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
QUESTIONS 1 of 6 1 2 3 4 5 6 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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. Tested Concept QID: 2852 FIGURES: A B C D E Type & Select Correct Answer 1 Figure A 3% (78/2497) 2 Figure B 8% (194/2497) 3 Figure C 75% (1882/2497) 4 Figure D 7% (172/2497) 5 Figure E 6% (157/2497) L 2 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review tested concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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: Tested Concept QID: 425 Type & Select Correct Answer 1 limb length discrepancy 5% (84/1746) 2 metatarsus adductus 76% (1331/1746) 3 pain 8% (131/1746) 4 family history of skeletal dysplasias 4% (71/1746) 5 limb rotational profiles 2 standard deviations outside of normal 6% (113/1746) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review tested concept
All Videos (1) Podcasts (1) Login to View Community Videos Login to View Community Videos In-toeing of gait Gaurav Sanjay General - Internal Tibial Torsion 4/24/2014 2119 views (16) PediatricsâȘInternal Tibial Torsion Orthobullets Team Pediatrics - Internal Tibial Torsion Listen Now 13:12 min 4/9/2020 88 plays (1)