C h a p t e r 4 3
Disorders of the Skeletal System: Trauma, Infections, Neoplasms, and Childhood Disorders
1107
usually is a painless process, although pain may be pres-
ent in severe cases, usually in the lumbar region. The
pain may be caused by pressure on the ribs or on the
crest of the ilium. There may be shortness of breath as
a result of diminished chest expansion and gastroin-
testinal disturbances from crowding of the abdominal
organs. Adults with less-severe deformity may experi-
ence mild backache. If scoliosis is left untreated, the
curve may progress to an extent that compromises car-
diopulmonary function and creates a risk for neurologic
complications.
Diagnosis andTreatment
Early diagnosis of scoliosis can be important in the pre-
vention of severe spinal deformity. The cardinal signs of
scoliosis are uneven shoulders or iliac crest, prominent
scapula on the convex side of the curve, misalignment of
spinous processes, asymmetry of the flanks, asymmetry
of the thoracic cage, and rib hump or paraspinal muscle
prominence when bending forward
79–80
(see Fig. 43-24).
A complete physical examination is necessary for chil-
dren with scoliosis because the defect may be indicative
of other, underlying pathologic processes.
Diagnosis of scoliosis is made by physical examina-
tion and confirmed by radiography. A scoliometer is
used at the apex of the curvature to quantify a promi-
nence; a scoliometer reading of greater than 10 degrees
requires referral to a physician. The curve is measured
by determining the amount of lateral deviation present
on radiographs and is labeled “right” or “left” for the
convex portion of the curve. Other radiographic proce-
dures may be done, including CT scanning, MRI, and
myelography.
Although school screening continues to be mandated
in a number of states, the USPSTF recommends against
the routine screening of asymptomatic adolescents for
idiopathic scoliosis, indicating that the potential harms
from screening include unnecessary follow-up visits and
evaluations due to false-positive results, and adverse
psychological effects, especially related to brace wear.
80
It is recommended, however, that health care profession-
als be prepared to evaluate idiopathic scoliosis when it is
discovered incidentally or when an adolescent or parent
expresses concern about scoliosis.
The treatment of scoliosis depends on the severity
of the deformity and the likelihood of curve progres-
sion. The three determinants of progression are gender,
the curve magnitude at the time of diagnosis, and skel-
etal growth potential.
82–83
In all cases, girls have a risk
progression 10 times greater than that of boys. Larger
curves are more likely to progress. Age of presentation
also is important. Curves that are detected before men-
arche are more likely to progress than those detected
after menarche. For persons with lesser degrees of
curvature (10 to 20 degrees), the trend has been away
from aggressive treatment and toward a “wait and see”
approach, taking advantage of the more sophisticated
diagnostic methods that now are available. Treatment
is considered for physically immature patients with
curves between 20 and 30 degrees. Curves between
30 and 40 degrees usually are considered for bracing,
and those greater than 40 to 45 degrees are considered
for surgery.
A brace may be used to control the progression of
the curvature during growth and can provide some cor-
rection. In an effort to improve compliance, a number
of new bracing techniques have been developed. These
orthoses consist of easily more concealed, prefabricated
forms that are modified to suit the patient.
The goals of surgery are to arrest progression of
the deformity, improve appearance, and achieve a bal-
anced spine, while limiting the number of vertebral seg-
ments that are stabilized. Instrumentation helps correct
the curve and balance, and spinal fusion maintains the
spine in the corrected position.
75–79
Several methods of
instrumentation (i.e., rods that attach to the vertebral
column and posterior fusion) are used. Combined ante-
rior and posterior surgery is used for more severe curva-
tures. The newer systems provide better sagittal control
and more stable fixation, which allow earlier mobility.
Despite great advances in spinal surgery, no one method
seems to be the best for all cases. There is recent inter-
est in growth modulation approaches using minimally
invasive techniques, which will result in curve correc-
tion while preserving spinal motion and intervertebral
disk viability.
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SUMMARY CONCEPTS
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Skeletal disorders can result from congenital or
hereditary influences or from factors that occur
during normal periods of skeletal growth and
development. Newborn infants undergo normal
changes in muscle tone and joint motion, causing
torsional conditions of the femur or tibia. Many of
these conditions are corrected as skeletal growth
and development take place.
■■
Osteogenesis imperfecta is a rare autosomal
hereditary disorder characterized by defective
synthesis of connective tissue, including bone
matrix. It results in poorly developed bones that
fracture easily.
■■
Disorders such as developmental dysplasia of
the hip and congenital clubfoot are present at
birth. Both of these disorders are best treated
during infancy. Regular examinations during the
first year of life are recommended as a means of
achieving early diagnosis.
■■
Other childhood skeletal disorders, such as the
juvenile osteochondroses and slipped capital
femoral epiphysis, are not corrected by the
growth process.These disorders are progressive,
can cause permanent disability, and require
treatment.
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