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Journal of Nursing

Abnormal Gait in Toddlers

Author: Karen Resseguie-Vickstrom BSN, BBA, MBA (current DNP student) [email protected]

Abnormal Gait in Toddlers
Skeletal structure begins in utero and continues to grow and develop during childhood where the bones mature in diameter, length and increase in bone mass (Grossman, 2013). The skeletal structure continues to change throughout one’s life with the formation of the macroscopic or modeling which stops at the age of maturity. (Grossman, 2013). Disorders of the skeletal system can develop as a result of abnormal growth and development due to hereditary or congenital abnormalities (Grossman, 2013). Three possible diagnosis that could result in a three year old child that is having a noted abnormal gait is Torsional Deformities, Developmental Dysplasia of the Hip and Legg-Calveʹ-Perthes disease.
Torsional Deformities
In infants and toddlers they have what is known as lax ligaments that with age will become tighter for the composition of their weight bearing posture (Grossman, 2013). Hypermobility is accompanied with joint laxity that is combined with the torsional forces applied during the limbs development (Grossman, 2013). Limb variants in children is caused by torsional forces in which intrauterine positions can twist the growing bones resulting in deformities as the child grows and develops (Grossman, 2013). Common diagnosis associated with torsional deformities that begins during embryonic development and is identified by the age of three or when the child begins to walk includes toeing-in which is metatarsus adductus and toeing-out which is external femoral torsion (Grossman, 2013).
Metatarsus adductus also known as pigeon toe is a common congenital foot deformity that affects one per every 1000 to 2000 live births and usually is a result of the positioning in the uterus (Grossman, 2013). Because the foot is adducted it gives it a kidney shape appearance in the front of the foot while leaving the hindfoot in normal position (Grossman, 2013). Examination for diagnosis includes evaluation of the plantar aspect of the foot, taking note of the overall shape and presence or absence of the arch (Grossman, 2013). Proper diagnosis is made by asking the child to walk in a large area that allows for walking and running observation (Grossman, 2013; Schoenecker, & Rich, 2006). It is best to observe the child with and without shoes on because in-toeing is more noticeable with shoes on due to the weight of the shoe that may be more taxing on the foots control muscles (Schoenecker, & Rich, 2006). Treatment is based on the grade level of I, II, or III where in grade I the deformity can be passively manipulated to a straight position with no other required treatment (Grossman, 2013). In grade II the deformity will only be corrected to a straight lateral border and in grade III the treatment may require interventions to include serial casting or leg braces that will push the abducted metatarsals into a straight position (Grossman, 2013).
Toeing-out is a common problem in children that is caused by the external femoral torsion that often occurs with calcaneovalgus and pes planovalgus (Grossman, 2013). Diagnosis supports that calcaneovalgus and pes planovalgus occurs when the femur is externally rotated to 90 degrees and its internal rotation is only able to be rotated to a neutral position (Grossman, 2013). An external tibial torsion may also develop in addition to femoral torsion because of the child’s habitually sleeping pattern in a prone position and therefore night splints maybe warranted to help aide in correcting the problem otherwise toeing-out usually corrects itself (Grossman, 2013).
Developmental Dysplasia of the Hip
The American Academy of Orthopaedic Surgeons ({AAOS}, 2014) indicates that a hip is a ball-and-socket joint that the ball of the upper femur fits snuggly into the socket of the pelvis bone. Infants and children who are diagnosed with developmental dysplasia (DDH) or most commonly known as congenital dislocation of the hip is best understood in that the hip joint has not developed normally (AAOS, 2014; Grossman, 2013). The ball remains loose or dislocated within the socket or the head of the femur is found outside the acetabulum (AAOS, 2014; Grossman, 2013). Yeagerman, Cross, Positano, et al. (2011) indicates that one in every one-hundred infants have some form of hip instability and one in every one-thousand live births have a hip dislocation. The disorder is common in the following areas (1) the first born child (2) in babies that are born breech (3) infants that have a family history of parents or siblings with DDH (4) is more common in girls than boys (5) in infants that had oligohydraminos and (6) limited hip abduction (Grossman, 2013; Yeagerman, Cross, Positano, et al. 2011).
