Lower Extremity Rotational and Angular Issues in Children

https://doi.org/10.1016/j.pcl.2014.08.006Get rights and content

Section snippets

Key points

  • There is a wide range of normal lower extremity positioning in growing children.

  • Angular and rotational status in children tends to follow standard developmental pathways over time.

  • Little or no intervention, beyond reassurance, is necessary for most patients, and their parents, who present with concerns regarding rotational or angular issues in children.

Introduction/overview

Parental questions and concerns regarding lower extremity rotational and angular status are some of the most common musculoskeletal issues facing primary care physicians and pediatric orthopedic surgeons.1 As such, it is important that all physicians providing care for children have a thorough understanding of appropriate methods of examination and of the natural history of these physical findings. In most patients, the natural history is benign, with self-resolution without the necessity of

The musculoskeletal evaluation/physical examination

An appropriate musculoskeletal evaluation in children includes both a comprehensive history and physical examination. The parents should be questioned regarding birth history, issues during pregnancy, development, and attainment of motor milestones. In addition, it is important to determine whether there is any family history of orthopedic or musculoskeletal disorders, particularly those that may cause pathologic rotational or angular deformities. In addition, it is valuable to ascertain

Intoeing/Out-toeing

Rotational issues in children, specifically intoeing and out-toeing, are among the most common musculoskeletal issues facing the primary care physician in office practice. It is important to know that most rotational issues are self-limiting, and require no active treatment.4 Parental concerns regarding intoeing seem to far outnumber those regarding out-toeing in clinical practice. The possible sources of intoeing are femoral anteversion, internal tibial torsion, and metatarsus adductus.

Overview

Knee alignment in children changes during skeletal development, and tends to do so in a predictable pattern in most patients. Most children start with an element of genu varum (bowed legs), progress toward neutral alignment with growth, and then may develop significant genu valgum (knock knees) before returning to the common mild physiologic valgus alignment of the lower limb around 5 or 6 years of age.

Genu Varum

Bowed legs are a common concern of parents, grandparents, and other caregivers. A large

Summary

Parental concerns regarding rotational and angular deformities of the lower limbs in children are common. As such, it is important for the primary care provider to understand and master the basics of the lower extremity musculoskeletal examination. In addition, it is important for the primary care provider to understand the natural history of lower extremity rotational and angular development. However, the natural history is well documented, and is predictable in most cases. Most lower

First page preview

First page preview
Click to open first page preview

References (12)

  • E.Y. Hsu et al.

    How many referrals to a pediatric orthopaedic hospital specialty clinic are primary care problems?

    J Pediatr Orthop

    (2012)
  • L.T. Staheli et al.

    Lower extremity rotational problems in children

    J Bone Joint Surg Am

    (1985)
  • J.T. Smith et al.

    Simple method of documenting metatarsus adductus

    J Pediatr Orthop

    (1991)
  • T.L. Lincoln et al.

    Common rotational variations in children

    J Am Acad Orthop Surg

    (2003)
  • D.R. Wenger et al.

    Corrective shoes and inserts as treatment for flexible flatfoot in infants and children

    J Bone Joint Surg Am

    (1989)
  • A. Driano et al.

    Psychosocial development and corrective shoewear use in childhood

    J Pediatr Orthop

    (1998)
There are more references available in the full text version of this article.

Cited by (23)

  • Osteotomies About the Knee: Managing Rotational Deformities

    2022, Operative Techniques in Sports Medicine
    Citation Excerpt :

    Femoral anteversion is described as the angle between 2 axial plane lines - one drawn from the center of the femoral head to the center of the base of the femoral neck and the other connecting the posterior most edges of the distal femoral condyles, and it typically measures 12°-20° on CT scan.7,8 Increased femoral anteversion is seen normally in infants and children and usually resolves before ten years of age.9-11 Notably, patients with cerebral palsy and myelomeningocele more commonly maintain increased femoral anteversion due to heightened baseline muscle tone, particularly of the medial hamstrings.12,13

  • Wedge-less oblique supracondylar femoral osteotomy and casting for genu valgum in older children and young adults

    2022, Journal of Clinical Orthopaedics and Trauma
    Citation Excerpt :

    The location of the deformity can be distal femur, knee joint, or proximal tibia. Correction of excessive physiologic or idiopathic genu valgum may be indicated in children older than 8 years when there is anterior knee pain, problems with running, abnormal gait patterns, patellar malalignment, ligamentous instability or excessive cosmetic concern.5 In growing children with open physis, hemiepiphysiodesis (temporary with staples or transphyseal screws or permanent via timed hemiepihysiodesis) can be done6–12 Hemiephysiodesis is an attractive option as a lesser procedure with minimal complications, but the growth potential in older children is limited as the distal femur physis fuses by 12 years of age in the majority of children, and, hence there is no role of growth modulation techniques.

  • The diagnosis and management of common childhood orthopedic disorders: An update

    2020, Current Problems in Pediatric and Adolescent Health Care
    Citation Excerpt :

    Increasing valgus of the knee after age 7 years is considered pathologic. Pathologic genu valgum can be the result of asymmetric growth of the distal femur that DOES NOT resolve spontaneously.99 Differential diagnosis includes rickets, posttraumatic valgus following a fracture, skeletal dysplasia, or benign bone tumor.

View all citing articles on Scopus

Disclosure: None.

View full text