Tibial Torsion And The Lower Leg Flashcards
What is torsion
Twist in the bone affecting positional alignment
What is the amount of tibial torsion which occurs during development
Between 18 and 23 degrees
How is tibial torsion measured
With malleolar position
How much external tibial position is noted by age 7 to 8
13 to 18 degrees
What is the trans malleolar axis at birth
0-5 degrees
What happens when less than the normal amount of time tibial torsion is present
In toeing
What happens if there is excessive external tibial torsion
An outtoeing gait pattern
How much does the tibial torsion increase by per year
1.5 degrees
What is the fibula’s role in torsion
- external rotation of the bone
- forms ankle mortise, directing position of the foto
- the foot follows the direction of the malleolar axis
What are some causes of of intoeing
- 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
Torsion (intoeing) is a leading biomechanical cause of compensatory __________
Pes Plano valgus
What is the differential diagnosis for tibial torsion in the foot
Hallux varus or adductus
What is the differential diagnosis for tibial torsion in the tibia
Internal tibial torsion
What is the differential diagnosis for tibial torsion in the knee
Psuedotorsion
What is the differential diagnosis for tibial torsion in the femur
Femoral antetorsion
What is the differential diagnosis for tibial torsion in the hip
Internal femoral position
How to assess tibial torsion in the foot
Clinical exam
Bleck’s test
X-ray - base of 5th/photograph
How to assess tibial torsion in the tibia
Malleolar position (18-23 degrees external)
How to assess tibial torsion in the knee
Transverse plane rotation (knee unlocked)
How to assess tibial torsion in the femur
Ryder’s test - position of femoral head to lower leg
How to assess tibial torsion in the hip
Hip rotation - flexed/extended
Describe the lower leg positional expectations
Less than 2 varum
2-4 straight
4-7 valgum
7-12 straight
13-18 - valgum
Adult - straight
Geriatric - varum
___% of children with met adductus also have internal tibial torsion
75%
What is the foot progression angle
Angular difference between the long axis of the foot and the mid-sagittal line of progression
Slightly external foot progression angle is normally, T or F
True
What is an abnormal foot progression angle
Greater than 5 degrees internal
What is the purpose of the patella position
Tells if the if gait abnormality is above or below the hip
- isolates hip/femur versus tibia/foot
What is the importance of outward kick of tibia in swing phase of running
Suggests femoral torsion
Best position to check hip rotation and thigh foot angle
Prone position
Being more internal than external is common in young children, T or F
True
Equal internal and external is expected in older children and teens, T or F
True
What is Hutter and Scott examination
- 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
If Met Adductus is present, what should you sue for a reference in a thigh-foot angle torsional exam
Hindfoot
What are some compensation patterns for transverse plane superstructural influence on the foot
- medial talar migration
- associated talar plantar flexion
- midtarsal abduction
Distal torsion vs proximal torsion treatments
Proximal - therapeutic exercises, stretching etc
Distal - Casts, braces
How does serial casts work for distal torsion
- 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
What are unilateral abduction braces
Wheaton
Tibial torsion transformer
What are bilateral abduction braces
Dobbs
Dennis-Browne
What is the Dennis-Brown orthoses
Bar with shoes that can be rotated; screwed on, can cause pronatory effects, mainly used for club foot
What is the Dobbs Brace
Allows for independent leg movement
What is the Ganley brace
Four foot plates with torque bar and shank bar; can address forefoot and rarefoot
What is fillauer brace
Dennis Browne with attached clamps
How to treat acquired pes valgus due to pedal compensation
- 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
How to treat acquired pes valgus due to super structural etiology - transverse
Negative
- cast manipulation
- neutral
- plantarflex 1st Ray
Positive
- aggressive RF control
- deeper heel seats
- medial skive
- flanges; 1/2 or full
What is tibial varum/valgum
- long axis of bone bows or goes into varus
- differnet from genu varum
- persistent cases (past 2-4 years)
What is metaphyseal dystopia
Asymmetric growth of the tibial or femoral physes (trauma)
Describe tibial valgum
- rare
- likely from trauma
- epiphyseal injuries and poorly managed fractures
What is Ricket’s
Deficiency in vitamin D intake
- severe malnutrition sunlight deprivation
Causes of Rickets
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
What is seen on radiographs in someone with rickets
Widening of metaphysis of bone giving mushroom appearance
Treatment for rickets
Vit D supplementation
Sequelar for rickets
Significant degenerative arthritis
What is Blount’s disease
Growth disturbances of the medial aspect of the tibia epiphysis at the proximal portion
- unilateral or bilateral
Describe the infantile stage of blount’s disease
12-16 mths
Chubby child, early walker, too early, very active
Pressure destroys physis
Describe the adolescent type of blounts disease
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
.Treament for blounts
Tibial osteotomy - prior to 8 years
Orthotics can control the pronated foot and shift the forces off of the medial growth plate
What is Osgood-Schlatter disease
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
What is the treatment for osgood schlater’s disease
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
