Pitfalls in Femur Length Measurements
Ruth B. Goldstein, MD·, Roy A. Filly, MD·, Gary Simpson, MOt
The following study was performed to determine the
precise anatomic correlate for the end points of sono-
graphic measurement of the fetal femur. A cadaveric
fetal thigh was dissected in layers and correlated with
sonographic images. The margins of the osseous por-
tion of the femur were determined on sonograms. Po-
tential for underestimating femur length (oblique
images) and overestimating femur length (including
nonosseous portions of the femur in measurement) can
be eliminated by requiring a view of the femur which
includes the epiphyseal cartilages. In this way, the mar-
M easurement of femur length (FL) is widely
employed and generally held as an impor~
tant contributor in the sonographic estima-
tion of gestational age and fetal weight in the second and
third trimesters of pregnancy. The femur is easily de-
tected with ultrasound by 11 menstrual weeks and read~
i1y measured throughout the remainder of the preg-
nancy. Femur measurements are particularly useful
when the head is difficult to measure, such as late in
pregnancy when the head lies low in the pelvis or in the
presence of oligohydramnios when the biparietal diam~
eter (BPD) may be unreliable. A recent study suggests
that FL may be a more accurate and stable predictor of
gestational age than BPD late in pregnancy when fetal
growth has deviated from normal. 1
Although some investigators have found FL superior
to BPD in estimating gestational age,l.2 most studies
have found FL comparable in accuracy to the BPD for
Re<:eived August 6, 1986, from the ·University of California, School
of Medicine, Department of Radiology, San Francisco, California; and
tPhoenix Prenatal Associates, Good Samaritan Hospital. Phoenix,
Arizona. Manuscript accepted for publication October 6, 1986,
Address correspondence and reprint requests to Dr. Goldstein: Uni-
versity of California School of Medicine. Department of Radiology.
L+374. San Francisco. CA 94143.
(f) 1987 by the American Institute of Ultrasound in Medicine.
gins of the osseous portion may be accurately estimated,
and there is assurance that the entire shaft has been
visualized. Images of the dissected specimen indicate
that the "distal femur point," which may cause confu-
sion in measurement, is not a part of the osseous femur,
but probably represents a specular reflection from the
lateral surface of the distal epiphysis. KEY WORDS: fetal
femur, ultrasound measurement; fetal femur, ultra-
sound anatomy; fetal femoral epiphysis. (I Ultrasoulld
Med 6:203, 1987)
prediction of gestational age and have recommended its
use as an adjunct in age and weight assessment 3 - 6 Sev-
eral charts of normal FL as a function of gestational age
have been published and are widely used in daily sono-
graphiC practiceP-9
Unfortunately, the landmarks of the femur suggested
for measurement are not always depicted and represent-
ative examples of appropriate femur measurements are
sparse in the literature. The described landmarks in the
text of many reviews are variable and include "greater
trochanter to distal metaphysis," 4 "proximal to distal
metaphYSiS," 1 and "diaphysis of femur from proximal to
distal metaphysis." 10 In general, most agree that the
length of the ossified shaft of the femur is the desired
measurement but that the length may be underesti-
mated by oblique imaging resulting in foreshortening of
the shaft. The potential for overestimating femur length
by including nonosseous portions of the femur has re-
ceived considerably less attention in the literature. In our
experience, overestimation often occurs as a result of
confusion in estimating the boundary of the distal ossi-
fied metaphysis at the junction with the cartilaginous
epiphysis. In this region, we have observed a bright
reflection ("distal femur point") which is not a part of
the metaphysis but often appears as an extension of the
J Ultrasound Med 6:203 - 207. 1987 • 0278-4297/87/$3.50
204 FETAL FEMUR MEASUREMENTS J Ultrasound Med &:203- 207, 1987

ossified shaft and thus has commonly been incorrectly Dissection

included in femur length measurement. To determine
the anatomic correlation of the sonographic images of
the fetal femur and elucidate the etiology of this "distal
femur point," the following study was performed.
METHODS
Ultrasound
Ultrasound examinations were performed using an
Acuson real-time scanner (Mountainview, CA) with a
5.0 MHz linear array multi focused transducer.
A normal male abortus of approximately 17 - 18 weeks'
gestational age served as the anatomic specimen. The
fetus was scanned in a water bath with specific attention
to the femur. Dissection of the thigh was performed in
layers in a step+wise fashion beginning on the lateral
surface of the distal thigh through skin, muscle, fascia,
and finally distal femoral epiphyseal cartilage. Sequen~
tial sonographic images were obtained after each of the
five layers of dissection until the distal femoral epiphy~
seal cartilage had been obviously transgressed (Figs. 1
and 2).

Figure 1 Sonographic images obtained

following sequential layers of dissection
beginning with the lateral cutaneous
surface of the specimen thigh. 1, predis-
section. Small arrows mark the bounda-
ries of the osseous shaft, measuring
24 mm . l.arge, curved arrow, "distal
femur point" (DFP), 2- 4, skin and mus-
cle removed (arrow). 5, fascia removed,
cartilage intact (arrow). 6, cartilage trans-
gressed (arrow.) Note that the appear-
ance of the "distal femur point" is al-
tered following dissection into the
ep iphyseal cartilage.

