-
3
3.5.3.12 Generalized skeletal abnormalities ( VII) (Apert and
Poland syndromes,
Arthrogryposis etc.) – 479
3.5.4 Dislocations of the shoulder – 4803.5.5 Growth
disturbances of the upper
extremities – 4843.5.5.1 Panner’s disease – 484
3.5.5.2 Osteochondrosis dissecans of the
capitellum – 484
3.5.5.3 Lunatomalacia – 485
3.5.6 Neuromuscular disorders of the upper extremity –
4853.5.6.1 Primarily spastic paralyses – 486
3.5.6.2 Primarily flaccid paralyses – 490
3.5.7 Fractures of the upper extremities – 4943.5.7.1 Scapular
fractures – 494
3.5.7.2 Clavicular fractures – 494
3.5.7.3 Proximal humeral fractures – 495
3.5.7.4 Humeral shaft fractures – 497
3.5.7.5 Elbow fractures – 498
3.5.7.6 Supracondylar humeral
fractures – 499
3.5.7.7 Epicondylar humeral
fractures – 503
3.5.7.8 Transcondylar humeral
fractures – 504
3.5.7.9 Radial head and neck
fractures – 507
3.5.7.10 Olecranon fractures – 508
3.5.7.11 Elbow dislocations – 509
3.5.7.12 Radial head dislocations
(Monteggia lesions) – 510
3.5.7.13 Forearm shaft fractures – 512
3.5.7.14 Distal forearm fractures – 515
3.5.7.15 Fractures of the carpal bones – 517
3.5.7.16 Fractures of the metacarpals and
phalanges – 518
3.5.8 Tumors of the upper extremities – 522
-
573.1.1 · Examination of the back
3
3.1 Spine , trunk
3.1.1 Examination of the back
History ▬ Trauma history: Has trauma occurred? If so:
– When did the trauma occur?– What was the patient doing (sport,
playing, normal
routine)?– Direct or indirect trauma?
▬ Pain history : Where is the pain located (neck, upper thoracic
spine,
lower t horacic s pine, l umbar sp ine, l umbosacral spine)? W
hen do es i t o ccur? I s i t r elated t o loadin g or movement, or
does it also occur at rest (e.g. while sitting) o r e ven a t nig
ht? I f s o, do es t he pa in o ccur only while changing position,
or does the pain cause the patient to wake up at night? Does the
pain occur on bending down or straightening up again? Does the pain
also radiate to the legs? D oes the pain occur on coughing or
sneezing ?
▬ Sports history What sports does the patient practice outside
school?
If spondylolysis is suspected ask specifically about the
following activities: gymnastics, figure skating, ballet,
javelin-throwing. If Scheuermann disease is suspected ask
specifically whether the patient is involved in cycle racing or
rowing.
▬ Neurological symptoms Is a leg w eakness present and, if s o,
since w hen? Are
there problems of micturition or defecation?
Inspection After the gait analysis (� Chapter 2.1.3), the
standing pa-tient’s back is inspected from behind.
! To ensure that the patient’s back is at eye-level, the
examiner himself should not stand but preferably sit on a chair of
the appropriate height (⊡ Fig. 3.1).
▬ Inspection from behind We observe the position of the
shoulders, the height
of the scapulae and particularly the symmetr y of the waist tr
iangles . W e lo ok f or p igmentation o ver t he spinous p
rocesses, es pecially o ver t he l umbar sp ine, as this can be an
indication of (usually pathological) kyphosis in this area. A
(hairy) nevus in this area can be a sign of an intraspinal
anomaly.
▬ Inspection from the side We ass ess t he s agittal c urves a
nd est ablish a p os-
tural typ e : normal (p hysiological) bac k, ho llow bac k
(increased t horacic k yphosis a nd l umbar lo rdosis), fully
rounded back (kyphosis extending down to the lumbar a rea), ho
llow-flat bac k (h yperlordosis o f t he lumbar sp ine wi th r
educed kyp hosis o f t he t horacic spine, common in small c
hildren), flat back (reduced kyphosis of the thoracic spine and
lordosis of the lum-bar spine; ⊡ Fig. 3.2).
! If the sagittal curves can be corrected by bending backwards
or forwards, then postural variants are involved rather than
(fixed) pathological changes. N.B.: beware of overdiagnosis and
overtreatment!
We observe whether a ventral or dorsal overhang is pres-ent (⊡
Fig. 3.3) and the extent of the pelvic tilt (⊡ Fig. 3.4).
⊡ Fig. 3.1a. Not like this! b During examination in the standing
position the patient ’s back should be at the ey e lev el of the
examiner , who should therefore be seated. Small children may need
to stand on a box so that the iliac cr est is at the examiner ’s
eye level. The child must be undressed down to the underpants. The
dignity of the child or adoles-cent must be pr eserved. Girls who
ha ve reached puberty should also be allo wed t o w ear their
brassier e. O therwise, all it ems of clothing , including socks,
should be removed.
a
b
-
A vertical line from the center of the shoulders should pass t
hrough t he cen ter o f t he a nkle. The f orward a nd downward
pelvic tilt is approx. 30° in relation to the hori-zontal. A r
eduction in t his tilt is a n indication of lumbar kyphosis (e .g.
in l umbar S cheuermann dis ease) o r o f spondylolisthesis.
In order to assess posture-related muscle performance, Matthiass
has proposed the arm-raising test . The child is asked to st and as
stra ight as p ossible and ra ise his a rms and keep them in a
horizontal position. He should try and maintain this position for
30 s econds. A c hild or adoles-cent with normal postural capacity
is able to maintain this position, in co ntrast with a c hild with
postural weakness (⊡ Fig. 3.5).
We no w ask t he c hild t o b end do wn as fa r as p os-sible
while keeping the knees perfectly straight. We now measure the
finger-floor distance (FFD; ⊡ Fig. 3.6). Nor-mally, children and
adolescents should be able to touch the f loor wi th t heir f
ingertips o r e ven p lace t he w hole palm of their hand on the
floor. If this is not possible, we measure the distance from the
fingertips to the f loor in
58 3.1 · Spine, trunk
3
⊡ Fig. 3.4. Pelvic tilt : The forward and do wnward pelvic tilt
in r elation to the horizontal is normally approx. 20°–30°
⊡ Fig. 3.2a–e. Postural types : a normal back, b hollow back, c
rounded back, d hollow-flat back, e flat back
a b c d e
⊡ Fig. 3.3a. Ventral and b dorsal overhang: A vertical line from
the cen-ter of the shoulders falls in fr ont of or behind the
center of the ankle
a b
⊡ Fig. 3.5a–c. Arm-raising test according to Matthiass : The
child is asked to stand as straight as possible and raise his arms
and keep them in a horizontal position. He should tr y to maintain
this position f or 30 sec-onds. A child or adolesc ent with normal
postural per formance is able
to maintain this position (a), in the case of a postural w
eakness this posture is lost (b), while a child with ex tremely
weak muscles cannot even adopt the upright posture (c)
a b c
-
3.1.1 · Examination of the back359
⊡ Fig. 3.6. Finger-floor distance (FFD): The patient bends down
as far as possible without bending the k nees. The distance between
the floor and the fingertips is measured. Normal value = 0 cm
⊡ Fig. 3.7. Straightening of the k yphosis: While in a f
orward-bending position the patient clasps his hands behind his
neck (t o prevent the shoulders from being pulled forward by the
arms) and tries to look up at the ceiling without changing this
flexed position at the hip . Ideally, the patient is held in this
position with a hand placed at the apex of the kyphosis and then
asked t o bend back (»look up at the c eiling«). We can then
observe whether the thoracic kyphosis is straightened out or
whether a fixed kyphosis is present
⊡ Fig. 3.8. Height of the iliac cr ests : Ex tended index
fingers ar e posi-tioned on both sides of the ilium. The thumbs ar
e ex tended and abducted at right angles t o serve as pointers. If
one iliac crest is lower than the other this will be r eflected in
the diff erence in the height of the thumbs . Boar ds ar e plac ed
under the shor ter leg until the iliac crests on both sides ar e at
the same lev el and the t wo thumbs ar e likewise at the same
height.
