Intoeing is caused by one of three types of deformity: metatarsus adductus, internal tibial torsion, and increased femoral anteversion (Figure 7). The cause of intoeing varies with the age of the child.In the first year of life, metatarsus adductus, alone or combined with internal tibial torsion, is usually the cause. In toddlers, the cause is internal tibial torsion alone or combined with metatarsus adductus, and may involve one or both sides. In early childhood, the cause is usually femoral anteversion, and is nearly always bilateral and symmetrical.
Metatarsus adductus is the most common congenital foot deformity,occurring in one out of 1,000 live births. It occurs more frequently in female children, and on the left side more than the right. The most likely cause is intrauterine packing. Examination reveals adduction of the forefoot with a convex lateral border. The ankle has normal motion. This entity is different from clubfoot, in which the foot does not plantar flex beyond normal, the heel is in varum (medial deviation), and the sole is kidney-shaped when viewed from the bottom. The foot should be assessed for flexibility by holding the heel in neutral position and abducting the forefoot to at least a neutral position (Figure 8). If this cannot be done, then the deformity is rigid (i.e., metatarsus varus). Eighty-five to 90 percent of cases of metatarsus adductus identified at birth resolve without treatment by one year of age.[Evidence level B, nonrandomized studies]
FIGURE 8. Technique for assessing flexibility of metatarsus adductus. The hind part of the foot is stabilized by lateral pressure over the calcaneal cuboid joint, and the forefoot is abducted.
Flexible metatarsus adductus is managed by stretching exercises during the first eight months of life. Parents are instructed to hold the infant’s hindfoot in one hand, the forefoot in the other, and stretch the midfoot, opening the “C”-shaped curve and slightly overcorrecting it. This exercise should be performed five times at each diaper change.Flexible deformities that persist beyond eight months, and rigid deformities, may need a cast (the patient can be referred to an orthopedist for cast application). Better results occur if treatment is begun before eight months of age. [Evidence level B, nonrandomized studies]
Casts should be changed biweekly with correction usually achieved after three or four casts. Residual adductus causes no long-term disability. Surgery is not recommended because surgical complications are frequent.
Infants may present with moderate metatarsus adductus and extreme adduction of great toe (metatarsus primus varus). Treatment is surgical release of the abductor hallucis tendon performed between six and
18 months of age.
INTERNAL TIBIAL TORSION
Internal tibial torsion is the most common cause of intoeing. It affects males and females equally, and is often asymmetrical with the left side affected more than right. The cause is believed to be intrauterine position, sleeping in the prone position after birth, and sitting on the feet (Figure 7). The child with internal tibial torsion walks with the patella facing forward and the feet pointing inward. This results in an internal foot progression angle and an internal foot-thigh angle. In 90 percent of cases, internal tibial torsion gradually resolves on its own by the time the child reaches eight years of age.9 [Evidence level B, nonrandomized studies] Avoiding prone sleeping and sitting on feet enhance resolution. Treatment with night splints, shoe wedges, and orthotics are unnecessary and ineffective.9 Osteotomy of the tibia has been associated with a high complication rate because of compartment syndrome or peroneal nerve injury. Conditions that may support operative correction include (1) being older than eight years of age, (2) a child with significant or functional deformity, and (3) a thigh-foot angle of greater than three standard deviations beyond the mean.
Ninety percent of internal tibial torsion cases resolve by the time the child reaches eight years of age.
