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

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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. I. ASHTON.B. B.: PICKLES.BARRIE;and RoLl.. J. W.: Reliability of Gonionietric Measurements of Hip Motion in Spastic Cerebral Palsy. Devel. Med. and Child Neurol. . 20: 87-94. 1978. 2. BOONE. D. C. . and AZEN. S. P.: Normal Range of Motion of Joints in Male Subjects. J. Bone and Joint Surg. , 61-A: 756-759, July 1979. 3. BooNE, D. C.: AZEN, S. P.: Ther.. 58: 1355-1360. 1978. LIN, C.-M.; SPENCE. CAROl.: BARON. CAROl.: and LEE. LYNN: Reliability of Goniometric Measurements. Phys. 4. Coos, VAt.ERIE:DONATO.GERALDINE:HOUSER.CAROlYN:and BLECK.E. E.: Normal Rangesof Hip Motion in Infants Six Weeks, Three Months and Six Months of Age. Clin. Orthop.. 110: 256-260, 1975. 5. EKSTRAND.JAN: WIKTORSSON.MARGARETA:OBERG. BIRGITTA:and GIL[.QUIST.JAN: Lower Extremity Goniometric Measurements: A Study to Determine Their Reliability. Arch. Phys. Med. and Rehab.. 63: 171-175. 1982. 6. ENGEI..G. M.. and STAHELI.L. 1.: The Natural History of Torsion and Other Factors Influencing Gait in Childhood. A Study of the Angle of Gait, Tibial Torsion, Knee Angle. Hip Rotation. and Development of the Arch in Normal Children. Clin. Orthop.. 99: 12-17. 1974. 7. FABRY, G.: Torsion of the Femur. Acta Orthop. Belgica. 43: 454-459. 1977. 8. FABRY. GUY: MACEWEN. G. D.: and SHANDS. A. R. . JR.: Torsion of the Femur. A Follow-up Study in Normal and Abnormal Conditions. Bone and Joint Surg.. 55-A: 1726-1738. Dec. 1973. 9. HAAS,S. S. Epps. C. H., JR.; and ADAMS.J. P.: Normal Ranges of Hip Motion in the Newborn. Clin. Orthop.. 91: 114-I 18. 1973. J. 10. HALPERN. A. A.: TANNER. JOSEPH:and RINSKY,LAWRENCE.:Does Persistent Fetal Femoral Anteversion Contribute to Osteoarthritis? A Preliminary Report.Clin.Orthop..145:213-216.1979. II. HUTTER.C. G.. JR.. and SCOTT.WALTER:Tibial Torsion. J. Bone and Joint Surg.. 31-A: 511-518, July 1949. 12. INSAI.L. JOHN: FALVO, K. A.: and WISE, D. W.: Chondromalacia Patellae. A Prospective Study. J. Bone and Joint Surg.. 58-A: 1-8, Jan. 1976. 13. KATE. B. R.. and ROBERT. S. L.: The Angle of Femoral Torsion. J. Anat. Soc. India. 12: 8-lI. 1963. 14. KUERMOSH.O. LLOR,G.: and WEISSMAN,S. L.: Tibial Torsion in Children. Clin. Orthop.. 79: 25-31. 1971. 15. KINGSLEY, P. C. , and OLMSTED. K. L.: A Study to Determine the Angle of Anteversion of the Neck of the Femur. J. Bone and Joint Surg.. 30-A:745-751.July1948. 16. KNITTEL.GUNTER,and STAHELI.L. T.: The Effectiveness ofShoe Modificationsfor lntoeing. Orthop. Clin. North America. 7: 1019-1025. 1976. 17. KOBYLIANSKY.E.: WEISSMAN. S. L.: and NATHAN. H.: Femoral and Tihial Torsion. A Correlation Study in Dry Bones. InternaL. Orthop.. 3: 145-147, 1979. 18. LANIER. J. C.: The lntoeing Child. Treatment with a Simple Orthopedic Appliance. J. Florida Med. Assn.. 58: 19-23. Dec. 19. LEDAMANY.P.: La torsion du tibia. Normale. pathologique. expÃ©rimentale. J. anal. physiol.. 45: 598-615. 1909. 1971. 20. Low. J. L.: The Reliability of Joint Measurement. Physiotherapy. 62: 227-229. 1976. THE JOURNAL OF BONE AND JOINT SURGERY
