Asymmetric Limbs

Asymmetric Limbs: Excerpt from In A Page: Pediatric Signs and Symptoms

With asymmetry of body parts, it can be difficult to differentiate whether one side is hypertrophic or the other side is atrophic. One of the most common asymmetries seen in children is leg-length discrepancy. Growth disturbances around the knee have a substantial effect on leg length, because distal femur (37%) and proximal tibia (28%) contribute the most to the growth of entire lower extremity.

Differential Diagnosis

• Physiologic: Left leg is often longer than right, and right arm is longer than left, though it is usually not noticeable
• Disturbances of bone
  –Increased blood flow such as occurs in arthritis (infectious, inflammatory), neoplasms, or AVM
  –Premature closure of epiphysis occurs with infection, fracture, radiation therapy, JRA
  –Fracture may also result in malposition or malunion
  –Diaphyseal operations (bone grafts, osteotomy)
  –Developmental dysplasia of the hip
  –Coxa vara, tibia vara (Blount disease)
  –Hypoplastic bones (short femur)
  –Legg-Calvé-Perthes disease
  –SCFE
  –Syndromes such as Albright; Ollier disease; neurofibromatosis
  –Rickets
  • Hemihypertrophy
    –Idiopathic: May be associated with other anomalies involving GU tract, hemangiomas, mental retardation, and pigmented skin lesions
    –Associated with tumors: Wilms, adrenocortical, hepatoblastoma
    –Associated with dysmorphogenic syndromes: Beckwith-Wiedemann, Russell-Silver, Proteus
    –Associated with soft tissue abnormalities: Lymphedema, Klippel-Trenaunay-Weber syndrome
  • Neuromuscular disorders
    –Cerebral palsy
    –Poliomyelitis
    –Myelomeningocele
    –Peripheral neuropathy
    –Focal cerebral lesions (Sturge-Weber syndrome)
    –Stroke (due to coagulopathies, sickle cell disease)
  • Hemophilia (bleeding into a joint)
  • Reflex sympathetic dystrophy (RSD)
  • Congenital syphilis
  • Absence or hypoplasia of thumb and radius (Holt-Oram syndrome, TAR syndrome)

  Workup and Diagnosis

  • History
    –Past medical and surgical history
    –Constitutional symptoms (fever, fatigue, weight loss)
    –Family history of similar disorder
  • Physical exam
    –Joint exam should include erythema, warmth, swelling, hyperflexibility, decreased range of motion, tenderness including pain localized to bone
    –Leg-length discrepancy can be measured from symphysis pubis to lateral malleoli while patient is supine or by putting blocks of various thickness under the short leg until pelvis is leveled
    –Dysmorpic features, skin lesions
    –Neurologic exam for muscle weakness, decreased tone, reflexes, mental status
  • Labs
    –Infectious and inflammatory markers such as CBC, ESR, CRP, viral or bacterial titers and/or cultures; tumor markers; chromosomal analysis and genetic markers
    –Radiologic evaluation as indicated by history and physical exam to find abnormalities in any part of musculoskeletal system (lytic lesions, soft tissue and joint swelling)
    –Bone age
    –Leg lengths measured by teleoroentgenogram, orthoradiograph, scanogram, or CT

  Treatment

  • Since underlying cause of an asymmetric limb is very broad, treatment varies depending on the etiology
  • In certain cases, especially in those in which specific treatment would make a difference (DDH, SCFE, infection, inflammation malignancy), diagnosis must be made as soon as possible to prevent permanent damage
  • Consider surgical (shortening or lengthening procedures, prostheses) and nonsurgical (orthotics, pressure stockings)
  • Angular deformity should be looked at carefully and corrected before or at the same time of length equalization to avoid joint dislocation

Book Source Details

• Book Title: In A Page: Pediatric Signs and Symptoms
• Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
• Year of Publication: 2007
• Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: In A Page: Pediatric Signs and Symptoms Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-4051-0427-9

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