Rotational Deformities

Aetiology

  1. Physiological
  2. Non Physiological
    • Congenital
    • Acquired

Definition

  • Torsion
    • Rotation 2 SD <> mean
  • Femoral Version
    • Angular difference between Transcervical & Transcondylar Axes
  • Tibial Version
    • Angular difference between transcondylar Axis of Knee & TMA

Normal Development

  • Lower limb bud develops during 4/52
  • Great Toe points lateral
  • During 7th week bud internally rotates
    • Brings hallux into midline
  • For remainder of intrauterine period & childhood limb is externally rotated
    • femoral anterversion decreases
    • tibial external rotation Increased
  • Neonates have external rotation hip contracture that masks the femoral Anteversion
  • Femoral Anteversion decreases with age
    • 40° Neonate
    • 15° Adult
  • Tibia Increased external rotation
    • 5° Neonate
    • 15° Adult
  • Internal Rotation In-toe toddlers become external rotation in adults

Cla>Classification

  • Toeing In
    • Internal Femoral Torsion IFT
    • Internal Tibial Torsion ITT
    • Metatarsus Adductus
  • Toeing Out
    • Physiological
    • External Tibial Torsion ETT
    • Pronation / Abduction of the Feet

Assessment

  • Initiator of referral
  • Reason for presenting
  • History
    • Age of onset
    • Severity
    • Disability
    • Previous Management
    • Age first walked
      • If delayed consider CP
    • Family History of In / Out Toeing
  • Examination
    • General screening
      • Assess Height percentile
      • Check Spine for Scoliosis
      • Check Hips
      • Examine Feet
  • Consider
    • CP (In-toeing)
    • CDH (Limb Asymmetry)
    • SUFE (Out-Toeing)
    • Genu Varum (In-toeing)
  • Staheli’s Torsional Profile
    1. Foot Progression Angle
      • Assessed on gait
      • Usually 10° out (0°-30°)
      • (5+/- 10)
    2. Hip Internal Rotation
      • Child prone
      • Usually < 65°
      • > 70° = FAV
      • (45+/-15)
    3. Hip external rotation
      • Usually 40° (20-60°)
      • (45+/- 15)
      • Greater in young child
      • Note Internal Rotation + external rotation should = 90°
    4. Thigh- Foot Angle TFA
      • Child prone & knees flexed
      • Reconstruct foot
      • Usually 15° (0°-30°) external rotation
      • (15 +/-15)
    5. Transmalleolar Axis (TMA)
      • Prone & knees flexed
      • Usually 0 -30° ER
    6. Foot
      • Shape of foot
      • Metatarsus ADD or Everted foot affects FPA
  • Normal Examination Figures
    • Foot Progression angle = 5° +/- 10°
    • Thigh Foot angle = 15° +/- 15°
    • ER & Internal Rotation hip = 45° +/- 15°
    • Transmalleolar Axis (TMA) = 0 -30° ER

Investigation<>Investigation

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  • Required if:
    • Problem complex
    • Intervention planned
  • AP Pelvis
    • Acetabular Version
    • DDH
    • SUFE
    • AP & lateral Hip allows calculation of version using tables by Magilligan Tech which converts measurements of neck length into an FAV angle
  • CT Scan
    • Direct measurement of femoral & tibial version

    • Management

      Management-list">
    • General Principles
      1. Trying to control the sleeping, walking, or sitting of infants & children is impossible
      2. surgery correction effective but carries significant risk
      3. surgery only justified in the child with sev defects that has failed to resolve with time
      4. skewfoot,
        • ITT <-10°
        • ETT>40°
        • FAV>50°
      5. Splints not benefit & interfere with child
      6. Observational Management >99% – only 1 in 1000 need surgery
      7. at least > 8 yrs prior to surgery

    Presentations by >Presentations by Age

    st">
  • 1st Year of Life
    • Feet turn in = MT Adductus
    • One foot external rotation = Metatarsus Adductus Contralatera
    • Both feet turn out = lateral rotation pattern of infants’ hips
  • 2nd Year of Life
    • Feet turn in = ITT
  • After 3rd Year of Life
    • Feet turn in = FAV
    • Foot turns in = ITT
    • Foot turns out = ETT

    • TOEING INTOEING IN

    st">
  • Most common causes are:
    • femoral Internal Torsion
    • Internal Tibial Torsion
    • MT ADD
    • Talar neck deviation
  • Neonate usually 2° MT ADD
  • 2 yo usually 2° Internal tibial Torsion
  • > 3yo usually 2° FAV
  • Mild in-toe helpful for runners

    • Metatarsus Adductus<>Metatarsus Adductus

    >
  • Commonest congenital foot deformity
  • Packaging disorder
  • Natural History
    • Flexible & resolves Spontaneously in >90%
      • no long term disability if untreated
      • cosmetic only
  • Treatment
    • only after 6-9m old (usually resolves prior)
    • POP successful up to 4-5 yo old
      • Above knee cast with knee flexed
      • change casts bi-weekly
    • achieve correction in 2-3 weeks in most
    • if recurs then repeat cast & follow with night splint for 3m
  • Operative treatment
    • nearly all correct Spontaneously but if not then at 6-9yo do abductor Halluxis release & MT osteotomy (ie level of deformity)

    • Metatarsus VarusMetatarsus Varus

    >
  • Rigid, plantar crease
  • Deforms medial cuneiform
  • Often persists & needs treatment
  • Cast from age of 3m as above

