Children Orthopaedics &

Deformities
Dr. Michael To
Clinical Assistant Professor
Division of Paediatric Orthopaedics

Objectives
Understand the normal development of
children
Children are not small adults

Normal vs Abormal
General principles in approaching limb
deformities

Growth

Are children just small adults?

Children are quite different
physiologically and anatomically

Modeling and Remodeling

Potential

Growth of Upper Limbs

Growth of Lower Limbs

Epiphyseal Growth

Growth
Skeletal
maturity
Female: 14
Male: 16

Commonly Asked?
Short Stature
Intoeing
Knock knees X
Bowlegs O
Flatfoot

Parents concern
What are the causes?

Is the problem abnormal?

Would the problem ever become
normal?
normal?
Is there any treatment?
Is the treatment necessary?

What is normal in children?

Short stature?
Percentile? Height of parents? Proportion of body?
Syndromal features? Skeletal dysplasia?

Intoeing gait?
Symmetrical? Which level? Neuromuscular problems?
Gait pattern?

Bowlegs? Knocked knees? Limb length discrepancy?

Unilateral? History of injury? Infection? Syndromal?
Dysplasia

Flatfoot?
Flexible? Rigid?

Short stature

Proportionate
Familial
Endocrine

Mucopolysaccharidosis

Achondroplasia

Disproportionate
Achondroplasia

Limb length discrepancy

Limb length discrepancy
is not uncommon
About 20-30% normal
subjects have LLD between
0.5-2cm
Other causes:
E.g. hemihypertrophy, postinjury, congenital, joint
dislocation and contracture

Usually compensated well if

LLD <2.5cm

Abnormal gait as
a result of LLD

Perthes Disease

Shapiro 5 basic patterns of

LLD
Type I: PFFD > 6cm LLD,
Poliomyelitis, Olliers disease
Type II: PFFD, Poliomyelitis
Type III: hemihypertrophy
Type IV: septic arthritis, AVN, DDH
Type V: Juvenile arthritis

Limb length discrepancy

Congenital (linear growth
pattern)
Proximal femoral focal
deficiency
Fibular hemimelia

Developmental (non-linear
growth pattern)
Physeal injury or infection
Olliers disease
Poliomyelitis

Scannogram

Limb length discrepancy

9 months old boy

Fibular hemimelia

Whats wrong?
Proximal Femoral Focal
Deficiency

1 yr. 8 mo.

2year 8 month

2 year 8 month

2 year 8 month

Limb length discrepancy and prediction

in congenital problems
E.g. PFFD or Fibular hemimelia
Constant proportional
Affected side = 12cm
Normal femur length = 19.6cm
Shortening = 39%
Projected LLD = 39% of 42cm
(femoral of patients father)
= 16.4cm

Epiphysiodesis

Mosely Chart
Developmental or acquired LLD demonstrate non-linear relationship
disease, post-trauma or infection

m = L m S m.

for S Method
Substituting ML for L m and MS
m,
Multiplier
for
Limb
length
discrepancy
le group (mean, mean
Predicting Limb-Length Discrepancy
=
ML

MS = M(L S).
m
an plus twoand
standard
prediction

1440

D. PALEY ET A

BY DROR PALEY, M.D., F.R.C.S.(C), ANIL BHAVE, P.T.,

TABLE V
L OWER -L IMB M ULTIPLIERS
FOR B OYS

JOHN E. HERZENBERG, M.D., F.R.C.S.(C), AND J. RICHARD BOWEN, M.D.

