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

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40 I.. T. STAEIII.I, MARIlYN (ORBETT. (â€˜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. Thighâ€”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 â€”¿the angular difference between the axis of the foot and the axis of the thigh. and (2) angle of the transmalleolar axis â€”¿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 \â€˜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 Interâ€”Lx Standard Mean I)eviationaniinerErrorI ntraâ€”Ex Standard Meami I)eviation@initner * Intraâ€”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 Â±L. @ :@: . D 0 0 0 0 1 3 5 7 9 11 13 15-19 a. 0 0 25D 0 0 0 Q â€˜¿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. 2â€”Athrough 2â€”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. 80Â° 60Â° 40Â° 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
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