Gait Abnormalities in Pediatric Orthopedics

1. Gait Abnormalities in Pediatric Orthopedics Thomas Jinguji, MD Seattle Children’s Hospital October 16,2012

2. What we’ll talk about • In-Toeing • Limping child • DDH

3. InToeing/Torsion • The vast majority of rotational deformities are variants of normal • Understand the natural, normal progression of rotational variations • Learn to localize (and less to quantify) the area of the concern of deformity • We’ll focus on In-Toeing

4. Physiologic/structural - from hip, leg, foot or toe Other structural-Tibia Vara, DDH, Clubfoot Neuromuscular disease- muscle imbalance, spasticity, cerebral palsy Metabolic bone disease - rickets Skeletal dysplasia Post-traumatic/post-infectious-SCFE, septic hip The Multiple Causes (And Rule Outs) of Toe-ing and Bowing Deformities

5. In-Toeing • Assume a normal healthy toddler or child (age 1-7) • Determine the location of the in-toeing using the Rotational Profile

6. Rotational Profile • Assessing hip rotation • Assessing tibial rotation • Determining the alignment of the foot and toe • Gait: foot progression angles

7. Foot Progression Angle • Where the rubber meets the road • By convention negative degrees are for in-toeing and positive denotes out-toeing • Also watch for limp, toe-walking, asymmetry • Watch out for the “doctor walk”

8. Rotational Profile • Gait: foot progression angles

9. Assessing Hip Rotation and Femoral Rotation • This is easiest done prone -Assess medial/internal rotation -Assess external rotation • Any asymmetry in hip rotation warrants further investigation

10. Femoral Anteversion • More common in girls at 2-5 • Sits in the “W” position • “Kissing patellae” • “Egg-beater” run • Severe if > 90° • Usually improves with growth - but it can persist • No association with hip osteoarthritis • Also call internal femoral version, medial femoral version, medial femoral torsion or femoral antetorsion

11. Femoral anteversion/antetorsion

12. 1. Internal rotation to about 75-80 degrees; 2. External rotation to about 75-80 degrees; 3. External rotation of about 20-30 degrees; 4. A need for a diaper (and better editing) Assessing hip rotation This child shows:

13. Assessing tibial rotation

14. Assessing tibial rotation: • This is done prone • Thigh-foot angle • (Transmalleolar axis) • Measureangles

15. Assessing tibial rotation L TFA R TFA

16. Medial tibial torsion • This can be one sided; often left greater than right • Often seen in kids 1-3 • Asymmetry of tibial rotation is common • Also called internal tibial version/torsion or medial tibial torsion

17. Assessing alignment of the foot • Shape of the foot; Lateral foot line • Heel-bisector angle: Normal lines runs between 2nd and 3rd toes Adductus Normal

18. Metatarsus Adductus • Medial deviation of the forefoot • Resolves spontaneously in 90% of infants • Test flexibility by gentle pressure at the medial forefoot • Also called metatarsus varus

19. Metatarsus Adductus • Majority are flexible • Adductus usually resolves by 3-4 yrs • 10% stiff and may benefit from casting • Refer if stiff and cannot straighten fully by 6 mos

20. Wandering Toe • Wandering toe resolves completely without intervention • This is dynamic deformity and there is no adduction of the toe when pt is sitting • Reassurance is the best course

21. You can determine the source • Excessive medial rotation of hips = femoral anteversion • Medially rotated thigh foot angle = medial tibial version • Curved foot = metatarsus adductus • Searching or wandering great toe produces dynamic in-toeing

22. Growth: lateral rotation of both femur and tibia • Femoral antetorsion improves over time • Medial tibial torsion improves over time • Flexible metatarsus adductus resolves by age 4 • Wandering toe is self limited and pretty much always resolves • In-toeing gets better with growth

23. How to treat intoeing? • Shoe lifts/inserts? No. • Twister cables or bracing? No. • Observation? Yes.

24. Out-toeing • In general out-toeing is much less common than in-toeing • R/O acute/other causes: SCFE, Septic hip (Note: Asymmetric loss of hip internal rotation signifies pathology and always requires work-up) • The rotational profile again

25. Out toeing • Complete the rotational profile to localize the site of the external rotation • Asymmetric hip rotation always requires further evaluation (external tibial version can be an isolated finding) External Tibial Torsion

26. Treatment of persistent Toeing • IF patient has persistent toeing related to femoral or tibial version/torsion after the age of 7-8 years • AND this causes pain, functional limitation, or cosmetic concerns. • Referral for consideration of surgical correction is appropriate • Delay of this referral does not change the long term outcome for the patient Remember: the cat is never out of the bag!

