Addressing pediatric intoeing

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1 1.0 CONTACT HOUR Jcqueline Southby / Thinkstock Addressing peditric intoeing in primry cre Abstrct: Primry cre providers frequently encounter children with n intoed git. Intoeing is most often norml vrition of development tht resolves without tretment. The well-informed primry cre NP cn identify the smll subset who need referrl through child nd/or fmily history, physicl exm, nd identifiction of red flgs. By Luren Dvis, DNP, RN nd Donn G. Ntivio, PhD, CRNP, FAAN, FAANP C oncern bout intoeing in children is common presenting complint in primry cre. Prents my expect this condition to require referrl to nd tretment with n orthopedic specilist nd/or physicl therpist. However, intoeing is one of the most common musculoskeletl findings nd is frequently due to norml vritions in development. An intoeing clinic conducted by dvnced prctice providers (NPs, clinicl nurse specilists, nd physicin ssistnts) with n orthopedic surgeon s consultnt evluted 926 otherwise helthy peditric ptients with intoeing nd found tht pproximtely 95% hd benign dignosis tht did not require ny tretment. 1 This is consistent with other reserch studies nd supports tht the mjority of children with intoeing cn be mnged in primry cre. 2 However, there is smll subset of ptients for whom intoeing is sign of n underlying pthologic condition or who will require interventions led by n orthopedic specilist. The ptient s history nd physicl exm will guide the NP to determine whether the ptient cn be mnged in primry cre or requires specilty cre referrl. Keywords: femorl nteversion, intoeing, mettrsus dductus, peditric physicl exm, tibil torsion The Nurse Prctitioner July

2 The three most common cuses of intoeing re mettrsus dductus, internl tibil torsion, nd incresed femorl nteversion. These conditions cn be dignosed by physicl exm without the use of rdiogrphicl studies nd cn be mnged by primry cre providers. 3 Antomy nd pthophysiology The formtion of lower extremity lignment begins t the seventh week of intruterine life when the lower limbs rotte medilly nd bring the gret toe towrd midline. 4 This intruterine positioning is hypothesized to influence limb rottionl deformities. Mettrsus dductus is chrcterized by the medil devition of the mettrsls. This most often occurs bilterlly nd is thought to be result of intruterine positioning. 3 Internl tibil torsion is internl rottion of the tibi on its long xis. 5 The exct etiology is unknown; however, it is lso thought to be result of intruterine positioning. 6 A newborn normlly hs pproximtely 40 degrees of femorl nteversion t birth, which decreses to 15 to 20 degrees by the ge of 8 to 10 yers. 4 Some believe tht incresed femorl nteversion is result of persistent infntile nteversion, wheres others believe it is cquired secondry to bnorml sitting hbits (W leg position) or the prone sleeping position. 4 History The clinicin should elicit complete birth nd medicl history, including developmentl milestones, presence of chronic illnesses, nd ny ssocited complints. 6,7 A fmily history of intoeing my suggest genetic vrition nd/or my be used to ressure prents tht these conditions frequently resolve with growth. 7,8 It is Expected clinicl course of intoeing 7-9 Condition Onset Course Mettrsus dductus Internl tibil torsion Incresed femorl nteversion Apprent t birth or erly in infncy Between ges 1 nd 2 yers (when the child begins wlking) After the ge of 2 yers Mild cses with good rnge of motion show improvement by 12 months nd resolve by ge 3 yers Improves by ge 6-8 yers Grdul improvement, resolves round ge yers lso helpful to gin informtion regrding the onset nd clinicl course of intoeing. (See Expected clinicl course of intoeing.) It is importnt to remember tht these conditions cn often occur in combintion. 