Chapter 667 Torsional and Angular Deformities
667.1 Normal Limb Development
An understanding of normal limb development is essential for pediatricians to recognize pathologic conditions during routine and targeted exams. During the 7th wk of intrauterine life, the lower limb rotates medially to bring the great toe toward the midline. The hip joint forms by the 11th wk; the proximal femur and acetabulum continue to develop until physeal closure in adolescence. At birth, the femoral neck is rotated forward approximately 40 degrees. This forward rotation is referred to as anteversion (the angle between the axis of the femoral neck and the transcondylar axis). The increased anteversion increases the internal rotation of the hip. Femoral anteversion decreases to 15-20 degrees by 8-10 yr of age. The second source of limb rotation is found in the tibia. Infants can have 30 degrees of medial rotation of the tibia, and by maturity the rotation is between 5 degrees of medial rotation and 15 degrees of lateral rotation (Fig. 667-1). Excessive medial rotation of tibia is referred to as medial tibial torsion. The tibial torsion is the angular difference between the axis of the knee and the transmalleolar axis. The medial or lateral rotation beyond ±2 standard deviations (SDs) from the mean is considered abnormal rotation.
The normal tibiofemoral angle at birth is 10-15 degrees of physiologic varus. The alignment changes to 0 degrees by 18 mo, and physiologic valgus up to 12 degrees is reached in between 3 and 4 yr of age. The normal valgus of 7 degrees is achieved by 5-8 yr of age (Fig. 667-2). Persistence of varus beyond 2 yr of age may be pathologic. Overall, 95% of developmental physiologic genu varum and genu valgum cases resolve with growth. Persistent genu valgum or valgus into adolescence is considered pathologic and deserves further evaluation.
Figure 667-2 The normal coronal alignment of the knee plotted for age.
(From Salenius P, Vanka E: The development of the tibiofemoral angle in children. J Bone Joint Surg Am 57:259–261, 1975.)
Arazi M, Ogun TC, Memik R. Normal development of the tibiofemoral angle in children: a clinical study of 590 normal subjects from 3 to 17 years of age. J Pediatr Orthop. 2001;21:264-267.
Cahuzac JP, Vardon D, Sales de Gauzy J. Development of the clinical tibiofemoral angle in normal adolescents: a study of 427 normal subjects from 10 to 16 years of age. J Bone Joint Surg Br. 1995;77:729-732.
Heath CH, Staheli LT. Normal limits of knee angle in white children—genu varum and genu valgum. J Pediatr Orthop. 1993;13:259-262.
Salenius P, Vankka E. The development of the tibiofemoral angle in children. J Bone Joint Surg Am. 1975;57:259-261.
667.2 Evaluation
Foot Progression Angle
Limb position during gait is expressed as the foot progression angle (FPA) and represents the angular difference between the axis of the foot with the direction in which the child is walking. Its value is usually estimated by asking the child to walk in the clinic hallway (Fig. 667-3). Inward rotation of the foot is assigned a negative value, and outward rotation is designated with positive value. The normal FPA in children and adolescents is 10 degrees (range, −3 to 20 degrees). The FPA serves only to define whether there is an in-toeing or out-toeing gait.
Femoral Anteversion
Measuring the hip rotation with the child in prone position, the hip in neutral flexion or extension, thighs together, and the knees flexed 90 degrees indirectly assesses the anteversion (Fig. 667-4). Both hips are assessed at the same time. As the lower leg is rotated ipsilaterally, this produces internal rotation of the hip, whereas contralateral rotation produces external rotation. Excessive anteversion increases internal rotation, and, retroversion increases the external rotation.
Tibial Rotation
Tibial rotation is measured using the transmalleolar angle (TMA). The TMA is the angle between the longitudinal axis of the thigh with a line perpendicular to the axis of the medial and lateral malleolus (Fig. 667-5). In the absence of foot deformity, the thigh foot angle (TFA) is preferred (Fig. 667-6). It is measured with the child lying prone. The angle is formed between the longitudinal axis of the thigh and the longitudinal axis of the foot. It measures the tibial and hindfoot rotational status. Inward rotation is assigned a negative value, and outward rotation is designated a positive value. Inward rotation indicates internal tibial torsion, whereas outward rotation represents external tibial torsion. Infants have a mean angle of −5 degrees (range, −35 to 40 degrees) as a consequence of normal in utero position. In mid-childhood through adult life, the mean TFA is 10 degrees (range, −5 to 30 degrees).
Foot Shape and Position
The foot is observed for any deformities in prone and standing position. The heel bisector line (HBL) is used to evaluate the foot adduction and abduction deformities. The HBL is a line that divides the heel in two equal halves along the longitudinal axis (Fig. 667-7). It normally extends to the 2nd toe. When the HBL points medial to the 2nd toe, the forefoot is abducted, and when the HBL is lateral to the 2nd toe, the forefoot is adducted.
Ruwe PA, Gage JR, Ozonoff MB, et al. Clinical determination of femoral anteversion: a comparison of established techniques. J Bone Joint Surg Am. 1992;74:820-830.
Thompson GH. Gait disturbances. In: Kliegman RM, editor. Practical strategies in pediatric diagnosis and therapy. ed 2. Philadelphia: WB Saunders; 2003:823-843.
