Torsion of the lower limb in children - Symptoms, Causes, Images, and Treatment Options

Diseases

Highlights & Basics

Key Highlights

Lower-extremity torsional abnormalities are common in children. Commonly attributed to femoral or tibial torsion, soft-tissue contractures, abnormal muscle tone, hindfoot varus/valgus, forefoot adduction/abduction, or a combination of these.
Clinical exam measuring the rotational profile and comparing these values to normal values can determine causes of malalignment.
Torsional variations (version) are defined as alignment that is within 2 standard deviations (SDs) of the mean and account for most rotational problems. Torsional deformities are defined as abnormalities outside the normal range of 2 SDs.
Torsional problems are commonly phenotypic variations that are considered statistically normal, although perhaps not ideal or desirable to parents. Most will spontaneously resolve with growth and development, and have no adverse effect on function.
Femoral and tibial torsion deformities in healthy children who fall outside the normal range of 2 SDs are managed with parental reassurance and education. Arrangements for regular follow-up should be provided. Corrective shoe wedges, night splints, twister cables, and physical therapy have not been shown to alter the natural history or ensure normal gait.

Photo of a child sitting in the W position

From the collection of Tamir Bloom, MD

Quick Reference

History & Exam
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Definition

Epidemiology

Etiology

Pathophysiology

Images

Photo of a child sitting in the W position
Foot progression angle (FPA) assessed while watching the child walk. FPA is formed by a line drawn in direction of walking and a line from the longitudinal axis of the foot. FPA is summation of torsional alignments of femur, tibia, and foot. Intoeing is designated as a negative number and out-toeing a positive number
Internal and external rotation of hip in extension is assessed with patient prone and knee flexed 90°
A,B: Thigh-foot axis assessed in prone position by measuring the angle between the longitudinal axis of the thigh and of the foot. C: Sole shape should be evaluated for forefoot adduction and abduction abnormalities such as metatarsus adductus. Heel-bisector line (drawn through midline axis of hindfoot and forefoot), in a normal foot, passes through the second web space. Lateral border of the foot is normally straight
Normal range and development of hip rotation throughout childhood. Green: normal ranges, mean ± 2 standard deviations
Normal range and development of foot progression angle throughout childhood. Green: normal ranges, mean ± 2 standard deviations
Normal range and development of thigh-foot angle throughout childhood. Green: normal ranges, mean ± 2 standard deviations
Severe torsional deformities may be assessed with gunsight CT scan by measuring the angle between the transverse axes on CT cuts of the proximal and distal juxta-articular regions

Citations

Key Articles

Staheli LT. Rotational problems in children. Instr Course Lect. 1994;43:199-209.[Abstract]
Staheli LT, Corbett M, Wyss C, et al. Lower-extremity rotational problems in children: normal values to guide management. J Bone Joint Surg Am. 1985 Jan;67(1):39-47.[Abstract]

Other Online Resources

Nemours Foundation: skeletal dysplasia
Pediatric Orthopaedic Society of North America

Referenced Articles

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