PATHOLOGY AND

MANAGEMENT OF LIMB
LENGTH DISCREPANCY
DR. AFENIFORO
OUTLINE
• INTRODUCTION
• AETIOPATHOGENESIS
• DIAGNOSIS
• FACTORS GUIDING TREATMENT OPTIONS
• COMPLICATIONS
• CONCLUSION
INTRODUCTION
• A condition where there is variation or differences in length (shorter
or longer) of the upper limbs & lower limbs.
• It’s also known as anisomelia.
• The lower Limbs constitute about half of the body’s height.
• Forms an important part of gait kinetics.
• LLD affects height and efficiency of gait
• Relatively common
• Reports suggest up to 70% of adult males
APPLIED ANATOMY
• Limbs develop from 3rd week of intrauterine life.
• Bone ossification start by 5th week.
• By 8th week, development is complete.
• Growth continues till 14yrs for boys & 16yrs for girls.
• Femur 52%, tibia 48% to lower limb growth.
PREDICTION OF GROWTH
• Arithmetic method by Dr Malcolm Menaleaus
• Growth remaining method by Andersen & Green
• Straight line method by Dr Colin Moseley
• Multiplier method
DETERMINATION OF SKELETAL AGE
• CALENDER METHOD

• OXFORD SCORING SYSTEM

• RISSER SIGN
CLASSIFICATION
• TRUE / STRUCTURAL / ANATOMICAL / DEVELOPMENTAL

• FUNCTIONAL
AETIOLOGY
 STRUCTURAL
I. Congenital defects / syndromes
• PFFD, club foot, amelia/hemimelia
II. Trauma
• Fractures, Bone loss, non union, malunions, dislocations
III. Idiopathic
IV. Infection
• Acute osteomyelitis, septic arthritis
V. Iatrogenic
• surgeries
VI. Others
• Tumor, Skeletal dysplasias, SCFE, Perthe’s disease
• FUNCTIONAL
I. Spine Pathologies
II. Pelvic Obliquity
III. Posture
IV. Joint Contractures
V. Angular deformities e.g. Coxa varum, Genu
varum/valgum
VI. Foot Deformities
VII. Muscle Spasms
VIII.Assymetrical Footwear
COMPENSATION
• Can occur in any joint in any plane.
• Depends on ROM available & size of LLD.
• Each pts is unique
• Children compensate better than adults

• SUBTALAR JOINT : Pronation of ‘long leg’ & Supination of ‘short’ leg.

• ANKLE JOINT : Plantar flexion or equinus of ‘short’ leg
& Dorsiflexion of ‘long leg’.

• KNEE JOINT : Hyperextension / flexion of ‘long’ leg. &

Genu varum / valgum of ‘long’ leg.

• SPINAL : Compensatory shoulder & pelvic drop on the

short side may result in ; a) No compensation, b)
Lumbar & cervical scoliosis, c) Lumbar scoliosis.
CLINICAL EVALUATION
HISTORY EXAMINATION
• BIODATA • LOOK
• FIND OUT CAUSE • FEEL
• MOVE
• MEASUREMENTS
• COMPENSATION / ADAPTATION
• Gait Analysis – Limping Gait
• Clinical Measurements
i. Real Length
ii. Apparent Length
• Allis Test / Galleazi Test/Skyline Test
CLINICAL MEASUREMENTS
DIRECT METHOD

FOR
STRUCTURAL
LLD i.e
REAL
LENGTH
INDIRECT
METHOD FOR
STRUCTURAL LLD
FUNCTIONAL
LLD i.e
APPARENT
LENGTH
 ALLIS TEST
• ASIS ALIGNED ON
SAME TRANSVERSE /
FRONTAL PLANE
• BOTH MALLEOLI
TOGETHER
RADIOGRAPHIC
MEASUREMENTS
• TELERADIOGRAPHY
- Pts supine, single exposure on one large film.
• SCANOGRAPHY
- Pts supine, narrow X-ray beam moved rapidly from
one end of a large film to another.
• ORTHOROENTGENOGRAPHY
- Most accurate. Eliminates magnification error.
- Pts supine, 3 successive exposures over hip, knee &
ankle.
Teleradiography
Scanogram
• CT SCAN
- AP scanogram of femur & tibia
- Bone length calculated on computer screen.
• MRI
- Less accurate than USS, but can evaluate soft tissue
disorders.
• REAL TIME USS
 TREATMENT
ADEQUATE COUNSELING
CONSIDER SOME IMPORTANT FACTORS
 FACTORS GUIDING TREATMENT OPTIONS
• Limb
• Upper or lower
• Aetiology (address the pathology)
• Spine
• Hip dislocation
• AVN of hip
• Severe osteoarthritis of hip
• Femoral neck fracture/non-union
• Coxa vara
• Malunited pertrochanteric fracture
• Femoral/tibia shaft malunion
• Femoral/tibia shaft non-union (with or without bone loss/open or closed)
• Physeal injuries and other growth plate pathologies
• Angular deformities of the knee
• Joint contractures
• Club foot
• Age
• Length of discrepancy
• 0 – 2 cm: No treatment, shoe modification

• 2 – 6 cm: Shoe modifications, Epiphysiodesis or shorten, lengthening

• >6 cm: Lengthen or combination

• >15 cm: Prosthetic fitting

Other factors
• State of soft tissue
• Range of motion of the joint
• Expertise available
• Resources available
• Psychologic Status
• Expectation of patient
NON OPERATIVE
• SHOE MODIFICATIONS
• SERIAL MANIPULATION & CASTING
• ORTHOSIS
• PHYSIOTHERAPY : Gait training, muscle strengthening exercise, ROM
of joints.
• PROSTHETIC FITTING
• Extension prosthesis
OPERATIVE OPTION
• SHORTENING PROCEDURE
I. ACUTE SHORTENING
II. EPIPHYSIODESIS

• LENGTHENING PROCEDURE
I. GROWTH STIMULATION
II. CALLOSTASIS ( distraction osteogenesis )
III. CHONDRODIASTASIS (physeal distraction/distraction epiphysiolysis)
• SOFT TISSUE RELEASE
• OSTEOTOMY
• OSTEOCLASIS
• TENDON TRANSFER
• EPIPHYSIODESIS
- Usually done with image
guidance.
- Preferred to staple or
screw application.
- Open Phemister
technique
• ACUTE SHORTHENING
- For skeletal mature pts with
physeal closure
- Max 7.5cm in femur, 5cm in
tibia.
- It may weaken muscle activity in
the limb.
• GROWTH STIMULATION
- Electrical stimulation,
- Sympathectomy,
- Surgical AV fistula,
- Foreign bodies,
- Subperiosteal bone insertion /
grafting.
• DISTRACTION
OSTEOGENESIS /
EPIPHYSIOLYSIS
- Theoretically any length
can be achieved.
- No method is superior,
Ilizarov is a simpler
device.
- Can correct angular
deformity.
- Pts can be mobile.
- High rate of infection.
COMPLICATIONS
• PIN TRACT INFECTION ( local care vs. removal )
• FRACTURE
• KNEE JOINT STIFFNESS
• SLIGHT OVER & UNDER CORRECTION
• NON UNION
CONCLUSION
• LLD MGT IS CHALLENGING
• ACCEPTED FUNCTION Vs EQUAL LENGTH
• PROGNOSIS DEPENDS ON THE CAUSE
• Overzealous lengthening on the other hand is fraught with a lot of
complication
•
• The ultimate goal may not always be to correct the discrepancy
completely but to achieve an acceptable function
THANK YOU !!!!!!!!!!