Intoeing, Outtoeing, and LimpingMaking Sense of Common Pediatric Gait Abnormalities

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In-toeing, Out-toeing, and LimpingMaking Sense
of Common Pediatric Gait Abnormalities

• Brian E. Grottkau, M.D.
• Massachusetts General Hospital for Children

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Rotational Angular Deformities in Children

• Objectives
• 1.) Review common physiologic and pathologic
  causes of in-toeing/out-toeing gait in children
• 2.) Review diagnosis and physical examination
  techniques used in assessing pediatric rotational
  and angular deformities
• 3.) Review the current management of pediatric
  rotational and angular deformities in children
• 4.) Review the differential diagnosis of limping
  gait/gait abnormality in children

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Rotational Angular Deformities in Children
Introduction

• Rotational and Angular Deformities are quite
  common in pediatrics
• Very diverse spectrum of diagnoses physiologic
  to pathologic
• In-toeing/Out-toeing, Genu varum (bowlegs)/valgum
  (knock-knees)

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The In-toeing Toddler or Child

• History Inquire about onset, severity,
  progression, disability, and previous treatment
• Always assess developmental history when did
  child start walking independently, gross and fine
  motor skills
• Screening examination to r/o hip dysplasia (DDH),
  other neurological problems (cerebral palsy)

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Causes of In-toeing Gait in Children

• The most frequent causes of childhood in-toeing
• Femoral anteversion
• Medial Tibial Torsion
• Metatarsus adductus

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The In-Toeing Toddler/Child Assessment

• Rotational Profile Evaluate in four steps
• 1.) Observe child walking and running.
• Estimate the foot progression angle (FPA)
  angular difference between the axis of the
  foot and the line of progression

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Assessing the Foot Progression Angle

• Nonspecific estimation
• Normal usually -5 tp 20 degrees
• In-toeing -5 to-10 degrees mild
• -10 to -15 degrees moderate
• gt-15 degrees severe

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The In-Toeing Toddler/Child Assessment

• 2.) Assess Femoral Version Measure external and
  internal rotation of the hips with the child
  prone and the knees flexed to 90 degrees. Assess
  both sides simultaneously. Internal rotation
  usually less than 65-70 degrees
• If greater than 70 degrees in-toeing likely from
  femoral anteversion/femoral torsion
• If rotation is asymmetrical, evaluate with AP of
  pelvis to r/o DDH or hip problem

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Assessing Femoral Anteversion Internal Rotation
of the Hip
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Internal Femoral Torsion/Anteversion

• In standing position, patellae will point inwards
  when feet are forward
• Compensatory external rotation of tibia

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Femoral Anteversion Clinical Assessment
Kissing patellae
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Femoral Anteversion Definitions

• Femoral version defined as the angular difference
  between axis of femoral neck and the
  transcondylar axis of knee
• Femoral anteversion ranges from 30-40 degrees at
  birth and decreases progressively to about 10-15
  degrees at skeletal maturity
• MeasurementX-rays (biplane) technically
  difficult
• CT--most accurate method

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Internal Femoral Torsion/Anteversion

• Usually first seen in the 3-5 year age group,
  usually most severe b/w 4-6 years
• Almost always symmetrical
• Mechanism unknown, genetic factors and position
  of fetus in uterus causing increased rotation
• More common in females approx. 2 1 ratio, often
  familial
• Gait/running described as awkward/clumsy by
  parents

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Femoral Anteversion Management

• Gait is often worse when running or when fatigued
• Children prefer the W sitting position because
  it is more comfortableshould not be discouraged
  or avoided
• Reassurance and Observation!!
• Special shoes, twister cables, etc avoided.no
  difference in outcome!!

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Internal Femoral Torsion Management

• Internal femoral torsion/antetorsion
• Mild internal rotation of hip 70-80 degrees
• Moderate internal rotation 80-90 degrees
• Severe internal rotation gt 90 degrees
• External hip rotation is usually reduced total
  arch of rotation is usually 90-100 degrees
• Resolves spontaneously without treatment in
  overwhelming majority of patients most
  literature-- 98-99
• Results from decrease in femoral anterversion
• over time (age 8-9 years) and from a lateral
  rotation
• of the tibia

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Femoral Anteversion Operative Treatment

• Indications for Osteotomy Individualized
• Tachdijian indications femoral anteversion gt45
  degrees
• hip unable to laterally rotate beyond neutral,
  functional disability and severe cosmetic
  deformity
• Must weigh the benefits from procedure versus the
  morbidity of surgical procedure

