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Introduction
  • An external rotational deformity of the lower extremity
    • in contrast to in-toeing, external rotational deformity may cause disability and degrade physical performance
  • Epidemiology
    • since the leg externally rotates with physical growth, this deformity usually worsens during late childhood and early adolescence.
    • may be bilateral but if unilateral most commonly involves the right lower extremity.
  • Associated Conditions
    • miserable malalignment syndrome
      • a condition defined as external tibial torsion with femoral anteversion
    • Osgood-Schlatter disease 
    • osteochondritis dessicans 
    • early degenerative joint disease
      • an association between external tibial torsion and early degenerative joint disease has been found
    • neuromuscular conditions
      • may be found with neuromuscular conditions such as myelodysplasia and polio
Anatomy
  • Normal development
    • tibia externally rotates on average 15 degrees during early childhood
    • femoral anteversion decreases on average 25 degrees during this time as well
Presentation
  • Symptoms
    • anterior knee pain 
      • caused by patellofemoral malalignment
  • Physical Exam camera
    • thigh-foot axis measurement  
      • best way to evaluate tibial torsion
        • average during infancy is 5 degrees internal rotation, that slowly derotates
        • average at 8 years of age is 10 degrees external, ranging from -5 to +30 degrees
      • technique
        • lie patient prone with knee flexed to 90 degrees
        • thigh-foot-axis is the angle subtended by the thigh and the longitudinal axis of the foot   
    • transmalleolar axis measurement
      • another way to evaluate tibial torsion
        • average at infancy is 4-5 degrees internal rotation
        • average at adulthood is 23 degrees external (range 0-40 degrees external)
      • technique
        • lie patient supine
          • an imaginary line from medial malleolus to lateral malleolus and another imaginary line from medial to lateral femoral condyle is made
          • the axis is the angle made at the intersection of these two lines
          • this helps to determine the direction and extent of tibial torsion present
Imaging
  • Usually none required.
Treatment
  • Nonoperative
    • rest, rehab, and activity modifications
      • indications
        • first line of treatment
  • Operative
    • supramalleolar derotational osteotomy or proximal tibial derotational osteotomy 
      • indications
        • surgery is reserved for children older than 8 years of age with external tibial torsion greater than three standard deviations above the mean ( >40 degrees external).
        • more likely to require surgery than internal tibial torsion
Techniques
  • Supramalleolar rotational osteotomy
    • technique
      • osteotomy
        • supramalleolar rotational osteotomy is most commonly performed
        • fibula is obliquely osteotomized if the deformity is severe
        • proximal tibial osteotomies are avoided secondary to higher risk factors associated with this procedure
      • plate fixation
        • cross pin fixation or plate fixation
      • intramedullary fixation
        • IM fixation with rotational osteotomy is reserved for skeletally mature adolescents
 

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Questions (1)

(OBQ09.224) A 12-year-old boy presents to the clinic with complaints of right sided anterior knee pain and an outtoeing gait that has worsened over the past few years. Examination reveals an external foot-progression angle of 25 degrees, a thigh-foot axis of +30 degrees, and a positive apprehension test for lateral patellar subluxation on the right side. There is also noted symmetrical hip rotation on exam. What is the most likely cause of this patient's outtoeing and knee pain? Review Topic

QID:3037
1

Bilateral developmentally dislocated hips

1%

(10/1243)

2

Excessive external tibial torsion

83%

(1033/1243)

3

Excessive femoral anteversion

10%

(122/1243)

4

External rotation contracture of the hips

1%

(10/1243)

5

Excessive internal tibial torsion

5%

(63/1243)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

Out-toeing gait in late childhood and early adolescence is most commonly caused by excessive external tibial torsion. By late childhood and early adolescence the average thigh foot axis is 10 degrees external (range -5 to +30), and the average foot progression angle is approximately 5 degrees external for late childhood/early adolescence.

External rotation contracture of the hips is most common cause of out-toeing in infancy and early toddlers. Excessive external tibial torsion is mostly unilateral affecting the right side and patients will also present with complaints of patellofemoral pain and instability.

Lincoln et al summarizes the most common deformities of children with intoeing and outtoeing gaits both in infancy, toddlers and adolescence. While uncommon, surgical treatment of tibial torsion is reserved for symptomatic patients with measurements > 3 standard deviations from the normal via supramalleolar rotational osteotomies. The two most common causes of intoeing reviewed in this article are internal tibial torsion and femoral anteversion in early childhood.

Staheli further discusses lower extremity rotational deformities in pediatric patients and provides treatment guidelines.


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