Slide 044 — Intoeing and Staheli rotational profile

Clean FRCS notes with inline figures

Clinical photo showing classic W sitting position

•I suspect the patient may be suffering or presenting with in-toe gait [PGO: fem anteversion]

History

Birth and perinatal history

•Developmental milestones

•Current problems: pain, limp, frequent tripping

•Onset and progression of intoeing

Examination

•Staheli rotational profile

•Femoral anteversion

•Hip ER/IR 20/70

•Craig’s test

•Tibial torsion

•Thigh foot angle -10 to 40

•Transmalleolar axis (when foot deformity+) → any negative is abnormal

•Heel bisector line – 2nd toe

•Foot progression angle: -5 to 20 deg

•Check spine, hips (DDH) and knees (blounts)

•Check ligamentous laxity

Management

•Once p. Neonate to childhood, there will be reduction in femoral anteversion and increase in tibial ER torsion

•→ Family may be interested to learn that the only effective treatment is to cut the femur, rotate it and fix it, which is a major surgical procedure with risks, for essentially a cosmetic problem

Indications for surgery:

•Thigh foot angle <-10 or >40

•Femoral anteversion >50 or hip IR >80

•+ disabling sx (rare as muscle balance improved into adulthood and it rarely presents a functional problem)

•Timing >10 yrs

•Femur: Intertrochanteric femoral osteotomy

•Tibial: supramalleolar tibial osteotomy

•Causes of intoe

•Infancy: MT adductus, tibial intorsion

•Toddler: tibial intorsion

•Childhood: femoral anteversion

•Pathological: DDH, CP, Blounts

•Causes of out toe

•Pes planus

•Femoral retroversion

•Infancy: hip ER contracture

•Later childhood: tibial extorsion

•Pathological: SCFE, Perthes, PFFD

Natural history of femoral version

•At birth: 30-40 anteversion

•Adult 8-15 anteversion

Natural history of tibia version (transmalleolar-thigh angle)

•at birth: 2-4 ER

•Adult: 10-20 ER

#	lvl	marL	indent	logical	original note line
1	0	None	None	0	Clinical photo showing classic W sitting position
2	0	None	None	0	I suspect the patient may be suffering or presenting with in-toe gait [PGO: fem anteversion]
3	0	None	None	0	Hx:
4	0	None	None	0	Birth and perinatal history
5	0	None	None	0	Developmental milestones
6	0	None	None	0	Current problems: pain, limp, frequent tripping
7	0	None	None	0	Onset and progression of intoeing
8	0	None	None	0	PE:
9	0	None	None	0	Staheli rotational profile
10	0	228600	-228600	1	Femoral anteversion
11	1	457200	0	1	Hip ER/IR 20/70
12	1	457200	0	1	Craig’s test
13	0	228600	-228600	1	Tibial torsion
14	1	457200	0	1	Thigh foot angle -10 to 40
15	1	457200	0	1	Transmalleolar axis (when foot deformity+) → any negative is abnormal
16	0	228600	-228600	1	Heel bisector line – 2nd toe
17	0	228600	-228600	1	Foot progression angle: -5 to 20 deg
18	0	0	0	0	Check spine, hips (DDH) and knees (blounts)
19	0	0	0	0	Check ligamentous laxity
20	0	0	0	0	Mx
21	0	0	0	0	Once p. Neonate to childhood, there will be reduction in femoral anteversion and increase in tibial ER torsion
22	0	0	0	0	→ Family may be interested to learn that the only effective treatment is to cut the femur, rotate it and fix it, which is a major surgical procedure with risks, for essentially a cosmetic problem
23	0	0	0	0	Indications for surgery:
24	0	171450	-171450	1	Thigh foot angle <-10 or >40
25	0	171450	-171450	1	Femoral anteversion >50 or hip IR >80
26	0	0	0	0	+ disabling sx (rare as muscle balance improved into adulthood and it rarely presents a functional problem)
27	0	0	0	0	Timing >10 yrs
28	0	0	0	0	Femur: Intertrochanteric femoral osteotomy
29	0	0	0	0	Tibial: supramalleolar tibial osteotomy
30	0	0	0	0	===================
31	0	0	0	0	Causes of intoe
32	1	457200	0	1	Infancy: MT adductus, tibial intorsion
33	1	457200	0	1	Toddler: tibial intorsion
34	1	457200	0	1	Childhood: femoral anteversion
35	0	0	0	0	Pathological: DDH, CP, Blounts
36	0	0	0	0	Causes of out toe
37	1	457200	0	1	Pes planus
38	1	457200	0	1	Femoral retroversion
39	1	457200	0	1	Infancy: hip ER contracture
40	1	457200	0	1	Later childhood: tibial extorsion
41	0	0	0	0	Pathological: SCFE, Perthes, PFFD
42	0	0	0	0	Natural history of femoral version
43	0	0	0	0	At birth: 30-40 anteversion
44	0	0	0	0	Adult 8-15 anteversion
45	0	0	0	0	Natural history of tibia version (transmalleolar-thigh angle)
46	0	0	0	0	at birth: 2-4 ER
47	0	0	0	0	Adult: 10-20 ER

