(1)
Groningen, The Netherlands
Neurological problems causing an abnormal gait have been left out of this discussion
Introduction
A child that has just started to walk has a broad aligned gait whereby the upper arms are kept in abduction in order to keep balance. The knees are not flexed and the toes reach the ground first and not the heel. At 2 years of age there is a normal gait. During the gait cycle knee flexion begins and the lateral part of the heel reaches the ground first.
In the first year of life there is an increased external rotation in the hip joints. After the age of about 2–4 years there is as a rule a symmetrical distribution between internal- and external rotation (Fig. 16.1). In the lower legs it is just the opposite. In newborns there is on average 5° of internal-up to 5° of external tibial torsion. At the age of two there is an external torsion in the lower legs of 10–20° (Fig. 16.2). The medial side of the foot should be straight (Fig. 16.2). In a normal gait the heel of the shoe wears out at most on the lateral side (Fig. 16.3).
Fig. 16.1
Rotations of the hips are measured prone with extended hips and 90° of knee flexion. Turning the lower legs outwards is internal rotation, moving the lower legs in the opposite direction is external rotation. (a) In newborns there is a strong external rotation in the hips of 80–90° and a diminished internal rotation of 10–20°. (b) From the age of 2–4 years there is as a rule a symmetrical distribution between internal- and external rotation. (c) In some children between the ages of 4 and 6 years there is a marked internal rotation and less external rotation. If the internal rotaton is 70° or more then the child walks with the toes turned inwards. The sum of the rotations in extended hips is usually 100°. Thus, with an internal rotation of 80° degrees there is an external rotation of 20°
Fig. 16.2
Assessment of torsion in the lower leg with a child lying prone with the left knee in 90° of flexion. (a) The foot is turned outwards 10–20° with regard to the upper leg (external tibial torsion). (b) In internal tibial torsion the foot is turned inwards with regard to the upper leg. (c) Inspection of the medial foot edge with the child lying prone and the left knee in 90° of flexion. The medial foot edge should be straight. In a metatarsus adductus and a metatarsus varus the mid- and fore-foot is angled inwards with regard to the hindfoot
Fig. 16.3
With a normal gait the heel of the shoe wears out on the lateral side
If the child walks with the toes turned inwards because of strong internal rotation of the hips or internal tibial torsion of more than 5°, then the heel wears out at most on the medial side (Fig. 16.4).
Fig. 16.4
If the child walks with intoeing then the heel will wear out on the medial side
Gait Disorders
Limping
Complaint: the parents complain that the child is limping.
Assessment: there is a leg length difference of 2 cm or more.
Diagnosis: one leg is shorter or longer than the other (for explanatory note, supplementary assessment, primary care treatment, when to refer, secondary care treatment, see Chap. 15).
Waddling Gait
Complaint: the child walks like a duck (sags as it were through the hips).
Assessment: the air space between the legs just under the perineum is widened (thigh gap). The Trendelenburg test is positive.
Differential diagnosis:
coxa vara
congenital coxa vara acquired coxa vara
missed bilateral hip dislocation
Explanatory note: in the Trendelenburg test the strength of the hip abductors are tested. One asks the patient for instance to stand on the right leg and lift the left leg. The pelvis on the left side will be lifted up if the hip abductors have normal strength. In that case the Trendelenburg test is negative (Fig. 16.5b). If the distance between the origin and insertion of the hip abductors is shortened as in coxa vara and a hip dislocation, for instance on the left side, then the hip abductors are relatively too long and therefore less powerful. The Trendelenburg test is positive if the pelvis sags down on the right side while the child stands on the left leg and tries to lift the pelvis on that side (Fig. 16.5c).
Fig. 16.5
Trendelenburg test. (a) Patient with a left hip dislocation stands with both feet on the ground. (b1–b2) One asks the patient to lift the left leg. The left pelvis half is lifted up if there is normal strength in the abductors of the right hip. The Trendelenburg test is negative. (c1–c2) In a dislocation of the left hip in which the distance between the origin and insertion of the abductors is shortened there is loss of strength in these left hip muscles and the right side of the pelvis cannot be lifted up. The Trendelenburg test is positive
In a congenital or acquired coxa vara the angle between the femoral head/neck and the femoral shaft is less, in which case the greater trochanter lies higher (more proximal) (Fig. 16.6). If the greater trochanter is at the same level as the upper edge of the femoral head as in coxa vara there is in 50 % of cases a positive Trendelenburg test. If the proximal part of the greater trochanter lies more proximal than the upper edge of the femoral head, then there is 50–100 % chance of a positive Trendelenburg test.
Fig. 16.6
Anteroposterior X-ray of the pelvis: bilateral coxa vara. In a coxa vara the angle between the femoral head/neck and the femoral shaft is lessened, whereby the greater trochanter is situated more proximal than normal
Congenital coxa vara
This type is rare and is present at birth. It is often associated with other inborn errors such as congenital short femur (femur hypoplasia), proximal focal femoral deficiency and a dysostosis cleidocranialis. This type is often recognized earlier due to the other deformities.
Acquired coxa vara
This type of hip deformity is as a rule finally diagnosed between the ages of 3 and 5. As a child gets older and heavier, the epiphysis glides slowly downwards and the angle between the femoral shaft and femoral neck, the so-called caput collum diaphyseal angle (CCD-angle), decreases whereby the greater trochanter finally lies proximal to the femoral head.
Missed bilateral hip dislocation
Apart from a widened air space between the legs just below the perineum (thigh gap), the Trendelenburg test for both hips is always positive. As a result of flexion contractures in the hips there is a compensatory hollow back (hyperlordosis), the pelvis is turned over anteriorly (Fig. 16.7) and there will be a waddling gait (Fig. 16.8). For further explanation, see Chap. 9.
Fig. 16.7
Hyperlordosis of the pelvis which is tilted anteriorly in a bilateral hip dislocation
Fig. 16.8
(a, b) There is a waddling gait as a result of less powerfull abductors in a bilateral hip dislocation
Supplementary assessment: anteroposterior X-rays of the pelvis.
Primary care treatment: none.
When to refer: if the X-ray is abnormal.
Secondary care treatment: see Chap. 9.
Toe Walking
Complaint: the child walks on the toes.
Assessment: apart from a bilateral limited dorsiflexion in the ankle joints no other orthopaedic or neurological anomalies will be found. As a rule the ankle can just be brought into a neutral position.
Diagnosis: habitual toe walker (idiopathic toe walking, congenital short achilles tendons).
For explanatory note, suplementary assessment, primary care treatment, when to refer and secondary care treatment, see pp. 276–279.
Out-Toeing
Complaint: from the beginning the child walks like Charlie Chaplin, with the toes turned outwards.
Assessment: the child walks with an out-toeing gait. The rotations in the hips are measured lying prone with extended hips and 90° of knee flexion. Turning the legs outwards is external rotation and inwards internal rotation. Examination of the torsion in the lower legs is carried out in the same position.
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