sim
al

ndard deviation, and

Because = L S,
Multiplier
Abstract
ancy in both the limb-lengthening and ep
ions) at each
age was method
Background: In patients with a congenital or devel- groups. The multipliers derived from the ra
= the short limb. grows clinical, and anthropological measurements
m
opmental limb-length discrepancy,
ariability, 0.03; maxiat a rate proportional to that of the normal, long limb.
and tibiae were all similar to each other des
This is the basis of predicting limb-length discrepancy
ences in race, ethnicity, and generation.
ata on both the femur
The congenital
discrepancy
at skeletal
Conclusions:
The multiplier method a
with existing limb-length
methods, which are complicated
and reand limb length
quick calculation of the predicted limb-leng
quire multiple data points. The purpose of our study
ancy at skeletal
without the need to
was topredicted
derive a simple arithmetic
formula that
can eas- only
This variability was
maturity can be
even
when
thematurity,
currentand is based on as few as one or two measure
ily and accurately predict limb-length discrepancy at
to predict
methodlimb-length
is independent of percentile group
skeletal maturity.
th increasingdiscrepancy
age. The
age-speci
c multiplier
(M) and the current
same for the prediction of femoral, tibial, and
Methods: Using available databases, we divided the
lengths. The multiplier values are also inde
and tibial lengths at skeletal maturity by the
LLD ( )femoral
areand
known.
h age-group the
and ultimate
pertibial lengths at each age for each percentile
generation, height, socioeconomic class, et
femoral
group. The resultant number was called the multiplier.
race. We veri
the accuracy of this metho
oximatelyExample:
the same as
For example,
a multiplier,
seven-year-old
boythe has
a limb-length
Using the
we derived formulae to predict
by evaluating
patients who had been manage
limb-length discrepancy and the amount of growth relengthening or epiphysiodesis. The method w
parable
with or more accurate
than the Mose
maining.
We
veri
ed
the
accuracy
of
these
formulae
by
ibia (mean variability,
discrepancy ofevaluating
6.3 twocentimeters
due to congenital
short
of limb-length prediction.
groups of patients with congenital shortening who were managed with epiphysiodesis or limb5) (Fig. 1). Because the
femur. The multiplier
for seven-year-old Limb-length
boys discrepancy
is 1.57.
in children is ge
lengthening. We also calculated and compared the multi7 years old boy with LLD 6.3
gressive until skeletal maturity. Treatment de
pliers for other databases according to radiographic, clinwere nearly identical,
Therefore, theical,predicted
discrepancy
at pend
skeletal
on the predictedmatulimb-length discrepanc
and anthropological lower-limb
measurements.
Multiplier = 1.57
maturity. Accurate prediction of the discrepan
Results: The multipliers for the femur and tibia were
fore important. We present a quick, convenien
in all percentile
groups,
by age
= 1.57
6.3
=varying
9.9onlycentimeters.
rity is m = M equivalent
both bones and avermethod for predicting limb-length discrepanc
and gender. Because congenital limb-length discrepancy
maturity.
increases
at
a
rate
proportional
to
growth,
the
discreper-limb multipliers for
Shapiro identi ed ve patterns of pro
ancy
at
maturity
can
be
calculated
as
the
current
discrepLLD at maturity = Multiplier
6.3cm x 1.57
Method
limb-length discrepancy in children. The curre
ancy timesfor
the multiplier for the current age and the
ipliers can be used to
of predicting limb-length discrepancy at ske
gender. This calculation can be performed with use of a
= 9.9cm
rity are applicable only to the Shapiro typ
single
measurement of limb-length discrepancy. For proDevelopmental
Discrepancies
ation, such as the pretionate progression pattern. Limb-length d
gressive developmental (noncongenital) discrepancies,
associated with other types of progression (Sh
the discrepancy at skeletal maturity can be calculated as
V) have
periods of acceleration or
the
current
discrepancy
plus
the
growth
inhibition
times
d the amount of growth
With developmental
discrepanciesIItionthrough
(for
example,
and therefore cannot be predicted acc
the amount of growth remaining. The timing of the epiphAND

G IRLS

Multiplier
Investigation performed at the Maryland Center for Limb Lengthening and Reconstruction,
Baltimore, Maryland
Age
(yrs. + mos.)
Birth

