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Pediatric Orthopedics > Tibial Torsion And The Lower Leg > Flashcards

Tibial Torsion And The Lower Leg Flashcards

1
Q

What is torsion

A

Twist in the bone affecting positional alignment

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2
Q

What is the amount of tibial torsion which occurs during development

A

Between 18 and 23 degrees

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3
Q

How is tibial torsion measured

A

With malleolar position

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4
Q

How much external tibial position is noted by age 7 to 8

A

13 to 18 degrees

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5
Q

What is the trans malleolar axis at birth

A

0-5 degrees

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6
Q

What happens when less than the normal amount of time tibial torsion is present

A

In toeing

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7
Q

What happens if there is excessive external tibial torsion

A

An outtoeing gait pattern

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8
Q

How much does the tibial torsion increase by per year

A

1.5 degrees

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9
Q

What is the fibula’s role in torsion

A
  • external rotation of the bone
  • forms ankle mortise, directing position of the foto
  • the foot follows the direction of the malleolar axis
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10
Q

What are some causes of of intoeing

A
  • tib-fib reasons (intoeing would be excessive)
  • internal genicular position
    • rotation of the lower leg when knee is unlocked
    • small amount of rotation proximally will cause significant change distally
  • excessive external rotation
    • occurs when the child ambulates in an abducted attitude
    • poorly managed tibia fracture that led to external
  • excessive femoral ante torsion
    • distal femoral section is rotated internally when hip is neutral
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11
Q

Torsion (intoeing) is a leading biomechanical cause of compensatory __________

A

Pes Plano valgus

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12
Q

What is the differential diagnosis for tibial torsion in the foot

A

Hallux varus or adductus

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13
Q

What is the differential diagnosis for tibial torsion in the tibia

A

Internal tibial torsion

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14
Q

What is the differential diagnosis for tibial torsion in the knee

A

Psuedotorsion

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15
Q

What is the differential diagnosis for tibial torsion in the femur

A

Femoral antetorsion

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16
Q

What is the differential diagnosis for tibial torsion in the hip

A

Internal femoral position

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17
Q

How to assess tibial torsion in the foot

A

Clinical exam
Bleck’s test
X-ray - base of 5th/photograph

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18
Q

How to assess tibial torsion in the tibia

A

Malleolar position (18-23 degrees external)

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19
Q

How to assess tibial torsion in the knee

A

Transverse plane rotation (knee unlocked)

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20
Q

How to assess tibial torsion in the femur

A

Ryder’s test - position of femoral head to lower leg

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21
Q

How to assess tibial torsion in the hip

A

Hip rotation - flexed/extended

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22
Q

Describe the lower leg positional expectations

A

Less than 2 varum
2-4 straight
4-7 valgum
7-12 straight
13-18 - valgum
Adult - straight
Geriatric - varum

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23
Q

___% of children with met adductus also have internal tibial torsion

A

75%

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24
Q

What is the foot progression angle

A

Angular difference between the long axis of the foot and the mid-sagittal line of progression

25
Q

Slightly external foot progression angle is normally, T or F

A

True

26
Q

What is an abnormal foot progression angle

A

Greater than 5 degrees internal

27
Q

What is the purpose of the patella position

A

Tells if the if gait abnormality is above or below the hip
- isolates hip/femur versus tibia/foot

28
Q

What is the importance of outward kick of tibia in swing phase of running

A

Suggests femoral torsion

29
Q

Best position to check hip rotation and thigh foot angle

A

Prone position

30
Q

Being more internal than external is common in young children, T or F

A

True

31
Q

Equal internal and external is expected in older children and teens, T or F

A

True

32
Q

What is Hutter and Scott examination

A
  • knees flexed over the table
  • have medial foot at midline, in sagittal with medial knee
  • x-ray parallel to long axis of the lower leg measure the axis of the malleolus against the axis of the knee joint
33
Q

If Met Adductus is present, what should you sue for a reference in a thigh-foot angle torsional exam

