What is the Differential Diagnosis of Intoeing and Outtoeing?

Patient Presentation
A 2-month-old male came to clinic for his 2-month health supervision visit.
His parents have no concerns other than his feet seem to turn in looking like a “C”.
This has been present since birth and they think that perhaps it is slightly improving over time but they are not sure.
The past medical history shows that he was the product of a 38 1/2 weeks gestation with spontaneous vaginal delivery birth with vertex presentation.
There were no complications and he has not had health care visits other than routine care. Past medical records do not mention any physical abnormalities.
The family history is negative for any orthopaedic problems.
The pertinent physical exam shows a happy male infant with normal developmental milestones and growth parameters in the 50-75%.
On inspection, both forefeet appear to turn inward with a curved lateral border. With the hindfoot stabilized, the forefoot can be brought to a normal neutral position with little effort and did not cause discomfort. There is no stiffness with motion of any of the toes, forefeet, ankle, knees or hips.
The medial malleoli were anterior to the lateral malleoli. The hips had normal ab- and ad- duction and a negative Barlow and Ortolani test bilaterally.
The diagnosis of bilateral metatarsus adductus was made. The parents were told that this is a common problem in infancy thought to be due to intrauterine positioning. They were instructed and shown how to do forefoot stretching exercise that could be done with each diaper change and they demonstrated the proper technique.
They were also told that this generally corrects as the child begins to put more weight on his feet.

Discussion
Intoeing or outtoeing are common complaints by parents. For most children, it is a normal variant or developmental problem that often resolves with a tincture of time.
In general, referral should be made to an orthopaedist if the body part cannot be brought back to a neutral position or if doing so involves pain or discomfort. If there is any stiffness or an incomplete range of motion is felt then patients should also be referred.
Patients with other abnormalities that may indicate that the in- or outtoeing may be part of a syndrome or neuromuscular problem should be referred too. Parents generally will complain about the in- or outtoeing if it is obvious (as in the patient above), the child seems to trip more often, there is excessive shoe wear, or other parents, teachers or family members have noticed the same problems.

Intoeing is complained about much more often than outtoeing because the children tend to trip more with intoeing. Outtoeing is common when children begin to bear weight and the outtoeing helps with balance. The outtoeing improves usually over the next several months as strength, coordination and balance are improved.
A normal gait has a slight outtoeing (i.e.10-15° external rotation).

Learning Point

The differential diagnosis of intoeing includes:

  • Metatarsus adductus
    • Cause: Intrauterine positioning deformity, i.e. a “packaging” problem.
    • Age: Infants
    • Diagnosis: Hold the hindfoot in one hand to stabilize and use other hand to attempt to bring toes back to midline. If this can be easily done without stiffness of the foot, then this is metatarsus adductus. There is also a tranverse midline crease on the plantar surface.
    • Prognosis: is excellent and it spontaneously corrects especially with weight bearing
  • Internal tibial torsion
    • Cause: Normal in newborns. Caused by the effects of gravity and dominant tone in ankle plantar flexor muscles and foot invertors
    • Age: Toddler – often seen when child begins walking and is generally better by age 2 and almost all are corrected by age 4.
    • Diagnosis:
      • Intermalleolar axis – The medial malleoli lies approximately 10 – 15% anterior to the lateral malleoli normally. With tibial torsion, they lie in the same plane.
      • Thigh foot angle – With child prone on table, flex the knee. Draw an imaginary line through the axis of the femur and another imaginary line between the midpoint of the heel and toes. Normally the angle between these two lines is 10-30° with the foot turned outward. Refer to orthopaedics if the angle is > 20°.
    • Prognosis: is excellent, generally no treatment is necessary, rarely requires surgery only if persistent
  • Femoral anteversion
    • Cause: Angular difference between the axis of the neck of the femur and the transcondylar axis of the knee. Normally reaches the adult angle of 10 – 20° in 5 – 8 year olds.
    • Age: School age children can often sit in “W” position without any problems (this position does not exacerbate the condition)
    • Diagnosis: Check the internal and external rotation of the hips. Internal rotation > 70° and limited external rotation are suggestive of femoral anteversion.
    • Prognosis: Improves but is often slow to do so. Once external rotation increases to 10 – 20° then intoeing generally is resolved.
  • Cerebral palsy
  • Clubfoot – is rigid deformity with plantar flexion and medial deviation at the ankle
  • Hip dysplasia

