What’s In and What’s Out…Toeing-Rotational Alignment in Children | Ellen Dean-Davis, MD

Introduction

The moderator introduces the webcast and speakers, explains the format of the event, and provides some background information.

Welcome and Features of Web Event Technology

• Moderator welcomes viewers to the webcast.

• Viewers can adjust audio using computer volume settings.

• Q&A window is available for submitting questions.

• Speakers are introduced.

Opening Remarks

• Dr. Whitake welcomes viewers to the annual course on pediatric orthopedics.

• Dr. Davis greets viewers and explains the purpose of the webcast.

Basics of Rotational Alignment

Dr. Davis discusses rotational alignment in children, including what's normal according to age, how to perform a physical exam, and when to refer patients.

What's Normal According to Age

• Intoeing is one of the most common things seen in pediatric orthopedics offices.

• Dr. Davis discusses what's normal for rotational alignment according to age.

Physical Exam for Intoeing

• A quick physical exam can determine where intoeing is coming from.

• Dr. Davis demonstrates how to perform a physical exam for intoeing.

When to Refer Patients

• Referral may be necessary if there are concerns about hip dysplasia or other issues.

• Dr. Davis provides guidance on when it may be appropriate to refer patients.

Developmental Dysplasia of the Hip

Dr. Minkowitz discusses developmental dysplasia of the hip, including risk factors, screening, and treatment.

Risk Factors

• Developmental dysplasia of the hip is a common condition in infants.

• Dr. Minkowitz discusses risk factors for developmental dysplasia of the hip.

Screening

• Screening for developmental dysplasia of the hip is important.

• Dr. Minkowitz explains how to perform a physical exam for developmental dysplasia of the hip.

Treatment

• Early detection and treatment are key to successful outcomes.

• Dr. Minkowitz discusses treatment options for developmental dysplasia of the hip.

Scoliosis

Dr. Fan discusses scoliosis, including diagnosis, monitoring, and treatment options.

Diagnosis

• Scoliosis is a curvature of the spine that can be diagnosed through physical exam or imaging.

• Dr. Fan explains how scoliosis is diagnosed.

Monitoring

• Monitoring scoliosis involves regular check-ups and imaging.

• Dr. Fan provides guidance on how often to monitor scoliosis based on severity.

Treatment Options

• Treatment options for scoliosis depend on severity and may include bracing or surgery.

• Dr. Fan discusses different types of braces used to treat scoliosis.

Sports Injuries

Dr. Cyran discusses common sports injuries in children, including prevention and treatment options.

Common Sports Injuries

• Children are at risk for a variety of sports injuries.

• Dr. Cyran discusses common sports injuries in children.

Prevention

• Preventing sports injuries involves proper training and equipment.

• Dr. Cyran provides guidance on how to prevent sports injuries in children.

Treatment Options

• Treatment options for sports injuries depend on the type and severity of the injury.

• Dr. Cyran discusses different treatment options for common sports injuries.

Fractures

Dr. Rieger discusses fractures in children, including diagnosis, treatment, and complications.

Diagnosis

• Fractures

Understanding Femoral Antiversion

In this section, the speaker discusses femoral antiversion and its impact on children's health.

What is Femoral Antiversion?

• Femoral antiversion is an inward twisting of the femur bone that occurs in early childhood.

• It is quantified by measuring the angle created by the femoral neck up by the hip and relating it to a line drawn across the femoral condyles in the back of the knee.

• The degree of femoral antiversion decreases with age until skeletal maturity.

Symptoms and Causes

• Children with femoral antiversion may run funny or have a heel whip when walking due to internal rotation of their femur bone.

• They may also appear knock-kneed, with their kneecaps pointing towards each other.

• The cause of femoral antiversion is unknown, but it is more common in girls than boys.

Diagnosis and Treatment

• A physical exam can quickly diagnose femoral antiversion using tools such as hip internal and external rotation measurements, five foot angle estimation for internal severe torsion, heel bisector line estimation for metatarsal ductus, and foot progression angle quantification for intowing.

