Intoeing Deformities

Question 1

What are the causes of intoeing?

Answer 1

• Femoral anteversion
• metatarsus adductus- infants
• internal tibial torsion- toddlers

Question 2

What is femoral anteversion characterised by?

Answer 2

• Increased anteversion of femoral neck cf femur
• compensatory internal rotation of femur
• lower extremity intoeing

Question 3

What is the epidemiology of femoral anteversion?

Answer 3

• Seen in early childhood 3-6 years
• X2 in girls cf boys
• can be hereditary
• often bilateral

Question 4

What is the pathophysiology of femoral anteversion?

Answer 4

• A packing disorder caused by intra-uterine positioning
• most spontaneously resolve by age 10 yrs

Question 5

What are the associated conditions of femoral anteversion?

Answer 5

• can be associated with other packing disorders
• DDH
• Metatarsus adductus
• congential muscular torticolis

Question 6

What is the normal anatomy of the femoral neck?

Answer 6

• degree of anteversion of femoral neck in relation to the femoral condyles- see pic
• At birth normal femoral anteversion 30-40^o
• Typically decreases in adult to 15^o
• minimal changes in femoral anteversion occur after age 8

Question 7

What are the symptoms of a child with femoral anteversion?

Answer 7

• Pt complain of child intoeing in gait in early childhood
• Child sits in w position
• knee pain when assoc with tibial torsion
• awkward running style
• difficultly in adl- tripping during walking or running
• worse in neuromuscular disease

Question 8

What is seen on physical examination of a child with femoral anteversion?

Answer 8

• Hip motion- tested in prone position
• increased internal rotation of >70^o, N= 20-60^o
• decreased external rotation of ^o N= 30-60^o
• anterversion estimated on degree of hip IR when greater trochanter is most prominent laterally
• Patella is internally rotated on gait analysis
• reduced foot progression angle= intoeing

Question 9

What is seen on physical examination of a child with tibial torsion?

Answer 9

• Look at thigh- foot angle in prone position
• <10^o is indicative of tibial torsion
• normal is 0-20^o of external rotation

Question 10

What is the examination of metatarsus adductus?

Answer 10

• Adducted forefoot deformity, lateral border should be straight
• a medial soft tissue crease indicates a more rigid deformity
• Evaluate for hindfoot and subtalar motion

Question 11

What are the ‘red flags’ associated with intoeing presentation that warrent further investigaton?

Answer 11

• Pain
• Limb length discrepancy
• progressive deformity
• Fhx positive for rickets/skeletal dysplasia/mucopolysaccharidosis
• limb rotational profiles 2 SD outside norm

Question 12

What is the tx of femoral ante version?

Answer 12

Non operative

• Observation and parental reassurance
  
  • indications
  • most usually resolve spontanoeusly by 10 yrs
  • technique
    
    • bracing
    • inserts
    • PT
    • sitting restrictions don’t change natural hx

Operative

• derotational femoral osteotomy
  
  • ​indications
  • <10^o of external rotation on exam in older child >8-10 years
  • usually preformed at intertroachanteric level
  • amount of correction can be calculated by IR-ER/2

Question 13

What is internal tibial torsion?

Answer 13

• A condition that is characterised by internal rotation of tibia
  
  • most common cause of intoeing

Question 14

What is the epidemiology of internal tibial torsion?

Answer 14

• Usually seen in toddlers 1-3 yrs
• location- often bilateral

Question 15

What is the pathophysiology of internal tibial torsion?

Answer 15

• exact aetiology is unknown
• believed to be caused by intra-uterine positioning
• possibily due to excessive tightness of medial ligamentous structures of the leg

Question 16

What are the associated conditions of internal tibial torsion?

Answer 16

• Developmental dysplasia of the hip- DDH
  
  • 15-20% cases
• Metatarsus adductus

Question 17

What are the prognosis of internal tibial torsion?

Answer 17

• Usually resolves by age 6

Question 18

What is the presentation of internal tibial torsion?

