Toeing in
· internal femoral torsion
· internal tibial torsion
· metatarsus adductus
Toeing out
· physiological
· external tibial torsion
· pronation/abduction of the feet
Varus
· physiological genu varum
· tibia vara (infantile/adolescent Blount’s disease)
· rickets
· anterolateral bowing of tibia (pseudarthrosis)
Valgus
· physiological genu valgum
· post traumatic genu valgum
· congenital posteromedial bowing
· anteromedial bowing (fibular hemimelia)
· version
· normal rotation
· femoral version
· angular difference between transcervical and the transcondylar axes
· tibial version
· angular difference between axis of knee and the transmalleolar axis
· torsion
· values 2 standard deviations above or below the mean
· lower limb bud develops during 4th wk
· great toe points laterally
· during 7th wk limb bud rotates medially to bring the hallux into the midline
· for remainder of intrauterine period and childhood limb rotates laterally
· femoral anteversion decreases from ~40o at birth to ~15o at maturity
· tibia increases its lateral rotation from ~5o at birth to ~15o at maturity
· initiator of referral
· reason for consultation
· age of onset
· severity
· disability
· previous management
· age first walked
· if delayed consider CP
· family history of in/out toeing
General screening
· assess height percentile
· check spine
· check hips
· examine feet
· consider
· CP (in-toeing)
· CDH (limb asymmetry)
· SUFE (out-toeing)
· genu varum (in-toeing)
Staheli's torsional profile
Foot progression angle (FPA)
· assessed on gait
· is usually 10o (0o-30o) out
Internal hip rotation (HIR)
· assessed with child prone
· usually 40o (20o-60o)
External hip rotation (HER)
· usually 40o (20-60o)
· greater in young child
Thigh - foot angle (TFA)
· assessed with child prone and knees flexed
· usually 15o (0o-30o) out
Transmalleolar axis (TMA)
· assessed with child prone and knees flexed
· usually 0-30o out
Foot
· shape of foot
· metatarsus adductus or everted foot affects FPA
· required if
· problem complex
· surgical intervention planned
AP x-ray of pelvis
· acetabular version
· hip dysplasia
AP and lateral x-ray of hip
· allows calculation of version using tables
· Magilligan technique
· uses standard AP and lateral views
· then uses a table to convert these measurements of neck length into an angle of anteversion
CT scan
· direct measurement of femoral and tibial version.
MRI or ultrasound
· may replace existing techniques
· trying to control the sleeping, walking, or sitting of infants and children is impossible
· operative correction effective but carries significant risk
· surgery only justified in the child with severe deformity that has failed to resolve with time
· daytime splints (twister cables, modified shoes) and nighttime splints (Dennis-Brown shoes) of no benefit and interfere with child
· observational management indicated for most children with rotational deformity
· 1% will come to surgery
· operative correction usually only appropriate after 8 years of age
· incidence of 15%
· most common identifiable causes are
· internal femoral torsion
· internal tibial torsion
· metatarsus adductus
· talar neck deviation
· first year of life
· usually due to metatarsus adductus
· second year of life
· usually caused by internal tibial torsion
· third and later years
· usually due to internal femoral torsion
· commonest cause of intoeing in first year of life
· may be associated with CDH (10-15%)
· treatment
· observe
· splint if does not correct
· operation not indicated
Epidemiology
· commonest cause of intoeing in the second year of life
Natural history
· 10% of children under 2 yrs have at least 1 leg in internal tibial torsion
· TMA increases from 0o to 5o in between age 1 to 2 yrs
· external tibial rotation usually continues throughout childhood
· most cases of internal tibial torsion resolve by 18 to 24 mths
· some resolution may occur beyond this
· correction should not be expected after age 8 yrs
· resolution not universal
· positive family history may be an indicator of poor prognosis
· consider neuromuscular cause if
· unilateral
· asymmetrical
· progressive
Aetiology
· believed to be due to fetal position
· prone sleeping with limbs internally rotated may delay spontaneous recovery
Clinical
· TFA usually medial
· usually little functional deficit
· may be compensatory pronation and abduction of foot
Treatment
· no treatment in toddler who is stable or improving
· surgery rarely indicated
· supramalleolar osteotomy considered
· if TMA > 3 standard deviations from the mean (< -10o or > 35o)
· should be delayed until age 10 - 12 years
Definition
· transverse plane rotation of the femoral neck axis anteriorly relative to the transcondylar axis
Aetiology
· cause for persistence of fetal anteversion in an otherwise normal child unknown
Natural history
· resolves with time in 95%
· compensatory lateral tibial torsion may develop after age 4 -5 yrs
· little functional disability
· >50% of patients with persistent femoral antetorsion achieve normal gait
· does not predispose to osteoarthritis
Presentation
· intoeing in early childhood
· apparent age 3 yrs
· most severe age 4-6 yrs
Findings
· squinting patellae
· typically sit in W position
· degree may be estimated by noting the position of the patella with the greater trochanter in the direct lateral position
· increased IR with concomitant decreased ER
· abnormal if internal rotation > 70o
· may be no external rotation possible in severe cases
· total arc of motion should > 90o
· if unilateral or progressive in toeing
· must rule out neglected hip dysplasia or cerebral palsy
Treatment
Nonoperative
· no evidence to support the use of orthoses
· may produce
· ligamentous problems at the knee and ankle
· valgus deformity at the knee
· severe external tibial torsion
Indications for surgery
· unusually severe gait disturbance
· rotational criteria
· IR >85o AND
· ER <10o AND
· measured anteversion > 50o
· cosmesis
Principles
· surgery in form of derotation osteotomy
· should not be performed before age 8 yrs
· better delayed until age 10 - 12 yrs
· may be performed at any level
· proximal intertrochanteric osteotomy preferred
· avoids knee stiffness
· better cosmesis for scar
· wide surface of cancellous bone for better union and fixation
· any loss of position producing a malunion is less obvious
· approximately equal amounts of ER and IR should be produced at surgery
· during first year of life
· normal
· due to external rotation contractures of hip
· during childhood
· due to external tibial torsion
Aetiology
· generally occurs
· in compensation for medial femoral torsion
· secondary to neuromuscular disease.
