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Femoral torsion in normal human development and as related to dysplasia.

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Femoral Torsion in Normal Human Development
and as Related to Dysplasia
WALTER H. ROBERTS
Schools o f Medicine and Dentistry, Lorna Linda University,
Lorna Linda, California
The angle of torsion of the femur, also
called the angle of declination is, by definition, the angle formed by the intersection
of lines drawn through the main transverse axis of the upper end and that of
the lower end. Le Damany ('03) whose
work was corroborated and extended by
Lanz and Mayet ('53) noted that torsion
of the upper end of the femur appears
first about the third month of fetal life
and that it reaches 40" (with a range of
30"-60") at birth. After birth it decreases:
it averages 25"-30" by the twelfth year,
and 12" by adulthood. The latter figure
coincides with that given by Durham ('15).
Parsons ('14) and Pearson and Bell ('15)
whose series were exceptionally large, give
a figure of 15" for the English adult.
Pearson and Bell ('15) and also Martin
('28) have noted significant racial differences as e. g. between Neolithic and Modern French. Kingsley and Olmstead ('48)
who used a slightly different method of
determining the angle give 8" although
Lofgren ('56) who appears to have used
the same method, albeit for a different
population group, gives 12". Shands and
Steele ('58) and Crane ('59), of this country, who x-rayed children and adults, find
the angle for the adult to average 15".
It seems reasonable to accept this last
figure for the average person of European
stock. It corresponds closely with that determined by direct measurement, and further the x-ray method must be, of necessity, the most accurate method used in
clinical practice.
There have been various explanations
for the increase in femoral torsion that
takes place during fetal development.
Friedlander ('01) believed that it was due
to the lower limb undergoing medial rotation. This view is discounted by Watanabe
('61) on the basis that most of the limb
rotation takes place between the eighth
and tenth weeks of fetal life. Le Damany
('06) explained femoral torsion on the
basis of the normal fetal posture in utero
but the reason given, namely that the
femoral shaft impinges against the anterior superior iliac spine which comes to
act as a fulcrum, is not convincing. Lanz
and Hennig ('53) concluded from their
mathematical considerations that activity
of the iliopsoas may be a factor. The usual
position of the fetus in utero, at least by
the sixth month, is one in which the lumbar spine and hips are fully flexed, in
which position, according to their own
figures, if one takes into consideration the
physiological limits of flexion and extension as defined by Walmsley ('28) and
Milch ('60) and if one can translate them
to the fetus, the rotational force would be
practically zero. The possibility of differential growth as a factor, as suggested by
Felts ('54) is not without some merit.
Frazer ('48) explains comparable changes
in the angle of inclination that occur after
birth on such a basis.
Shands and Steele ('58) noted that the
angle of declination takes a sharp drop
in the first year after birth and again
between the fourteenth and sixteenth
years. The latter drop might be explained,
as indicated by Le Damany ('13) on the
basis of the intensity of torsion being proportional to the degree of activity of osteogenesis; it must also be taken into account
however, as shown by McGregor ('50),
that the plane of the epiphyseal line, which
is horizontal in early childhood, becomes
more vertical after the age of ten.
Moss and Noback ('58) have shown
that the length of time between the beginning of epiphyseal fusion and its com369
370
WALTER H. ROBERTS
pletion is about the same for male and
the female, and thus likewise would be
the time period during which mechanical
forces could influence femoral development. Certain postural habits acquired
during the postnatal growth period are
probably responsible for the occasional occurence of retrotorsion on the one hand,
and the high degree of antetorsion (in the
absence of hip dislocation) on the other,
sometimes seen.
Garden (’61) has shown that the peculiar angulation and the spiral conformation
of the internal structure of the proximal
end of the adult femur, has been achieved,
as a result of weight bearing, by simple
twisting of the upper end of the original
shaft first in an inward and forward direction, and then in a backward direction.
Pearson and Bell (’15) also indicate that
a primary torsion and then a retrotorsion,
or a turning back on this torsion, can
explain the general features of the upper
end of the femur.
