Lower-Extremity Rotational Problems in Children - The Journal of ...

ABSTRACT: We studied 1,000 normal lower extrem
ities of children and adults in order to establish normal
values for the rotational profile. The intrauterine posi
tion of the fetus molds the femur by rotating it laterally
and molds the tibia by rotating it medially These mold
ing effects usually resolve spontaneously during infancy,
and then genetically
are unmasked.
determined individual differences
Rotational prob'ems should be clinically evaluated
and the findings compared with the normal values pro
vided by this study. Out-toeing in infants, medial tibial
torsion in toddlers, and medial femoral torsion in young
children are extremes of a normal developmental pat
tern In the vast majority, these rotational variations fall
within the broad range of normal and require no treat
ment.
Variations and deformities ofthe lower limbs involving
rotation in the transverse plane are associated with many
clinical problems. ranging from harmless in-toeing in chil
dren to disabling osteoarthritis of the hip in adult pa
tients''2'2t3435.
In the past. rotational problems in the transverse plane
have often been ignored because they are difficult to assess.
This is in contrast to frontal-plane and sagittal-plane de
formities. which are easily visualized and measured on con
ventional radiographs. These difficulties in assessment have
led to varied opinions and controversy regarding the eval
uation and management of rotational problems. These prob
hems are likely to attract increasing attention because
accurate assessment is now possible using computerized
transverse-plane tomography and optical and electronic
techniques of motion analysis.
For routine clinical evaluation, physical examination
remains the primary method for assessment. To be useful,
this examination must include measurements of each limb
segment and give acceptably reproducible results that can
be compared with an established range of normal values.
However, previous studies have failed to meet these require
ments@794SR222327333.
The present investigation was designed to establish
normal values for the rotational profile29 by studying I .000
* Department of Orthopedics. Childrens Orthopedic Hospital and
Medical Center, P.O. Box C537l. Seattle. Washington 98105.
1@Department of Orthopedics. University of Washington School of
Medicine. 1959 N.E. Pacific Street. Seattle, Washington 98105.
Copyright 1985 by The Journal of Bone and Joint Surgery. Itmcorporated
lower limbs of normal subjects of varying ages. Given this
information, the clinician could manage the comtiion ro
tational problems of childhood with more objectivity . and
could quantitatively document deformity in the transverse
plane when treating serious problems such as congenital
dysplasia ofthe hip. club foot. and neuromuscular disorders.
In this study. we have used the terniinology recoin
mended by the Pediatric Orthopaedic Society1. Normal is
defined as that which occurs within two standard deviations
of the mean. Rotational problems with values within the
normal range are termed rotational variations'
outside the normal range are referred to as @torsional de
formities''.
@ and those
VOL. 67-A, NO. I. JANUARY 1985
Lower-Extremity Rotational Problems in Children
NORMAL. VALUES TO GUIDE MANAGEMENT
BY LYNN T. STAHELI, M.D.*, MARILYN (ORBETT, B.S.t. CRAIG WYSS. P11.1).1', AND
HOWARD KING. M.D.t, SEATTLE. WASHINGTON
!@?Ofli the Deporttnetmt of Oit/iopedie.s. CImi/dre,is ()ii/mopedi Hospital iou! ,%1('(/i((,I Center. Seattle
Materials and Methods
The I .000 limbs included in this study were both lower
extremities ofSOO subjects (279 female and 221 male rang
ing in age from less than one year to seventy years (Fig.
1). These subjects were white and had no history of mus
culoskeletal abnormality. They were selected from hospital
personnel and siblings of children seen in non-orthopaedic
outpatient clinics.
The 500 subjects were divided into twenty-two groups
based on chronological age (Fig. I ). The first group Colli
prised infants who were less than one year old. Subjects
aged one through fourteen were divided into fourteen
groups, one for each chronological year; that is. one-year
olds, two-year-olds. and so on. Subjects fifteen through
nineteen years old comprised @henext group. while those
between twenty and sixty-nine years old were divided into
five groups, one for each decade. The final group comprised
individuals aged seventy and older. The number of limbs
in each group ranged from eighteen to ninety-eight (average.
forty-five).
The average for both limbs fc'r each subject was used
in all measurements. One of us (M. C.) made the following
measurements on each of the 500 subjects.
