Scoliosis

Scoliosis• Scoliosis is defined as an abnormal curvature and

rotation of the spine

Types of Scoliosis

Functional scoliosis• It is a curvature due to a problem that does not involve

the spine, such as having legs that are different lengths or muscle spasms caused by pain. These can cause to lean to the side, creating the appearance of scoliosis.

• The curvature is flexible and will go away if the problem that causes to lean to the side goes away.

Structural scoliosis• The spine curvature is not flexible and does not go

away with a change in position.• There is no evidence that functional scoliosis will lead to

structural scoliosis.

Cont… Idiopathic structural scoliosis (80% of children

with structural scoliosis ) Structural scoliosis associated with other

conditions• In about two out of every 10 cases, children with

structural scoliosis also have one of these conditions:– Born with vertebrae that do not develop normally

(congenital scoliosis) – An underlying problem in the brain or spinal cord,

such as a cyst or a tumor. – A problem with nerves or muscles, such as cerebral

palsy or muscular dystrophy.

Signs of scoliosis

• .

Radiology

– PA view – Lateral view – Right and left bending view – Oblique view

Cobb method

• Measuring the degree of scoliosis : -

• choose the most tilted vertebrae above and below the apex of the curve.

• The angle between intersecting lines drawn perpendicular to the top of the top vertebrae and the bottom of the bottom vertebrae is the Cobb angle.

Cobb`s method

Treatment

– Early detection of the curve

– A curve that is obvious in standing position has already approached 30 – 40 degree.

– The treatment depends on the age of the patient and the severity of the curve

Cont.. Nonsurgical treatment :

Generally accepted guidelines : – Curves of less than 20 degree in skeletally immature

persons are examined every 6 months– Curves less than 20 degree in skeletally mature

persons require no further evaluation – Curves of more than 20 degree in skeletally immature

patients should be examined every 3 – 4 months– Orthotic TX. For curve more than 25 degree– Curves more than 30 – 40 degree in skeletally mature

persons do not require Tx .but they are examined radiographically for progression every 2 – 3 years

Orthotic Tx .

• Boston Brace

Milwaukee Brace

Charleston Bending Brace

Surgical treatment

Indication : – Curves more than 50 degree in the mature

patients– Curves more than 10 degree with marked

rotations– Double major curves more than 30 degree– Idiopathic scoliosis

Cont…

• Distractive techniques

• Halopelvic

a: pre-operation b: after anterior release and halo-pelvic traction.c: after second stage correction d: follow-up 6 months later.

Halofemoral distraction• A-B: AP radiographs before

treatment showing right thoracic scoliosis measured 92°.

• C:Bending films showed right thoracic scoliosis corrected to 77°.

• D:The right thoracic curve correction obtained with Halo-femoral traction treatment was 40.2%.

• E-F:The major curve measured 35° after posterior spinal fusion

• G-H: AP and lateral radiographs at 20-month follow-up showed solid spinal fusion with a 37° right thoracic curve.

Kyphosis

– Also called as Scheuermann's disease; Roundback; Hunchback; Postural kyphosis

– Defined as increase in normal posterior convexity of the thoracic spine

Cont…

Causes

• Degenerative disease (such as arthritis)

• Developmental problems • Trauma

Other causes of kyphosis include:

• Certain endocrine diseases • Connective tissue disorders • Disk degeneration • Infection (such as tuberculosis) • Muscular dystrophy • Neurofibromatosis • Paget's disease • Polio• Spina bifida • Tumors

Symptoms

– Difficulty breathing (in severe cases) – Fatigue – Mild back pain – Round back appearance– Tenderness and stiffness in the spine

Types

• Knuckle : prominence of single spinous process indicating collapse of single vertebra

• Angular : 2 – 3 vertebral body are collapsed

• Round : several vertebrae are involved and hence gives a round appearance

Investigations : - – X – ray of the thoracic spine – CT scan – MRI

Treatment : -– Mild : anterior hyperextension bracing

– Severe : Surgical decompression

Cont…

Complications

- Decreased lung capacity – Disabling back pain – Neurological symptoms including leg

weakness or paralysis – Round back deformity

Perthes' disease

– It is a condition where the top of the thigh bone (the femoral head) softens and breaks down.