centimeters. However, this distance is less a n indication of re
duced m obility of t he b ack t han of c ontraction of the
hamstrings. With t he patient in a f orward-bending position we
observe whether the lumbar lordosis is cor-rected a nd w hether t
he t horacic sp ine sho ws t he r ight degree of kyphosis
(correction of p ostural curvature in the cas e o f a ho llow o r f
lat bac k). The pa tient is no w asked t o c lasp his ha nds b
ehind his nec k (t o p revent the sho ulders f rom b eing p ulled f
orward b y t he a rms) and tr y t o lo ok u p a t t he ceilin g wi
thout c hanging t he flexed po sition a t th e h ip. I deally, th e
pa tient i s h eld in t his p osition wi th a ha nd p laced a t t
he a pex o f t he kyphosis and then asked to bend back (»look up at
the ceiling«). W e ca n t hen obs erve w hether t he t horacic
kyphosis stra ightens o ut o r w hether a f ixed kyp hosis is p
resent (e .g. as in a cas e o f t horacic S cheuermann disease; ⊡
Fig. 3.7). I f t he latter is susp ected, t he condi-tion of the
pectoral muscles must also be assessed at the same time. To this
end, the shoulders of the erect patient are p ushed bac kwards b y
ha nd. I f t he p ectoral m us-cle is co ntracted, t he sho ulder r
emains in f ront o f t he thoracic plane.▬ Evaluation of the iliac
crest We p lace extende d index f ingers o n b oth sides o f
the ilium and extend and abduct the thumbs at right angles, w
hich t hen s erve as p ointers. We tr y to hold both thumbs
horizontally (⊡ Fig. 3.8). If one iliac crest is lower than the
other this will be reflected in the dif-ference in the height of
the thumbs. However, since it can be difficult to establish the
precise difference, we place boards under the shorter leg until the
iliac crests on both sides are at the same level and the two thumbs
are likewise at the same height. The t hickness of the boards co
rresponds t o t he leg len gth dis crepancy in centimeters.
-
! When measuring leg length indirectly it is extremely important
to ensure that both the knee and hip joints are fully extended,
unless this is rendered im-possible because of flexion
contractures.
▬ Vertical a lignment A cord with a symmetr ical weight is p
laced against
the v ertebra p rominens, a nd w e ass ess w hether t he weight
is in line wi th t he a nal c left o r, if no t, ho w many fi
ngerwidths i t d eviates t o th e ri ght o r l eft (⊡ Fig.
3.9).
Examination of mobility ▬ Examination of mobility from behind We
exa mine t he m aximum la teral i nclination o f the
standing patient’s spine from behind (⊡ Fig. 3.10). We observe
whether the whole spinal column curves har-moniously to the side or
whether individual segments are f ixed and do no t move with the
rest of the spine (indication of fixed scoliosis). The pelvis must
be fixed in o rder t o e valuate tr unk r otation. The r otation o
f the shoulder g irdle in r elation to t he f rontal plane is
measured in degrees and is best observed from above (⊡ Fig.
3.11).
The pa tient is no w ask ed t o b end f orward un til t he
thoracic s pine f orms t he ho rizon. The symmetr y o f the t horax
is ass essed. P rotrusion o f t he r ib cag e on one side is termed
a rib prominence . Using a protrac-tor (or – if a vailable – a s
coliometer or inclinometer ) we measure the angle between the rib
prominence and the h orizontal (th e la tter ca n be d etermined pa
rallel to a door or window frame in the examination room; ⊡ Fig.
3.12).
60 3.1 · Spine, trunk
3
⊡ Fig. 3.9. Vertical alignment : A c ord with a symmetrical w
eight is placed against the v ertebra pr ominens and checked t o
see whether it is in line with the anal clef t or how many
fingerwidths it deviates to the right or left
⊡ Fig. 3.10a, b. Lateral inclination of the trunk : The angle
between the vertical and maximum lat eral inclination of the spine
is estimat ed in degrees from behind the standing patient (normal
value: 30° –50°). We observe whether the whole spinal column bends
harmoniously to the side or whether individual seg ments are fixed
and do not mo ve with the rest of the spine
a b
⊡ Fig. 3.11a, b. Rotation of the trunk: With the pelvis fixed,
the rotation of the shoulder g irdle in r elation to the fr ontal
plane is measur ed in degrees and is best obser ved from above.
Normal value: 40° – 50°
a
b
-
3.1.1 · Examination of the back361
A ri b p rominence o f m ore th an 2 ° t ogether wi th a
horizontal pelvis is a r eliable indication of a f ixed ro-tation
of the vertebral bodies. A rib prominence of 5° or more represents
a s erious case of scoliosis and re-quires radiographic
investigation. The pa tient is no w asked to continue b ending
forward until t he lumbar spine forms the horizon so that we can
then identify any lumbar prominence . Here, too, it is important
that the pelvis is ho rizontal. If one leg is sho rter than the
other, t he leg len gth dis crepancy m ust b e co rrected using a b
oard o f a ppropriate t hickness. The l umbar prominence is als o
me asured wi th a p rotractor. An angle of 5° or more requires
x-ray examination.
▬ Examination of the mobility of the cervical spine The head
rotation to b oth sides is ide ally measured
from a bove wi th t he pa tient in a si tting p osition (⊡ Fig.
3.13). The r otation ca n b e ac tively (ask t he patient t o t urn
his he ad) o r passi vely (ho ld t he sides of the head with both
hands and turn to either side). We ca n als o obs erve a ny t
ensing o f t he st er-nocleidomastoid m uscle d uring t his ma
neuver. I f a contracture due t o muscular (congenital) t
orticollis is present, the muscle tenses on the side of the
rota-tion movement.
We then check lateral inclination (⊡ Fig. 3.14), which can al so
be m easured a ctively o r pa ssively. H ere, too, the tensing of
the sternocleidomastoid muscle is observed. If contracture is p
resent, the muscle tenses when the head is inclined to the opposite
side.
Finally, inclination and reclination are examined. With the head
inclined forward the chin-sternum distance is me asured. The pa
tient t hen b ends his he ad bac k and t he angle wi th t he axis o
f t he b ody is estima ted (⊡ Fig. 3.15).
⊡ Fig. 3.12a, b. Measurement of rib pr ominence : The patient
bends forward until the thoracic spine forms the horizon. a With a
protractor, the angle bet ween the horiz ontal (i.e. parallel t o
the door or windo w frame) and the sur face of the back is measur
ed. b A simpler and more accurate measur ement is obtained with an
inclinomet er with int e-grated spirit level and a not ch in the c
enter to avoid any distortion of the measurement caused by the
projecting spinous process
a b
⊡ Fig. 3.13a, b. Head rotation : Head rotation to both sides is
measured from above with the patient in a sitting position. The
rotation is stated in degrees measured from the midline. It can be
measured actively (by asking the patient t o turn his head) or
passiv ely (by holding the sides of the head with both hands and
turning to either side). Normal value: 60° – 80°. Obser ve any
tensing of the st ernocleidomastoid muscle at the same time
a b
⊡ Fig. 3.14a, b. Lateral inclination of the head: This can be
measur ed actively or passiv ely. The deviation fr om the midline
is stat ed in degrees. Normal value: 40° – 50°. Obser ve any
tensing of the st erno-cleidomastoid muscle at the same time
a b
⊡ Fig. 3.15a. Inclination of the head: The chin-sternum distance
is mea-sured (in c entimeters or finger widths; normal value: 0
cm). b Reclina-tion: Estimate the angle in r elation to the axis of
the body in deg rees. Normal value: 40° – 60°
a b
-
▬ Schober measurement The Schober test is used to determine the
mobility of
the spine in t he sagittal plane and involves measure-ment o f t
he str etching o f t he skin o ver t he t horacic and lumbar spine.