Foot-progression angle: This was defined as the an
gular difference between the long axis of the foot and the
line of progression. In order to assess it, the subjects dusted
their feet with chalk and then walked across the study area
on a long strip of paper. We measured the angles of six
footprints (three from each limb) and recorded the average
for each subject. A plus sign denoted an out-toeing angle
and a minus sign. an in-toeing angle. Infants were not inca
sured for foot-progression angle.
39

40 I.. T. STAEIII.I, MARIlYN (ORBETT. (‘RAft;WYSS. AND HOWARD KIN(I
RI)
C
a
0
0
.0 E
C
50
25
0
(n500)
.5 1 2 3 4 5 6 7 8 9 10 11 12 131415- 203040506070
19
years of age
Fi. I
Distribution of suh@ects according to the twenty-two age groups studied. Forty-etght subjects soere less than one year old: elesen. one to tsoo years
old: twenty-tour. two) to three @earsold: and 50)Ofl. There were ut) subjects between sixteen and tssemty sears old in the soad@ population. Subjects
who were more than twenty years old were divided into) six ten-year age groups. as shown.
Hip rotation: This was measured with the patient prone
and the knees flexed to 90 degrees. With the pelvis level.
the thighs were rotated to the angle that would be maintained
by gravity alone. We photographically recorded the posi
Lions of the legs using a camera located distally and directed
cephalad in line with the axes of the thighs. Medial and
lateral rotations were measured with a goniometer on an
eight by ten-inch (twenty by twenty-five-centimeter) neg
ative image projected by a photographic enlarger.
Thigh—footci@igle(1,1(1(lFli,'/@? (.)f the lraFl.vtnalleol(ir a.vis:
These were used to determine transverse-plane rotational
variations of the tibia and foot. They were measured with
the subject prone. the knees flexed to 90 degrees. and the
ankles in neutral position. The center point ofeach malleolus
was marked, and these points were joined by a line across
the plantar aspect of the heel. This line was used to ap
proximate the transmalleolar axis. A photograph was made
with the camera positioned above each foot and aimed in
line with the tibiae. The measurements made from the pro
jected photographic negative were as follows: ( 1) thigh-foot
angle —¿the angular difference between the axis of the foot
and the axis of the thigh. and (2) angle of the transmalleolar
axis —¿the angular difference between a line projected
toward the heel at right angles to the transmalleolar axis
and the axis of the thigh. In-toeing angles were given neg
ative values and out-toeing angles. positive values.
Intro -Examiner (111(1lizter-Exarni,u'r Variability
Standard deviations and mean errors were computed
to assess the intra-examiner and inter-examiner variabilities
in the measurements of medial and lateral rotation of the
hip. thigh-foot angle, and angle of the transnialleolar axis
made on the photographic negatives and by direct clinical
examination (Table I).
Intra-examiner variability was assessed by one exam
iner (a pre-medical student). who made photographic mea
surements of three subjects (a twenty-seven-year-old man.
a twenty-two-year-old man. and a forty-six-year-old worn
an) on three separate occasions over a two-week period.
The average standard deviations. in degrees. for the pho
ErrorPhotographicMedial
.48Lateral rotation3.812.652.07I
rotation4.243.481.521.11Thigh-foot
angle3.652%1.671.24Angle
thetransmalleolar of
16IClinical*Medial axis4.073.222.
rotation4.9))3.33Lateral
rotation5.814.50Thigh-foot
angle6.31)5.02Angle
thetransmalleolar of
axis8.906.78
TABL,F; I
INTER-EXAMINER ANt) IN1RA-Ex.ASIINI:R \‘ARisitii iTtilS
IN THE MEASUREMENTS (IN [)EaRI:rs 01 Mt:I)t.st
AND LATERAl. ROTATION (IF TIlE Hip. TEIIGII.FooT AN(i I
AND ANGIE OF THE TRANsSIAI,I.Ioi AR Axis
Inter—Lx
Standard Mean
I)eviationaniinerErrorI
ntra—Ex
Standard Meami
I)eviation@initner
* Intra—examiner variability in clinical nieasuremcmits so as not loves
tigated.
tographic measurements were 2.07 for n@edialrotation. I .52
for lateral rotation. 1.67 for thigh-foot angle. and 2. 16 for
transmalleolar axis. The over-all average standard deviation.
in degrees, for all measuretilents was I .86. The mean errors
for these measurements were 1.48. 1.11. 1.24. and 1.56
for medial and lateral rotation of the hip. thigh-foot angle.
and angle of the transmalleolar axis. respectively.