#	semantic level	section?	rewritten line
1	0		Clinical photo showing classic W sitting position
2	1		I suspect the patient may be suffering or presenting with in-toe gait [PGO: fem anteversion]
3	0	yes	History
4	0	yes	Birth and perinatal history
5	1		Developmental milestones
6	1		Current problems: pain, limp, frequent tripping
7	1		Onset and progression of intoeing
8	0	yes	Examination
9	1		Staheli rotational profile
10	1		Femoral anteversion
11	1		Hip ER/IR 20/70
12	1		Craig’s test
13	1		Tibial torsion
14	1		Thigh foot angle -10 to 40
15	1		Transmalleolar axis (when foot deformity+) → any negative is abnormal
16	1		Heel bisector line – 2nd toe
17	1		Foot progression angle: -5 to 20 deg
18	1		Check spine, hips (DDH) and knees (blounts)
19	1		Check ligamentous laxity
20	0	yes	Management
21	1		Once p. Neonate to childhood, there will be reduction in femoral anteversion and increase in tibial ER torsion
22	1		→ Family may be interested to learn that the only effective treatment is to cut the femur, rotate it and fix it, which is a major surgical procedure with risks, for essentially a cosmetic problem
23	0	yes	Indications for surgery:
24	1		Thigh foot angle <-10 or >40
25	1		Femoral anteversion >50 or hip IR >80
26	1		+ disabling sx (rare as muscle balance improved into adulthood and it rarely presents a functional problem)
27	1		Timing >10 yrs
28	1		Femur: Intertrochanteric femoral osteotomy
29	1		Tibial: supramalleolar tibial osteotomy
30	0		——
31	1		Causes of intoe
32	1		Infancy: MT adductus, tibial intorsion
33	1		Toddler: tibial intorsion
34	1		Childhood: femoral anteversion
35	1		Pathological: DDH, CP, Blounts
36	1		Causes of out toe
37	1		Pes planus
38	1		Femoral retroversion
39	1		Infancy: hip ER contracture
40	1		Later childhood: tibial extorsion
41	1		Pathological: SCFE, Perthes, PFFD
42	0	yes	Natural history of femoral version
43	1		At birth: 30-40 anteversion
44	1		Adult 8-15 anteversion
45	0	yes	Natural history of tibia version (transmalleolar-thigh angle)
46	1		at birth: 2-4 ER
47	1		Adult: 10-20 ER

044. Intoeing and Staheli rotational profile

Clean FRCS notes with inline figures

Clinical photo showing classic W sitting position

History

Birth and perinatal history

Examination

Management

Indications for surgery:

Natural history of femoral version

Natural history of tibia version (transmalleolar-thigh angle)

Direct Q&A

Staheli rotational profile

At birth: 30-40 anteversion

Raw speaker-note hierarchy audit

Improved semantic hierarchy used for the study notes