Lower-extremity torsional abnormalities are common in children. Commonly attributed to femoral or tibial torsion, soft-tissue contractures, abnormal muscle tone, hindfoot varus/valgus, forefoot adduction/abduction, or a combination of these.
Clinical examination measuring the rotational profile and comparing these values with normal values can determine causes of malalignment.
Torsional variations (version) are defined as alignment that is within 2 standard deviations (SDs) of the mean and account for most rotational problems. Torsional deformities are defined as abnormalities outside the normal range of 2 SDs.
Torsional problems are commonly phenotypic variations that are considered statistically normal, although perhaps not ideal or desirable to parents. Most will spontaneously resolve with growth and development and have no adverse effect on function.
Femoral and tibial torsion deformities in healthy children who fall outside the normal range of 2 SDs are managed with parental reassurance and education. Arrangements for regular follow-up should be provided. Corrective shoe wedges, night splints, twister cables, and physiotherapy have not been shown to alter the natural history or ensure normal gait.
In otherwise healthy children, operative treatment consisting of derotational osteotomy is rarely indicated. Considered only for severe tibial rotation that does not correct by the age of 4 years and femoral malrotation that does not correct by the age of 8 years.
In patients with neuromuscular disease, such as cerebral palsy or myelomeningocele, deformities may persist or worsen with time. If left untreated, these deformities may contribute to inefficient gait in ambulatory patients and interfere with sitting posture in wheelchair users.
Lower-extremity torsional problems commonly present in the first decade of life with parental complaints about in-toeing or out-toeing. In-toeing refers to medial (internal) rotation of the foot relative to the direction in which the child is walking or running; out-toeing refers to lateral (external) rotation of the foot. Torsion results from a summation of anatomical axial (transverse) plane tilt or twist between the ends of the bones (i.e., version), capsular laxity or tightness, and muscular control during growth.
History and exam
Key diagnostic factors
- convex lateral border of the sole of the foot
- asymmetric hip range of motion
Other diagnostic factors
- foot progression angle >2 standard deviations outside the mean for age
- hip medial rotation >2 standard deviations outside the mean for age
- hip lateral rotation >2 standard deviations outside the mean for age
- thigh-foot axis >2 standard deviations outside the mean for age
- transmalleolar axis >2 standard deviations outside the mean for age
- heel-bisector line
- sitting in the W position
- medial-facing patella (squinting or cross-eyed patella)
- lateral knee thrust
- neuromuscular disease
- family history of rotational problems
- female sex
- intrauterine position abnormalities
- short stature or disproportionate body-limb ratio
- ligamentous laxity
1st investigations to order
- anteroposterior pelvic x-rays
- cross-table lateral x-ray of knee and hip
- foot x-rays
Investigations to consider
- 3-dimensional imaging
- CT rotational profile evaluations
- quantitative gait analysis
Sanjeev Sabharwal, MD, MPH
Professor of Clinical Orthopaedics
University of California, San Francisco
Director & Chief, Orthopaedic Surgery
UCSF Benioff Children's Hospital Oakland
SS declares that he has no competing interests.
Dr Sanjeev Sabharwal would like to gratefully acknowledge Dr Tamir Bloom, the previous contributor to this topic. TB declares that he has no competing interests.
Moon Seok Park, MD
Department of Orthopedic Surgery
Seoul National University Bundang Hospital
Seoul National University College of Medicine
MSP is an author of a reference cited in this topic.
Shyam Kishan, MD
Assistant Professor of Orthopaedics
Department of Orthopaedic Surgery
Loma Linda University
SK declares that he has no competing interests.
In Young Sung, MD, PhD
Department of Rehabilitation Medicine
Asan Medical Center
University of Ulsan College of Medicine
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