Visual Diagnosis in Pediatrics
1st Edition

42
Leg Asymmetry
Jeoffrey K. Wolens
Approach to the Problem
Asymmetry between the lower extremities has a wide range of etiologies. Discrepancies in length can be caused by structural bone abnormalities or by alterations in rates of bone growth. Variations in the overall size of the lower extremities can be caused by neurologic disorders, vascular or lymphatic abnormalities, or processes that restrict growth. Understanding the etiology of the discrepancy is important because some conditions need to be followed closely for associated conditions.
P.276

P.277

DIAGNOSIS ICD-9 DISTINGUISHING CHARACTERISTICS ASSOCIATED FINDINGS COMPLICATIONS PREDISPOSING FACTORS
Developmental Dysplasia of the Hip (DDH) 754.30 Leg(s) adducted and externally rotated
Limited abduction of the hip, if the hip dislocated
Involved side appears shorter
Positive Galeazzi sign
Asymmetric thigh and buttocks folds when unilateral
Recurrent dislocation
Avascular necrosis of femoral head
Early degenerative joint disease with pain and stiffness in hip
Shortening of affected limb
Positive family history
History of breech birth
Newborns with restriction of motion in the hips and legs as can be seen with oligohydramnios
More common in girls than boys
Hemihypertrophy 759.89 Rarely apparent at birth Skin and hair are thicker on the affected side Ipsilateral organs may also be affected
Contralateral macroglossia common
Wilms tumor, hepatoblastoma, adrenal carcinoma
Compensatory scoliosis may develop May be isolated or part of a syndrome (see Other Diagnoses to Consider)
Lymphedema of Lower Extremity 457.1 acquired
757.0 congenital
Edema may be pitting or nonpitting May be associated with vascular abnormalities Verrucous hypertrophy of skin
Recurrent infections
Unilateral causes of lymphedema typically acquired by congenital abnormalities, surgery, trauma or postinflammatory scarring (burns, infections, radiation)
Hemiatrophy of Leg 728.2 Neurologic exam may show flaccid paralysis
Scarring of the skin may be present
Hip and back pain Hip and back pain Polio was a common etiology in the prevaccine era Tethered cord
Leg Length Discrepancy 736.81 acquired
755.30 congenital
Asymmetry of posterior superior iliac crest
Difference ≥ I cm between legs as measured from iliac crest to lateral malleolus
Lift placed under shorter leg alleviates discrepancies
Previous physeal injury
Flexion contractures of the long side
Toe walking on short side
Limp with or without pain Previous physeal injury
Legg-Calves-Perthes Disease 732.1 Avascular necrosis caused by impairment of blood supply to the femoral head
Antalgic limp with mild to no pain initially
Examination finds pain on internal rotation and abduction of the hip
Typical age 4 to lly Unable to maintain pelvis level when standing on involved side
May have flexion contracture of affected hip and limb
May be associated with hypercoagulable states.
Hip dislocation
Early degenerative joint disease
More common in boys
Slipped Capital Femoral Epiphysis 732.2 Painful limp after jumping
No history of significant trauma
Limb held externally rotated
May have flexion contracture of affected hip and limb may appear shorter than other side
Endocrinopathies may be found in patients with bilateral involvement
Avascular necrosis of femoral head
Early degenerative joint disease
Occurs around puberty typically in obese males
P.278

Figure 42-1 Positive Galaezzi sign. Note asymmetry in femoral heights. (Courtesy of Douglas A. Barnes, MD.)
Figure 42-2 Asymmetric thigh folds in young infant. Note asymmetry between overall configuration in number and location of thigh folds. (Courtesy of Douglas A. Barnes, MD.)
Figure 42-3 Hemihypertrophy of right lower extremity in a child with Proteus syndrome. Also note contralateral hemihypertrophy of left upper extremity. (Courtesy of Shriners Hospitals for Children, Houston, Texas.)
Figure 42-4 Isolated hemihyertrophy of the right lower extremity. (Courtesy of Shriners Hospitals for Children, Houston, Texas.)
P.279

Figure 42-5 Lymphedema of foot caused by constriction band syndrome. (Courtesy of Douglas A. Barnes, MD.)
Figure 42-6 Child with hemiatrophy of the right leg. Note the overall decrease in length and bulk of leg compared to normal side. (Courtesy of Shriners Hospitals for Children, Houston, Texas.)
Figure 42-7 Hemiatrophy of left leg because of linear scleroderma. Note normal appearing size, muscle mass, and overall bulk of normal right leg. (Courtesy of Shriners Hospitals for Children, Houston, Texas.)
P.280

Other Diagnoses to Consider
  • Congenital absence or shortening of the tibia, fibula, or femur
  • Burns or dermal scarring
  • Local swelling because of envenomation or allergic reaction
  • Bone tumors and cysts
  • Silver Russel syndrome
  • Klippel-Trenaunay-Weber syndrome
  • Ollier disease
  • Radiation therapy
Suggested Readings
Ballock RT, Weisner GL, Myers MT, Thompson GH: Hemihypertrophy—concepts and controversies. J Bone Joint Surg Am. 1997;79(11):1731-1738.
Finch GD, Dawe CJ. Hemiatrophy. J Pediatr Orthop. 2003;23:99–101.
Guidera K. Leg length inequality. In: Cramer CE, Scherl SA, eds. Pediatrics: orthopedic surgery essentials. Philadelphia: Lippincott Williams & Wilkins;2004:74–80.
Percy AK. Static encephalopathy. In: McMillan JA, DeAngelis CD, Feigin RD, Warshaw JB, eds. Oski’s pediatrics principles and practice. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 1999:1923–1925.
Shapiro BK, Capute AJ. Cerebral palsy. In: McMillan JA, DeAngelis CD, Feigin RD, Warshaw JB, eds. Oski’s pediatrics principles and practice. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 1999:1910–1917.
Staheli L. Practice of pediatric orthopedics. Philadelphia: Lippincott Williams & Wilkins; 2001:24,68,76–79,146–151,297.