  If UL normal: 
•  •  ?Waddling - pelvis swinging
•  •  ?Limping - tip toeing
•  •  ?Scissoring - narrow base and tip toeing
•  •  ?Absent plantar flexion in Spina Bifida
  1. If suspect proximal myopathy, ask child to squat down and gets up
  2. If suspect Hemiplegic gait, ask child to do Fog’s test and run
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3
Q

Diplegia

A 
Upper limbs are affected less severely than lower limbs
Causes:
1. Prematurity (Periventricular Leukomalacia 
2. Genetic causes
3. Birth injury
4. Acquired: 
•  Venous sinus thrombosis
•  Hydrocephalus
•  Meningitis, IVH
5. Sjogren Lasson Syndrome
6. Spina bifida / Other spinal cord lesion
7. Congenital infection
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4
Q

DDx of Diplegia

A
  • Diplegia only - Above

* Diplegia + Ataxia - Hydrocephalus

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5
Q

Approach to Diplegic gait

A
  1. LL exam –> +ve UMN Signs then:
    • Look for: Deformity at joints, muscle wasting, scars and length discrepancy
    • Feel for: Tight TA tendon, tight Adductors, Brisk jerks, Clonus and upgoing plantar reflex
    • Shoe - tip wearing
  2. UL exam —> Normal/ less affected
  3. Spine —> ?Abnormal: Note if with Icthyrosis (Sjogren Lasson Syndrome)
  4. Head —> Size, Shape and RLF of eye
  5. Examine for cranial nerves —> test primitive reflexes and developmental achievement
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6
Q

Waddling gait causes

A
  1. Due to hip problems
    • Bilateral hip dislocation
    • Achondroplasia
  2. Proximal myopathy
    a. Neurological
    • Myasthenia Gravis
    • Myopathy
    • Muscular dystrophy
    • SMA

b. Metabolic
• Cushing’s syndrome
• Thyrotoxicosis

c. Connective tissue disease
• Dermatomyositis
• Polymyositis

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7
Q

Approach to Waddling gait

A
  1. Waddling gait
    • Note increased lumber lordosis
    • Ask child to do Gower’s sign / Squatting
    • Note if child is short, with short limbs
2. Face:
•  Features of Achondroplasia
•  Cushingnoid / Thyrotoxic
•  Heliotropic / Butterfly rash
•  Myopathic face
•  Face of MG - test fatiguability
•  Tongue fasciculation
3. LL
A) Look
•  Note muscle bulk - Enlarged --> DMD
•  Fasiculation present--> SMA
B) Examine
•  Discrepancy in LL length --> Congenital dysplasia of hip
•  Muscle tenderness --> Myositis
•  Tendon reflex
•  Scar for muscle Bx
  1. Examine UL for proximal weakness eg. Raise UL above head / Winging scapula - facio-scapulo- humeral dystrophy (AD) - Beevor sign - upward movement of umbilicus towards the head when flexing the neck (due to weak abdo muscle)
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8
Q

Ataxic Gait causes

A

A) Acute Onset
1. Head injury - Posterior fossa subdural haematoma

  1. CNS infection
    • Viral - Chickenpox, IM, Poliomyelitis, Coxsackie abscess
  2. Tumor - Astrocytoma with bleeding or oedema
  3. Drugs - Phenytoin, Alcohol, Lead, Glue-sniffing
  4. Metabolic - Hartnup’s disease, Maple syrup urine disease, Hypoglycaemia
  5. Occult Malignancy
    • Neuroblastoma = Nystagmus + bending movement of trunk
B) Chronic non-progressive
1. Perinatal brain damage
•  Asphyxia, birth injury
•  Hyperbilirubinaemia
•  Congenital hypothyroidism
2. Malformation of brain
•  Hypoplasia of cerebellum
•  Cerebellar haemangioblastoma e.g. Von Hippel Lindau Syndrome
•  Occipital encephalococele
•  Werdnig Hoffman disease
•  Dandy Walker syndrome
•  Fetal Alcohol Syndrome
  1. Hydrocephalus
    • Typically have ataxic diplegia
C) Chronic Progressive
1. Tumor
 2. Drug toxicity
3. 'FARM' 
•  Friedreich's Ataxia
•  Abetalipoproteinaemia
•  Ataxia Telangiectasia
•  Refsum's disease 
•  Metachromatic Leukodystrophy
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9
Q

