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Leg-length discrepancy • asymmetric gluteal folds and popliteal fossae • positive Galeazzi test • Dx?
THE CASE
A healthy 6-month-old girl born via spontaneous vaginal delivery to a 33-year-old mother presented to her family physician (FP) for a routine well-child examination. The mother’s prenatal anatomy scan, delivery, and personal and family history were unremarkable. The patient was not firstborn or breech, and there was no family history of hip dysplasia. On prior infant well-child examinations, Ortolani and Barlow maneuvers were negative, and the patient demonstrated spontaneous movement of both legs. There was no evidence of hip dysplasia, lower extremity weakness, musculoskeletal abnormalities, or abnormal skin markings. The patient had normal growth and development (50th percentile for height and weight, average Ages & Stages Questionnaire scores) and no history of infection or trauma.
At the current presentation, the FP noted a leg-length discrepancy while palpating the bony (patellar and malleolar) landmarks of the lower extremities, but the right and left anterior superior iliac spine was symmetrical. The gluteal folds and popliteal fossae were asymmetric, a Galeazzi test was positive, and the right leg measured approximately 2 cm shorter than the left leg. There was no evidence of scoliosis or pelvic abnormalities. Physical examination revealed no ecchymosis or trauma. Orthopedic evaluation by the FP of the hips, knees, and ankles was normal, including negative repeat Ortolani and Barlow maneuvers and normal range of motion. We obtained x-rays of the lower extremities and ordered an orthopedic consultation.
THE DIAGNOSIS
The differential diagnosis included congenital, traumatic, infectious, inflammatory, idiopathic, and neurologic causes.1-3 The most common etiologies of leg-length discrepancies are summarized in TABLE 1.1-3 Radiographic imaging showed a femur length discrepancy, which was determined to be congenital without indication of trauma or disease; therefore, a diagnosis of congenital femoral bowing was made.
Initial orthopedic evaluation revealed a femur length discrepancy of approximately 2 cm. Plain films showed lateral femoral bowing (FIGURE 1A).
DISCUSSION
Congenital femoral bowing, which can present as a leg-length discrepancy in infants, is a relatively rare finding with an incidence of 1 per 52,000 births.4 Our patient presented with an isolated limb deformity, but congenital femoral bowing is recognized as a clinical feature of several skeletal dysplasias (TABLE 2).5
What’s recommended
The American Academy of Pediatrics recommends routine age-appropriate physical examination without specifying leg-length assessment.6 There is insufficient evidence, according to
Congenital femoral bowing requires plain film diagnosis
Following physical examination, diagnosis of congenital femoral bowing should be confirmed by plain films. Plain radiography remains the main imaging modality for proximal focal femoral deficiency and fibular hemimelia, and appropriate identification of the osseous abnormalities seen on radiographs allows for accurate classification of congenital femoral bowing, prognosis, and surgical planning.
Continue to: Early diagnosis can improve treatment outcome
Early diagnosis can improve treatment outcome
Both early diagnosis of congenital femoral bowing and prediction of leg-length discrepancy at skeletal maturity can influence potential treatment options, which range from conservative management (eg, watchful waiting, physical therapy, shoe lifts, orthotics, bracing) to surgical intervention. Several models have been used to predict skeletal growth, including the Moseley straight line graph, Green and Anderson growth curve, Amstutz method, and Paley’s multiplier method.4,9-14
Intervention for leg-length discrepancy generally is dictated by the magnitude of the inequality and the presence of functional deficits and/or pain.2 If the degree of femur angulation begins to affect structural development, surgical intervention should be considered to align development and/or correct the discrepancy. Physical therapy, shoe lifts, orthotics, and bracing are treatment options for managing smaller discrepancies.2,15
Our patient. The physician (CP) reviewed treatment options with the family that included watchful waiting, use of a shoe lift and/or orthotics, and bracing. The family chose watchful waiting due to the structural integrity of the patient’s other major joints and her relatively preserved function.
Surgery. Ultimately the patient underwent medial distal femoral hemiepiphysiodesis of the right lower extremity at 6 years of age due to increasing leg-length discrepancy and lateralization of the patella from the valgus deformity. The patient’s mother reported that she did well postoperatively, with increased range of motion, improved physical capabilities, and reduced discomfort in the right leg.
