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Average 4.3 of 75 Ratings
Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC.
Which of the following methods of determining skeletal maturity correlates most closely with the curve acceleration phase for children with idiopathic scoliosis?
Lenke classification method
Greulich and Pyle method
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Of the methods given, the Tanner-Whitehouse III RUS (radius, ulna, selected metacarpals and phalanges) correlates most closely with the curve acceleration phase for children with idiopathic scoliosis.
Assessing a child's skeletal maturity has important clinical implications when treating patients with idiopathic scoliosis. Current methods include the Greulich and Pyle method, the Oxford method, the Risser sign, and the Tanner-Whitehouse III method. The Tanner-Whitehouse III method specifically uses the distal radial and ulnar epiphyses and the metacarpal and phalangeal epiphyses of the first, third, and fifth digits for determination of skeletal age. In contrast, the Risser sign refers to the amount of calcification of the human pelvis as a measure of maturity. While the Tanner-Whitehouse method is more time consuming, it provides a better assessment of maturity and prognosis determination for curve progression in idiopathic scoliosis.
Sanders et al. (2007) evaluated a variety of maturity measurements and how closely they are related to scoliosis progression. They found the Tanner-Whitehouse-III RUS method was superior to all other indicators of maturity.
Sanders et al (2008) discussed a simplified version of the Tanner-Whitehouse III classification for skeletal maturity assessment. Their classification consists of 8 stages, from the juvenile slow stage to the mature stage, and is based on the radiographic appearance of all digital epiphyses. They found high intra- and extra-observer reliability, and a close correlation to the behavior of idiopathic scoliosis.
The following example shows how to use the Tanner-Whitehouse method. Illustration A shows the regions of interest. All bones are given a grade, as shown in Illustration B. The grade is then converted into a score, as shown in Illustration C. This data is then plotted on Illustration D to determine skeletal maturity. Illustration E shows a correlation between the Tanner-Whitehouse-III system and the Risser staging.
Answer 1: The Lenke classification refers to scoliotic curves, not skeletal age determination.
Answer 2, 3, 5: The Tanner-Whitehouse RUS method more closely correlates with the curve acceleration phase than either the Oxford method, Risser sign, or the Greulich and Pyle method.
Sanders JO, Browne RH, McConnell SJ, Margraf SA, Cooney TE, Finegold DN
J Bone Joint Surg Am. 2007 Jan;89(1):64-73. PMID: 17200312 (Link to Abstract)
Sanders, JBJS 2007
Sanders JO, Khoury JG, Kishan S, Browne RH, Mooney JF, Arnold KD, McConnell SJ, Bauman JA, Finegold DN
J Bone Joint Surg Am. 2008 Mar;90(3):540-53. PMID: 18310704 (Link to Abstract)
Sanders, JBJS 2008
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Average 2.0 of 45 Ratings
Skeletal maturity is an important variable in the progression of idiopathic scoliosis. Figures A-E are radiographs showing varying stages of skeletal maturity. The patient represented by which Figure would be expected to have the highest risk of progression of an idiopathic scoliotic curve?
The patient shown in Figure C is the most skeletally immature, and therefore would have the highest risk of progression of an idiopathic scoliotic curve.
Skeletal maturity can be determined by the stage of different apophyses. An AP radiograph of the pelvis is one commonly used. When the iliac apophysis has not yet begun ossification (Risser 0) and the triradiate cartilages are open, the child has not yet entered the rapid phase of growth. This is seen in the patient with the youngest skeletal age, and thus the highest risk of progression.
DiMeglio et al. published a review of items to consider when evaluating the potential of progression of a scoliotic curve. They report that Risser 0 is present during the initial two-thirds of pubertal growth, and that ossification patterns of the elbow can also be used during this critical time period (Illustration A).
Ryan et al. published a retrospective review of patients with adolescent idiopathic scoliosis (AIS) that had undergone brace treatment and identified a significantly lower likelihood of progression in patients with closed triradiate cartilages at the time of bracing.
Nault et al found limited reliability of the Risser grading system in determining the onset of the curve acceleration phase based on the digital skeletal age (DSA). They proposed a modified a system based on the fact that Risser 0 patients with open triradiate cartilages were all seen prior to the curve acceleration phase and those at Risser 0 with closed triradiates and patients at Risser 1 were within the peak growth velocity. Risser 2 thru 5 patients were all past this phase.
Answer 1: Radiograph shows a patient at Risser 3.
Answer 2: Radiograph shows a patient at Risser 5
Answer 4: Radiograph shows a patient that has already begun fusion of their olecranon apophysis, which begins after closure of the triradiate cartilage.
Answer 5: Radiograph shows a patient at Risser 4.
