Torsion

Signs and Symptoms

The term torsion refers to in-toeing and out-toeing.

In-toeing, or "pigeon toes," is a normal stage in childhood lower-limb development. In more than 95 percent of children who have in-toeing, their lower limbs eventually rotate out on their own by 10 years of age. At this point, the adult shape of the legs has set in, and no further improvement can be expected. In-toeing almost always gets better on its own and does not pose a problem during childhood or adulthood.

Out-toeing also can be a normal part of development. Unlike in-toeing, however, it doesn't spontaneously correct itself, for the lower limbs tend to rotate outward with growth rather than inward. At best, out-toeing stays the same as the child matures; at worst, it can become more pronounced. Out-toeing can get worse with age and can interfere with a child's ability to participate in physical activities, such as sports.

Diagnosis

In 95 percent of children, in-toeing corrects itself by the time the child is 10 years old. Because of this, children with symptoms are observed -- usually by their pediatricians -- until they are around 10 years old. This allows normal development to take its course, while looking out for potential problems. If significant in-toeing or out-toeing persists, you may want to consult an orthopedic surgeon.

Significant torsion is characterized by the following:

• Functional Problems -- In severe cases, the rotation of the lower limbs is so extreme that the child has difficulty running, playing and participating in normal childhood activities. Out-toeing is more likely to present functional problems than in-toeing. In fact, in-toeing may be a functional advantage as athletes tend to be in-toed more often than others.

• Unacceptable Appearance -- Your child may regard severe in-toeing or out-toeing as ugly, which may have negative effects on his or her body image and self-esteem. While it may be more acceptable to address a medical problem for functional reasons, appearance can't be ignored and needs to be factored into treatment decisions as well.

Treatment

Braces, special shoes and physical therapy aren't effective treatments for in-toeing or out-toeing.

Surgery is the only intervention that can alter the shape of the lower limbs in a child with in-toeing or out-toeing. The thighbone (femur) or other bones of the leg (the tibia and the fibula) are cut and rotated so that the feet align properly. Metal implants -- typically pins or a plate and screws - keep the bones in place while they heal in their new orientation.

This type of surgery is called rotational osteotomy. It is a major operation with the risk of complications that include:

• Bleeding and Infection -- These risks commonly are associated with orthopedic operations.

• Implant Failure -- The metal implants can dislodge from the bone. When this happens, the correction is lost and the implants must be replaced.

• Injury to the Blood Supply to the Hip -- While this occurs in well under 10 percent of the children who undergo surgery, it can have devastating consequences to hip function, including painful arthritis and stiffness.

Although surgery is the only way to change severe in-toeing or out-toeing, the benefits have to be carefully weighed against the risks for each child.