Torsion of the lower limb in children

Last reviewed: May 2019

Last updated: January 2018

Summary

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 exam measuring the rotational profile and comparing these values to 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 physical therapy 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 age 4 years and femoral malrotation that does not correct by age 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.

Definition

Lower-extremity torsional problems commonly present in the first decade of life with parental complaints about intoeing or out-toeing. Intoeing 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 anatomic axial (transverse) plane tilt or twist between the ends of the bones (i.e., version), capsular laxity or tightness, and muscular control during growth. [1]

History and exam

Key diagnostic factors

convex lateral border of the sole of the foot
asymmetric hip range of motion

Full details

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

Full details

Risk factors

neuromuscular disease
FHx of rotational problems
female gender
intrauterine position abnormalities
short stature or disproportionate body-limb ratio
ligamentous laxity

Full details

Diagnostic investigations

1st investigations to order

anteroposterior pelvic x-rays
cross-table lateral x-ray of knee and hip
foot x-rays

Full details

Investigations to consider

3-dimensional imaging
CT rotational profile evaluations

Full details

Emerging tests

quantitative gait analysis

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Treatment algorithm

ONGOING

no comorbidity

specific comorbidity

Contributors

Authors VIEW ALL 

Sanjeev Sabharwal, MD, MPH

Professor

Division of Pediatric Orthopaedic Surgery

Department of Orthopaedics

Rutgers, The State University of New Jersey

Newark

Disclosures

SS declares that he has no competing interests.

Acknowledgements

Dr Sanjeev Sabharwal would like to gratefully acknowledge Dr Tamir Bloom, the previous contributor to this monograph. TB declares that he has no competing interests.

Peer reviewers VIEW ALL 

Moon Seok Park, MD

Assistant Professor

Department of Orthopedic Surgery

Seoul National University Bundang Hospital

Seoul National University College of Medicine

Seongnam

South Korea

Disclosures

MSP is an author of a reference cited in this monograph.

Shyam Kishan, MD

Assistant Professor of Orthopaedics

Department of Orthopaedic Surgery

Loma Linda University

Loma Linda

Disclosures

SK declares that he has no competing interests.

In Young Sung, MD, PhD

Professor

Department of Rehabilitation Medicine

Asan Medical Center

University of Ulsan College of Medicine

Seoul

South Korea

Disclosures

Not disclosed.

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Torsion of the lower limb in children

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Emerging tests

Treatment algorithm

no comorbidity

specific comorbidity

Contributors

Authors VIEW ALL 

Sanjeev Sabharwal, MD, MPH

Disclosures

Acknowledgements

Peer reviewers VIEW ALL 

Moon Seok Park, MD

Disclosures

Shyam Kishan, MD

Disclosures

In Young Sung, MD, PhD

Disclosures

Differentials

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