DiMeglio A, Canavese F, Charles YP.
J Pediatr Orthop. 2011 Jan-Feb;31(1 Suppl):S28-36. PMID: 21173616 (Link to Abstract)
DiMeglio, JPO 2011
Ryan PM, Puttler EG, Stotler WM, Ferguson RL.
J Pediatr Orthop. 2007 Sep;27(6):671-6. PMID: 17717469 (Link to Abstract)
Ryan, JPO 2007
Nault ML, Parent S, Phan P, Roy-Beaudry M, Labelle H, Rivard M.
J Bone Joint Surg Am. 2010 May;92(5):1073-81. PMID: 20439651 (Link to Abstract)
Nault, JBJS 2010
Average 4.0 of 16 Ratings
The orthosis shown in Figure A is indicated for the treatment of the spinal deformity shown in which of the following radiographs?
Figure A shows a thoracic lumbosacral orthosis (TLSO). TLSO bracing is indicated in adolescent idiopathic scoliosis for curves of 25-40deg, apex below T7, in skeletally immature (Risser 0,1,2) patients. This is best seen in Fig E.
In contrast, similar curves <25deg are best treated with observation, and those >40deg do not respond favorably to bracing.
Fayssoux et al. discuss the history of bracing. Brace treatment is indicated for children and adolescents with curves of 25-40deg who have at least 2 years of growth remaining (Risser 0,1,2 and <1yr postmenarchal). Bracing is contraindicated in severe hypokyphosis and severe rib deformities. Rigid TLSO (worn 18-23h/day) is standard of care for idiopathic thoracic curve with apex at or below T7.
Schiller et al. recommend bracing curves >30deg on initial presentation, or curves that progress >10deg to a magnitude >25deg. Bracing should continue until growth stops (unchanged height 6mths apart, Risser 4 in females or Risser 5 in males, post menarchal 18-24mths, or skeletal maturity on bone age determination).
Hedequist et al. discuss congenital scoliosis. They state that primary bracing is rarely indicated because braces usually do not affect progression as congenital curves are inflexible and unresponsive to bracing. Continued efforts at bracing may cause chest wall deformities in young children with compliant thoracic cavities.
Weinstein et al. examined the effectiveness of bracing in idiopathic scoliosis. The rate of treatment success was 72% after bracing compared with 48% after observation. Intention-to-treat analysis revealed success rates of 75% and 42% respectively.
Answer 1: Fig B demonstrates a mild scoliosis that can be observed without bracing. Bracing is contraindicated in curves <25deg without documented progression.
Answer 2: Fig C demonstrates severe scoliosis. Bracing is contraindicated in curves >45deg and this type of curve is best treated with surgery.
Answer 3: Fig D demonstrates a double thoracic curve. Double thoracic curves and thoracic curves with apex above T8 do not respond to TLSO bracing and are best treated with a CTLSO (Milwaukee brace).
Answer 4: Fig F demonstrates congenital scoliosis which is unlikely to respond to bracing and surgery is indicated.
Fayssoux RS, Cho RH, Herman MJ.
Clin Orthop Relat Res. 2010 Mar;468(3):654-64. Epub 2009 May 22. PMID: 19462214 (Link to Abstract)
Fayssoux, CORR 2010
Schiller JR, Thakur NA, Eberson CP.
Clin Orthop Relat Res. 2010 Mar;468(3):670-8. Epub 2009 May 30. PMID: 19484317 (Link to Abstract)
Schiller, CORR 2010
Hedequist D, Emans J
J Am Acad Orthop Surg. 2004 Jul-Aug;12(4):266-75. PMID: 15473678 (Link to Abstract)
Hedequist, JAAOS 2004
Weinstein SL, Dolan LA, Wright JG, Dobbs MB
N. Engl. J. Med.. 2013 Oct;369(16):1512-21. PMID: 24047455 (Link to Abstract)
Weinstein, NEJM 2013
Average 3.0 of 17 Ratings
A 13-year-old girl is referred to the orthopedic clinic for evaluation of scoliosis. She denies back pain and states she began her menses 3 months ago. On Adams forward bending, she measures 6 degrees. She has 5 of 5 motor strength in all muscles groups in her lower extremities and symmetric patellar and Achilles reflexes. A standing PA and lateral radiograph is shown in Figures A and B. All of the following should be performed as part of her evaluation EXCEPT:
Evaluation of leg lengths
Assessment of abdominal reflexes
Evaluation of waist asymmetry
Evaluation for café-au-lait spots
Figures A and B depict a standing PA and lateral of a 13-year-old-girl with a right-sided thoracic curve of 18 degrees with an associated thoracolumbar curve. An adequate physical exam includes an evaluation of spinal balance, leg lengths, shoulder height, waist asymmetry, café-au-lait spots, foot deformities and reflexes.