Figure 2 Anatomic specimen follOWing

the final layer of dissection (corresponds to
image no. 6 in Fig. 1). Part of the cartilage
has been removed (arrows).
J Ultrasound Med 6:203- 207, 1987
X-Ray
Standard 40-inch radiographs of the anatomic speci·
men, including a ruled margin, were obtained prior to
dissection (Fig. 3). To confirm the presence of the entire
osseous shaft following the dissection process and to
correlate a third standardized measurement, 1.5-mm
sagittal computed tomographic images of the thigh were
obtained using a GE 9800 CT (computed tomography)
scanner (Fig. 4).
Living Fetuses
Images of the femurs of normal fetuses obtained as part
of routine obstetrical ultrasound in our laboratory were
GOLDSTEIN ET AL 20S
Figure 3 Standard radiograph of the specimen
before dissection. Ruled margin included in the
original radiograph not included here. FL '='
24 mm.
Figure 4 Computed tomographic image of the
specimen femur following complete dissection (in ~
eluding part of epiphysis) demonstrates entire os-
seous shaft remains. CT estimated length ;: 24 mm.
compared to images of the anatomic specimen. These
images were obtained for the purpose of morphologic
comparison and not in an attempt to assess accuracy in
estimating gestational age (Fig. 5).
RESULTS
The measurement of the cadaveric femur on the predis·
section plain film was 24 mm (Fig. 3). The sonographic
estimate was identical at 24 mm (Fig. 1). CT scans and
sonograms postdissection confirmed that the osseous
femoral shaft remained intact and sonographic mea·
surements remained at 24 mm (Fig. 4). By sequential
206 FETAL FEMUR M ASUREMENTS J Ultrasou nd Med 6:203 - 207, 1987

dissection of multiple layers of soft tissue overlying the
lateral aspect of the distal femoral epiphysis down to and
including part of the cartilage, we were able to exclude
the skin or overlying muscle or fascia as the source of the
"distal femur point." Transgression of the epiphyseal
cartilage altered the reflector in question.
The measurements of the femur obtained using ultra-
sound, excluding the proximal epiphysis (nonossified
greater trochanter) and distal femoral epiphysis (nonos-
sified distal femoral condyle), correlated precisely with
measurements of the true ossified femoral shaft ob-
tained on CT and radiography. The cartilaginous ends of
the femur were readily demonstrated on sonograms of
both the abortus and living fetuses.II
DISCUSSION
The femur is readily identified on sonograms due to its
high level of intrinsic cont rast. However, significant
errors in age and weight estimates may resu lt when th~
femur length is improperly measured. Although some
variance in femur length is undoubtedly due to growth
variations and gestational age, our research and that of
otherst document that there is a greater technical error
associated with femur length estimates than might be
anticipated from the apparent simplicity of the measure-
ment. By standardizing the manner in which femur
length is measured, we can eliminate some of the varia-
biHty contributed by technical error in estimating its
length.
In this study we have demonstrated the anatomic cor-
relates to what is commonly seen on sonographic images
of the fetal femur. Femur length is estimated by mea-
surement of the osseous femur shaft. Oblique images
through the femur will cause foreshortening of the bone
and underestimate femur length. This pitfall has been
addressed in the literature and has resulted in the tend-
ency among sonographers to accept the "longest" femur
length estimate as the most accurate. Overestimation of

Figure 5 Images of thl! femur of a fetus emphasize the potential for overestimating FL and gestational age. A,
recommended view of femur for measurement. GT, future greater trochanter; DE, distal epiphysis; DFE, distal
femoral secondary ossification center; DFP, "distal femur point." B, recommended landmarks of FL measurement.
The proximal and distal epiphyses are not included. FL "'" 6.4 cm corresponds to 32.5 menstrual weeks. s C,
incorrect FL measurement of same fetus as above includes DFP (and thus cartilage). This overestimates FL by
6 mm (7.0 cm) and menstrual age by 3.5 weeks (36.0 menstrual weeks). D, incorrect FL measurement includes the
DFP. Note that the brightness of the DFP may approximate the brightness of the shaft (arrow).
J Ultrasound Med 6:203 - 207, 1987
femur length may be an equally serious error, however.
This occurs when nonosseous portions of the femur are
included in the measurement. Neither the proximal
epiphyseal cartilage (future greater trochanter) nor distal
femoral epiphyseal cartilage (future distal femoral con-
dyles) are a part of the osseous femur and should be
excluded from the measurement.
We have demonstrated that the "distal femur point,"
which can be a source of confusion in femur length
measurement, does not represent part of the osseous
femur and should therefore be excluded from measure-
ment. The sequential dissection failed to alter the ap-
pearance of this reflector until the distal epiphyseal car-
tilage was transgressed. Thus, we believe this "point" to
be a specular reflector from the smooth surface of the
lateral aspect of the distal femoral epiphyseal cartilage. If
this non osseous high amplitude reflection from the car-
tilage is included in the measurement, the femur length
may overestimate gestational age by as much as 2-3
weeks (Fig. 5). To avoid all potential confusion in select-
ing the end point for femur measurement, we recom-
mend that the epiphyseal cartilages are specifically
sought and imaged while scanning the fetal femur. In
this way, the sonographer may be assured that the entire
osseous femur has been identified (no potential for fore-
shortening), and that the cartilages have been excluded
from the femur length estimate (no potential for overes-
timation caused by nonosseous high amplitude reflec-
tors).
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GOLDSTEIN ET AL 207
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