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Melanie Cole (Host): If your child was born with a limb difference or has undergone an amputation due to a disease or an accident, it can be difficult to know where to turn for support. Since Shriner’s Hospitals for Children – Chicago was founded in 1926, braces, orthotics and prosthetics have been an important part of the services offered to our patients. My guest today is Dr. Jeffrey Ackman. He’s a pediatric orthopedic surgeon and Co-Medical Director of the Motion Analysis Center at Shriner’s Hospitals for Children – Chicago. Welcome to the show, Dr. Ackman.

Dr. Jeffrey Ackman, MD (Guest): Thank you.

Melanie: What is limb length discrepancy? What are limb differences and how do we know?

Dr. Ackman: Leg length discrepancy actually occurs in a fair number of individuals. Some people estimate as many as 1 in 1,000 or even more frequently. It’s just a difference in the overall length of the lower extremity, but it can occur in the upper extremity as well. A lot of times, you know, people small, don’t even notice small differences. It doesn’t cause any abnormality of gait or any back pain or hip pain or other dysfunction, but for, you know, for bigger discrepancies it takes a professional to evaluate it and to formulate a treatment plan.

Melanie: Do we know what causes it? Is it something that you might be able to see in vitro if they’re looking at an ultrasound? Can you see if the bones are growing at an uneven rate?

Dr. Ackman: For certain conditions where there’s a congenital abnormality of the bones, it can be seen on a prenatal ultrasound, if you get a good view of the skeleton such as if, you know, if they’re missing an entire bone like a femur or a tibia, or one is markedly shortened compared to the other, but I would think for the majority of discrepancies, you know, you’re probably not going to notice much because there’s relatively small. You’re not going to see much on a prenatal ultrasound. The discrepancies can be either congenital, which means they’re born with them, which means that something happened during the development of that limb in utero, or it can be due to trauma or infection or, you know, other causes as well.

Melanie: Are there some signs or symptoms if a child is growing at a normal rate, would a parent notice if they’re starting to learn to crawl or to walk, would they notice if one side was a little more uneven?

Dr. Ackman: Usually, it’s kind of best picked up when the child’s walking, and you can notice that, you know, they’ll walk with a limp, or they seem to be favoring one leg or the other or perhaps, you know, for the upper extremities, one arm appears to be shorter than the other, and that’s kind of the best way to pick up on it.

Melanie: What happens if it’s left untreated? Because we all know some adults who have hip pain or back pain, and then they’re told by an orthopod at some point later in life, well, your right leg is shorter than your left? Or you know, you’ve got an imbalance here. Is it important for those reasons that these things be caught early?

Dr. Ackman: Yes, especially, you know, for those can be treated. I mean, slight differences, often will not change over the course of time, but it’s ascertaining or determining, you know, what difference is going to get worse and what difference is going to remain the same. For those that are going to get worse, oftentimes, they can be associated with hip pain or back pain. They’re not always the cause, but an association exists between the two. And it really takes sort of an expert to decide, okay, is this something that we’re going to need to worry about as time goes forward or is this something that, you know, we can just observe and probably will not amount to much?

Melanie: So, let’s talk about that, then. What would be your first line of defense if you notice this in a child or a parent has some concerns, and they bring their child in to you, what would be some non-invasive treatments, non-surgical treatments, you might try first if it’s not too severe a discrepancy?

Dr. Acker: Well, first, you know, first, we do a good history and physical of the patient, examine the patient, watch them walk, kind of take a clinical measurement of their discrepancies. Is it in the femur, is it the tibia, is it in the, you know, the forearm or the upper arm? And what we think the discrepancy is at present. Oftentimes, for, you know, if it’s a mild discrepancy, simple things like a shoe lift can be prescribed, and then again, it’s sort of determining if this is something that’s going to be progressive or not, and if it is, then that patient needs follow up with plotting out what the difference is over time so we can formulate some kind of treatment plan.

Melanie: So, you mentioned an orthotic or a heel lift or something along that nature. You have a clinic there. You have an on-site laboratory at Shiner’s that can provide orthotics for parents that need them for their children.

Dr. Ackman: Yes. That’s correct.

Melanie: And how does that work?

