MEDIAL TIBIAL TORSION
 
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    MEDIAL TIBIAL TORSION

     

    DEFINITION:

    A skeletal disorder characterized by excessive medial rotation of the tibia resulting in in-toeing.

    EPIDEMIOLOGY:

    • incidence: ?
    • age of onset:
      • at ambulation
    • risk factors:
      • may be a familial component

    PATHOGENESIS:

    1. Background

    • torsion is a rotational deformity where there is a twisting of a bone along its longitudinal axis
    • the rotational deformity may be lateral or medial and in the lower limbs may involve the femur or tibia
    • Medial Tibial Torsion (Internal Tibial Torsion) and Medial Femoral Torsion (Femoral Anteversion) are two common causes of in-toeing in children
    • age dependent foot progression angle, medial rotation, and lateral rotation graphs are available (Nelsons, p.1699; Ped. Clinics of North America 33: 1373 (1986)

    2. Medial Tibial Torsion

    • is the most common cause of in-toeing in the 2nd year of life and the leading cause of in-toeing in toddlers
    • is usually bilateral
    • may be associated with Femoral Anteversion, genu varum, and/or Metatarsus Adductus

    CLINICAL FEATURES:

    1. Symptoms

    1. Standing

    • thighs, knees, and patellae are straight with the feet internally rotated
    • the medial malleolus is posterior to the lateral malleolus
    • the centre of gravity falls lateral to the 2nd metatarsal

    2. Gait

    • "pigeon-toed" or with in-toeing

    2. Signs

    1. Gait or Foot Progression Angle

    • angle between the line of walking progression and the long axis of the foot
    • a positive value between 5-10 degrees is normal
    • a negative value suggests in-toeing

    2. Thigh-Foot Angle

    • examine the child in the prone position (on stomach) with the knees flexed to 90 degrees; looking down on the soles and observe the angle between the longitudinal axis of the thigh and the long axis of the foot
    • normal value is zero
    • a value of >10 degrees suggests medial tibial torsion
    • this angle is usually negative at birth (out-toeing)

    INVESTIGATIONS:

    1. Skeletal X-Rays

    • not necessary for the diagnosis

    MANAGEMENT:

    1. Supportive

    • shoe modifications, long-leg braces, and twister cables are to be avoided
    • avoidance of knee-chest sleeping position does not alter the natural history
    • the use of a Denis-Browne splint at nighttime is controversial and may only accelerate the rate of resolution of the in-toeing but not the final outcome

    2. Surgery

    1. Tibial Rotational Osteotomy

    • only proven method to alter the rotational deformity
    • indications for: significant disability, association with a neuromuscular disorder, i.e., cerebral palsy
    • should not be considered until age 8 to allow for spontaneous lateral tibial torsion

    3. Prognosis

    • natural history is one of decreasing in-toeing due to lateral rotation of the tibia with increasing age
    • Medial Tibial Torsion which is familial or is associated with an underlying neuromuscular disorder is more likely to persist past 8 years of age and into adolescence
    • there is no evidence that uncorrected Medial Tibial Torsion produces arthritis, or walking or running disabilities


     

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