Skip to main content

Advertisement

SpringerLink
Log in

Assessing Leg Length After Fixation of Comminuted Femur Fractures

  • Symposium: Femoral Fractures: Contemporary Treatment Approaches
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Background

Nailing comminuted femur fractures may result in leg shortening, producing significant complications including pelvic tilt, narrowing of the hip joint space, mechanical and functional changes in gait, an increase in energy expenditures, and strains on spinal ligaments, leading to spinal deformities. The frequency of this complication in patients managed with an intramedullary (IM) nail for comminuted diaphyseal fractures is unknown.

Questions/purposes

We therefore determined (1) the frequency of LLDs, (2) whether a specific fracture pattern was associated with LLDs, (3) the frequency of reoperation, and (4) whether revision fixation ultimately corrected the LLD.

Methods

We studied 83 patients with 91 AO/OTA Type B or Type C fractures fixed with either an antegrade or retrograde IM nail from July 2002 through December 2005. There were 60 males and 23 females, with a mean age of 30 years (range, 15–79 years). All underwent a digitized CT scan in the immediate postoperative period. Measurements of both legs were performed. Any fixation producing a discrepancy and requiring a return to surgery was identified.

Results

An mean LLD of 0.58 cm was found in 98% of the patients, but only six (7%) patients had an LLD of greater than 1.25 cm. No fracture pattern or the presentation of bilateral injuries demonstrated a greater incidence of LLD. Of the patients with LLD, two patients refused further surgery while the remaining four patients, two Type B and two Type C fractures, ultimately underwent revision fixation. Repeat CT scans after revision surgery of all four patients demonstrated a residual LLD of only 0.2 cm.

Conclusions

Postoperative CT scans appear to be an efficient method to measure femoral length after IM nailing. Although residual LLDs may be common in comminuted femurs treated with IM nails, most LLDs do not appear to be functionally relevant. When an LLD of greater than 1.5 cm is identified, it should be discussed with the patient, who should be told that potential complications may occur with larger LLDs and that sometimes patients may benefit from repeat surgery.

Level of Evidence

Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1A–B
Fig. 2A–C

Similar content being viewed by others

References

  1. Aaron A, Weinstein D, Thickman D, Eilert R. Comparison of orthoroentgenography and computed tomography in the measurement of limb-length discrepancy. J Bone Joint Surg Am. 1992;74:897–902.

    CAS  PubMed  Google Scholar 

  2. Canadian Orthopaedic Society. Nonunion following intramedullary nailing of the femur with and without reaming: results of a multicenter randomized clinical trial. J Bone Joint Surg Am. 2003;85:2093–2096.

    Google Scholar 

  3. Edeen J, Sharkey PF, Alexander AH. Clinical significance of leg-length inequality after total hip arthroplasty. Am J Orthop. 1995;24:347–351.

    CAS  PubMed  Google Scholar 

  4. Friberg O. Leg length asymmetry in stress fractures: a clinical and radiological study. J Sports Med Phys Fitness. 1982;22:485–488.

    CAS  PubMed  Google Scholar 

  5. Friberg O. Clinical symptoms and biomechanics of lumbar spine and hip joint in leg length inequality. Spine (Phila Pa 1976). 1983;8:643–651.

    Article  CAS  Google Scholar 

  6. Giles LG, Taylor JR. Low-back pain associated with leg length inequality. Spine (Phila Pa 1976). 1981;6:510–521.

    Article  CAS  Google Scholar 

  7. Grill F, Chochole M, Schultz A. [Pelvic tilt and leg length discrepancy] [in German]. Orthopade. 1990;19:244–262.

    CAS  PubMed  Google Scholar 

  8. Grützner P, Hochstein P, Simon R, Wentzensen A. [Determination of torsion angle after shaft fractures of the lower extremity—clinical relevance and measurement techniques] [in German]. Chirurg. 1999;70:276–284.

    Article  PubMed  Google Scholar 

  9. Gurney B, Mermier C, Robergs R, Gibson A, Rivero D. Effects of limb-length discrepancy on gait economy and lower-extremity muscle activity in older adults. J Bone Joint Surg Am. 2001;83:907–915.

    PubMed  Google Scholar 

  10. Gustillo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma. 1984;24:742–746.

    Article  Google Scholar 

  11. Harris I, Hatfield A, Walton J. Assessing leg length discrepancy after femoral fracture: clinical examination or computed tomography? ANZ J Surg. 2005;75:319–321.

    Article  PubMed  Google Scholar 

  12. Hüfner T, Kendoff D, Citak M, Geerling J, Krettek C. [Precision in orthopedic computer navigation] [in German]. Orthopade. 2006;35:1043–1055.

    Article  PubMed  Google Scholar 

  13. Jaarsma RL, Verdonschot N, van der Venne R, van Kampen A. Avoiding rotational malalignment after fractures of the femur by using the profile of the lesser trochanter: an in vitro study. Arch Orthop Trauma Surg. 2005;125:184–187.

    Article  CAS  PubMed  Google Scholar 

  14. Johnson EE. Acute lengthening of shortened lower extremities after malunion or non-union of a fracture. J Bone Joint Surg Am. 1994;76:379–389.

