The femur is internally rotated (anteversion) about 30° at birth, decreasing to about 10° at maturity. The tibia begins with up to 30° of internal rotation at birth and can decrease to a mean of 15° at maturity.
Torsional variations should not cause a limp or pain. Unilateral torsion raises the index of suspicion for a neurologic (hemiplegia) or neuromuscular disorder.
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In-Toeing, Out-Toeing, and Toe-Walking
Internal femoral torsion or femoral anteversion is the most common cause of in-toeing in children 2 years or older (Table 200-1). It is at its worst between 4 and 6 years of age, and then resolves. It occurs twice as often in girls. Many cases are associated with generalized ligamentous laxity. The etiology of femoral anteversion is likely congenital and is common in individuals with abnormal sitting habits such as W-sitting.
Clinical Manifestations. The family may give a history of W-sitting, and there may be a family history of similar concerns when the parents were younger. The child may have kissing kneecaps due to increased internal rotation of the femur. While walking, the entire leg will appear internally rotated, and with running the child may appear to have an egg-beatergait where the legs flip laterally. The flexed hip will have internal rotation increased to 80° to 90° (normal 60° to 70°) and external rotation limited to about 10°. Radiographic evaluation is usually not indicated.
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In-Toeing, Out-Toeing, and Toe-Walking
FIGURE 200-1 Thigh-foot angle measurement. The thigh-foot angle is useful for assessment of tibial torsion. The patient lies prone, with knees flexed to 90°. The long axis of the thigh is compared to the long axis of the foot to determine the thigh-foot angle. Negative angles are associated with internal tibial torsion, and positive angles are associated with external tibial torsion.
This is the most common cause of in-toeing in a child younger than 2 years old. When it is the result of in utero positioning, it may be associated with metatarsus adductus.
Clinical Manifestations. The child will present witha history of in-toeing. The degree of tibial torsion may bemeasured using the thigh-foot angle (Fig. 200-1). Thepatient lies prone on a table with the knee flexed to 90°.The long axis of the foot is compared with the long axis of the thigh. An inwardly rotated foot represents a negativeangle and internal tibial torsion. If follow-up is warranted,measurements should be done at each visit to document improvement.
Treatment of In-toeing
The mainstay of management is to identify patients who have pathologic reasons for in-toeing and reassurance and follow-up to document improvement for patients with femoral anteversion and internal tibial torsion. It can take until 7 to 8 years of age for correction, so it is important to inform families of the appropriate timeline. Braces (Denis Browne splint) do not improve these conditions. Fewer than 1% of all patients with in-toeing will need surgical intervention because of functional disability or cosmetic appearance.
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In-Toeing, Out-Toeing, and Toe-Walking
FIGURE 200-2 Bowleg and knock-knee deformities. A, Bowleg deformity. Bowlegs are referred to as varus angulation (genu varum) because the knees are tilted away from the midline of the body. B, Knock-knee or valgus deformity of the knees. The knee is tilted toward the midline. (From Scoles P: Pediatric Orthopedics in Clinical Practice, Chicago, 1982, Year Book Medical Publishers, p 84.)