Paediatric orthopaedics for GPs: when to refer in-toeing, bow legs, knock knees and the slipped hip (SCFE)

Speaker 2 (presenter)

Dr Jeff Donald (name as captured by ASR, spelling unconfirmed) — paediatric orthopaedic surgeon. He says he treats “the lion’s share of severe slips in Brisbane”, that his team at “the Kids Hospital” performed the first subcapital realignment osteotomy for SCFE in Australia in 2008, and that he trained as a fellow at a UK hospital the ASR renders as “Great Wall Street” (probably Great Ormond Street — not confirmed).

Speaker 1 (chair)

Introduces the talk as “when to refer to the orthopaedic surgeon” and names the presenter as “Dr Jeff Donald”. Not otherwise identified.

Speaker 3 / unknown speakers

Brief audience comments near the end; no questions were captured.

Session context

Otter title Pediatric Orthopedic Surgery Seminar · id hm75VFg4X8AFR85bp5bNR_Zs8NU · ~24 min, recorded 14 March 2026 1:39 pm AEST. Slides (graphs, X-rays, MRIs, clinical photos) were shown but not captured. He refers to an earlier talk by “Mr Fowler” (name as captured) at the same meeting. No sponsor is named on this transcript.

Key messages for GPs

• In-toeing, bow legs, knock knees and flat feet are very common and usually normal. In his words, it is “when it is not getting better” that you refer.
• Age eight is the theme. Most of the natural correction of femoral anteversion and internal tibial torsion happens in the first eight years; whatever is left after eight “is not going to really change much”.
• W-sitting is not pathological. Children with high femoral anteversion sit that way because it is comfortable for them — there is no need to stop it.
• Persistent anteversion can cause real problems in older children: tripping, anterior knee pain, patellar instability, hip or trochanteric pain, and possibly knee arthritis later. Ask for a rotational profile, not just an MRI of the knee.
• “Don’t operate on kids’ feet” — metatarsus adductus is not a surgical condition in children.
• Bow legs are normal up to about two; children should be knock-kneed by three to four. Bow legs after three, or knock knees still present at about eight, deserve review (and think of rickets).
• SCFE: unexplained knee or thigh pain in an adolescent is a hip until proven otherwise. Check internal rotation of the hip. Caught early it is a simple pin; caught late it is a major operation with a risk of avascular necrosis.

In-toeing: three causes, one magic age

He opened with a few fracture slides (the everyday work of “weekends and nighttimes”: supracondylar, proximal humerus and femoral fractures), then moved to the lower-limb presentations GPs see most: in-toeing, knock knees, bow legs and flat feet.

In-toeing has three common causes, from the top down:

1. Femoral anteversion (the thigh bone is twisted forward at the hip),
2. Internal tibial torsion (the shin bone is twisted inwards), and
3. Metatarsus adductus (the front of the foot curves inwards).

Some children are “unlucky enough to have all three” and look “funky when you walk” — “but just because you look funky and you’re only three years of age doesn’t mean it’s not gonna get better.”

Femoral anteversion and W-sitting

Anteversion describes the forward twist of the femoral neck relative to the knee. The more anteverted the femur, “the more in-toed you become”. That is normal for little kids:

• Babies have high femoral anteversion — about 40° — which improves to 12–15° by skeletal maturity.
• The twist is not finished at birth because it is part of how we develop to stand and walk; the unwinding continues through childhood, particularly in the first eight years.
• After eight there is little further change through to the end of growth (he said about 13 for girls and 16 for boys). So “if they’ve still got persistent femoral anteversion after eight, that’s tough.”
• As anteversion falls, hip external rotation increases, ending at roughly a 50/50 split of internal and external rotation in adults.

History lesson: before the natural history was understood, children were put in braces (the ASR’s “Forest County” is probably a Forrest Gump–style leg-brace reference) — “treating things that got better on their own, treating natural history.”

When anteversion persists: symptoms and work-up

Anteversion is not necessarily benign if it lasts into the teens and adulthood. He listed the presentations:

• In-toeing itself, with tripping, clumsiness and injuries;
• Anterior knee pain, often every time they run — “which for years we didn’t worry about”;
• Patellofemoral instability — maltracking, subluxation or dislocation;
• Hip pain, or pain over the greater trochanter, because the trochanter sits in a different position and irritates the ITB;
• Long-term, joint wear — particularly arthritis of the knee.

A practical question he asks: “Can you play a whole game?” Most children can; how much pain they have afterwards helps gauge severity.