The differential diagnosis of outtoeing includes:

  • Normal gait when first learning to walk
  • Femoral retroversion
  • External tibial torsion – usually seen as a compensatory mechanism to femoral anteversion

Questions for Further Discussion
1. What causes knock-knees and bowlegs?
2. What causes flat feet?
3. What causes leg length discrepancies?
4. When would radiographs be indicated for intoeing or outtoeing?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check Foot Injuries and Disorders

and at Pediatric Common Questions, Quick Answers for this topic: Intoeing and Outtoeing

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Mier RJ, Brower TD. Pediatric Orthopedics A Guide for the Primary Care Physician. Planum Medical Book Company, New York NY. 1994:95-102.

Lincoln TL,
Suen PW.
External rotation contracture of the extended hip. A Journal of the American Academy of Orthopaedic Surgeons. 2003;11(5);312-20.

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Interpersonal and Communication Skills
    18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.

    Author
    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    May 28, 2007

  • What Organisms Cause Otitis Externa?

    Patient Presentation
    A 7-year-old male came to clinic with drainage from his left ear for 2 days. The small amount of drainage was clearish-yellow and came and went over the day.
    There was more dried discharge on his pillow in the morning. The ear was somewhat painful but not excruciating and was somewhat pruritic. He denied sore throat, teeth pain or other pain.
    He had been swimming in a chlorinated pool and hot tub for several days before the onset of the drainage.
    The pertinent physical exam showed a well-appearing male with growth parameters in the 10-50%. His right ear was normal.
    His left external canal had pale yellow, thin discharge with white macerated skin and areas of erythema. Part of the tympanic membrane could be visualized and appeared non-erythematous and in normal position.
    There was mild pain produced with pressure on the tragus.
    There was shoddy anterior cervical adenopathy bilaterally.
    The diagnosis of otitis externa was made. The patient was begun on ciprofloxacin otic drops to be used for 5 days and to return if symptoms were not improved.
    He was also told to use a few drops of vinegar after swimming and baths to help prevent otitis externa from recurring.

    Discussion
    Otitis externa, also known as swimmer’s ear, is a common infection, especially in school age children. Moisture in the ear causes edema, skin breakdown and bacteria to grow. Swelling and debris may obstruct the external canal exacerbating the problem.
    Common predisposing factors include swimming (especially in water with high bacterial counts), foreign body (including hearing aids, retained cerumen, insects, etc.), dermatitis, viral infections and local trauma (i.e. finger nails, cotton-tipped applicators, etc.).
    Patients usually complain of unilateral ear pain or pruritus, drainage or decreased hearing. On physical examination, pressure on the tragus may elicit pain, and debris/drainage can be seen in the canal.
    The skin may look macerated with edema and erythema. The tympanic membrane may or may not be visible. Lymphadenopathy may be palpable and a conductive hearing loss may be measured. Unless infections extend beyond the canal, serious auricular problems usually do not occur.
    Cultures are not obtained unless there is an unusual history or physical examination such as a patient who is immunocompromised.

    Treatment for pain is usually acetaminophen or ibuprofen but occasionally oral narcotics are needed. Topical anesthetics such as antipyrine/benzocaine can be used but not if there is tympanic membrane perforation as it causes ototoxicity.
    Topical antibiotics are usually used. Fluoroquinolones such as ciprofloxacin and ofloxacin are the drugs of choice. Polymyxin B/neomycin/hydrocortisone has been used in the past with good results but increasing bacterial resistance and pain during administration along with sensitivity to neomycin and potential for ototoxicity is limiting it use.
    Systemic antibiotics are usually not necessary for most patients but may be used with infections beyond the canal or immunocompromised patients. Historically, some physicians have used a small cotton wick placed into the ear to aid medication delivery but this has not been systematically evaluated.
    Prevention centers on trying to keep the external canal as dry as possible. Using ear plugs and/or bathing cap, or blow drying with a low dryer setting after swimming may help. Decreasing the pH of the ear also helps by using a few drops of isopropyl alcohol, acetic acid or boric acid after swimming..

