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
– 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
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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)
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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