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  • There are three main causes of intoeing including
    • femoral anteversion (this topic)
    • metatarsus adductus (infants)  
    • internal tibial torsion (toddlers)  
  • Femoral anteversion is characterized by
    • increased anteversion of the femoral neck relative to the femur
    • compensatory internal rotation of the femur
    • lower extremity intoeing
  • Epidemiology
    • demographics
      • seen in early childhood (3-6 years)
      • twice as frequent in girls than boys
      • can be hereditary
    • location
      • often bilateral
        • be cautious of asymmetric abnormalities
  • Pathophysiology
    • a packaging disorders caused by intra-uterine positioning
    • most spontaneously resolve by age 10
  • Associated conditions
    • can be seen in association with other packaging disorders
      • DDH 
      • metatarsus adductus 
      • congenital muscular torticollis 
  • Prognosis
    • multiple studies have been unable to reveal any association with degenerative changes in the hip and knee when increased anteversion persists into adulthood
  • Is based on degree of anteversion of femoral neck in relation to the femoral condyles 
    • at birth, normal femoral anteversion is 30-40°
    • typically decreases to normal adult range of 15° by skeletal maturity
    • minimal changes in femoral anteversion occur after age 8
  • Symptoms
    • parents complain of an intoeing gait in early childhood
    • child classically sits in the W position (see above image)
    • knee pain when associated with tibial torsion
    • awkward running style
    • when extreme in an older child occasional functional limitations in sports and activities of daily living can occur
      • difficulty with tripping during walking or running activities
    • can be more symptomatic in those with neuromuscular diseases and brace-dependent walkers
      • secondary to lever-arm dysfunction and decreased compensatory mechanisms
  • Physical exam
    • evaluation for intoeing 
      • femoral anteversion
        • hip motion (tested in the prone position) 
          • increased internal rotation of >70° (normal is 20-60°)  
          • decreased external rotation of < 20° (normal 30-60°) 
        • anteversion estimated on degree of hip IR when greater trochanter is most prominent laterally
          • trochanteric prominence angle test  
        • patella internally rotated on gait evaluation
      • tibial torsion
        • look at thigh-foot angle in prone position
        • normal value in infants-  mean 5° internal (range, −30° to +20°)
        • normal value at age 8 years- mean 10° external (range, −5° to +30°)
      • metatarsus adductus
        • adducted forefoot deformity, lateral border should be straight
        • a medial soft-tissue crease indicates a more rigid deformity
        • evaluate for hindfoot and subtalar motion
  • Radiographs
    • recommended views
      • none required typically
  • CT or MRI
    • may be useful in measuring actual anteversion
  • Nonoperative
    • observation and parental reassurance
      • indications
        • most cases usually resolve spontaneously by age 10
      • technique
        • bracing, inserts, PT, sitting restrictions do not change natural history
  • Operative
    • derotational femoral osteotomy
      • indications
        • < 10° of external rotation on exam in an older child (>8-10 yrs)
        • rarely needed
      • technique
        • typically performed at the intertrochanteric level
        • amount correction needed can be calculated by (IR-ER)/2

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