الفهرس 
Aetiology
Radiological FindingsOnly 14 pages are availabe for public view
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Abstract
Summary
Summary
Patient with intoeing gait represents a very common referral group in a
pediatric orthopaedic practice. It may be due to a variety of abnormalities of
congenital or acquired origin. The level of pathologic involvement may be in
the hip, femur, leg, ankle, or the foot. Excessive femoral anteversion, internal
tibial torsion and metatatrsus varus are the most common causes of toeing-in
gait. This deformity may also occur in some paralytic conditions as in cerebral
palsy and myelomeningocle.
Tachdjian (1990), on the other hand, suggested that protective intoeing
due to pronated feet and developmental genu-valgum is the most common
causes of this gait.
Some deformities are simple, occurring at a single level, where as other
are more complicated. A combination of mild metatarsus varus and medial
tibial torsion together with increased femoral anteversion may produce a severe
intoeing gait (Staheli,1990).
Genetic factors play a role in many of these deformities. Ponseti and
Becker (1966), Kite (1967) and Giannestras (1973) reported a definite familial
diathesis in congenital metatarsus varus. Blumel et al., (1957) reported eight
cases of hereditary bilateral medial tibial torsion. Medial femoral torsion has
been reported in siblings of children with the disorder (Taclldjian, 1990).
The effect of posture upon the rotational development of the growing
bone has been the subject of much speculation. Hutter and Scott (/949),
Knight (/954), Crane (1950) Axer et al., (/971), suggested that sitting and
sleeping positions will influence rotational alignment of the bone. Staheli
(1980) is of the opinion that the posture is an effect rather than a cause.
With careful physical examination, an accurate diagnosis can actually be
made without complex roentgenographic measurements. A clear understanding
of the deformity and its natural history is important to care for children with
these conditions since many of them correct spontaneously.
For accurate clinical determination of the deformity and its level and
severity, Staheli (1990) devised what he has called the torsional profile, which
include the following measurements:
Foot progression angle which measures the over al1 torsions present
along the whole length of the lower limb.
_ Hip rotation which is used for assessment of femoral anteversion.
Thigh-foot angle which reflects the degree of torsion of tibia and hind
foot.
Angle of toransmal1eolar which measures the degree of tibial torsion.
A number of roentgenographic methods are available for measuring
femoral anteversion. These methods are not necessary in routine orthopedic
office practice. If surgery is planned, however, it may be helpful to obtain some
of these special views to document the extent of femoral anteversion, (Staheli,
1980, Kumar and MacEwen 1982).
According to Ruby et al., (1979), Staheli (1980), and Sullivan et al.,
(1982), the methods developed to radiological1y evaluate anteversion can be
classified into three distinct groups: fluoroscopic, axial and biplanar.
Ryder and Crane (1953); evaluated fluoroscopic method and concluded
that fluoroscopy is not reproducible between independent investigators, dose
not provide a permanent record, and potential1y subjects the patient to more
radiation exposure.
La Gasse and Staheli (1972), Ruby et al., (1979), and Staheli (1980)
concluded that biplane techniques art the preferred methods, and they are the
safest and least’difficult to apply.
In addition, the methods are reproducible, provides a clinically useful set
of x-rays for a permanent record, and can be done by x-ray personnel after
limited instruction.
Axial view include: plain film with an axial projection and computerized
tomography.
La Gasse, and Stahe/i (1972) and Ruby et al., (1979) concluded that
plain film with an axial projection is the least satisfactory method because of
the difficulties in penetration of soft tissues. They also concluded that after the
age of 6, this method is quite unsatisfactory. In addition, radiation exposure is
excessive and the final radiographs have limited clinical usefulness.
Summary
There is a general agreement that the computerized tomography is the
most accurate method. Weiner et al., (1987), and Peterson (1981) cautioned
against using computerized tomography for the measurement of femoral neck
anteversion. The dose of radiation was reported to be too large to make it safe
for routine use.
Ultrasound scanning has been employed for the measurement of
femoral, neck anteversion. Although it is an easy, non invasive and safe
method, yet the results are ,not sufficiently accurate to recommend its general
use (Berman, 1987).
According to Tachdjian (1972), Kumar and MacEwen ’(1982), lind
Harris (1983), a number of roentgenographic methods are available for
measuring tibial torsion, but these are cumbersome and unnecessary in routine
office practice. A sufficiently accurate estimate can be made clinically.
To manage the problem effectively, it is essential that the level of the
deformity be determined, as it may occur anywhere between the foot and hip.
and management for each condition is different.
The mild passively correctable metatarsus varus deformity tends to
improve spontaneously. If the foot appears rigid in the early stages then serial
plasters will propably be effective. If there is still a significant varus deformity
which is rigid and uncorrectable, then exploration and release of the tibialis
posterior or anterior, if anomalous, are worthwhile. If these abnormalities are
not present, then release of the abductor hallucis and capsulotomy of the first
metatarsocuneiform joint may well correct the foot.
If the foot is still not correctable, then a tarsometatarsal release up to the
age of 8 years will correct the foot. Finally, over the age of 8, multiple
metarasal osteotomies can be considered (Fixen, 1983).
In most patients increased medial tibial torsion will improve
spontaneously. Treatment is needed for children who have not improved by 15
to 18 months of age or who, have positive family history of persistent increased
medial tibial torsion, according to Knight (1954), Staheli (1977), Kumar and
MacEwen (1982) tibial torsion is best treated by Denis-Browne splints. In the
exceptional case in which increased medial tibial torsion persists past 8 years
Summar,!’
and the gait is awkwad and cosmetically displeasing, derotation osteotomy
should be considered.
Fabry et aL, (1973), Staheli (1980), Kumar and MacEwen (1982)
concluded that there is no conservative treatment for excessive femoral
anteversion, Roentgenographic evaluations have shown that there is no significant
natural decrease in anteversion after the age of 8 years. If femoral anterversion is
severe in children of these age, surgical intervention, in the form of derotation
osteotomy of the femur may be considered.
Many variations exist in the method of treating deformity. Conservative
treatment in the form of night splints, special braces or twister cables, although
it seems helpful in treating many cases of tibial torsion it is proved to be totally
ineffective in correcting increased femoral anteversion. Most orthopaedists
reported that tibial torsion is best treated by Denis-Browne splints, and
excessive femoral anteversion can not be effectively treated by non operative
methods.
In many instance treatment should be prescribed for the parents rather
than the child, and it perhaps wiser to educate the family rather than to subject
the child to ineffective and sometimes expensive methods of treatment. It
appears that in many cases improvement occurs spontaneously, consistent with
the natural history of the disease, and is not due to treatment prescribed by the
physician.
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