Torsional
Problems of the Lower Limb
Anteversion = directed forward
Antetorsion = twisted about long axis
Femoral Anteversion
Femoral
version is the angle formed between the axis of the neck of the
femur and an axis across the distal condyles – normally 30
to 40º at birth - decreases progressively until <15º.
Femoral
anteversion or medial femoral torsion - common cause of in-toe gait
and excessive tripping – awkward gait can result in ‘teasing’
from peers. Walk with patella medially rotated – when running,
thighs are medially rotated during swing and legs rotate outwards.
F 2x > M.
Usually
most pronounced at ages 4 –6 years - should improve at about
1.5 degrees/year - 80% resolve by 10 years.
Conscious
compensations may develop.
Surgical
correction indicated for severe persistent deformity – eg
> 50º anteversion and > 80º medial hip rotation.
Internal tibial torsion
Tibial
torsion can not be evaluated clinically, so the malleolar position
is used as a surrogate. The malleoli are normally rotated externally
18-25° in adults when the femoral condyles are in the frontal
plane and the knee fully extended – usually 0-5° at birth
May
be associated with a femoral anteversion.
Rotational malignment syndrome
Consists
of external tibiofibular rotation and internal femoral torsion.
The knee does not flex at 90 degrees to the line of progression.
Out toe/abducted Gait
Causes:
1. Retrotorsion – external twist in femur
2. Retroversion – positional alteration in hip joint (eg posterior
positioning of acetabular socket; muscle or ligament contracture)
3. External genicular position
4. External tibiofibular position
5. Flat/pronated foot
Clinical
presentation:
Parental concern about appearance of gait; abducted gait; a compensatory
pronation of the foot may occur because of the abducted gait.
In-toe/adducted Gait
Causes:
1. Antetorsion – internal twist in the femur (normally 30
degrees at birth, but should have reduced to 8 – 12 in childhood)
2. Anteversion – positional alteration in the hip joint
3. Internal genicular position
4. Internal tibiofibular position (normally up to 5 degrees external
at birth – should be up to 18 degrees by adulthood)
5. Metatarsus adductus
Clinical
presentation:
Adducted gait; parental concern; may appear as though ‘knock
knees’ are present; fatigue is common; ‘tripping’
is common; a compensatory foot pronation may occur to ‘straighten’
the foot
Treatment
* Change
of sitting or sleeping position – avoid ’W’ sitting
position for in-toe problems and use as part of treatment for out-toe
problems
* Bars or braces – eg Dennis-Browner bar; Ganley splint; Counter
Rotation Splint™ - allows more freedom for child to move around
* Gait plates – designed to encourage in- or out-toe gait
– unclear as to efficacy, but may help tripping
* Foot orthoses to protect foot from compensatory pronation (? evidence)
* Surgical correction – rarely needed |