Boys

Girls*

5.080

4.630

0+3

4.550

4.155

0+6

4.050

3.725

0+9
1+0

3.600
3.240

3.300
2.970

1+3
1+6

2.975
2.825

2.750
2.600

1+9
2+0

2.700
2.590

2.490
2.390

2+3
2+6

2.480
2.385

2.295
2.200

2+9

2.300

2.125

3+0

2.230

2.050

3+6
4+0

2.110
2.000

1.925
1.830

4+6
5+0

1.890
1.820

1.740
1.660

5+6
6+0

1.740
1.670

1.580
1.510

6+6
7+0

1.620
1.570

1.460
1.430

7+6
8+0

1.520
1.470

1.370
1.330

8+6

1.420

1.290

9+0

1.380

1.260

9+6

1.340

1.220

10 + 0

1.310

1.190

10 + 6

1.280

1.160

11 + 0

1.240

1.130

11 + 6
12 + 0

1.220
1.180

1.100
1.070

12 + 6

1.160

1.050

13 + 0

1.130

1.030

13 + 6

1.100

1.010

1.080

1.000

1.060
1.040

NA
NA

15 + 6
16 + 0

1.020
1.010

NA
NA

16 + 6
17 + 0

1.010
1.000

NA
NA

14 + 0
14 + 6
15 + 0

34

*NA = not applicable.

graphic measurements are. Clinical measurements are

au
of
th
(th
dr
w
th
m
in
le
st
m
w
sim
al
w
19
al
st
he
m
m
an
M
le
la
im
of
ca
an
di

cl
Am
st
fro
riv
Ta

gr
dr
fro
to
sia

e data of Anderson et

commissioned by the
linical measurements
rom the iliac crest to
and tibiale length
or) in American chils were made between
marks. We performed
ree clinical measureal limb length includral length, and tibial
use there were no subtipliers for these three
e data of Snyder et al.
e femur and the tibia,
data of Anderson et
data of Snyder et al.
liers derived from the
he study by Snyder et
st and most detailed
ments. Because foot
and iliocristale-length
demonstrates that the
o predict limb length
ive of foot height. The
s of predicting limbt for discrepancies reis becomes especially
al discrepancies, which
he multiplier method
limb-length discrepbial, and foot-height

ed radiographic and
n children of North
e found two clinical
he multipliers derived
y similar to those deet al. 5 (Figs. 3 and 4,

rted upper leg-length

ape Coloured chilultipliers calculated
were also equivalent
al.s study of CaucaVI).

Limb length discrepancy

Treatment
Treat the underlying cause
Observation or shoe raise
Limb length equalization surgery
Epiphysiodesis
longer limb
Lengthening

no need to consult the

e the percentile group

Epiphysiodesis vs Stapling / 8 plate

o of the length of the

ng limb stays the same
th congenital
cienhe length of the short
n be calculated by mulngth of the short limb
g limb (L) by the prekeletal maturity (L m).

L.

growth of the short limb in comparison with the growth

of the long limb remains xed. To predict the limblength discrepancy at skeletal maturity, the inhibition
(I), the amount of growth remaining (G), and the current limb-length discrepancy ( ) must be known. The
inhibition can be calculated from the ratio of growth
of the short limb to growth of the long limb during the
same time-interval. Two separate measurements of
limb length made since the beginning of the growth
disturbance are needed to calculate inhibition. Inhibition is de ned as the amount of growth of the short
limb ( S S' ) divided by the amount of growth of the
long limb ( L L' ) during the same time-interval, subtracted from 1:
I =1

(S

S' ) (

).

S' and L' are the lengths of the short and long limbs,
respectively, measured on previous radiographs that
preferably were made at least six or twelve months before the current radiographs. The radiographs must
have been made after the date of the growth disturbance, with use of the same radiographic method and

Limb Lengthening
Resting
Lengthening
1mm/day
Consolidation
usually takes at
least twice the
time of
lengthening

Congenital Skeletal Limb Deficiency

In normal skeletally mature young adults, centre of hip,

centre of knee and centre of ankle should be in a
straight line

Limb Malalignment
Bowlegs /Knock
knees
Procurvatum /
Recurvatum
Intoeing