Kevin, Stanley and all,
In regard to my concerns as to where external torques are applied, this may help.
Moreland MS. Morphological effects of torsion applied to
growing bone: an in-vivo study in rabbits. J Bone Joint Surg
1980;62B:230-7.
For internal tibial torsion, some
clinicians claim success in using the Dennis-Brown
splint but there has been no scientific proof of its
usefulness. In the rabbit tibial model, lateral rotation
forces have been shown to lead to angulation of the
cells within the zone of hypertrophy of the physis, but
no cortical remodelling occurs.In a similar rabbit
model, lateral rotation splinting changes the static
foot angle but does not change bone rotation, which
indicates that the 'correction' achieved occurs primarily
through the ankle joint, thus potentially damaging
the ankle joint.
Now I realise it's rabbits!!, but does not the same principle apply?
Tony Achilles
________________________________
From: A group for the academic discussion of current issues in podiatry on behalf of Dr. Stanley Beekman
Sent: Mon 22/11/2004 03:57
To: [log in to unmask]
Subject: Re: Serial Casting for Internal Tibial Position
Tony and colleagues,
I just want to add a few things to what I wrote first of all I appreciate
the fine line of questioning. This really helps to refine our thoughts in
this area. Secondly, I am still bothered by the article you quoted. I would
like to see it in its entirety, as I feel there is something that is
important in it even though I cannot agree with its conclusions. I will go
to the library tomorrow and get a copy to read. Finally, I have used the DB
bar since I was a student at NYCPM in 1974. When I was a clinician at the
Podopediatrics clinic at OCPM in 1978-1981, there were approximately 40
patient visits daily, mostly for "slewfootedness" and "flatfeet" and
subsequently in practice. I haven't seen the joint laxity that you are
rightfully concerned about. On the other hand, in a few severe cases,
another podiatrist (who will remain nameless) used twister cables. I had
the opportunity to evaluate these children, and it was enough to disgust
me. The subtalar/ankle joint had horizontal movement that I still remember
to this day. There was also transverse plane movement in the knee. Enough
to concern me about a lifetime of arthritis. So I am painfully aware of
your concerns.
By the way, while we are on the topic of in toe, I think I found that the
reason for internal femoral position. During my fellowship, I read
Fitzhugh's article on sitting position (I think here first name was
Margaret) written in the early 1900's. the question was why do these kids
sit in the "W" position? I noticed that most of these kids were also
clumsy, and when they started to walk (prior to developing the in toe),
they would fall forwards and hit their knees and then their head, or they
would fall backwards and hit their heads. It seems that they did not spend
the normal 2 weeks in the sitting position at 6 months prior to crawling
(the majority of these kids), or they took an exceptionally long time to
walk, so they spent an exceptionally long time in the kneeling position. It
seemed that the kids that sat but took a long time to walk did not have the
clumsiness. My hypothesis is that the sitting position wires the balance
and reflexes around the hips, so the child when he starts to walk can stick
out his butt and land there. The child that misses sitting and therefore
ends up kneeling gets wired around the knee, so when he loses his balance,
he flexes his knee, which results in the falling. The rest of the
hypothesis agrees with Fitzhugh. The treatment to get rid of the
clumsiness, in addition to treating the internal femoral position, is to
develop balance around the hips. I have the mother sit with the child and
roll a ball back and forth to the child while the child is in the sitting
position.
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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