What is limb length discrepancy?

​April is Limb Loss and Limb Length Discrepancy Month, and just about a year ago, I published a book about that very subject. I thought I would do a deeper dive into the disability that Gulliver has in my book Butterflies and Hazel Eyes. If you've read the book, you know that he has what is called limb length discrepancy. What that means is, one limb is shorter than the opposite limb. It can happen in the arms or the legs, but the most common is the legs. You can be born with a large discrepancy or it can happen over time. In fact, many of us have a minor limb length discrepancy and we never even know it. Some have a limb length difference that causes pain or discomfort in their hips and back, and they can adjust that by wearing a lift in their shoes to make both legs even. Some people, however, have a bigger discrepancy that will require different treatment. Limb length can also be affected by illness or injury that will cause the difference in length to happen over time. This will cause the individual to walk with a limp or have noticeable pain and fatigue at the end of the day. 

When we have our legs x-rayed our knees and ankles should be at the same level, right? Sometimes they aren't, and whether it's by a little or a lot, there are certain things that cause this to happen.  Usually, the bones that are most often involved in leg length discrepancy are the femur (thighbone) and tibia (shinbone). Those are the bones most often broken in a way that cause the injured limb not to grow as much or as quickly as the uninjured limb. If a child breaks a limb through a growth plate (as Gulliver did) before they are done growing, that can cause the limb to have slow growth afterwards or stop growing altogether. Bone infections are another cause of limb length discrepancy especially when the child is quite small. Finally, there are certain diseases that cause it including: 

• Neurofibromatosis
• Multiple hereditary exostoses
• Ollier disease
• Neurologic conditions
• Juvenile arthritis

So how is limb length discrepancy treated? There are several ways.

1. The first is by shortening the longer limb. This requires a specialized hospital and is the least frequently used option for treatment. It has to be done at exactly the right time and the doctors have to know exactly how much the other leg will grow and how much to remove of the longer side. Doctors can only remove 2-3 inches depending on the bone, and the patient must be done growing. Waiting isn't always ideal when a child is struggling with a LLD. 
2. Limb lengthening. This can be done internally or externally. Internal lengthening involves the doctor cutting the bone in the shorter leg and implanting an expandable metal rod. The rod stays inside the bone and gradually lengthens it due to normal movements of the limb. Since there is no external fixator there is less risk of infection, but the lack of control over the rate of lengthening is more difficult to predict. External lengthening is where the doctor cuts the bone in the shorter leg into two segments, then applies an external fixator that looks like a halo to the leg. It is a frame held to the bone with wires and pins. After a few days, they begin the lengthening process by turning the dials on the fixator to pull the bones apart. New bone will grow into the space made by turning the dial and the tissue and muscles will grow as well. Usually, you will make one inch of new bone a month. However, if the bone has been injured or if there have been infections, like Gulliver, they may need to length it slower or it may not work at all. Using an external fixator is a time consuming process for families that requires very careful cleaning of the areas around the pins and fixator, being diligent about adjusting the frame several times a day, abiding by the rules set forth by the doctor regarding physical activity, and the importance of proper nutrition during this time.

The third option for surgery is amputation of the shortened side. It sounds drastic, and it is, but often if the limb is painful or unusable even wearing a lift, then it's an option to be considered. Once the limb is amputated and the residual limb is healed, the prosthesis will correct the limb length discrepancy and allow the patient to walk correctly for the first time since their injury.

The final treatment used for LLD is external sole lifts. While extreme, some people find even a five inch lift to be the best solution for their situation. A orthotist measures their limbs, figures out the amount of lift they need on their shoe, and build it to those exact specifications. While these shoes used to be heavy and cumbersome, the new products available on the market make them lighter for the patient. The ability to curve the sole like a rocker also makes each step easier, so the patient doesn't fatigue as easily. The shoe lift evens out their gait and gives them the ability to participate in their favorite activities again without the pain and trauma surgery can cause. 

When the Lady of the Lake speaks, she expects you to listen...

Never one to linger, computer security expert Charity Puck doesn't expect to be romanced by the small-town charm of her latest job. But when her RV rolls into Plentiful, Wisconsin, nestled along the breathtaking shores of Lake Superior, she's convinced nothing could be more alluring—until she gazes into the delectable hazel eyes of her new client.

Underestimated due to the crutches on his arms and braces on his legs, CEO and researcher Gulliver Winsome doesn't expect his job to put his life in danger. But as he rushes to bring an eco-friendly pesticide to market, in an attempt to save the pollinators, he finds himself the target of a sinister plot—uncovered by the tiny blonde dynamo he hired to fix his servers.
​
Someone is trying to steal Gulliver's research, and they'll stop at nothing to bury the evidence. With feelings in bloom and the would-be couple's lives in peril, it's up to Charity to decipher the clues before they both end up in the Lady of the Lake's cold-water castle.