    • Skew FootSkew Foot

    >
  • Rare
  • Valgus heel, plantar flexed talus, abducted midfoot
  • Flexible
  • Diagnosis confirmed with AP & lateral XR
    • AP XR – Z due to abd at mid-tarsal jnts & add at MTs
    • Lateral XR – flexion of talus
  • Treatment
    • Nonoperative
      • is not helpful
    • Operative
      • Surgery at >/= 6yo
      • opening wedge osteotomy of calcaneus
      • correct midtarsal abduction & to elevate sustentaculum tali under neck of talus to correct talus flexion
      • opening wedge osteotomy of 1st cuneiform to correct forefoot adductus

    • Dynamic Hallux Adductu>Dynamic Hallux Adductus

    li>Searching toe
  • No treatment necessary
  • Natural History
    • resolves

    • Internal Tibial Torsio>Internal Tibial Torsion

    li>Angular difference between Transcondylar Axis of Knee & TMA
  • No 1 cause of intoeing in 2 yo
  • does not occur in preterm infants
  • Natural History – 10% < 2 yrs ITT
    • 2/3 bilateral (ie 1/3 unilateral of these usually left side)
    • associated with MT ADD in 1/3
    • TMA (transmalleolar Axis) Increased 0-5° from age 1 to 2 yrs
    • Tibial external rotation usually continues through childhood
    • presents on walking
    • patella normal position
    • kids tend to trip & appear clumsy
    • Most cases of ITT resolve by 2yo
      • few resolve > 8 yo
    • Resolution not universal
    • +ve FamHistory = Poor prognosis
    • Consider Neuromuscular Disease if:
      • Unilateral
      • Asymmetrical
      • Progressive
    • associated with tibial vara, polio, tibial fractures
  • Aetiology
    • ? Packaging defect
    • Prone sleeping with limbs Internal Rotation may delay Spontaneously recovery
  • Clinical
    • TFA usually Medial
    • Usually little final deficit
    • May be compensatory pronation & ABD of foot
    • most runners apparently intoe
      • ? advantage
  • Treatment
    • almost never required
    • Nonoperative treatment
      • of any sort does not work
      • Splints shown not to work
    • Surgery
      • rarely indicated
      • Supramalleolar Osteotomomy
        • Indications
          • 1 TMA > 3 SD (< -10° or > 40°)
          • 2 Age 10+ years
          • 3 Severe disability

    • Internal Femoral Torsion<>Internal Femoral Torsion

    Transverse plane rotation of the femoral neck axis anteriorly relative to the transcondylar axis
  • F:M = 2:1
  • Bilateral, symmetrical
  • Familial
  • Aetiology
    • Unknown
  • Natural History
    • Resolves in 95%
    • Compensatory ETT may develops after 5 yo
    • Little final disability
    • >50% of patients with persistent femoral Antetorsion achieve normal gait
    • Doesn’t predispose to OA
  • Presentation – Intoeing in early childhood
    • Starts 3 yo
    • Max 4-6 yo
  • Examination
    • Squinting patellae
    • Sit in W
    • run like egg beaters & trip over
    • Degree estimated by noting the position of the patella with the GT in the direct lateral position
    • Prone Rotation test – find position where greater trochanter most prominent from neutral
    • Increased Internal Rotation = decreases external rotation = 90°
    • abnormal if Internal Rotation > 70°
    • If severe, no external rotation possible
    • If unilateral or progression of in-toeing then Rule out DDH / CP
  • Treatment
    • Nonoperative
      • No evidence for orthoses
      • May produce:
        • Lig problems at Knee & Ankle joints
        • Genu Valgum
        • Severe ETT
    • Operative
      • Very severe functional gait disturbance
      • age > 10
      • Rotational criteria
        • 1 Internal Rotation >85°
        • 2 external rotation <10°
        • 3 Measured Anteversion > 50°
      • Cosmesis
  • Imaging
    • Xray
      • AP & lateral Hip allows calculation of version using tables by Magilligan Tech which converts measurements of neck length into an FAV angle
    • CT Scan
      • Direct measurement of femoral & tibial version
  • Principles
    • leave at least >8-10 because many resolve
    • not needed if 10° external rotation present
    • Derotation osteotomy > 8yo, Better > 12 yo
    • Proximal Intertrochanteric osteotomy best
      • No knee stiffness
      • Cosmesis
      • Better union & fixation
      • Malunion is less obvious
      • Aim Internal Rotation = external rotation

    • Management Toeing OutManagement Toeing Out

    n neonates
  • Due to external rotation hip contractures of hip
  • During childhood 2° ETT

    • External Tibial TorsionExternal Tibial Torsion

    in late childhood
  • Often unilateral
  • More often Right side
  • Natural History
    • tends to increase
      • rarely a problem until late childhood
      • associated with patellofemoral instability & pain
  • Aetiology
    • May occur 2° to IFT; CP; Orthoses for IFT
  • Treatment
    • Nonoperative Management
      • useless
    • Operative
      • Osteotomy
        • indicated if TFA > 40°
      • Certain cases of CTEV & NMD

    • External Femoral TorsionExternal Femoral Torsion

    with OA, Increased stress fracture in LL, SUFE

    Torsional Malalignment SyndromeTorsional Malalignment Syndrome

    rable Malalignment syndrome “
  • IFT with compensatory ETT
  • Knee Internal Rotation to axis of progression
  • Management
    • generally observation only
  • Most deformities show
    • Lack of disability
    • Lack of long-term problems
    • Ineffectiveness of Nonoperative Management
  • Disability producing defects persist in 1/ 1000

    • Acetabular Version

    >Acetabular Versionatively constant through life at 15°
  • Not a source of rotational problems

    • Normal Examination Findings<>Normal Examination Findings

    sion angle = 5° +/- 10°
  • Thigh Foot angle = 15° +/- 15°
  • ER & Internal Rotation hip = 45° +/- 15°
  • Transmalleolar Axis (TMA) = 0 -30° ER

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