Updated: 10/10/2018

Internal Tibial Torsion

Topic
Review Topic
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Questions
6
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Evidence
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Videos
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Introduction
  • A condition that is characterized by internal rotation of tibia
    • most common cause of in-toeing in toddlers
  • Epidemiology
    • demographics
      • usually seen in 1-3 year olds
    • location
      • often bilateral
  • Pathophysiology
    • exact etiology unknown
    • believed to be caused by intra-uterine positioning and molding
  • Prognosis
    • usually resolves spontaneously by age 4
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°)
    • 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 in childhood 
        • 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
 
Tibial Torsion Thigh-foot angle > 10 degrees internal

Femoral Anteversion Internal rotation >70 degrees and < 20 degrees of external rotation
Metatarsus Adductus   Medial deviation of the forefoot (abnormal heel bisector), normal hindfoot
  • 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
 

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Questions (6)
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(OBQ09.39) A 2-year-old boy is brought to your clinic by his mother for being "pigeon-toed". Each of the following measurements found on physical examination are a routine part of defining the child's lower extremity rotational profile EXCEPT. Review Topic

QID: 2852
FIGURES:
1

Figure A

3%

(69/2065)

2

Figure B

8%

(158/2065)

3

Figure C

76%

(1561/2065)

4

Figure D

7%

(138/2065)

5

Figure E

6%

(129/2065)

ML 2

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(OBQ08.39) An 18-month-old girl is brought to clinic by her mother for in-toeing. All of the following features should prompt the physician to perform further evaluation (including radiographs) if found in conjunction with in-toeing EXCEPT: Review Topic

QID: 425
1

limb length discrepancy

5%

(71/1436)

2

metatarsus adductus

76%

(1096/1436)

3

pain

7%

(104/1436)

4

family history of skeletal dysplasias

4%

(63/1436)

5

limb rotational profiles 2 standard deviations outside of normal

6%

(90/1436)

ML 2

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ARTICLES (7)
VIDEOS (1)
Topic COMMENTS (10)
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