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Femoral Torsion

Femoral torsion is an acquired defect associated with ligamentous laxity. Ligamentous laxity is not pathologic in and of itself; half the people in this room have it, but it allows one to have a whole host of other sort of quasi normal conditions, femoral torsion is one of which. This is the most common cause of in-toeing in children over the age of three, remember, that the in-toers from tibial torsion will have grown out of this usually by three, so femoral torsion is whatís left over after the age of three. Children give this to themselves by femoral torsion.

Once children go to school and start sitting on chairs most of the time instead of on the floor, this will slowly correct on itís own. It takes a long time to tell parents up until the age of 10. There is the "W" sitting right there in the middle, thatís what causes tibial torsion, itís putting a lot of torque.

When the child comes to your office, how do you tell which of these three things they have, and you do a little series of tests called rotational profile and you can make a fancy little chart like this in your record and over time, see how this is progressing, and it looks kind of intimidating here, but it takes about 30 seconds to do. The first thing is the foot progression angle.

Then you are going to look at the internal and external rotation of the hip, and you do that with the child in the prone position. Their lying on their stomach and typically, children will have 45 degrees in each direction, adults have less internal rotation than that.

What theyíre showing you here with the feet heading out this way, thatís internal rotation at the hip, this is internal rotation of the hips, this is external. You should have 45 degrees in both directions. This child has about 60 degrees internal rotation and about 30 degrees external rotation. So this child has femoral torsion which is what you would expect in a child of this age, she looks like she is about four. Often, these children are very lax and can actually put their feet down on the table in this position, you can get a full 90 degrees of internal rotation out of some of them. Over time this will correct and you will be able to see them improve.

To check for internal tibial torsion, have the child in the same position, lying prone and you measure something called the five foot angle which is what they are showing you here, a bisector down the thigh, the bisector down the foot and this angle. This child doesnít have internal tibial torsion, this is a normal thigh foot angle of positive 10 degrees out away from the body. If she had internal tibial torsion, her toes would be pointing in this direction and this angle would be a negative angle here.

Out-toeing is another packaging defect, most kids of sort of positioned in this fetal position with their legs turned in, but some are positioned with their legs turned out and their feet dorsiflexed up, and they are going to end up with external tibial torsion and calcaneal valgus feet as opposed to internal tibial torsion and metatarsus adductus and thatís what they are showing you here, just like in that first slide with this childís knees pointing straight ahead, their feet are turned out and thatís external tibial torsion.