THE JOURNAL OF BONE AND JOINT SURGERY

Inter-examiner variability was assessed by six exam
iners (the director of the orthopaedic departtiient. two or
thopaedic residents. two medical students, and a pre
medical student). Each of the six examiners measured the
medial and lateral rotation of the hip. thigh-foot angle. and
transmalleolar axis on the same three subjects (a twenty
seven-month-old girl. an eleven-year-old boy. and a forty
one-year-old woman). In addition, we compared the inca
surements made on the photographic negatives and during
20â€
@ ., 0
100
0
@100
0
LOWER-EXTREMITY ROTATIONAl. PROBlEMS IN (IIII.I)REN
0
0
0
@ 0
P@,
0
0 a
the clinical examinations. Clinical measurements of rotation
of the hip were made with a gravity goniometer. and the
thigh-foot angle and transmalleolaraxis were measured with
a protractor. The standard deviations and mean errors for
the photographic and clinical measurements are shown in
Table I. An F test of equality of variances of the photo
graphic and clinical measurements showed no significant
differences (p > 0.05). Thus. inter-examiner variabilities
in the photographic and clinical measurements were similar.
@ ,@bH@:
@ 2SD
@0
±L.
@ :@: . D
0 0
0
0
1 3 5 7 9 11 13 15-19
a.
0
0 25D
0
0 0 Q ‘¿I
1 3 5 7 9 11 13 15-19 30's 50's 70+
0
0
a
\
0
30's 50's 70+
Figs. 2—Athrough 2—F:The five measurements plotted as the mean salites plus or tuititis Isoa stamdard deviations for each of the tsoentv-two age
groups. The solid lines show the mean changes with age: the shaded areas. the miormualranges: the solid circles. the mueamimeasuremilents for the different
age groups: and the open circles. plus or minus two standard deviations t@r the samiiemean miicasureniemits.
Fig. 2-A: Foot-progression angle.
80°
60°
40°
VOL. 67-A, NO. I. JANUARY 19115
0
0
Age (years)
Fi. 2-A
0@
0
Age (years)
Fii@.2-B
Medial rotation of the hip in male subjects.
0
0
0
2 SD
2 SD
41

@
42 I.. T. STAFIELI. MARIlYN (ORBETI. (RAI(i WYSS, ANI) HOWARD KING
Findings
Data on male and female subjects were compared for
each Of the five measurements: foot-progressIon angle. me
dial and lateral rotation of the hip. thigh-foot angle. and
angle of the transmalleolar axis. Medial rotation of the hip
was significantly different (p < ().05 in male and female
subjects. Therefore. separate graphs for medial rotation
were prepared. one for each sex. For all other measurements
there were fl() significant diftCrences (p > ().05 between
80°
@ 0
T\
60°
40°
20°
0
100°
80°
60°
40°
20°
0
0
0
0
0
a
a 0
@ 0
0
0
3
0
00
@0
0
a
0
0
male and female subjects. and their data were pooled for
analysis.
For each of the twenty-two age groups we computed
the mean and standard deviation of each of the measure
ments. These calculations were plotted on graphs (Figs.
2-A through 2-F) showing the means and the points for plus
and minus two standard deviations as functions of the mean
ages for the twenty-two groups. Smooth lines were drawn
through the data points by computing quadratic functions
using a non-linear least-squares fitting algorithm.
0
0 0
a 0
5 11 13 15-19
Age (years)
Fi( .
Niedmal rotation oil the hip mifcmiiale suh@ects.
O'9
0
3 5 7 9 11 13 15-19 30's 50's 70+
Age (years)
Fi.. 2-I)
I.ateral rotatiomi(if the limpin mii@mIe and femiialesubjects conibined
0
0
0
0
a
70+
2 SD
2 SD
2 SD
THEJOURNALOF BONEANDJOINTSURGERY

@
@
LOWER-EXTREMITY ROTATIONAl. PROBLEMS IN (HII.DRIN
Foot-progression angle (Fig. 2-A): This angle was
greatest and most variable during infancy. During childhood
and adult life it showed little change. with the mean re
maining approximately + 10 degrees and the normal range
being between —¿ 3 and + 20 degrees.
