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Torsion of the lower limb in children

Last reviewed: 1 May 2025
Last updated: 15 May 2025

Summary

Definition

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
  • family history of rotational problems
  • female sex
  • intrauterine position abnormalities
  • short stature or disproportionate body-limb ratio
  • ligamentous laxity
Full details

Diagnostic tests

1st tests to order

  • anteroposterior and frog lateral pelvic x-rays
  • anteroposterior and cross-table lateral knee x-ray
  • foot x-rays
Full details

Tests to consider

  • 3-dimensional imaging
  • CT rotational profile evaluations
Full details

Emerging tests

  • quantitative gait analysis

Treatment algorithm

ONGOING

no comorbidity

specific comorbidity

Contributors

Authors

Jon C. Wall, MD

Assistant Professor of Orthopaedic Surgery

Baylor College of Medicine

Texas Children's Hospital

Houston

TX

Disclosures

JCW declares that he has no competing interests.

Scott B. Rosenfeld, MD, FAOA, FAAP

Professor of Orthopaedic Surgery

Director, Pediatric Orthopaedic Surgery Fellowship Program

Baylor College of Medicine

Associate Chief of Research and Education

Director, Hip Preservation Program

Texas Children's Hospital

Houston

TX

Disclosures

SBR is a board member for the Pediatric Orthopaedic Society of North America and a consultant for OrthoPediatrics Corp. He has received royalties from Wolters Kluwer for a chapter he has written in UpToDate.

Acknowledgements

Dr Scott B. Rosenfeld and Dr Jon C. Wall would like to gratefully acknowledge Dr Sanjeev Sabharwal and Dr Tamir Bloom, previous contributors to this topic. SS and TB declare no competing interests.

Peer reviewers

James F. Mooney III, MD

Professor

Orthopedic Surgery and Rehabilitation

Atrium Health Wake Forest Baptist

Winston-Salem

NC

Disclosures

JFM declares that he has no competing interests.

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 topic.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Staheli LT. Rotational problems in children. Instr Course Lect. 1994;43:199-209. Abstract

Staheli LT, Corbett M, Wyss C, et al. Lower-extremity rotational problems in children: normal values to guide management. J Bone Joint Surg Am. 1985 Jan;67(1):39-47. Abstract

Rerucha CM, Dickison C, Baird DC. Lower extremity abnormalities in children. Am Fam Physician. 2017 Aug 15;96(4):226-33.Full text  Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

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