An MRI is not part of the initial evaluation in patients with idiopathic scoliosis without red flags or abnormal curve types. Typical indications for MRI include patients with a left thoracic curve, abnormal reflexes, rapid curve progression, neurologic symptoms, excessive kyphosis and foot abnormalities.
Based on her skeletal maturity, curve magnitude, and menarche status, the risk of curve progression is low. In females, the onset of menses typically occurs one year after peak height velocity. In this scenario, treatment can consist of observation with further follow-up.
Average 3.0 of 23 Ratings
Which of the following figures show an asterisk that correctly quantifies the amount of sagittal imbalance?
Sagittal vertical axis offset, or sagittal imbalance, is determined by measuring the distance from the C7 plumb line (dropped from the center of the C7 vertebral body) to the posterior-superior corner of the S1 vertebral body on a standing lateral radiograph. This is correctly illustrated in Figure B.
Restoring sagittal balance is a critical component in the treatment of adult spinal deformity. With "neutral" sagittal balance, the C7 plumb line will directly intersect the posterior-superior corner of S1. Positive or negative sagittal balance is described when plumb line is anterior and posterior to this sacral landmark, respectively.
Joseph et al review sagittal plane deformity in the adult patient. They report that sagittal imbalance is a reliable predictor of the clinical health status in patients with spinal deformity, and that the mainstay of treatment is surgical correction back to neutral sagittal balance.
Schwab et al performed a level 2 prospective study that introduces the concept of the "gravity line" in healthy adult volunteers. The gravity line is the center of recorded pressures measured on a footplate. With further studies, they hypothesize, the gravity line may prove itself to be superior to the plumb line in measuring spinal deformity.
Joseph SA Jr, Moreno AP, Brandoff J, Casden AC, Kuflik P, Neuwirth MG.
J Am Acad Orthop Surg. 2009 Jun;17(6):378-88. PMID: 19474447 (Link to Abstract)
Joseph, JAAOS 2009
Schwab F, Lafage V, Boyce R, Skalli W, Farcy JP.
Spine (Phila Pa 1976). 2006 Dec 1;31(25):E959-67. PMID: 17139212 (Link to Abstract)
Schwab, SPINE 2006
Average 3.0 of 27 Ratings
A 12-year-old female presents with a left thoracic rib prominence. Physical exam shows absent abdominal reflexes in the upper and lower quadrants on the left side, but present on the right. A PA standing radiograph is shown in Figure A. What is the next step in management?
Observation with repeat radiographs in 6 months
Bracing with a thoraco-lumbar-sacral orthosis
Magnetic resonance imaging (MRI)
Posterior spinal fusion with instrumentation
Anterior and posterior spinal fusion with instrumentation
The clinical presentation is consistent with a left thoracic curve with abnormal abdominal reflexes and therefore an MRI is indicated to look for abnormalities of the neural axis such as Chiari malformations and syringomyelia. One should recognize that right thoracic curves are more commonly seen in idiopathic scoliosis.
Spiegel et al performed a a retrospective radiographic review on 41 patients with scoliosis associated with a Chiari I malformation and/or syringomyelia. Approximately 50% of patients had an "atypical" pattern (left thoracic, double thoracic, triple, long right thoracic). They recommend that MRI should be considered in these patients.
Yngve et al reviewed the sensitivity of abnormal abdominal reflexes on physical exam. They found the finding of abdominal reflexes consistently present on one side and consistently absent on the other side did not occur in normal subjects. They recommend further workup with an MRI if found in a patient with scoliosis.
Illustration A shows the MRI of the patient presented in this question. It shows a large syringomyelia with dilatation in the lower cervical and upper thoracic area. Also noted was an Arnold-Chiari malformation. This patient was referred to a neurosurgeon and treated with a posterior fossa decompression.
Spiegel DA, Flynn JM, Stasikelis PJ, Dormans JP, Drummond DS, Gabriel KR, Loder RT.