A second surgery. At approximately 8 years and 9 months of age, the orthopedist noted that the patient’s leg-length discrepancy had increased, and she had right extensor mechanism malalignment and severe patellar subluxation. The patient subsequently underwent surgery to remove the existing hardware, including right extensor mechanism realignment via a Roux-Goldthwait procedure (with reconstruction of the medial patellofemoral ligament and anterior cruciate ligament), as well as left distal femoral epiphysiodesis. She did very well postoperatively and continues to participate in physical therapy approximately once weekly. She has had an improvement in her gait and stability using shoe lifts.
Continue to: THE TAKEAWAY
THE TAKEAWAY
A routine well-child examination can be an opportunity to identify congenital musculoskeletal problems. Congenital femoral bowing is a relatively rare finding4 that may present as a leg-length discrepancy. With proper evaluation, including visual inspection, palpation, range-of-motion testing, and special tests as needed (eg, Galeazzi test, Ortolani and Barlow maneuvers), early intervention is possible if a leg-length discrepancy is noted. Close monitoring of gait abnormalities at routine well-child visits is essential.
Physical therapy, shoe lift therapy, and surgical approaches are treatment options for leg-length discrepancy,2 and early intervention can improve treatment outcomes.14 Understanding how to manage congenital femoral bowing over time is important in providing options and counselling patients and their families.15
Treatment of leg-length discrepancy in pediatric patients requires long-term management with a team approach that includes patients and their families. The goal of intervention is to reduce physical and emotional trauma, while addressing complications and maintaining function of the affected limb, as well as the whole body.15
CORRESPONDENCE
Beth P. Davis, DPT, MBA, FNAP, Emory University School of Medicine, Department of Rehabilitation Medicine, Division of Physical Therapy, 1462 Clifton Road NE, Suite 312, Atlanta, GA 30342; bethpdavis@emory.edu.
1. Shailam R, Jaramillo D, Kan JH. Growth arrest and leg-length discrepancy. Pediatr Radiol. 2013:43(suppl 1):S155-S165.
2. Brady RJ, Dean JB, Skinner TM, et al. Limb length inequality: clinical implications for assessment and intervention. J Orthop Sports Phys Ther. 2003;33:221-234.
3. Stanitski DF. Limb-length inequality: assessment and treatment options. J Am Acad Orthop Surg. 1999;7:143-153.
4. Bedoya MA, Chauvin NA, Jaramillo D, et al. Common patterns of congenital lower extremity shortening: diagnosis, classification, and follow-up. Radiographics. 2015;35:1191-1207.
5. Alanay Y, Krakow D, Rimoin DL, et al. Angulated femurs and the skeletal dysplasias: experience of the International Skeletal Dysplasia Registry (1988-2006). Am J Med Genet. 2007;143A:1159-1168.
6. Hagan JF, Shaw JS, Duncan PM, eds. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2017.
7. Shipman SA, Hefland M, Moyer VA, et al. Screening for developmental dysplasia of the hip: a systematic literature review for the US Preventive Services Task Force. Pediatrics. 2006;117:557-576.
8. US Preventive Services Task Force. Screening for developmental dysplasia of the hip: recommendation statement. Pediatrics. 2006;117:898-902.
9. Paley D, Bhave A, Herzenberg JE, et al. Multiplier method for predicting limb-length discrepancy. J Bone Joint Surg Am. 2000;82-A:1432-1446.
10. Castaneda P, Urquhart B, Sullivan E, et al. Hemiepiphysiodesis for the correcting of angular deformity about the knee. J Pediatr Orthop. 2008;28:188-191.
11. Mosley CF. A straight-line graph for leg-length discrepancies. J Bone Joint Surg Am. 1977; 59:174-179.
12. Anderson M, Messner MB, Green WT. Distribution of lengths of the normal femur and tibia in children from one to eighteen years of age. J Bone Joint Surg Am. 1964;46:1197-1202.
13. Amstutz HC. The morphology, natural history, and treatment of proximal femoral focal deficiency. In: GT Aitken, ed. Proximal Femoral Focal Deficiency: A Congenital Anomaly. Washington, DC: National Academy of Sciences; 1969: 50-76.
14. Amstutz HC. Natural history and treatment of congenital absence of the fibula. J Bone and Joint Surg Am. 1972;54(A):1349.