2,8,9 Red flgs obtined while cquiring the ptient s history my include unilterl or symmetric intoeing, with findings suggestive of cerebrl plsy or developmentl dysplsi of the hip, delyed developmentl milestones, ssocited pin or limping, dily recurrent trips or flls, or positive fmily history for disorders tht cn led to intoeing requiring tretment. 7,10 Physicl exm A thorough developmentl, musculoskeletl, nd neurologic exm must be completed for the child presenting with intoeing. An ge-pproprite ssessment of developmentl socil nd emotionl, lnguge nd communiction, cognitive, nd gross nd fine motor milestones should be documented. 7 If the ptient is mbultory, he or she should be ssessed while stnding, wlking, nd running while observing for symmetry, limping, nd foot or ptellr s. 2,3,7 Specific physicl exm techniques re used to determine the origin of intoeing (see Physicl exm techniques to identify intoeing). 2,3,11-14 When ptient s presenttion is consistent with one of these three dignoses nd there is lck of red flgs or significnt physicl exm findings indictive of nother dignosis, the NP cn properly educte the fmily bout the condition nd mnge the ptient in primry cre. (See Physicl exm findings of intoeing.) Differentil dignosis Pthologic conditions ssocited with the presence of red flgs discussed in the history of intoeing include neuromusculr diseses (cerebrl plsy), developmentl dysplsi of the hip, lower leg deformities such s club foot nd skewfoot, infection, nd bone tumor or lesion. 8,10 It is lso key to differentite intoeing from genu vrum (bowleg). Genu vrum is most often physiologic nd norml vrition seen in 1- to 3-yer-olds. Similr to internl tibil torsion, it is often first noticed once the child begins mbultion. On physicl exm, there is typiclly wddling git with symmetricl nd diffuse lower extremity bowing nd n incresed distnce between the knees when stnding. There is no csting, brcing, or surgery indicted for physiologic bowing. 3 If genu vrum continues to 32 The Nurse Prctitioner Vol. 43, No. 7

3 Physicl exm techniques to identify intoeing 2,3,7,8 Exm technique Explntion Findings Picture Foot/ptellr Determined while viewing the foot nd ptell s the ptient wlks forwrd Foot nd/or ptellr ngle my be described s internl, neutrl, or externl View of lterl nd medil mlleolus With the ptient sitting nd ptell fcing stright forwrd, view the reltionship of the lterl mlleolus to the medil mlleolus Normlly, lterl mlleolus is posterior to the medil mlleolus (0 to -10 degrees internl rottion is verge) Norml tibil torsion Knee cps point stright hed Internl tibil torsion Heel bisector line With the ptient prone, view line through the xis of the heel to the forefoot Normlly, the line crosses the forefoot between the second nd third toes b Thigh-foot ngle With the ptient prone, knee flexed, nd foot flexed, n ngle is formed by drwing line tht is bisecting the thigh nd line bisecting the foot Norml men in infnts is 5 degrees internl ngle Norml men by ge 8 is 10 degrees externl Hip internl/ externl rottion With the ptient prone: Internl (legs rotted wy from center of the body) Norml internl during childhood is 40 to 50 degrees 45 Externl rottion. 0 Internl rottion 40 c Externl (legs rotted towrd center of the body) Norml externl is 40 to 70 degrees These ngles re often mesured subjectively, but geniometer cn be used to determine more precise objective mesurement. Reproduced with permission from Merens TA. The toddler git norml or not. Peditric Annls. 2015;44(5) b Reproduced with permission from Rosenfeld SB. Approch to the child with in-toeing. In: UpToDte, Post TW, eds. Wlthm, MA: UpToDte. Copyright 2018 UpToDte, Inc. c Reproduced with permission from Beethm WP, Polley HF, Slocumb CH, Wever WF. Physicl Exmintion of the Joints. Phildelphi, PA: Sunders; The Nurse Prctitioner July

