Rotational Profile

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 

 

 

 

 

 

General Principles

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

 

 

 

 

 

 

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 

 

W sitting

 

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