A

Hindfoot

34
Q

What are some compensation patterns for transverse plane superstructural influence on the foot

A
  • medial talar migration
  • associated talar plantar flexion
  • midtarsal abduction
35
Q

Distal torsion vs proximal torsion treatments

A

Proximal - therapeutic exercises, stretching etc
Distal - Casts, braces

36
Q

How does serial casts work for distal torsion

A
  • manipulate lower leg on the thigh at the knee
  • apply lateral pressure on the malleoli at the ankle
  • Wolf’s law to direct the growth
37
Q

What are unilateral abduction braces

A

Wheaton
Tibial torsion transformer

38
Q

What are bilateral abduction braces

A

Dobbs
Dennis-Browne

39
Q

What is the Dennis-Brown orthoses

A

Bar with shoes that can be rotated; screwed on, can cause pronatory effects, mainly used for club foot

40
Q

What is the Dobbs Brace

A

Allows for independent leg movement

41
Q

What is the Ganley brace

A

Four foot plates with torque bar and shank bar; can address forefoot and rarefoot

42
Q

What is fillauer brace

A

Dennis Browne with attached clamps

43
Q

How to treat acquired pes valgus due to pedal compensation

A
  • Tissue stress principles
  • RCSP
  • Midfoot. Collapse
  • 1st ray position
  • Root based - post to measured deformities
  • rearfoot and forefoot varus posts as needed
  • higher RF correction for torsional influence
44
Q

How to treat acquired pes valgus due to super structural etiology - transverse

A

Negative
- cast manipulation
- neutral
- plantarflex 1st Ray

Positive
- aggressive RF control
- deeper heel seats
- medial skive
- flanges; 1/2 or full

45
Q

What is tibial varum/valgum

A
  • long axis of bone bows or goes into varus
  • differnet from genu varum
  • persistent cases (past 2-4 years)
46
Q

What is metaphyseal dystopia

A

Asymmetric growth of the tibial or femoral physes (trauma)

47
Q

Describe tibial valgum

A
  • rare
  • likely from trauma
  • epiphyseal injuries and poorly managed fractures
48
Q

What is Ricket’s

A

Deficiency in vitamin D intake
- severe malnutrition sunlight deprivation

49
Q

Causes of Rickets

A

Sprue - not absorbing the vitamin D
Diarrhea - rapid loss of fat and increases excretion of vitamins
Improper supply of active form of vitamin D from renal disease or impaired liver function

50
Q

What is seen on radiographs in someone with rickets

A

Widening of metaphysis of bone giving mushroom appearance

51
Q

Treatment for rickets

A

Vit D supplementation

52
Q

Sequelar for rickets

A

Significant degenerative arthritis

53
Q

What is Blount’s disease

A

Growth disturbances of the medial aspect of the tibia epiphysis at the proximal portion
- unilateral or bilateral

54
Q

Describe the infantile stage of blount’s disease

A

12-16 mths
Chubby child, early walker, too early, very active
Pressure destroys physis

55
Q

Describe the adolescent type of blounts disease

A

8-13 years
Unilateral
Hereditary factors
Boney beaking on the medal side of he metaphysis of the tibia
Painless
Internal leg position/pronated foot
Epiphysis encroaching on the metaphysis and fuses and slopes the articular surface of the tibia

56
Q

.Treament for blounts

A

Tibial osteotomy - prior to 8 years
Orthotics can control the pronated foot and shift the forces off of the medial growth plate

57
Q

What is Osgood-Schlatter disease

A

10-14 years, males, but can increase in female athletes
Avulsion of a portion of developing ossification center and overlying hyaline cartilage
X-ray evidence of avulsed area at tibial tuberosity
Palpable bump

58
Q

What is the treatment for osgood schlater’s disease

A

Avoid excessive flexion (catchers)
Avoid kneeling
Surgical repair if significant and he physis is closed
Control of the foot and leg to reduce knee flexion
Control also reduces the rotation of the tibia during gait

Pediatric Orthopedics (18 decks)

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