rotational deformities of lower extremity in children
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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
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