Chapter 667 Torsional and Angular Deformities

667.1 Normal Limb Development

An understanding of normal limb development is essential for pediatricians to recognize pathologic conditions during routine and targeted exams. During the 7th wk of intrauterine life, the lower limb rotates medially to bring the great toe toward the midline. The hip joint forms by the 11th wk; the proximal femur and acetabulum continue to develop until physeal closure in adolescence. At birth, the femoral neck is rotated forward approximately 40 degrees. This forward rotation is referred to as anteversion (the angle between the axis of the femoral neck and the transcondylar axis). The increased anteversion increases the internal rotation of the hip. Femoral anteversion decreases to 15-20 degrees by 8-10 yr of age. The second source of limb rotation is found in the tibia. Infants can have 30 degrees of medial rotation of the tibia, and by maturity the rotation is between 5 degrees of medial rotation and 15 degrees of lateral rotation (Fig. 667-1). Excessive medial rotation of tibia is referred to as medial tibial torsion. The tibial torsion is the angular difference between the axis of the knee and the transmalleolar axis. The medial or lateral rotation beyond ±2 standard deviations (SDs) from the mean is considered abnormal rotation.

Figure 667-1 A-F, The rotational profile from birth to maturity is depicted graphically. All graphs include 2 standard deviations from the mean for the foot progression angle (FPA) for femoral medial rotation (MR) and lateral rotation (LR) (for boys and girls), and the thigh-foot angle (TFA).

(From Morrissey RT, Weinstein SL, editors: Lovell and Winter’s pediatric orthopaedics, ed 3, Philadelphia, 1990, Lippincott Williams & Wilkins.)

Limb rotation is also found in the foot. The abnormalities could be excessive adduction or abduction. Torsional deformity may be simple, involving a single segment, or complex, involving multiple segments. Complex deformities may be additive (internal tibial torsion and internal femoral torsion are additive) or compensatory (external tibial torsion and internal femoral torsion are compensatory).

The normal tibiofemoral angle at birth is 10-15 degrees of physiologic varus. The alignment changes to 0 degrees by 18 mo, and physiologic valgus up to 12 degrees is reached in between 3 and 4 yr of age. The normal valgus of 7 degrees is achieved by 5-8 yr of age (Fig. 667-2). Persistence of varus beyond 2 yr of age may be pathologic. Overall, 95% of developmental physiologic genu varum and genu valgum cases resolve with growth. Persistent genu valgum or valgus into adolescence is considered pathologic and deserves further evaluation.

Figure 667-2 The normal coronal alignment of the knee plotted for age.

(From Salenius P, Vanka E: The development of the tibiofemoral angle in children. J Bone Joint Surg Am 57:259–261, 1975.)

667.2 Evaluation

Lawrence Wells, Kriti Sehgal

In evaluation of concerns relating to the limb, the pediatrician should obtain a history of the onset, progression, functional limitations, previous treatment, evidence of neuromuscular disorder, and any significant family history.

The examination should assess the exact torsional profile and include (1) foot progression angle, (2) femoral anteversion, (3) tibial version with thigh-foot angle, and (4) assessment of foot adduction and abduction.

Foot Progression Angle

Limb position during gait is expressed as the foot progression angle (FPA) and represents the angular difference between the axis of the foot with the direction in which the child is walking. Its value is usually estimated by asking the child to walk in the clinic hallway (Fig. 667-3). Inward rotation of the foot is assigned a negative value, and outward rotation is designated with positive value. The normal FPA in children and adolescents is 10 degrees (range, −3 to 20 degrees). The FPA serves only to define whether there is an in-toeing or out-toeing gait.

Figure 667-3 Foot progression angle. The long axis of the foot is compared with the direction in which the child is walking. If the long axis of the foot is directed outward, the angle is positive. If the foot is directed inward, the angle is negative and indicates in-toeing.

(From Thompson GH: Gait disturbances. In Kliegman RM, editor: Practical strategies in pediatric diagnosis and therapy. Philadelphia, 2004, Saunders.)

Femoral Anteversion

Measuring the hip rotation with the child in prone position, the hip in neutral flexion or extension, thighs together, and the knees flexed 90 degrees indirectly assesses the anteversion (Fig. 667-4). Both hips are assessed at the same time. As the lower leg is rotated ipsilaterally, this produces internal rotation of the hip, whereas contralateral rotation produces external rotation. Excessive anteversion increases internal rotation, and, retroversion increases the external rotation.

Figure 667-4 Anteversion measured by medial rotation of hip (A) and lateral rotation of hip (B).

Tibial Rotation

Tibial rotation is measured using the transmalleolar angle (TMA). The TMA is the angle between the longitudinal axis of the thigh with a line perpendicular to the axis of the medial and lateral malleolus (Fig. 667-5). In the absence of foot deformity, the thigh foot angle (TFA) is preferred (Fig. 667-6). It is measured with the child lying prone. The angle is formed between the longitudinal axis of the thigh and the longitudinal axis of the foot. It measures the tibial and hindfoot rotational status. Inward rotation is assigned a negative value, and outward rotation is designated a positive value. Inward rotation indicates internal tibial torsion, whereas outward rotation represents external tibial torsion. Infants have a mean angle of −5 degrees (range, −35 to 40 degrees) as a consequence of normal in utero position. In mid-childhood through adult life, the mean TFA is 10 degrees (range, −5 to 30 degrees).