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U N I T 1 2
Musculoskeletal Function
meaning that the femur is rotated externally from under
the epiphysis. It is considered the most common hip dis-
order of adolescence with an increased prevalence among
males, most often between 11 and 16 years of age.
72
The cause of slipped capital femoral epiphysis is
obscure, but it may be related to the child’s susceptibil-
ity to stress on the femoral neck as a result of genetics
or structural abnormalities. Affected children often are
overweight with poorly developed secondary sex char-
acteristics, or, in some instances, are extremely tall and
thin. In many cases, there is a history of rapid skeletal
growth preceding displacement of the epiphysis. The
condition also may be affected by nutritional deficien-
cies or endocrine disorders such as hypothyroidism,
hypopituitarism, and hypogonadism.
Children with the condition often complain of referred
knee pain accompanied by difficulty in walking, fatigue,
and stiffness. The diagnosis is confirmed by radiographic
studies in which the degree of slipping is determined and
graded according to severity.
72
Early treatment is impera-
tive to prevent further slippage and permanent deformity.
Avoidance of weight bearing on the femur and bed rest
are essential parts of the treatment. Traction or gentle
manipulation under anesthesia is used to reduce the slip.
Surgical insertion of pins to keep the femoral neck and
head of the femur aligned is a common method of treat-
ment for children with moderate or severe slips. Crutches
are used for several months after surgical correction to
prevent full weight bearing until the growth plate closes.
Children with the disorder must be followed closely
until the epiphyseal plate closes. Long-term prognosis
depends on the amount of displacement that occurs.
Complications include avascular necrosis, leg shorten-
ing, malunion, and problems with internal fixation.
Degenerative arthritis may develop, requiring joint
replacement later in life.
Scoliosis
Scoliosis is a lateral curvature of the spine in the upright
position. Scoliosis is classified as postural or structural.
With postural scoliosis, there is a small curve that cor-
rects with bending. It can be corrected with passive and
active exercises. Structural scoliosis does not correct with
bending. It is a fixed deformity classified according to
the cause: congenital, neuromuscular, or idiopathic.
75–79
Types of Scoliosis
Congenital scoliosis is caused by disturbances in verte-
bral development during the sixth to eighth weeks of
embryologic development.
75–79
It may involve failures of
formation or failures of segmentation. Failures of for-
mation indicate the absence of a portion of the vertebra,
such as hemivertebra (absence of a whole side of the
vertebra) and wedge vertebra (missing only a portion
of the vertebra). Failure of segmentation is the absence
of the normal separation between the vertebrae. The
child may have other anomalies and neurologic com-
plications if the spine is involved. Early diagnosis and
treatment of progressive curves are essential for children
with congenital scoliosis. Surgical intervention is the
treatment of choice for progressive congenital scoliosis.
In neuromuscular scoliosis, there is often a long,
C-shaped curve from the cervical to the sacral region. It
is seen in children with cerebral palsy, in whom severe
deformity may make treatment difficult. It also develops
in children with Duchenne muscular dystrophy and usu-
ally is not severe.
Idiopathic scoliosis is a structural spinal curvature for
which no cause has been established. It occurs in healthy,
neurologically normal children. Although the incidence
is only slightly greater in girls than boys, it is more likely
to progress and require treatment in girls.
8,77–79
It seems
likely that heredity is involved because mother–daugh-
ter pairings are common, but identical twins are not
uniformly affected, and the magnitude of the curvature
in an affected individual is not related to magnitude of
curvature in relatives. A recent study of the melatonin
receptor 1B (MTNR1B) gene in persons with adolescent
idiopathic scoliosis suggests that the MTNR1B gene
may serve as a susceptibility gene.
81
Idiopathic scoliosis usually appears clinically between
the age of 10 and skeletal maturity, but may be seen at
any age. By definition, the curve must be greater than
10 degrees—this has historically been used because 10
degrees is the limit that can be detected by physical exami-
nation.
8
Although the curve may be present in any area of
the spine, the most common curve is a right thoracic curve.
Manifestations
Scoliosis usually is first noticed because of the deformity
it causes. A high shoulder, prominent hip, or projecting
scapula may be noticed by a parent or in a school-based
screening program (Fig. 43-24). Idiopathic scoliosis
Right rib
hump
Left
lumbar
hump
Elevated
shoulder
Prominent
hip
FIGURE 43-24.
Scoliosis: Abnormalities to be determined at
initial screening examination.
