dr. Zairin Noor Helmi, SpOT.(K).MM.

FICS

Version: normal twisting of long bone on its

anatomic longitudinal axis

Torsion: Abnormal / deformity, version

beyond (+or-)2 SD
Reference axis: a line joining designated

bony landmarks at the end of a long bone

Anteversion: the prox ref axis is lat twisted

relative to the distal (X-retroversion(

4-5/52 Paddle bud appear on the anterolateral

wall.

8/52 toes apposed praying feet.

Differential growth of ectoderm and

mesoderm
medial rotation of the L.L
bringing the big toe to the midline i.e.
plantegrade feet.

Intrauterine mechanical molding

lat. femoral and med. tibial torsion.

Lat. Femoral torsion creates the normal

femoral antitorsion angle

average 32 at one year
decline to 16 at 16 years

After birth the tibia start to rotate lat. reaching

15 at skeletal maturity.

 Angle of line joining

head centre - shaft

center and line joining
post. points of the
femoral condyles
Avg.35 at birth
8 and 14
After 8 very slow

regression

Clinical

Prone with 90 knee

flexion
Feel midpoint of
greater troch.it
should be the most
lateral
In antitorsion it is
post.
Rotate the hip
medially until the gr.
troch. is most lat.
degree of
antitorsion

Lat. hip
rotation

Med. hip
rotation

CT
Very accurate
Done if surgery is

Planned
Coast, radiation

Generally in-toeing(good boy) is usually

associated with normal developmental causes

(metatarsus varus, tibiofibular med. rotation,
femoral anteversion)
Out-toeing(bad boy) is more with pathologic

causes
( DDH, coxa vara, SCFE, CP)

In the infant: metatarsus varus

In 2nd year : excessive med. tibiofibular

torsion
3 years + : Femoral antetorsion, evidenced by

hip med. rotation and restricred lat. rotation

Protective in-toeing

In developmental genu valgum and flat

foot (flexible pes planovalgus)
Here the child is shifting the center of
gravity to the foot center
Neuromuscular (all ages)

Spasticity of ant and/or post tibial muscles,

hip med rotators and hip adductors

Relative fibular overgrowth, seen in cong

longitudinal deficiency of the tibia and in
Achondroplasia

Tarsal coalition (rigid flat foot), spastic varus

posture of the foot

Intrauterine fetal

posture
contracture of the
hips lat rotators,
masking hip
anteversion, by
time such
contracture resolve

Missed DDH
Coxa vara, due to associated femoral

retroversion (the rare primary hip retroversion

doesnt correct with growth and may lead to O.A.)
SCFE, adolescent + obesity
Cong longitudinal deficiency of the fibula
Missed vertical talus

Bowlegs in new born and infant

With medial tibial torsion = fetal position

Becomes straight by 18/12

By 2 or 3 genu valgus develop

(avg. 12)

By 7 spontaneous correction
To the normal of adult valgus ( 8 and 7)

Worried parents
About 3 years old +bow legs +mild lateral

thrust at the knees + in-toeing

Assessment:

- History
- etiologic factors

Height
See ( front, back & side) bowlegs is by lat. Hip rotation
+/- medial tibial torsion+/- knee flexion

Measure IC distance,
lateral thigh-leg angle,
center of gravity

Site of varus

In ligamentous laxity
notelat.Widening
Of knee joints

In Blount angulation at med.tib

metaphysis

In cong. Pseudarthrosis of tibia,the

angulation is in the distal

In coxa vara ,angulation at the

neck shaft level

Gait: intoeing, lateral thrust-the fibular

head and upper tibia shift laterally in
Blount due to laxity and incompetence of
the lat. Collat. Lig.

Stability
Symmetry
Level of fibular head, normally at
the level of the upper tibial growth plate,
while it is proximal in Blount,
cong.longitudinal dificiency of the tibia and
achondroplasia

3 years and older

Getting worse
Abnormal site of

angulation
Large physis and
epiphysis
History taruma,
infection, possible metal
intoxication(lead or floride)

Metaphysial/diaphysial
angle 18

Physis, thick and frayed

in rickets

In physiologic genu

varum

no intrinsic bone
disease, gentle curve,
medial cortices thickening,
horizontal joit lines of the
knee & ankle are tilted
medially

Legs are bowed

inwards in the
standing position.
Bowing occurs at
or around the
knee. On standing
with knees
together, the feet
are far apart.

Most children are bowlegged from birth

until around3 years old, then become knock
kneed until age 4 to 5, and straighten
towards adult alignment by age 6 to 7.

Measurement of intermalleolar distance. i.e

distance between two malleoli when the

knees are gently touching with legs in
adduction.
Up to 3 and a half inches (9 centimeters)
with child lying down is acceptable.
75% of children aged 2 - 4 years have
some degree of intermalleolar separation.

Intermalleolar separation under 3 inches is

normal at any age.

Periodic observation and measurement if less
than 3.5 inches.
If > 3.5 inches, need AP X-Ray with both legs
on same film for knee deformity, hip and
ankle joints and view of both long bones.

Pronounced

asymmetry
Short stature
Other skeletal
abnormalities
Intermalleolar
separation greater
than 3.5 inches

Developmental
Miscellaneous syndromes e.g Rickets (Alk

Phos raised, with x-ray changes)

Rare Genetic disorders e.g Cohen
Syndrome
Nutritional conditions e.g Vitamin C
deficiency
Autoimmune e.g RA
Degenerative e.g OA

Age > 7 with knock knee

Unilateral problem i.e Asymmetry of legs
Intermalleolar distance > 3.5 inches (9 cms)
Associated symptoms e.g Pain, Limp

No evidence that shoe modification, splints, or

exercises affect condition

No evidence to justify surgical intervention
under 6 inches of intermalleolar separation.
Surgical options:
Medial epiphyseal stapling at 10 to 11 years
Corrective osteotomy at maturity.

Flat foot(Pes

Planus) Absent or
depressed
longitudinal arch

Pes Planovalgus:

associated hindfoot
eversion, forefoot
abd and everted

Flexible
Developmental the
most common

Hypermobile (ligamentous
hyperlaxity; Ehlers-Donlos,
Marfan, Down)

Neurogenic( rare and

usually cause the reverse-Pes

Cavus)

Rigid, very rare

Congenital (Tarsal
coalition,Vertical talus)

Aquired

) inflammatory)

Physiologic flat foot is NORMAL up to 6 years ( the

foot fat pad shrinks and ligaments become taut)
If there is pain look for other pathologic
conditions
Foot orthoses not a ttt but relief strain, improve
gait pattern,even shoe wear, may prevent
structural tarsal deformities
Surgery- very rare, not before 12 years

Stick to basics
History
Look, feel, move
Most of these common presentation needs
assurance and follow up
Surgery is rarely needed