15. Guidera KJ, Helal AA, Zuern KA. Management of pediatric limb length inequality. Adv Pediatr. 1995;42:501-543.
THE CASE
A healthy 6-month-old girl born via spontaneous vaginal delivery to a 33-year-old mother presented to her family physician (FP) for a routine well-child examination. The mother’s prenatal anatomy scan, delivery, and personal and family history were unremarkable. The patient was not firstborn or breech, and there was no family history of hip dysplasia. On prior infant well-child examinations, Ortolani and Barlow maneuvers were negative, and the patient demonstrated spontaneous movement of both legs. There was no evidence of hip dysplasia, lower extremity weakness, musculoskeletal abnormalities, or abnormal skin markings. The patient had normal growth and development (50th percentile for height and weight, average Ages & Stages Questionnaire scores) and no history of infection or trauma.
At the current presentation, the FP noted a leg-length discrepancy while palpating the bony (patellar and malleolar) landmarks of the lower extremities, but the right and left anterior superior iliac spine was symmetrical. The gluteal folds and popliteal fossae were asymmetric, a Galeazzi test was positive, and the right leg measured approximately 2 cm shorter than the left leg. There was no evidence of scoliosis or pelvic abnormalities. Physical examination revealed no ecchymosis or trauma. Orthopedic evaluation by the FP of the hips, knees, and ankles was normal, including negative repeat Ortolani and Barlow maneuvers and normal range of motion. We obtained x-rays of the lower extremities and ordered an orthopedic consultation.
THE DIAGNOSIS
The differential diagnosis included congenital, traumatic, infectious, inflammatory, idiopathic, and neurologic causes.1-3 The most common etiologies of leg-length discrepancies are summarized in TABLE 1.1-3 Radiographic imaging showed a femur length discrepancy, which was determined to be congenital without indication of trauma or disease; therefore, a diagnosis of congenital femoral bowing was made.
Initial orthopedic evaluation revealed a femur length discrepancy of approximately 2 cm. Plain films showed lateral femoral bowing (FIGURE 1A).
DISCUSSION
Congenital femoral bowing, which can present as a leg-length discrepancy in infants, is a relatively rare finding with an incidence of 1 per 52,000 births.4 Our patient presented with an isolated limb deformity, but congenital femoral bowing is recognized as a clinical feature of several skeletal dysplasias (TABLE 2).5
What’s recommended
The American Academy of Pediatrics recommends routine age-appropriate physical examination without specifying leg-length assessment.6 There is insufficient evidence, according to
Congenital femoral bowing requires plain film diagnosis
Following physical examination, diagnosis of congenital femoral bowing should be confirmed by plain films. Plain radiography remains the main imaging modality for proximal focal femoral deficiency and fibular hemimelia, and appropriate identification of the osseous abnormalities seen on radiographs allows for accurate classification of congenital femoral bowing, prognosis, and surgical planning.
Continue to: Early diagnosis can improve treatment outcome
Early diagnosis can improve treatment outcome
Both early diagnosis of congenital femoral bowing and prediction of leg-length discrepancy at skeletal maturity can influence potential treatment options, which range from conservative management (eg, watchful waiting, physical therapy, shoe lifts, orthotics, bracing) to surgical intervention. Several models have been used to predict skeletal growth, including the Moseley straight line graph, Green and Anderson growth curve, Amstutz method, and Paley’s multiplier method.4,9-14
Intervention for leg-length discrepancy generally is dictated by the magnitude of the inequality and the presence of functional deficits and/or pain.2 If the degree of femur angulation begins to affect structural development, surgical intervention should be considered to align development and/or correct the discrepancy. Physical therapy, shoe lifts, orthotics, and bracing are treatment options for managing smaller discrepancies.2,15
Our patient. The physician (CP) reviewed treatment options with the family that included watchful waiting, use of a shoe lift and/or orthotics, and bracing. The family chose watchful waiting due to the structural integrity of the patient’s other major joints and her relatively preserved function.
Surgery. Ultimately the patient underwent medial distal femoral hemiepiphysiodesis of the right lower extremity at 6 years of age due to increasing leg-length discrepancy and lateralization of the patella from the valgus deformity. The patient’s mother reported that she did well postoperatively, with increased range of motion, improved physical capabilities, and reduced discomfort in the right leg.