4 worsen or is seen beyond the ge of 3 or 4 yers, referrl to n orthopedist for dditionl investigtion is wrrnted. Pthologic cuses of genu vrum include rickets, epiphysel dysplsi, dwrfism, nd other metbolic bnormlities or growth disturbnces. 3 Mngement Routine rdiogrphs re not recommended for children with intoeing nd re typiclly only indicted if there re complints of pin to rule out hip dysplsi fter n bnorml hip exm or if there re dditionl Physicl exm findings of intoeing 2,3,7,8 Mettrsus dductus Internl, neutrl, or externl foot nd ptell Mild deformity (heel bisector crosses third toe) Moderte deformity (heel bisector crosses between third nd fourth toes) Severe deformity (heel bisector crosses between fourth nd fifth toes) Internl tibil torsion Internl, neutrl, or externl foot nd ptell Thigh-foot ngle >10 degrees internl With ptell forwrd, lterl mlleolus is prllel or nterior to medil mlleolus Incresed femorl nteversion Internl foot nd ptell Incresed hip internl rottion (my be up to 90 degrees [legs rotte flt ginst exm tble]) Preference to sit in W position Indictions for orthopedic referrl 7,8 Mettrsus dductus Cnnot pssively bring foot into neutrl position (my indicte club foot) Severe deformity (heel bisector crosses between fourth nd fifth toes) Tibil torsion Child older thn 8 yers with severe intoeing cusing functionl or cosmetic deformity Incresed femorl nteversion Child is >8 yers old nd complins of severe functionl or cosmetic deformity with: femorl nteversion >50 degrees (mesured rdiogrphiclly) internl hip rottion >80 degrees Any dignosis of intoeing tht does not follow n expected clinicl course risk fctors present for pthologic condition. Furthermore, surgicl mngement is not necessry for these conditions most of the time. 1,7,8 Orthotics (brces nd splints) do not chnge the nturl history or dvnce resolution. 7 For ptients with mettrsus dductus, providers cn encourge fmilies to mssge nd lightly stretch the inside of the foot into neutrl position; however, no reserch consistently supports the use of specific stretching or exercise to resolve intoeing quicker thn the child s nturl growth nd development. 8 Fmilies were previously educted to discourge their children with incresed femorl nteversion from sitting in the W position (sitting on the bottom with knees bent in the front center nd legs splyed out towrd the bck of ech side); however, reserch hs shown this is unlikely to chnge the nturl history s well. 6,7 The W position is comfortble for the child nd this sitting position is not detrimentl to norml development. The child will stop sitting in this position once they cn sit cross-legged more comfortbly s nturl improvement occurs. 6 One of the most importnt spects to the mngement of intoeing is fmily ressurnce. If the child s prents or gurdins choose not to seek further workup tretment fter obtining the ptient s history nd performing physicl exm, fmilies should be educted on the prevlence of these conditions nd their expected resolutions. For long-term prognosis, these rottionl deformities do not led to n incresed risk of hip or knee rthritis. 7,15 Children with mettrsus dductus, internl tibil torsion, nd incresed femorl nteversion do not require ctivity restrictions or dditionl precutions. These conditions re common developmentl vritions tht often resolve without tretment s the child grows. 7 When to refer Any of the red flgs discussed in the history section indicte need for referrl to n orthopedic specilist. Physicl exm findings of limb length discrepncy nd deformity progression should be referred s well. 6 (See Indictions for orthopedic referrl.) Implictions for prctice Intoeing cn be distressing to peditric ptients nd fmilies, especilly s ptients get older nd begin school nd ctivities. NPs cn ressure ptients nd 34 The Nurse Prctitioner Vol. 43, No. 7