An ini tial mark is made o ver spi-nous process S1 a nd a s econd
mark 10 cm above the first. The distance between these skin marks
increases as t he pa tient b ends f orward, r eaching a maxim um of
15–17 cm. Tho racic sp ine: A ma rk is made o ver spinous process
C7, and a second mark is made 30 cm below this. As the patient
bends forward the distance between the two increases by 2–3 cm (⊡
Fig. 3.16).
The maximum reclination of the spine is measured as shown in ⊡
Fig. 3.17. We observe whether the patient complains o f pa in a
round t he l umbosacral j unction (indication of
spondylolysis).
PalpationWe palpate t he sp inous processes a nd est ablish w
hether pain i s e licited on pre ssure, p ercussion or v ibration.
To check pa in o n vib ration w e grasp t he sp inous p rocesses
between forefinger and thumb and move them back and forth. If the
patient finds this painful, particularly around the lumbosacral
junction, this is an important indication of possible
spondylolysis.
We palpate the paravertebral muscles to assess wheth-er these
are strong, normal or weak, palpate any painful areas o f m uscle
ha rdening (m yogeloses) a nd c heck f or tenderness o ver t he m
uscle a ttachments. The t ransverse processes can also be felt by
deep palpation.
During palpation, the skin moisture, temperature and elasticity
of the skin a re ass essed and any dermographic urticaria noted.▬
Heel-drop test The patient is asked to stand on tiptoe and the
exam-
iner r ests his ha nds o n t he p atient’s sho ulders. The
patient is no w asked to drop onto his heels w hile the examiner
simultaneously presses down on the shoul-ders. This ma neuver wi ll
elici t a ny vib ration-related pain in t he spine caused by
inflammation, tumors or herniated disks.
▬ Iliosacral joints We check for pain on pressure or percussion
and pain
on compression from the side a nd sagittally. Mennell sign : In
disorders of this joint, pain is elicited if the hip on the same
side is overextended.
Neurological examination A co mplete exa mination o f t he bac k
( ⊡ Table 3.1) als o includes at least a c ursory investigation of
the neurologi-cal status. A very rough (and quick) indication of a
motor disorder can be obtained by checking the patient’s ability to
walk o n ti ptoes o r o n heels. The most im portant as-pects of
the neurological examination from the orthopae-dic standpoint are
described in � chapter 2.1.2.
Brief overview of spinal status (e.g. in mass screening or if
the child is being seen specifically f or a back problem):▬
Inspection from behind,▬ Height of the iliac crests,▬ Finger-floor
distance,▬ Rib prominence, lumbar prominence on forward
bending?▬ Walking on tiptoes and heels .
62 3.1 · Spine, trunk
3
⊡ Fig. 3.17. Reclination of the trunk : The maximum r eclination
of the spine is measured as the angle between the upper body’s
vertical axis and the frontal plane. Normal value: 30°–60°
⊡ Fig. 3.16. Schober sign . Lumbar spine: Make an initial mark
over spinous process S1 and a sec ond mark 10 cm abo ve this. The
distance between these sk in marks incr eases as the patient bends
f orward, r eaching a maximum of 15–17 cm. Thoracic spine: A mark
is made o ver spinous process C7, and a second mark is made 30 cm
belo w this. As the patient bends forward the distance between the
two increases by 2–3 cm
-
3.1.2 · Radiography of the spine363
3.1.2 Radiography of the spine
The following standard spinal x-rays are recorded:▬ Cervical
spine, AP and lateral: The patient can ei ther st and or lie do wn
for t he AP
x-ray of the cervical spine. The cen tral x-ray beam is targeted
on the 4th cervical vertebra (at the level of the Adam’s apple) and
is inc lined towards the head at an angle of 15°–20°. (⊡ Fig. 3.18
left). For the lateral x-ray, the patient can either stand, sit or
lie down, and hold his head up straight in a neutral position. The
central beam is t argeted ho rizontally o n C4 (c hin heig ht; ⊡
Fig. 3.18 right).
▬ Transbuccal x-ray of the dens : For the specialist dens x-ray
the patient is p laced on
his back with the head in t he neutral p osition. With the p
atient’s mo uth o pened as wide as p ossible, t he central b eam is
v ertically aligned wi th t he cen ter o f the open mouth ( ⊡ Fig.
3.19a). While the x-ray is r e-corded, t he patient is ask ed t o s
ay »ah«, ca using t he tongue to press against the floor of the
mouth thereby preventing its shadow from being projected onto
ver-tebral bodies C1 and C2. The dens, axis, lateral masses
of the atlas and the atlantoaxial joints will b e c learly
visible on the resulting x-ray.
▬ Functional x -rays of the ce rvical spine f rom the side
during maximum inclination and reclination:
If instability or a ligamentous injury is susp ected, the
cervical spine is x-ra yed (on the awake patient) from the side , w
hile t he pa tient is si tting u p a nd d uring maximum inclination
and reclination (⊡ Fig. 3.19b).
▬ Thoracic spine, AP and lateral: The AP and lateral x-rays of
the thoracic spine should,
if possible, be recorded while the patient is st anding. For the
AP view, the central beam is targeted perpen-dicularly onto a point
approx. 3 cm above the xiphoid process of the sternum. For the
lateral x-ray of the tho-racic spine, the patient is asked to raise
his arms. The central beam is targeted horizontally at the level of
the 6th t horacic v ertebra a nd til ted t owards t he he ad a t an
angle of about 10°. The r esulting x-ray shows the vertebral b
odies a nd t he in tervertebral disks vie wed from the side (⊡ Fig.
3.20).
▬ Lumbar spine, AP and lateral The AP and lateral x-rays of the
lumbar spine should
likewise be recorded while the patient is standing. For
⊡ Table 3.1. Examination protocol for the back
Examination position Examination Questions
I. Walking Movement pattern? Limping? Ataxia? Neurological
lesion?
II. Standing from behind Position of the shoulders?Scapulae
symmetrical?Spine straight?Iliac crests horizontal?Gluteal folds
symmetrical?Waist triangles symmetrical?Plumbline in the
center?Pigmentation over spinous processes?Hardening of
paravertebral muscles?(if necessary examine on the lying patient as
w ell)Pain on percussion/vibration of the vertebral bodies?(if
necessary examine on the lying patient as w ell)
Scoliosis? Plexus paresis?Sprengel deformity?Winged scapula?
Sprengel deformity?Scoliosis?Leg length discrepancy?Hip
condition?Scoliosis?Severe scoliosis?Lumbar kyphosis?Myogelosis
(muscle spasm)?Tumor? Infection?Spondylolysis?
III. Standing from the side Shoulders pulled forward?Sagittal
curves?Transition between front/back
Contracture of the pectoralis muscles?Scheuermann’s
disease?Contracture of psoas or hamstrings?
IV. Standing with flexed back from behind
From the side
Spine straight?Rib hump >5°Lumbar prominence >5°
FFD?Can the thoracic kyphosis be straightened out?
Scoliosis?Thoracic scoliosis?Lumbar scoliosis?
Contracture of hamstrings?Thoracic Scheuermann’s disease?