A second surgery. At approximately 8 years and 9 months of age, the orthopedist noted that the patient’s leg-length discrepancy had increased, and she had right extensor mechanism malalignment and severe patellar subluxation. The patient subsequently underwent surgery to remove the existing hardware, including right extensor mechanism realignment via a Roux-Goldthwait procedure (with reconstruction of the medial patellofemoral ligament and anterior cruciate ligament), as well as left distal femoral epiphysiodesis. She did very well postoperatively and continues to participate in physical therapy approximately once weekly. She has had an improvement in her gait and stability using shoe lifts.
Continue to: THE TAKEAWAY
THE TAKEAWAY
A routine well-child examination can be an opportunity to identify congenital musculoskeletal problems. Congenital femoral bowing is a relatively rare finding4 that may present as a leg-length discrepancy. With proper evaluation, including visual inspection, palpation, range-of-motion testing, and special tests as needed (eg, Galeazzi test, Ortolani and Barlow maneuvers), early intervention is possible if a leg-length discrepancy is noted. Close monitoring of gait abnormalities at routine well-child visits is essential.
Physical therapy, shoe lift therapy, and surgical approaches are treatment options for leg-length discrepancy,2 and early intervention can improve treatment outcomes.14 Understanding how to manage congenital femoral bowing over time is important in providing options and counselling patients and their families.15
Treatment of leg-length discrepancy in pediatric patients requires long-term management with a team approach that includes patients and their families. The goal of intervention is to reduce physical and emotional trauma, while addressing complications and maintaining function of the affected limb, as well as the whole body.15
CORRESPONDENCE
Beth P. Davis, DPT, MBA, FNAP, Emory University School of Medicine, Department of Rehabilitation Medicine, Division of Physical Therapy, 1462 Clifton Road NE, Suite 312, Atlanta, GA 30342; bethpdavis@emory.edu.
THE CASE
A healthy 6-month-old girl born via spontaneous vaginal delivery to a 33-year-old mother presented to her family physician (FP) for a routine well-child examination. The mother’s prenatal anatomy scan, delivery, and personal and family history were unremarkable. The patient was not firstborn or breech, and there was no family history of hip dysplasia. On prior infant well-child examinations, Ortolani and Barlow maneuvers were negative, and the patient demonstrated spontaneous movement of both legs. There was no evidence of hip dysplasia, lower extremity weakness, musculoskeletal abnormalities, or abnormal skin markings. The patient had normal growth and development (50th percentile for height and weight, average Ages & Stages Questionnaire scores) and no history of infection or trauma.
At the current presentation, the FP noted a leg-length discrepancy while palpating the bony (patellar and malleolar) landmarks of the lower extremities, but the right and left anterior superior iliac spine was symmetrical. The gluteal folds and popliteal fossae were asymmetric, a Galeazzi test was positive, and the right leg measured approximately 2 cm shorter than the left leg. There was no evidence of scoliosis or pelvic abnormalities. Physical examination revealed no ecchymosis or trauma. Orthopedic evaluation by the FP of the hips, knees, and ankles was normal, including negative repeat Ortolani and Barlow maneuvers and normal range of motion. We obtained x-rays of the lower extremities and ordered an orthopedic consultation.
THE DIAGNOSIS
The differential diagnosis included congenital, traumatic, infectious, inflammatory, idiopathic, and neurologic causes.1-3 The most common etiologies of leg-length discrepancies are summarized in TABLE 1.1-3 Radiographic imaging showed a femur length discrepancy, which was determined to be congenital without indication of trauma or disease; therefore, a diagnosis of congenital femoral bowing was made.
Initial orthopedic evaluation revealed a femur length discrepancy of approximately 2 cm. Plain films showed lateral femoral bowing (FIGURE 1A).
DISCUSSION
Congenital femoral bowing, which can present as a leg-length discrepancy in infants, is a relatively rare finding with an incidence of 1 per 52,000 births.4 Our patient presented with an isolated limb deformity, but congenital femoral bowing is recognized as a clinical feature of several skeletal dysplasias (TABLE 2).5
What’s recommended
The American Academy of Pediatrics recommends routine age-appropriate physical examination without specifying leg-length assessment.6 There is insufficient evidence, according to
Congenital femoral bowing requires plain film diagnosis
Following physical examination, diagnosis of congenital femoral bowing should be confirmed by plain films. Plain radiography remains the main imaging modality for proximal focal femoral deficiency and fibular hemimelia, and appropriate identification of the osseous abnormalities seen on radiographs allows for accurate classification of congenital femoral bowing, prognosis, and surgical planning.