Medicil rotation of the hip (Figs. 2-B and 2-C): Since
medial rotation was greater in female than in male subjects
by a mean difference of 7 degrees. separate graphs for the
sexes were constructed. Medial rotation was greatest in early
childhood and then declined throughout later childhood and
adulthood. From the middle of childhood on. for tiiale sub
jects the mean was about 50 degrees and the normal range
0
0
0
was from 25 to 65 degrees. For female subjects the mean
was about 40 degrees and the normal range was froni I5 to
60 degrees.
Lateral Fotatioll @?tt11(' hi/) (Fig. 2—D): Unlike medial
rotation, lateral rotation of the hip showed flO sex-related
difference. so all values were pooled. Lateral rotation was
greatest during infancy. declined throughout childhood. and
then remained relatively constant during adult IlIC. From
the middle ofchildhood on. the mean was about 45 degrees
and the normal range was from 25 to 65 degrees.
Thigh-foot angle (Fig. 2-E): This angle increased and
became less variable throughout childhood. From the middle
0
0
0 0
0
0
0 a
2 SD
40°
20°
-20°
-40°
0
0
3 5 7 9 11 13 15-19 30s 50s 70+
0
0
0
Age (years)
i)
Ft(. 2-I:
Thmiih—fonitatigle.
0
Age (years)
0
Fmo. 2@F
Angle of the transnial leolar axis.
a
0
0
0 0
0
0
0
@
@
0
0
0
0
0
2 SD
VOL.67-A,NO. I. JANUARY1985
0
0
.0
3 5 7 9 11 13 15-19
rz.
0
0
0
‘¿I
2 SD
0 2SD
43

@
44 L. T. STAHELI, MARILYN CORBETT, CRAIG WYSS, AND HOWARD KING
ErrorPresent
* Averages are in parentheses.
Inter-ExaniinerIntra-ExaniinerStandardMeanStandard
MeanL)eviationErrorDeviation
studyPhotographic3.81-4.252.65-3.481.52-2.16
1.11-1.56(3.941(3.081(l.86(
(1.35)Clinical.
investigated(6.481(4.911Other
over-all4.9()-8.9()3.33-6.78Not
studiesAshton
1.70(hip)(8.40)Bocmne
et al.6.01-I
TABLE II
RANGES AND AVERAGES* FOR INTER-EXAMINER AND INTRA-EXAMINER
VARIABILITIES IN MEASUREMENT (IN DEGREES) DETERMINED IN THIS ANt) OTHER STUDIES
.4(shoulder. and Aze&0.2-I
.0)forearm. elbow .I I
hip.knee. wrist.
footBooneankle.
al.1.5-4.60.6-1.4(shoulder.
et
elbow.(2.9)(1.0)wrist.
knee.tOot)Ekstrand
hip.
al.'2.5-5.5(hip. et
ankle)(3.7)Low knee.
(elbow. wrist 14.4-7. 7
(5.62)3.3-6.3 (4.6)0.69-3.69
of childhood on, the mean angle remained approximately
10 degrees and the range of normal values was from —¿ 5
to 30 degrees.
Angle of the transnialleolar O.V1S(Fig . 2-F): The angle
of this axis increased and became slightly less variable with
age. The mean angles and the normal ranges of the trans
malleolar axis were greater than those of the thigh-foot
angle. From the middle of childhood on. the mean approx
imated 20 degrees and the ranges of normal were from zero
to 45 degrees.
Discussion
As shown in Table II, the inter-examiner and intra
examiner variabilities, standard deviations, and mean errors
were used to compare the examiner variabilities in the cur
rent study with the findings in other reliability studies'5
The findings in our study compare favorably with the values
reported in other studies (Table II). For the intra-examiner
variabilities in the present study. the over-all average stan
dard deviation was within the range of the average standard
deviations in other studies ( 1.0 to 37)2.3.5.215The mean error
values for these variabilities were also within the range of
0.6 to 3.3 found in Low's study2. For the inter-examiner
variabilities in the current study. the over-all standard de
viations were within the range reported in other studies
(over-all average standard deviations ranging from 2.9 to
8.4)225. and the mean errors were within the range of 3.3
to 6.3 reported by Low2. As would be expected, in the
present study the inter-examiner variabilities were greater
than the intra-examiner variabilities, a finding that was con
sistent with those in previous studies22.
Inter-examiner variabilities of the measurements that
0.06-3.3
(2.24) (1.9)
were made on the photographs were similar to those of the
measurements that were made during clinical examinations.