    CAS  PubMed  Google Scholar 

  15. Karapinar L, Kaya A, Oztürk H, Altay T, Kayali C. Leg length discrepancies in adult femoral shaft fractures treated with intramedullary nailing. Ulus Travma Acil Cerrahi Derg. 2009;15:256–261.

    PubMed  Google Scholar 

  16. Kaufman KR, Miller LS, Sutherland DH. Gait asymmetry in patients with limb-length inequality. J Pediat Orthop. 1996;16:144–150.

    Article  CAS  Google Scholar 

  17. Konermann W, Gruber G. Ultrasound determination of leg length. Orthopade. 2002;31:300–305.

    Article  CAS  PubMed  Google Scholar 

  18. Krettek C, Miclau T, Grün O, Schandelmaier P, Tscherne H. Intraoperative control of axes, rotation and leg length in femoral and tibial fractures: technical note. Injury. 1998;29(suppl 3):S-C29–S-C39.

    Article  Google Scholar 

  19. Langer JS, Gardner MJ, Ricci WM. The cortical step sign as a tool for assessing and correcting rotational deformity in femoral shaft fractures. J Orthop Trauma. 2010;24:82–88.

    Article  PubMed  Google Scholar 

  20. Leitzes AH, Potter HG, Amaral T, Marx RG, Lyman S, Widman RF. Reliability and accuracy of MRI scanogram in the evaluation of limb length discrepancy. J Pediatr Orthop. 2005;25:747–749.

    Article  PubMed  Google Scholar 

  21. Liodakis E, Kenawey M, Liodaki E, Mommsen P, Krettek, C, Hankemeier S. The axis-board: an alternative to the cable technique for intraoperative assess of lower limb alignment. Techol Health Care. 2010;18:165–171.

    CAS  Google Scholar 

  22. Marsh JL, Slongo TF, Agel J, Broderick JS, Creevey W, DeCoster TA, Prokuski L, Sirkin MS, Ziran B, Henley B, Audigé L. Fracture and Dislocation Classification Compendium-2007. J Orthop Trauma. 2007;21(suppl 10):S35–S38.

    Google Scholar 

  23. Owens WD, Felts JA. ASA physical status classification: a study of consistency ratings. Anesthesiology. 1978;49:239–243.

    Article  CAS  PubMed  Google Scholar 

  24. Sabharwal S, Kumar A. Methods for assessing leg length discrepancy. Clin Orthop Relat Res. 2008;466:2910–2922.

    Article  PubMed Central  PubMed  Google Scholar 

  25. Shih-Chieh H, Takahide K, Kozo N, Takashi M, Shiro R, Okazaki H. Narrowing of the joint space of the hip after traumatic shortening of the femur. J Bone Joint Surg Br. 1996;78:718–721.

    Google Scholar 

  26. Siffert RS. Lower limb-length discrepancy. J Bone Joint Surg Am. 1987;69:1100–1106.

    CAS  PubMed  Google Scholar 

  27. Song KT, Halliday SE, Little DG. The effect of limb-length discrepancy on gait. J Bone Joint Surg Am. 1997;79:1690–1698.

    Article  CAS  PubMed  Google Scholar 

  28. Strecker W, Keppler P, Gebhard F, Kinzl L. Length and torsion of the lower limb. J Bone Joint Surg Br. 1997;79:1019–1023.

    Article  CAS  PubMed  Google Scholar 

  29. Subotnick SI. Limb length discrepancies of the lower extremity (the short leg syndrome). J Orthop Sports Phys Ther. 1981;3:11–15.

    Article  CAS  PubMed  Google Scholar 

  30. Suger G, Liener U, Schmelz A, Kinzl L. [Correction of post-traumatic diaphyseal malalignment of the lower extremity] [in German]. Chirurg. 1998;69:1167–1177.

    Article  CAS  PubMed  Google Scholar 

  31. Vink P, Huson A. Lumbar back muscle activity during walking with a leg inequality. Acta Morphol Neerl Scand. 1987;25:261–271.

    CAS  PubMed  Google Scholar 

  32. Vink P, Kamphuisen HA. Leg length inequality, pelvic tilt and lumbar back muscles activity during standing. Clin Biomech. 1989;4:115–117.

    Article  CAS  Google Scholar 

  33. White SC, Gilchrist LA, Wilk BE. Asymmetric limb loading with true or simulated leg-length differences. Clin Orthop Relat Res. 2004;421:287–292.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Florida Orthopaedic Institute, 13020 Telecom Parkway, Temple Terrace, FL, 33637, USA

    Dolfi Herscovici Jr DO & Julia M. Scaduto ARNP

Authors
  1. Dolfi Herscovici Jr DO
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Julia M. Scaduto ARNP
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Dolfi Herscovici Jr DO.

Additional information

Each author certifies that he or she, or a member of his or her immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.

Clinical Orthopaedics and Related Research neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA approval status, of any drug or device before clinical use.

Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.

This work was performed at Tampa General Hospital, Tampa, FL, USA.

About this article

Cite this article

Herscovici, D., Scaduto, J.M. Assessing Leg Length After Fixation of Comminuted Femur Fractures. Clin Orthop Relat Res 472, 2745–2750 (2014). https://doi.org/10.1007/s11999-013-3292-0

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11999-013-3292-0

Keywords

Search

Navigation