Addressing Subsequent Gait Issues In A Child Who Had An Intracranial Ventricular Shunt And Hydrocephalus In Utero

As I mentioned in an earlier blog (see http://bit.ly/otq05C ), I recently visited family in Canada and, of course, served as a personal podiatric physician to my parents’ and in-laws’ relatives, friends and neighbors. As our family knows, my big interest lies in pediatric foot and ankle deformities. With this in mind, my mother-in-law asked me to meet with a next-door neighbor‘s child, whom she described as “interesting.” For once (wink wink), my mother-in-law was right.
 
The child was a very rambunctious 20-month-old girl who, for all intents and purposes, looked and acted completely normal. In talking to her mother, I learned that the child had been diagnosed with an intracranial ventricular shunt in utero and developed hydrocephalus while in the womb. Aborting the pregnancy had been recommended to the family but the family was intent on dealing with any adversity they encountered with the child. It was unclear to me whether the shunt resolved in utero or once the child was born.

Miraculously, her delivery and development was rather uneventful, and her pediatric neurologist was amazed at her progress. Her management team did notice low core muscle tone. Otherwise, she hit all of her pediatric milestones. She started walking at 17 months and all of her reflexes developed with minimal time deviations. She also had recently started talking and had no difficulty following commands or expressing her needs.
 
Interestingly, there was no thorough gait evaluation during the child’s care. Her occupational therapist did notice that she had flatfoot and recommended a flexible, over-the-counter orthotic. The occupational therapist also noticed low core muscle tone and suggested exercises and techniques to improve this gradually.
 
When I met this young patient, the first thing I did was ask her to give me a high five while her mother held her. The child immediately met my gaze and was very attentive albeit slightly shy. Once I put my hand up for the high five, she immediately lifted her hand and responded. Having no weakness or tremor, she hit the mark with a loud slap and giggled at her feat. Gross motor skills and socialization seemed intact for a child her age.
 
With her mom still holding her, I then performed a lower extremity examination. She seemed to have normal muscle strength in the extrinsic and intrinsic musculature of both feet. She had normal hip rotation for her age and showed no femoral or tibial torsion or rotation. The child did have mild gastroc soleus equinus with a very slight clonus and her midtarsal joint was somewhat rigid on passive range of motion. (I did not have my goniometer with me so I could not assess the degree of equinus.)
 
Things got interesting when I asked the girl to walk. I kept reminding myself that she had only been walking for three months but I was intrigued by the type of gait she displayed. I immediately noticed that she had quite a pronounced steppage gait pattern with very little arm swing. She still displayed the “arm up” gait that new walkers use to maintain their balance. However, her gait was still rather wide and she was not able to increase her speed as much as I expected without having balance issues. She also had an abducted gait pattern with medial talar escape and a good amount of compensated metatarsus adductus.
 
I looked at the orthotics she had used and they were hardly adequate for a child with these gait issues. I recommended that her mother ask a local podiatrist if he or she could make custom orthotics with a rearfoot post and medial flange to reorient the foot into a more neutral morphology. I also recommended potentially splinting the feet when the child is sleeping although her mother became noticeably uncomfortable when we discussed this. 
 
As I performed this evaluation in my in-laws’ home, I made the following recommendation to the child’s mother. I asked her to film her daughter walking and running in a large room from every angle (front, back and both sides). I also asked her if she could get three weight bearing radiographs (three views of each foot) and send them to me. I then suggested that she discuss the slight clonus with her daughter’s neurologist and occupational therapist.
 
I am hopeful the family will comply with my request about the video and radiographs, and send me a copy. If they do, I will certainly pass on my findings to you. Stay tuned.



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