CLINICAL ORTHOPAEDICS AND RELATED RESEARCH
Number 302,pp. 22-26
Normal and Abnormal Torsional
Development in Children
Guy Fabry, M.D., Ph.D., Liu Xue Cheng, M.D.,
and Guy Molenaers, M.D.
This study presents findings in a series of 123
children with intoeing gait. The intoeing was
caused by increased femoral anteversion
(IFA) in 70% of the cases, and internal tibial
torsion (I") in 30%. Rotation of the hips,
thigh-foot angle, Q-angle, and computed to-
mography measured anteversion and tibial
torsion divided the two groups very clearly.
In the IFA group, 40.3% of the patients pre-
sented with an externally rotated tibia and
59.7% had an internally rotated tibia. In the
IT" group, the anteversion was normal for
age and the tibial torsion was significantly
decreased. Eighty children who corrected
their intoeing gait, and of whom 83.4% had
IFA, were also reviewed: a decrease in ante-
version was observed in 20.5% of the pa-
tients; 62.9% showed no decrease in antever-
sion.
In an article published 20 years ago," 864
anteversion studies were performed in 432
normal children from one to 16 years old
using the Dunlap-Shands m e t h ~ d .These
~ dren with rotational abnormalities was
studies showed a decrease in anteversion
from an average of 32' at age one to 16'
From Orthopaedic Department, University Hospital
Pellenberg, Katholieke Universiteit Leuven, Belgium.
Reprint requests to Guy Fabry, M.D., University Hos-
pital, Orthopaedic Department, Weligerveld 1, B-3212
Pellenberg, Belgium.
Received: September 16, 1993.
Revised: November 18, 1993.
Accepted: November 22, 1993.
22
8 1994 J. 8. Lippincott Company
at age 16 (Fig. 1). Children with intoeing
showed an average anteversion of 42.68'
compared with an average of 24.14' in the
normal group. The children with intoeing
were reevaluated after an average follow-up
time of five years six months (154 hips).
They showed no significant decrease in
anteversion, which averaged 39.48". It was
noted that after the age of eight no signifi-
cant change in anteversion occurred. The
study also showed that conservative treat-
ment did not effectively alter the antever-
sion. An additional important finding was a
compensatory external rotation of the tibia
(ERT) that created a malalignment of the
patella in 30% of children in the first group
and 50% in the second group.
A review of the literature shows that
the findings of this early article have not
been challenged significantly, and, to the
authors' knowledge, no other large series
has been published. A review of 125 chil-
published by Cahuzac et al.,' classifying
them clinically according to their gait
pattern. They observed that 30% walked
with internal rotation of the knees and
outtoeing feet, resulting in compensatory
ERT.
Svenningsen et al. l 3 studied hip rotation
and intoeing gait in 761 normal subjects,
from age four years to adult. Sixteen percent
of the subjects had an intoeing gait, decreas-
Number 302
May, 1994 Torsional Development in Children 23

AGE IN YEARS

Fig. 1. Normal anteversion (N) and comparison of femoral torsion in 154 hips in 77 patients with
intoeing (2) after five years six months' follow-up time (1 = first study, 2 = after follow-up, N =
normal). (Reprinted with permission from Fabry, G., MacEwen, G. D., and Shands, Jr., A. R.: Torsion
of the femur. J. Bone Joint. Surg. 55A:1726, 1993.)