Answer 18

• commonly noticed when child starts to walk
• pt reports legs “turned in”
• Increased tripping /falling by parents

Symptoms

• usually asymptomatic

Signs

• assess tibial torsion in prone position
• thigh- foot angle
  
  • av childhood is 5⁰ internal rotation
  • <10^o = tibial torsion
• Transmalleolar angle
  
  • line thru the lat/med mall relative to line perpendicular to long axis of the thigh
  • av 5 degrees of internal rotation
  • <10 = tibial torsion
• Foot progression angle
  
  • normal -5 to 20 degrees

Question 19

What is the tx of internal tibial torsion?

Answer 19

Non operative

• observation and parental education
  
  • most cases
  • usually resolves spontaneously by age 6
  • braces/orthotics doesn’t change natural hx of condition

Operative

• derotational supramalleolar tibial osteotomy
  
  • child >6 yrs of age with >10^o of internal rotation
  • severe cases of functional problems
  • v rarely required

Question 20

What is metatarsus adductus?

Answer 20

• Adduction of forefoot ( at Tarsometatarsal joint) with normal hindfoot alignment
  
  • mechanism thought to do with packing disorders by intra-uterine positioning

Question 21

What is the epidemiology of metatarsus adductus?

Answer 21

• Occurs 1 in 1000 births
• M= F
• bilateral in 50% cases
• increase in
  
  • late pregnancy
  • 1st pregnancy
  • twin pregnancy
  • Oligohydraminos

Question 22

What are the associated conditions Metatarsus adductus?

Answer 22

• DDH- 15-20%
• Torticollis

Question 23

What is the prognosis of Metatarsus adductus?

Answer 23

• Long term studies show that residual Metatarsus adductus is not related to pain or decreased foot function
• assoc with late medial cuneifrom obliquity

Question 24

What are the symptoms and signs of Metatarsus adductus?

Answer 24

• Parents notice intoeing in first year

Physical exam

• ​Metatarsus adductus
  
  • ​forefoot adducted
  • lateral foor border is convex cf normal straight
  • medial sodt tissue crease indicates a more rigid deformity
  • nomal hindfoot and subtalar motion
• Femoral anteversion
  
  • int rotation >70 o and ext rotation <20
• tibial torsion
  
  • decreased foot- thigh angle- ie internal rotation <0 normal 0-20 external rotation

Question 25

What is the classification of Metatarsus adductus?

Answer 25

• Beck
• heel bissector angle
• normal - heel bisector line thru 2-3 toe webspace
• moderate- heel bisector line thru 3rd toe
• severe- heel bissector line thru 4/5th webspace

Question 26

What is the tx of Metatarsus adductus?

Answer 26

• Non operatively
  
  • majority 90% cases by 4 yrs
  • another 5% resolve in early walking yrs (1-4yrs)
  • flexible corrects to midline- no tx
  • flexible passively corrects to midline- stretching
  • rigid deformity=serial casting to obtain straight lateral border of foot
• ​Operative
  
  • ​Lateral colum shortening & medial column lengthening
  • for resistant cases of consx tx
  • children >5 yrs
  • lateral column shortening= cuboid closing wedge osteotomy
  • medial column lengthening- cuneiform opening wedge osteotomy & medial capsular release, abductor hallucis longus recession

Question 27

What is a serpetine/ complex Skew foot?

Answer 27

• condition on the axis of severity of metatrsus adductus
• residual tarsometatarsal adductus
• talonavicular lateral subluxation
• hindfoot valgus

Question 28

What is the tx of serpetine foor/skew foot?

Answer 28

• non op tx and casting is ineffective cf metatarsus adductus
• surgery
  
  • ​opening wedge and closing wedge osteotomies
    
    • ​if symptomatic & limits function
    • calcaneal ostoetomy for hindfoot valgus
    • possible midfoot osteotomies to correct midfoot and forefoot deformities
    • mulitple metatarsal osteotomies with forefoot pinning & tarsometatarsal capsular release