Continue to: Early diagnosis can improve treatment outcome
Early diagnosis can improve treatment outcome
Both early diagnosis of congenital femoral bowing and prediction of leg-length discrepancy at skeletal maturity can influence potential treatment options, which range from conservative management (eg, watchful waiting, physical therapy, shoe lifts, orthotics, bracing) to surgical intervention. Several models have been used to predict skeletal growth, including the Moseley straight line graph, Green and Anderson growth curve, Amstutz method, and Paley’s multiplier method.4,9-14
Intervention for leg-length discrepancy generally is dictated by the magnitude of the inequality and the presence of functional deficits and/or pain.2 If the degree of femur angulation begins to affect structural development, surgical intervention should be considered to align development and/or correct the discrepancy. Physical therapy, shoe lifts, orthotics, and bracing are treatment options for managing smaller discrepancies.2,15
Our patient. The physician (CP) reviewed treatment options with the family that included watchful waiting, use of a shoe lift and/or orthotics, and bracing. The family chose watchful waiting due to the structural integrity of the patient’s other major joints and her relatively preserved function.
Surgery. Ultimately the patient underwent medial distal femoral hemiepiphysiodesis of the right lower extremity at 6 years of age due to increasing leg-length discrepancy and lateralization of the patella from the valgus deformity. The patient’s mother reported that she did well postoperatively, with increased range of motion, improved physical capabilities, and reduced discomfort in the right leg.
A second surgery. At approximately 8 years and 9 months of age, the orthopedist noted that the patient’s leg-length discrepancy had increased, and she had right extensor mechanism malalignment and severe patellar subluxation. The patient subsequently underwent surgery to remove the existing hardware, including right extensor mechanism realignment via a Roux-Goldthwait procedure (with reconstruction of the medial patellofemoral ligament and anterior cruciate ligament), as well as left distal femoral epiphysiodesis. She did very well postoperatively and continues to participate in physical therapy approximately once weekly. She has had an improvement in her gait and stability using shoe lifts.
Continue to: THE TAKEAWAY
THE TAKEAWAY
A routine well-child examination can be an opportunity to identify congenital musculoskeletal problems. Congenital femoral bowing is a relatively rare finding4 that may present as a leg-length discrepancy. With proper evaluation, including visual inspection, palpation, range-of-motion testing, and special tests as needed (eg, Galeazzi test, Ortolani and Barlow maneuvers), early intervention is possible if a leg-length discrepancy is noted. Close monitoring of gait abnormalities at routine well-child visits is essential.
Physical therapy, shoe lift therapy, and surgical approaches are treatment options for leg-length discrepancy,2 and early intervention can improve treatment outcomes.14 Understanding how to manage congenital femoral bowing over time is important in providing options and counselling patients and their families.15
Treatment of leg-length discrepancy in pediatric patients requires long-term management with a team approach that includes patients and their families. The goal of intervention is to reduce physical and emotional trauma, while addressing complications and maintaining function of the affected limb, as well as the whole body.15
CORRESPONDENCE
Beth P. Davis, DPT, MBA, FNAP, Emory University School of Medicine, Department of Rehabilitation Medicine, Division of Physical Therapy, 1462 Clifton Road NE, Suite 312, Atlanta, GA 30342; bethpdavis@emory.edu.
1. Shailam R, Jaramillo D, Kan JH. Growth arrest and leg-length discrepancy. Pediatr Radiol. 2013:43(suppl 1):S155-S165.
2. Brady RJ, Dean JB, Skinner TM, et al. Limb length inequality: clinical implications for assessment and intervention. J Orthop Sports Phys Ther. 2003;33:221-234.
3. Stanitski DF. Limb-length inequality: assessment and treatment options. J Am Acad Orthop Surg. 1999;7:143-153.
4. Bedoya MA, Chauvin NA, Jaramillo D, et al. Common patterns of congenital lower extremity shortening: diagnosis, classification, and follow-up. Radiographics. 2015;35:1191-1207.
5. Alanay Y, Krakow D, Rimoin DL, et al. Angulated femurs and the skeletal dysplasias: experience of the International Skeletal Dysplasia Registry (1988-2006). Am J Med Genet. 2007;143A:1159-1168.
