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.