Spine (Phila Pa 1976). 2003 Sep 15;28(18):2139-46. PMID: 14501926 (Link to Abstract)
Spiegel, SPINE 2003
J Pediatr Orthop. 1997 Jan-Feb;17(1):105-8. PMID: 8989711 (Link to Abstract)
Yngve, JPO 1997
Average 4.0 of 21 Ratings
A mother and her 16-year-old daughter present to your clinic because the daughter has noticed asymmetries in her back. She has no back pain and no neurologic symptoms. She is two years post-menarcheal. After a complete history and physical, you order PA thoracolumbar radiograph, which is seen in figure A. The cobb angle is 38 degrees. When discussing the natural history of the disease, you tell the family they should expect:
difficulty with vaginal child birth in the future.
decreased pulmonary function in the future
to undergo an MRI to rule out any underlying neurologic pathology, as this is an abnormal curve
an increased risk of chronic back pain over her lifetime
this curve magnitude has the highest curve progression rate without operative intervention
Discussion: The patient is presenting with classic adolescent idiopathic scoliosis (AIS). She has an apex at T8, which makes this a main thoracic, Lenke type 1 curve. While AIS is commonly referred to as a painless condition, Weinstein et al. published the 50-year follow-up, of 117 untreated patients with AIS compared to 62 age- and sex-matched controls and found a statistically significant (p = 0.003) increase in chronic back pain over 50 years.
In the aforementioned study by Weinstein et al. they found that while there was an increase risk of chronic low back pain, 68% of the patients with scoliosis and low back pain reported mild or moderate discomfort. Additionally, they found that there was only an increased risk of shortness of breath in patients with a curve greater than 80 degrees.
In another study by the same group, they reported on the risk of curve progression over 40.5 years. They found that curves less than 30 degrees rarely progressed, and thoracic curves measuring over 50 degrees were most likely to progress.
Danielsson and Nachemson reported on the effect of scoliosis, and scoliosis treatment on women’s ability to bear children. They found no difference in rate of cesarean section between women treated with surgery, a brace or a control group. They did find a slight increase in the risk of having to have vacuum extractions in the surgery group compared to either of the other two groups.
Answer 1: Women who have scoliosis do not have an increased risk of cesarean sections than those without scoliosis
Answer 2: Patients with a 38-degree curve do not have an increased risk of pulmonary dysfunction.
Answer 3: The patient has a Lenke type 1, main thoracic curve. No advanced imaging is needed
Answer 5: The patient is post-menarcheal by 2 years, and her curve is 38 degrees. She has a low risk of curve progression
Weinstein SL, Dolan LA, Spratt KF, Peterson KK, Spoonamore MJ, Ponseti IV
JAMA. 2003 Feb;289(5):559-67. PMID: 12578488 (Link to Abstract)
Weinstein, JAMA 2003
Weinstein SL, Ponseti IV.
J Bone Joint Surg Am. 1983 Apr;65(4):447-55. PMID: 6833318 (Link to Abstract)
Weinstein, JBJS 1983
Danielsson AJ, Nachemson AL.
Spine (Phila Pa 1976). 2001 Jul 1;26(13):1449-56. PMID: 11458150 (Link to Abstract)
Danielsson, SPINE 2001
Lenke LG, Betz RR, Harms J, Bridwell KH, Clements DH, Lowe TG, Blanke K.
J Bone Joint Surg Am. 2001 Aug;83-A(8):1169-81. PMID: 11507125 (Link to Abstract)
Lenke, JBJS 2001
Average 3.0 of 21 Ratings
When compared to normal controls, adults with untreated idiopathic scoliosis and a Cobb angle of greater than 60 degree at the time of skeletal maturity have a higher rate of which of the following?
Acute and chronic back pain
Limitation in activities of daily living
Patient with untreated adolescent idiopathic scoliosis with a curve of 60 degrees or greater at skeletal maturity have an increased rate of low back pain relative to normal controls.
Weinstein et al (1981) looked at patients with untreated AIS. They found "many curves continued to progress slightly in adult life, particularly thoracic curves that had reached between 50 and 80 degrees at skeletal maturity. Backache was somewhat more common in these patients than in the general population, although it was never disabling. Pulmonary function was affected only in patients with thoracic curves."
Weinstein et al (2003) looked at patients with 50-year follow-up of patients with untreated AIS (same cohort as prior study) and compared them with age/sex matched normal controls. They found 61% of patients with AIS reported chronic back pain compared with 35% of controls (P =.003). However, the pain reported was only mild or moderate. There was no statistically significant difference in disability, depression, age at death of patients, and capacity to perform activities of daily living. They conclude untreated AIS causes little physical impairment other than back pain and cosmetic concerns.
Weinstein SL, Zavala DC, Ponseti IV.
J Bone Joint Surg Am. 1981 Jun;63(5):702-12. PMID: 6453874 (Link to Abstract)
Weinstein, JBJS 1981
Average 3.0 of 38 Ratings
Part 3 of 3This video explains posterior corrective surgery for adolescent idiop...
Part 2 of 3This video explains posterior corrective surgery for adolescent idiop...
Part 1 of 3This video explains posterior corrective surgery for adolescent idiop...
HPI - A 22F patient presents with a prominent deformity of her spine.
She states that she has had idiopathic scoliosis since age 12, with no management (bracing or surgery) up to this point.
How would you manage this patient?