Torsion of the lower limb in children

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.

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]Staheli LT. Rotational problems in children. Instr Course Lect. 1994;43:199-209. http://www.ncbi.nlm.nih.gov/pubmed/9097150?tool=bestpractice.com