Rotational Deformity of Lower Extremity in Children

Embryology Limb buds begin a 5th week Lower leg starts with feet facing each other and knees out Leg rotates medial By 7th week hallux is midline Subsequent intrauterine molding causes External rotation of hip Internal rotation of tibia Variable foot position

Rotational Profile Hip rotation Thigh foot axis Heel bisection line Internal rotation External rotation Thigh foot axis Heel bisection line Foot progression angle

Prone Hip Rotation

Femoral Anteversion

Femoral Anteversion Values Birth = average 40º Usually corrects 25º by 10 years old Adult = average 15º

Normal Ranges of Motion (Combination of soft tissue restraints & femoral anteversion) Birth IR = 40º (10º - 60º) ER = 70º (45º - 90º) Age 10 IR = 50º (25º - 65º) ER = 45º (25º - 65º) Adult IR = 35º ER = 45º

Thigh Foot Axis

Normal TFA Values Birth = -5º (-30º to 20º) Age 10 = 8º (-5º to 30º) Adult = 23º (0º to 40º)

Heel Bisect Line Normal bisects second web space

Foot Progression Angle

Example of FPA Adult normal FPA about 15º

In toeing Metatarsus adductus Calcaneovalgus Internal Tibial Torsion Femoral anteversion

Calcaneovalgus Maybe most common foot deformity Estimated to be .1% up to 50%

Metatarsus Adductus Most common cause of intoeing in infant 1/5000 births Male > female More common twins and preterm 1/20 if family history Severity should be based on flexibility 90% resolve without treatment

Metatarsus Adductus Lateral border of foot is curved Base of 5th metatarsal prominent May have deep medial crease Hind foot in valgus

Treatment If stiff and deep medial crease cast at 3 months If flexible consider casting at 6-9 months Operative intervention Questionable if ever indicated Can cast up to 5 years old Functional deformity

Operative Procedures Capsulotomy of Lisfranc joint & release intermetatarsal ligament (Heyman-Herndon) Abuctor hallicus lengthening with capulotomy of navicular, cuneiform & first metatarsal joint Osteotomy metatarsal bases Opening wedge medial cuneiform with closing wedge cuboid or release capsule 2nd-4th metatarsal (Gold Standard)

Internal Tibial Torsion Most common cause intoeing 1-3 years 66% bilateral Abnormal thigh foot angle or transmalleolar angle Negative FPA but patella forward facing 1/3 have MTA Clumsy and tripping

Thigh Foot Angle in Tibial Torsion

Treatment Spontaneous resolution by age 4 No functional deficit Intoeing may lead to faster runners (Staheli, J. Ped. Ortho., 1996) DO NOT consider surgery until after age 8 Deformity > -15º

Femoral Anteversion Most common intoeing age 4-10 Negative FPA Patellas facing medial (squinting patella) Marked internal rotation of hip Female > male Bilateral Sit ‘W” position

Treatment Peaks at age 5 and resolves by age 8-10 Corrects about 1.5º-3º per year (average 25º total correction) Surgical indications > 8-10 years old Functional deficit Femoral anteversion >50º Hip internal rotation >90º

Surgical Procedure Proximal femoral osteotomy Distal femoral osteotomy

Out-Toeing External rotation contracture of hip Spontaneous resolution by 18 months External femoral torsion External tibial torsion Calcaneal varus foot

Take Home 99% of problems resolve No corrective shoes, brace, cables wedges or other devices alter course In-toeing Infant = metatarsus adductus Young child = tibial torsion Older child = femoral anteversion Out-toeing External rotation contracture of hips