Rotational and Angular Deformities in Children

1. Knock Knees & Pigeon Toes Rotational and AngularDeformities in Children February 9th 2012 Lauren Cochran MD

2. To-Do • Search PREP for more questions? • Email Myra to ensure no Mac-to-PC glitches? • Summary slide / reasons to refer • Clean up references slide

3. Objectives • To review the common causes of intoeing & outtoeing in children • To describe the progression of normal physiologic alignment over time & how to evaluate a child with genu varum or genu valgum • To describe the physical examination techniques used in assessing rotational and angular deformities • To review indications for imaging and/or Orthopedics referral

4. 4 Categoriesof Lower Extremity Problems • Rotational Deformities • Intoeing (“Pigeon Toes”) • Outtoeing • Angular Deformities • Genu Varum (“Bow legs”) • Genu Valgum (“Knock knees”) • Foot Deformities (e.g., clubfoot & pes planus) • Hip Disorders (e.g., DDH & SCFE)

5. Intoeing

6. Intoeing • Often raised as concern by parents • Sometimes associated with tripping/falling • Possible origin: • Foot = metatarsus adductus • Between knee & ankle = internal tibial torsion • Between hip & knee = medial femoral torsion

7. Metatarsus Adductus

8. Metatarsus Adductus (MTA) • “Packaging Defect” (1st born children at higher risk) • Tarsal & phalangeal bones angled toward midline • + convex lateral curvature of foot • + medial instep crease • Evaluation includes: • Degree of adduction (heel bisector) • Degree of flexibility

9. Metatarsus Adductus

10. Heel Bisectors

11. Heel Bisectors

12. Metatarsus Adductus • Heel bisector (quantifies degree of adduction): • Normal: between 2nd/3rd toes • Mild MTA: 3rd toe • Moderate MTA: 3rd/4th toe • Severe MTA: 4th/5th toe

13. Metatarsus Adductus • Degree of Flexibility  determines need for treatment! • Actively correctable: tickle foot on lateral border  no treatment required • Passively correctable: gentle lateral pressure to 1st metatarsal head  “stretching” 10sec per foot x5 with each diaper change  REFER if not corrected by 4-6mo • Rigid: REFER for possible casting/bracing

14. Metatarsus Adductus

15. Wheaton Brace

16. Metatarsus Adductus & DDH? • Previously reported association between MTA & DDH  now disputed • Still warrants careful hip exam

17. What Metatarsus Adductusis NOT…

18. Clubfoot • aka talipes equinovarus • Constellation of metatarsus adductus PLUS: • Equinus positioning = inability to dorsiflex foot (shortening of gastroc/soleus & tendon) • Hindfoot varus (supination) • Inversion of the forefoot • Warrants early referral to Orthopedist • Famous athletes with clubfoot: Troy Aikman, Kristi Yamaguchi, Mia Hamm

19. Clubfoot

20. Where’s the Intoeing Origin?

21. Internal Tibial Torsion • Origin of intoeing between knee & ankle • Most common intoeing etiology for children less than 3yrs • “Packaging defect”  present from birth but often noticed only when child begins to stand/walk • Almost never requires treatment: • Most cases gradually resolve by age 2-3yrs • REFER if persists beyond age 6

22. Where’s the Intoeing Origin?

23. Medial Femoral Torsion • Origin of intoeing between hip & knee • aka “femoral anteversion” but to a pathologic degree (> 60-65) • Most common intoeing etiology for children older than 3yrs • Associated with “W sitting position” (unclear effect on progression/outcome) • “Egg beater” or “windmill” running pattern • Almost always corrects gradually by age 10

24. Medial Femoral Torsion

25. W Sitting Position

26. “Kissing Patellae”

27. Tibial Torsion vs.Femoral Torsion

28. Intoeing: H&P • HPI: onset, progression, pain, disability, previous evaluation/treatment • Development: particularly gross motor milestones including walking • General screening exam: • Growth parameters • Evaluation for DDH (Ortolani/Barlow, Galeazzi, skin fold asymmetry) • Basic neurological exam (UE+LE reflexes, ankle clonus, heel/toe walking)

29. Intoeing: “Rotational Profile” • Foot progression angle • Heel bisector • Thigh foot angle • Hip rotation

30. Foot Progression Angle

31. Foot Progression Angle • Normal = -5 to +20 • Mild intoeing: -5 to -10 • Moderate intoeing: -10 to -15 • Severe intoeing: > -15

32. Heel Bisector

33. The V-Finger Test

34. Thigh Foot Angle • Patient prone with knees flexed to 90 degrees + natural foot position • Line down center of thigh to heel bisector • Normal = 0 to +10-15 • Negative = internal tibial torsion

35. Thigh Foot Angle

36. Thigh Foot Angle

37. Thigh Foot Angle

38. Hip Rotation • Child is prone with knees flexed to 90 • Assess both sides simultaneously • Normal (varies by age): ~-45 to +45

39. Hip Rotation

40. Hip Rotation • If asymmetric get XR (AP pelvis AP) to evaluate for DDH or other hip problem • Increased internal rotation > 60-65= femoral anteversion • > 80  = moderate • > 90  = severe

41. Hip Rotation

42. Ortho Referrals for Intoeing

43. Benefits of Intoeing? • Some evidence that persistent intoeing is actually beneficial for some sports that require quick directional shifts: • Tennis • Basketball • Soccer • Etc.

44. Outtoeing

45. Outtoeing • Much less common than intoeing • Origin: • Foot: Calcaneovalgus deformity • Between knee & ankle: External tibial torsion • Between hip & knee: Femoral retroversion • Hip: External rotation contracture • Most cases resolve within first 1-2yrs of ambulation

46. Calcaneovalgus Foot • Hyperdorsiflexion of foot • Abduction of forefoot • Forefoot often rests on anterior surface of leg • REFER for casting if foot cannot be plantar-flexed below neutral

47. Calcaneovalgus Foot

48. Calcaneovalgus Foot

49. External Tibial Torsion • Thigh foot angle > +20 • Possible compensation for femoral anteversion • REFER for severe cases (> 40) • REFER if persistent > age 6yrs

50. External Tibial Torsion