Intoeing Deformities Flashcards
What are the causes of intoeing?
- Femoral anteversion
- metatarsus adductus- infants
- internal tibial torsion- toddlers
What is femoral anteversion characterised by?
- Increased anteversion of femoral neck cf femur
- compensatory internal rotation of femur
- lower extremity intoeing
What is the epidemiology of femoral anteversion?
- Seen in early childhood 3-6 years
- X2 in girls cf boys
- can be hereditary
- often bilateral
What is the pathophysiology of femoral anteversion?
- A packing disorder caused by intra-uterine positioning
- most spontaneously resolve by age 10 yrs
What are the associated conditions of femoral anteversion?
- can be associated with other packing disorders
- DDH
- Metatarsus adductus
- congential muscular torticolis
What is the normal anatomy of the femoral neck?
- degree of anteversion of femoral neck in relation to the femoral condyles- see pic
- At birth normal femoral anteversion 30-40o
- Typically decreases in adult to 15o
- minimal changes in femoral anteversion occur after age 8
What are the symptoms of a child with femoral anteversion?
- 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
What is seen on physical examination of a child with femoral anteversion?
- Hip motion- tested in prone position
- increased internal rotation of >70o, N= 20-60o
- decreased external rotation of o N= 30-60o
- 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
What is seen on physical examination of a child with tibial torsion?
- Look at thigh- foot angle in prone position
- <10o is indicative of tibial torsion
- normal is 0-20o of external rotation
What is the examination of metatarsus adductus?
- Adducted forefoot deformity, lateral border should be straight
- a medial soft tissue crease indicates a more rigid deformity
- Evaluate for hindfoot and subtalar motion
What are the ‘red flags’ associated with intoeing presentation that warrent further investigaton?
- Pain
- Limb length discrepancy
- progressive deformity
- Fhx positive for rickets/skeletal dysplasia/mucopolysaccharidosis
- limb rotational profiles 2 SD outside norm
What is the tx of femoral ante version?
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
- <10o 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
What is internal tibial torsion?
- A condition that is characterised by internal rotation of tibia
- most common cause of intoeing
What is the epidemiology of internal tibial torsion?
- Usually seen in toddlers 1-3 yrs
- location- often bilateral
What is the pathophysiology of internal tibial torsion?
- exact aetiology is unknown
- believed to be caused by intra-uterine positioning
- possibily due to excessive tightness of medial ligamentous structures of the leg
What are the associated conditions of internal tibial torsion?
-
Developmental dysplasia of the hip- DDH
- 15-20% cases
- Metatarsus adductus
What are the prognosis of internal tibial torsion?
- Usually resolves by age 6
What is the presentation of internal tibial torsion?
- 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
- <10o = 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
What is the tx of internal tibial torsion?
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 >10o of internal rotation
- severe cases of functional problems
- v rarely required
What is metatarsus adductus?
-
Adduction of forefoot ( at Tarsometatarsal joint) with normal hindfoot alignment
- mechanism thought to do with packing disorders by intra-uterine positioning
What is the epidemiology of metatarsus adductus?
- Occurs 1 in 1000 births
- M= F
- bilateral in 50% cases
- increase in
- late pregnancy
- 1st pregnancy
- twin pregnancy
- Oligohydraminos
What are the associated conditions Metatarsus adductus?
- DDH- 15-20%
- Torticollis
What is the prognosis of Metatarsus adductus?
- Long term studies show that residual Metatarsus adductus is not related to pain or decreased foot function
- assoc with late medial cuneifrom obliquity
What are the symptoms and signs of Metatarsus adductus?
- 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
What is the classification of Metatarsus adductus?
- 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
What is the tx of Metatarsus adductus?
-
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
What is a serpetine/ complex Skew foot?
- condition on the axis of severity of metatrsus adductus
- residual tarsometatarsal adductus
- talonavicular lateral subluxation
- hindfoot valgus
What is the tx of serpetine foor/skew foot?
- 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
- opening wedge and closing wedge osteotomies