One of the most extreme disturbances
of epiphyseal growth is seen in achondroplasia. In this condition the epiphyseal
cartilage is narrowed and the zone of proliferation is absent, being replaced to some
degree, as stated by Illingworth and Dick
(’49), by fibrous tissue, mucoid areas, and
dense bone. Considerable deviation from
the normal in the angle of declination
might be expected in such cases, as has
been found to be true in the present study.
The following observations are relevant
from the standpoint of mensuration of the
femur. The shaft of the femur of the
fetus and newborn child according to
Bryce (’15) is nearly straight, and bowing
does not appear until the second or third
year, being completed between the eighth
and twelfth years. The head of the femur
is not perfectly spherical either in the
fetus or in the adult. In the human fetus
and up to the first and second years of
life, as shown by Walmsley (’28) the
radius of curvature of the meridian is less
than the radius of curvature of the equator; after the third year the ratio is reversed (corresponding changes were noted
in the acetabulum). He felt that the transmission of weight might be the retarding
influence of the growth of the femoral
head in the plane at right angles to the
axis of the movements of flexion and extension. The retardation in growth would
be in harmony with Delpechs law, which,
according to Paturet (’51), states that abnormal pressure on the epiphyseal cartilage will slow down bone growth whereas
diminished pressure will accelerate it.
According to Hass (’51) the dysplasia
present in ‘‘congenital dislocation”involves
not only the acetabulum but also the upper
end of the femur. The condition is seen
clinically more commonly in females than
in males and it is the left hip that is the
more often involved. Hart (’49) believes
the dysplasia to be of genetic origin. That
viral infections are a possible cause of hip
abnormalities has been intimated by Joseph, Pellerin and Job (’58) and by Drachman and Banker (’61). Constitutional
factors such as gross maternal dietary deficiency, as in famine areas, is known to
increase the incidence of congenital hip
disorders. Browne (‘34) attributes the club
foot anomaly to faulty intrauterine posture
in association, in some cases, with oligohydramnios. This is not excluded as a
possible factor in the occasional intrauterine hip dislocation.
MATERIALS AND METHODS
Both femora of one hundred and fifty
fetuses of various ages and of about equal
sex ratio were examined. In eight instances femoral dysplasia or other related
pathology was found to be present, in
which cases the pelvis was also examined.
Included in the total number were twelve
anencephalics and one achondroplastic.
The femora of an achondroplastic child of
one year of age were also examined for
comparison. The anencephalic and achondroplastic and dysplastic specimens were
considered separately. The number of femora in a particular group of normal specimens (as determined by length) is as
follows: 30-39 mm, 35; 40-49 mm, 60;
50-59 mm, 36; 60-69 mm, 42; 70-79 mm,
33; 80-89 mm, 34; 90-99 mm, 15; 100109 mm, 15.
The femora were dissected free of their
muscular and capsular attachments, care
being taken to preserve the articular cartilages intact. The length of the femur was
measured in millimeters. In determining
the angle of declination a slight modifica-
371
FEMORAL TORSION AND DEVELOPMENT
tion of the method of Reynolds and Herzer
(’59) was employed. Antero-posterior and
lateral x-ray views of the femora were
taken. A line was drawn through the center of the shaft as viewed in the anteroposterior projection; the perpendicular distance from the center of the head to this
line, was recorded as distance “b” (fig. 1 ) .
A line was then drawn through the point
of maximum concavity of the posterior
aspect of the shaft (as seen on the lateral
projection) parallel to the plane on which
the posterior surfaces of the condyles and
of the greater (or lesser) trochanter of the
femur would rest were it placed on a flat
surface. The perpendicular distance from
the center of the femoral head to this line
was recorded as distance “a”. A rightangled triangle with a base line corresponding to distance “b” and a vertical
component equal to distance “a” was
drawn. The angle opposite “a” corresponded to the angle of declination based
upon the trigonometric formula: Tan an-
gle A equals a/b. Direct measurements
of the angle using a protractor were also
made as a check on the accuracy of the
x-ray findings.
