How To Address Pediatric Intoeing

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Continuing Education Course #149 — January 2007

I am pleased to introduce the latest article, “How To Address Pediatric Intoeing,” in our CE series. This series, brought to you by the North American Center for Continuing Medical Education (NACCME), consists of complimentary CE activities that qualify for one continuing education contact hour (.1 CEU). Readers will not be required to pay a processing fee for this course.
Given the diagnostic confusion and varying opinions on pediatric intoeing, Edwin Harris, DPM, reviews congenital etiologies as well as static skeletal abnormalities that may play a role. He also discusses treatment protocols for conditions ranging from talipes equinovarus to femoral antetorsion.
At the end of this article, you’ll find a 10-question exam. Please mark your responses on the enclosed postcard and return it to NACCME. This course will be posted on Podiatry Today’s Web site (www.podiatrytoday.com) roughly one month after the publication date. I hope this CE series contributes to your clinical skills.

Sincerely,

Jeff A. Hall
Executive Editor
Podiatry Today

INSTRUCTIONS: Physicians may receive one continuing education contact hour (.1 CEU) by reading the article on pg. 65 and successfully answering the questions on pg. 74. Use the enclosed card provided to submit your answers or log on to www.podiatrytoday.com and respond via fax to (610) 560-0502.
ACCREDITATION: NACCME is approved by the Council on Podiatric Medical Education as a sponsor of continuing education in podiatric medicine.
DESIGNATION: This activity is approved for 1 continuing education contact hour or .1 CEU.
DISCLOSURE POLICY: All faculty participating in Continuing Education programs sponsored by NACCME are expected to disclose to the audience any real or apparent conflicts of interest related to the content of their presentation.
DISCLOSURE STATEMENTS: Dr. Harris has disclosed that he has no significant financial relationship with any organization that could be perceived as a real or apparent conflict of interest in the context of the subject of his presentation.
GRADING: Answers to the CE exam will be graded by NACCME. Within 60 days, you will be advised that you have passed or failed the exam. A score of 70 percent or above will comprise a passing grade. A certificate will be awarded to participants who successfully complete the exam.
TARGET AUDIENCE: Podiatrists
RELEASE DATE: January 2007
EXPIRATION DATE: January 31, 2008
LEARNING OBJECTIVES: At the conclusion of this activity, participants should be able to:
• discuss the importance of the child’s history and neurological status in making a diagnosis;
• describe how congenital conditions, such as hallux varus and talipes equinovarus, may be etiologies for pediatric intoeing;
• review the potential impact of femoral antetorsion and tibial torsion;
• discuss possible treatment modalities for hallux varus in patients with intoeing; and
• discuss treatment considerations in cases of tibial torsion in which the condition does not resolve spontaneously.

Sponsored by the North American Center for Continuing Medical Education.

Here one can see hallux varus associated with a short first ray in a 4-month-old with a longitudinal epiphyseal bracket.
This 2-month-old female with metatarsus adductus has deep medial concavity that apexes at the first metatarsal base.
With talipes equinovarus, the forefoot is adducted, the rearfoot is inverted and the ankle is in equinus as shown above.
This 12-year-old male with Charcot-Marie-Tooth syndrome has an adducted forefoot, an inverted heel and cavoid medial arch.
In this example of internal tibial torsion, the knee is slightly externally rotated while the ankle and foot are internally rotated.
The same patient with internal tibial torsion, shown off-weightbearing, also has mild tibia varum.
Here one can see a 3-year-old female with femoral antetorsion. The right patella is internally rotated and the foot is slightly internally rotated to the line of progression. Swing phase of gait on the left is just beginning and the limb is already intern
74
Author(s): 
By Edwin Harris, DPM

      Intoeing is one of the most common pediatric gait disturbances. Prompted by parental concerns, it accounts for a large number of new patient specialist visits. Intoeing is not a diagnosis. It is a complaint and an objective finding on physical examination. In spite of the frequent occurrence of pediatric intoeing, clinical management is complicated by diagnostic confusion and difference of opinion on both the necessity for treatment and its effectiveness. Intoeing has been the topic of many publications directed both toward primary care physicians and parents. However, information expressed in these articles can be confusing to both groups.

      The essential question regarding the lower extremity causes of intoeing is whether they represent alterations in the shape and contour of a normal foot and limb or are true structural malformations.1-6 Some authors offer personal bias regarding the cause and treatment of intoeing. The opinions most often expressed are that treatment is not necessary, that most of the problems spontaneously correct on their own, and the benefits attributed to therapy are the result of natural resolution of the conditions as a part of their natural history.7-14 Other authors regard pediatric intoeing as alterations in physiologic developmental stages that have become pathological.5,15,16

      Although there are many causes for intoeing, a careful systematic approach will yield a diagnosis and a treatment plan in most cases.17 Organizing the causes for intoeing is simply a matter of considering the anatomical area or areas of potential involvement. It is important to keep in mind that the more common causes of intoeing outside the foot are deviations of normal development while the abnormalities in the foot are purely pathological. An understanding of the natural history of the various pathologies is also crucial in order to offer a correct diagnosis and prognosis as well as facilitate the development of a successful treatment plan.

      There are really only two broad categories of pathology to consider. Intoeing is most often caused by static skeletal abnormalities in one or several parts of the lower extremity. Less frequently, intoeing may result from a movement disorder. On some occasions, intoeing is caused by a combination of these two.

      The history of the complaint is very helpful in pinpointing the cause of intoeing. Clinicians should place special emphasis on how old the child is when the symptoms first develop. When intoeing is noticed at birth, it is usually the result of some adducting deformity within the foot. These deformities include hallux varus, talipes equinovarus, metatarsus adductus and the various forms of pes cavus. When one first notices intoeing between the ages of 1 and 2, it is most likely caused by abnormality in the tibiofibular segment.18 Intoeing beginning after 18 months is most likely caused by femoral antetorsion (anteversion) and issues within the pelvis.

      The child’s neurological status is critical to the diagnosis and treatment of intoeing. The developmental history identifies issues that might place the fetus at risk for central nervous system damage. These issues might include bleeding during early pregnancy, premature labor, difficulty in delivery, meconium aspiration, intracranial hemorrhage and post-delivery seizures. Static encephalopathy (cerebral palsy) is associated with a number of foot deformities.19 Acquisition of the major motor milestones at the appropriate times is a good indicator of normal central nervous system development.20

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