· njudicious use of orthoses for medial femoral torsion may result in excessive external tibial torsion
Presentation
· often worsens with time
· natural tendency is for leg to externally rotate with growth
Treatment
· rarely indicated on functional grounds
· lever action of the foot is not lost until the FPA angle > 50o - 60o
· osteotomy indicated
· if TFA > 35o
· certain cases of CTEV and neuromuscular disorders
Feet turn in
· metatarsus adductus
One foot turns out
· metatarsus adductus on other side
Both feet turn out
· lateral rotation pattern of infants’ hips
Feet turn in
· internal tibial torsion
Feet turn in
· internal femoral torsion
Foot turns in
· internal tibial torsion
Foot turns out
· external tibial torsion
Malalignment of patella
· internal femoral torsion plus external tibial torsion
· generally observation only
· most deformities show
· lack of disability
· lack of long-term problems
· ineffectiveness of nonoperative management
· disability-producing deformities persist in 1 in 1000 children
· progression of bow legs to knock knees to physiological valgus
· birth
· 15o varus (range 1o to 30o varus)
· age 2
· neutral (range 16o varus to 16o valgus)
· age 3
· 10o valgus (range 5o varus to 30o valgus)
· age 6
· 6o valgus (range 8o varus to 24o valgus)
· persistence of physiologic variations may occur
· esp. in some families and racial groups
· family history
General
· height and weight
· rotational profile
· joint laxity
Angular profile
· femorotibial angle
· intramalleolar distance
· AP film
· weight-bearing
· patellae directed forward
· femur and tibia on same film
· peform if pathological form suspected
· positive family history
· asymmetry
· other musculoskeletal abnormalities
· inconsistent with normal sequence of development
· below 5th percentile
· severe deformity
Early infancy
· lateral tibial bowing
Late infancy
· common bowing
Early childhood
· common knock-knees
Varus
· Blount’s disease
· unresolved physiological varus
Valgus
· post-tibial metaphyseal fracture
· lateral condylar hypoplasia
· unresolved physiological valgus
Either
· trauma
· malunion
· partial physeal arrest
· metabolic
· rickets
· renal disease
· osteopaenia
· osteogenesis imperfecta
· rheumatoid arthritis
· avoid dogmatic predictions
· clinical course variable
· not all cases resolve
· shoe wedges and other bracing ineffective
· uncertain
· genu valgum may cause
· chondromalacia
· patellar dislocations
· genu varum may cause
· OA knee
Clinical
· two forms
1. lateral tibial bowing
· occurs in 1st year of life
· nearly always resolves
2. common bowing
· involving the femur and tibia
· seen in 2nd year
· prior to age 2 yrs, development of medial femoral condyle lags behind lateral
· resolution occurs in most children
Treatment
· bracing does not affect the natural history
· exclude pathological causes of deformity and reassure the parents
Surgery
· corrective osteotomy or epiphyseal stapling
· recommended for those chidren with persistence or worsening of physiologic varus
· stapling
· of femoral or tibial epiphysis (depending on the site of deformity)
· should be delayed until age 12 yrs
· osteotomy
· for children too old to benefit from stapling
· disordered growth of proximal tibial physis
· associated with internal tibial torsion
· usually treated with osteotomy
· causes severe genu varum (or valgum)
· associated with stunting and osteopaenia
Aetiology
· may be due to wide-based gait of toddlers
Natural history
· knock knees extremely common in age 2-6 yrs
· startes at age 2 yrs
· most pronounced at age 3-4 yrs
· resolves by age 7 yrs
· may not always resolve
· correction should not be expected after age 8 yrs
Investigation
· x-ray if
· asymmetrical
· unilateral
· progressive
· leg length discrepancy
· intermallelolar distance > 10 cm
Treatment
Bracing
· thought to be useful by some
· indicated if > 10o valgus
Surgery
· indications
· cosmesis
· poor gait / function
· > 15o valgus
· age
· avoided before age 12
· technique
· hemiepiphyseodesis
· osteotomy
· usually occurs after incomplete reduction of distal femoral physeal injury
· usually SH I or II injuries
· several forms
· different consequences
· predictable by direction of bow
· normal variant during 1st yr of life
· usually resolves spontaneously
· usually associated with fibular hemimelia
· associated with short tibia
· may require leg lengthening
· associated with
· calcaneus foot
· triceps surae weakness
· extension contracture of ankle
· anisomelia
· probably caused by intrauterine fracture or malposition
· corrects spontaneously with growth
· shortening is problem
· treated by epiphyseodesis of opposite side
· dangerous form
· associated with pseudarthrosis of tibia
· fracture should be prevented by bracing