Introduction Common causes of LLD congenital disorders hemihypertrophy dysplasias PFFD DDH unilateral clubfoot paralytic disorders spasticity (cerebral palsy) polio physis disruption infection trauma tumor Epidemiology 2cm LLD occurs in up to 2/3 of the population Associated conditions back pain increased prevalence of back pain osteoarthritis decreased coverage of femoral head on long leg side leads to osteoarthritis 84% of the time functional scoliosis inefficient gait equinus contracture of ankle Classification Static malunion of femur or tibia Progressive physeal growth arrest congenital absolute discrepancy increases proportion stats the same Presentation Symptoms usually asymptomatic Physical exam block testing with the patient standing, add blocks under the short leg until the pelvis is level, then measure the blocks to determine the discrepancy block testing is considered the best initial screening method tape measurement measure from the anterior superior iliac spine to the medial malleolus with a tape measure evaluate for hip, knee and ankle contractures affect apparent limb length hip adduction contracture causes apparent shortening of adducted side Imaging Radiographs teleoroentgenography (scanography) measure discrepancy with single exposure from 2m away bone age hand films determine bone age with bone age xray (hand) CT Scanography CT scanography is the most accurate diagnostic test with contractures of the hip, knee, or ankle LLD Projections General assumptions growth continues until 16 yrs in boys and until 14 yrs in girls Methods to project LLD at maturity Mosley graph estimation technique leg grows 23 mm/year, with most of that coming from the knee (15 mm/yr) proximal femur - 3 mm / yr (1/8 in) distal femur - 9 mm / yr (3/8 in) proximal tibia - 6 mm / yr (1/4 in) distal tibia - 5 mm / yr (3/16 in) Can be tracked with Green-Anderson tables uses extremity length for a given age Moseley straight line graph improves on Green-Anderson method by reformatting data in a graph form accounts for differences between skeletal and chronologic age minimizes error averages serial measurements Multiplier method prediction based on multiplying the current discrepancy by a sex and age specific factor most accurate for congenital LLD 1/2 of final leg length girls at age 3 boys at age 4 Treatment Nonoperative shoe lift or observation only indications < 2 cm projected LLD at maturity outcomes not associated with scoliosis or back pain Operative shortening of long side via epiphysiodesis of femur, tibia, or both indications 2-5 cm projected LLD limb lengthening of short side indications > 5 cm projected LLD lengthening often combined with a shortening procedure (epiphysiodesis, ostectomy) on long side physeal bar excision indications bony bridge involves <50% of physis at least 2 years left of growth amputation and prosthetic fitting indications non-reconstructable limb > 20 cm projected LLD Surgical Techniques Distraction osteogenesis (Ilizarov principles) initiation perform osteotomy and place fixator metaphyseal corticotomy to preserve medullary canal and blood supply distraction wait 5-7 days then begin distraction distract ~ 1 mm/day following distraction keep fixator on for as many days as you lengthened concurrent procedures may lengthen over a nail so ex-fix can be removed sooner lengthening often combined with a shortening procedure (epiphysiodesis, ostectomy) on long side Complications Incomplete arrest/ angular deformity open technique percutaneous technique Pin site infections Fracture Delayed union Premature cessation of lengthening Joint subluxation/dislocation Mechanical axis deviation (MAD) lengthening along the anatomical axis of the femur leads to lateral MAD shortening along the anatomical axis of the femur leads to medial MAD
Technique Guide 10/4/2016 Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. Growth Guided Hemiepiphysiodesis Lindsay Andras Paul D Choi Pediatrics - Leg Length Discrepancy (LLD)
