Torsion of the lower limb in children

Torsion of the lower limb in children is common. The most common causes of lower extremity torsional variations are femoral or tibial torsion, soft-tissue contractures, abnormal muscle tone, hindfoot varus/valgus, forefoot adduction/abduction, or a combination of these.

Clinical examination measuring the rotational profile and comparing these values with normal values can determine causes and severity of malalignment.

While it is one of the most common reasons for a referral to a paediatric orthopaedist, the vast majority of these issues do not require orthopaedic evaluation and can be successfully managed in the primary care office. 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 standard deviations (SDs) of the mean are managed with parental reassurance and education. Arrangements for regular follow-up should be provided. Corrective shoe wedges, night splints, twister cables, and physiotherapy have not been shown to alter the natural history or ensure normal gait.

In otherwise healthy children, operative treatment consisting of derotational osteotomy is rarely indicated. These procedures are considered only for severe tibial rotation that does not correct by the age of >8 years and femoral malrotation that does not correct by the age >11 years.

In patients with neuromuscular disease, such as cerebral palsy or myelomeningocele, deformities may persist or worsen with time. If left untreated, these deformities may contribute to inefficient gait in ambulatory patients and cause difficulty with shoe wear and interfere with sitting posture in wheelchair users.

Lower-extremity torsional problems commonly present in the first decade of life with parental complaints about in-toeing or out-toeing. In-toeing refers to medial (internal) rotation of the foot relative to the direction in which the child is walking or running; out-toeing refers to lateral (external) rotation of the foot. Torsion results from a summation of anatomical axial (transverse) plane tilt or twist between the ends of the bones (i.e., version), capsular laxity or tightness, and muscular control during growth.[1]Staheli LT. Rotational problems in children.Instr Course Lect. 1994;43:199-209. http://www.ncbi.nlm.nih.gov/pubmed/9097150?tool=bestpractice.com

Torsional variations of the lower extremity are extremely common and are defined as rotational differences that fall within 2 SDs of the mean.[2]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. http://www.ncbi.nlm.nih.gov/pubmed/3968103?tool=bestpractice.com ​ 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 due mostly to cosmetic concerns.