Overview

Your child has been diagnosed with a leg-length discrepancy. This means that your child?s legs are slightly different lengths, with one leg longer than the other. The difference in lengths can vary widely. The larger the difference in lengths, the more problems that can result as the child gets older. Because of this, your child may be referred to a pediatric orthopedist (doctor specializing in treating bone and joint problems in children) for evaluation and possible treatment.

Causes

Some causes of leg length discrepancy (other than anatomical). Dysfunction of the hip joint itself leading to compensatory alterations by the joint and muscles that impact on the joint. Muscle mass itself, i.e., the vastus lateralis muscle, pushes the iliotibial band laterally, causing femoral compensations to maintain a line of progression during the gait cycle. This is often misdiagnosed as I-T band syndrome and subsequently treated incorrectly. The internal rotators of the lower limb are being chronically short or in a state of contracture. According to Cunningham's Manual of Practical Anatomy these are muscles whose insertion is lateral to the long axis of the femur. The external rotators of the hip joint are evidenced in the hip rotation test. The iliosacral joint displays joint fixations on the superior or inferior transverse, or the sagittal axes. This may result from many causes including joint, muscle, osseous or compensatory considerations. Short hamstring muscles, i.e., the long head of the biceps femoris muscle. In the closed kinetic chain an inability of the fibula to drop inferior will result in sacrotuberous ligament loading failure. The sacroiliac joint dysfunctions along its right or left oblique axis. Failure or incorrect loading of the Back Force Transmission System (the longitudinal-muscle-tendon-fascia sling and the oblique dorsal muscle-fascia-tendon sling). See the proceedings of the first and second Interdisciplinary World Congress on Low Back Pain. Sacral dysfunction (nutation or counternutation) on the respiratory axis. When we consider the above mentioned, and other causes, it should be obvious that unless we look at all of the causes of leg length discrepancy/asymmetry then we will most assuredly reach a diagnosis based on historical dogma or ritual rather than applying the rules of current differential diagnosis.

Symptoms

The symptoms of limb deformity can range from a mild difference in the appearance of a leg or arm to major loss of function of the use of an extremity. For instance, you may notice that your child has a significant limp. If there is deformity in the extremity, the patient may develop arthritis as he or she gets older, especially if the lower extremities are involved. Patients often present due to the appearance of the extremity (it looks different from the other side).

Diagnosis

The only way to decipher between anatomical and functional leg length inequalities (you can have both) is by a physical measurement and series of biomechanical tests. It is actually a simple process and gets to the true cause of some runner?s chronic foot, knee, hip and back pain. After the muscles are tested and the legs are measured it may be necessary to get a special X-ray that measures both of your thighs (Femurs) and legs (Tibias). The X-ray is read by a medical radiologist who provides a report of the actual difference down to the micrometer leaving zero room for error. Once the difference in leg length is known, the solution becomes clear.

Non Surgical Treatment

A personalized approach to leg length discrepancy treatment works best for each patient. Your child's doctor will consider many factors when deciding on a course of treatment for this condition. Such factors can include your child's age, extent of the leg length discrepancy, medical history, how your child tolerates certain treatments and procedures, your child's health and prognosis, growth rate, and parental preferences. There is no cookie cutter treatment for each child, or even each centimeter of leg difference. Once all of these factors have been carefully considered, your child's physician will come up with an appropriate course of care. In situations of a very small leg length discrepancy, no treatment, only periodic medical evaluation, may be necessary.



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Surgical Treatment

Surgical operations to equalize leg lengths include the following. Shortening the longer leg. This is usually done if growth is already complete, and the patient is tall enough that losing an inch is not a problem. Slowing or stopping the growth of the longer leg. Growth of the lower limbs take place mainly in the epiphyseal plates (growth plates) of the lower femur and upper tibia and fibula. Stapling the growth plates in a child for a few years theoretically will stop growth for the period, and when the staples were removed, growth was supposed to resume. This procedure was quite popular till it was found that the amount of growth retarded was not certain, and when the staples where removed, the bone failed to resume its growth. Hence epiphyseal stapling has now been abandoned for the more reliable Epiphyseodesis. By use of modern fluoroscopic equipment, the surgeon can visualize the growth plate, and by making small incisions and using multiple drillings, the growth plate of the lower femur and/or upper tibia and fibula can be ablated. Since growth is stopped permanently by this procedure, the timing of the operation is crucial. This is probably the most commonly done procedure for correcting leg length discrepancy. But there is one limitation. The maximum amount of discrepancy that can be corrected by Epiphyseodesis is 5 cm. Lengthening the short leg. Various procedures have been done over the years to effect this result. External fixation devices are usually needed to hold the bone that is being lengthened. In the past, the bone to be lengthened was cut, and using the external fixation device, the leg was stretched out gradually over weeks. A gap in the bone was thus created, and a second operation was needed to place a bone block in the gap for stability and induce healing as a graft. More recently, a new technique called callotasis is being use. The bone to be lengthened is not cut completely, only partially and called a corticotomy. The bone is then distracted over an external device (usually an Ilizarov or Orthofix apparatus) very slowly so that bone healing is proceeding as the lengthening is being done. This avoids the need for a second procedure to insert bone graft. The procedure involved in leg lengthening is complicated, and fraught with risks. Theoretically, there is no limit to how much lengthening one can obtain, although the more ambitious one is, the higher the complication rate.