Ask for a rotational profile

His main investigation tip: “We always get lots of MRIs of the joint, but we never ask for a rotational profile, which is what I would do most of the time.” Many of these children have a structurally normal knee on MRI — the problem is the twist above and below it. The rotational profile report gives numbers for femoral anteversion and tibial torsion. The figures he quoted:

Transcript caveat: the imaging modality is not fully clear — he says “a MRI scan of that sort of knee with a rotational profile”. The Otter summary mentions rotational X-ray measurements; check what your local radiology offers (CT or MRI rotational studies) before ordering.

Derotation surgery and recovery

For a symptomatic older child with persistent anteversion, the fix is a femoral derotation osteotomy held with a plate and screws. It “looks pretty nasty” on X-ray, but:

• It is done through a small incision; the muscle is not cut — it is lifted off the intermuscular septum, the bone is corrected, and the muscle is laid back down.
• A couple of nights in hospital.
• Crutches at first, with progressive weight-bearing over 4–6 weeks.
• Pain relief usually for about 5–7 days.
• The dressing is left alone (“we don’t touch the dressing”).
• From about six weeks, a return-to-sport program from roughly 6 to 12 weeks, focusing on getting the hip abductors working properly again.

Transcript caveat: the ASR then says “really want to take them to operation by three months”. The Otter summary turns this into “treating femoral anteversion by age three”, which contradicts the rest of the talk (wait until after eight). The most likely meaning is back to sport by about three months after surgery — not confirmed.

Tibial torsion

• Internal tibial torsion is normal in little kids and usually resolves. “If you’ve got internal tibial torsion, we wait until eight before you do anything, because [it gets] better in most kids” — it is the ones that have not improved that matter. Recovery after correction follows the same timeframe as the femoral operation.
• External tibial torsion is much rarer. Because the limbs naturally rotate outwards as we grow, children who already have a lot of “turn-out” at a young age are tricky: if you fix them, there is a high relapse rate, unlike internal torsion.

Metatarsus adductus (and flat feet)

Metatarsus adductus is “a bit of a hard problem, because we don’t operate on the feet”. Surgery on children’s feet makes a scar and the joints get very stiff — his rule of thumb is don’t operate on kids’ feet. The talk did not go into non-operative options (stretching, casting or footwear were not discussed).

Flat feet were listed among the common presentations at the start but were not discussed further.

Bow legs and knock knees

He showed a freely available published chart of the development of the tibiofemoral angle (said to be from the 1970s; about 1,000 children). The pattern, as he described it:

• Bow legs (genu varum) are normal in the first two years.
• Children are about straight at two, then become knock-kneed (genu valgum) — quite noticeably by three to four, which is normal.
• Adult alignment is not reached until about six; knock knees are normal “up until about six anyway”.

What this means for timing

• Bow legs “can be treated at any time after three, because they should be knock-kneed by that stage.”
• Knock knees: “you wait until they’re older, because it might just correct.” If a child is still knock-kneed at about eight (ASR says “80 years of age”), “probably it’s not gonna get better.”
• He noted that the large majority (he said “over 90%”) of children with these alignment and rotational variants get better by about age eight; only a minority have an ongoing issue (passage garbled).
• Parents “can get quite stressed about this” — he showed an older boy whose parents noticed the problem in a photo of him standing next to others at basketball (details garbled).

Guided growth with 8-plates

• Who: genu varum treated in children over about three; genu valgum more often in pre-teens.
• How: coronal-plane deformities are corrected with guided growth using small plates (ASR “P plates / a plates / penny plates” — almost certainly 8-plates), placed on one side of the growth plate. It is fairly minimally invasive — “a bit like braces” for teeth, steering growth rather than cutting bone.
• Where: plates can go on the tibia or femur; “most of the time” he treats on the femur “because it’s faster, more growth”.
• When plates fail: sometimes an 8-plate cannot correct the deformity — “because it is a growth plate problem” — and a bigger operation is needed (ASR unclear on exactly which procedure).
• Lesson from history: before the natural-history data were published, “we treated a whole lot of these kids unnecessarily.”

Editor’s note (not from the talk): guided growth needs remaining growth, which is why timing before the end of growth matters.

At-a-glance: what is normal, and by when

Slipped capital femoral epiphysis (SCFE)

This was the section he was most passionate about. He treats many of the severe slips in Brisbane — cases “where it’s all gone really wrong”: the head has slipped as far as it can off the back of the neck, or come off completely.

The typical story

• An adolescent with months of knee or thigh pain — “more often than not, it’s just the knee” — frequently after lots of physiotherapy.
• A limp, groin/hip, thigh or knee pain.
• Often a heavier child (“can be quite chubby, but not always”) — he sees a reasonable number of slim children too; in those they look for an endocrinopathy, though usually it is normal.

What is actually happening

The femoral head stays in the socket while the neck (metaphysis) rotates off it — “a pure posterior sliding through the growth plate.” He contrasted this with the usual “ice cream falling off the cone” description: really, the ice cream stays put and the cone moves. As it slips, the leg goes into more and more external rotation.

