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Limb length discrepancies
- 1. Limb Length Discrepancies Dr.Sairamakrishnan S
- 2. • Limb lengthdiscrepancy or anisomelia, is defined as a condition in which the paired limbs have a noticeably unequal length.
- 3. • Asymptomatic lengtheningof <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
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- 9. Classification – McCawand Bates • Mild – <3 cm • Moderate – 3-6 cm • Severe – >6 cm
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- 11. History • Congenital ordevelopmental. • Onset and mode of deformity • Family history • Fractures/injury
- 12. Examination • The examinermust 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 – legtechnique
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- 19. Imaging – CTscan • 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
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- 26. • Paley multiplier –State of the art – multiplier for chronological or skeletal age – predicts LLD at maturity
- 27. Congenital Limb LengthDiscrepancy • Δm = Δ x M – Δ:Current Limb-length discrepancy – Δm: Limb discrepancy at skeletal maturity – M:multiplier
- 28. Developmental LLD Leg-lengthdiscrepancy • Δm = Δ + (IxG) • I=1 -(S – S’)/(L – L’) • G=L(M-1)
- 29. – G= amountof 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= lengthof 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 lengthdiscrepancy • Poor underlying bone quality for lengthening • Dysfunctional/ painful limb