    Ofloxacin and ciprofloxacin with dexamethasone may be used with tympanic membrane perforation or pressure-equalizing tubes as they are not ototoxic.

    Learning Point
    Otitis externa is most commonly caused by Pseudomonas aeruginosa and Staphylococcus aureus. These often co-exist.

    Questions for Further Discussion
    1. What diseases should be considered in the differential diagnosis of otitis externa?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Ear Infections

    and at Pediatric Common Questions, Quick Answers for this topic: Otitis Externa

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Stone KE. Otitis Media. Pediatr Rev. 2007 Feb;28(2):77-8.

    Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:1255-1256.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

    Author
    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    May 21, 2007

  • What is the Best Treatment for Molluscum Contagiosum?

    Patient Presentation
    A 3-year-old male came to clinic because of ‘bumps’ on his arms. The lesions have been there for several weeks but the mother noted that they seem to be spreading.
    The lesions were always skin colored, raised, pinpoint or slightly larger and didn’t appear to itch or bother the boy. She hadn’t tried anything to help them.
    He was in daycare but no one had a rash that the mother knew. She denied other contacts, new soaps, lotions, etc.
    The past medical history was non-contributory and he had no underlying dermatological conditions.
    The pertinent physical exam showed a well-appearing male with growth parameters around the 75%. The lesions were on the dorsal and volar surfaces of both forearms. They were flesh-colored, papular with central umbilication and 1-4 mm in size.
    There were 5 lesions on the right arm and 8 on the left and they appeared in a sporadic distribution.
    The diagnosis of of molluscum contagiosum was made. After discussion with the mother including that most lesions resolve spontaneously but also that autoinoculation or transmission to others could occur, she refused cryotherapy and wanted to try salicylic acid/lactic acid treatment which she applied 3 times per week at night and washed the residue off in the morning.
    The patient’s clinical course after one month of treatment showed 3 lesions were almost completely gone and some of the larger ones appeared to be smaller. The mother continued the treatment and 2 months after his initial appointment, the lesions were gone.

    Discussion
    Molluscum contagiosum is a common viral skin infection caused by a poxvirus. They are small flesh-color papular lesions with central umbilication where the virus resides. They are painless and generally are 1-10 mm in size.
    They can occur anywhere on the skin. They often spontaneous resolve in 6-9 months, but can also have widespread dissemination (especially in patients with underlying dermatological conditions), pruritus, secondary bacterial superinfection, acute and chronic inflammatory changes, and scar formation. They can also be transmitted to others.

    There have been many treatments advocated. One recent prospective randomized trial in 124 children ages 1-18 years found that curettage was the most effective treatment with the lowest side effects, but it needed adequate anesthesia and was time-consuming.
    The Cochrane Collaboration project recently reviewed the medical literature and found that there was insufficient evidence to determine if treatments are effective.
    The randomized trial above concluded by stating “???the ideal treatment for mollusca depends on the individual patient preference, fear, and financial status, distance from the office, and whether they have dermatitis or blood-borne infections.”

    Learning Point
    Potential treatments for molluscum contagiosum include:

    • Watchful waiting
    • Cryotherapy – generally only used with a few lesions, may cause pain, psychological fear, blistering or secondary bacterial superinfection
    • Curettage – coring out of the central viral core with a curette, can be time consuming and needs adequate anesthesia. May cause pain, psychological fear, and secondary bacterial superinfection
    • Expression or pricking with a sterile needle – time consuming, may not obtain all the viral core material
    • Duct tape occlusion
    • Topical therapy – may cause irritation, blistering, secondary bacterial superinfection
      • Cantharidin (Cantharone®)
      • Hydrogen peroxide
      • Imiquimod (Aldara®) – works as an immunomodulator
      • Phenol
      • Podofilox (Condylox®)
      • Potassium hydroxide
      • Salicylic acid with or without lactic acid (Duofilm®)
      • Silver nitrate
      • Tretinoin (Retin-A®])
      • Trichloroacetic acid
    • Pulsed dye laser therapy
    • Systemic treatment – Cimetidine (Tagamet®) works as an immunomodulator

