Discusses regarding orthopedic aspects of limb length discrepancy, classification, etiology, goal of treatment, case based questions, epiphysiodesis, lengthening and shortening procedures. The entire slides are incorporated with intelligently put five questions for applicability of the concepts and better understanding

1. L I M B L E N G T H
D I S C R E P A N C Y
P R E S E N T E D B Y - D R . S I B A S I S
G A R N A Y A K
M O D E R A T O R S R - D R . Y O G E S H
P A T E L
C O N S U L T A N T - D R . R E H A N U L H A Q

2. C O N T E N T
• Introduction
• Classification
• Etiology of LLD
• Mechanism of compensation
• Evaluation of LLD
• Predictor of growth
• Guideline for management
• Epiphysiodesis
• Limb Shortening procedures
• Limb Lengthening procedures
• Questions and discussions

3. D E F I N I T I O N
• Limb length discrepancy is defined as a condition in which the paired
extremity limbs have a noticeably unequal length.

4. I N T R O D U C T I O N
• Frequent parental concern.
• Incidentally during screening examinations.
• Cosmetic and functional concern
• 0.5-2.0 cm are usually asymptomatic.
• >2.5 cm – significant
• Increasing likelihood of hip, knee and lumbar spine pain

5. I N T R O D U C T I O N
• Short leg gait- awkward
• excessive vertical rise and fall of pelvis.
• Changes in facet joint orientation- back pain
• Compensatory scoliosis and decreased spinal mobility.
• Compensatory ankle movement
• Management-complex
• Cause of the discrepancy, associated conditions, pain, and patient/family
expectations.

6. C L A S S I F I C AT I O N
• Structural
• Anatomical
• Actual shortening of skeletal
system.
• Congenital or acquired.
mild<3 cm
moderate 3-6 cm
severe >6 cm
• Functional
• Apparent
• Functional inequality occurs.
• Without concomitant shortening of
osseous component.
• Usually acquired.

7. E T I O L O G Y O F S H O R T L I M B
• Congenital limb deficiency- congenital femoral deficiency, congenital fibular
deficiency, tibia hemimelia
• Asymmetrical neurological disorders- poliomyelitis, hemiplegic cp, hemi
myelomeningocele
• Traumatic- malunion, growth plate arrest
• Hemi atrophy- idiopathic, Russel-Silver syndrome
• Other- infection, tumor, post irradiation, Blounts disease, unilateral club foot,
congenital pseudoarthrosis of tibia.

8. E T I O L O G Y O F L O N G L I M B
• Post traumatic- femur shaft # (why?), tibia shaft #
• Soft tissue overgrowth- Beckwith-Wiedemann syndrome, Klippel-
Trenaunary syndrome, proteus syndrome, gigantism
• Chronic inflammatory arthritis- Rheumatoid arthritis
• Idiopathic hemihypertrophy

9. M E C H A N I S M O F C O M P E N S AT I O N
Compensatory mechanisms-
• Excessive pelvic motion and tilt
• Persistent flexion of the longer limb
• Circumduction of the longer limb
• Toe-walking on the shorter limb (minor LLD)
• More mechanical work by longer limb
• Vertical displacement of centre of gravity

10. E VA L U AT I O N O F L L D
• History
• Examination
• Imaging
Radiograph
Bone age
Scanogram

11. H I S T O R Y A N D E VA L U AT I O N
• Congenital or developmental
• Age of onset
• Determine cause
• Determine deformity- rotational or angular, joint mobility
• Functional status of joints
• Foot height differences
• Current and predicted discrepancy in limb length

12. E X A M I N AT I O N
• Wood block test:
• Blocks under short leg until pelvis level
• Simplest method
• Best initial screening method.
• Error in pelvic asymmetry or obliquity
• Leg length measurement:
• Apparent length: umbilicus to medial malleolus
• True length: ASIS to medial malleolus

13. S TA N D I N G O R T H O R A D I O G R A P H
A N D S C A N O G R A M

14. C T S C A N O G R A M
• Software measures distance.
• Accurate up to 0.2 mm.
• Fast method
• Legs must be in same position
• No magnification error
• knee flexion contracture or is
in a circular external fixator.

