Femoral Anteversion

Aka: Femoral Anteversion, Medial Femoral Torsion, Femoral Antetorsion, Congenital Anteversion of Femur

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II. Epidemiology

  1. Femoral Anteversion is most common cause for In-Toeing for school aged children
  2. More common in girls (2:1)
  3. Most common onset ages 3-5 years (most severe for ages 4 to 7 years old)

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 (feet at either side of hips)
    2. Contrast with most children who would typically sit cross legged
    3. 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 (kissing Patellae)
    3. Results in a clumsy, Circumduction Gait
  3. Measure rotation of hip
    1. See Hip Rotation Evaluation in Children
    2. Increased internal hip rotation (60 to 90 degrees)
    3. Decreased external hip rotation (10 to 15 degrees)

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
  3. Femoral Rotational Osteotomy Indications
    1. Comorbid neuromuscular disease (e.g. Cerebral Palsy) or
    2. Severe functional Disability at age > 8 (0.1% of cases)
      1. Femoral Anteversion >50 degrees
      2. Internal rotation >80 degrees

X. Complications

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

XI. Course

  1. Spontaneously resolves to normal range in 80% of cases by age years
  2. Unlikely to resolve after age 8 years
  3. Compensatory lateral tibial torsion may occur

XII. Patient Resources

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

XIII. 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
  4. Rerucha (2017) Am Fam Physician 96(4): 226-33 [PubMed]

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