    Questions for Further Discussion
    1. How is molluscum contagiosum related to other warts?
    2. What treatments does the local dermatologist offer?
    3. What are indications for referral to a dermatologist?

    Related Cases

      Symptom/Presentation

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Skin Conditions

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Hanna D,
    Hatami A,
    Powell J,
    Marcoux D,
    Maari C,
    Savard P,
    Thibeault H,
    McCuaig C.
    A prospective randomized trial comparing the efficacy and adverse effects of four recognized treatments of molluscum contagiosum in children. Pediatr Dermatol. 2006 Nov-Dec;23(6):574-9.

    Lindau MS,
    Munar MY. Use of duct tape occlusion in the treatment of recurrent molluscum contagiosum. Pediatr Dermatol. 2004 Sep-Oct;21(5):609.

    van der Wouden JC, et al. Interventions for cutaneous molluscum contagiosum. Cochrane Database Syst Rev 2006;(2):CD004767. Available from the Internet at http://www.cochrane.org/reviews/en/ab004767.html (cited 4/16/07).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Interpersonal and Communication Skills
    18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.

    Author
    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    May 14, 2007

  • What is the Differential Diagnosis of a Breast Mass?

    Patient Presentation
    A 15-year-old female came to adolescent clinic with a lump in her left breast that she noticed 2-3 weeks previously.
    It was painless and not changing in size. A soccer ball had hit her 1 week ago in that area and she said that she was bruised but the bruise had resolved.
    She denies other trauma, skin changes, nipple discharge and had no fever or weight changes. She had normal menses and currently was having her period.
    The family history was positive for diabetes but no cancer or breast disease.
    The social history showed her to be good student who was not sexually active in the past or currently, and had no body piercings.
    The review of systems was negative.
    The pertinent physical exam showed a well-appearing female. She had a 1 x 2 cm ovoid, non-tender mass that was freely mobile, with regular margins that was located at ~11 o’clock next to the areola.
    The rest of the breast tissue showed uniform, very finely thickened “cord-like” texture on palpation consistent with patient age and nulliparity. There were no other masses or axillary or other adenopathy.
    The physicians felt that this was most likely due to a fibrocystic cyst, fibroadenoma, mammary ductal ectasia or trauma.
    They considered abscess but the lack of historical or physical evidence made this less likely, and malignancy was also considered but because of her age and physical findings felt to be also less likely.
    The physician instructed the girl return to clinic in two weeks for re-examination and to monitor and report any changes during the interval, especially if the skin was changing color, the mass increased in size or there was fever.
    The patient’s clinical course continued as she returned to clinic two weeks later and reported that 10 days after the her previous visit she had some increase in mass size, and the skin broke down with discharge of yellowish fluid. She still had no fever. On examination she had a 4 x 3 cm mass with a punctum near the areola. The mass felt regular and no discharge could be obtained with palpation.
    There was overlying skin redness, but no extension and some tenderness of the mass. The diagnosis of a breast abscess was made and she was placed on Cephalexin (Keflex®). She was to told to use warm packs. The radiologic evaluation of an ultrasound of the breast showed fluid and blood within the mass consistent with an abscess/hematoma.
    She was also referred to a surgeon who saw her 7 days later. On examination at that time she had minimal discoloration of the area, a healed punctum and no definitive mass palpable.
    The surgeon thought that maybe she had an initial fibrocystic cyst that because of trauma ruptured causing local irritation and hematoma. This later became infected producing the abscess.
    This would be consistent because she had draining at the areolar margin which is classic for a subareolar process. She was to return to her primary care physician in another two weeks to confirm complete resolution.


