outcomes that outweigh the potential risks of surgical correction — through |
A |
the direction of the patellae through stance phase as this may indicate that |
||||||
either motion blocking implants or |
the deformity arises above the knee |
|||||||
bony and soft tissue corrections . |
( at the level of the hip ). Finally , hav- |
|||||||
While the condition will persist into |
ing the patient run ( if they are able ), |
|||||||
adulthood in a small percentage of |
may unmask any subtle neuromuscu- |
|||||||
the general population , the number |
lar condition , such as cerebral palsy . |
|||||||
needed to treat does not justify sur- |
Alterations in rotational profile |
|||||||
gery of any kind in the initial instance |
typically originate from one of three |
|||||||
in most cases . 9 |
regions in the lower limb : the hip , |
|||||||
Some biomechanical studies sug- |
tibia or foot . A systematic physical |
|||||||
gest that a persistent flat foot puts |
examination of these three regions |
|||||||
the ankle at a biomechanical disad- |
will typically determine the origin |
|||||||
vantage , resulting in less power being |
of the deformity and the degree to |
|||||||
generated during toe-off than would |
which it is evident — and ultimately |
|||||||
otherwise be possible in a ‘ normal |
the treatment required . |
|||||||
foot ’. Countering this , is the fact that |
||||||||
some athletes compete and excel at |
HIPS |
|||||||
high level sport despite persistence of |
Femoral anteversion is the most com- |
|||||||
flat feet into adulthood . The legend- |
mon cause of in-toeing in early child- |
|||||||
|
ary sprinter , Usain Bolt , is a noteworthy case in point .
When to refer
Flat foot deformity is an extremely
common condition . Given that much of the population with this condi-
|
B |
Figure 5 . Clinical photographs demonstrating the features of congenital vertical talus . |
hood ; it occurs more commonly in females and is typically symmetrical . 3 , 10 Children with increased anteversion leading to in-toeing typically like to ‘ W ’ sit as this is more comfortable than crossing their legs . The deformity typically increases until |
|||||
|
tion will go on to complete resolution , there is almost no need to refer . Having said this , if there are any redflag signs or symptoms on history or examination , then further investigation and early referral may be sought .
IN- AND OUT- TOEING
IN-toeing is more commonly known
as pigeon-toed gait . The toes will tend to turn in while walking , occasionally resulting in multiple episodes of tripping and falling . Conversely , out-toeing — sometimes described as duck feet — is noted when an individual walks with the toes turning out in an exaggerated manner . Both deformities fall on the normal spectrum of the rotational profile . 3 The deformity may arise from the hips ( excessive femoral anteversion or retroversion ), tibiae ( tibial internal or external torsion ) or feet ( metatarsus adductus and severe pes planus ).
While most cases of rotational deformity present with in-toeing rather than out-toeing , these ambulatory deformities exist on a very broad spectrum of normal . 3 Much like flat foot deformities , the tendency is for complete self-resolution without any intervention with the fullness of time . 3 , 10 Presentation to the GP is more likely to be driven by parental concern rather than any true functional deficit or pain syndrome .
An understanding of the wide range of normal and the ages at which resolution can be expected will allow GPs to confidently and safely reassure parents and patients that intervention , be it surgical or otherwise , is unnecessary . This knowledge also allows physicians to identify those
|
Table 1 . Paediatric rotational profile
Age Internal rotation (°) External rotation (°)
Infants 40 ( 10-60 ) 70 ( 45-90 )
Younger than 10 years 50 ( 25-65 ) 45 ( 25-65 )
falls , tripping or , in extreme cases , pain . In adolescence , there is also a cohort whose primary concern is purely cosmetic and highlighted by incidences of unwanted attention from their peers . 11 While there is no need to actively pursue treatment for the deformity itself , its impact on the patient ’ s social and psychological wellbeing must be addressed .
prior trauma , infection or tumour differentials .
It is essential to ask about perinatal and family history — specifically regarding risk factors associated with developmental dysplasia of the hips and other packaging disorders ( see box 3 ). Determining the age at which the child began to stand and walk and the pattern of ambulation since that
Both in- and out-toeing deformities fall on the normal spectrum of the rotational profile .
|
Box 3 . Risk factors for DDH / packaging disorders
• First born .
• Female .
• Family history .
• Breech presentation .
• Large for gestational age .
• Asymmetrical or incomplete hip abduction .
• Asymmetrical gluteal or thigh folds .
• Positive hip ‘ click ’ or ‘ clunk ’ with hip examination .
• Unequal limb lengths .
• Lateral posturing of the head due to tight neck muscles .