– It occurs in some children and causes a limp and other symptoms.

– The bone gradually heals and reforms as the child grows.

– The aim of treatment is to ensure that the femoral head regrows back into its normal shape so that the hip joint can function well.

Cont…

Cont…

– Occurs in a part of the hip joint called the 'femoral head'. Injury to the small blood vessels which supply the femoral head with blood. So, parts of the femoral head lose their blood supply. As a result, the bone cells in the affected area die and so the bone 'softens', and can fracture or become distorted.

– Over several months the blood vessels regrow, and the blood supply returns to the bone tissue. New bone tissue is laid down, and so the femoral head regrows.

Cont…

– Femoral head forms a good spherical (rounded) shape. This helps it fit well into the hip joint socket.

– If the femoral head is less rounded, hip movements may be affected and there may be more 'wear and tear' on the hip joint.

Symptoms• Limp. gradually worse over a few weeks.

• Pain in the hip and groin area (radiate to the knee or thigh ).

• Stiffness and reduced range of movement of the affected hip.

• The affected leg may become slightly thinner (wasted), because it is not used as much as the other leg.

• Shortening of leg

Diagnosed

• Examination of the hip, • X-ray (both hips )

Others test : – MRI scan, – Bone scan and – Arthrogram (an X-ray where dye is injected

into the joint space). – Blood tests, or a sample of fluid from the joint

(to rule out other problems such as infection ).

Treatment

– The aim of treatment is to promote the healing process and to ensure that the femoral head remains well seated in the hip socket as it heals and regrows.

– Treatment depends on the age of the child and the severity of the condition.

– Treatments may include 'observation', bed rest and crutches, a plaster cast or special leg brace, or surgery.

Nonsurgical Treatment– Anti-inflammatory ----- ibuprofen – Encouraged to walk with crutches and

participate in physical therapy.– Bed rest in traction .– With physical therapy, the child will be shown

some simple exercises to do until the final stage of healing has occurred.

- Hip abduction

- Hip rotation

Observation and physiotherapy– In the past, children with Perthes' disease were treated with

a plaster cast, a brace, or surgery. However, it is now known that at least half of cases heal well without any treatment, particularly children aged five and under, and milder cases.

Most children with Perthes' disease can be treated by physiotherapy and home exercises - these are to keep the hip joint mobile and in a good position in the hip socket.

– Regular reviews to check how the femoral head is healing. Advice may include to encourage swimming (to keep the hip joint active in the full range of movements), but

– Avoid heavy impact on the joint such as running or jumping.

– Bed rest and/or crutches : - if symptoms are bad.

Plaster casts or a special brace

• Considered in more severe cases or in older children.

• The aim is to keep the femoral head well positioned in the hip socket (slightly pointing outwards).

• Special braces (also called called 'orthotic' devices') may be advised.

Surgery

• Help to keep the femoral head well positioned, or can improve the shape and function of the joint if it has not healed well.

Examination pattern

• Total marks = 200 Pass marks = 120

• Theory = 100 marks

• Practical = 100 marks

Division of practical marks : – Internal assessment ----------------- 15 marks– Viva -------------------------------------- 15 marks– Practical : 70 marks

Cont…Division of practical marks ------- 70 marks • Long case ----------------------------- 30 marks • Short case ---------------------------- 20 marks• Spotting ------------------------------- 20 marks

Long case

Case with or without diagnosis Short history about that case General examination Systemic examination :

– Respiratory system examination– CVS examination– Per abdominal examination– CNS examination

Local examination : site of injury

Cont…• Differential diagnosis• Investigation• Provisional diagnosis• Management

Short case • Two short case -------------- 15 + 15 = 30 marks Systemic examination , example ;

– 1 . Motor system examination– 2 . Sensory system examination– 3 . Respiratory system examination– 4 . CVS or P / A examination or percussion of chest or

auscultation of heart and lungs or vitals examination or PILCCOD examination etc.

– 5. Upper limbs and lower limbs ( joints : shoulder , elbow , wrist , hip , knee , ankle ) examination .