15. S K E L E TA L A G E
1. Greulich Pyle atlas
• X ray left hand
• Corelates with Green Anderson
table
• Less accurate <6
• Improved accuracy by focusing on
hand bones rather than carpal
bones
• Tanner Whitehouse atlas
• More refined
• 20 landmarks graded left hand
• More accurate
• Cant us as not correlated with LL

16. P R E D I C T I O N O F G R O W T H
R E M A I N I N G
• Time of limb equalization.
• Green Anderson growth
remaining chart
• Moseley chart
• Menelaus method
• Multiplier app
• Paley multiplier

17. P R O B L E M S W I T H G R E E N
A N D E R S O N A N D M O S L E Y M E T H O D
• Do not estimate foot height.
• Not applicable to modern children.
• Growth not always mathematically predictable.
• Role of nutritional, metabolic, hormonal, and
socioeconomic factors.
• LLD in Juvenile rheumatoid arthritis and Perthes
disease- discrepancy corrects itself

18. G R O W T H I N L O W E R L I M B
( M E N E L A U S M E T H O D )
• Proximal femur
3 mm/year
• Distal femur
9mm/year
• Growth cessation
14 year in girls
16 year in boys
• Proximal tibia
6mm/year
• Distal tibia
3mm/year

19. Q U E S T I O N 1
• A 9-year-old male sustains the fracture seen in the figure. If a complete growth
arrests occurs, his expected leg length discrepancy at skeletal maturity would
be?
• A. 2 cm
• B. 3 cm
• C. 4 cm
• D. 6 cm
• E. none

20. PA L E Y M U LT I P L I E R
• Take LLD for boy or girl
• Multiplier for skeletal or chronological age
• Predicts LLD at maturity.
• Limb length discrepancy at skeletal
maturity= current limb length discrepancy
x multiplier.
• Can help predict timing of epiphysiodesis.
Current LLD in a 10 year old boy with
congenital hemihypertrophy is 4 cm.
What will be the approximated limb
length discrepancy at maturity?

21. G O A L O F T R E AT M E N T
• Balanced spine and pelvis
• Equal limb lengths
• Correct mechanical weight-bearing axis
• Methods :
• Shoe lift or prosthetic conversion
• Epiphysiodesis of the long leg
• Shortening of the long leg
• Lengthening of the short leg
• Lengthening+ contralateral
epiphysiodesis

22. S H O E L I F T
• Patients who do not wish or are not
appropriate for surgery.
• Small discrepancy- heel lift, large
difference- full shoe lift
• >5 mm – poorly tolerated, unstable

23. P R O S T H E T I C F I T T I N G
• Significant discrepancy, functionally useless foot
• Discrepancy more than 15-20 cm and femoral length less than 50 %
• Fibula hemimelia with unstable ankle
• PFFD : A/K prosthesis or B/K prosthesis with van nes rotation plasty.
• Optimal age- Syme amputation – end of 1 year
• Rotation plasty- 3 years

24. P R O S T H E T I C F I T T I N G

25. E P I P H Y S I O D E S I S
• Arrest of growth of a particular physis.
• Physeal, rather than epiphyseal, growth is
halted.
• Phemister - 1933
• For growing children, small discrepancy (2-5 cm)
• Slowing growth rate of long leg, allowing short
leg to catch up.
• Very low morbidity and complication rate.

26. P E R C U TA N E O U S E P I P H Y S I O D E S I S

27. Q U E S T I O N 2
• Lateral tibial physeal stapling is a treatment option for adolescent Blount’s
disease. How is the staple an example of the Hueter-Volkmann principle?
• A. Increased compression along the growth plate slows longitudinal growth
• B. Decreased compression along the growth plate slows longitudinal growth
• C. Increased tension along the growth plate slows longitudinal growth
• D. Decreased tension along the growth plate slows longitudinal growth
• E. Increased compression along the plate increases longitudinal growth

28. E P I P H Y S E A L S TA P L I N G
• Blount and Clark
• Growth stops immediately.
• Three staples should span physis.
• Position verified on both AP and lateral
• Vitallium staples >stainless steel.