6. Hagan JF, Shaw JS, Duncan PM, eds. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2017.
7. Shipman SA, Hefland M, Moyer VA, et al. Screening for developmental dysplasia of the hip: a systematic literature review for the US Preventive Services Task Force. Pediatrics. 2006;117:557-576.
8. US Preventive Services Task Force. Screening for developmental dysplasia of the hip: recommendation statement. Pediatrics. 2006;117:898-902.
9. Paley D, Bhave A, Herzenberg JE, et al. Multiplier method for predicting limb-length discrepancy. J Bone Joint Surg Am. 2000;82-A:1432-1446.
10. Castaneda P, Urquhart B, Sullivan E, et al. Hemiepiphysiodesis for the correcting of angular deformity about the knee. J Pediatr Orthop. 2008;28:188-191.
11. Mosley CF. A straight-line graph for leg-length discrepancies. J Bone Joint Surg Am. 1977; 59:174-179.
12. Anderson M, Messner MB, Green WT. Distribution of lengths of the normal femur and tibia in children from one to eighteen years of age. J Bone Joint Surg Am. 1964;46:1197-1202.
13. Amstutz HC. The morphology, natural history, and treatment of proximal femoral focal deficiency. In: GT Aitken, ed. Proximal Femoral Focal Deficiency: A Congenital Anomaly. Washington, DC: National Academy of Sciences; 1969: 50-76.
14. Amstutz HC. Natural history and treatment of congenital absence of the fibula. J Bone and Joint Surg Am. 1972;54(A):1349.
15. Guidera KJ, Helal AA, Zuern KA. Management of pediatric limb length inequality. Adv Pediatr. 1995;42:501-543.
1. Shailam R, Jaramillo D, Kan JH. Growth arrest and leg-length discrepancy. Pediatr Radiol. 2013:43(suppl 1):S155-S165.
2. Brady RJ, Dean JB, Skinner TM, et al. Limb length inequality: clinical implications for assessment and intervention. J Orthop Sports Phys Ther. 2003;33:221-234.
3. Stanitski DF. Limb-length inequality: assessment and treatment options. J Am Acad Orthop Surg. 1999;7:143-153.
4. Bedoya MA, Chauvin NA, Jaramillo D, et al. Common patterns of congenital lower extremity shortening: diagnosis, classification, and follow-up. Radiographics. 2015;35:1191-1207.
5. Alanay Y, Krakow D, Rimoin DL, et al. Angulated femurs and the skeletal dysplasias: experience of the International Skeletal Dysplasia Registry (1988-2006). Am J Med Genet. 2007;143A:1159-1168.
6. Hagan JF, Shaw JS, Duncan PM, eds. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2017.
7. Shipman SA, Hefland M, Moyer VA, et al. Screening for developmental dysplasia of the hip: a systematic literature review for the US Preventive Services Task Force. Pediatrics. 2006;117:557-576.
8. US Preventive Services Task Force. Screening for developmental dysplasia of the hip: recommendation statement. Pediatrics. 2006;117:898-902.
9. Paley D, Bhave A, Herzenberg JE, et al. Multiplier method for predicting limb-length discrepancy. J Bone Joint Surg Am. 2000;82-A:1432-1446.
10. Castaneda P, Urquhart B, Sullivan E, et al. Hemiepiphysiodesis for the correcting of angular deformity about the knee. J Pediatr Orthop. 2008;28:188-191.
11. Mosley CF. A straight-line graph for leg-length discrepancies. J Bone Joint Surg Am. 1977; 59:174-179.
12. Anderson M, Messner MB, Green WT. Distribution of lengths of the normal femur and tibia in children from one to eighteen years of age. J Bone Joint Surg Am. 1964;46:1197-1202.
13. Amstutz HC. The morphology, natural history, and treatment of proximal femoral focal deficiency. In: GT Aitken, ed. Proximal Femoral Focal Deficiency: A Congenital Anomaly. Washington, DC: National Academy of Sciences; 1969: 50-76.
14. Amstutz HC. Natural history and treatment of congenital absence of the fibula. J Bone and Joint Surg Am. 1972;54(A):1349.
15. Guidera KJ, Helal AA, Zuern KA. Management of pediatric limb length inequality. Adv Pediatr. 1995;42:501-543.