OBSERVATIONS
The curve showing the angles of declination of the normal fetal femora according
to their lengths, is shown in table 1. The
anencephalic femurs, while not included,
actually would have fallen within the normal range; the angles of declination of
the achondroplastic fetus and of the
achondroplastic infant of one year were
zero.
Table 2 gives the findings of the eight
specimens where dysplasia of one of the
femora and associated pathology related
to the hip joint was found to be present.
In the first case ( # 0 5 ) a female fetus,
the right hemipelvis was dysplastic and
the roof of the acetabulum just a membrane (fig. 2). The entire right femur
and upper tibia were of smaller dimensions
TABLE 1
Femoral torsion in normal human fetal development and as related to dysplasia
40”
35.66O
h
z
L
/G%T
35O-
8
-
32.7’
0
2 30”+
v
5
5
=5
t:
0
25”20015O
-
LL
0
5
10”-
W
Z
Q
5”I
,
r
I
I
40-49 50-59 60-69 70-79 80-89 90-99 100-109
I
30-39
I
3 72
WALTER H. ROBERTS
TABLE 2
Femoral torsion i n normal human fetal development and as related to dysplasia
No.
Sex
Femoral length Dysplasia
inmm
offemur
R
L
R
X
X
05
10
58
60
75
76
21
FE
M
M
M
M
M
M
51.5
76.5
60
73
73
71
64
52
78
62
74
72
70
68
57
M
75
74
L
X
X
Dysplasia
of acetab.
Angle of
declination
R
L
xxxx
15"
7"
X
X
15'
R
L
Other
anomalies
multiple
17'
x
x
X
X
X
36" 20
40' 40'
25' 16"
x
20°
X
X
X
O
8'
bilateral
club
foot
Apparent
etiology
unknown
unknown
unknown
unknown
unknown
unknown
malposition and
extrinsic
pressure
malposition and
extrinsic
pressure(? )
"x" indicates a minimal degree of dysplasia, whether of the femur or of the acetabulum; "xxxx" indicate? a
Severe degree of dysplasia. In the first six specimens the dysplasia was considered to be of primary origm.
Five of the six were males. In the seventh and eighth specimens the dysplasia was considered to be of secondary origin.
than on the left. The head of the femur
was .5 mm less in diameter than on the
normal side and the lower end of the
femur was about 3 mm less in width
(figs. 3 and 4). Other anomalies involving
the heart, intestine and right pelvi-ureteric
junction were present. Cases nos. 10, 58,
60, 75 and 76 were all males. The diameter of the femoral head, the femoral
length and width of lower end of femur
averaged about 1 mm less on the affected
side, with one exception (in case #60 the
lower end of the affected femur was 3 mm
less in width than on the normal side).
In #05 (Fe.) the angle of declination
on the affected side was greater than on
the normal side; in specimen #76 the angle was the same on the two sides; in
specimens nos. 58 and 75 it was less. The
angles in cases nos. 10 and 60 could not
be compared as the pelves and femora
were twisted due to the position of the
specimens in their original containers.
In one of the two additional cases, and
perhaps both (nos. 21 and 57) the femoral
dysplasia present was due to fetal malposition and related factors. In case #21 the
fetal malposition was obvious. The foot
had become impinged against the mandible. Pressure of the uterine wall against
the prominent knee had caused both a
subluxation of the corresponding half of
the mandible and a displacement of the
superior femoral epiphysis, which, in turn,
had caused a marked shortening of the
femur and a considerable increase in the
angle of declination. The diameter of the
femoral head again was about 1 mm less
than on the normal side. The acetabular
roof was indented but dislocation had not
occurred. In case #57, a male, an actual
intrauterine hip dislocation had occurred
on the left side, the femoral head lying
posteriorly and laterally in relation to the
acetabulum. As in the previous cases the
femoral head was about 1 mm less in
diameter than on the normal side (the
angle of declination was considerably less
than on the normal side). The ligamentum capitis femoris was stretched taut and
had notched the adjacent acetabular part
of the ilium. Bilateral club foot (talipes
equinovarus) was also present.