5 fmilies tht these benign conditions resolve with growth nd development nd the child cn prticipte in ctivities the sme s other children. Awreness of the red flgs nd indictions for referrl cn help NPs identify ptients who require dditionl specilty cre nd llow them to mnge the mjority of intoeing ptients who will not need referrl. REFERENCES 1. Fulks S, Brown K, Birch JG. Spectrum of dignosis nd disposition of ptients referred to peditric orthopedic center for dignosis of intoeing. J Peditr Orthop. 2017;37(7):e432-e Sieltycki JA, Hennrikus WL, Swenson RD, Fnelli MG, Reighrd CJ, Hmp JA. In-toeing is often primry cre orthopedic condition. J Peditr. 2016;177: Zitelli BJ, McIntire S, Nowlk AJ. Atls of Peditric Physicl Dignosis. 7th ed. Phildelphi, PA: Elsevier; Kliegmn RM, Stnton B, Geme J, Schor NF. Nelson Textbook of Peditrics. 20th ed. Phildelphi, PA: Elsevier; Innotti JP, Prker RD. Netter Collection of Medicl Illustrtions: Musculoskeletl System, Volume 6, Prt II Spine nd Lower Limb. 2nd ed. Phildelphi, PA: Sunders; Mooney JF 3rd. Lower extremity rottionl nd ngulr issues in children. Peditr Clin North Am. 2014;61(6): Reruch CM, Dickison C, Bird DC. Lower extremity bnormlities in children. Am Fm Physicin. 2017;96(4): Spiegel DA, Horn BD. Lippincott s Primry Cre Orthopedics. 2nd ed. Phildelphi, PA: Lippincott Willims & Wilkins; Hrris E. The intoeing child: etiology, prognosis, nd current tretment options. Clin Poditr Med Surg. 2013;30(4): Evns AM. Mitigting clinicin nd community concerns bout children s fltfeet, intoeing git, knock knees or bow legs. J Peditr Child Helth. 2017;53(11): Crr JB 2nd, Yng S, Lther LA. Peditric pes plnus: stte-of-the-rt review. Peditrics. 2016;137(3):e Merens TA. The toddler git norml or not. Peditr Ann. 2015;44(5): Rosenfeld SB. Approch to the child with in-toeing com. 14. Willim P, Polley HF, Slocumb CH, Beethm WFW. Physicl Exmintion of the Joints. Phildelphi, PA: Sunders; Weinberg DS, Prk PJ, Morris WZ, Liu RW. Femorl version nd tibil torsion re not ssocited with hip or knee rthritis in lrge osteologicl collection. J Peditr Orthop. 2017;37(2):e120-e128. Luren Dvis is recent DNP grdute from the University of Pittsburgh School of Nursing, Pittsburgh, P. Donn G. Ntivio is n ssocite professor nd DNP Progrm Director t the University of Pittsburgh School of Nursing, Pittsburgh, P. The uthors nd plnners hve disclosed no potentil conflicts of interest, finncil or otherwise. DOI /01.NPR d0 For more thn 278 dditionl continuing eduction rticles relted to Advnced Prctice Nursing topics, go to NursingCenter.com/CE. Ern CE credit online: Go to nd receive certificte within minutes. INSTRUCTIONS Addressing peditric intoeing in primry cre TEST INSTRUCTIONS To tke the test online, go to our secure website t www. nursingcenter.com/ce/np. View instructions for tking the test online there. If you prefer to submit your test by mil, record your nswers in the test nswer section of the CE enrollment form on pge 36. You my mke copies of the form. Ech question hs only one correct nswer. There is no minimum pssing score required. Complete the registrtion informtion nd course evlution. Mil the completed form nd registrtion fee of $12.95 to: Lippincott Professionl Development CE Group, 74 Brick Blvd., Bldg. 4, Suite 206, Brick, NJ We will mil your certificte in 4 to 6 weeks. For fster service, include fx number nd we will fx your certificte within 2 business dys of receiving your enrollment form. You will receive your CE certificte of erned contct hours nd n nswer key to review your results. Registrtion dedline is June 5, DISCOUNTS nd CUSTOMER SERVICE Send two or more tests in ny nursing journl published by Lippincott Willims & Wilkins together nd deduct $0.95 from the price of ech test. We lso offer CE ccounts for hospitls nd other helthcre fcilities on nursingcenter.com. Cll for detils. PROVIDER ACCREDITATION Lippincott Professionl Development will wrd 1.0 contct hour for this continuing nursing eduction ctivity. Lippincott Professionl Development is ccredited s provider of continuing nursing edu ction by the Americn Nurses Credentiling Center s Commission on Accredittion. This ctivity is lso provider pproved by the Cliforni Bord of Registered Nursing, Provider Number CEP for 1.0 contct hour. Lippincott Professionl Development is lso n pproved provider of continuing nursing eduction by the District of Columbi, Georgi, nd Florid CE Broker # The Nurse Prctitioner July