Four Physical Outcomes
1. Symmetrical Stance & Level Pelvis
A. LL Equality
- Components equal with no deformity
B. Components equal with bilateral symmetrical deformity
- eg Bilateral varus knees
2. Symmetrical Stance with Oblique Pelvis
Uncompensated LLD
3. Asymmetrical Stance & Level Pelvis
A. Fully Compensated LLD
- Flexed contralateral knee
- Equinus ipsilateral ankle
B. Sagittal deformity with ipsilateral sagittal compensation
- FFD knee with Equinus & hip flex OR
- Fixed Equinus with flex knee & hip OR
- FFD hip with equinus & flex knee
C. Coronal deformity with contralateral coronal deformity
- Valgus of knee & contralat varus of knee
4. Asymmetrical Stance with Oblique Pelvis
A. Partly compensated LLD
- Partly flexed contralateral knee
- Partly equinus of ipsilateral ankle
B. Coronal hip deformity with sagittal compensation
- Fixed hip adduction with contralateral knee flexion / ipsilateral equinus
- Fixed hip abduction with ipsilateral knee flexion / contralat equinus
C. Sagittal def c coronal compensation
- FFD knee c ipsilateral hip abduction
- Fixed equinus c ipsilateral hip ADD
Leg length Examination
1. Look
Posture
- flexed knee
Signs hemihypertrophy
- NF
- haemangiomas / lipomas (Proteus, Klippel-Trenau-Weber, Beckwith)
Scars
- trauma, infection
Aids / Shoes
- heel inserts / raises
2. Gait
Children
Compensate well
- Walk on toes short leg usually / equinus
- Flexion long knee uncommon as energy++
Adults
Compensate less well
- Walk with bilateral heel-toe gait
- Vaults over long leg
- Excess Sagittal head motion
3. Measure LLD
A. Functional LLD
- on blocks
- heels flat, nil knee FFD (if able)
- correct pelvic tilt
- should correct scoliosis
Conclusion
- if can make pelvis stable
- ASIS equal
- blocks are a quantitative measure of functional LLD
B. Apparent LLD
Lying on bed
- measure from xiphisternum to medial malleolus
- no correction for contractures
C. Real / True LLD
Must correct for deformity in coronal and sagittal plane
Exclude
- hip adduction / abduction contracture
- hip FFD
- knee FFD
Scenarios
1. Hip FFD
- pillow under both thighs
2. Knee FFD
- pillow under both knees
3. Hip adduction contracture won't correct to neutral
- measure each leg crossed over the other
4. Hip abduction contracture won't correct to neutral
- place both legs in similar position
If there is a contracture, perform the above measures
- then meaure the intercalated segments
- from ASIS to medial joint line
- medial joint line to medial malleolus
4. Identify site of shortening
Galeazzi
- must not forget can have small foot / old calcaneal fracture / wasted buttock
- hips and knees flexed
- side by side
- look for tibial / femoral shortening
If shortening above knee, find out if shortened above greater trochanter
- i.e. hip deformity
Bryant's triangle
- line perpendicular to GT and ASIS
- distance between
- quantify in fingerbreadths
Nelaton's line
- line from ischial tuberosity to ASIS
- GT should be on or below line
Klisics line
- GT to ASIS
- should aim to umbilicus
- will be more parallel
5. Other
Examine Knee stability
- can have problems lengthening femur if ACL deficient
- i.e. fibula hemimelia