2) Rotational Development and Abnormalities

Question 1

Rotational abnormalities

Answer 1

• Femoral anteversion
• Low tibial torsion
• Femoral retroversion
• Genu varum (“bow legged”)
• Genu valgum (“Knock knee”)

Question 2

Hip joint frontal plane development

Answer 2

• The angle of femoral inclination
• Neonate: 140 -150 degrees
• 6 yrs: 120 -132 (128)

Question 3

Coxa vara vs. coxa valga

Answer 3

• Coxa vara = reduction to less than 128

- Coxa valga = failure to reduce to 128

Question 4

Coxa vara etiologies

Answer 4

• May be secondary to slipped capital femoral epiphysis
• May be developmental
• Traumatic
• May result in genu valgum

Question 5

Coxa valga etiologies

Answer 5

• May be developmental
• Trauma
• May result in genu varum

Question 6

Angle of femoral anteversion

Answer 6

• Anterior angulation of the femoral head and neck relative to the femoral shaft
• Birth: 30-50 degrees
• Adult: 18-16 degrees

Question 7

Femoral retroversion

Answer 7

• Posterior angulation of the femoral head and neck relative to the femoral shaft

Question 8

Excessive anteversion

Answer 8

• Antetorsion (internal or medial femoral torsion)

Question 9

Excessive retroversion

Answer 9

• Retrotorsion (external or lateral femoral torsion)

Question 10

Rotational gait abnormalities

Answer 10

• Intoed gait
• Outoed gait
• Bow legs (genu varum)
• Knock knees (genu valgum)
• Flat feet (pes planus)

Question 11

Intoed gait

Answer 11

• The most common rotational abnormality
• Frequently results in tripping / clumsy gait
• Always results in excessive subtalar / midtarsal joint pronation

Question 12

Outoed gait

Answer 12

• Much less common than intoed gait
• Results in mild excessive subtalar joint pronation
• Cosmetic concern

Question 13

Physical examination: determination of the level of the deformity

Answer 13

• Hips: femoral anteversion / retroversion
• Knees: pseudo – lack of a malleolar torsion
• Malleoli: Low / high malleolar position
• Feet: metatarsus adductus

Question 14

Hip (femur) abnormalities

Answer 14

• Femoral anteversion / retroversion
• Spasticity
• Ligamentous laxity / tightness
• Anterior placement of the acetabulum

Question 15

Femoral anteversion complications

Answer 15

• Intoed with tripping / clumsy gait
• Reverse tailors sitting position
• Internal rotation > external rotation
• Abrupt / spongy end ROM
• Gait with patella rotating internally at heel contact

Question 16

Femoral retroversion

Answer 16

• Outoed gait with history of awkward / apropulsive gait
• Hip external rotation > internal rotation
• Abrupt / spongy end ROM
• Outoed gait with patella external

Question 17

Pseudo-lack of malleolar torsion

Answer 17

• Uncommon cause of intoed gait
• Internally rotated position of tibia relative to femur (limited internal rotation noted)
• Secondary to tight / spastic medial hamstring / gastrocnemius
• Intoed gait with patella midline

Question 18

Malleolar torsion (position)

Answer 18

• Low malleolar position = intoed gait
• High tibial position = outoed gait
• Clinical measurement abnormal
• Intoed gait with patella midline

Question 19

Low malleolar torsion etiology

Answer 19

• Retention of intrauterine position
• Auto. Dom. Inheritance
• Sitting position
• Persistent medial deviation of the talar head and neck

Question 20

Metatarsus adductus

Answer 20

• Relatively common transverse plane deformity at Lisfranc’s joint
• “C – shaped” foot
• Cosmetic concern / intoed gait

Question 21

Intoe / outoe management

Answer 21

• Severity: functional disability / cosmesis
• Severity: compensatory pronation
• Level of the deformity

Question 22

Intoed gait prevalence

Answer 22

• 30 % at 4 yrs
• 4 % in adults
• 85 – 95% of intoe and outoe problems resolve spontaneously

Question 23

Management of femoral anteversion

Answer 23

• Frequently outgrown by age 14 yrs
• Modify sitting position
• Recommend activities such as ballet, roller / ice skating or blading (exercises)
• Functional orthosis
• Bars, gait plates or twister cables are necessary only when functional problems are present

Question 24

Management of femoral retroversion

Answer 24

• Frequently outgrown
• Functional orthosis (decreases angle of gait)
• Rarely are bars, gait plates or twister cables necessary

Question 25

Management of pseudo-lack of malleolar torsion

Answer 25

• Manipulation
• Serial casting
• Functional orthosis

Question 26

Management of low/high malleolar position

Answer 26

• Generally not outgrown
• Bars and splints
• Serial casting
• Functional orthosis
• Gait plates
• Twister cables

Question 27

Management of metatarsus adductus

Answer 27

• Not usually outgrown
• Initiate treatment when < 1 yrs.
• Serial casting
• Ipos anti – adductus shoes
• Reverse – last shoes
• Straight – last shoe
• Bebaux anti – adductus shoes
• Wheaton brace

Question 28

Bars and splints

Answer 28

• Ganley splint
• Denis – Browne bar
• Fillauer bar
• Counter rotational splint (CRS)
• Tibial torsion transformer
• Friedman counter splint
• Brachman skate
• Twister cables
• Torque (Thomas) heels

Question 29

Prescribing bars and splints

Answer 29

• Rx for one bar and one pair of high – top straight – last, open - toed shoes (mounted)
• Length of bar: width of shoulders or asis to asis + 1 inch
• Place varus (10 degree) bend in bar or varus wedge / orthosis in shoe
• For PM use only. Add daytime use if no results within 2 - 3 months

Question 30

Dispensing bars and splints

Answer 30

• Not before 3 months old
• Treatment may last one year
• Allow child to “acclimate”
• Set in a conservative position
• Increase setting at monthly visits
• Never approach the available amount of hip external/internal rotation available (not within 10 degrees of end ROM)