ing in frequency from 30% in the four-year- anterior knee pain in adolescents in view of
old group to 4% in adults. They report a rotational deformities of the leg^.^,'^^,'^ The
significant correlation between intoeing and problem of possible secondary changes in
increased internal hip rotation or decreased knees and hips is far from elucidated. In-
external hip rotation. The decrease in inter- creased anteversion does not correct fully
nal hip rotation with age was very similar to with age and malrotation at the knee seems
that found for femoral anteversion in normal to be frequent. In this paper, a recent study
subjects in the authors' original study.4 on a series of children with intoeing gait,
Svenningsen et al. studied 30 children with a more detailed analysis of the different
with intoeing who showed a decrease of components of the deformity, is presented.
anteversion from an average of 42" at age
seven to 28" at age 16, suggesting that sig-
nificant regression of the anteversion can MATERIALS AND METHODS
occur after eight years of age. The internal A consecutive group of 123 children was ana-
rotation of the hips also decreased, but not lyzed during a period of approximately six
to normal values, and correlated with the months for torsion problems of the lower ex-
increased anteversion. They conclude that
all but five of the 30 children had a normal
gait at the last examination, suggesting that TABLE 1. Characteristics of All
Subjects
with increased anteversion, most of the cor-
rection has occurred at the tibial level.
NO. of Average age Gender
These findings differ from those of the cur- Group Limbs (Yeam) M F
rent authors' earlier study. However, they
point out that this series was much smaller IFA 124 6.9 ? 2.9 43 43
and that anteversion at age 16 is still ITT 43 6.9 2 2.7 18 19
abnormal. COR 54 8.2 -c 2.8 36 44
The problem of compensatory external IFA, increased femoral anteversion; ITT,internal tibial torsion;
tibial rotation has led many authors to study COR, spontaneously corrected intoeing gait.
 Clinical Orthopaedics
24 Fabry et al. and Related Research

TABLE 2. Clinical and Computed Tomographic

Measurements

Sign IFA In COR

MR 73.2 2 12.4 53.5 2 8.7 61.8 ? 14.4
LR 19.9 5 11.6 32.4 f 10.5 29.1 t 9.8
TFA -4.3 t 10.3 -13.2 2 10.2 2.3 t 8.2
Q-angle 16.2 % 5.8 13.2 2 6.2 16.9 2 5.8
AV 39.1 t 7.9 24.0 2 5.6
TT 12.6 t 11.8 -5.3 2 9.6

MR.medial rotation of the hip; LR. lateral rotation of the hip; TFA, thigh-foot angle; AV, anteversion;
V, tibial torsion; IFA, increased femoral anteversion; In.internal tibial torsion; COR, spontaneously
corrected intoeing gait.

tremities. One hundred twenty-four limbs
showed an increased femoral anteversion (IFA)
and 43 an increased internal tibial torsion ( I n ) .
We also reviewed 80 children with intoeing who
corrected their gait during a mean period of 5.2
years (Table 1).
Clinical evaluation included the determina-
tion of medial (MR) and lateral rotation (LR) of
the hip in prone position with the knee flexed,
the thigh-foot angle (TFA), and the Q-angle.
Radiographic measurements included deter-
mination by computed tomography (CT) scan of
the anteversion according to Weiner et al.," and
the tibial torsion ('IT) according to Jacob e l a[.'
The current authors established normal antever-
sion of 24" based on values from their original
a r t i ~ l e Normal
.~ tibial torsion is 30".'
LR in the IFA group; in the ITT group, MR
and LR are within normal limits. The TFA
is low normal in the IFA group, but less
than normal in the ITT group.
The Q-angle is increased in the IFA and
I'IT group, although less so in the latter.
The anteversion is significantly increased in
the IFA group and normal for age in the
ITT group. The TI' is less than normal in
the IFA group and significantly decreased
in the I'IT group.
In the correction group, there is also a
large discrepancy between MR and LR; the
TFA is low normal, but the Q-angle is
clearly increased. No CT measurements
were done in this group because of radiation
hazards to the children. Clinical rotation