DISCUSSION
The use of the x-ray has been found to
facilitate the calculation of the angle of
declination in that one can readily determine certain specific landmarks as a basis
of measurement. The flattening of the
curve showing the angles of declination
of the normal fetal femora according to
their lengths, toward the latter end of
pregnancy, as shown in figure 1, coincides
closely with the findings of Lanz and
Mayet ('53). It may be due to a progress
FEMORAL TORSION AND DEVELOPMENT
of ossification into the neck of the femur
or there may be a genetically determined
limiting factor.
It is noted that the incidence of dysplasia, in this particular series, is much
higher in the male, there being only one
female among the six cases encountered.
The degree of acetabular dysplasia in the
one female specimen was of more severe
degree than in any of the others. In case
#21 there was an obvious fetal malposition. It is possible that the hip dislocation
and associated dysplasia present in case
#57 may have been of a similar cause;
Browne ('34), as noted above, attributes
club foot, which was present bilaterally,
to faulty intrauterine position, and perhaps
oligohydramnios. The degree of dysplasia
was of about the same magnitude as observed in the other specimens.
373
Two instances where femoral and acetabular dysplasia was of secondary origin
have been described. In one there was a
displacement of the upper femoral epiphysis; in the other an in utero hip dislocation
had occurred. Their occurrence in males
is probably just a coincidence as fetal malposition was responsible for one and most
likely both. In an achondroplastic fetus
and infant, the angle of declination was
found to be zero in each instance.
ACKNOWLEDGMENTS
Appreciation is extended to the AudioVisual Department for assistance in the
preparation of the accompanying tables
and figures and to Drs. Ted and Edgund
Fernish for their assistance in translating
the rather highly technical German references.
LITERATURE CITED
CONCLUSIONS
It has been confirmed by x-ray studies
that the angle of declination of the fetal
femur towards the latter end of pregnancy,
shows a diminished rate of increase. This
may be attributable to the extension of
ossification into the femoral neck or there
may be a genetically determined limiting
factor.
Unilateral femoral and associated acetabular dysplasia, in the absence of obvious
contributory pathology shows a much
higher incidence in the male, there being
found only one female among the six
fetuses coming in this category. The angle
of declination of the affected femur, as
compared to the normal one, showed no
particular pattern being the same in one,
increased in another and decreased in two,
(in two it was not possible to compare
them). There was no evidence that metabolic factors such as perhaps dietary deficiency might be contributory but this
factor is not thereby necessarily excluded.
The severe degree of dysplasia of the
acetabulum present in the female fetus,
in contrast to the lesser degrees noted in
the five males, would have favored dislocation postnatally had pregnancy continued. To this extent the findings parallel
the clinical observation of a greater incidence of congenital dislocation of the hip
in the female.
Browne, D. 1934 Talipes equinovarus Lancet
227: 969-974.
Bryce, T. H. 1915 Quain's Elements of Anatomy, eleventh ed. part 1. Longmans, Green and
Co., London, pp. 204-205.
Crane, L. 1959 Femoral torsion and its relation to toeing-in and toeing-out. J. Bone Jt.
Surg., 41-A: 4 2 1 4 2 8 .
Drachman, D. B., and B. Q. Banker 1961 Arthrogryposis multiplex congenita. Arch. Neurol.,
5: 89-93.
Durham, H. A. 1915 Anteversion of the femoral neck in the normal femur. J. Amer. med.
Ass., 65: 223-224.
Felts, William J. 1954 The prenatal development of the human femur. Amer. J. Anat.,
94: 1-44.
Frazer, J. E. 1948 The Anatomy of the Human
Skeleton, fourth ed., J. and A. Churchill Ltd.,
London, p. 119.
Friedlander, F. V. 1901 Uber die Entstehung
der angeborenen Huftuenenkung. Z. orthop.
Chir., 9: 515-543.
Garden, R. S. 1961 The structure and function
of the proximal end of the femur. J. Bone Jt.
Surg., 4343: 576-589.
Hart, V. L. 1949 Congenital dysplasia of the
hip joint. Ibid., 31-A: 357-372.
Hass, J. 1951 Congenital Dislocation of the
Hip. C C Thomas, Springfield, pp. 11-21,36-40.