Thus, similar accuracy of measurement can be obtained
using either method.
Foot-Progression Angle
In the current study. the foot-progression angle varied
with age (Fig. 2-A). In young children the mean was higher
and the range was broader than in older children. This early
relative out-toeing was apparently due to the greater lateral
rotation of the hip in this age group. During adult life lateral
rotation again occurred, presumably due to progressive loss
of medial rotation of the hip.
The data for the foot-progression angle in the current
study were consistent with those in previous reports. Scrut
ton and Robson, in their study of fifty normal children.
found that in 94 per cent of the children who were one to
three years old the mean was + 6 degrees and the range
was from —¿ 5 to + 15 degrees. while in the children who
were older than four the mean was 4 degrees and the range
was from —¿ 2 to + 12 degrees. Eighteen per cent of these
fifty children had in-toeing on one side27. Schwartz et al.,
in a study of adults. found that the mean was between 5
and 9 degrees, with more out-toeing occurring in subjects
who were more than sixty years old26.
The foot-progression angle may be normal in patients
with torsional deformity because medial femoral torsion is
often associated with compensating lateral tibial torsion.
This association was found by Fabry et al.75 in 30 per cent
of the patients in their series and it was also found by
Kobyhiansky et al.7 in their study ofdried
from the same limbs.
tibiae and femora
THEJOURNALOF BONEANDJOINTSURGERY

Femur
Our study showed that in early infancy lateral rotation
of the femur is greater than medial rotation, but that with
advancing age lateral rotation decreases while medial ro
tation increases (Figs. 2-B. 2-C, and 2-D). The findings in
this study were consistent with previous findings for mean
values during childhood4°@53.15.25but in addition provided
a range of normal values. This normal range is great at all
ages. with the upper limit of medial rotation being about
65 degrees in male subjects and 60 degrees in female sub
jects (Figs. 2-B and 2-C). The lower limit of lateral rotation
is about 25 degrees for both sexes.
Severity of medial femoral torsion may be graded as
follows: mild if medial rotation is between 70 and 80 degrees
and lateral rotation is between 10 and 20 degrees (two or
three standard deviations from the mean). moderate if me
dial rotation is between 80 and 90 degrees and lateral ro
tation is between zero and 10 degrees (three or four standard
deviations), and severe if medial rotation is greater than 90
degrees and no lateral rotation is possible (more than four
standard deviations). The degree of joint laxity influences
these values, and both medial rotation and lateral rotation
will be increased in a child with joint laxity.
The relationship between rotation of the hip and ra
diographically measured femoral anteversion was studied
by Staheli et al.32. A reasonable correlation was found,
although other factors, such as acetabular inclination. can
affect rotation of the hip.
Tibia
Tibial rotation is defined as the relationship beween
the axis of rotation of the knee and the transmalleolar axis2'.
In 1909. le Damany measured the rotation in 100 dried
tibiae'1. In the newborn. the average angle of the trans
malleolar axis was 4 degrees of medial rotation. Thereafter.
lateral rotation gradually increased throughout childhood
40e
200
0
-20°
-40°
VOL. 67-A, NO. I. JANUARY 1985
LOWER-EXTREMITY ROTATIONAl. PROBLEMS IN (I-IILDREN 45
Ft;. 3
until the mean rotation was 23 degrees of lateral rotation.
with a range of zero to 40 degrees in @idults.
Later studies confirmed this early work. Nachlas oh
served that medial rotation of the tibia is common in the
orangutan and gorilla. and suggested that medial tihial tor
sion is an atavistic variation4. Hutter and Scott measured
forty adult skeletons and found that the mean lateral tihial
rotation was 21 degrees on the right and 19 degrees Ofl the
leftâ€. They then studied fifty children, two to three years
old, and found that 30 per cent had in-toeing. usually due
to medial tibial torsion. The prevalence was 8 to 10 per cent
in the five to seven-year age group and 8 to 9 per cent in
early adolescence, with a nearly equal sex distribution. They
also found that 3 per cent of 200 adults whom they studied
showed persistence of significant medial torsion. hut this
was not defined. They considered this to be a serious prob
lem in about 1 per cent.
Wynne-Davies. using a special caliper to measure tihial
rotation in normal adults5@' found that it ranged froni zero
to 40 degrees of lateral rotation. the mean being 20 degrees.
