LLD

1. Limb Length Discrepancies
Dr. Sairamakrishnan S

2. • Limb length discrepancy or anisomelia, is
defined as a condition in which the paired
limbs have a noticeably unequal length.

3. • Asymptomatic lengthening of <2cm has been
found in upto 50% of normal population
• Any LLD of more than 2.5 cms is significant
and needs to be corrected.

4. Causes – Shortening
• Congenital limb deficiency
– Congenital femoral deficiency
– Congenital fibular deficiency
– Tibial hemimelia
• Asymmetric neurologic disorders
– Hemimyelomeningocele
– Poliomyelitis
– Asymmetric static encephalopathy
– Asymmetric peripheral neuropathy

5. • Trauma
– Malunion
– Physeal growth disturbance or arrest after fracture
• Other acquired causes of physeal growth
disturbance
– Infection
– Tumor
– Irradiation
– Blount's disease
– Legg-Calvé-Perthes disease

6. Causes - Lengthening
• Post-traumatic overgrowth
– Femoral shaft fracture
– Tibial shaft fracture
• Soft tissue overgrowth syndromes
– Gigantism with neurofibromatosis
– Klippel-Trénaunay syndrome
– Beckwith-Wiedemann syndrome
– Proteus syndrome
– Idiopathic hemihypertrophy
• Inflammatory arthritis

7. Classification
• Congenital
• Developmental
• Acquired

8. Classification
• Structural
• Functional

9. Classification – McCaw and Bates
• Mild – <3 cm
• Moderate – 3-6 cm
• Severe – >6 cm

10. Evaluation
• History
• Exmination
• Imaging

11. History
• Congenital or developmental.
• Onset and mode of deformity
• Family history
• Fractures/injury

12. Examination
• The examiner must be sure that the child is
standing evenly, with the knees extended and
the feet flat on the floor.
• Galeazzi's sign.
• Legs should be held in symmetric positions
while examination.

15. Thigh – leg technique

16. Imaging - Telerongentography

17. Imaging – Orthorongentography

18. Imaging – Scanogram

19. Imaging – CT scan
• Software measures distances
– accurate to 0.2 mm
– legs must be in same position
– fast

20. Determining skeletal age
Greulich- Pyle Atlas
– Xray non dominant hand
– less accurate
– improved accuracy by focusing on hand bones
rather than carpal bones

21. Tanner- Whitehouse Atlas
– more refined
– 20 landmarks graded L Hand
– more accurate

22. Prediction of shortening
• Green & Anderson tables
– Growth remaining method
– Uses skeletal age
– Requires graph
– Estimates growth potential in distal femur and
proximal tibia at various skeletal ages
– Separate charts for girls and boys

23. • Moseley charts
– Straight - Line Graph Method
– At least 3 measurements each time
• Length long leg
• Length short leg
• Skeletal age
– Do so atleast 3 times separated by 3-6 months

25. • Menelaus Method

26. • Paley multiplier
– State of the art
– multiplier for chronological or skeletal age
– predicts LLD at maturity

27. Congenital Limb Length Discrepancy
• Δm = Δ x M
– Δ:Current Limb-length discrepancy
– Δm: Limb discrepancy at skeletal maturity
– M:multiplier

28. Developmental LLD Leg-length discrepancy
• Δm = Δ + (IxG)
• I=1 -(S – S’)/(L – L’)
• G=L(M-1)

29. – G= amount of growth remaining
– I=amount of growth inhibition
– L= current length of long limb
– L’=length of long limb as measured on previous
radiograph
– S= current length of short limb
– S’ =length o f short limb as measured on previous
radiographs

30. Time of Epiphysiodesis
• Lm=L x M
• L ε = Lm – G ε
• M ε =Lm/Lε

31. – Lm= length of femur or tibia at skeletal maturity
– L= current length of long limb
– M=multiplier
– Lε =desired length of bone to undergo epiphysiodesis
at time of epiphysiodesis
– ε=desire d correction following epiphysiodesis
– Gε=amount of femoral or tibial growth remaining at
age of epiphysiodesis(G ε= ε/0.71 for femur and
ε/0.57 for tibia)
– Mε=multiplier at age of epiphysiodesis

32. Management
• <2 - No treatment or shoe lift
• 2-5 - Growth Modulation(Shoe lift /
Epiphysiodesis / Shortening)
• 5-12.5 - Consider bone-lengthening
• >12.5 - Combinations of above or amputation

33. Amputation
• Significant length discrepancy
• Poor underlying bone quality for lengthening
• Dysfunctional/ painful limb