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Updated: Jun 14 2021

Internal Tibial Torsion

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  • summary
    • Internal Tibial Torsion is a common condition in children less than age 4 which typically presents with internal rotation of the tibia and an in-toeing gait. 
    • Diagnosis is made clinically with a thigh-foot angle > 10 degrees of internal rotation in a patient with an in-toeing gait. 
    • Treatment is observation in most cases as the condition usually resolves spontaneously by age 4. Surgical management is indicated in children > 6-8 years of age with functional problems and thigh-foot angle >15 degrees.
  • Epidemiology
    • Incidence
      • most common cause of in-toeing in toddlers
    • Demographics
      • usually seen in 1-3 year olds
    • Anatomic location
      • often bilateral
  • Etiology
    • Pathophysiology
      • exact etiology unknown
      • believed to be caused by intra-uterine positioning and molding
  • Presentation
    • History
      • commonly noticed once child begins walking
      • parents report that the legs are "turning in"
      • increased tripping and/or falling
    • Symptoms
      • usually asymptomatic
    • Physical exam
      • Rotational profile assessment
        • foot progression angle
        • hip internal rotation to identify increased femoral anteversion
        • thigh foot angle to quantify tibial torsion
        • heel bisector to identify metatarsus adductus
      • Foot progression angle directed internal
        • product of hip rotation, tibial torsion and shape of foot.
        • measure angle between foot position and imaginary straight line while walking
        • normal is -5 to +20 degrees
      • thigh-foot angle directed internal
        • technique
          • prone position
          • angle formed by a line bisecting the foot and line bisecting the thigh
        • normal values
          • infants- mean 5° internal (range, −30° to +20°)
          • age 8 years- mean 10° external (range, −5° to +30°)
        • thigh-foot angle > 10 degrees internal is generally considered as intoeing
      • transmalleolar axis > 15 degrees internal
        • technique
          • measure the angle formed by an line from the lateral to the medial malleolus, and a second line from the lateral to the medial femoral condyles.
        • normal
          • average = 0 to -10 degrees internal rotation during infancy (which gradually laterally rotates to 15 degrees external rotation during growth)
          • abnormal = greater than 15 degrees internal rotation
  • Imaging
    • Radiographs
      • usually not indicated unless other conditions present (see above)
    • Advanced imaging
      • CT or MRI can be utlized for surgical planning (in the few cases that require surgery)
  • Differential
      • Causes of Intoeing
      • Condition
      • Key findings
      • Metatarsus Adductus
      • Medial deviation of the forefoot (abnormal heel bisector), normal hindfoot
      • Tibial Torsion
      • Thigh-foot angle > 10 degrees internal
      • Femoral Anteversion
      • Internal rotation >70 degrees and < 20 degrees of external rotation
    • In-toeing associated with the following necessitates further work-up
      • pain
      • limb length discrepancy
      • progressive deformity
      • family history positive for rickets/skeletal dysplasias/mucopolysaccharidoses
      • limb rotational profiles 2 standard deviations outside of normal
  • Treatment
    • Nonoperative
      • observation and parental education
        • indications
          • most cases
        • outcomes
          • usually resolves spontaneously by age 4
          • bracing/orthotics do not change natural history of condition
    • Operative
      • derotational supramalleolar tibial osteotomy vs. proximal osteotomy
        • indications
          • rarely required
          • child > 6-8 years of age with functional problems and thigh-foot angle >15 degrees
        • technique
          • associated with lower complications than proximal osteotomy
          • fixaton with plate or smooth K wires
          • intramedullary nail fixation if skeletally mature
  • Prognosis
    • Usually resolves spontaneously by age 4
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