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CT assessment of children with in-toeing gait

Poster No.: C-0234

Congress: ECR 2011
Type: Educational Exhibit
Authors: 1 2 2 1 2
C. L. Holland , A. Kamil , A. Puttanna ; Walsall/UK, Birmingham/
Keywords: Pediatric, Musculoskeletal bone, CT, Diagnostic procedure,
Computer Applications-General
DOI: 10.1594/ecr2011/C-0234

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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.


• An in-toeing gait is a frequent complaint encountered by paediatric

orthopaedic surgeons in the UK. It is a physiological symptom causing a
pattern of gait that is often inefficient and limiting to function. There are also
cosmetic features created by the abnormal gait that cause concern for both
parents and the child. If unresolved the deformity can progress to worsening
internal rotation of the hip resulting in knocked knees, frequent tripping,
increased wearing away of shoes and have a negative effect on the child's
self esteem.

• 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

• Misalignment is more noticeable in toddlers and tends to improves with age.

It is important that pathological causes such as developmental dysplasia
of the hip and cerebral palsy are identified early as rapid treatment has a
positive effect on morbidity.

• Management is guided by the natural progression of the condition and is

dependent on the cause. For most physiological cases, assessment of the
progression of mal-alignment and successful formulation of a treatment plan
can be achieved solely through clinical examination of the rotational profile.
[3] Figure 2

• In more significant cases of deformity or when the cause is suspected

to be pathological, imaging proves to be more beneficial. This is of more
relevance if the clinician requires accurate assessment of the degree of
deformity to determine the necessity for surgical intervention.

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Images for this section:

Fig. 1: Rotational deformity at the proximal, middle and distal joints of the leg causing

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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:


General Electric Lightspeed VCT (64 slices per rotation)


Helical acquisition, Medium F.O.V (hips + knees), Small F.O.V (ankles).

120 kVp, 200mA smart mA (auto mA modulation), 0.8 second rotation

0.625mm slice thickness, pitch 0.531:1, table speed 10.62 mm/rotation

Patient position / Centring:

Feet 1st in to scanner, , legs extended, toes together and lightly restrained. Centre on
iliac crests. Scout from crests to below feet.

Average dose:

Dose Length Product - 50.45 mGy/cm.

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.

Measurement Of Femoral Anteversion

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• 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

Femoral Horizontal Angle Measurements

• 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

Measurement femoral condylar horizontal angles

• Measure the left and right independently.

• Ensuring the correct horizontal plane is selected to obtain accurate
• Normal values are between 15-20

• 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

• This is the twist of the tibia on its long axis

• o,
This angle increases from birth to adulthood, at birth measures 5 age 10
o, o o.
10 age 15 15 and adults 25-31
• If there is lateral rotation this is referred to as external torsion and the angles
expressed as a positive.
• If there is internal rotation this is medial tibial torsion and is expressed as a

Measurement of 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.

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• 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]

Measurement tibial torsion figure 5

• o
Right tibia; 26 - 1.2 = 24.8

• o
Left tibia; 29.6 - 6.9 = 22.7

• Rotation lateral therefore positive

Metatarsus Adductus

• This is usually clinically assessed so we do not include CT of the tarso-

metatarsal junction.
• If requested plain radiographs can demonstrate well the adduction of the
metatarsals with respect to the mid-tarsal axis.

Images for this section:

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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

Fig. 2: Measurement Femoral Horizontal Angle

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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

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Assessment of in toeing gait is a common clinical problem.

We have presented a simple CT method for assessment of excessive femoral

anteversion and increased internal tibial torsion that are common causative mechanism.

Personal Information

Dr C Louise Holland

Consultant Radiologist

Manor Hospital



Dr Anver Kamil


Russells Hall Hospital



Dr Amar Puttanna


University Hospital Coventry and Warwickshire



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