Femoral anteversion

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Updated by: Allison Duey-Holtz
Updated on: 8/2/17

The angular difference between the femoral neck axis and the transcondylar axis of the knee


Signs and symptoms

  • Parents report child is clumsy and trips frequently (1,11)
  • Parents report children characteristically sit with their legs in the “W” position (1,3,4,11)
  • Often familial (3)
  • Typically bilateral (3,4)
  • Affects females more than males (3)
  • One in ten children “in‐toe” between the ages of two and five years (4)


  • Differential Diagnosis
    • Internal tibial torsion
    • Cerebral palsy
    • MTA
    • Spina bifida
    • Rickets
    • DDH


  • Limb buds appear in the fifth week in utero, subsequent intrauterine molding causes external rotation at the hip and internal rotation of the tibia (1,3)
  • At birth neonates have an average of 40 degrees of femoral anteversion. By age 8 years, average anteversion decreases to the typical adult value of 15 degrees (1,2,3,4,7,10)
  • Femoral anteversion typically increases until age 5 years and then resolves by age 8, after this point no significant change in anteversion occurred (1,4,5,6,8,9,10,11)

Referring provider's initial evaluation and management:

Diagnostic tests

  • Radiographs
    • Short stature
    • Abnormal hip examination
    • Marked limb asymmetry
    • Pain


  • Observation, as natural history point to spontaneous resolution (1,2,4,5,6,9,10,11)
  • Education
    • Treatment with splinting, shoe modifications, exercises and braces has proved to be ineffective (1,2,4,5,6,8,9,10,11,12)
    • Reassure families there is no association between increased femoral anteversion and DJD (1,4,10)
    • Surgical intervention may be indicated in a child older than 10 years with a marked cosmetic or functional deformity or child with underlying neuromuscular condition with functional impacts(1,3,6,10)

When to initiate referral/ consider refer to Orthopedic Clinic:

Parental or provider concern

  • For patients under 10, otherwise healthy and without symptoms-Well Child Lower Extremity Clinic (APP run screening clinics)
  • For patients with symptoms/pain General Orthopedic Clinic
  • Referral to General Ortho MD if over 10, neuromuscular, second opinion

What can referring provider send to Orthopedic Clinic?

1. Using Epic

  • Please complete the external referral order

In order to help triage our patients and maximize the visit, the following information would be helpful include with your referral order:

  • Urgency of the referral
  • What is the key question you would like answered?

Note: Our office will call to schedule the appointment with the patient.

2. Not using Epic external referral order:

  • In order to help triage our patients maximize the visit time, please fax the above information to (414) 607-5288
  • It would also be helpful to include:
  • Chief complaint, onset, frequency
  • Recent progress notes
  • Labs and imaging results
  • Other Diagnoses
  • Office notes with medications tried/failed in the past and any lab work that may have been obtained regarding this patient's problems.

Follow-up recommendations

  • Follow-up with PA/NP as needed
  • If age/developmentally appropriate, physiologic, family would like follow-up for reassurance
  • Follow-up with surgeon:
    • If child older than 10 years of age
    • If child has marked functional or cosmetic deformity in which family would like surgical intervention
    • Abnormal neuromuscular exam or bony pathology
  • Second opinion

Specialist's workup will likely include:

After referral to Orthopedic Clinic:

  • Comprehensive birth history
  • Family history
  • HPI
  • Neuromuscular exam
  • Gait evaluation
  • Evaluate for hip dysplasia (9)
  • Complete rotational profile (internal and external hip rotation, thigh-foot axis, transmalleolar axis, heel bisector angle, foot progression angle) (1,3,4)