Friedreich vs Ataxia

A

Due to degeneration of cerebellum, corticospinal and spinocerebellar tracts
Features: Ataxa + Scoliosis + MD + Cardiomyopathy (With arrthymic) + Pes Cavus + DM prone

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10
Q

Cerebellar Signs

A
  1. Eye - Nystagmus / Opsoclonus
  2. Upper Limb
    • Intentional tremor eg. can’t do button, can’t cap the ballpen, can’t pile up cubes
    • Past pointing
    • Dysdiadochokinesia
    • Hypotonia
    • Pendular jerk (better demonstrate it at LL)
3. Lower Limb
•  Failure of heel shin test
•  Hypotonia
•  Pendular jerk
4. Wide base gait, unsteady
5. Scanning speech
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11
Q

Steps in physical examination for Ataxia

A
  1. Test Toe- Heel waking, Turn around & Romberg sign
  2. General examination
    • Head- Size, ?Shunt / scar
    • Face - ?Coarse
    • Eye - ? Nystagmus, Vision, Telangiectasia, Squint
    • Ear - ? Deafness
    • Mouth - Gum Hypertrophy and brown teeth
    • Neck for ? goitre
    • Skin - photosensitivity rash, scar of chicken pox
    • Foot for pes cavus
    • Note scanning speech
  3. Demonstrate cerebellar signs
    • Eyes
    • UL & LL
  4. Complete Neuro exam
    • UMN signs
    • Sensory - esp positional sense
    • Cranial nerves (VI, VII, VIII); Fundi for optic atrophy and Retinitis pigmentosa (Refsum’s disease)
  5. Examine ear for OM & Abdomen (Downs)
  6. Examine Abdomen for mass
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12
Q

Hemiplegic Gait Causes

A

A) Acute Onset
1. Trauma with CNS haemorrhage

  1. CNS infection
    • Meningitis
    • Abscess
    • Encephalitis
3. Vascular cause
•  Haemorrhage - AVM, Aneurysm, tumor
•  Emboli
•  Thrombosis
•  Vasculitis
  1. Idiopathic

B) Chronic Non- progressive

  1. Perinatal Insults
    • Asphyxia
    • Prematurity with IVH
  2. Porencephalic cyst
  3. Hydrocepalus
  4. Perinatal Stroke due to polycythaemia, Hypotension and embolism
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13
Q

Ddx of Acute Hemiplegia

A
  1. Todd’s Paralysis
  2. Post Migraine attack
  3. TIA
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14
Q

Signs suggesting chronicity of Hemiplegia

A
  1. Wasting of muscle
  2. Flexion contracture of muscle
  3. Shortening of limbs at the hemiplegic side
  4. Presence of trophic change: Mottling, poor circulation
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15
Q

Steps in physical examination of Hemiplegia

A
  1. Demostrate the hemiplegic gait
    • Exaggerated via running
    • Do Fog’s test
    • For mild cases, just walk with tip- toe and decreased UL swinging
  2. Look for signs of chronicity (usually present in examination case)
  3. Demonstrate UMN lesion signs at the hemiplegic side:
    • UL - Spastic approach for gripping, tight pronator, affected UL sags & pronates when raised above head
    • LL - Tight Adductor and Tendon Archilles
  4. To localised the level of lesion
    • Examine the integrity of cranial nerves
    • Test conjugate eye movements
    • Look for signs of cortical damage (Check cortical sense, visual field and speech)
    • Look for contralateral somatic sensory loss and signs of dorsal column lesion
    • Test for cerebellar signs
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16
Q

