Intoeing: When to Worry? Sukhdeep K. Dulai SPORC 2018

Transcription

1 Intoeing: When to Worry? Sukhdeep K. Dulai SPORC 2018

2 What is it? Intoeing: When to worry? Why isn t it always cause for worry? What are the benign causes of intoeing? What are the pathologic causes of intoeing and how are they identified? What are the red flags in intoeing?

3 What is it? Internal Foot Progression Angle Normal Range: -3 to +20, Mean +10 Reference: Lower-extremity rotational problems in children. Normal values to guide management.l T Staheli ; M Corbett ; C Wyss ; H KingJ Bone Joint Surg Am, 1985 Jan; 67 (1):

4 Why It Isn t Always Cause for Worry? Normal evolution of rotational limb alignment Birth: tibia and femur are internally rotated (disguised by flexion and external rotation contracture of hips) Gradual resolution of external rotation contracture of the hips over first year internal tibial torsion and femoral anteversion become apparent Gradual correction of tibial and femoral rotation up to approx. 8 years of age

5 Normal Rotational Profile Femoral anteversion: Newborn: 40 8 years: Internal rotation of the hip: Up to: 70 for girls, 60 for boys Thigh Foot Angle: 10 external (range -3 to 20 ) Bimalleolar Axis Newborn: 5 external Adults: external

6 Benign Causes of Intoeing Pictures from: Courtesy of Texas Scottish Rite Hospital for Children

7 Diagnosis Metatarsus Adductus Typical Presenting Age Signs/Symptom s Natural History Infancy Medially curved lateral and Medial Foot Borders, Heel bisector lateral to 2 nd web space 85% resolve spontaneously Picture from: Courtesy of TSRH for Children Indications for Intervention Failure to resolve, Rigidity, Pain, Shoewear problems Treatment Early: Observation, Stretching, Serial Casts Late: Medial release or Midfoot/metatarsal osteotomy Reference: E. E. Bleck, Metatarsus Adductus: Classification and Relationship to Outcomes of Treatment, Journal of Pediatric Orthopaedics, Vol. 3, No. 1, 1983, pp. 2-9.

8 Diagnosis Internal Tibial Torsion Presenting Age Signs/Sympto ms Natural History Indications for Intervention Treatment 1-3 years Tripping, bowleg appearance, Increased Thigh-Foot Angle and Bimalleolar Angle 99% resolve Persistent deformity and functional disability at >6 yo Early: Reassurance *Tip: Sprinters have more ITT than non-athletes (Fuchs & Staheli JPO 1996) Late: Supramalleolar derotation osteotomy Picture from: Courtesy of TSRH for Children

9 Diagnosis Femoral Anteversion Presenting Age Signs/Sympto ms >3 years Awkward gait (eggbeater running), tripping, patellar winking, W-sitting, increased IR/decreased ER of hip Picture from: aaos.org, Courtesy of TSRH for Children Natural History Most resolve Indications for Intervention Treatment Persistent deformity and functional disability at >8 yo Early: Reassurance only Late: proximal or distal femoral derotation osteotomy (significant risk of complications)

10 Intoeing: Pathologic Causes Miserable Malalignment Syndrome Cerebral Palsy Developmental Hip Dysplasia Genu Varum/Tibia Vara associated Clubfoot/Cavovarus foot Skewfoot Metatarsus Primus Varus Hallux Vatus

11 Miserable Malalignment Syndrome Femoral anteversion, external tibial torsion and pes planovalgus Presents with anterior knee pain with activity (usually in adolescents) due to patellofemoral overload Treatment: Femoral and Tibial derotation osteotomies +/- flatfoot reconstruction

12 Cerebral Palsy Esp. mild spastic hemiparesis unilateral intoeing Intoeing can be due to pes varus, metatarsus adductus, femoral anteversion, internal tibial torsion and/or internal pelvic rotation Look for significant birth history and physical exam findings of spasticity Can result in lever arm dysfunction and tripping Treatment: often surgical as they do not remodel normally

13 Developmental Hip Dysplasia Intoeing (due to femoral anteversion) Associated with Trendelenburg sign/gait Investigate with hip xray

14 Genu Varum/ Tibia Vara Appearance of bowing also present in ITT Assess coronal plane alignment with the patellae pointing directly forwards Potential diagnoses: Blount s disease Metabolic Bone Disease Skeletal Dysplasia

15 Clubfoot/Cavovarus foot In addition to metatarsus adductus, look for cavus, varus and/or equinus History may suggest recent development of deformity with neurologic findings on examination Courtesy: CDC

16 Skewfoot Adducted forefoot and valgus hindfoot and plantarflexed talus May resolve; May require surgery if symptomatic Surgical intervention: calcaneal and cuneiform opening wedge osteotomies

17 Metatarsus Primus Varus Straight lateral border Medial deviation of first metatarsal (increased intermetatarsal angle) Associated with development of hallux valgus Treatment: Early casting recommended by some May require corrective osteotomy later if symptomatic

18 Hallux varus Medial border of the foot is straight but the great toe is medially deviated Abnormal pull of the Abductor Hallucis Often associated with anatomic abnormalities of preaxial polydactyly If anatomic abnormalities or does not resolve by age 2 years, surgical intervention is recommended

19 Summary: Red Flags in Intoeing History: Developmental delay History of prematurity Progressive or new-onset deformity Pain Persistent functional disability

20 Summary: Red Flags in Intoeing Physical Examination: Neuromuscular abnormalities Marked limb asymmetry Syndromic features Short stature Abnormal hip exam Abnormal hindfoot position Isolated toe deformity Rigid foot deformity

21 Thank you