Background
Aetiology
1. Physiological
2. Non Physiological
- congenital
- acquired
Definition
Version
- normal rotation
Torsion
- rotation 2 SD <> mean
Femoral Version
- angular difference between transcervical & the transcondylar axis
Tibial Version
- angular difference between transcondylar axis of knee & transmalleolar axis
Normal Development
Lower limb bud develop during 4/52
- great toe points lateral
- during 7th week bud IR
- brings hallux into midline
Limb continues to ER through intra-uterine and childhood
- femoral anteversion decreases
- tibial ER increases
Neonates have ER hip contracture that masks the femoral anteversion
Natural History
In-toeing toddlers become outoeing adults
Femoral anteversion decreases with age
- 40° neonate
- 15° adult
Tibial ER increases with age
- 5° neonate
- 15° adult
Classification
Toeing In
- Internal Femoral Torsion IFT / Femoral anteversion FAV
- Internal Tibial Torsion ITT
- Metatarsus Adductus
Toeing Out
- Physiological
- External Tibial Torsion ETT
- Pronation / Abduction of the Feet
DDx
Intoeing
- increased FAV
- CP
- genu varum
- metatarsus adductus (residual CTEV)
Out-Toeing
SUFE
ETT
Presentations by Age
1st Year of Life
- intoeing usually metatarsus adductus
2nd Year of Life
- intoeing usually FAV
After 3rd Year of Life
- bilaterally intoeing FAV
- unilaterally intoeing ITT
- unilateraly outoeing ETT
Issues
1. Is it in femur?
2. Is it in tibia?
3. Is it in foot?
History
Age of onset
Severity
Disability - i.e. clumsiness
Age first walked
Previous management
If walking age delayed consider CP
- FHx of In / Out Toeing
- sitting W position
Examination
Alignment
- genu varum
Gait
- squinting patella (increased FAV)
- patella anterior (ITT)
- out toeing
Spine / scoliosis
Staheli's Torsional Profile (6)
1. Foot Progression Angle
- assessed on gait
- usually 10° out (0°-30°)
2. Hip IR
- child prone
- usually < 65°
- > 70° = FAV
3. Hip ER
- usually 40° (20-60°)
- greater in young child
- note IR + ER should = 90°
4. Thigh- Foot Angle TFA
- child prone & knees flexed
- reconstruct foot
- usually 15° (0°-30°) ER
- measures tibial torsion
5. Transmalleolar Axis (TMA)
- prone & knees flexed
- usually 0 - 30° ER
6. Foot
- shape of foot
- Metatarsus adductus / everted foot affects foot progression angle
Xray
AP Pelvis
- acetabular version
- SUFE
Malligan Technique
- AP & lateral hip allows calculation of version
- using tables by Magilligan
- converts measurements of neck length into an FAV angle
CT scan
Direct measurement of femoral & tibial version
Management
General Principles
1. Trying to control the sleeping, walking, or sitting of infants & children is impossible
2. Splints are of no benefit & interfere with child
3 Observational Management successful >99%, only 1 in 1000 need OT
4. OT correction effective but carries significant risk
5. OT only justified in the child with severe deformity that has failed to resolve with time
- ITT < -10°
- ETT > 40°
- FAV > 50°
6. At least > 8 years old prior OT
External tibial torsion
Epidemiology
Presents in late childhood
Often unilateral
More often right side
NHx
Tends to increase with age
- rarely a problem until late childhood
- associated with PF instability & pain
Aetiology
Spina bifida / CP
Torsional Malalignment Syndrome
Miserable Malalignment Syndrome
- IFT with compensatory ETT
Management
Non-operative Management
Useless
- rarely indicated on functional grounds
- lever action of foot is not lost until the FPA > 60°
Operative Management
Indications
- osteotomy indicated if TFA > 40°
- certain cases of CTEV & NMD
Internal femoral torsion
Definition
Transverse plane rotation of the femoral neck axis anteriorly relative to the transcondylar axis
Epidemiology
F:M = 2:1
Bilateral, symmetrical
Aetiology
Unknown
Familial
NHx
Increases up to age of 5
- resolves by age of 8
Resolves in 95%
- compensatory ETT may develop after 5 years
- little functional disability
>50% of patients with persistent femoral anteversion achieve normal gait
Doesn't predispose to OA
Presentation
Intoeing in early childhood
- starts 3 years old
- maximum 4-6 years old
Examination
Squinting patellae
Sit in W
Run like egg beaters & trip over
Prone Rotation test / Gages Trochanteric Angle
- find position where GT most prominent laterally
- angle tibia makes from vertical is FAV
Increased IR
- abnormal if IR > 70°
- if severe, no ER possible
CT scan
If surgical intervention deemed likely
DDx
If unilateral / progressive rule out DDH / CP
Non operative
No evidence for orthoses
Operative
Indications
Very severe functional gait disturbance
Cosmesis
Age > 10
Rotational criteria
- IR > 85° & ER <10°
- measured Anteversion > 50°
Principles
Leave until at least > 8-10 years old because many resolve
Not required if 10° ER present
Subtrochanteric derotation osteotomy
Proximal femoral plate
Aim IR = ER on table
Internal tibial torsion
Definition
Angular difference between transcondylar axis of knee & transmalleolar axis
Aetiology
Though to be a packaging disorder
Epidemiology
Number 1 cause of intoeing in 2 year odl
- does not occur in preterm infants
10% < 2 years ITT
- 2/3 bilateral
- 1/3 unilateral of these usually left side
NHx
Normal 0 - 30o ER
Most cases of ITT resolve by 2 years of age
- TMA increases 0-5° from age 1 to 2 years
- few resolve > 8 years
- resolution not universal
- positive FHx association with poor prognosis
Associations
Associated with MT Adductus in 1/3
NMD / CP
DDx
NMD
Fracture
Tibia vara
Symptoms
Children tend to trip & appear clumsy
Examination
Patella normal position
- in-toeing
- thigh foot angle < 0o
- TMA < 0o
Management
Non-operative Management
Splints shown not to work
Operative Management
Complication rate of proximal tibial osteotomy very high
Supramalleolar Osteotomy
Indications
1. TMA > 3 SD (< -10° or > 40°)
2. Age 10+ years
3. Severe disability
Technique
- anterolateral approach
- DCP plate