Examination

• The child may walk with the foot turned out.
• Obligatory external rotation with flexion: as you flex the hip, the leg swings outwards.
• Internal rotation is painful (and reduced); sometimes abduction too.

Editor’s note (not from the talk): the obligatory external rotation on flexion is often called Drehmann’s sign.

Imaging

• X-rays can be very subtle — even radiology can miss early slips. Look for the epiphysis sliding so it is no longer fully covered by the metaphysis, and a slightly widened growth plate.
• Klein’s line (ASR “client’s line”): a line drawn along the top of the femoral neck should intersect part of the capital epiphysis. If it misses, suspect a slip.
• MRI is “pretty obvious” and MRI is now more accessible for children — “big plus”. If an MRI is being done for knee pain or query internal derangement and the knee is normal, think hip (passage garbled).

SCFE treatment — and why late is so bad

• Early slips are easy: “We can just pin that. It’s so easy, it’s just a straight pin.” The decision is to stabilise the slip — end of story. Slips under about 30–40° are not realigned; they are pinned where they are.
• Growing screw: in younger children a telescoping “male inside female” screw lets the neck keep growing and remodel — “really quite cool”. He said it has been available for about three years (ASR “three more years now” — unclear).
• Severe slips: the head ends up against the back of the neck and can slip no further until it comes off — an unstable slip. These need a subcapital realignment osteotomy (ASR “sub capital rear line osteotomy”; the Otter summary’s “retroversion osteotomy” is likely an ASR error). His team did Australia’s first at the Kids Hospital in 2008 and has done them for 18 years.
• Blood supply: in a child, the femoral head’s blood supply runs up the neck in the retinacular vessels (ASR “red macula”) and enters the head from the side, around the growth plate — unlike adults, where it can travel straight up the neck. A slip or the surgery can disrupt it, so the risk of avascular necrosis is significant. “Our mission [is to] get those kids before they get to that stage.”

Referral red flags

Transcript caveat: his last referral item, “the child with illegal quality”, is garbled (possibly leg-length inequality — not confirmed).

Questions and close

He invited questions after the knee section, but none were captured. The talk ended with an anecdote about a young patient — a dancer — who had both legs treated in frames; the boy was later an invited guest at a company meeting and did a backflip on stage in his frames (details garbled on the ASR).

GP clinic checklist

1. In-toeing under eight: work out the level (hip, shin, foot), reassure, and set a review — most improve by eight. Don’t discourage W-sitting.
2. In-toeing or anterior knee pain after eight — especially with tripping, patellar instability or trochanteric pain: ask for a rotational profile (femoral anteversion and tibial torsion), not just a knee MRI, and refer if symptomatic.
3. Metatarsus adductus: reassure that surgery is not the answer in children; refer if you are worried.
4. Bow legs: normal to two. After three, or if worsening, assess properly and think rickets (and a growth-plate cause) before calling it physiological.
5. Knock knees: normal at three to four and up to six; still present at eight → refer (guided growth is easier with growth remaining).
6. Any adolescent with a limp, or thigh or knee pain without a knee cause: examine the hip — internal rotation, external rotation on flexion.
7. Order hip X-rays and check Klein’s line and growth-plate width — but remember early slips can look normal; MRI is very sensitive.
8. Can’t weight-bear? Treat as possible unstable SCFE — same-day paediatric orthopaedic/ED assessment.
9. Heavier child is typical, but slim children slip too; their specialist may look for an endocrine cause.
10. Physiotherapy for knee pain that isn’t improving over weeks to months is a cue to re-think the hip.

Transcript caveats

• The presenter’s name, “Dr Jeff Donald”, is as captured by ASR; spelling unconfirmed. The hospital “the Kids Hospital” and the fellowship hospital (“Great Wall Street”) are not fully identified.
• Slides were not captured: published graphs, X-rays and MRIs, the Australian SCFE incidence data and the clinical photos are described only from the speaker’s words.
• Garbled numbers/terms: “take them to operation by three months” (likely return to sport by ~3 months); “20 would be about what you’d expect a neighbor of to have”; “over 90%” resolution; “three mediators” in the career-incidence quote; “growing screw… three years”; “illegal quality”; the second cause of pathological bow legs (“layouts” — possibly Blount’s).
• The Otter summary’s “treating femoral anteversion by age three” and “subcapital retroversion osteotomy” are not supported by the transcript and were not used.
• The 95% hip-replacement figure is attributed to another speaker (“Mr Fowler”) and lacks context.
• Editor’s notes (Drehmann’s sign, non-weight-bearing advice, growth remaining for guided growth) are standard teaching added for clarity and are labelled as such.

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