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Hello All,
I don't have much experience with kids as yet, and would appreciate your input:
18 month old, just commenced walking, two older siblings both walked at similar age. Walks with left foot at normal angle of gait, but right abducted from the midline at nearly 90 degrees. Px doesn't appear to bend knees much, stiff legged type gait from the hip down. Was unable to be examined properly on initial visit, but am considering reviewing to try and assess hip range of motion, internal/ external hip rotator muscles etc. Some articles I have read report that intoe/ out toe will correct over time, but this looks quite odd.
Thanks,
Kara

 

4 days and not a reply.......

Hi Kara
It does sound strange, the right knee stiffness maybe part of the cause of the abducted gait as the child finds the path of least resistance for that limb? but both knees are stiff you say, so that may rule that idea out.

For me l would send the child to an Osteopath for a full range of motion assessment and the all important second opinion, from the feet up.

If you cant get a hand on the child to asses ROM, ask Mum to do it under your direction, its a start.

 

hi sounds interesting!
Alternatively to the osteopath, refer to a podiatrist who is experienced in treating in children/toddlers, they can also assess well up to the hip. Yes it is difficult assessing the unco-operative child but it can be done quickly ( if Necessary) , particularly if experienced at what to look at and to do a neuro exam if required. Mums can keep you play games that helps keep the child distracted.
Many pods would also be happy for you to come along and sit in , giving you more confidence next time. podiatry are the foot specialist afterall.
I,m on the midnorth coast too , am happy to help if this interests you.

 

Hi Kara, welcome to the world of paeds. They are tricky little mites to assess.

I think dsfeet has given great advice. This little one needs more thorough assessment by someone that is has more experience either together with you or on referral.

I work in community health a close link to a neuro and ortho paed clinic. One of the biggest causes for referral is asymmetry. Kids are meant to be symmetrical at this age.

 

I'd have a bet on neuro with an each way on DDH

 

This sounds like an extra pedal cause. The best advice would be first to do an initial LE physical followed by a hip to floor B/L radiograph to assess the level of the deformity. My guess on this would be either severe tibial torsion or perhaps femoral torsion. The other possibility is hip ante version. Get an x-ray. It will give you a lot to go on.

 

Thank you all,
Haven't been able to contact the mother as yet to bring the child back in, will keep you posted.
Thanks for your helpful advice.
Kara

 

Dr. Volpe here.

Sounds to me like the hip may be the issue. That is a very significant asymmetry with a rectus L foot and the R foot at a 90 degree angle. I would be interested to know how this foot looks on weightbearing. Is it severly pronated - look like a calcaneovalgus or a convex pes plano valgus? - those could give you severe unilateral abduction - but absent that with a fairly normal looking foot, I'd look proximal and rule out DDH and other hip/femoral pathology. A hemiplegia or other unilateral neuromuscular issue needs to be on your mind as well.

The other thing to keep in mind is that the Left side may have a relative in-toe (usually ITT or met add) making the right side look more (relatively) abducted (though not usually 90 degrees abducted on R and rectus on L). I see this all the time as a podopediatrician.

Hope that helps.