    Figure 49 – Sagittal ultrasound image of the upper outer quadrant of the left breast demonstrates skin thickening and a 4 cm mass-like area of disorganized breast tissue and edema with a small adjacent fluid collection. The constellation of findings was felt to represent an abscess.

    Discussion

    Thelarche is the onset of breast development and is usually the first sign of puberty in girls. It occurs at an average age of 11-11.5 years with a range of between 8 and 13 years.
    The breasts grow over the next 2-4 years as classified by Tanner staging. If no breast development occurs by 13 years of age then this is delayed and an evaluation is warranted.

    All adolescents should be examined and taught self-examination particularly adolescents with a family history of breast cancer or other malignancies. Risk factors for breast cancer include chest wall radiation and girls with a family history of breast cancer.

    Most breast masses in children and adolescents thankfully are benign in nature.
    Evaluation and management of breast masses depends on the history and examination. Ultrasonography is most helpful to characterize the lesion and can be performed serially. Mammography is not helpful because of the dense breast tissue of adolescents.
    Aspiration and/or excision of the mass may be necessary.

    Learning Point
    The differential diagnosis of breast masses includes:

    • Prepubertal breast masses (almost all are non-malignant)
      • Breast buds at birth secondary to maternal hormones
      • Premature thelarche
      • Supernumerary breast tissue including accessory nipples and accessory breast tissue
      • Breast assymmetry – one side larger than the other, often because of initial thelarche
      • Mammary duct ectasia – benign dilatation of the subareolar duct resulting in inflammation and fibrosis, that usually has a bloody nipple discharge
      • Abscess
      • Mastitis
      • Hemangioma
      • Lymphangioma
    • Adolescent benign breast masses
      • Fibroadenomas – is the most common cause of adolescent breast pathology (67-94% of all causes). There is a localized exaggerated response to estrogen where the lesion increases in size usually over 6-12 months and then becomes stable. Most are 2-3 cm in size.
      • Fibrocystic breast disease – breast will have thickened, cord-like lesions that are diffuse and often because larger and tender with menses. Occurs in 50% of reproductive age women.
      • Juvenile hypertrophy – extremely rapid breast growth that occurs shortly after thelarche
      • Juvenile papillomatosis – localized, proliferative lesion that is similar to a fibroadenoma on examination
      • Retroareolar cysts – also known as Cysts of Montgomery that serve in lactation – are small raised projections at the edge of the areola which can obstruct and cause inflammation or a mass
      • Mammary duct ectasia – benign dilatation of the subareolar duct resulting in inflammation and fibrosis, that usually has a bloody nipple discharge
      • Mastitis
      • Abscess
      • Trauma – can cause a hematoma or fat necrosis.
    • Adolescent malignant breast masses
      • Phyllodes tumors – these may be benign, intermediate or malignant. They are usually seen around 45 years of age, but have been reported in girls as young as 10.
      • Primary breast carcinoma – has been reported in 39 children ages 3-19 years of age
      • Sarcoma
      • Cancer metastatic to the breast – common tumors include Hodgkin’s lymphoma, Non-Hodgkin’s lymphoma, primary hepatocellular carcinoma, neuroblastoma, and rhabdomyosarcoma.

    Questions for Further Discussion
    1. What is the current age that most women should receive a screening mammogram?
    2. What are the Tanner stages of breast development?
    3. Describe the major pubertal changes in males and females in the proper order of appearance?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Breast Diseases.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    De Silva NK, Brandt ML.
    Disorders of the breast in children and adolescents, Part 1: Disorders of growth and infections of the breast.
    J Pediatr Adolesc Gynecol. 2006 Oct;19(5):345-9.

    De Silva NK, Brandt ML.
    Disorders of the breast in children and adolescents, Part 2: breast masses.
    J Pediatr Adolesc Gynecol. 2006 Dec;19(6):415-8.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.

    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    16. Learning of students and other health care professionals is facilitated.

  • Interpersonal and Communication Skills

    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Author
    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    May 7, 2007