pediatric orthopaedic

1. INTOEING GAIT
Shady Mahmoud
MRCS, Msc ortho
Assistant lecturer orthopaedist
Ain Shams University

2. Objectives:
• Identify the normal rotation of the lower extremity.
• Differentiate between physiological and pathological rotation of the
lower extremity.
• Discuss common causes of intoeing of the lower extremity.

3. Definition
• When a child walks, the feet will turn inward instead of panting
straight ahead.

5. Etiology
• Excessive femoral anteversion.
• Internal tibial torsion.
• Metatarsus adductus.

6. Evaluation (Staheli rotational profile)
• 1) Foot progression angle.

7. 2. Hip rotation

8. 3. Foot thigh angle

9. 4. Heel bisector 5.Transmalleolar angle

10. Red flags
• Intoeing is a common benign rotational variation seen in children.
• Red Flags to prompt further evaluation include:
Progressive deformity.
Limb length discrepancy (possible hip dysplasia).
Extreme limb rotational profiles and pain (possible malignancy or
fracture).
A positive family history for rickets, achondroplasia, skeletal
dysplasias, or mucopolysaccharidoses.

11. Etiology
• Excessive femoral anteversion.
• Internal tibial torsion.
• Metatarsus adductus.

12. Excessive femoral anteversion
• Definition: Femoral anteversion is the angle between the neck of the
femur and the shaft in the sagittal plane.
• It is the commonest cause of intoeing
between the age of 3 - 8.

13. • This angle is about 40 degree at birth and decreases when the child
start walking.
• In diseases which affect the child`s ability to walk (e.g. cerebral palsy),
the child continues to have a high angle of femoral anteversion.
It reaches the normal value (about 17 degree) by the age of 8.

14. Clinical picture
• May presents with apparent genu valgum.
• W position upon sitting.
• Patellae are facing inward
During gait.
• Awkward running style and
frequent falls.

15. • Examination will show that hip IR exceeds hip ER:
IR > 70 degree (n: 20-60)
ER < 20 degree (n: 30-60)

16. Anteversion degree
• Can be determined clinically using Craig test: the degree of hip IR when greater
trochanter is most prominent laterally.
• Radiologically using CT axial cut to the femoral neck in relation to femoral
condyles

17. Treatment
• No treatment is required: Parent reassurance.
• Usually resolves spontaneously around the age of 8.
• Bracing and orthotics don`t change the natural history of the disease.
• If the condition doesn't improve by the age of 9 and it is symptomatic
and severe : Femoral derotation osteotomy (rarely needed).

18. Derotation femoral osteotomy
• Can be performed at the intertrochanteric level, midshaft,
or supracondylar level.
• amount correction needed can be calculated by (IR-ER)/2.

19. Internal tibial torsion
• Definition: Inward rotation of the shaft of the tibia.
• It is considered a normal finding in newborn due to intra-uterine
position.
• It is the commonest cause of intoeing gait: usually seen in infants
around the age of 2 – 3.

20. • Diagnosed by a negative femoral thigh
angle > 15 degree. (n: 0 , +20).
• >-15 transmalleolar angle.

21. Treatment
• No treatment is required: Parent reassurance.
• Usually resolves spontaneously around the age of 6.
• Bracing and orthotics don`t change the natural history of the disease.
• If the condition doesn't improve by the age of 8 and it is
symptomatic: supramalleolar derotation osteotomy (rarely needed).

22. Metarsus adductus
• Definition: adduction and inward rotation of the forefoot in relation
to the hindfoot.

23. Classification
Classification by heel bisector method (Beck, JPO 1983)
• Normal: heel bisector line through 2nd and 3rd toe webspace.
• Mild: heel bisector line through 3rd toe.
• Moderate: heel bisector through 3rd and 4th toe webspace.
• Severe: heel bisector through 4th and 5th toe webspace.

24. Clinical picture
• Foot has a curved lateral border rather than straight one.
• May be associated with other conditions related to uterine
malposition (DDH and torticollis).
• Intoeing gait

25. • Differentiated from club foot by:
Absence of eqiunus.
Absent hindfoot varus.
• Differentiated from serpentine foot by:
Absence of hindfoot valgus.
Can respond to conservative treatment.

26. Treatment
• Most of the infants will improve without interference.
• Observation is recommended in the 1st 6 months of life.
• If the condition persists beyond 6 months
and the deformity is rigid, serial casting or bracing
may be required.
• Surgery is rarely indicated.

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