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