Orthopaedics

1. Scoliosis

2. Scoliosis
 Scoliosis from Greek: skoliōsis meaning from skolios ,
"crooked“ “twisted”)
 It is a complex three-dimensional deformity
 Abnormal lateral curvature of spine in which there is
deformity in the coronal plane
 May alter sagittal plane as well

3. Scoliosis
 Spinal rotation causes posterior prominence
 Upto 10 degrees is normal.
 Can be seen as C- curve or S-curve.
 S- curve is usually compensatory.

4. Demography
 Occurs in 2-3% of population below the age of 16 years.
 0.1% have a curve greater than 40 degrees.
 Girls are more affected than boys.

5. Demography
 Those with a curve of more than 30 degrees are generally
girls, outnumbering boys by 10:1
 Generally progresses during the period of ‘growth spurts’.
 Adolescents are more routinely tested for this.

6. Types of Scoliosis
 Congenital
 Neuromuscular
 Cerebral palsy
 Syndrome related
 Marfan’s syndrome
 Idiopathic
 80% are this

7. Etiological Theories
 Growth abnormalities
 Genetic
 Tissue deficiencies
 Central nervous system alteration

8. Growth abnormalities

9. Genetic
 11% incidence in first relatives of patients
 Normal incidence < 3%
 Monozygote twins more common
 No gene identified to date

10. Tissue Deficiencies`1
 Marfan’s syndrome deficient fibrillin
 Osteopenia noted in girls
 Elevated calmodulin
 Involved in contractile properties of actin & myosin
 Elevated in platelets
 No consistent findings to date

11. Central Nervous System
 Different size cerebral cortices
 Altered equilibrium
 Primary or secondary
 Deficient melatonin
 Inconclusive in humans

12. Terminology
 Named by apex
 Cervical if between C2-C6
 Cervicothoracic if between C7-T1
 Thoracic if between T2-T11
 Thoracolumbar if between T12-L1
 Lumbar if between L2 and below

13. Terminology
 Primary vs secondary
 Structural vs non-structural

14. Classification
 Infantile: 0-3 years old (.5%)
 Juvenile: 4-9 years old (10.5%)
 Adolescent: 10-17 years old (89%)
 Adult: >18 years old

15. Physical Exam
 Family history
 Affected sibling 7 times more frequent
 Affected parent 3 times more frequent
 Recent growth history
 Pain
 ‘Fatigue pain’
 Post diagnostic pain
 ‘Severe pain’

16. Physical Exam
 Iliac crest height
 Shoulder height
 Arm trunk space
 Scapular position
 Trunk shift
 Inspection of skin
 Café au lait spots

17. Physical Exam

18. Physical Exam
 Features suggestive of polio, neurofibromatosis, Von
Reclinghausen syndrome, Down’s, Marfan’s,
Hurler’s syndrome, neural tube defects and
osteogenesis imperfecta.
 Forward protrusion of chest wall on affected side.

19. Physical Exam
 Increased flank creases on opposite side.
 Higher ASIS and PSIS on concave side.
 Spinous process turned into concave side.

20. Tests of flexibility of spine
 Adam’s forward bending test.
 Pushing the curve from convex side and noting
 the correction.
 Lifting the patient up from head.
 Lateral bending.

21. Forward Bend Test
Adam’s sign

22. Neurologic Exam
 Observe gait
 Hop test
 Heel and toe walk
 Reflexes

23. Early Detection
 Visual examination of gait, posture, limb length and
lateral curvature of spine.
 A posterior view taken, bent at 90 degrees at hips.
 Can also be detected accidently when radiographs are
taken to rule out other pathologies.

24. Imaging
 Plain x-rays
 Posterior to anterior
 Decrease thyroid and breast exposure 3-7 fold
 Note rotation
 Measure deformity by Cobb method
 Skeletal maturity

25. Cobb Method
 Choose the most tilted vertebrae above and below
the apex of the curve.
 Draw a line perpendicular to that vertebrae.
 The angle created between these intersecting lines
is the Cobb angle.

26. Cobb Method

27. Rotation
 Spinous process rotates into concavity
 Pedicle position

28. Skeletal Maturity
 Triradiate cartilage fusion
 Risser sign

29. MRI
 Neurologic deficit
 Infantile and juvenile curves
 Spinal cord abnormality in younger children
 Infantile idiopathic scoliosis 50%
 Juvenile 20%

30. Who needs an MRI
 A thoracic curve to the left.
 Painful scoliosis.
 Abnormal neurological findings.
 Untoward stiffness.
 Deviation to one side during the bend test.
 Sudden rapid progression of a previously stable
curve.

31. Curve Progression
 Three factors involved in progression
 patient’s gender
 future growth potential
 curve magnitude at time of diagnosis
 Females are 10 times more likely to have
progression than males.
 The greater the growth potential and larger the
curve = more likely to progress

32. Curve Progression
 Curves 30 to 50 degrees progress an average of
10 to 15 degrees over a lifetime.
 Curves > 50 at maturity progress steadily at a rate
of 1 degree per year.
 Curves less than 30 at bone maturity are unlikely
to progress.

