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Special Test

Femoral Anteversion

Excessive femoral anteversion has been believed to be a cause of in-toed gait in children, which is a common complaint. The proximal femoral torsional profile (the femoral anteversion) changes in growing children.

The parents may complain that their child is sitting in a “W” posture.

Children have the maximum amount of anteversion at birth, and it gradually decreases as the child approaches adulthood. The mean anteversion at birth is about 40°, and it comes down to a value of around 15° in adulthood. Failure of this gradual decrease results in an in-toeing gait.

“W”-sitting in a child
“W”-sitting in a child
in toeing
In-toeing

Femoral Anteversion Measuring

Clinically, the increased femoral anteversion can be estimated by Craig’s test.

Another method of estimating whether the anteversion is appropriate for the age of the child is by measuring the internal rotation and external rotation of the hip. This is performed with the patient prone.

Internal rotationexternal rotation measurement
Internal rotation/external rotation measurement of hip joint in a prone position. In children with exaggerated anteversion, internal rotation is more than the external rotation.

Staheli and colleagues have reported that infants have an average of 40° of internal rotation (range 10–60°) and 70° of external rotation (range 45–90°) at the hip joint. There is a gradual change in these values, and by the age of 10 years, internal hip rotation averages 50° (range 25–65°) and external rotation 45° (range 25–65°).

Thus, if a child has an internal rotation measuring more than 70° at 10 years of age, then it is an indicator of increased femoral torsion, and further clinical and radiological evaluation must be done.

Confirmation of the same is best estimated by CT scan or MRI studies.

It has been suggested that children with a normal gait and children who in-toe have a gradual reduction in femoral anteversion between 7 and 14 years of age. While most children with in-toeing gait can be managed non-operatively, there are a few who can be offered a femoral osteotomy.

See Also: Craig’s test
Femoral Anteversion in toeing

Staheli has concluded that surgery can be offered if:

  1. The child has age >8 years;
  2. Deformity resulting in a significant cosmetic and functional disability;
  3. Anteversion >50°;
  4. Internal rotation of hip >85°
  5. External rotation <10°;
  6. If the family consents after being made aware of the risks of the procedure.

Summary of the Femoral Anteversion Values in Children at Different Ages

AgeFemoral Anteversion
3–12 months40° (mean)
At 2 years31° (mean)
3–10 yearsMean decrease of around 1–2° per year
10–14 yearsAround 20° (mean)
At 16 yearsAround 16° (mean)
Summary of the Femoral Anteversion Values in Children at Different Ages
Femoral Anteversion progression
Femoral Anteversion progression

References

  1. Staheli LT, Corbett M, Wyss C, King H. Lower-extremity rotational problems in children. Normal values to guide management. J Bone Joint Surg Am. 1985 Jan;67(1):39-47. PMID: 3968103.
  2. Fabry G, MacEwen GD, Shands AR Jr. Torsion of the femur. A follow-up study in normal and abnormal conditions. J Bone Joint Surg Am 1973;55:1726.
  3. Shands AR Jr, Steele MK. Torsion of the femur; a follow-up report on the use of the Dunlap method for its determination. J Bone Joint Surg Am 1958;40:803.
  4. Crane L. Femoral torsion and its relation to toeing-in and toeing-out. J Bone Joint Surg Am 1959;41:423.
  5. Matovinović D, Nemec B, Gulan G, et al. Comparison in regression of femoral neck anteversion in children with normal, intoeing and outtoeing gait prospective study. Coll Antropol 1998;22:525.
  6. Staheli LT. Torsion—treatment indications. Clin Orthop Relat Res 1989;247:61.
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