V. Mobility Lateral inclination of the head?Head
rotation?Reclination/Inclination of head?Lumbar pain on
reclination?(if necessary examine on the lying patient as w
ell)
Torticollis?Torticollis?Klippel-Feil syndrome?Spondylolysis?
-
64 3.1 · Spine, trunk
3
⊡ Fig. 3.18. Recording lat eral and AP x -rays of the c ervical
spine . (after [1])
⊡ Fig. 3.20. Recording thoracic spine x-rays, lateral (left) and
AP (right). (after [1])
⊡ Fig. 3.21. Recording lumbar spine x -rays, lateral (left) and
AP (right). (after [1])
⊡ Fig. 3.19a, b. Recording cervical spine x-rays. a Radiographic
technique for the transbuccal view of the dens, b Functional
lateral x-rays of the cervical spine in maximum reclination (left)
and inclination (right)
a b
-
3.1.2 · Radiography of the spine365
the AP view, the central beam points perpendicularly, at t he le
vel o f t he iliac cr ests, onto t he center o f t he abdomen. F or
t he la teral x-ra y, t he cen tral b eam is targeted on L3 at the
patient’s waist level (⊡ Fig. 3.21). In adolescents, wide cass
ettes should be used so that the iliac cr est is inc luded in t he
x-ray (so that the re-maining growth potential can be
assessed).
▬ Thoracolumbar junction, lateral: For this x-ray the central
beam is targeted on T12.▬ Lumbosacral junction, lateral: For this
x-ray the lateral beam path is centered on L5.▬ Oblique x-rays of
the lumbosacral junction: For the oblique x-rays of the lumbar
spine, the patient
lies o n his side o n t he exa mination t able a nd t hen turns
45° to the right so that the small vertebral joints on the right
are viewed (similarly, raising the left side will enable the facet
jo ints on the lef t to b e vie wed). The central beam is targeted
vertically onto the center of L3 (⊡ Fig. 3.22). See ⊡ Fig. 3.68 and
3.69 for examples and explanations.
▬ Whole spine, AP and lateral: With children and younger
adolescents i t is p ossible
to depict the whole spine on a single normal cassette. The cen
tral b eam p oints t o T12. I f def ormities a re present, t his o
verview is mo re us eful f or e valuating the statics of the spine
than individual images of the thoracic a nd l umbar sp ine. Here, t
oo, wide cass ettes should b e us ed s o t hat t he iliac cr est is
inc luded in the x-ra y. For f ull-grown pa tients t he sp ine must
b e x-rayed usin g co mbined f ilms in sp ecial cass ettes. Since
the distance from the x-ray tube is considerable, this not only has
a n adverse ef fect on image quality, but also involves a high dose
of radioactivity. We only record such x-rays in exceptional
cases.
▬ CT of the spine : CT is extremely useful in fractures for
revealing frag-
ments in t he spinal canal. They are also ef fective for
identifying intraosseous tumors.
▬ Myelo-CT : Myelo-CT h as la rgely s uperseded th e co
nventional
myelogram w hen i t co mes t o vie wing a ny im pedi-ment in the
spinal canal resulting from a neurological lesion.
▬ Angiogram : Angiograms ca n be r ecorded co nventionally, a s
M R
angiograms or, using a mo re recent technique, as CT angiograms,
which produce the best view of the blood vessels. S uch imag es a
re r equired in cer tain t umors or f or dep icting t he a rtery o
f A damkiewicz p rior t o vertebrectomies.
▬ MRI of the spine: The MRI s can is us ed for cases of inf
lammation and
tumors (p rimarily f or t he imagin g o f t he s oft tissue
components) and for revealing intraspinal anomalies before
scoliosis operations (particularly for congenital scolioses).
▬ Bone scan : The technetium scan is us eful for revealing small
t u-
mors that are not c learly depicted with conventional imaging t
echniques (e .g. ost eoblastomas) o r in t he search for
metastases.
▬ Ultrasound scans: Ultrasound scans are recorded in cases of a
suspected
spinal abscess or seroma.
Reference1. Greenspan (2003) Skelettradiolog ie. Urban & F
ischer, Munich
Jena
⊡ Fig. 3.22. Positioning of the patient and targeting of the
central beam in oblique x-rays of the lumbosacral junction (after
[1])
-
3.1.3 Can the »nut croissant«1 be straightened out by
admonitions? – or: To what extent is a bent back acceptable? –
Postural problems in adolescents
» The body is the visible manifestation of the soul. (Christian
Morgenstern, Steps) «
The back – a mirror of the soul?Parents’ concerns about the p
osture or the shape of the back of their offspring are one of the
commonest reasons for a visi t to the pediatrician or the
orthopaedist. Their worries a re ess entially a ttributable t o tw
o ma in fac tors: On the one hand they are worried that an
non-correct-able d eformity of t he s pine m ight re sult f rom t
he p oor posture, as an expression of some sinister frame of mind.
On t he o ther ha nd, i t is a g enerally kno wn fac t t hat back
pa in is o ne o f t he co mmonest co nditions suf fered in
adulthood and one t hat mig ht p ossibly b e prevented by a
ppropriate me asures t aken d uring c hildhood a nd
adolescence.
But why are parents so worried about their child’s ap-pearance,
particularly in r elation to b ack problems, even though the back
is usuall y covered by clothing and thus less exposed than, say,
the face or the hands? – The bac k has sp ecial symbolic signif
icance in lin guistic us age and is, to a particularly great
extent, the »visible manifestation of the soul«, as Chr istian
Morgenstern puts it. A »g ood« posture for the spine is »upright«,
just as a p erson’s char-acter can be described as »upright«. This
also reflects the relationship between truth and dishonesty.
But t erms ass ociated wi th t he bac k ca n als o ha ve other
co nnotations. P oliticians w ho ado pt a pa rticular standpoint a
nd do no t al ways c hange t heir o pinion t o match the prevailing
mood are said to show »backbone«. But there are also others who are
so thick-skinned that they ca n li ve wi thout a bac kbone. P
articularly str ong-willed p eople a re des cribed as »un bending«.
I f t heir will is broken we say that it is »bent« to the will of
an-other. People with a lot of problems are »weighed down by w
orries« un til t hey e ventually »co llapse under t he load«. Thos
e w ho wish t o in gratiate t hemselves wi th others »b ow a nd s
crape«. Thos e wi th h uge deb ts a re »laid lo w« a nd a p erson w
ho r efuses t ake r esponsibil-ity f or his o wn mist akes a nd
accep t t he co nsequences may tr y a nd »p lace all t he b lame o
n s omeone els e’s shoulders«.
So we can see how terms connected with the back and spine can
also be used to describe emotion-provoking ac-tivities and
properties that are closely related to a person’s state o f mind .
L inguists a re una ble t o exp lain w hether the la nguage ac
tually cr eates t his link b etween p hysical posture a nd men tal
o utlook. W e als o f ind »cr ooked« characters in li terature.
Victor Hugo, in pa rticular, made a hunchback the lead character in
two of his works: Qua-simodo in Notre-Dame de Paris a nd t he co
urt jest er in Le Roi s’amuse. The la tter p lay was us ed as t he
basis f or Giuseppe Verdi’s famous opera Rigoletto. And the French
poet Paul Féval has a hunchback as the main character in Le Bossu.
But in these literary examples the hunched back does no t r
epresent t he ma nifestation o f a sinist er s oul. Quite the
opposite, since t hey are kind-hearted sensitive individuals who
have been disadvantaged by nature and brutally exp loited by o
thers b ecause o f t heir ina bility t o defend themselves.
But w hile t he b ody is indis putably a n exp ression o f the
so ul, th e co nnections a re m uch m ore m ultilayered and complex
than suggested by the vernacular language. Viewed at a s uperficial
le vel, nature can als o b e at vari-ance with linguistic usage.