29. T E N S I O N P L AT E E P I P H Y S I O D E S I S

30. P R O B L E M S O F E P I P H Y S I O D E S I S
• Under correction
• Over correction
• Rebound phenomenon
• Failure of growth restoration
• Breakage or bending

31. Q U E S T I O N 3
• A 14-year-old male patient with a leg-length discrepancy undergoes a distal femoral
and proximal tibial epiphysiodesis on the longer leg. What is the anticipated amount
of correction achieved with this procedure in this child?
• A. 1.6 cm
• B. 2 cm
• C. 3.2 cm
• D. 4 cm
• E. 6.4 cm

32. S H O R T E N I N G P R O C E D U R E S
• Skeletally mature patients.
• Ultimate length and alignment should be considered.
• Femur-5 to 6 cm, tibia- 2 to 3 cm.
• Femoral shortening is tolerated better than tibial shortening (why?)
• Wagner-metaphyseal osteotomy for angular correction, diaphyseal if
shortening alone.
• Complications :
fat embolism
AVN of the femoral head
muscle weakness

33. S H O R T E N I N G P R O C E D U R E - F E M U R

34. S H O R T E N I N G P R O C E D U R E T I B I A

35. L I M B L E N G T H E N I N G
• Callotasis- low-energy corticotomy followed by
gradual distraction
• Multiple percutaneous drill holes
• Avoid disruption of soft tissues.
• Latent period of 1 to 3 weeks-Distraction to allow
for early callous formation.
• 1 mm/ day divided over four 0.25-mm increments
• Device -1 month for every 1 cm of length
achieved.
• Complications : deep infection, nonunion,
fracture after device removal, malunion, joint
stiffness, and nerve palsy.

36. D E V I C E S F O R L E N G T H E N I N G
• Wagner’s low profile mono lateral
fixator
• DeBastiani’s Orthofix
• The Ilizarov device
• Taylor Spatial Frame- six-axis
deformity analysis incorporated in
a computer program.

37. D E V I C E S F O R L E N G T H E N I N G
• Lengthening initiated by rotation
of the involved limb (Albizzia nail)
• Controlled rotation, ambulation,
and weight bearing
(Intramedullary Skeletal Kinetic
Device)
• Electrically activated motorized
drive (Fitbone)
• Externally applied magnetic field
(PRECICE Nail),

38. • Frame applied
perpendicular to
mechanical axis.
• Distal reference wire-
parallel to femoral condyles.
• Proximal reference pin-
perpendicular to
mechanical axis.
• Middle ring is larger than
distal two rings to
accommodate conical
shape of thigh.

39. • In skeletally immature child with intact
physes,
• Single ring distal to proximal tibial
epiphysis is used with drop wire for
additional segmental stabilization of
proximal segment.
• For significant amount of lengthening,
third ring can be placed more distally
to allow greater mass of soft tissue for
recruitment into lengthening process.

40. C O M P L I C AT I O N S O F
L E N G T H E N I N G
• Pin site infection
• Muscular problems- Tricep surae and quadriceps
• Joint subluxation or dislocation
• Neurovascular problems
• Premature or delayed consolidation
• Malunion and axis deviation

42. R O L E O F A M P U TAT I O N
• Significant length discrepancy
• Poor underlying bone quality for lengthening
• Dysfunctional of painful limb

43. Q U E S T I O N 4
• A 4-year-old boy sustains a midshaft femur fracture with less than 2 cm of
shortening that was treated with immediate closed reduction and hip-spica
casting. Of the following listed potential complications, which is the most
common requiring early surgical intervention in this age group?
• A. delayed union
• B. Non union
• C. cosmetic deformity
• D. leg-length discrepancy
• E. loss of reduction

44. Q U E S T I O N 5
• A 15-year-old male presents with pain and progressive deformity
about his left knee. A standing AP radiograph is seen in figure A,
with the tibial growth plate nearly closed. Physical examination
reveals significant varus and a leg-length discrepancy of 2.5cm
right greater than left. Which of the following is the most
appropriate method of management at this time?
• A. Orthotics
• B. Hemi epiphysiodesis of the left proximal tibia, medial side only
• C. Epiphysiodesis of the left proximal tibia
• D. Left proximal tibia osteotomy with placement of lengthening
external fixator
• E. Left proximal tibia osteotomy with plate fixation

45. R E F E R E N C E S
• Campbells operative orthopaedics, 13/e
• Tachdjians pediatric orthopaedics 5/e

46. THANK
YOU