It is important for early diagnosis of DDH through a clinical evaluation of the hips to identify for legs that have different lengths, have uneven skin folds in the thighs, decreased mobility or flexibility on one leg side, noted limping, walking on toes or having a waddling walk (AAOS, 2014; Storer, & Skaggs, 2006). Evaluation should be performed at birth and every several months in the first years of the infant’s life to provide proper treatment (Andriesse, & Hagglund, 2008). Treatment for DDH will vary depending on whether the hips are subluxated or dislocated (Grossman, 2013). Grossman (2013) indicates that an infant with subluxation of the hip at birth will resolve without treatment within two weeks. If subluxation goes beyond this two week marker then a referral to an Orthopedist is recommended to obtain correction by gentle manipulation or by an abduction device known as the Paylik harness which is provided to newborns up to six months to help maintain the femoral head positioned in the acetabulum (Grossman, 2013). Infants that have dislocated hips and toddlers whom lack the acetabular socket will require a more aggressive interventions to include open reduction and joint reconstruction to promote immobilization of the legs in an abducted position which may be followed by a hip spica cast, plaster splints or an immobilizer known as an abduction splint (Grossman, 2013).
Legg-Calveʹ-Perthes Disease
Legg-Calveʹ-Perthes disease is a juvenile osteochondroses disorder in which growth ossification undergoes a phase of degeneration, necrosis, or inactivity that follows a regeneration of deformity that is caused by localized osteonecrosis in the epiphyseal center (Grossman, 2013).
This idiopathic osteonecrotic disease affects the proximal femoral epiphysis in one out of every twelve hundred children that primarily is seen more commonly in boys between the ages of three to twelve (Grossman, 2013). Legg-Calve’-Perthes is an avascular necrosis disease that involves a portion or the entire bone marrow of the epiphyseal growth plate with no known cause (Grossman, 2013). Clinical presentations typically support a boy that in 90% of patients have a shorter stature and one third are found to have hyperactive attention deficit disorder (Spiegel, & Horn, 2008). Supported findings include a noticeable limp when walking with complaints of pain in the groin, knee or thigh upon activity and the pain is relieved by rest (Spiegel, & Horn, 2008).
Legg-Calve’-Perthes disease involves four stages to include (1) the avascular stage in which the ossification center becomes necrotic and damages the femoral head, (2) is the revascularization stage in that resorption of the necrotic bone occurs, (3) is the reossification stage in which radiolucent areas become dense and the shape of the femoral head will improve and (4) is the healing stage which involves forming of immature bone cells by normal bone cells that results in the femoral head restoration (Shane, Ebeling, et al. 2010).
Early diagnosis is important so treatment options can begin to preserve the femoral head and reduce deformity (Grossman, 2013). Treatment includes conservative and surgical options to relieve the force of weight bearing, muscle tension and subluxation of the femoral head that involves maintaining the femur in a correct anatomical position of abduction and mild internal rotation (Grossman, 2013). Conservative treatment will include frequent rest periods, walking with assisted devices, periods of being non-weight bearing and a brace to keep the legs in an abduction and mild internal rotation position (Grossman, 2013). If surgical intervention is needed it is usually performed when the child is six or older and before the epiphysis becomes necrotic (Grossman, 2013). Surgical interventions include removing the necrotic marrow and replacing it with neurovascular tissue that has pluripotent cells and in time depending on the degree of avascular necrosis a total hip replacement maybe necessary (Grossman, 2013).
Conclusion
Skeletal structure begins in utero and continues to grow and develop during childhood where the bones mature in diameter, length and increase in bone mass (Grossman, 2013). Disorders of the skeletal system can develop as a result of abnormal growth and development due to hereditary or congenital abnormalities (Grossman, 2013). Three possible diagnosis that could result in a three year old child that is having a noted abnormal gait is Torsional Deformities, Developmental Dysplasia of the hip and Legg-Calveʹ-Perthes disease. Early diagnosis in all disorders is prevalent so treatment options can remain conservative with gainful outcomes prior to any surgical intervention.

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