Illingworth, C. F. W., and B. M. Dick 1949 A
Textbook of Surgical Pathology. J. and A.
Churchill Ltd., London, pp. 134-135.
Joseph, R., D. Pellerin, and J. C. Job 1958 Congenital multiple arthrogryposis. Semaine hop.
Paris, 34: 525-536. (Abstracted i n J. Amer.
med. Ass., 167: 787).
Kingsley, P. C., and K. L. Olmstead 1948 A
study to determine the angle of anteversion of
the neck of the femur. J. Bone Jt. Surg.,
30-A: 745-751.
374
WALTER H. ROBERTS
Lanz, T. V., and A. Hennig 1953 Rollwirkungen
des M. iliopsoas and Femurtorsion. Anat., 117:
382-409.
Lanz, T. V., and A. Mayet 1953 Die Gelenkorpen
des menschlichen Juftgelenkes in der progredienten Phase ihrer umwegigen Ausformung.
Ibid., 117: 317-345.
Le Damany, P. 1903 Les Torsions osseuses.
Leur Role dans la Transformation des Membres. J. Anat., 39: 126-134, 161-165, 313-337,
4 2 6 4 5 0 , 534-545.
1906 Les torsions osseuses. Ou se Fontelles? Ibid., 42: 293-296.
Lofgren, L. 1956 Some anthropometric anatomical measurements of the femurs of Finns
from the viewpoint of surgery. Acta chir.
scand., 1 1 0: 4 7 7 4 8 4 .
Martin, R. 1928 Lehrbuch der Anthropologie.
Gustav Fischer, Jena Vol. 1 pp. 328, 416, 11401141.
McGregor, A. L. 1950 A Synopsis of Surgical
Anatomy, seventh ed., The Williams and Wilkins Co., Baltimore, pp. 451-454.
Milch, H. 1961 The measurement of pelvi-femoral motion. Anat. Rec., 140: 135-145.
Moss, M. L., and C. R. Noback 1958 A longitudinal study of digital epiphyseal fusion in
adolescence. Ibid., 131: 19-32.
Parsons, F. G . 1914 The characters of the
English thigh bone. J. Anat. Physiol., 48:
238-267.
Paturet, G. 1951 Traite d'anatomie humaine,
Vol. 1. Masson and Cie, Paris, p. 47.
Pearson, K., and J. Bell 1919 A study of the
Long Bones of the English Skeleton. Drapers
Company Research Memoirs, Biometric Series
X and XI, Part I, Section I, Chap. 1-6 and
Part 11, Section 11, Chaps. 7-10. Cambridge
U. Press, London.
Reynolds, T. G., and F. E. Herzer 1959 Anteversion of the Femoral Neck. Clin. Orthop.,
14: 80-89.
Shands, A. R., Jr., and M. K. Steele 1958 Torsion of the femur. J. Bone Jt. Surg., 40-A:
803-816.
Walmsley, T. 1928 The articular mechanism
of the diarthroses. J. Bone Jt. Surg., 10: 40-45.
Watanabe, R. 1961 Embryological development
of the human hip. (unpublished).
FEMORAL TORSION AND DEVELOPMENT
PLATE 1
Walter H. Roberts
The method of calculating distances “b” and “a” is illustrated. Distance “b” is the length
of a perpendicular line drawn from the center of the head to a line through the center of the
upper shaft; distance “a” is the perpendicular distance from the center of the head to a line
through the point of maximum concavity of the shaft and parallel to the surface on which the
femur would rest if placed flat. From these measurements the angle of declination can be
determined as described in the text. The femur shown in antero-posterior and lateral views is
that of a n eleven-month old child (reduced).
Pelvis #05 (actual size). Right hemipelvis is dysplastic.
Femora #05 (actual size). Right femur is dysplastic as shown on antero-posterior view.
Femora #05 shown on lateral view, again showing the lesser diameter of the head of the
femur on the affected side.
Note that the curve indicating the average for the angle of declination in femurs of specific lengths
flattens towards the latter end of fetal development.
375
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