7/31/2019 Intoeing, Outtoeing and Leg Pain
1/17
Lizzie Doll, PGY-2University of Utah
7/31/2019 Intoeing, Outtoeing and Leg Pain
2/17
HPI: 4 yo girl who presents for assessment offrequent tripping.
Has some difficulty keeping up with kids her ownage
Also complains of night pain in her legs 3-4 timesper week, but doesnt interfere with activities
Denies any redness or swelling around the knees
Likes to W sit
7/31/2019 Intoeing, Outtoeing and Leg Pain
3/17
BIRTH HISTORY:Full-term vaginal delivery, 6 lbs. 6 oz.
DEVELOPMENTAL HISTORY:
Crawled at 9 monthsWalked at 11 months
All other milestones normlal
FAMILY HISTORY:
One grandmother was pigeon-toed and one unclewith clubfeet
7/31/2019 Intoeing, Outtoeing and Leg Pain
4/17
VS: age-appropriate, Wt: 17 kg (37%), Ht: 100.5 cm (7%)
GAIT:
Intoeing gait
Foot-progression angle: 30 degrees inward
Windmills with running
MUSCULOSKELETAL:No deformities of spine or upper extremities
Genu valgum
Internal rotation of hips: 90 degrees bilaterallyExternal rotation of hips: 15-20 degrees bilaterally
Tibial torsion: +5 degrees
Thigh-foot angle: +5 degrees
Feet: mild bilateral metatarsus adductus
7/31/2019 Intoeing, Outtoeing and Leg Pain
5/17
Infection/Infection-related
Septic arthritisOsteomyelitis
Reactive arthritis
Rheumatic fever
Lyme disease
Toxic synovitis
Trauma/Overuse FractureSoft-tissue injury
Osgood-Schlatter disease
HypermobilityMalignancy
Leukemia
Neuroblastoma
Bone tumors
Hematologic
HemophiliaSickle cell anemia
Inflammatory
Juvenile idiopathic arthritis
Systemic lupus erythematosus
Henoch Schnlein purpura
Orthopedic/Mechanical
Slipped capital femoral epiphysis
Legg-Calv-Perthes disease
Noninflammatory Growing painsFibromyalgia
Reflex sympathetic dystrophy
Conversion reaction
7/31/2019 Intoeing, Outtoeing and Leg Pain
6/17
Basic ScreeningComplete blood count
Differential count
Blood smear
Erythrocyte sedimentation rate
C-reactive proteinRadiographs
Further InvestigationsBlood (antinuclear antibody,rheumatoid factor, culture,viral/bacterial serology, creatinekinase, partial thromboplastintime, sickle cell screen,
immunoglobulins, complement)
Urinalysis
Synovial fluid (cell count, Gramstain, culture)
Tuberculin skin test
Imaging (bone scan,ultrasonography, computedtomography scan, magneticresonance imaging)
Bone marrow aspiration
Slitlamp examination of eyes
7/31/2019 Intoeing, Outtoeing and Leg Pain
7/17
Birth history
Developmental history
Sleeping posture
Sitting posture
Pain/Limp/Disability
History
7/31/2019 Intoeing, Outtoeing and Leg Pain
8/17
7/31/2019 Intoeing, Outtoeing and Leg Pain
9/17
Observe gait
Hip rotation while prone
Tibial torsion (thigh-foot angle)
Foot
Physical
7/31/2019 Intoeing, Outtoeing and Leg Pain
10/17
Natural history
Infant 40
ER > IR
Age 1 year 30
IR > ER
Adolescent 15IR = ER
7/31/2019 Intoeing, Outtoeing and Leg Pain
11/17
Infant 0
Age 1 year +5
Child +10
Adolescent +15-20
Natural history
7/31/2019 Intoeing, Outtoeing and Leg Pain
12/17
Hips
Femoralanteversion
LegInternal tibialtorsion
FeetMetatarsusadductus
7/31/2019 Intoeing, Outtoeing and Leg Pain
13/17
7/31/2019 Intoeing, Outtoeing and Leg Pain
14/17
7/31/2019 Intoeing, Outtoeing and Leg Pain
15/17
Internal Rotation External Rotation
7/31/2019 Intoeing, Outtoeing and Leg Pain
16/17
7/31/2019 Intoeing, Outtoeing and Leg Pain
17/17
Essentials of Musculoskeletal Care. John F.Sarwack, ed. 4th edition, 2010.
Nelson Textbook of Pediatrics. 19th edition,2011.
Tse SM, Laxer RM. Approach to acute limb painin childhood. Pediatrics in review / AmericanAcademy of Pediatrics. May 2006;27(5):170-
179.Thanks to Dr. Jacques DAstous, orthopedicsurgeon at Shriners for his help with this
presentation