Ortho Journal LLD

8/6/2019 Ortho Journal LLD

1/16

Limb Length Discrepancies

Kelvin A. Barry, BS

New York College of Podiatric Medicine

A look at various etiologies that affect people with

limb length differences and the podiatric

manifestations of discrepancies in limb length.


2/16

Introduction

Also known as short-leg syndrome or asymmetry of length in the

lower extremities.

Limb length discrepancies occur in two different types: congenital and

acquired. These limb length differences can create problems from theneck down to the toes.

A majority of the manifested problems tend to be localized to the

back, particularly the vertebral column, hip, and the feet.

...About 85% of the worlds population exhibits limblength differences DO YOU HAVE ONE???


3/16

Introduction

Congenital LLD is present form birth and is associated with manybirth defects & deformities.

Acquired LLD may result from developmental changes, post-trauma, & post-surgical.

LLD is frequently discovered

during the early growing years

Cosmetic effects are well

recognized, but the functional and

mechanical aspects are constantly

overlooked.


4/16

Congenital Eti

ology

Congenital hemiatrophy with skeletal anomalies.

Global aplasia, femoral aplasia, coxa vara

Olliers Disease (dyschondroplasia).

Non-hereditary; causes tumors in bones of one extremity, affecting thelong bones and the bones of the foot.

Dysplasia epiphysealis punctata.

Multiple exostoses.

Congenital dislocated hip, coxa vara, clubfoot.

Cutis marmorata telangiectatica congenita (CMTC)

a rare benign condition usually present at birth

characterized by areas of cutaneous marbling that often become more

pronounced with lower temperatures

Partial giantism with vascular abnormality (Klippel-Trenaunay, Parkes-Weber)

Hemarthrosis due to hemophilia


5/16

Epiphyseal plate destruction due to osteomyelitis (femur, tibia).

Tuberculosis (hip, knee, foot).

Septic arthritis

Poliomyelitis diaphyseal osteomyelitis of femur or tibia

Brodies abscess.

Metaphyseal TB of femur or tibia

Syphilis of femur or tibia

Elephantitis as a result of soft tissue infections

Thrombosis of femoral or iliac veins

Infecti

ous Eti

ology


6/16

Osteochondroma (solitary exostosis)

Giant cell tumors

Osteitis fibrosa cystica generalista

Neurofibromatosis (von Recklinghausens disease)

Hemangioma

Lymphangioma

Fibrous Dysplasia (Jeff-Lichtenstein)

Neoplastic Eti

ology


7/16

Damage of epiphyseal plate due to dislocation or surgery

Diaphyseal fractures with marked overriding of fragments

Diaphyseal & metaphyseal fracture of femur or tibia (osteosynthesis)

Diaphyseal operation

stripping of periosteum

bone graft

osteotomy

Sever burns Resulting in soft tissue contractures

Trau

ma Etio

logy


8/16

Paralysis

Immobilization of long duration by weight-relieving braces

Legg-Calve-Perthes disease

epiphyseal osteonecrosis of the upper end of the femur

SYN: coxa plana, osteochondritis deformans, pseudocoxalgia

Slipped upper femoral epiphysis

damage to femoral or tibial epiphyseal plates due to radiation

Piriformis syndrome

Other Eti

ological Fact

ors


9/16

Diagno

sis Complete and thorough history and physical

provides cause of LLD

previous treatment

nueromuscular status of the limbs and trunk

Evaluation of the discrepancy requires an understanding of significance

of the disparity, as well as the natural history of the disorder

Patient is evaluated in two legged

stance in order to assess pelvicobliquity relative to height of the knees


10/16

Diagno

sisClinical exam is performed with the patient in a number of different

positions to evaluate the level at which the limb length difference occurs

- prone, with knees flexed to 90 degrees to see

the heights of the tibias

- supine, with knees flexed to evaluate height of

the femurs

- supine, knees extended to see positions of the

medial malleoli


11/16

Podiatric Manifestati

ons

Equinus compensation of the shorter limb

Toe Walking -- plantarflexed attitude of the ankle

Gastrocnemius tightness, metatarsal head lesions, plantar fascia stretch

Supination of subtalar joint with varus attitude of calcaneus on short side

higher foot relative to neutral position (Cavus foot type)

submet lesions due plantarflexed metatarsals

dorsiflexed proximal phalanges of digits --> hammer digits

Pronation of subtalar joint on longer limb

shorter foot relative to neutral position

Valgus attitude of calcaneus as it helps to lower STJ and entire rearfoot of the

longer limb.