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Surgical Treatment of Femoral Anteversion
Derotational Femoral Osteotomy

• Because of high spontaneous resolution
  rate...derotational osteotomy is not done before
  8-9 years
• Very rare surgery delayed until adolescence to
  determine if spontaneous correction will occur

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Internal (Medial) Tibial Torsion

• Toddler or young child often presents with c/o
  bowing legs
• Usually symmetric in-toeing, if
  unilateral--usually worse on left
• Often noticed when child is first starting to
  walk
• With patellae facing forwards
• (in neutral position), feet turn in

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Measurement of Thigh Foot Angle Medial Tibial
Torsion

• 3.) Quantify Tibial Version
• Thigh Foot Angle patient is prone, knees flexed
  90 degrees TFA is the angular difference between
  the axis of the foot and the axis of the thigh
• Allow foot to fall into natural position, avoid
  manual positioning of foot
• Medial Tibial Torsion Negative Thigh Foot Angle

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Internal Tibial Torsion Diagnosis

• Resolves spontaneously in 95-98 of patients by
  age 4-6 years
• Stretching, special shoes are inefffectivedoes
  not speed up resolution and makes no clinical
  difference
• Can occasionally have mild persistence with no
  handicap or functional significance
• Usually simple observation is best treatment and
  all that is needed

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Medial Tibial Torsion Management

• CT Scan is the best diagnostic study to precisely
  diagnose the degree of torsion
• Always pursue conservative treatment
  OBSERVATION!!
• If medial tibial torsion is causing gait problems
  and significant disability (usually gt 40 degrees
  internal rotation)... can consider derotational
  osteotomy after age 8 years (very rare!!)

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Metatarsus Adductus in Infants

• Assess the foot for forefoot adductus
• Lateral border of foot should be straight
• Convexity of lateral border and forefoot
  adduction are features of metatarsus adductus

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Grading Severity of Forefoot Adductus

• Project a line that bisects the heel. Normally
  it falls on the 2nd toe
• Mild falls through the 3rd toe
• Moderate falls between toes 3-4
• Severe falls between toes 4-5

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Metarsus Adductus in Infant

• Most common foot deformity in children 1-3/1000
• Prognosis is directly related to the degree of
  stiffness
• Differentiate between metatarsus varus and
  talipes eqinovarus
• Associated with DDH in 2 of cases--careful hip
  examination

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Metatarsus Adductus Assessment

• Exact cause is unknown
• Commonly believed to be caused by intrauterine
  positioning or crowding
• No correlation between gestational age at birth,
  maternal age, or birth order

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Metatarsus Adductus Management

• Forefoot can gently be stretched passively with
  each diaper change
• Occasionally will use serial casting and
  reverse/straight last shoes to correct deformity
• Observation and Reassurance will resolve
  spontaneously in 90-95 of patients (tends to
  persist until age 12-18 months)

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Physiologic Infantile Out-Toeing

• Out-toeing in early infancy is usually due to a
  lateral rotation contracture of the hips
• When infant is positioned upright, the feet will
  usually turn out
• Resolves spontaneously with ambulationno
  treatment is needed

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Out-toeing External Tibial Torsion

• Most common cause of out-toeing in children
• May worsen over time because of the normal
  lateral rotation of the tibia that occurs with
  growth
• May be associated with patellofemoral knee pain
• If combined with femoral anteversion ( knee
  internally rotated and ankle externally
  rotated)miserable malalignment
  syndromeinefficient gait and patellofemoral
  joint pain

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Mean Tibio-Femoral Angle In Children
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Lower Extremity Rotational Profile at Various Ages

• Normal alignment progresses from 10-15 degrees of
  varus at birth to maximum valgus angulation of
  10-15 degrees at 3-4 years of age

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Genu Valgum (Knock-Knees)

• Physiologic knock-knee deformity very common in
  children aged 3-5 years
• Screening evaluation normal height and body
  proportions, symmetrical, localized or
  generalized, limb lengths equal
• Measure rotational profile, measure
  inter-malleolar distance with the knees together
• If generalized deformity, order metabolic
  screening labs

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Physiologic Genu Valgum Assessment
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Pathologic Causes of Genu Valgum

• Post-traumatic (most common)
• Dysplasias
• Primary tibial valga
• Tumor
• Infection
• Rickets
• Renal osteodystrophy
• Congenital deficiency of fibula (fibular
  hemimelia)

