Rotational Deformity of Lower Extremity in Children

1. Rotational Deformity of Lower Extremity in Children

2. Embryology • Limb buds begin a 5th week • Lower leg starts with feet facing each other and knees out • Leg rotates medial • By 7th week hallux is midline • Subsequent intrauterine molding causes • External rotation of hip • Internal rotation of tibia • Variable foot position

4. Rotational Profile • Hip rotation • Internal rotation • External rotation • Thigh foot axis • Heel bisection line • Foot progression angle

5. Prone Hip Rotation

6. Femoral Anteversion

7. Femoral Anteversion Values • Birth = average 40º • Usually corrects 25º by 10 years old • Adult = average 15º

8. Normal Ranges of Motion(Combination of soft tissue restraints & femoral anteversion) • Birth • IR = 40º (10º - 60º) • ER = 70º (45º - 90º) • Age 10 • IR = 50º (25º - 65º) • ER = 45º (25º - 65º) • Adult • IR = 35º • ER = 45º

9. Thigh Foot Axis

10. Normal TFA Values • Birth = -5º (-30º to 20º) • Age 10 = 8º (-5º to 30º) • Adult = 23º (0º to 40º)

11. Normal bisects second web space Heel Bisect Line

12. Foot Progression Angle

13. Example of FPA Adult normal FPA about 15º

14. In toeing • Metatarsus adductus • Calcaneovalgus • Internal Tibial Torsion • Femoral anteversion

15. Maybe most common foot deformity Estimated to be .1% up to 50% Calcaneovalgus

16. Metatarsus Adductus • Most common cause of intoeing in infant • 1/5000 births • Male > female • More common twins and preterm • 1/20 if family history • Severity should be based on flexibility • 90% resolve without treatment

17. Lateral border of foot is curved Base of 5th metatarsal prominent May have deep medial crease Hind foot in valgus Metatarsus Adductus

18. Treatment • If stiff and deep medial crease cast at 3 months • If flexible consider casting at 6-9 months • Operative intervention • Questionable if ever indicated • Can cast up to 5 years old • Functional deformity

19. Operative Procedures • Capsulotomy of Lisfranc joint & release intermetatarsal ligament (Heyman-Herndon) • Abuctor hallicus lengthening with capulotomy of navicular, cuneiform & first metatarsal joint • Osteotomy metatarsal bases • Opening wedge medial cuneiform with closing wedge cuboid or release capsule 2nd-4th metatarsal (Gold Standard)

20. Internal Tibial Torsion • Most common cause intoeing 1-3 years • 66% bilateral • Abnormal thigh foot angle or transmalleolar angle • Negative FPA but patella forward facing • 1/3 have MTA • Clumsy and tripping

21. Thigh Foot Angle in Tibial Torsion

22. Treatment • Spontaneous resolution by age 4 • No functional deficit • Intoeing may lead to faster runners (Staheli, J. Ped. Ortho., 1996) • DO NOT consider surgery until after age 8 • Deformity > -15º

23. Femoral Anteversion • Most common intoeing age 4-10 • Negative FPA • Patellas facing medial (squinting patella) • Marked internal rotation of hip • Female > male • Bilateral • Sit ‘W” position

24. Treatment • Peaks at age 5 and resolves by age 8-10 • Corrects about 1.5º-3º per year (average 25º total correction) • Surgical indications • > 8-10 years old • Functional deficit • Femoral anteversion >50º • Hip internal rotation >90º

25. Surgical Procedure • Proximal femoral osteotomy • Distal femoral osteotomy

26. Out-Toeing • External rotation contracture of hip • Spontaneous resolution by 18 months • External femoral torsion • External tibial torsion • Calcaneal varus foot

27. Take Home • 99% of problems resolve • No corrective shoes, brace, cables wedges or other devices alter course • In-toeing • Infant = metatarsus adductus • Young child = tibial torsion • Older child = femoral anteversion • Out-toeing • External rotation contracture of hips