In-Toeing: A Primary Care Problem Referred to Pediatric Orthopaedic Clinic?

Saturday, October 26, 2013: 11:26 AM
Blue Spring (Hyatt Regency Orlando, formerly the Peabody)
John Sielatycki, MD1, William Hennrikus, MD2, Jennifer Slough2, Jane Hamp, RN2 and Cindy Reighard, NP2, (1)Orthopaedics, Vanderbilt College of Medicine, Nashville, TN, (2)Orthopaedics, Penn State College of Medicine, Hershey, PA

Purpose   'In-toeing' includes conditions such as metatarsus adductus (MTA), tibial torsion (TT), and femoral torsion (FT).  Parents and grandparents often seek medical evaluation for the child due to concerns that the condition is cosmetically disfiguring, may cause permanent musculoskeletal problems, or interfere with athletics. Most cases of in-toeing resolve spontaneously and require no treatment; however, to our knowledge the prevalence of in-toeing cases indicated for active treatment remains unknown.  The purpose of this study is to determine the percentage of in-toeing consults indicated for  treatment, to identify the percentage of consults that turn out to be another diagnosis, and to determine the percentage of in-toeing consults that could be cared for by a primary care physician.

Methods   143 consecutive patients referred with a new consult noted as “in-toeing” were studied. Active treatment was defined as casting for rigid metatarsus adductus and osteotomy for rotational abnormalities.  Each patient underwent a  history and physical exam to exclude neurologic disorders, osseous malformations, or inflammatory conditions.  A rotational profile was documented.  An explanation of the natural history of the disorder and a handout about the disorder were provided at each visit.  For some parents/grandparents displaying overabundant anxiety, a follow up evaluation was arranged for family reassurance and to minimize detrimental patient satisfaction scores.     

Results   143 patients were referred for ‘in-toeing.’  After the pediatric orthopaedic evaluation, 121 of 143 (85%)  patients  were confirmed with an ‘in-toeing diagnosis’.  61 (43%)  patients demonstrated  internal tibial torsion, 23 (16%)  internal femoral torsion,  12 (8%)  metatarsus adductus and 25 (17%) had a combination of TT, FA, or MTA.  No patient was indicated for casting or surgery.  74% of patients with in-toeing were discharged from care after the initial consultation and 18% after the first follow up visit.  8% of patients had more than 2 visits.  22 additional  patients who presented with ‘in-toeing’ on the consult were diagnosed with another condition. For example,  12 (8%) had flexible flat feet,  2 (1%)  physiologic genu varum, 3 (2%)  tight heel cords and  cerebral palsy, and 4 (3%) normal exams.   126 (88%) patients were referred from a primary care physician, 9 (6%) from a general orthopaedic surgeon, and 8 (6%) were self-referred.  The ave age was 4 years (range 2 mo to 13 years).   85 (59%) were female and 58 (41%) were male.  

Conclusion Casting or surgery for in-toeing disorders in childhood is rarely indicated.   25% of patients with received serial clinic visits in order to reassure the parents.   15% of patients actually had another diagnosis including 2% with a subtle neurologic diagnosis.  More than 95 % of patients could be readily managed by a primary care physician. The finding of this study have implications for pediatric musculoskeletal education, pediatric orthopaedic reimbursement under the Affordable Care Act, and pediatric orthopaedic workforce needs.