Rotational Deformity of Lower Extremity in Children

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Rotational Deformity of Lower Extremity in
Children
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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

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Rotational Profile

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

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Prone Hip Rotation
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Femoral Anteversion
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Femoral Anteversion Values

• Birth average 40º
• Usually corrects 25º by 10 years old
• Adult average 15º

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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

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Thigh Foot Axis
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Normal TFA Values

• Birth -5º (-30º to 20º)
• Age 10 8º (-5º to 30º)
• Adult 23º (0º to 40º)

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Heel Bisect Line
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Foot Progression Angle
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Example of FPA
Adult normal FPA about 15º
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In toeing

• Metatarsus adductus
• Calcaneovalgus
• Internal Tibial Torsion
• Femoral anteversion

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Calcaneovalgus

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

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Metatarsus Adductus

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

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Metatarsus Adductus

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

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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

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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)

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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

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Thigh Foot Angle in Tibial Torsion
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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 gt -15º

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Femoral Anteversion

• Most common intoeing age 4-10
• Negative FPA
• Patellas facing medial (squinting patella)
• Marked internal rotation of hip
• Female gt male
• Bilateral
• Sit W position

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Treatment

• Peaks at age 5 and resolves by age 8-10
• Corrects about 1.5º-3º per year (average 25º
  total correction)
• Surgical indications
• gt 8-10 years old
• Functional deficit
• Femoral anteversion gt50º
• Hip internal rotation gt90º

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Surgical Procedure

• Proximal femoral osteotomy
• Distal femoral osteotomy

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Out-Toeing

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

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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