C h a p t e r 4 3
Disorders of the Skeletal System: Trauma, Infections, Neoplasms, and Childhood Disorders
1099
The foot progression value serves only to define whether
there is an intoeing or outtoeing gait.
Intoeing may be secondary to foot deformities or
may be due to inward rotation of the femur or tibia, or
a combination of the two.
54
Increased internal torsion
of the femur (femoral anteversion) is the most common
finding. In many cases intoeing is a variation of normal
development. Outtoeing is a common problem in chil-
dren and is caused by external femoral torsion. Because
the femoral torsion persists when a child habitually
sleeps in the prone position, an external tibial torsion
also may develop. External tibial torsion rarely causes
outtoeing; it only intensifies the condition. Outtoeing
usually corrects itself as the child becomes proficient
in walking.
Intoeing due to a condition called
metatarsus adduc-
tus
is a common congenital deformity characterized
by forefoot adduction with a normal hindfoot, giving
the foot a kidney-shaped appearance
55–57
(Fig. 43-14).
It may occur in one foot or both feet. Diagnostic meth-
ods include examination of the plantar aspect of the
foot, noting the overall shape of the foot and the pres-
ence or absence of an arch. The severity of the deformity
can be determined by assessing the flexibility of the foot
and using a heel bisection line. Normally, a line bisect-
ing the heel crosses the forefoot between the second
and third toes. In mild metatarsus adductus, the foot is
flexible and can be passively manipulated and the line
crosses the third toe; in a moderate deformity, the foot
is less flexible and the line falls between the third and
fourth toes; and in a severe deformity, the foot is more
rigid and the line crosses between the fourth and fifth
toes. Most infants do not require treatment, although
parents are advised to avoid positioning the infant in the
prone position with the feet turned in, a position that
accentuates metatarsus adductus. Because the condition
often corrects itself spontaneously, treatment is usually
not instituted until the infant is 6 months of age.
56
When
needed, treatment consists of serial long leg casting or
a brace that pushes the metatarsals (not the hindfoot)
into abduction.
Femoral Torsion.
Femoral torsion
refers to abnormal
variations in hip rotation.
54
Hip rotation is measured at
the pelvic level with the child in the prone position and
the knees flexed at a 90-degree angle (Fig. 43-15A).
In this position, the hip is in a neutral position.
Rotating the lower leg outward produces internal or
medial femoral rotation; rotating it inward produces
external or lateral rotation. During measurement of
hip rotation, the legs are allowed to fall to full inter-
nal rotation by gravity alone; lateral rotation is mea-
sured by allowing the legs to fall inward and cross. Hip
rotation in flexion and extension also can be measured
with CT.
Excessive
internal femoral anteversion
is a normal
variant commonly seen during the first 6 years of life,
especially in 3- and 4-year-old girls.
55
Characteristically,
there is 80 to 90 degrees of internal rotation of the hip
in the prone position.
54,56
The condition is thought to
be related to increased laxity of the anterior capsule of
the hip such that it does not provide the stable pres-
sure needed to correct the anteversion that is present
at birth. Children are most comfortable sitting in the
“W” position, with their hips between their knees. It is
believed that this position allows the lower leg to act as
a lever, producing torsional changes in the femur. When
the child stands, the knees turn in and the feet appear
to point straight ahead, and when the child walks, the
Thigh–foot angle
B
Medial rotation
A
Lateral rotation
1
2
3
FIGURE 43-15.
(A)
Hip rotation is measured with the child
prone and knees flexed at a 90-degree angle. On outward
rotation the leg produces internal (medial) hip and femoral
rotation; on inward rotation the leg produces external hip
and femoral rotation.
(B)
Assessment for tibial torsion using
thigh–foot angle. When the child is in the prone position with
the knee flexed, with normal alignment there is slight external
rotation (2); internal tibial torsion produces inward rotation (3);
external tibial torsion produces outward rotation (1). (Adapted
from Staheli LT.Torsional deformity. Pediatr Clin North Am.
1986;33(6):1373–1383; and Kliegman RM, Neider MI, Super DM,
eds. Practical strategies in pediatric diagnosis and therapy.
Philadelphia, PA: W.B. Saunders; 1996.)
Only front
part bent
Back part
straight
FIGURE 43-14.
Shape of foot.The left foot is normal,
whereas the right foot has metatarsus adductus.