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Post-Traumatic Genu Valgum

• Usually results from overgrowth following
  fracture of the proximal tibial metaphysis in
  early childhood
• May also be due to malunion or soft tissue
  interposition
• Valgus deformity develops during the 1st 12-18
  months post-injury due to tibial overgrowth
• Management Most will correct spontaneously over
  course of years without operative treatment
• If deformity persists osteotomy or
  hemiepiphyseodesis

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Rickets Diagnosis and Management

• Suspect rickets in child with increasing genu
  varum/valgum, short stature, poor nutritional
  status (vitamin D deficiency)
• Produces generalized genu varum/valgum with
  bowing of the diaphysis and distinctive cupping
  and widening of the epiphysis
• Refer to endocrinologist for medical management
  Ca, Phos supplementation (Vitamin D resistant
  form possible)
• Correction (if necessary) usually delayed until
  the end of growth as recurrence of deformity is
  quite common

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Clinical Assessment Rickets
Costochondral beading
Severe genu valgum
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Clinical Assessment Genu Valgum-Rickets
Family with Rickets increased varus in toddler,
valgus in 5 and 12 year old females
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Genu Valgum General Management

• Age 2-6 years 95-98 will resolve spontaneously
• If intermalleolar distance is gt 8-10 cm at age 10
• 1.) Hemiephiphyseodesis of distal femur and/or
  proximal tibia
• 2.) If skeletally mature a.) tibial varus
  osteotomy
• b.)
  femoral osteotomy medial
• closing
  wedge if genu valgum
• gt 12-15
  degrees and superolateral
• tilt of joint gt 10 degrees

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Physiologic Genu Varum Assessment

• Parents will often note bow leg deformity,
  usually recognized when child starts to walk
  (12-18 months)
• Commonly bilateral and symmetric bowing
• Seldom causes functional disability X-rays
  unnecessary until at least 18 months of age
• Physiologic bowing usually spontaneously resolves
  by the age of two years

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Differentiating physiological Genu Varum vs.
Blounts disease

• Physiological bilateral, symmetrical,
  metaphyseal-diaphyseal angle lt15 degrees, upper
  tibial metaphysis/ epiphysis normal
• Blounts unilateral/ bilateral, asymmetrical,
  metaphyseal-diaphyseal angle gt 15 degrees,
  fragmentation of upper tibial metaphysis, tibial
  epiphysis slopes medially, norrowing of tibial
  physis medially, widening laterally

Diagnosis of Blounts cannot be made before age 2
years
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Infantile Blounts Disease Radiographs
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Pathological Conditions Causing Varus Deformity
of the Legs

• Metabolic bone disease Vitamin D deficiency,
  Vitamin D refractory rickets
• Asymmetrical growth arrest or retardation
  Blounts disease, Trauma, Infection, Tumor
• Bone dysplasia metaphyseal dysplasia
• Congenital
• Neuromuscular

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Infantile Blounts Disease Epidemiology

• Risk factors Obesity, African American,Walking
  at early age, Family history
• Differential Diagnosis Physiologic genu varum
  (metaphyseal-diaphyseal angle less than 15
  degrees)
• Rickets
• Osteomyelitis,
• Trauma, Tumor
• Fibrous dysplasia
• Metaphyseal chondrodysplasia
• 
  

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Blounts Disease Classification

• Infantile (early onset)
• onset between 1-3 years, bilateral, usually
  symmetric, pts often large for age, etiology is
  abnormal compression on medial proximal tibial
  physis, may feel bony prominence or beak over
  the medial tibial condyle, often have lateral
  thrust to gait
• Very difficult to differentiate from physiologic
  varus/ bowlegs in patients lt 2 years
• Adolescent (onset over 11 years)
• often presents with tenderness/pain over the
  medial prominence of the proximal tibia, pts
  often obese
• Prevalence General population lt0.3, Obese
  African American male2.5

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Metaphyseal/Diaphyseal Varus Angle

• Often used to differntiate physiologic from
  Blounts disease
• If greater than 15-17 degrees, tibia vara or
  Blounts disease is likely
• Follow radiographs every six months.physiologic
  varus will gradually improve after age 2 years
  while Blounts will progressively worsen

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Measuring the Tibial-Femoral Angle

• Line is drawn down center of tibia and femur.
  Intersecting angle is the tibio-femoral angle

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Blounts Disease Radiographs
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Adolescent Blounts Disease

• Definition Growth disorder involving the medial
  portion of the proximal tibial growth plate that
  produces a localized varus deformity
• More often unilateral, usually seen in obese
  individuals, slightly more males than females,
  African American, certain geographic regions
• Definite cause unknown biomechanical overload to
  proximal tibia physis due to varus alignment and
  excessive body weight

