Updated: 5/20/2017

Femoral Anteversion

Review Topic
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https://upload.orthobullets.com/topic/4059/images/w sitter_moved.jpg
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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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(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? Review Topic | Tested Concept

QID: 630

Thigh-foot angle with 15 degrees of internal rotation




Thigh-foot angle with 40 degrees of external rotation




Convex lateral border of foot




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




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



L 2 C

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