INCREASED FEMORAL ANTEVERSION
Femoral anteversion describes the normal position of the femur, which is medially rotated on its long axis at birth. It is often familial and is usually bilateral, affecting females more than males. The child with increased femoral anteversion walks with his or her patellae and feet pointing inward. The gait appears clumsy and the child may trip as a result of crossing his or her feet.9 The child will have strong tendency to sit in a “W” position (Figure 7). Physical examination reveals increased internal hip rotation (up to 90 degrees) and decreased external rotation. Increased femoral anteversion is usually diagnosed after three years of age, peaks at four to six years, and then gradually resolves. Spontaneous resolution occurs in more than 80 percent of cases by late childhood. [Evidence level B, nonrandomized studies] The hip range of motion can be measured every six to 12 months to document gradual decrease in femoral anteversion. Nonoperative treatment is ineffective. Increased femoral anteversion is a benign condition and complications of surgery are frequent.9Conditions that may support a surgical approach include (1) being older than eight years of age, (2) severe deformity that creates significant cosmetic and functional disability, (3) anteversion in excess of 50 degrees, (4) deformity more than three standard deviations beyond the mean, and (5) a family who is aware of the risks of the procedure.
Out-toeing is less common than intoeing, and its causes are similar but opposite to those of intoeing.
Femoral retroversion is common in early infancy and is caused by external rotation contracture of the hip secondary to intrauterine packing. It becomes apparent when the prewalking child stands with his or her feet turned out to nearly 90 degrees (this is sometimes called a “Charlie Chaplin appearance”). Femoral retroversion occurs more commonly in obese children. When femoral retroversion is unilateral, it is more common on the right side.
Physical examination reveals increased external rotation to almost 90 degrees and decreased internal rotation. It may gradually improve on its own during the first year of walking. If resolution is not evident and persistent external rotation is present on successive visits at two to three years of age, referral to an orthopedist is indicated because persistent lateral femoral torsion is associated with osteoarthrosis, increased risk of stress fracture of the lower limbs, and slipped capital femoral epiphysis. [Evidence level C, expert opinion] Nonoperative treatment is ineffective.
EXTERNAL TIBIAL TORSION
External tibial torsion is usually seen between four to seven years of age. It is often unilateral and more common on the right side. The tibia rotates laterally with growth, making lateral tibial torsion worse. Surgery has a high complication rate and should not be done until after the child is more than 10 years of age. The deformity should be severe with a thigh-foot angle of more than 40 degrees to justify operative correction. Disability from lateral tibial torsion is usually caused by patellofemoral instability and pain.Therefore, lateral tibial torsion is a more common indication for osteotomy than internal torsion.
Flat feet are common in children because arch development occurs primarily before four years of age, and because the development has a wide variation in the rate or onset in any given child.Physical examination should test for flexibility. If an arch is reconstituted on toe standing, then it is termed a flexible flat foot. The arch also should recreate when the foot is dependent, hanging over the examination table.
Differential Diagnosis for Genu Varum and Genu Valgum
|Information from Greene WB. Genu varum and genu valgum in children: differential diagnosis and guidelines for evaluation. Compr Ther 1996;22:22-9|
The most common etiology of the flexible flat foot is ligamentous laxity, which allows the foot to sag with weight bearing.11 Spontaneous correction is usually expected within one year of walking.8 No treatment is indicated for painless flexible flat foot. Trauma, occult infection, a foreign body, tarsal coalition, bone tumors, or osteochondrosis of the tarsal navicular bone may cause a stiff and painful flat foot. Referral to an orthopedist is indicated.11
Many children will look bowlegged when they start to walk and then knock-kneed between three to seven years. The gradual change from varum to valgum may be caused by a widening pelvis.2
Genu varum (bowlegs) is seen from birth until two years of age, while genu valgum (knock-knees) peaks from two to four years.3,14 The most common reason is physiologic or a normal developmental variation. Management is by serial measurement of intercondylar/intermalleolar distance to document gradual spontaneous resolution. Unilateral deformity, progressive deformity, or lack of spontaneous resolution should alert the physician to the possibility of pathologic angular deformity (Table 3).3 Guidelines for obtaining radiographs include (1) genu varum or genu valgum that is beyond two standard deviations for the child’s age (Figure 6), (2) height less than 25th percentile, (3) genu varum that has been increasing in severity, and (4) asymmetry of limb alignment.
If physiologic genu varum or genu valgum persists beyond seven to eight years of age, orthopedic referral is indicated. Pathologic conditions should be referred for appropriate management.
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