Johns Hopkins Pediatric Orthopaedics Patient Guide to Internal Tibial Torsion

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What is Internal Tibial Torsion?

Internal tibial torsion is a condition in which the tibia (the larger of the two bones going from the knee to the ankle, forming the shin) is rotated inwardly (internally) or outwardly (externally) along its long axis. The rotation of the tibia also causes the foot and ankle to be rotated. Such rotation is seen throughout the course of normal development, but too much rotation is considered a developmental abnormality.

What causes Internal Tibial Torsion?

It is believed that a variety of genetic factors as well as how the fetus was positioned inside the uterus can lead to internal tibial torsion. The exact cause is not known.

What are the Signs and Symptoms?

A parent usually notices a strange appearance in the movement of a child's affected leg when he or she begins to walk. It is often not picked up sooner, especially if the child is the first born, because parents have not witnessed what the natural rotation and angles are in a normal growing child.

The parents of a patient with internal tibial torsion may also notice that the child is tripping and falling to a considerable degree. The patient may rarely complain of pain. Limping has never been reported and is not associated with this condition.

Can internal tibial torsion be confused with other conditions?
Yes. There are several other conditions that can cause "in-toeing" (walking with the toes turned inwards) and a similar clinical picture. A trained physician, however, can rule these out with a careful physical examination. For example, cerebral palsy might cause a similar abnormality, but these children normally do not walk by striking the ground with the heel and then rolling the weight of the body towards the toes. In developmental dysplasia of the hip, there may also be in-toeing, but this is associated with a limp (see Patient Guide to Hip Developmental Dysplasia). As mentioned above, a limp is never seen in internal tibial torsion.

The pediatric orthopaedic surgeon normally measures tibial torsion with an exam of certain angles in the leg. This can give him or her and idea of the presence or severity of the torsion.

What is the treatment?

The treatment, as with many other pediatric conditions and disorders, depends on the severity of the abnormality. In most cases, the child will simply be followed without a special treatment to see if it naturally disappears. Surgery may be performed if the rotation is so severe that the doctor can be sure that it will not naturally go away. Surgery is seldom needed before 5 years of age except in children with cerebral palsy, especially if there is an injury to the soft tissue (i.e. tissue that is not hard like bone). It should be put off until the child is at least 8 years of age.

The procedure most commonly performed is called a "derotational osteotomy." This consists of intentionally cutting the tibia bone ("osteotomy") near the ankle and rotating it back into a more normal position ("derotation"). The tibia is then fixed with hardware into the more normal position and often placed in a cast until the bone is healed.

The derotational osteotomy is usually performed when there is internal rotation of 35 degrees or more. Surgery is to be avoided when possible because of the potential complications it can cause. These include injuries to the growth plate if the osteotomy is done in the wrong place, failure of the intentional break to heal, and problems with the hardware used to hold the fracture in place.

How often should I see the doctor about this condition?

It is recommended that your child see a doctor once each year so that he or she can document the expected changes in rotation as the child grows.

What is the prognosis of this condition?

As mentioned above, the prognosis is good. Natural rotation with development after birth tends to correct tibial torsion so that no surgery is needed.

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