This will be a look and proceed case. Examiners will want to see your thought process in ruling out which level the shortening is occurring at.
- [Stand and Look]
- From front
- Obvious LLD with shortening of one limb - ideally expose to underwear,
- Compensating with an equinus ankle
- Pelvis tilting down
- Look for features of dysplasia/ syndromes
- Fibula/ tibial hemimelia
- Isolated club foot
- From side
- Scars - previous ops (hip, femur)
- From back
- Looking for compensatory scoliosis
- Request for blocks to evaluate extent of LLD
- [Walk]
- For trendelenberg gait [if shortening is proximal to GT]
- Short limb gait with
- Toe gait, equinus contracture
- Circumduction on the long limb
- Look for aids and heel raises
- Come back for trendelenberg test
- [Lie down]
- LLD assessment:
- When lying down naturally - measure apparent limb length from midline structure
- Square pelvis - measure true limb length
- Galeazzi test for femur vs tibia shortening
- Digital bryant’s triangle test
- Knee laxity for association in PFFD - Lachmann, ACL
- Ankle - check that equinus is not contracture, ROM of ankle (ball and socket)
- Check Neuro-vascular - PT, DP, Foot drop
- Complete my examination
- History for TIT, congenital conditions
- Possible scenarios
- Shortening at femur
- Proximal to GT - all the hip pathologies - DDH, Perthes, Coxa vara, PFFD, tom smith arthritis
- Distal to GT - previous distal femur #,
- Shortening at tibia
- Previous fractures
- Tumor - MHE
- Fibula/ tibial hemimelia
- Lengthening at femur - previous femur shaft #
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