Lower Extremity Deformities

Deformities related to intoeing

Intoeing

• 3 causes of intoeing affecting otherwise normal children:

• metatarsus adductus• internal tibial torsion• excessive femoral anteversion.

Approach to DDx of Intoeing

• Hx: • Symptoms: Pain (more sever rotational anomalies are usually

not painful)• Physical Exam

– Ht/Wt: r/o skeletal dysplasias and metabolic disease– MSK: Limited hip adduction, leg-length discrepancy to R/O DDH– Neuro: R/O Cerebral palsy, spinal dysraphisms, diastematomyelia,

hydrocephalus and hereditary motor-sensory neuropathies• FH: a family history of rotational anomalies that persist into

adulthood indicate increased likelihood of persistence

Metatarsus Adductus

– Definition• adduction or medial deviation of the forefoot relative

to the hindfoot• No hindfoot carus or equines as with clubfoot

– 1/1000-1500 births

Metatarsus Adductus

Metatarsus Adductus

• Diagnosis: clinical• Convex lateral border of the foot• Medial instep skin crease• Medial deviation of the forefoot• Failure to fully correct the deformity by abduction or

laterally deviating the forefoot while holding the hindfoot• Place a straight edge in the midportion of the heel and

look for where it intersects the forefoot (2nd toe or 1st web space is normal. Any other toe/space = medial deviation.

• DDX: clubfoot, skewfoot (medially deviated forefoot and hindfoot valgus

Metatarsus Adductus

– DDX: clubfoot, skewfoot (medially deviated forefoot and hindfoot valgus)

– Treatment: aim to stretch the tight medial structures of the foot• Stabilize the heel with one hand and abduct the forefoot or pull

the great toe toward the little toe (during diaper changes)• This technique leads to correction by 4-6mo if diagnosed early• 10-15% require additional tx: reverse last shoes, casting, soft

tissue release of the tight medial structured• If persistent abduction in a 4-6 mo -> promptly refer to ortho• <5% of patient have residual isssues

Metatarsus Adductus– DDX: clubfoot, skewfoot (medially deviated forefoot and hindfoot valgus)

• Management Patriculars• Category A: Mild/flexible deformity (Most common)

• Parents Stretch child's foot: 5 repetitions at each diaper change• Category B: Moderate/fixed deformity

– pediatric ortho specialist– Serial corrective casts– Cast every 1-2 weeks for 3-4 casts

• Category C: Severe/rigid deformity (rare) (CANNOT ABDUCT FOREFOOT AT ALL)– – Serial casts in first few weeks of life

• Takes advantageous of neonates ligament laxity– – Corrective Surgery if above not effective (2-4yo)

– Age <7: Soft tissue release tarsometatarsal joint– Age >7: Metatarsal Osteotomy

• Which of the following is a characteristic of metatarsus adductus?

• A. Hindfoot equinus deformity.• B. Hindfoot varus deformity.• C. Hindfoot valgus deformity.• D. Lateral deviation of the forefoot.• E. Medial crease of the instep.

• Which of the following is a characteristic of metatarsus adductus?

• A. Hindfoot equinus deformity.• B. Hindfoot varus deformity.• C. Hindfoot valgus deformity.• D. Lateral deviation of the forefoot.• E. Medial crease of the instep.

Which one is MTA?

Tibial Torsion

• Definition– Very common cause of inteoing– Rotational deviation of the tibia leads to the foot

being misaligned with respect to the knee– Deviation may be external or internal– Internal is more common,– left leg more common

Tibial Torsion

• Pathogenesis– Internal torsion thought to be related to intrauterine

packaging– Family history– Associated with early walking and infantile tibial vara

(bowleggedness)– External torsion may acquired as a compensation for

femoral anteversion– Both internal and external may be associated with

neuromuscular disorders (i.e. CP, myelodysplasia)

Tibial Torsion

• Clinical Presentation– Common chief complaint – “Pigeon toes”, frequent falls

(age 1-3)– Place child in prone position and measure the “thigh-foot

angle”– Normal mature angle is 15-20degrees externally

(laterally)– Newborn commonly have and angle of 5 degrees: nl– External tibial torsion: > 20 degrees angle externally– Internal tibial torsion: any negative angle (internal

rotation past midline)

Tibial Torsion

Tibial Torsion

• Exam: • Knee bent to a right angle and the tibial tubercle pointing

forward. • Examiner’s hands are placed on the medial and lateral

malleolus. • The mean position of the lateral malleolus is 2 to 4

degrees posterior to the medial malleolus in newborns, 9 degrees posterior in 5-year-olds, and 15 to 22 degrees posterior in adults.

• If the lateral malleolus is less posterior than this, internal tibial torsion is present.

Tibial Torsion

• Clinical course– Internal tibial torsion usually resolves by age 5-6– May persist after age 6

• Treatment– Reassurance: 95% resolution– If gait affected or deformity is associated, consider surgical

intervention:– Surgical: derotational distal tibial osteotomy– No evidence to date shows that intervention is effective (short of

osteotomy of the rotated bone) or necessary to avoid long-term disability.

– No evidence exists that persistent internal tibial torsion causes

arthritis or knee dysfunction.

Femoral Anteversion

• Definitions– Normal angulation of the femoral neck with

respect to femoral shaft is 15 degrees– Anteversion : >20 degrees angulation– Retroversion: <10degress angulation

Femoral Anteversion

• Pathogenesis– Newborn: normal anteversion: 40 degrees– Adult: normal anteversion: 15 degrees– Thus: during growth and development, there is a

natural regression of anteversion by 25 degrees– May persist if abnormal muscle tone (i.e. CP,

excessive joint laxity)

Femoral Anteversion

• Clinical course– If in-toeing persisting past age 3-4– Place patient prone or supine with the hips extended, and

internally and externally rotating the hip.– Normal anteversion: 15 to 25 degrees with respect to the axis

of the femoral condyles in the knee in adults.

– The femoral neck is more anteverted in children.– Medial thigh rotation or internal rotation > 60-65 degrees– Often associated with external hip rotation, pes planus,

external tibial torsion, overweight– Xray or CT not indicated unless surgical intervention expected

Femoral Anteversion

Femoral Anteversion

Femoral Anteversion

• Prognosis– anterversion +acquired external tibial torsion, may

lead to patella-femoral arthritis but some studies indicate no relationship to such sequelae

– In-toeing may be beneficial in some sports– Factors associated with anteversion (i.e. obesity)

may predispose patients to slipped capital femoral epiphysis

– Three studies have assessed outcomes after derotation of the femur. In all three studies, the incidence of major complications was 14 percent

to 15 percent.

Femoral Anteversion: W-sitting

Femoral Anteversion

• Treatment– Anteversion as a cause of in-toeing usually resolves by age 10-12– If severe and persistent, may require surgery: femoral

derotation osteotomy– Need for intervention is more common with CP, CVD, abnormal

mechanics or joint laxity– Growth helps with the process of remodeling– Bracing, twister cables, shoe modifications are ineffective– W-sitting may prevent remodeling (controversial), and may be

associated with external tibial torsion (acquired). May also lead to patella femoral malalignment due to torsional forces on the knee. (“miserable misalignment syndrome”)