Cara mengukur shortening pada

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Muhammad Irsyad Khresna Aji
30101307006
• Penentuan selisih panjang tungkai merupakan salah satu komponen penting dalam
pemeriksaan pasien dengan kelainan muskuloskeletal. Selisih panjang tungkai dapat
dibagi ke dalam dua kelompok etiologi : 1. Selisih panjang tungkai struktural :
berhubungan dengan pemendekan dari struktur tulang, 2. Selisih panjang tungkai
fungsional : hasil dari gangguan perubahan mekanik tungkai bawah. (Gurney B, 2002;
Subotnick S, 2001)

• Selisih panjang tungkai dapat berupa perbedaan nyata dari panjang tungkai ataupun
akibat kemiringan dari pelvis. Perbedaan nyata ini dapat terjadi akibat dari
pemendekan atau pemanjangan dari femur maupun tibia, atau keduanya. Meskipun
pengukuran menggunakan pita ukur tergolong mudah dilakukan, namun validitas
pengukuran ini belum diketahui pasti dan belum terdapat panduan penentuan letak
masalah apakah pada regio hip joint atau regio femoral berdasarkan hasil pengukuran
selisih panjang tungkai menggunakan metode pita ukur teknik konvensional
Appearance Leg Length dan True Leg Length (ALL – TLL). (Woerman AL et al., 2004;
Guichet JM et al., 2001; Blake RL et al., 1992)
True leg length measurements
This method involves measuring from the protuding pelvis bone, anterior superior illiac (see red points
on the diagram below) to the ankle joint, medial malleoli. The use of a tailors tape measure is accepted.
You should be able to easily feel the protruding bone on your pelvis, either at the front of back of your
body. These points are a good point of reference for the measurement. With a tailor's type tape
measure, simply measure from this bone to your ankle bone - it's best to do this whilst lying flat and
have someone do it for you. By comparing the results for each leg the discrepancy can easily be found.

Apparent leg length measurement

This method is similar to the above, however it usually gives slight less accurate results. To measure a
leg length discrepancy using this technique, measure from the belly button (umbilicus) to the ankle
joint, medial malleoli.

Anatomical leg length

Differences in leg length resulting from inequalities in bony structure.
An actual shortening or lengthening of the skeletal system occurs between the head of the femur and
the ankle joint mortise, which may have a congenital or acquired cause
• Penggunaan hasil pengukuran selisih panjang tungkai menggunakan metode
pita ukur dengan metode konvensional Appearance Leg Length dan True Leg
Length (ALL – TLL) selama ini telah memberikan panduan apakah kejadian
selisih panjang tungkai timbul akibat kelainan struktural tulang sepanjang
tungkai (selisih panjang tungkai struktural) ataukah hanya akibat gangguan
fungsi serta kelainan mekanik pada tulang belakang, pelvis maupun tungkai
bawah (selisih panjang tungkai fungsional). Sama halnya dengan
pemeriksaan klinis pada selisih panjang tungkai menggunakan metode
Galeazzi sign, hanya mampu menggambarkan kemungkinan letak penyebab
selisih panjang tungkai apakah timbul pemendekan di regio femoral atau
akibat pemendekan di regio cruris. Kedua metode penilaian ini belum dapat
memberikan panduan pemeriksaan klinis untuk prediksi penyebab selisih
panjang tungkai apakah timbul akibat adanya masalah di regio hip joint
ataukah di regio femoral. (Solomon L et al., 2010; Nagayam S, 2010)
• Sementara itu, metode pemeriksaan klinis
Bryant’s triangle dan Roser-Nelaton line yang
merupakan bagian pemeriksaan klinis pada
regio hip joint bersama-sama dapat digunakan
dalam memprediksi kemungkinan penyebab
kejadian timbulnya selisih panjang tungkai
yang timbul di regio hip joint. (Solomon L et
al., 2010; Nagayam S, 2010)
 Bryant’s triangle
• This test measures supratrochanteric shortening. Again candidates should know this test and be prepared
to demonstrate it to the examiners. The patient can lie supine with the pelvis square and limbs in identical
positions. We don’t think you will be asked to draw it out but you may need to be able to demonstate it
with a tape measure. An alternative position to demonstrate landmarks is lateral,some candidates find it
easier
• Identify the ASIS with your thumb and the tip of the greater trochanter with your main finger and the base
of the triangle with your index finger.
• This is not strictly Bryants triangle test- it is a test for proximal migration of the greater trochanter.
Bryants triangle test involves officially drawing out with pen various lines on the pelvis
• A perpendicular line is dropped from the anterior superior iliac spine (ASIS) onto the bed.
From the tip of the greater trochanter another perpendicular line is dropped onto the first line (Base of the
triangle). The tip of the greater trochanter is joined to the ASIS’s on the respective sides. This forms a
triangle ABC.Each side of the triangle is compared with its counterpart on the opposite side. The length of
BC line is compared between the two sides.Relative shortening on one side indicates that the femur is
displaced upwards as a result of a problem in or near the hip joint. If the problem is bilateral, Bryant’s
triangle is unhelpful.
• Shortening above the trochanter may be caused by destruction of the femoral head or acetabulum or
both, a dislocated hip, coxa-vara deformity of a mal-united inter-trochanteric fracture.
• “I would like now to perform Bryants triangle test to see whether there is any shortening above the
trochanter (supra-trochanteric)”. “When Bryants triangle is constructed the perpendicular distance is
shorter by 2 finger widths between the ASIS and greater trochanter on the right side.”
 Nelatons line

