TEMA: TORSIÓN TIBIAL INTERNA
Introduction to Internal Tibial Torsion
This section provides an introduction to internal tibial torsion, including its definition and classification, as well as the diagnosis and management at different levels of healthcare.
Definition and Classification
- Internal tibial torsion is the rotation of the tibia along its longitudinal axis, resulting in a change in alignment of the joint planes.
- It is commonly seen in newborns due to intrauterine positioning and can cause inward rotation of the feet.
- In children aged 1 to 3 years, it often manifests during the onset of walking.
- The condition tends to correct spontaneously between 7 to 8 years of age.
- It affects both males and females but is more commonly bilateral. If unilateral, it usually affects the left side.
Classification based on Gait Progression Angle
- Gait progression angle refers to the angle formed when walking in a straight line with the longitudinal axis of the foot.
- A normal gait progression angle is positive, indicating outward rotation of the foot.
- In internal tibial torsion, where the feet turn inward during walking, a negative gait progression angle is observed.
- The severity of internal tibial torsion is classified based on this angle:
- Mild: Less than -10 degrees
- Moderate: Less than -15 degrees
- Severe: Less than -20 degrees
Diagnosis by Physical Examination
This section focuses on diagnosing internal tibial torsion through physical examination.
Physical Examination Findings
- Observation of a child's gait reveals inwardly rotated feet, giving a "pigeon-toed" appearance.
- The legs may appear bowed or arched.
- The child may exhibit clumsiness and instability while standing or walking.
- The patella (kneecap) remains in a neutral position.
- The "plumb line sign" can be used to assess alignment. A plumb line dropped from the center of the kneecap should ideally fall on the second toe. If it falls on the third, fourth, or fifth toe, it indicates internal tibial torsion.
Thigh-Foot Angle Measurement
- The thigh-foot angle is measured with the patient lying prone on a table and their knee flexed.
- It assesses the angle between the thigh axis and foot axis.
- A negative thigh-foot angle indicates inward rotation of both the thigh and foot.
- Severity is classified as follows:
- Mild: Between -10 and -20 degrees
- Moderate: Between -20 and -30 degrees
- Severe: More than -30 degrees
Management at Different Levels of Healthcare
This section discusses management strategies for internal tibial torsion at different levels of healthcare.
First-Level Healthcare Management
- Parents are advised to follow certain postural guidelines, such as avoiding sleeping face down, sitting with knees together and feet turned inward, and sitting in a "W" position.
- Walking on tiptoes or heels with toes pointing outward helps reinforce proper gait patterns and muscle strengthening.
- Recommended sitting position is known as "Buddha position," where the patient sits on their glutes with knees bent forming a double V shape, keeping feet turned outward.
Rehabilitation Physician's Management
- Persistent cases of negative gait progression may require referral to a rehabilitation physician.
- Multidisciplinary teamwork involving various healthcare professionals is essential for effective management.
- Rehabilitation aims to improve gait patterns, correct lower limb misalignments, and potentially avoid or delay the need for corrective surgery.
Referral to Orthopedic Surgeon
- If conservative management fails or severe deformities persist, referral to an orthopedic surgeon may be necessary.
- The goals of rehabilitation are to improve gait patterns, correct lower limb misalignments, and potentially avoid or delay the need for corrective surgery.
The transcript provided does not cover further details on surgical interventions or additional management strategies beyond the scope of this summary.
Observation of Gait Pattern and Education for Parents
This section discusses the observation of gait patterns in patients undergoing physical therapy. It emphasizes the importance of educating parents about the physiological origin of the condition, spontaneous correction, and postural hygiene guidelines.
Gait Pattern Observation and Spontaneous Correction
- The gait pattern in patients with internal tibial torsion generally corrects spontaneously by the age of 5 or 6.
- Even if the condition persists, it tends to have a benign natural history.
Rehabilitation Management and Postural Hygiene Guidelines
- Rehabilitation management includes stretching exercises, strengthening exercises, and postural hygiene guidelines.
- Stretching exercises help reduce muscle tension and tightness progressively.
- Strengthening exercises aim to increase muscle strength and power to maintain alignment of the tibia, ankle, and foot.
Benign Natural History
This section highlights that internal tibial torsion typically follows a benign natural history.
Benign Natural History
- Internal tibial torsion usually has a benign natural history.
Stretching Exercises
This section focuses on stretching exercises as part of rehabilitation management for internal tibial torsion.
Stretching Exercises
- Stretching exercises are useful for reducing muscle tension and tightness progressively.
- Recommended to perform between 3 to 6 sets held for 10 to 20 seconds with a 30-second pause.
- Muscles targeted include dorsiflexors (e.g., tibialis anterior), inverters (e.g., tibialis posterior), flexor digitorum longus, and flexor hallucis longus.
Strengthening Exercises
This section discusses strengthening exercises as part of rehabilitation management for internal tibial torsion.
Strengthening Exercises
- Strengthening exercises aim to increase muscle strength and power to maintain the alignment of the tibia, ankle, and foot.
- Recommended to perform 10 repetitions per exercise, gradually increasing intensity.
- Muscles targeted include plantar flexors (e.g., gastrocnemius, soleus), dorsiflexors (e.g., extensor digitorum longus), and anterior tibialis.
Rehabilitation Management and Postural Hygiene Guidelines
This section emphasizes the importance of postural hygiene guidelines in rehabilitation management for internal tibial torsion.
Postural Hygiene Guidelines
- Postural hygiene guidelines should be followed throughout the therapy process.
- Torsional profile assessment is necessary to evaluate significant changes in gait progression angle, thigh-foot angle, plumb line sign, and treatment effectiveness.
Physical Exercise
This section highlights the significance of physical exercise as part of therapy for internal tibial torsion.
Importance of Exercise
- Exercise plays a crucial role in therapy by preparing muscles, improving flexibility, facilitating alignment of the tibia through abduction/pronation/eversion movements.
- Helps reduce muscle tension and tightness progressively.
- Stretching exercises target internal hip rotators (e.g., hip adductors), while passive exercises promote external hip rotation with extended hips.
- Assisted active exercises focus on strengthening hip rotators such as gluteus medius, biceps femoris, anterior tibialis.
Medical Management for Severe Cases
This section discusses medical management options for severe cases of persistent internal tibial torsion.
Medical Management
- Severe cases of persistent internal tibial torsion may require referral to a traumatologist.
- Indications include gait progression angle less than -20 degrees after 8 years of age, functional disability, pain, and lower limb asymmetry.
- Surgical intervention may involve distal tibial rotational osteotomy.
Referral to Rehabilitation Specialist
This section highlights the need for referral to a rehabilitation specialist in specific situations related to internal tibial torsion.
Referral Criteria
- Referral to a rehabilitation specialist is recommended when there is a disability due to frequent falls, persistent negative gait, or pronounced toe-walking.
References
- The transcript does not provide any references.