Tony,
This is an excellent question, and as a result of this discussion, I am
going to look at something that which haven't but should have. I will check
the malleolar position with relative to the knee joint axis, the malleolar
position relative to tibial tuberosity, and the range of rotation with the
knee flexed of the tibia. This will take me several years, as I don't have
a very large pediatric practice.
All this aside, I tend to think it is occurring at the knee. When the
concept of pseudomalleolar torsion came out, this was from the Philadelphia
college and Dr. Ganley. They performed knee range of motion and if it was
greater in internal rotation they called in pseudomalleolar torsion and
casted it. They also stopped talking about internal tibial torsion (lack of
external tibial torsion). What is interesting is that it was standard in
the podiatric colleges to teach that there was a 5 degree difference
between malleolar position and tibial position.
Regarding how the DB bars work, I think we are putting a mild torque on the
leg. I start out with the feet pointed straight ahead and have the child
wear it at night. This way the mother knows that if the child cries it is
because of something foreign being applied. After the first week we
increase the setting by about 10-15 degrees a week. Once in a while this
adjustment will cause pain in the child, and the child will not sleep until
the bar is taken off. Reapplication has the same result. So we decrease the
correction for a few weeks and then we can reapply with the increased
correction.
I am not sure the exact time that this process stops, but clinically I find
that at about 4 years, we have reached the maximum. I know this is not the
exact time and one of the more astute academicians will set me straight.
Regarding the tibia varum, it is present as a result of the intrauterine
position. The fat may make it seem less, but it is present nonetheless.
Respectfully,
Stanley
At 11:24 PM 11/21/04 +0000, you wrote:
>Stanley,
>In respect of pseudomalleolar torsion, isn't this a tibio-fibular rotation
>and doesn't the malleolar position continues to externally rotate for
>several years. A delay in ontogenic development does not necessarily mean
>that in the long term the rotation will not be achieved. In regard to the
>presence of tibial varum, this is primarily due to fat distribution, an X
>ray would show that the varus component is in fact much less than than is
>visually present.
>In regard to your statement, that DB bars alter sleep position and
>therefore enable normal derotation, this I can see as a
>possibility,however, using a splint to change sleeping position and using
>it to apply external torque to the tibia are two completely different concepts
>respectfully
>Tony
>
>________________________________
>
>From: A group for the academic discussion of current issues in podiatry on
>behalf of Dr. Stanley Beekman
>Sent: Sun 21/11/2004 20:56
>To: [log in to unmask]
>Subject: Re: Serial Casting for Internal Tibial Position
>
>
>Tony,
>
>Sorry I didn't make my self clear. What I originally wrote was "
>.....the knee has two basic movements. One is flexion-extension, and the
>other is internal rotation of the tibia with varus-external rotation of
>the tibia with valgus.
>Babies are born with an internal rotated tibia that is in varus, and they
>are supposed to externally rotate and go into a more valgus attitude. If
>at 18 months this has not occurred, then it is not unreasonable to use the
>Denis-Browne bar".
>
>I hoped to show that this motion does occur at the knee. I also wrote that:
>"...at the Philadelphia College with Dr. Ganley, part of the pediatric in
>toe evaluation was to check for rotation of the tibia with the knee bent
>to 90 degrees. If there was an excessive amount of internal rotation
>relative to external rotation, it was called pseudomalleolar torsion.
>
>At the New York College we didn't learn this, but I think this is a very
>important part of the evaluation. This reinforces that the in toe is
>coming from the knee.
>
>I agree that the tendency is to out grow the in toe from the knee, and
>when it is not, the prudent thing to do is to assist this. In my practice
>I look for the tibial varum with the lack of external malleolar position.
>If I see this then I realize the patient is just lagging behind. If I see
>the varus corrected and the lack of external malleolar position, then I
>think that there is something stopping the normal external out growing of
>this position. We typically help patients in this regard. If a patent has
>a tight gastrocnemius, we use night splints. If a patient has a tight
>external range of the knee, then we should use DB bars. One of the
>theories as to why the DB bar works is that it changes the sleeping
>position which prevents the normal derotation of the lower leg.
>
>Respectfully,
>
>Stanley
>
>
>
>
>
>At 07:35 PM 11/21/04 +0000, you wrote:
>
>
> Stanley, Kevin et al
> I can accept that if you apply an external torque to the lower
> limb, once the hip has reached it's end ROM and the knee has been
> externally rotated as far as it's soft tissue structure and bony
> architecture will allow it, you will eventually apply an external torque
> to the proximal end of the tibia, but where does your 'correction' take place?
> Stanley, you feel that the external rotation occurs at the knee,
> could you further explain this?
> My concern is that in applying an external torque in the lower
> limb, where in a young child the acetabulum in relation to the head and
> neck of femur is in an externally rotated position, which subsequently
> reduces form 60 degrees to approx 10 degrees ext. rotated, what effect
> this external torque will have on the natural ontogenic development? The
> knees being in a flexed position will allow further external rotation at
> the knee, but surely the force will be applied along the path of least
> resistance i.e. the hip!
> I find it very diffficult to comprehend the use of a "splint" in
> which there is no evidence to support it's use, and I do not doubt that
> lower limb external rotation occurs, but I find it unlikely to have
> occured within the tibia. For example a gait plate can alter an intoeing
> gait pattern by altering the line of progression, but it does not solve
> the underlying pathology.
> respectfully
> Tony Achilles
>
>
>
>
>
>
>
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