RESULTS
TABLE 3. Comparison by Student's
Table 1 documents the characteristics of all of Two
subjects. Only the pathologic limbs were
considered for further analysis, as normal Probability
values have been well established in previ- IRT ERT of Similarity
ous publications. The average age of the
groups did not vary significantly, except for MR 73.0 510.8 74.6 i7 12.1 0.79
LR 22.2 +-
11.4 16.5 t 10.2 0.14
an older age for the correction group. Male-
Q-angle 14.9 t 5.6 16.2 5 5.3 0.006
female distribution was almost even. TFA -9.0 t 8.5 0.1 2 6.6 0.00
The distribution of intoeing patients ac- 38.2 2 7.8 40.6 % 8.2 0.81
cording to the pathology is as follows: IFA, TT 5.3 t 7.9 21.6 t 9.9 0.00
70%; I n , 30%. The clinical and CT mea-
surements are listed in Table 2. mereis a IRT, internalrotation tibia; ERT, externalrotation tibia: MR,medial
rotation of the hip; LR, lateral rotation of the hip; TFA, thigh-foot
significant increase in MR and decrease in angle; AV, anteversion; n, tibial torsion.
Number 302
May, 1994
-P
U
c
50
.-0 40
Q
>
Q
IFA
5
c
30
.c
0
-m
0 2o
c 1- Normal
I
10
0 4 8 12 16
Fig. 2. Comparison of anteversion of the IFA
versus normal group.
measurements correlated very well with ra-
diographic determination^.^^'^
In the correction group, 83.4% of patients
with intoeing had IFA. A decrease in antever-
sion was observed in 11 patients (20.5%),
and 34 (62.9%) patients developed compen-
satory ERT. Seven patients with ITT and two
with metatarsus adductus showed a correc-
tion of their deformity.
The IFA group was divided into two sub-
groups, IRT and ERT. The IRT group (74
limbs) walked with internally rotated knees
and feet, the ERT group (50 limbs) with
internally rotated knees and straight forward
or outward pointing feet.
Table 3 lists the different measurements
in the two subgroups. Medial rotation, LR,
and anteversion remain abnormal as ex-
pected, with no difference between the two
groups. There is a significantly higher Q-
angle, TFA, and TT in the ERT group. The
data were evaluated by Student's t-test.
DISCUSSION
The primary cause of intoeing in midchild-
hood is IFA and less frequently ITT.The
authors' study shows a frequency of 70%
and 30% respectively at an average age of
seven years. The I l T usually corrects spon-
taneously before age seven." Figure 2
shows the degrees of anteversion of the IFA
Torsional Development in Children 25
IFA
I
20 0 3 6 9 12 15
Fig. 3. Comparison of tibial torsion in IFA and
I l T groups.
group, plotted against the normal curve.
Again, no significant decrease in antever-
sion appears to occur after age eight. The
comparison of tibial torsion in the IFA and
the ITT group is interesting. In the latter
group, the TT has a slight tendency to de-
crease, and in the former a definite increase
of TT occurs with age (Fig. 3). This is also
reflected in the ERT subgroup (Table 3),
with a very significant increase in external
tibial torsion, causing the Q-angle to in-
crease and the intoeing gait to correct. Fifty
limbs (40.3%) in the IFA group presented
with this deformity. This is a somewhat
higher percentage than the 30% of Cahuzac
et aL2
According to Staheli et aZ.," the mean
ntMR is 50" in male and 40" in female pa-
tients. The mean LR is 45" (range, 25'45")
in both genders. The mean TFA is 10"
(range, -5"-30"). Tibia1 torsion averages
20" (range, 0'45"). All data refer to mid-
childhood (approximately seven years of
age). The tibial torsion measured by CT av-
erages 30". The Q-angle, as determined by
Brattstrom,' averages 8" to 10" in male, and
10" to 20" in female patients. According to
Hughston and Walsh? however, a Q-angle
of more than 10" is considered pathologic.
The mean age of the ERT group is one
year older than the IRT group. External rota-
tion of the tibia is present at all ages, and

26 Fabry et al.
does not show a tendency to decrease. Of
the children reviewed after their intoeing
gait had been corrected, in 34 (75.5% of
the 45 children with IFA) it occurred by
compensatory ERT. A substantial number
of children with IFA develop torsional
malalignment syndrome with an increased
Q-angle and possible consequences for the
knee function. Correction of either the ante-
version or the ERT does not seem to occur.
Since it is not yet clear what the conse-
quences of an uncorrected anteversion or
malalignment for the knee or hip are, thera-
peutic restraint is indicated. However, once
malalignment has occurred it is irreversible.
When anteversion in excess of 50" with ex-
tremes of MR and LR of the hip is diag-
nosed, it should be corrected before ERT
occurs (usually after eight years of age).
Once rotational malalignment of the limb
occurs, correction at two levels should only
be considered in severe cases, or in those
patients with painful knees.
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