Overview
Differences between lengths of the two upper extremities (upper and/or lower arms) or between the lengths of the two lower extremities (upper and/or lower legs) are called limb length discrepancy (LLD). A limb length discrepancy may be due to a normal variation that we all have between the two sides of our bodies, or it may be due to other causes. Some differences are so common that they are normal and need no treatment. For example, one study reported that 32 percent of 600 military recruits had a 5mm to 15mm (approximately 1/5 to 3/5 inch) difference between the lengths of their two lower extremities; this is a normal variation. Greater differences may need treatment because a discrepancy can affect a patient?s well being and quality of life.
Causes
Sometimes the cause of LLD is unknown, yet the pattern or combination of conditions is consistent with a certain abnormality. Examples include underdevelopment of the inner or outer side of the leg (hemimelias) or (partial) inhibition of growth of one side of the body of unknown cause (hemihypertrophy). These conditions are present at birth, but the limb length difference may be too small to be detected. As the child grows, the LLD increases and becomes more noticeable. In hemimelia, one of the two bones between the knee and the ankle (tibia or fibula) is abnormally short. There also may be associated foot or knee abnormalities. Hemihypertrophy or hemiatrophy are rare conditions in which there is a difference in length of both the arm and leg on only one side of the body. There may also be a difference between the two sides of the face. Sometimes no cause can be found. This type of limb length is called idiopathic. While there is a cause, it cannot be determined using currect diagnostic methods.
Symptoms
In addition to the distinctive walk of a person with leg length discrepancy, over time, other deformities may be noted, which help compensate for the condition. Toe walking on the short side to decrease the swaying during gait. The foot will supinate (high arch) on the shorter side. The foot will pronate (flattening of the arch) on the longer side. Excessive pronation leads to hypermobility and instability, resulting in metatarsus primus varus and associated unilateral juvenile hallux valgus (bunion) deformity.
Diagnosis
A qualified musculoskeletal expert will first take a medical history and conduct a physical exam. Other tests may include X-rays, MRI, or CT scan to diagnose the root cause.
Non Surgical Treatment
The treatment of LLD depends primarily on the diagnosed cause, the age of the patient, and the severity of the discrepancy. Non-operative treatment is usually the first step in management and, in many cases, LLD is mild or is predicted to lessen in the future, based on growth rate estimates in the two legs. In such cases, no treatment may be necessary or can be delayed until a later stage of physical maturity that allows for clearer prognostic approximation. For LLD of 2cm to 2.5cm, treatment may be as simple as insertion of a heel lift or other shoe insert that evens out leg lengths, so to speak. For more severe cases, heel lifts can affect patient comfort when walking, decrease ankle stability, and greatly increase the risk of sprains. For infants with congenital shortening of the limb, a prosthetic ? often a custom-fit splint made of polypropylene ? may be successful in treating more severe LLD without surgery. In many instances, however, a surgical operation is the best treatment for LLD.
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Surgical Treatment
Surgeries for LLD are designed to do one of three general things ? shorten the long leg, stop or slow the growth of the longer or more rapidly growing leg, or lengthen the short leg. Stopping the growth of the longer leg is the most commonly utilized of the three approaches and involves an operation known as an epiphysiodesis , in which the growth plate of either the lower femur or upper tibia is visualized in the operating room using fluoroscopy (a type of real-time radiographic imaging) and ablated , which involves drilling into the region several times, such that the tissue is no longer capable of bone growth. Because the epiphyseal growth capabilities cannot be restored following the surgery, proper timing is crucial. Usually the operation is planned for the last 2 to 3 years of growth and has excellent results, with children leaving the hospital within a few days with good mobility. However, it is only appropriate for LLD of under 5cm.
Differences between lengths of the two upper extremities (upper and/or lower arms) or between the lengths of the two lower extremities (upper and/or lower legs) are called limb length discrepancy (LLD). A limb length discrepancy may be due to a normal variation that we all have between the two sides of our bodies, or it may be due to other causes. Some differences are so common that they are normal and need no treatment. For example, one study reported that 32 percent of 600 military recruits had a 5mm to 15mm (approximately 1/5 to 3/5 inch) difference between the lengths of their two lower extremities; this is a normal variation. Greater differences may need treatment because a discrepancy can affect a patient?s well being and quality of life.
Causes
Sometimes the cause of LLD is unknown, yet the pattern or combination of conditions is consistent with a certain abnormality. Examples include underdevelopment of the inner or outer side of the leg (hemimelias) or (partial) inhibition of growth of one side of the body of unknown cause (hemihypertrophy). These conditions are present at birth, but the limb length difference may be too small to be detected. As the child grows, the LLD increases and becomes more noticeable. In hemimelia, one of the two bones between the knee and the ankle (tibia or fibula) is abnormally short. There also may be associated foot or knee abnormalities. Hemihypertrophy or hemiatrophy are rare conditions in which there is a difference in length of both the arm and leg on only one side of the body. There may also be a difference between the two sides of the face. Sometimes no cause can be found. This type of limb length is called idiopathic. While there is a cause, it cannot be determined using currect diagnostic methods.
Symptoms
In addition to the distinctive walk of a person with leg length discrepancy, over time, other deformities may be noted, which help compensate for the condition. Toe walking on the short side to decrease the swaying during gait. The foot will supinate (high arch) on the shorter side. The foot will pronate (flattening of the arch) on the longer side. Excessive pronation leads to hypermobility and instability, resulting in metatarsus primus varus and associated unilateral juvenile hallux valgus (bunion) deformity.
Diagnosis
A qualified musculoskeletal expert will first take a medical history and conduct a physical exam. Other tests may include X-rays, MRI, or CT scan to diagnose the root cause.
Non Surgical Treatment
The treatment of LLD depends primarily on the diagnosed cause, the age of the patient, and the severity of the discrepancy. Non-operative treatment is usually the first step in management and, in many cases, LLD is mild or is predicted to lessen in the future, based on growth rate estimates in the two legs. In such cases, no treatment may be necessary or can be delayed until a later stage of physical maturity that allows for clearer prognostic approximation. For LLD of 2cm to 2.5cm, treatment may be as simple as insertion of a heel lift or other shoe insert that evens out leg lengths, so to speak. For more severe cases, heel lifts can affect patient comfort when walking, decrease ankle stability, and greatly increase the risk of sprains. For infants with congenital shortening of the limb, a prosthetic ? often a custom-fit splint made of polypropylene ? may be successful in treating more severe LLD without surgery. In many instances, however, a surgical operation is the best treatment for LLD.
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Surgical Treatment
Surgeries for LLD are designed to do one of three general things ? shorten the long leg, stop or slow the growth of the longer or more rapidly growing leg, or lengthen the short leg. Stopping the growth of the longer leg is the most commonly utilized of the three approaches and involves an operation known as an epiphysiodesis , in which the growth plate of either the lower femur or upper tibia is visualized in the operating room using fluoroscopy (a type of real-time radiographic imaging) and ablated , which involves drilling into the region several times, such that the tissue is no longer capable of bone growth. Because the epiphyseal growth capabilities cannot be restored following the surgery, proper timing is crucial. Usually the operation is planned for the last 2 to 3 years of growth and has excellent results, with children leaving the hospital within a few days with good mobility. However, it is only appropriate for LLD of under 5cm.
