Ortho Journal LLD
Transcript of Ortho Journal LLD
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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.
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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???
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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.
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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
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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
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Osteochondroma (solitary exostosis)
Giant cell tumors
Osteitis fibrosa cystica generalista
Neurofibromatosis (von Recklinghausens disease)
Hemangioma
Lymphangioma
Fibrous Dysplasia (Jeff-Lichtenstein)
Neoplastic Eti
ology
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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
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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
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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
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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
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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.
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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
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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.
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References
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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.
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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
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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 .