II. Epidemiology

  1. Femoral Anteversion is most common cause for Toeing-In
  2. More common in girls (2:1)
  3. Most common onset ages 3-5 years

III. Definitions

  1. Anteverted hip (Femoral Anteversion)
    1. Femoral head significantly anterior to Femoral neck
    2. Associated with Toeing-In (normal in young child)
    3. Antetorsion used to describe abnormal anteversion
  2. Normal hip
    1. Femoral head slightly anterior to Femoral neck
  3. Retroverted hip
    1. Femoral head posterior to Femoral neck
    2. Associated with Toeing-Out

IV. Mechanism

  1. Excessive medial rotation of the femur
  2. Normal Femoral Neck Anteversion angles
    1. Adults: 15-25 degrees
    2. Children
      1. Age 3-12 months: 39 degrees
      2. Age 1-2 years: 31 degrees

V. Symptoms

  1. Standing appearance: "Kissing Patellae"
  2. Clumsy gait
    1. Running appearance: "Egg-Beater"
  3. In-Toeing feet ("Pigeon-Toed")
  4. Sitting position: "Inverted W"
    1. Sitting with hips flexed and internally rotated
    2. Does not worsen Femoral Anteversion

VI. Signs

  1. Observe lower extremity via tunnel view
    1. Create imaginary line longitudinally along femur
      1. Femoral neck
      2. Femoral shaft
      3. Midline Patella
      4. Webspace between second and third toes of foot
    2. Survey foot from level of iliac crest at Pelvis
      1. In-Toeing of foot suggests Femoral Anteversion
  2. Observe child's gait
    1. See Foot Progression Angle (Gait Rotational Angle)
    2. Patellae and feet point inward
  3. Measure external rotation of hip
    1. See Hip Rotation Evaluation in Children

VII. Differential Diagnosis

  1. See Toeing-In
  2. Infants
    1. Congenital Hip Dysplasia
    2. Cerebral Palsy or other neuromuscular disorder
  3. Toddlers
    1. Legg-Calve-Perthes Disease
  4. Teen and pre-teen
    1. Slipped Capital Femoral Epiphysis

VIII. Diagnosis

  1. Biplanar Radiography
    1. Used to Measure Femoral Anteversion

IX. Management

  1. Watchful waiting until age 8 years
  2. Avoid non-helpful measures
    1. Shoe Modifications
    2. Night splints
    3. Dennis-Browne splint
    4. Twister cables
    5. Passive StretchingExercises
    6. Physical Therapy

X. Management: Femoral Rotational Osteotomy Indications

  1. Severe functional Disability at age > 8 (0.1% of cases)
  2. Comorbid neuromuscular disease (e.g. Cerebral Palsy)

XI. Complications

  1. Chondromalacia Patellae (Patellofemoral Syndrome)
  2. No known association with hip or knee Arthritis
  3. Does not significantly affect Running or walking

XII. Course

  1. Spontaneously resolves to normal range in 95% cases
  2. Unlikely to resolve after age 8 years
  3. Compensatory lateral tibial torsion may occur

XIII. Patient Resources

  1. Hughston Sports Medicine Foundation
    1. http://www.hughston.com/hha/a_12_3_2.htm

XIV. References

  1. Pediatric Database Homepage by Alan Gandy, MD
    1. http://www.icondata.com/health/pedbase
  2. Hoppenfeld (1976) Physical Exam, Appleton-Lange
  3. Bates (1991) Physical Exam, Lippincott

Images: Related links to external sites (from Bing)

Related Studies (from Trip Database) Open in New Window