Rotational Deformities of the Lower Limbs in

ChildrenAhmed Ashour dr.

Unit 3 Orthopaedics Khoula hosp.

Embryology• Limb buds begin at the 4th-5th week of intra

uterine life• Lower extremities starts with feet facing

each other and knees out• Later: Leg rotates medially

By the 7th week hallux is in the midline, Subsequent intrauterine molding causes:- External rotation of the hip- Internal rotation of tibia=90 deg.- Variable foot position

Emberyoscopy/uteroscopy

Sleeping position

Development of L.L.rotation

• At the 4-5th w == paddle bud appears on the anterolateral wall of the abdomen.

• 7-8th w == toes apposed ”praying feet”.

• Differential growth of ectoderm and mesoderm == medial rotation of the L.L bringing the big toe to the midline .

• Intrauterine mechanical molding ==lat. femoral and medial tibial torsion.

• Lat. Femoral torsion creates the normal

femoral antiversion angle

• After birth the tibia start to rotate lat. reaching 15° at skeletal maturity.

Terminology

• Version: normal twisting of long bone on its anatomic longitudinal axis

• Torsion: Abnormality or deviation of the normal version beyond +/- 2SD

• In-ToeingGait or stance in which the feet point inward or medially

• Out-ToeingGait or stance in which the feet point laterally

Terminologycont.

• Reference axis: a line joining 2 designated bony landmarks at

the two end of a long bone.• Anteversion: the prox. ref. axis is laterally twisted relative to

the distal.• Retroversion: the prox. ref. axis is medially twisted relative to

the distal.

Torsion ?• an internal/external twist of a bone on

itself, requires a force - counterforce.– Types of torsion:

• Internal / external tibial• Internal /external femoral

In-toeing and Out-toeing

• Generally in-toeing (good boy): usually associated with normal developmental causes (metatarsus adductus, tibiofibular med. rotation, excessive femoral anteversion…)

• Out-toeing (bad boy): more with pathologic causes ( DDH, coxa vara, SCFE, CP…)

Rotationsl deformities

Out toeing

Rotational deformities

In toeing

In-toeing

Causes:• Metatarsus adductus• Internal tibial torsion• Excessive femoral Anteversion

-Internal femoral and

- internal tibial torsion

Diagnosis ?

Diagnosis ?• Proper history taking• Parents history and examination• Examinations ( upper limbs, spine exam, mental

and physical status)• Rotational profile: Hip rotation Thigh foot axis (TFA) Foot progression angle (FPA)

– Testing procedures:

• Step 1: Determine that a torsion is present or not ? while

subject is standing (patella and feet do not line up)

• Step 2: Have subject sit on table with feet dangling free:

– Femoral torsion == feet point in, patellae facing medially

– Tibial torsion === patella faces forward* Feet point out = external tibial torsion* Feet point in = internal tibial torsion

1-Foot Progression Angle (FPA)

2-Medial Rotation of Hips (MR)

3- Lateral Rotation of Hips (LR)

4-Thigh Foot Angle (TFA)5-Foot/ Heel bisector line6- Assess right and left

sides 7-Compare to normals for

age and gender

Rotational Profile

Foot progression angle (FPA)

Adult normal FPA about +15º

Foot Progression Angle

Hip Rotation in prone position

Normal range of hip rotation(Combination of soft tissue restraints & femoral anteversion)

• At birth :– IR = 40º (10º - 60º)– ER = 70º (45º - 90º)

• Age 10 yrs :– IR = 50º (25º - 65º)– ER = 45º (25º - 65º)

• Adult :– IR = 35º– ER = 45º

Rotational profile in a child with increased femoral

Anteversion

1Metatarsus Adductus

Heel Bisector Line

Normally, bisects 3rd toe or 2nd web space

Metatarsus Adductus

• Bilateral in 50%• More common in

1st born• 10% of pts have

acetabular dysplasia

so, check the hips

Metatarsus Adductus

• Most common cause of in toeing in infants• 1/5000 births

– Male > female– More common in twins and preterm– 1/20 if family history

• Severity should be based on flexibility• 90% resolve without treatment

Diagnosis ?

