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Page 1 of 13
Learning objectives
Our poster is designed to provide a user friendly method for performing and interpreting
CT imaging in children with in-toeing gait who may require surgery.
Background
• In-toeing has a wide spectrum of causes that can affect the proximal, middle
and distal joints of the leg and usually varies with age. In infants the most
common cause is metatarsus adductus and after 2 years of age most
presentations result from internal tibial torsion. [1] This can lead to excessive
femoral anteversion which is usually observed in children at 3 years of age.
Femoral version is defined as the angular difference between axis of femoral
neck and transcondylar axis of the knee. Figure 1
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Images for this section:
Fig. 1: Rotational deformity at the proximal, middle and distal joints of the leg causing
in-toeing
Page 3 of 13
Fig. 2: Management plan for a child with in-toeing gait
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Imaging findings OR Procedure details
Patients are referred following formal orthopaedic assessment . Only patients suitable
for correctional surgery are considered. Technical factors were as follows:
Scanner:
Parameters:
Feet 1st in to scanner, , legs extended, toes together and lightly restrained. Centre on
iliac crests. Scout from crests to below feet.
Average dose:
Both AP and lateral scouts are needed for dose modulation. . 5mm Axial reconstructions
through the hips, knees and ankles are obtained. Angles were measured both on the CT
workstation and the PACS (GE). Figure 1
Leg length measurements were obtained from centres of femoral head to distal talar
pilion when requested.
Page 5 of 13
• Measuring the degree of rotation of the femoral bone around the shaft. [9]
• The proximal measurement is taken through the femoral neck.
• The distal along a tangent through the distal femoral condyles. Which is
used as a reproducible proxy for the transcondylar axis of the femur.
• The normal measurement is between 15-20
o
• Level selected where femoral necks are best seen. The sides need
considering separately.
• With the curved CT table it important to ensure a true horizontal baseline
relative to the whole pelvis.
• Slice selected reflecting the best representation of the femoral neck.
• Angle measured. Figure 2
• If the knees are internally rotated the angles are calculated by addition, see
Figure 3.
With the knees in external rotation, figure 4 the angles are calculated by subtraction
Tibial Torsion
• The proximal plane is a horizontal axis through the tibial plateau. Figure 4
• The distal axis is through the bimalleolar plane, figure 5.
Page 6 of 13
• This actually gives one the angle of talo-fibular torsion as the fibula is also
used in the measurements. A variety of other planes have been used [10].
However this is the preferred measurement for our clinicians. [10]
• o
Right tibia; 26 - 1.2 = 24.8
o
• o
Left tibia; 29.6 - 6.9 = 22.7
o
Metatarsus Adductus
Page 7 of 13
Fig. 1: AP and lateral scout case 1. Anatomically neutral positioned. As well as being used
for planning both leg length measurements and individual bone length measurements
can be obtained
Page 8 of 13
Fig. 3: Measurement tibial horizontal condyle angles. Note knees internally rotated.
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Fig. 4: Externally rotated knees
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Fig. 5: Measurement tibial torsion
Page 11 of 13
Conclusion
Personal Information
Dr C Louise Holland
Consultant Radiologist
Manor Hospital
Walsall
UK
Dr Anver Kamil
FY2
Dudley
UK
Dr Amar Puttanna
FY2
Coventry
UK
Page 12 of 13
References
7) Brody AS; Frush DP; Huda W; Brent RL; Radiation risk to children from computed
tomography
8) L C Baker and S K WheelerManaged care and technology diffusion: the case of MRI.
Health Affairs, Vol 17, Issue 5, 195-207 1998)
10) Jakob RP, Haertel M, Stüssi E. Tibial torsion calculated by computerized tomography
Page 13 of 13