12/16


13/16

Treatments

Non-Surgical Modalities

In -shoe modifications

heel elevators/lifts to accommodate the equinus compensation

orthotics and/or lifts

Shoe sole heightening

Surgical Modalities

Epiphysiodesis (femoral shortening) of the longer limb in pediatric patients

for small discrepancies

Leg Lenghtening with a circular or cantilever external fixator

may be combined with intramedullary rod

cut bone by minimally invasive corticotomy; distract bone ends


14/16

Summary

Limb length discrepancy affects a larger population than one would

normally expect. Many people are discovering for the first time that they have

uneven limb lengths; and many of them have symptoms that they never suspected

were attributed to the difference in their lower extremities.

There is a need for more observations of patients gait and posture to

help medical professionals make more accurate and earlier diagnosis of limb

length problems, that can cause mild to severe symptoms in patients. This can

lead to earlier preventative or corrective measures that can, in the later future,

prevent a persons symptoms from progressing to worst.


15/16

References

1. Stanitski DF: Lim-length inequality: Assessment and Treatment Options. J Am Acad Orthop Surg,

7(3): 143-153, 1999.

2. Dutkowsky JP, Kasser JR, Kaplan LC: Leg Length discrepancy associated with vivid cutis

marmorata. J Pediatric Orthop, 13(4):456-458, 1993

3. Bloedel PK, Hauger B: The effects of limb length discrepancy on subtalar joint kinematics during

running. J Orthop Sports Phys Ther, 22(2): 60-64, 1995.

4. Pappas AM, Nehme AM: Leg length discrepancy associated with hypertrophy. Clin Orthop, 144:

198-211, 1979.

5. Moseley CF: Leg-length discrepancy. Pediatric Clin North Am, 33(6): 1385-1394, 1986.

6. Vogel F Jr.: short-leg syndrome. Clin podiatry, 1(3): 581-599.

7. Gurney B, Mermier C, Robergs R, Gibson A, Rivero D: effects of limb-length discrepancy on gait

economy and lower-extremity muscle activity in older adults. J Bone Joint Surg Am, 83-A(6): 907-

915, 2001.

8. Song KM, Halliday SE, Little DG: The effect of limb-length discrepancy on gait. J Bone Joint Surg

Am, 79(11): 1690-1698, 1997.


16/16

References

9. Galardi G, Comi G, Lozza L, Marchettini P, Novarina M, Facchini R, Paronzini: Peripheral nerve

damage during limb lengthening. Neurophysiology in five cases of bilateral tibial lengthening. J Bone

Joint Surg Br, 72(1): 121-124, 1990.

10. Menelaus MB: Correction of length discrepancy by epiphysial arrest. J Bone Joint Surg Br, 48(2):

336-339,

1966

.11. Frantz CH, Delgado S: Limb-length discrepancy after third-degree burns about the foot and ankle.

Report of four cases. J Bone Joint Surg Am, 48(3): 443-450, 1966.

12. Limb Length Inequalities/Growth Deformities. Wheeless Textbook of Orthopaedics. 6

September 2002 .

13. Kiper, DPM D. Leg Length Discrepancies. Fitness Runner Holiday 1999. 6 September 2002

.

14. Extended possibilities for patient with leg length discrepancy. Shriners Hospital Page. 6

September 2002 .

15. Leg Length Differences. Maryland Center for Limb Lengthening and Reconstruction. 6 September

2002 .

16. Limb Length Inequality: Evaluation & Treatment. Orthopaedics. Connecticut Childrens MedicalCenter. 27 September 2002 .

Ortho Journal LLD

Documents

Transcript of Ortho Journal LLD