The 2nd Annual BLT Paediatric Orthopaedic Course 6 October 2009 2 Overview
Aetiology
Complications
Clinical assessment
Management
Outcomes
3 Aetiology
Congenital
Acquired
4 Congenital
Long bone deficiency
Fibula
Femur
Tibia
Hemiatrophy
Silver-Russell
Hemihypertropy
Haemangioma
Lipomatosis
NF
Beckwith-Wiedemann
McCune-Albright
5 Fibula Hemimelia
Most common congenital long bone deficiency
Incidence 150,000
Spectrum of severity
May involve the whole leg
small fibula absent fibula 3 ray foot
6 Fibula Hemimelia
Classification
Coventry (1952)
I partial fibula
II absent fibula
III bilateral or femoral involvement or other congenital abnormalities
Achterman Kalamchi (1979)
IA fibula present
IB fibula absent 30-50
II no fibula
Stanitski (2003)
fibula morphology I II III
Distal tibia epiphysis shape H V S
? Tarsal coalition c
Number of rays in foot 1-5
7 Acquired
Trauma
Overgrowth
Malunion
Bone loss
AVN
Physeal injury
Olliers
Polio
CP
Apparent LLD hip spine 8 Complications
Does it matter?
Are there long term adverse effects ?
9
Relationship of limb length inequality with radiographic knee and hip osteoarthritis.
Osteoarthritis Cartilage 2007 15 824-9
-- Increased risk of knee OA (not hip) with gt2cm LLD
The effect on low back pain of shortening osteotomy for leg length inequality.
Int Ortho. 1992 16 388-91
-- Reduced LBP symptoms after length equalisation (3cm)
Changes in pain and disability secondary to shoe lift intervention in subjects with limb length inequality and chronic low back pain a preliminary report.
J Orthop Sports Phys Ther. 2007 37 380-8
-- Wearing a shoe raise (2cm) reduced LBP symptoms
10
Leg-length inequality in people of working age. The association between mild inequality and low-back pain is questionable.
Spine 1991 16 429-31.
Mild LLD (lt2cm) no association with LBP
Preoperative leg-length inequality and hip osteoarthrosis a radiographic study of 100 consecutive arthroplasty patients.
Skel Radiol. 2005 34 136-9
OA more likely on the side of the LONGER leg
11
Leg length inequality. A prospective study of young men during their military service. Upsala J Med Sci. 1988 93 245-53
600 recruits
lt0.5cm 64
0.5-1.5 cm 32
gt1.5 cm 4
No correlation between LLD and LBP
Does unequal leg length cause back pain? A case-control study.Lancet. 1984 2 256-8
No association found
Short-leg syndrome.BMJ 1971 1 245
gt1/2 inch shortening required a shoe raise
12
What is the risk of cancer in a child with hemihypertrophy?
Arch Dis Childhood. 2005 90 1312-3
5
Abdominal USS every 3 months until aged 6
13 Clinical assessment
History
Examination
Investigations
14 Clinical assessment
History
Congenital or acquired ?
Trauma / Infection ?
Progressive / static ?
?syndrome
15 Clinical assessment
Examination
Gait
Lower Limb
Determine which segment is shortened
Is it too long or too short ?
Foot
Exclude fixed deformities knee and foot
? Wasting
Spine
?scoliosis fixed or mobile
Upper limb
Face
16 Clinical assessment
Examination
Standing on blocks
Check that knees fully extended
ASIS level
Ask the patient
Check spine
Supine
Real and apparent leg lengths
Hips / knees / ankles
Galeazzi (Allis) test
17 Clinical assessment
Investigations
Standing radiographs
Block up the shorter leg
Standardised position patella forwards
Calibration ball
CT scannogram
18 Radiographs
Teleorentgenogram
Single cassette
Single exposure
Problem magnification errors
Orthoroentgenogram
Single cassette
3 exposures centered at hip knee and ankle
Problem only see the joints
Scanogram
2 or 3 cassettes
Cassette moved between exposure
Images stitched togethor
Problem must keep still
19 Management
Depends on
the projected LLD at skeletal maturity
Final height
Age
20 How do I know what the final LLD will be?
4 methods
Arithmetic (Menelaus)
Growth remaining (Green Anderson)
Straight line graph (Moseley)
Limb Multiplier (Paley)
21 Chronological vs skeletal age
Skeletal age
Use the Greulich and Pyle atlas
Left hand carpus
Recommended for Moseley Green / Anderson methods
I use chronological age
Cundy et al JPO 1988 8 513-515
Little et al JPO 1996 16 173-179
To comply with the accepted standard, skeletal age should be used for patients who are 10 years or older. However, in most cases, we prefer to use the chronological age. 22 Pattern of altered limb growth
803 children
Variety of aetiologies
PFFD
Polio
Traumatic growth arrest
Olliers
Perthes
femur
CP
NF
JRA
Hemiatrophy / hypertrophy
Shapiro JBJS 1982 64A 639-651 23 Type 3 34 Type 4 3 Type 5 8 Type 2 14 Type 1 41 Shapiro JBJS 1982 64A 639-651 24 Type 5 11 ? 31 Type 4 3 Type 3 22 Type 1 33 n36 Boys 13 Girls 23 Type 2 0 25 Arithmetic method of Menelaus
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