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

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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