Khermosh et al. studied tibial rotation in 230 children in
infancy and early childhood and found that the mean lateral
rotation was 2 degrees at birth and 10 degrees at the age of
five years'4. Staheli and Engel used a caliper method to
survey 160 normal children5. They found a gradual increase
from 5 to 14 degrees of lateral rotation between the ages of
one and thirteen years. while Ritter et al. found the increase
to be from 4 degrees at birth to I 1 degrees at two years@.
Malekafzali and Wood, in 200 adult subjects. found the
normal range to be from 7 to 20 degrees of lateral rotation.
with a mean of 14 degrees21.
The current study demonstrated that the angle of the
transmalleolar axis and the thigh-foot angle become pro
gressively larger lateral angles throughout growth (Figs.
2-E and 2-F). The findings relative to the angle of the trans
malleolar axis were comparable with those found in other
studies. From the middle of childhood through adult life.
. . .
1 3 5 7 9 11 13 15-19 30's 50's
Age (years)
Comiiparison of the angle of the transmalleolar axis ITMA) amidthe thigh-fiat angle (TFA).
70+
IMA
TFA

46 L. T. STAHELI, MARILYN CORBETT, CRAIG WYSS, AND HOWARD KING
the normal range is from about zero to 45 degrees of lateral
rotation, with a mean of 25 degrees.
The thigh-foot angle is a composite measurement that
reflects rotation of both the tibia and the hind part of the
foot3 . This angle roughly parallels the angle of the trans
malleolar axis, but its mean value is lower (Fig. 3).
The thigh-foot angle is easier to measure than the angle
of the transmalleolar axis and is the most practical mea
surement of the usual torsional deformity. However, for
more complex torsional deformities, such as the torsion
associated with a club foot, measurements of both the trans
malleolar axis and the thigh-foot angle are useful. These
measurements clarify the anatomical location of the de
formity. Thus, torsional deformity of the tibia is assessed
by the angle of the transmalleolar axis; deformity of the
hind part of the foot is assessed by the difference between
the angle of the transmalleolar axis and the thigh-foot angle;
a combined deformity of both the tibia and the hind part of
the foot, by the thigh-foot angle; and finally, deformity of
the middle and distal portions of the foot, by the difference
between the clinical measurements ofthe hind and fore parts
of the foot.
Foot
Deformities of the foot were not assessed in this study.
The most common foot deformities affecting the rotational
profile are metatarsus adductus producing in-toeing and the
hypermobile flat foot producing out-toeing.
Lateral rotation caused by eversion of the foot is see
ondary to joint laxity or muscle imbalance. Such foot de
formities are detectable during the physical examination and
should be the last entries in the rotational profile.
Conclusions
During infancy. the rotational profile appears to be
References
influenced by the effects of intrauterine molding. The hips
are flexed and laterally rotated in utero, resulting in greater
lateral than medial rotation of the hips and femora. The feet
are medially rotated, producing medial rotation of the tibia
and sometimes metatarsus adductus. The spontaneous res
olution of molding results in equalization of medial and
lateral rotation of the hip, lateral rotation of the tibia, and
decreasing variability in the foot-progression angle during
the second year of life.
Genetic factors effect the rotational profile during early
childhood. Medial femoral torsion becomes evident at the
age when medial rotation is greatest. Continued lateral ro
tation of the tibia corrects residual medial tibial-torsion an
gulation.
During late childhood, medial rotation of the hip di
minishes, correcting in-toeing due to femoral torsion. Con
tinued lateral rotation of the tibia, however, may aggravate
a lateral tibial-torsion deformity. During adult years. the
rotational profile is relatively constant except for medial
rotation of the hip, which decreases, presumably due to a
generalized loss of joint mobility with age.
The graphs showing normal values for the rotational
profile of the lower limbs will allow the clinician to deter
mine the location and severity of torsional problems. In the
past, many infants and children with normal rotational val
ues were treated with splints. braces, exercises, or even
surgery.
Such treatment is both harmful to the child and ex
pensive for the parents.
In evaluating children with torsional deformity. the
potential for long-term disability in the absence of treatment
and the risks of treatment should be weighed. Non-operative
treatments are usually ineffective. Rotational osteotomies
of the femur or tibia are effective but are associated with
significant complication rates.
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Ther.. 58: 1355-1360. 1978.
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