Dr. Ackman: Well, what they would do is a patient would be seen here, you know, by the orthopedic surgeon. The, you know, child, would be examined, evaluated, and if they needed an orthotic and/or a shoe lift, we have an on-site laboratory that can come in and measure the patient and in the case of a shoe lift, usually it can be delivered that day if they need something like an ankle/foot orthosis brace or some other more sophisticated thing, they would be measured and then have to come back to pick it up.

Melanie: So, if it’s really severe, Dr. Ackman, and it’s something that maybe was congenital or from an infection, something pretty severe, what kinds of surgical treatments are available to children for this?

Dr. Ackman: Well, there’s, you know, some general rules of thumb. If it looks like the predicted discrepancy at maturity, and that’s the key sort of term or concept here, we make an evaluation on what the differences at the present, but what’s it going to be when the child is fully grown? And that discrepancy will sort of predicate which treatment method is preferred. If it’s going to be just a small discrepancy, usually under an inch or so, either nothing or a simple shoe lift will probably be adequate, and that’s all the child would need, you know, throughout their life. If it’s going to be about maybe an inch to up to 2.5 to 3 inches, we talk about doing what’s called an epiphysiodesis, which is slowing down the growth of the longer leg at the appropriate time so that when the child reaches maturity and is fully grown, sort of the shorter leg catches up to the longer one, and they’ll be near even in length.

Other options are lengthening bones, which is the more complicated of the two, and that’s cutting the bone and either putting an internal rod or an external frame attached to the bone and you cut the bone with a surgery, apply the device, and then about a week or so later, you start lengthening, and you lengthen about a millimeter a day for the length that you want with again, there’s sort of an upper limit of lengthening of about 20% of the bone, and so you stretch the bone out gradually and then you wait for it to heal, and then the last option is to actually, if they’re done growing to take out a piece of bone, and that’s a shortening. But again, there’s limits to how much you can shorten it to make up the difference in discrepancy.

Melanie: So, for something like a bone resection, the teen must be done growing. So, they’re going through life with this discrepancy until they can have that type of surgical intervention. What do you say to the parents, Dr. Ackman, about the emotional and psychosocial affects that this could have if it’s a very noticeable situation?

Dr. Ackman: Well, you know, that’s why we kind of have a team approach. You know, you see the physician, but you’ll also see the nurse. You will see, if necessary, a psychologist to help them, you know, deal with peer relationships, activities at school, activities within the family, etcetera, and sort of, you know, adjusting to their situation, and, you know also to let them know that there is a treatment for this that we can do. Here are your options and that’s what our job as a physician is to sort of explain to the family what their options are, give them the pros and cons of each option, and then sort of let them or perhaps, help them, select what they think would be best for their child and, we obviously, you know, try to involve the child as much as possible in making that decision.

Melanie: How is your team approach in clinic different than what families might see at a typical doctor’s office if they go to a more standard, typical office than Shriner’s? What’s the difference? Tell us about your team approach.

Dr. Ackman: Well, we’re, obviously, we’re very familiar with dealing with leg length discrepancies because we see a lot, and we treat a lot. So, hopefully when the families, you know, walk in, they don’t find, you know, people who are scratching their heads saying, oh, we’ve never seen this before. You know, we’re very comfortable with it. We say, okay, your child has this. They see the nurse. They see the attending physician. They will see an occupational or physical therapist as needed. We have x-ray right here down the hall, so they just go down the hall to get their x-ray. We have the prosthetic and orthotic laboratory present there. So, it’s like one-stop shopping, you know, and you’ll leave here with hopefully a complete and thorough evaluation and sort of a plan formulated, and I hope the families have a comfort level that, okay, these people sort of know what they’re doing and know what they’re talking about. They answered all my questions. They sort of laid out what to expect, and you know, here’s the plan that we’re going to choose.

Melanie: And wrap it us for us with your best advice about people who are seeking care for a limb length discrepancy and what you want them to know.

Dr. Ackman: That, you know, Shriner’s as a system is very familiar with this condition. We’ll give you an accurate diagnosis. We’ll give you a treatment plan and hope for correcting things that’s going to work out best for you and your child.

Melanie: Thank you so much, Dr. Ackman, for being with us today. This is Pediatric Specialty Care Spotlight with Shriner's Hospital for Children – Chicago. For more information, please visit shrinerschicago.org. That's shrinerschicago.org. This is Melanie Cole. Thanks so much for listening.