Thus, parents always want their child t o ado pt as stra ight a p
osture as p ossible. B ut t he drooping and loutish posture of the
adolescent is precisely an expression of the desire not to »bend«
to the will of his parents.
Economic significance of back pain Lumbar bac k pa in is o ne o
f t he co mmonest co nditions suffered by adults and the number one
reason for lost pro-ductivity . Thus, acco rding to o ne ep
idemiological st udy, 66% o f em ployees st ated t hat t hey had
suf fered bac k pain in the previous 12 months [5]. And e ven a
group of individuals in t heir twenties (Swiss recruits and
soldiers) showed a p revalence o f 69% f or l umbar bac k pa in
[7]. An American study showed that 11% of men and 9.5% of women
visi ted a g eneral p ractitioner b ecause o f l umbar back pain
[3]. In the USA, the loss of earnings is estimated
66 3.1 · Spine, trunk
3
1 Nut croissant: term used in Switzerland for a croissant filled
with nuts. The expression »nut cr oissant figure« is c ommonly used
in S witzer-land to refer to a particularly drooping, kyphotic
posture.
-
3.1.3 · Can the »nut croissant« be straightened out by
admonitions?367
at around 10 billion dollars [8]. In Switzerland, too, back pain
is t he s econd co mmonest ca use o f dis ability, a fter
accidents. A hig h p revalence o f l umbar b ack p ain, a t 48.2%,
has b een reported for industrial workers in R us-sia [9], indica
ting that back pain is no t a sp ecialty of the West, although it
is clearly a much more serious problem in ind ustrial na tions t
han in t he de veloping w orld. The significance o f b ack p ain e
vidently tends to p arallel t he degree of industrialization.
In Oma n, t he dema nd f or bac k tr eatment has r isen
dramatically since the oil boom [2], a f inding that is also of
major economic significance. According to a Canadian statistical
survey, approximately 30% o f the total amount paid in 1981 as co
mpensation for loss o f earnings in t he form of disability
pensions was pa id to back patients [1]. The pa in f requently st
arts a t a y oung a ge, a nd a round half of adolescents complain
of occasional back pain [10] (� Chapter 3.1.15).
For all o f t he r easons o utlined a bove, i t is p erfectly
understandable that parents are worried about what could happen to
their children’s backs in future.
Evolution of upright walking and postureHumans are unique among
all living creatures in exhibit-ing an erect posture. While
primates evidently developed the mechanism for maintaining t he tr
unk in a n upright position at a very early stage, only humans are
capable of standing and walking upright on two legs f or prolonged
periods. This species-specific bipedal, erect posture freed up t he
ha nds s o t hat h umans co uld us e t hese f or t asks other than
locomotion. In fact, this discriminating use of the hand was
probably the very first evolutionary step. A secondary consequence
of the discovery that hands could be used not just for locomotion
was t he development of the brain and upright walking. The us e of
hands as t ools and also the use of tools with the hands was
therefore the first st ep in t he e volution o f ma n, s ome 5
millio n y ears ago, f rom p rimate t o ho mo er ectus, t he p
recursor o f today’s homo sapiens.
This u pright p osture ca used t he e yes t o b e shif ted
forwards, thereby widening the field of vision and even-tually p
roducing b inocular, s tereoscopic visio n. C om-pared to
quadrupeds and the c limbing anthropoid ape, humans ha ve b etter
visual , aco ustic a nd t actile spa-tial o rientation. F rom t he
p hylogenetic st andpoint, t he adoption of an erect posture in h
umans did no t simply involve a rotation of 90° at the hip, but
primarily around the l umbosacral j unction as a r esult o f t he c
uneiform shape of the 5th lumbar and 1st sacral vertebrae. The
sa-crum is the resting point about which this erect posture is
achieved.
The de velopment o f t he u pright p osture r equires a
specially-shaped sp inal co lumn. The do uble-S-shaped human sp ine
dif fers f rom t he sin gle-S-shaped sp ine o f the q uadruped in i
ts addi tional l umbar lo rdosis. Al-
though t his l umbar lo rdosis is no t abs olutely ess ential
for an upright posture, it came about primarily for func-tional
reasons. The S sha pe o f t he sp ine is t he optimal design for
the corresponding dynamic loads. The cer vi-cal and lumbar
lordosis, and also the thoracic kyphosis, act lik e link ed elastic
sp rings. An y ma jor de viations from these functionally-adapted
curves in t he spine are mechanically inappropriate and result in
adverse loading conditions.
The upright p osture als o has im plications for other organs as
w ell as t he s pine. Thus t he iliac win g in h u-mans is m uch
wider t han in q uadrupeds, since i t has to hel p ca rry t he
internal o rgans. The det orsion o f t he femoral nec k d uring gr
owth is a nother p henomenon specific to h umans. I n fac t, h
umans ha ve p aid ver y dearly f or t his uniq ue ad vantage o f a
n u pright p osture and ha ve e vidently no t y et co mpletely co
me to ter ms with t his e volutionary step. Man’s unique erect p
osture not only contributes to his sp ecial dominant role in
na-ture, a t t he s ame time i t has b ecome a dir ect p otential
disease fac tor w hose im plications ca nnot y et b e f ully
grasped.
Postural development in childrenThe p hylogenetic de velopment o
f t he b ack is imi tated during ma turation f rom t he f etus t o
t he c hild a nd t hen from the child to the adult. In the uterus,
the fetus is in a flexed position and the spinal column is
completely ky-photic. The neonate also holds the shoulders, elbows,
hips and knees in f lexion, ca using t he sp ine, a part f rom t he
cervical section, to be held in kyphosis, as is also the case
Postural dev elopment fr om the f etus, via the infant and t
oddler, t o the child
-
with q uadrupeds. Flexio n co ntractures o f u p t o 30° a re
physiological. At a later stage, the neck, back and femoral
extensors are t he f irst to b e strengthened, providing t he
infant wi th he ad co ntrol . Af ter a f ew mo nths t he ba by is a
lso capable of s itting up, a lbeit with total kyphosis of the
back. At this stage the lumbar lordosis is still lac king, which is
a physiological finding during this period before the start of
walking.
Once t he ba by st arts walkin g, t he l umbar lo rdosis itself
starts to develop. But this process does not fully par-allel the
strengthening of the muscles, and a hyperlordosis usually forms at
this stage as a result of gravity acting on the ventral side. In
toddlers this hyperlordosis is often not compensated b y a h
yperkyphosis o f t he t horacic sp ine, resulting in the scenario
of the »hollow back«. This type of posture in t he toddler is
characterized by the physiologi-cal weakness of the muscles and the
general laxity of the ligaments that is typ ical of the
constitution at this stage. The to ddler’s b ack sha pe o nly de
velops in to t he ad ult shape shortly b efore puberty , a lthough
t his shape is st ill dependent on the state of the muscles. In the
elderly, the spine aga in resembles t he kyp hotic p icture o f t
he infant (⊡ Fig. 3.23).
An im portant c haracteristic f eature o f t he infa nt is the
asymmetr ical t onic nec k r eflex . The p ersistence o f this r
eflex ca n le ad to a n asymmet rical de velopment o f the muscles
and the condition known as resolving infan-tile s coliosis . Res
olving infa ntile s coliosis is a sin gle a rc-shaped c urvature o
f t he w hole sp ine r esulting f rom t he asymmetrical tone of the
muscles. The c urvature is ass o-ciated with little rotation and
occurs with a left- or right-sided co nvex c urve wi th eq ual f
requency. I f t he c hild is
held by the head and feet, the opposite side can be made to c
urve. Res olving infa ntile s coliosis us ed t o b e m uch more co
mmon in t he pas t, a nd is ra rely enco untered nowadays. This is
p ossibly attributable to the trend (after 1970) o f p lacing t he
infa nt in t he p rone p osition . More recently (since
approximately 1992), the prone position is being abandoned
following the discovery that sudden in-fant death syndrome occurs
more frequently in the prone position than the supine position. We
have, however, not seen an increase in resolving infantile
scoliosis since then. Therefore there must be other etiological
factors (e.g. ge-netic intermixture?).
