Internal Tibial Torsion - Pediatrics

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

Treatment