Overview



A bunion is a bony bump on the joint at the base of your big toe. The bony growth on the joint sometimes causes your big toe to Bunion Surgery at Nuffield Health Hospitalsturn in towards your second toe. Symptoms include pain, swelling of your big toe and, as the bunion sticks out, it can often rub on the inside of your shoe. The cause is not always known, there may be a deformity of the joint, called hallux valgus (hallux means big toe, valgus means bent outwards). Or it can be as simple as ill fitting footwear not allowing enough width to fit the toes in their natural position. Sometimes bunions are associated with arthritis in the joint at the base of your big toe. Left untreated bunions can continue to grow and become more painful.

Causes

Long periods of pressure from a tight-fitting shoe can cause the inflammation and the pain. This often happens when the big toe is forced into a position where it presses inward and overlaps the second toe. The base of the big toe then is pushed beyond normal alignment of the foot, resulting in the prominence typical of a bunion.

SymptomsYour bunion may not cause any symptoms. Or you may have pain in your big toe, red or irritated skin over the bunion, and swelling at the base of the big toe. The big toe may point toward the other toes and cause problems in other toes, such as hammer toe . A bunionette can cause similar symptoms at the base of the little toe.

Diagnosis

Physical examination typically reveals a prominence on the inside (medial) aspect of the forefoot. This represents the bony prominence associated with the great toe joint ( the medial aspect of the first metatarsal head). The great toe is deviated to the outside (laterally) and often rotated slightly. This produces uncovering of the joint at the base of the big toe (first metatarsophalangeal joint subluxation). In mild and moderate bunions, this joint may be repositioned back to a neutral position (reduced) on physical examination. With increased deformity or arthritic changes in the first MTP joint, this joint cannot be fully reduced. Patients may also have a callus at the base of their second toe under their second metatarsal head in the sole of the forefoot. Bunions are often associated with a long second toe.

Non Surgical Treatment

You can try over-the-counter remedies like pads to stop them rubbing, or take painkillers such as paracetamol or ibuprofen if they play up. Devices that fit into your shoe, called orthotics, or splints that you wear at night, can slow the progression of bunions. If these don't help and the bunion is causing a painful and substantial deformity that?s seriously limiting your footwear, your GP will probably refer you to see a podiatrist, medical professionals who specialise in feet. They can give further advice about non-invasive treatments and also refer you for an operation, either with a podiatric or orthopaedic (bone) surgeon, ultimately the only thing that can correct the gnarly blighters. You can visit a podiatrist privately, which will cost anything from ?140-?200. But Mike O?Neill, spokesperson for the Society of Podiatrists and Chiropodists, suggest always going via your GP, who will know the best qualified. Such is the complexity of the bone structure of the foot, there are more than 130 different surgical procedures for bunions. One person?s op may be very different from another?s, so be wary of sounding out a friend about theirs.



Surgical Treatment

The decision to have bunion surgery is personal and different everyone. While there are many reasons to have bunion surgery, the most common reasons include. Pain. Difficulty walking. Difficulty fitting shoes. Worsening bunion. Pain at the ball of the foot. Failed conservative measures. See Non-surgical Treatment. Some people have surgery simply because they don?t like the way the bunion looks. While some doctors may correct your bunion if it doesn?t hurt, you should be aware that permanent pain may occur after your surgery.

Prevention

To minimize the chance of developing bunions, never force your feet into shoes that don?t fit. Choose a shoe that conforms to the shape of your foot. Opt for shoes with wider insteps, broad toes, and soft soles. Shoes that are short, tight, or sharply pointed should be avoided.