Limb Length Discrepancies

A look at various etiologies that affect people with limb length differences and the podiatric manifestations of discrepancies in limb length.

Kelvin A. Barry, BS New York College of Podiatric Medicine

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 the neck 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 world s population exhibits limb length differences DO YOU HAVE ONE???

Introduction
Congenital LLD is present form birth and is associated with many
birth defects & deformities. Acquired LLD may result from developmental changes, posttrauma, & 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.

Congenital Etiology
Congenital hemiatrophy with skeletal anomalies. Global aplasia, femoral aplasia, coxa vara Olliers Disease (dyschondroplasia). Non-hereditary; causes tumors in bones of one extremity, affecting the long 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

Infectious Etiology
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

Neoplastic Etiology
Osteochondroma (solitary exostosis) Giant cell tumors Osteitis fibrosa cystica generalista Neurofibromatosis (von Recklinghausens disease) Hemangioma Lymphangioma Fibrous Dysplasia (Jeff-Lichtenstein)

Trauma Etiology
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

Other Etiological Factors

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

Diagnosis
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 pelvic obliquity relative to height of the knees

Diagnosis
Clinical 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

Podiatric Manifestations
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.

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

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.

References
1. Stanitski DF: Lim-length inequality: Assessment and Treatment Options. J Am Acad Orthop Surg, 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): 907915, 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.

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 <http://www.medmedia.com/o2/29.htm>. 13. Kiper, DPM D. Leg Length Discrepancies. Fitness Runner Holiday 1999. 6 September 2002 <http://www.drkiper.com/articles/LegLength.html>. 14. Extended possibilities for patient with leg length discrepancy. Shriners Hospital Page. 6 September 2002 <http://www.shrinershq.org/shc/houston/olliers1-01.html>. 15. Leg Length Differences. Maryland Center for Limb Lengthening and Reconstruction. 6 September 2002 <http://www.umm.edu/mcllr/mcllr_treat.html>. 16. Limb Length Inequality: Evaluation & Treatment. Orthopaedics. Connecticut Childrens Medical Center. 27 September 2002 <http://www.ccmckids.org/departments/Orthopaedics/orthoed10.htm>.