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 motorsensory 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 (2 nd 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 thighfoot 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.
Examiners 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

Femoral Anteversion: Wsitting

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)