Updated: 6/14/2021

Femoral Anteversion

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  • summary 
    • Femoral Anteversion is a common congenital condition caused by intrauterine positioning which lead to increased anteversion of the femoral neck relative to the femur with compensatory internal rotation of the femur. 
    • Diagnosis is made clinically with the presence of intoeing combined with an increase in internal rotation of the hip of greater than 70° with an accompanying decrease in external rotation of the hip of less than 20°.
    • Treatment is observation with parental reassurance as most cases resolve by age 10. Rarely, surgical management is indicated in the presence of less than 10° of hip external rotation in children greater than 10 years of age.
  • Epidemiology
    • Demographics
      • seen in early childhood (3-6 years)
      • twice as frequent in girls than boys
      • can be hereditary
    • Anatomic location
      • often bilateral
        • be cautious of asymmetric abnormalities
  • Etiology
    • Femoral anteversion is characterized by
      • increased anteversion of the femoral neck relative to the femur
      • compensatory internal rotation of the femur
      • lower extremity intoeing
    • There are three main causes of intoeing including
      • femoral anteversion (this topic)
      • metatarsus adductus (infants)
      • internal tibial torsion (toddlers)
    • 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
  • Anatomy
    • 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
  • Presentation
    • 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
  • Imaging
    • Radiographs
      • recommended views
        • none required typically
    • CT or MRI
      • may be useful in measuring actual anteversion
  • Treatment
    • 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 (>10 yrs)
          • rarely needed
        • technique
          • typically performed at the intertrochanteric level
          • amount correction needed can be calculated by (IR-ER)/2
  • Prognosis
    • Multiple studies have been unable to reveal any association with degenerative changes in the hip and knee when increased anteversion persists into adulthood

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(OBQ08.244) A 6-year-old girl is referred for bilateral in-toeing gait. Which of the following physical examination findings would make increased femoral anterversion the most likely reason for this finding?

QID: 630
1

Thigh-foot angle with 15 degrees of internal rotation

12%

(211/1781)

2

Thigh-foot angle with 40 degrees of external rotation

7%

(128/1781)

3

Convex lateral border of foot

1%

(23/1781)

4

Hips with 80 degrees of internal rotation and 15 degrees of external rotation

74%

(1315/1781)

5

Hips with 50 degrees of internal rotation and 30 degrees of external rotation

5%

(90/1781)

L 2 C

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