The prognosis for resolving infantile scoliosis is v ery good,
as almost all o f these curvatures disappear during the f irst y
ear o f lif e. This did no t al ways us ed t o b e t he case. Some
cases of apparently resolving infantile scoliosis persisted a nd de
veloped in to p rogressive idio pathic in-fantile s coliosis, a co
ndition t hat us ed to b e particularly common in G reat B ritain
[6]. The obs ervation t hat t he difference b etween t he a ngle
made b y t he r ibs a nd t he spine when seen from the side is
greater in the progressive forms than in cases that spontaneously
resolve themselves means t hat t he p rogressive f orms ca n b e
det ected a t a n early stage (� Chapter 3.1.4).
The co ndition o f p rogressive infa ntile s coliosis has almost
disappeared even in Scotland, where the condition was particularly
common. While the progressive form of the dis ease has a n extr
emely p oor p rognosis, r esolving infantile scoliosis is not
associated with any long-term se-quelae. It is completely unrelated
to idiopathic adolescent scoliosis, and patients with a history of
resolving infantile scoliosis show no increased risk of developing
idiopathic adolescent scoliosis in later life.
Postural types in the adolescent Posture is influenced by the
following factors:▬ The shape of the bony skeleton The shape is
determined by genetic factors (the moth-
er: »His f ather h as exa ctly t he sa me cr ooked ba ck«). The
position of the sacrum, which in t urn is dep en-dent o n t he p
elvic til t, als o p lays a n im portant r ole. The steeper the
sacrum, the less pronounced the sagit-tal curvatures (lordosis and
kyphosis).
▬ Ligamentous apparatus Posture can be active or passive. If our
muscles are not
activated, then we simply »hang« from our ligaments. Such a p
osture can best be adopted by overstretching the hips, sticking out
the tummy, positioning the lum-bar spine in hyperlordosis and
tilting the upper body backward to offset the forward shif ting of
the center of gra vity. I f t he cen ter o f gra vity is shif ted f
orward or backward we t alk of a v entral or dorsal overhang (�
Chapter 3.1.1). This posture cannot be adopted pas-sively, however,
since it is unstable and must be com-pensated for by muscle
activity.
68 3.1 · Spine, trunk
3
⊡ Fig. 3.23. Postural c ycle (the old man r eturns to the k
yphotic pos-ture of the fetus)
-
3.1.3 · Can the »nut croissant« be straightened out by
admonitions?369
▬ Muscles The state of the muscles has a co nsiderable
influence
on o ur p osture. S trong m uscles wi th g ood t one ca n
maintain a n ac tively er ect p osture t hroughout t he day. The co
ndition of the muscles depends partly on constitutional factors and
partly on the training status. But one other factor needs to be
taken into account in relation t o t he gr owing b ody: The m
uscles, t ogether with the skeleton, undergo substantial length
growth but are unable to increase in width to the same extent.
Consequently, a cer tain m uscle w eakness is p hysi-ological in t
he growing child. Only on completion of the growth phase can the
»muscle corset« be trained and built up in the optimal way.
Postural insufficiency is frequently associated with an intoeing
gait and re-duced hip flexion [4].
▬ Pelvic tilt The p elvic til t is c losely r elated t o t he st
eepness o f
the sacrum. Straightening the pelvis reduces the lum-bar lo
rdosis a nd t hus t he t horacic kyp hosis as w ell (⊡ Fig. 3.24,
3.25).
▬ Influence of the psyche Posture is not a constant anatomical
feature of an indi-
vidual. Apart from constitutional factors, posture rep-resents a
snapshot that depends not only on muscular activity b ut, to a v
ery g reat exten t, o n psy chological status. As previously
mentioned, linguistic usage also highlights this link. A st ate of
mind c haracterized by joy, happiness, success, s elf-confidence,
trust and op-timism tends to affect the erect posture and the
asso-ciated efficient postural pattern. By contrast, worries,
conflicts, depression, failures and feelings of inferior-ity
produce precisely the opposite effect and promote poor postural
patterns.
Another special factor comes into play in adolescents: Puberty
is a st age of life marked by internal conflicts associated wi th f
inding one’s own p ersonality. S ince an im portant elemen t in t
his p rocess is t he lo osen-ing of the bond with the parents, a
certain protesting posture in r espect o f t he p arents ca n b e
co nsidered physiological.
Since a straight posture is usually considered the ideal by pa
rents, t he in ternal p rotest aga inst t he pa rents’ world
manifests itself in the form of an – often osten-tatiously – p oor
p osture (pa rticularly w hile si tting). The p oor p osture r
esulting f rom t he p hysiological muscle weakness of the growing
body is f urther em-phasized by »casual« sitting. The more
frequently the parents admo nish t heir c hild wi th »si t u p stra
ight«, the q uicker he o r she r esumes t he »n ut cr oissant«
position. It is striking to observe how children with a very
pronounced kyphotic posture are very frequently withdrawn a nd ha
ve o ne v ery do minating pa rent. When suc h ado lescents a re q
uestioned a bout t heir symptoms or probl ems du ring t he c
onsultation, t he
mother or father will constantly reply on their behalf. It is no
ticeable that the chi ld is cle arly overwhelmed by the mother or
father.
But o ther p roblems ca n als o ca use ado lescents t o adopt a
v ery kyp hotic p osture, e .g. if a f emale un-consciously tr ies
t o conceal her b reasts by hunching her shoulders forward and
folding her a rms in f ront of her. Some girls are unable to accept
the growth of
⊡ Fig. 3.24. Normal pelvic tilt with f orward/caudal inclination
of the pelvis by approx. 20°
⊡ Fig. 3.25. Cancellation of the pelvic tilt and consequent
reduction of the lumbar lordosis and the thoracic kyphosis
Abb. 3.24 Abb. 3.25
Adolescents of ten deliberat ely adopt a seat ed postur e that
goes against their parents’ ideas about good posture...
-
their own breasts. This is pa rticularly apparent if t he girl
has a very dominant mother who herself has large breasts. But also
a funnel or keeled chest can cause the girl t o ado pt a p
ermanently kyp hotic p osture in t he unconscious desire to conceal
this part of her body.
▬ Social aspects Not e very s ocial c lass o r era has t he s
ame co ncep-
tion of the ideal posture. Since ancient times, st atues and
paintings have tended to present the ideal of an upright p osture.
I n E uropean r oyal d ynasties, a stif f posture was o ften p
romoted b y co nstraining t he in-dividual in a brace. But the
social notions of the ideal posture have changed since then, and
the ideals of the modern age are f requently c haracterized by a ma
rk-edly »casual« posture.
As alr eady men tioned, p osture r epresents a »snapshot«. Every
individual can adopt a variety of postures.
The standing posture can be subdivided into the fol-lowing
stages (⊡ Fig. 3.26–3.28):▬ ha bitual posture,▬ p assive posture,▬
actively straightened posture.
We ca n als o distin guish b etween constitutional postur al
types (normal back, hollow back , rounded back , flat back ,
hollow-flat back , � chapter 3.1.1).