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Adolescent Blounts Theorized Cause of
Progressive Varus Deformity
Childhood Varus
Rapid Weight Gain
Medial Growth Plate Injury
Progressive Varus Knee
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Adolescent Blounts Disease Clinical Assessment
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AP Radiographs Assessing the Tibia Vara Deformity
Left
Right
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Blounts Disease Non-Operative Treatment

• Non-operative Observation only until age 2 years
• Anti-Blounts Brace Usually used for pts aged
  2-3 years with
• 1.) metaphyseal/diaphyseal angle gt 15-17 degrees
• 2.) tibial/femoral angle gt 15 degrees
• 3.) brace is designed to provide rotational
  support, usually worn FT
• 4.) usually takes 1 year to determine
  effectiveness of brace
• 5.) brace is ineffective in adolescents
• If operative correction necessary in infantile
  Blounts.results are better when done before the
  age of 4 years

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Blounts Disease Operative Treatment

• For optimum correction and results in infantile
  tibia vara Surgical treatment in early stages is
  crucial
• Avoids sequelae of joint incongruity, limb
  shortening, and persistent angulation
• Proximal tibial osteotomy distal to patellar
  tendon insertion (avoid proximal physis (dome,
  closing or opening wedge)
• Adolescent tibia vara predominately surgical
  treatment
• 1.) Lateral epiphyseodesis recommended as
  initial procedure if more than one year of growth
  remaining
• 2.) High tibial osteotomy with internal fixation
  ( usually correct to about 0-5 degrees of varus)
• 3.) Realignment by external fixation Ilizarov,
  Dynamic Axial External fixator, Taylor Spatial
  Frame

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Surgical Correction Proximal Tibial Osteotomy

• Demonstration of opening wedge tibial osteotomy
  procedure for correction of infantile blounts
  disease
• Usually recommend slight overcorrection into mild
  valgus (reverse excessive compression forces
  medially avoid injury to physis)

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Adolescent Blounts Realignment by External
Fixation-Taylor Frame
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Rotational and Angular deformities Summary

• Most rotational/alignment problems are
  physiological and will resolve without
  intervention
• Good history and physical examination important
• Investigate more if asymmetrical, rapidly
  progressive
• Orthotics, special braces/shoes, twister cables
  are frequently not helpful or necessary
• Most will never require surgery

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The Limping Child.

• Relatively large differential diagnosis list
• Obtain good history VERY important
• Observe childdo they look sick, do they have
  fever, will he/she put weight on leg or let you
  move extremity?---rule out septic
  arthritis/infection first!!
• Determine history of trauma, fall, or injury?
• Age of patient, duration of symptoms, onset of
  symptoms, family history

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The Limping Child

• Observe Child walking/running in hallway
• Generally 4 types of limping gait described
• 1.) Antalgic gait shortened stance
• 2.) Abductor lurch trendelenburg gait
• 3.) Equinus gait toe toe progression
• 4.) Circumduction gait leg length discrepency

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Limping Gait in Child Differential

• Fracture, Trauma, Overuse MOST common
• Transient synovitis Must differentiate from
  septic arthritis
• Discoid Lateral Meniscus
• Infection septic arthritis, lyme disease,
  osteomyelitis
• LCPD, SCFE, DDH Hip pathology
• Cerebral Palsy, Neurologic disorders
• Neoplasm/Tumor benign, malignant
• JRA, other Rheum disorders

The cause of a limp can range from a
life-threatening bone tumor to a pebble in a
shoe!
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The Limping ChildTransient Synovitis vs Septic
Arthritis

• Transient synovitis
• Child refuses to walk
• Movement of hip is painful
• May have fever
• Moderately elevated WBC
• Lasts a few days
• Disappears without treatment

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The Limping Child Septic Arthritis
Bacteria
White cells
Enzymes
Enzymes
Destroy cartilage
Irreversable joint damage
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Septic Arthritis of the Hip

• The Worst Scenario.
• Destruction of articular cartilage
• Destruction of femoral head
• Destruction of femoral neck

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The Limping Child Septic Arthritis

• Treatment
• Kill the bacteria!
• IV Antibiotics
• Eliminate the white cells
• Early Incision and drainage
• Dont delay!!!

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The Limping Child Transient Synovitis vs. Septic
Arthritis

• How to tell the difference?
• Four predictors
• History of fever gt101.5
• Refusal to weight-bear
• ESR gt 40 mm/hr
• WBC gt 12,000
• If in doubt
• Review in 12 hours
• Do incision and drainage!

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Questions?
Thank You!!!