• The patient lies with the affected side

uppermost.With the hip flexed up 90 degrees
the tip of the greater trochanter should lie on
or below a line connecting the anterior
superior iliac spine and ischial tuberosity. In
cases of supra-trochanteric shortening the
trochanter will be proximal to this line
 Galleazzi’s test

• If there is shortening in a limb a candidate should go on and perform

Galleazzi’s test. This test demonstrates whether the shortening is in
the femur or tibia. The patient is supine with the hips flexed to 45º
and the knees flexed up to 90º.Place the malleoli together(the test is
inaccurate if you are unable to do so).
The examiner assesses the position of both knees from the end of the
bed and from the sideComment on whether the knees are level or at
a different level and on the parallelism of the femora and tibia.
Normally both knees are at the same level. When one knee projects
farther forwards than the other,either that femur is longer or the
contra-lateral femur is shorter. When one knee is higher than the
other,either the tibia of that side is longer or the contra-lateral tibia is
shorter
• A tape measure is typically used to measure the length of each lower extremity
by measuring the distance between the anterior superior iliac spine (ASIS) and
the medial malleolus and is referred to as the ‘‘direct’’ clinical method for
measuring LLD (Fig. 2). However, differences in the girth of the two limbs, and
difficulty in identifying bony prominences as well as angular deformities can
contribute to errors using this clinical measurement tool. Moreover, there are
certain causes of LLD such as fibular hemimelia and posttraumatic bone loss
involving the foot where a significant portion of the limb shortening is distal to
the ankle mortise. Thus, it may be more accurate to measure the true length
from the pelvis to the bottom of the heel as it is more easily reproducible and
can account for shortening distal to the ankle. In some cases, lengths of the
appendicular skeleton may be equal, but apparent shortening may result from
pelvic obliquity or contractures around the hip and knee joints. An apparent leg
length can be measured from the umbilicus to the medial malleoli of the ankle
(Fig. 2).
• Another method to measure LLD is to level the pelvis
of the erect patient by placing blocks of known
height under the short limb. This is referred to as the
‘‘indirect’’ clinical method for measuring LLD (Fig. 3).
This method takes into account the disparity in foot
height between the two limbs and also aids in
determining the functional LLD (which may be
different from the actual LLD) by using varying
heights of the block to establish the additional length
required for the patient to feel level.