Approach to Hemiplegia

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A

Brain stem lesion

  1. Ataxia on same side of hemiparesis
  2. Contralateral Cranial nerve palsy
  3. Loss of conjugate eye movement

Cortical lesion

  1. Isilateral Cranial nerve palsy
  2. Presence of signs of cortical lesion (Contralateral motor paralysis and UML signs), Broca / Wernicke’s Aphasia, Frontal signs, hemianopia
  3. Spinal cord lesion
    • Contralateral somatic sensory loss (Romberg Sign +ve)
17
Q

Tip-toe Gait Causes

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A
  1. Normal child
  2. Due to tight planter flexors
    • Muscle dystrophy
    • Spastic CP - Hemiplegia/ Diplegia
    • Dystonia e.g. Dystonia musculorum deformans
    • CMT
    • Congenital shortening of tendo- archilles tendon
  3. Club foot
18
Q

Approach to Tip-toe gait

Study These Flashcards
A
  1. Look at the shoe for “Tip wears”
  2. Do Gower’s sign –> Muscular Dystrophy
  3. Lower Limb examination:
    a) Deformity present (Club foot; Tight TA) —> Look for SCARS
    b) Neurological exam:
    • UMN sign: Spina Bifida /CP
    • LMN sign: CMT syndrome / Myopathic
    c) Dystonia
  4. Examine Head for Size, Scar , Shunt and Spine for Scar

IF ALL NORMAL —> NORMAL VARIANT

19
Q

Toe-in Gait Causes

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A
  1. Normal variant
  2. Hip problem - femoral anteversion
  3. Knee problem
    • Bow leg
    • Rickets
    • Spina Bifida, CP
    • Blount’s disease
  4. Ankle problem -
    • Calcaneovarus
    • CMT syndrome
  5. Foot deformity
    • Metatarsus varus
20
Q

Toe-out gait causes

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A
  1. Normal for child of 12 to 18 months
  2. Hip diseases
    • Femoral retroversion
    • Congenital hip dislocation
3. Knee problems
•  Knock knee
•  Rickets
•  Spina Bifida, CP 
•  Rarely NF and Osteogenesis Imperfecta
  1. Ankle deformity
    • Calcanovalgus
21
Q

Limping Gait Causes

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A 
A) Painful conditions
1. Traumatic conditions
•  Fracture of bone
•  Haemarthrosis 
•  Sprain of muscles/ tendons
  1. Bone disease
    • Osteomyelitis
    • Leukaemia
    • Osteoid Osteoma
3. Hip disease
•  Septic arthritis
•  Tuberculous arthritis
•  JRA
•  Transient synovitis
•  Slipped femoral epiphysis
  1. Knee disease
    • Arthritis as above
    • Torn meniscus / ligament
    • Loose body in knee e.g. osteochondritis dessicans
B) Unequal leg length
Due to diseases of bone, joint, or disused atrophy
1. Apparent difference
•  Congenital hip dislocations
•  Deformity of knee/ ankle
•  Soliosis

2. True difference in shortening 
•  Poliomyelitis
•  Hemiplegia
•  Previous fracture
•  Congenital
  1. True difference in length
    • NF
    • Haemangioma
    • Previous infection - osteomyelitis

C) Neuromuscular incoordination or weakness

  1. Spinal or cerebral lesion
  2. Muscle dystrophy
  3. Hemiplegia/ Monoplegia
  4. CMT syndrome/ Poliomyelitis

D) Hysteria

22
Q

Steps to examination of Limping Gait

Study These Flashcards
A

Trendelenberg Sign
Limping gait

A. Painful
• Bone - inflammatory sign/ deformity
• Joint - inflammatory sign/ posture / deformity

B. Painless

  1. Do Trendelenberg Sign (Drop of pelvis on the non-wt bearing side
  2. Measure limb length discrepancy –> differentiate level of shortening
  3. Look for flexion deformity / Scars/ Haemangiomas/ Signs of CDH
  4. Neurological exam
    • UMN –> CP
    • LMN –> Polio, CMT syndrome
  5. Examine spine for Scar and Scoliosis
23
Q

DDx of Positive Trendelenburg’s test

Study These Flashcards
A
  1. Congenital hip dislocation
  2. Proximal muscle weakness
  3. Pain at hip –> inhibit gluteal muscle function
  4. Coxa vara
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