QUESTIONS 1 of 20 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ11.203) A 13-year-old boy presents with a leg-length discrepancy with the right leg shorter than the left. He has normal height for his age and his skeletal age is equal to his chronologic age. History and examination of Tanner staging reveals that he began puberty 1 month ago. His final leg length discrepancy at skeletal maturity is projected to be 4.0cm. Which of the following surgical options is the most appropriate? Review Topic QID: 3626 1 Physeal stapling of the medial left tibial and femoral physis now with staged removal of staples at age 16 10% (272/2706) 2 Immediate lengthening of the right femur with ring external fixator 2% (55/2706) 3 Epiphysiodesis of the left femur 1 year after the onset of puberty 21% (575/2706) 4 Epiphysiodesis of the left femur and tibia 6 months from now 65% (1762/2706) 5 Epiphysiodesis of the bilateral femurs and shortening of the left tibia now 1% (21/2706) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (OBQ12.29) At what age does longitudinal growth usually arrest in boys at the distal femur physeal growth plate? Review Topic QID: 4389 1 18 10% (288/2955) 2 16 83% (2446/2955) 3 14 6% (174/2955) 4 12 1% (22/2955) 5 10 0% (7/2955) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (OBQ05.159) A 9-year-old girl presents with a history of juvenile rheumatoid arthritis, and a 20 degree flexion contracture of her left knee. A clinical photo is shown in Figure A. Which of the following is the most accurate method of determining leg length discrepancy in this patient? Review Topic QID: 1045 FIGURES: A 1 Teloradiograph 5% (63/1211) 2 Orthoradiograph 15% (177/1211) 3 Scanogram 20% (242/1211) 4 CT scanogram 59% (714/1211) 5 Bone scan 0% (6/1211) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (OBQ08.6) A 14-year-old boy sustains a significant distal femoral physeal fracture. Assuming that he has a complete growth arrest, what is the predicted leg length discrepency? Review Topic QID: 392 1 1cm 4% (86/2277) 2 2cm 88% (1996/2277) 3 3cm 5% (104/2277) 4 4cm 3% (64/2277) 5 5cm 1% (23/2277) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (OBQ04.62) A 14-year-old boy has complete growth arrest of his left proximal tibia after a skateboarding injury. He currently has a 3mm leg-length discrepancy with left shorter than the right. A radiograph of the patients left hand, wrist, and fingers demonstrate a bone-age of 14 years. What is the most appropriate management of this patient? Review Topic QID: 1167 1 Observation 63% (331/525) 2 Left tibial lengthening 1% (7/525) 3 Right tibia epiphysiodesis 30% (157/525) 4 Right femur epiphysiodesis 5% (27/525) 5 Amputation 0% (1/525) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 1 (OBQ06.108) 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? Review Topic QID: 294 1 1.6 cm 3% (78/2357) 2 2 cm 6% (145/2357) 3 3.2 cm 84% (1970/2357) 4 4 cm 5% (118/2357) 5 6.4 cm 2% (37/2357) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 3 (OBQ07.255) A 9-year-old male sustains the fracture seen in Figure A. If a complete growth arrests occurs, his expected leg length discrepancy at skeletal maturity would be? Review Topic QID: 916 FIGURES: A 1 2 cm 2% (24/1161) 2 3 cm 3% (32/1161) 3 4 cm 6% (71/1161) 4 5 cm 11% (127/1161) 5 6 cm 78% (907/1161) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 5 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK
Congenital Malformations (C2574) Pediatrics - Leg Length Discrepancy (LLD) HPI - This is the case of a 10 month old girl with a hypotrophic malformation syndrome of the left half of the body. She has thumb duplication with a second inter-digital space angle of about 80 degrees, a radial club hand, and a hypoplastic radius. Hallux duplication deviated 88 degrees medially, tibia hypoplasia with a 3 cm leg length discrepency. She underwent surgical treatment (by non-expert hands) of these duplications without correcting the deviations. She is now 7 months post-op. Do you think that this is Silver-Russell syndrome? 4/24/2016 99 0 2 limb length discrepency (C2212) Pediatrics - Leg Length Discrepancy (LLD) HPI - 25 yr female presented with rt lateral pelvic tilt,thigh adduction,internal rotation and tight rt hamtrings since childhood underwent adductor release plus hamstring release and derotation osteotomy 6 months ago,pelvic tilt improved(3cm on standing,5cm supine), patient now wear 1.8cm shoe lift and still have limping What is the best treatment method to correct limp length inequality? 4/26/2015 38 0 7