33. Complications
 Neurological Deficit
 At 100 degrees or greater: increased potential for
life threatening effects on pulmonary function.
 Psychologic illness: seen in up to 19% of
females with curves great than 40 degrees as
adults.
 Cosmetic
 Growth disturbance

34. Treatment principles
 Orthotic braces - 74% success rate at halting
progression
 Must be worn 20 hours a day, but most pts
are not compliant.
 Braces do not correct scoliosis.
 Surgical therapy is definitive, but indicated only
for those at 40 degrees or above

35. Infantile Treatment
 90% are left thoracic
 3 female : 2 male
 90% resolve spontaneously
 Predict progression by RVAD
 < 20 degrees 83% resolve
 >20 degrees 84% progress

36. Juvenile Treatment
 Younger onset likely to progress
 >30 degree curve almost always progress
 Some adolescent curves are missed juvenile

37. Adolescent Treatment
 Most curves <10 degrees
 Boys = girls for these curves
 Usually don’t progress
 More severe curves (>30 degrees)
 8 girls : 1 boy
 Predicting who will progress

38. Risk for Progression
 Younger onset
 Skeletal age
 Risser 0-1 at presentation 60-70% progress
 Risser 3 only 10% risk
 Female more likely than male
 Curve pattern
 Apex above T12
 Degree at presentation
 20-29 degrees 68% risk for progression
 30-59 degrees 90% risk for progression

39. Natural History
 If curve <30 degrees at maturity
 No adult consequences
 Unlikely to ever progress
 Curves >45 degrees may progress a degree/year
 Mortality not increased unless curve >90 degree
 Right heart failure
 Decreased pulmonary function

40. Treatment : 10 degrees curve or
less
 This curve is considered normal.
 No action is taken.
 Follow up appointments are prescribed to monitor the
patient.
 Usually done every 3-6 months, but at the physician
discretion.

41. Treatment:10 to 25 degree curve
 Sometimes no treatment needed, if no progression.
 Begins with simple orthotics(very effective)
 daytime/nighttime braces.
 Shoe lifts for leg length discrepancies.
 Stretches, exercises.

42. Shoe Lifts
 Used for leg length discrepancies.
 Worn in regular shoes.
 Places opposing pressure on scoliosis curvatures.
 Must be worn during every scoliosis radiograph.

43. Treatment: 25 to 35 degree curve
 Day and night brace worn 20+ hours/day.
 Shoe lifts may also be needed.
 Stretches and exercises to loosen muscles and to
relieve pain if present.

44. Treatment: 45 degree + curve
 Almost always treated with surgery.
 Vertebrae are fused using-
Bone grafts.
Hardware(metal splints)
 Still require braces to be worn in post op period.
 Causes growth to stop.
 Can cause nerve damage, infection and other
problems.

45. Treatment: 45 degree + curve
 Almost always treated with surgery.
 Vertebrae are fused using-
Bone grafts.
Hardware(metal splints)
 Still require braces to be worn in post op period.
 Causes growth to stop.
 Can cause nerve damage, infection and other
problems.

46. If untreated ?
 If progressing, can worsen upto 70 degrees + curve.
 Places pressure on vital organs.
 Can cause cardio-respiratory problems.
 Can eventually become untreatable.

47. Non-Operative Treatment
 <25 degrees monitor every 4-12 months
 Depends on skeletal maturity
 >25 degrees monitor every 3-6 months
 >30 degrees in skeletally immature brace
 Curve >10 degrees brace
 Curve >40-45 degrees surgery

48. Braces
 Made of polypropylene.
 Contoured to size and shape of body.
 Curved to oppose specific points of scoliosis
curvature.
 Flexible and comfortable.
 Worn under clothing.
 Night time/day time use.
 Must be worn faithfully.

49. Bracing
 Duration and time in brace
 23 hours per day
 Wear until skeletally mature
 Types
 Milwaukee
 Underarm orthosis
 boston
 Electrical stimulation

50. Braces

51. Successful Bracing
 Prevent curve progression
 Randomized study
 Braced 74% did not progress
 Not braced 34% did not progress
 Electrical stimulation
 33% did not progress

52. Problems with Braces
 Argued efficacy
 Narrow treatment window to initiate
 Poor compliance
 Must have good orthotist
 Curves corrected by 20 degrees in brace do better

53. Surgery
 Failed bracing
 Curves >45 degrees
 Unbalanced curves >40 degrees
 Surgery is fusion with instrumentation

54. Surgical Options
 Infantile and juvenile scoliosis:
 <8 yrs- instrumentation without fusion.
 After 8 years- anterior and posterior spinal
fusion.
 After 11 years- posterior spinal fusion.

55. Surgical Options
 Adolescent scoliosis:
 Posterior spinal fusion with instrumentation.
 Anterior spinal fusion if younger than 11 years
and with open triradiate cartilage.

56. THANK YOU…