The classification of the first 4 back shapes dates back to the
19th century (Staffel 1889 [2]). These are physiolog-ical variants
with essentially no pathological significance. We have added t he
5th back shape since i t is a r elatively common p hysiological va
riant, p articularly in chi ldren. Instead of a »normal back«
perhaps we should rather refer
to a harmonious back. Using the term »normal back« can easily
give the impression that the other back shapes are abnormal, w hich
is cer tainly no t t he cas e b y def inition, since these are,
after all, types of posture. We only speak of a pathological shape
if there is fixed hyperkyphosis of the thoracic spine, a permanent
absence of lumbar lordosis or even a kyphosis in this area. The
investigation of the cor-rectability or fixation of individual
segments is described in � chapter 3.1.1.
Pathological significance of poor posture Whether »p ostural da
mage« ac tually exis ts is a ma tter of c onsiderable d ispute. Si
nce b ack sy mptoms ar e c om-mon in ad ults and have also
increased over the past f ew decades, t he dis cussion o f t his
sub ject is hig hly t opical. Unfortunately t here is a s carcity o
f s cientifically-estab-lished hard facts and, on the other hand,
widely diverging opinions bas ed o n sub jective im pressions. H
owever, a number of factors in recent years have thrown some light
on the subject.
Various widely-held traditional views first need to be corrected
somewhat:▬ The deve lopment o f s tructural sc oliosis h as n
othing
to do w ith pos ture . A p oor p osture ca nnot ind uce
idiopathic ado lescent s coliosis. S coliosis is kno wn to result f
rom a dis crepancy between the growth of the vertebral body
anteriorly and the growth of the posterior elemen ts, r esulting p
rimarily in lo rdosis. Adolescents wi th s coliosis a re t herefore
co nspicu-ously straight and erect, and also often very keen on
sport. The la teral c urvature de velops as a r esult o f the
rotation of the vertebral bodies and has no thing to do wi th p
osture ( � Chapter 3.1.4). A leg len gth discrepancy may possibly
promote lumbar scoliosis. This is def initely t he cas e with
uncompensated dif-ferences o f more t han 2 cm. W hether i t
applies f or differences of less t han 2 cm is co ntroversial, and
it is possible that the leg length discrepancy only influ-ences t
he dir ection o f t he s coliosis ra ther t han i ts
development.
▬ Of t he p hysiological po stural ty pes, a part f rom t he
harmonious posture, the hollow back has a much better prognosis tha
n the f lat b ack. Although th e f lat ba ck is the esthetic ideal,
the future prospects in t erms of subsequent sym ptoms a re m uch w
orse f or t he f lat back th an f or a ba ck wi th m arkedly sa
gittal cur ves, given t he p oorer sho ck-absorbing p roperties o f
t he former. Lumbar disk da mage occurs more frequently with this
back shape and is also often associated with pain. The p roblem
arises primarily from the kyphos-ing o f t he l umbar s pine. The
lac k o f lo rdosis shif ts the ce nter o f gr avity f orward, wh
ich m eans th at th e lumbar paravertebral muscles have to work
harder to maintain posture. The kyphosing of the lumbar spine is
also often very pronounced during sitting.
70 3.1 · Spine, trunk
3
⊡ Fig. 3.26. Habitual posture posture
⊡ Fig. 3.27. Passive posture
⊡ Fig. 3.28. Actively straightened posture
Abb. 3.26 Abb. 3.27 Abb. 3.28
-
3.1.3 · Can the »nut croissant« be straightened out by
admonitions?371
▬ The development of a fixed kyphosis can be influenced by p
osture. A p ermanent kyp hotic p osture ca n tr ig-ger S cheuermann
dis ease d uring p uberty . Al though the p rognosis in t erms o f
sym ptoms is no t bad in Scheuermann dis ease in volving t he t
horacic r egion, it becomes increasingly worse the further down one
goes, and lumbar Scheuermann disease is ass ociated with a very
high risk of subsequent chronic lumbar back pa in. Usually t he co
ndition r esults in elimina-tion o f t he l umbar lo rdosis, o r e
ven kyp hosing in this area. This is extremely undesirable from the
me-chanical st andpoint b ecause of t he for ward-shifting of the
center of gravity. It has to be offset by lordosing of the thoracic
spine and considerable postural work by the paravertebral muscles
in the lumbar area. The shock-absorbing properties o f t his typ e
o f s pine a re also poor.
Therapeutic optionsOf t he fac tors t hat det ermine p osture, w
e ca n inf luence two in particular:▬ the status of the muscles,▬
possibly the psychological factors.
All o ther pa rameters a re gi ven a nd w e ha ve no wa y o f
influencing them.
As regards the muscles, we should always bear in mind that a
certain amount of physiological muscle weakness is associated with
growth.
! Muscles can only be strengthened by activity. Such activity
must be undertaken by the child or ado-lescent and cannot be imbued
into the child from the outside. Consequently, the crucial factor
in determining whether activity takes place or not is the child’s
motivation. The surest way of demotivat-ing the child is to compel
it to undertake an activity against its will.
Since physical therapy is no t an attractive type of activ-ity,
it i s p ointless t o pre scribe m onths, or e ven ye ars, of p
hysical t herapy, a t t he exp ense o f he alth in surance funds,
when the child is not remotely motivated. The out-come will be a
complete lack of any effect on the muscles. Equally questionable in
my view are the »postural physi-cal ed ucation less ons « p rovided
in ma ny s chools. S ince all st udents a ttending such less ons a
re la beled as t hose with »p oor p osture« t he pa rticipants a re
stigma tized from the outset. Since i t is s elf evident that such
less ons are un likely to mo tivate t he st udents t o k eep ac
tive, i t would be much more useful to encourage the adolescent to
exercise within the context of a sport that affords him or her a
cer tain amount of p leasure. Al though t he typ e of sport
selected is not ultimately important, activities in which the arms
are also used are preferable. Swimming is best, of course, although
other ball-based sports such as
baseball, basketball or volleyball are extremely beneficial.
Sports that exercise the muscles on one side of the body, e.g.
tennis, are also perfectly appropriate since, as already mentioned,
there is no need to worry at all about the pos-sibility of
scoliosis developing as a result of the unilateral muscle tension.
Even scoliosis patients should be allowed to play tennis. The
important thing is the pleasure gained from t he sp ort. P assive a
nd no n-athletic c hildren do not lik e t aking pa rt in ball-bas
ed sp orts b ecause t hey invariably los e. However, p erhaps suc h
c hildren ca n b e motivated to take up swimming or possibly attend
a f it-ness center on a r egular basis. This a voids t he problem
of their having to constantly measure themselves against their
peers.
One p articular f actor t hat prom otes p assivity i s t he
considerable a mount o f t ime sp ent si tting a t s chool or in t
he ho me. The l umbar sp ine t ends t o kyp hose during passi ve si
tting. C ertain us eful me asures ca n b e taken t o co unter t his
t endency, e ven t hough t hese a re implemented in only a very
small proportion of schools: An inc lined wr iting sur face r
educes t he k yphosing o f the l umbar sp ine d uring wr iting; t
he wr iting sur face should be positioned suf ficiently high; a
ball c hair also promotes lo rdotic si tting a nd stim ulates t he
si tter t o constantly p erform slig ht co mpensation mo vements; a
kneeling chair wi th support for t he lower leg als o pro-motes
lordotic sitting (⊡ Fig. 3.29). Such aids promote a habitual lo
rdotic si tting p osture t hat p roduces p ositive effects in the
long term.
In theory, psychological factors can also be influenced,
although this is much more difficult. Since fixed hyperky-phosis of
the thoracic spine is often indicative of a conflict between the
adolescent and a parent, the doctor must pro-ceed very cautiously.