LOWER-EXTREMITY ROTATIONAL PROBLEMS IN CHILDREN 47 21. MACEWEN. G. D., and SHANDS. A. R.. JR.: Rotational and Angulation Def@rIi1ities of the Lower Extremity in Childhood. Orthopedics. 2: 66- 70. April 1960. 22. MCSWEENY. ANTHONY: A Study of Femoral Torsion in Children. J. Bone and Joint Surg.. 53-B(I): 90-95. 1971. 23. MALEKAFzALI, SAEED. and WooD. M. B.: Tibial Torsion â€”¿A Simple Clinical Apparatus for Its Measurement and Its Application to) a Normal Adult Population. Clin. Orthop.. 145: 154-157. 1979. 24. NACHLAS. I. W.: Medial Torsion of the Leg. Arch. Surg. . 28: 909-919. 1934. 25. RITTER. M. A.: DEROSA. G. P.: and BABCOCK, J. L.: Tibial Torsion? Clin. Orthop.. 120: 159-163. 1976. 26. SCHWARTZ. R. P.: HEATH. A. L.: MORGAN. D. W.: and TowNS. R. C.: A Quantitative Analysis of Recorded Variables in the Walking Pattern of â€˜¿NormaE'Adults. J. Bone and Joint Surg. . 46-A: 324-334. March 1964. 27. SCRUTTON, D. S., and ROBSON, P.: The Gait of 50 Normal Children. Physiotherapy. 54: 363-368. 1968. 28. SHANDS. A. R.. JR. . and STEELE. M. K.: Torsion of the Femur. A Follow-up Rejxrt on the Use of the Dunlap Method for Its Determination. J. Bone and Joint Surg.. 40-A: 803-816. July 1958. 29. STAHELI, L. T.: Torsional Deformity. Pediat. Clin. North America. 24: 799-81 I . 1977. 30. STAHELI. L. T.: Report of the Pediatric Orthopaedic Society (POS) Subcommittee on Torsional Deformity. Orthop. Trans. . 4: 64-65. 1980. 31. STAHELI, L. T., and ENGEL. G. M.: Tibial Torsion. A Method of Assessment and a Survey of Normal Children. Clin. Orthop.. 86: 183-186. 1972. 32. STAHELI, L. 1.: DUNCAN. W. R.: and SCHAEFER.ETHEL: Growth Alterations in the Hemiplegic Child. A Study of Femoral Anteversion. Neck Shaft Angle. Hip Rotation. C. E. Angle. Limb Length and Circuni%@rence in 50 Hemiplegic Children. Clin. Ortbop.. 60: 205-212. 1968. 33. STAHELI, L. 1. : LIPPERT, FREDERICK:and DENOTTER, PAMELA:Femoral Anteversion and Physical Pethrmance in Adolescent and Adult Life. Clin.Orthop..129:213-216.1977. 34. TERJESEN. 1.: BENUM. P.: ANDA. S.: and SVENNINGSEN.S.: Increased Femoral Anteversion and Osteoarthritis of the Hip Joint. Acta Orthop. Scandinavica. 53: 571-575. 1982. 35. TURNER, M. S.. and SMILLIE. I. S.: The Effect ofTibial Torsion on the Pathology of the Knee. J. Bone and Joint Surg.. 63-B(3): 396-398. 1981. 36. WYNNE-DAVIES. RUTH: Talipes Equinovarus. A Review of Eighty-tour Cases after Completiomi of Treatmiient. J. Bone and Joint Surg. . 46-B(3): 464-476. 1964. VOL.67-A,NO. I. JANUARY1985
Page 1 and 2: ABSTRACT: We studied 1,000 normal l
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