• Treatment options include observation, physical therapy exercises to strengthen muscles around the hip joint, or surgery in rare cases.

Internal Tibial Torsion

This section covers internal tibial torsion, which causes toddlers to toe-in when walking.

What is Internal Tibial Torsion?

• Internal tibial torsion is an internal rotation of the tibia bone that causes toddlers to toe-in when walking.

• It is caused by in utero packaging, where the baby's leg bones are positioned tightly in the womb.

Symptoms and Diagnosis

• Children with internal tibial torsion may begin to toe-in when they start walking around one to three years old.

• A physical exam can diagnose internal tibial torsion using tools such as hip internal and external rotation measurements, five foot angle estimation for internal severe torsion, heel bisector line estimation for metatarsal ductus, and foot progression angle quantification for intowing.

Treatment

• Observation is usually recommended since most cases of internal tibial torsion resolve on their own as children grow.

• Physical therapy exercises can help strengthen muscles around the hip joint and improve gait.

Metatarsus Adductus

This section covers metatarsus adductus, which causes a kidney bean-shaped foot due to inward rotation or abduction of the forefoot relative to the heel.

What is Metatarsus Adductus?

• Metatarsus adductus is a condition where there is inward rotation or abduction of the forefoot relative to the heel, causing a kidney bean-shaped foot.

• It occurs in about one in a thousand births and is often bilateral.

Associated Conditions

• Metatarsus adductus is associated with developmental dysplasia of the hip (DDH), which requires prompt diagnosis and treatment.

• It also has an association with torticollis.

Diagnosis and Treatment

• Observation is usually recommended since most cases of metatarsus adductus resolve on their own as children grow.

• In severe cases, casting or surgery may be necessary to correct the foot's position.

Understanding Pediatric Gait Abnormalities

In this section, the speaker discusses how to identify and measure pediatric gait abnormalities.

Identifying Gait Abnormalities

• The feet pointing outwards may actually be the hips turning inwards.

• Internal or external rotation can be measured by drawing a line from the ceiling to the knee and along the tibia itself.

• Internal or external tibial torsion can be determined by dropping a line down the middle of the foot wherever it is pointing after flexing the knees to 90 degrees.

• The heel bisector line should intersect around the second toe or between the second and third. If it falls lateral to that, it means that forefoot is rotated in.

Measuring Gait Abnormalities

• Foot progression angle quantifies how much in-toeing there is. It can be additive from both femur and tibia.

• These measurements are helpful for serial exams when patients come back after some time. They help quantify changes over time.

• Spontaneous resolution is expected for most cases of gait abnormalities by age 3 or 4 years old.

Treatment and Reassurance

• There is no need for physical therapy, special shoes, orthopedic shoes, braces, etc., as these do not work.

• Parents should be reassured that their child's gait abnormality will resolve on its own with time. There are no long-term problems associated with in-toeing such as arthritis or joint problems.

• In fact, there may even be an advantage to having a little bit of in-toeing as it may improve sprinting ability.

W-Sitting and Metatarsus Adductus

In this section, the speaker talks about W-sitting and metatarsus adductus.

W-Sitting

• W-sitting is not associated with femoral antiversion.

• Unless a child is sitting in this position for extended periods of time, it will not cause any long-term problems.

• Neuromuscular conditions like cerebral palsy or spina bifida may require separate treatment algorithms.

Metatarsus Adductus

• If there is a medial skin crease present, it indicates a more severe deformity.

• A couple of serial casts and maybe some bracing can be used to treat metatarsus adductus.

• Surgery may be necessary if there is persistent deviation after expected improvement, knee pain, or unacceptable cosmesis. Derotation osteotomy is the surgery performed.

Conclusion

The speaker concludes by summarizing the key points discussed in the previous section.

• Toe walking is one of the most common things seen in pediatric orthopedics.

• The speaker acknowledges that some parents may continue to worry despite reassurance and encourages them to come back to the office for further consultation if needed.