Rotational Abnormalities

Differential Diagnosis

  • Patients commonly present with intoeing.
  • Bilateral equal intoeing is usually a normal variant.
  • Version: Within normal limits of rotation.
  • Torsion: Abnormal.

Main Differential Diagnoses

  • Femoral torsion
  • Tibial torsion
  • Metatarsus adductus
  • Skewfoot

Normal Variants

Hips

  • Femoral Anteversion
    • 40 degrees at birth
    • 20 degrees at 10 years
    • 15 degrees at skeletal maturity

Tibia

  • Thigh-Foot Angle
    • -7 degrees at birth
    • +7 degrees at 7 years
    • +10 degrees at 10 years

Femoral Torsion

Aetiology

  • Physiologic femoral anteversion: 40 degrees at birth.
    • Reduces to 10-15 degrees by age 10.
    • Girls have 5 degrees more mean torsion than boys.
  • Retroversion is rare and usually pathologic.
  • Significant anteversion may relate to other conditions, e.g., SUFE.

Miserable Malalignment Syndrome

  • Femoral anteversion with compensatory tibial external torsion.
  • High incidence of anterior knee pain.

Clinical Presentation

  • Intoeing
  • Awkward gait
  • Anterior knee pain

Clinical Examination (Assess 4 Things)

  1. Foot Progression Angle
    • Negative: Anteversion
    • Positive: Retroversion
  2. Thigh-Foot Angle (Prone)
    • Assesses tibial torsion (>10 degrees is abnormal).
  3. Femoral Version (Prone)
    • In anteversion: Increased IR, decreased ER.
    • Gage’s Test: Estimate of femoral anteversion by IR of leg until GT is most prominent.
  4. Foot Borders or Deviation from Foot Bisector Axis
    • Lateral convexity: May indicate metatarsus adductus.
    • Medial convexity: May indicate planovalgus.

Management

  • No treatment required in most cases.
  • Reassure parents that anteversion resolves by age 10.

Indications for Surgery

  • IR >70 degrees, ER <10 degrees, child >10 years.
  • Very awkward gait.
  • Psychological distress due to appearance (child, not parents).
  • Patellofemoral pain.
  • As part of another condition (e.g., DDH).

Rotational Osteotomy

  • Types: Intertrochanteric, subtrochanteric, diaphyseal, or supracondylar.
  • Stabilisation:
    • IM Nail: For closed physes.
    • Fixed Angle Plate: For open physes.
  • Union:
    • Metaphysis: More reliable.
    • Diaphysis: Also effective in children.
  • Supracondylar Osteotomy: For patellofemoral pain or instability.

Tibial Torsion

Key Facts

  • Most common cause of intoeing: Internal tibial torsion.
  • Normal tibial torsion: 10 degrees external torsion.

Aetiology

  • Packaging disorder, associated with metatarsus adductus.
  • May result from neuromuscular disorders.
  • External tibial torsion may compensate for femoral anteversion (miserable malalignment syndrome).

Clinical Presentation

  • Tripping over feet.
  • Awkward gait.

Assessment

  • Full rotational profile, including femoral version.
  • Tibial torsion best assessed prone with thigh-foot axis.

Management

  • Usually resolves spontaneously.
  • Surgery (supramalleolar osteotomy) only if symptomatic in children >10 years.

Metatarsus Adductus

Epidemiology

  • Seen in 12% of newborns.

Aetiology

  • Adduction of forefoot with normal hindfoot.
  • Packaging problem.
  • Associated with DDH.
  • 90% resolve by age 4 years.

Classification

  • Bleck Classification
    • Based on heel bisector line and stiffness of deformity.

Diagnosis

  • Clinical evaluation:
    • Screen for other deformities and associated conditions.
    • Tickle Test: Stimulates peronei and indicates flexibility.
    • Heel bisector angle:
      • Normal: Passes between 2nd and 3rd toes.
      • Metatarsus adductus: Passes more laterally.

Management

  • Flexible Deformities: Passive stretching.
  • Stiff Deformities (Young Children): Serial casting.
  • Older Children (>7 Years): Surgery.
    • Osteotomies:
      • Medial column lengthening.
      • Lateral column shortening.

Skewfoot

Aetiology

  • Uncommon, complex condition.
  • Features:
    • Forefoot adduction.
    • Hindfoot valgus.
  • Packaging disorder.

Management

  • Most cases are asymptomatic. Observe.
  • For symptomatic cases:
    • Non-operative treatment is usually unsuccessful.
    • Combination of osteotomies required:
      • Medial sliding calcaneal osteotomy for valgus.
      • Lateral shortening or medial column lengthening for adduction.
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