1. Rotational Deformity of Lower Extremity in Children

2. 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

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

5. Prone Hip Rotation

6. Femoral Anteversion

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

8. 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

9. Thigh Foot Axis

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

11. Heel Bisect Line
Normal bisects second web space

12. Foot Progression Angle

13. Example of FPA
Adult normal FPA about 15º

14. In toeing Metatarsus adductus Calcaneovalgus Internal Tibial Torsion
Femoral anteversion

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

16. 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

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

18. 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

19. 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)

20. 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

21. Thigh Foot Angle in Tibial Torsion

22. 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

23. 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

24. 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

25. Surgical Procedure
Proximal femoral osteotomy
Distal femoral osteotomy

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

27. 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