27. Case 0 • 20 month old with a limp • Started yesterday. • History: You pick

28. History A • “Yesterday he was sliding down a slide with his big brother and his leg got caught.” • Or • “He was walking and slipped on wet grass.”

29. The Ministry of Funny Walks • Gait: Described in terms of stance and swing phase • Antalgic gait • Trendelenberg Gait: Compensated and Uncompensated

33. History B • “He had a little cold 2-3 days ago and then yesterday he had a fever to 102 and seemed fussy. Today he has a fever again and his leg looks puffy.”

34. Infection • Worry about Osteomyelitis and Septic Joint. • Consider getting labs (CBC, ESR, CRP, Blood Cx) • Consider getting US if hip involved. • Consider bone scan if unsure of diagnosis • What’s worse Osteo or Septic Joint? • Are Xrays helpful?

35. History C • “She had a cold about 1-2 weeks ago and yesterday he seemed to be sore and fussy. I am not sure if she has a fever but she feels hot. Today she is fussy and does not move her leg.”

36. Transient Synovitis • also called Toxic Synovitis • Involves hip only (vs involving knee) • Must differentiate from infection • Labs: CBC, ESR, CRP • Bone scan very helpful here!

37. “The Limping Child/Toddler has Infection Until Proven Otherwise”

38. Case 1 • 13 year old male with limp and knee pain • Overweight. • Gait shows an externally rotated foot • Exam shows loss of hip IR • Xray: Klein’s line

39. This is the real slide

40. SCFE • Stable and unstable slips. • Be careful about the history/exam • Xrays are often “normal” • Acute treatment: NWB and referral for surgical stabilization.

41. Case 2 • 6 year old boy with limp • Skinny, “hyper” little guy • Exam shows “funny” pain free gait and loss of hip IR

42. Perthe’s Disease • Avascular necrosis of the femoral head • Boys more common than girls, Age 4-8 • Treatment is quite variable. • Kids are healthy and besides the pain free limp are fine • No further additional imaging is needed for diagnosis

43. Teaching point • Intra-articular hip pathology presents with a loss of hip internal rotation. • Asymmetry of hip rotation requires further evaluation • Include the hip exam with knee and thigh pain • What is another pediatric cause of loss of hip internal rotation?

44. Case 3. • 19 month female with a leg length discrepancy • Breech presentation • Exam: Galeazzi + • Pain free gait that “walks in a hole”

45. Teaching point • Late hip dislocation presents with a loss of hip abduction • Hip IR/ER is actually excessive • Children tolerate leg length discrepancies of up to 2cm without much problem

46. Screening for DDH (infants) • Developmental Hip Dysplasia/Dislocation • Used to be called Congenital Hip Dislocation • Dysplasia vs Dislocation -Dysplasia is silent and can be missed (dislocation can be missed as well)

47. Dislocation on Ultrasound Normal Dislocation

48. Dislocation: Exam Galeazzi Barlow Ortalani

49. For Hip Dislocation • If there is exam concern for hip dislocation in newborn nursery: “clunk” not “click” • Recommend referral to pediatric orthopedics or • Recheck hip in 2 weeks if this feels stable; continue recheck and get US at 6 weeks of life • (Most people refer…)

50. Concern for hip dislocation/dysplasia • Risk factors: Breech presentation, family history of DDH, and female • How to check for DD(ysplasia)H radiographically: Get US at 6weeks or Get xray at 4-6 months • (Usually) refer if radiology is abnormal…