• Foot abnormalities .
• Stigmata of spinal dysraphism ( tufts of hair , dimpling , large birth marks over spine ).
Source : de Hundt M et al 2012 12
A . Bilateral congenital vertical talus deformities in a six-week-old infant , demonstrating the convex plantar surface of the feet .
B . Deep creases are present on the dorsolateral aspect of the foot in an eightweek-old infant with bilateral congenital vertical talus .
dysraphism — are cause for concern .
|
age five and then corrects to the adult version by age eight . 3 , 10
A cursory passive range-of-motion test on each of the lower-limb joints can determine any stiffness or irritability and offer clues as to a likely diagnosis .
Ask the patient to lie prone on an examination table , thighs flat to the table and knees bent to 90 °, with the soles of the feet pointing to the ceiling . Then rotate the tibia medially and laterally from the midline . Measure the degree to which the tibia can be rotated ( see figures 7 and 8 ).
Early studies looking at paediatric rotational profile offer an insight into the numbers used in the paediatric orthopaedic literature when evaluating children with this deformity ( see table 1 ). As the figures indicate , the average hip-rotation profile allows for similar degrees of internal and external rotation . If a patient ’ s internal rotation measure is 70 °, 80 ° or 90 ° ( mild , moderate , severe ) after the age of 10 , then a diagnosis of increased femoral torsion can be made . This may be evident during gait , with the patella facing medially . 3
TIBIA Tibial torsion is less common than femoral rotational as a cause of in- or out-toeing but has been found to be most common in children aged 1-3 . 10 Internal torsion is typically associated with intrauterine positioning and linked to tibia vara in extremis ; however , excessive external rotation is associated with neuromuscular conditions , such as myelodysplasia ( congenital failure of closure of the spinal canal ) and polio . 10 Rotational deformity involving the tibia is likely to cor-
|
|||||
cases that are atypical and warrant an |
They may indicate a direct neurologi- |
rect itself by age four . 3 10 |
||||||
orthopaedic opinion . |
cal cause , syndromes associated with |
Functionally , the presence of |
||||||
|
Clinical presentation
Patients are likely to present at an age
when they have started walking . The
|
This presentation may , very rarely , be the result of underlying pathology that will require specialist referral and treatment . Associated condi- |
time may offer insights into something more sinister — for example : if their gait was relatively normal and has become notably worse over time . |
skeletal dysplasia , or hereditary or acquired vitamin deficiencies .
Having the patient stand with the patellae pointing forward will offer
|
in-toeing has been shown to improve sprinting ability . 13
Conversely , out-toeing is likely to increase with age and is associated
|
exact age may vary between those who have just started to ambulate and slightly older patients whose deformity |
tions not to be missed include developmental dysplasia of the hips and the full spectrum of skeletal dyspla- |
Examination
Determine a complete rotational pro-
|
some information about functional limb-length discrepancy , any compensatory posturing and , in some |
with miserable malalignment syndrome , leading to patellofemoral pain and instability . Those with out-toeing |
may have been unmasked or exagger- |
sias , as well as any underlying neuro- |
file in any examination of a child pre- |
cases , concomitant joint stiffness . In |
due to tibial torsion and symptoms |
ated by a growth spurt . Depending on |
muscular disorders , such as cerebral |
senting with concerns about excessive |
any examination of the lower extrem- |
that are concerning for persistent |
the age at presentation , the deformity |
palsy . |
internal or external foot progression |
ity , a cursory check of the spine for |
malalignment leading to functional |
can be expected to arise from different parts of the lower extremity . Screen for other conditions that may arise from |
Signs and symptoms
The history-taking allows GPs to
|
angle . Gross asymmetry is a red flag and should prompt the examiner to look closer to rule out sinister causes . |
midline birth marks , dimpling or tufts of hair , along with any scoliotic deformity , is essential . |
disability and pain may be candidates for surgical correction . Surgical treatment is typically reserved for those |
each contributing part . |
screen for abnormal presentations |
Begin the examination by observ- |
Then ask the patient to walk at |
aged over eight with severe deformity |
Extremes of internal and exter- |
that may require further atten- |
ing the whole patient . Short stature , |
a slow , steady pace . Make a note of |
— that is , greater than three standard |
nal foot progression may result in |
tion and investigation . Questions |
abnormal facies or conditions of the |
the foot progression angle and its |
deviations from the mean . All chil- |
an awkward , unstable gait , causing |
pertinent to a diagnosis involve |
skin — particularly stigmata of spinal |
symmetry or otherwise . Also note |
dren under eight can be reassured |