Metatarsus Adductus

• Assessed by abduction of

forefoot to neutral position

Metatarsus Adductus

Metatarsus Adductus

• Lateral border of foot is curved

• Base of 5th metatarsal prominent

• May have deep crease medially

• Hind foot in valgus

Treatment ?

Treatment of metatsus adductus

• If stiff, and deep medial crease, cast at 3 months.

• If flexible, consider casting at 6-9 months• Operative intervention:

– Questionable if ever indicated– Failled cast up to 5 years old– Functional deformity

Operative Procedures

• Capsulotomy of Lisfranc joint & release intermetatarsal ligament (Heyman-Herndon)

• Abductor hallucis lengthening with Capsulotomy of navicular, cuneiform & first metatarsal joint

• Osteotomy metatarsal bases• Opening wedge of medial cuneiform with closing

wedge of cuboid or release capsule of 2nd- 4thth metatarsal (Gold Standard)

• Closing wedge osteotomies at the bases (not head) of the metatarsals

• Internal fixation holds until healing

2Internal Tibial Torsion

Internal Tibial Torsion

• Most common cause of toeing 1-3 years• 66% bilateral• Abnormal thigh foot angle or

transmalleolar angle• Negative FPA but patella forward facing• 1/3 may have metatarsus adductus• Clumsy and tripping frequently

Internal tibial torsion

Thigh foot angle (TFA)

Normal TFA Values

• Birth = -5º (-30º to 20º)

• Age 10 = +8º (-5º to 30º)

• Adult = +23º (0º to 40º)

Thigh Foot Angle in Tibial Torsion

Treatment of Internal tibial torsion ?

Treatment of internal tibial torsion

• Avoid prone sleeping and sitting on feet• 90% gradually resolves on its own by 8

years of age.

Salenius P. Rotational problem in children. Inst Course Lect 1994;13:429-39

Treatment Internal tibial torsion

• Spontaneous resolution by age 8yrs• No functional deficits• In toeing may lead to faster runners• DO NOT consider surgery until: - After age 8

- Deformity > -15º

(Staheli, J. Ped. Ortho., 1996)

Surgical treatment

Surgical treatment

3Excessive Femoral Anteversion

Excessive femoral Anteversion

• Most common cause of in-toeing age 4-10• Negative FPA

– Patellae facing medial (squinting patellae)• Marked internal rotation of hip• Female > male• Bilateral• Sit ‘W” position

Hip Rotation in prone position

Normal ranges of hip rotation(Combination of soft tissue restraints & femoral anteversion)

• At birth :– IR = 40º (10º - 60º)– ER = 70º (45º - 90º)

• Age 10 yrs :– IR = 50º (25º - 65º)– ER = 45º (25º - 65º)

• Adult :– IR = 35º– ER = 45º

How to determine distal femoral condylar axis ?

How to determine distal femoral condylar axis?

How to determine distal femoral condylar axis?

Femoral anteversion ?

• Angle of line joining head centre - shaft center and line joining post. points of the femoral condyles

• Avg. 35°-40 ° at birth• After 8 very slow

regression down to 16 ° 16 yrs

Femoral Anteversion

FEMORAL ANTEVERSION

NATURAL HISTORY :• Normally, 30- 40 degrees at birth• Usually corrects 25º by 10 years old• Gradual decrease in version to 10-16 degrees by early

adolescence• Most common cause of in-toeing > 3 years• Masked by external rotation contracture• Resolves after independent walking• Cosmetic deformity• Not associated with arthritis

Rotational profile in a child with increased femoral

anteversion

Measuring Femoral Torsion

- Prone with 90° knee flexion - Feel midpoint of greater troch. it should be the most lateral prominent-Rotate the hip medially until the gr. troch. is most lat.

Lat. hip rotation

Med. hip rotation

Radiological diagnosis

• CT:– Very accurate – Done if surgery

is Planned

– Coasty– irradiation

Excessive Femoral Anteversion

• Int rotation 70-80 deg• Ext rotation 10-30 deg

Sitting ‘W” position

Sitting ‘W” position

Management of excessive femoral anteversion ?

Conservative management

• Reassure• Assess hip ROM every 6 m.• Conditions supporting surgical approach:

– > 8-10 years old– Functional deficit (athletic failure/tripping)– Femoral anteversion >50º– Hip internal rotation >90º– family understands risks of surgery

Surgical Procedure

• Proximal femoral Osteotomy

• Distal femoral Osteotomy

Proximal femoral Osteotomy

Proximal femoral osteotomy

Rotationsl deformities

Out toeing In toeing

Rotational deformities

Out toeing

Causes:• External rotation contracture of hip

– Spontaneous resolution by 18 months• External femoral torsion (retroversion)• Excessive external tibial torsion• Flat feet ( pes planus)• Calcaneovalgus foot

Out-toeing

• Intrauterine fetal posturecontracture of the hips lat rotators, masking hip anteversion

• By time, such contractures resolve

Diagnosis of out-toeing

• Often associated with genu valgum deformity

• May be worsened with prone sleeping or wide diapers pad and walkers.

• Examine patella and malleoli to localize lesion

Calcaneovalgus

• One of the most common foot deformity

• Estimated to be 1% up to 50%

Calcaneovalgus foot mild degree

Rare causes

• Missed DDH• Coxa vara, due to associated femoral

retroversion (the rare primary hip retroversion doesn’t correct with growth and may lead to O.A.)

• SCFE, adolescent + obesity • Cong longitudinal deficiency of the fibula• Missed congenital vertical talus

Pes Planus (flatfoot)

Types of flat foot

• Flexible, common

1- Developmental : the most common

2- Hypermobile :(ligamentous hyperlaxity; Ehlers-

Donlos, Marfan, Down………)

3-Neurogenic:( rare and usually cause the reverse-

Pes Cavus)

• Rigid, very rare

1- Congenital :(Tarsal coalition,Vertical talus)

2- Aquired:( inflammatory)

Treatment of out-toeing

• Generally….• Stretching if there is hip deformity• Avoid Aggravating positions• Observe and reassure till resolution

although…….,• Surgery rarely needed

Management of flat foot

- Physiologic flat foot is NORMAL up to 6 years ( the foot fat pad shrinks and ligaments become tight).

- If there is pain, look for other pathologic conditions.

-Foot orthoses – not a ttt but relief strain, improve gait pattern, even shoe wear, may prevent structural tarsal deformities.

- Surgery: very rare, not before 12 years

Treatment of flat foot

(i) Flexible/asymptomatic: - no further work up/treatment is necessary! - no studies show flex flatfoot has increased risk for pain as an adult.

(ii) Rigid/painful: - must r/o tarsal coalition (congenital fusion or failure of seg. b/w 2 or more tarsal bones) - usually assoc with peroneal muscle spasm - need AP/lat weight bearing films of foot

External tibial torsion

causes:• Acquired deformity.• Band contracture.• Usually seen between 4-7 yrs old• Right>left• Internal femoral torsion with external tibial

torsion is termed miserable malalignment syndrome (very rare)==

External tibial torsion

• Associated with patellofemoral pain, subluxation or dislocation.– Treatment: stretching exercises; medial rotational

osteotomy ( at 10-12 yrs)Note:Out-toeing deformity does not correct with

growth

External Femoral torsion

• Common in early infancy.• Intrauterine constriction bands.• May gradually improve during first year of

walking• If no improvement at 2 to 3 yrs, intervension

should be taken as it may be associated with hip or knee arthritis in adults or SCFE in teenagers.

Remember• In-toeing

– Infant => metatarsus adductus– Young child => internal tibial torsion– Older child => excessive femoral anteversion

• Out-toeing– External rotation contracture of hips

CONCLUSION

Stick to basics:• History (proper, meticulous, family history…….)• Examine ( look, feel, move , family exam.,…..)• Most of these common presentation needs only

assurance and follow up.• 99% of problems resolve spontaneously.• corrective shoes, brace, cables, wedges or other

devices will not alter the course.• Surgery is rarely needed