Psychological counseling can prove worthwhile o n o ccasion ho
wever. Ano ther p otentially fruitful stra tegy in mo tivating t he
ado lescent t o t ake up sport is for him or her to meet other
relevant individuals who could s erve as ne w p ositive mo dels. In
most cas es, however, i t ca n b e v ery dif ficult t o exp lore o
ften de ep-seated conflicts, particularly since both sides (parents
and child) frequently adopt a hig hly defensive attitude. What is
certain, however, is that constant admonitions to sit up straight
are counterproductive.
! In other words, the question posed at the start, i.e. whether
the »nut croissant« posture can be straight-ened out by cajoling,
can be answered resoundingly in the negative. A permanent
improvement in pos-ture will only be achieved if the adolescent is
moti-vated to take part in enjoyable activities.
References 1. Andersson GB (1981) Epidemiolog ic aspects on lo
w-back pain in
industry. Spine 6: 53–60 2. Debrunner AM (1994) Orthopädie –
orthopädische Chirurgie. Hu-
ber, Bern
-
3. Frymoyer JW , P ope MH, C ostanza MC, Rosen JC, Gogg in JE,
Wilder DG (1980) Epidemiolog ic studies of lo w-back pain. Spine 5:
419–23
4. Ihme N, Olsz ynska B, Lorani A, Weiss C, Kochs A (2002) Z
usam-menhang der vermehrten Innenrotation im Hüftgelenk mit einer
verminderten Beckenaufrichtbarkeit, der Rückenf orm und Hal-tung
bei K indern – Gibt es das so genannt e Ant etorsionssyn-drom? Z
Orthop Ihre Grenzgeb 140: p423–7
5. Masset D , M alchaire J (1994) L ow back pain. Epidemiolog ic
aspects and work-related factors in the st eel industry. Spine 19:
143–6
6. McMaster MJ (1983) I nfantile idiopathic sc oliosis: Can it
be pr e-vented? J Bone Joint Surg (Am) 65: 612–7
7. Rohrer MH, Sant os-Eggimann B , P accaud F , Haller -Maslov E
(1994) Epidemiologic study of lo w back pain in 1398 S wiss
con-scripts between and 1985 and 1992. E ur Spine J 3: 2–7
8. Rothman RH, Simenone FA (1992) The spine. Saunders,
Philadel-phia
9. Toroptsova NV , Benev olenskaya LI, K aryakin AN, S ergeev
IL, Erdesz S (1995) » Cross-sectional« study of low back pain among
workers at an industrial enterprise in Russia. Spine 20: 328–32
10. Widhe T (2001) Spine: posture, mobility and pain. A
longitudinal study from childhood to adolescence. Eur Spine J 10:
p118–23
3.1.4 Idiopa thic scolioses
» While her elegance in ballet may appeal, the risk of scoliosis
is very real. «
> Definition Condition involving lateral bending of the spine
of >10°
of unknown origin. There are two basic clinical pictures of
scoliosis:▬ A rare form in which the deformity starts as early
as infancy or childhood ( infantile or juvenile sco-liosis) .
Boys and girls are equally affected by this type. Scolioses at the
thoracic level frequently have their convexity to the left and are
associated with kyphosis.
▬ The more common adolescent form starts during pu-berty . Girls
are mainly affected and the thoracic form is always right convex.
This type of scoliosis is usually associated with lordosis.
72 3.1 · Spine, trunk
3
⊡ Fig. 3.29a–e. Seated postures and sitting aids: a upright
seated posture; b drooping seated posture; c kyphotic seated
posture; d influence of writing height and slope
of the writing surface on seated posture; e ball chair
a b
c d e
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3.1.4 · Idiopathic scolioses373
Classification
Classification by age at onset (according to the Ameri-can
Scoliosis Research Society ):▬ I nfantile: 0–3 years ▬ Juv enile:
4–10 years ▬ Adolescent over 10 years old
Because juvenile scolioses are extremely rare (and do not behave
according to a typical pattern), the British Scoliosis Society
classifies only two entities:▬ Early onset: 0–7 years ▬ Late onset
over 7 years old
The condition known as resolving infantile scoliosis is not
classed as a n idiopathic s coliosis but is a sp ecial typ e of
scoliotic posture. However, since it can progress to infan-tile
idiopathic scoliosis it is discussed here.
Resolving infantile scoliosis Resolving infa ntile s coliosis o
ccurs a t t he ag e o f a f ew months, b ut has b ecome r elatively
ra re in t he w est as a result of the frequent use of the prone
position. Resolving infantile scoliosis is c haracterized by a lo
ng, usually left-convex, thoracolumbar, C-shaped arch with little
rotation. The r ib v ertebral a ngle dif ference (R VAD) according
t o Mehta [68] is measured to distinguish it from progressive
infantile scoliosis (see ⊡ Fig. 3.30). The p rognosis is g ood and
a spontaneous recovery can be expected in over 96% of cases.
Isolated cases can progress to infantile idiopathic scoliosis.
Infantile (early onset) scoliosis This ra re typ e is lo cated
in t he t horacic a rea in 98% o f cases and occurs 1.5 times more
frequently in boys than in girls. In 76% of cases the scoliosis is
left convex and often associated with a kyphosis. In the infant, an
rib vertebral angle difference according to Mehta of more than 20°
[68] indicates t hat t he co ndition is no t t he b enign r
esolving
infantile scoliosis, but rather a progressive form of infan-tile
idio pathic s coliosis ( ⊡ Fig. 3.30). The c haracteristic features
of infantile scoliosis differ from those of the ado-lescent form to
such a n extent that it can clearly be con-sidered as a dif ferent
disease. The p rognosis for infantile scoliosis is very poor.
Despite brace treatment, it will often undergo substantial
progression , resulting in the need for surgery even at an early
age in many cases.
Juvenile scoliosis If the scoliosis occurs between the ages of 4
a nd 10, t he juvenile form is co nsidered to b e present . Girls
are only slightly mo re f requently a ffected t han b oys. I n addi
tion to the thoracic location, lumbar and S-shaped curves also
occur. The p rognosis is p oor. Onl y 5% o f s colioses a re
non-progressive, while the rest increase annually by 1–3° up t o ag
ed 10, a nd by 5–10° a y ear during t he p ubertal growth spurt
[88].
Adolescent (late onset) idiopathic scoliosis
This is by far the commonest form of scoliosis and is
characterized by the following features:▬ It is usually located at
the thoracic level and almost
without exception involves a right-convex curve.▬ It occurs less
commonly at the thoracolumbar
and lumbar levels, and such cases show a marked tendency to go
out of alignment. Sometimes these scolioses are not truly
idiopathic but occur second-arily to leg length discrepancies or a
lumbosacral junction anomaly.
▬ In around 10% of cases, adolescent scoliosis is S-shaped ,
i.e. there are 2 primary curves: Since the lumbar curve is usually
more rotated than the tho-racic curve, S-shaped scolioses are less
conspicu-ous in cosmetic respects than C-shaped thoracic scolioses
of the same severity.
▬ It is almost always associated with relative lordosis (for the
thoracic level, an overall kyphotic angle of less than 20° is
considered to be relative lordosis).
▬ I t always involves rotation , whereby the posterior parts of
the vertebral bodies are always rotated towards the concave side of
the cur ve (if this is not the case then a structural idiopathic
scoliosis is not present); for a given degree of curvature, the
rotation is always more pronounced at the lumbar level than the
thoracic level.
▬ Adolescent scoliosis probably develops as the result of a
disparity between the growth of the posterior and anterior
vertebral body sections; the diminished growth of the posterior
sections forces the vertebral bodies to deviate laterally and to
ro-tate. Instead of a scoliosis, one might describe this as a
rotational lordosis.
⊡ Fig. 3.30. RVAD according to Mehta [64]. In scolioses in the
infant, the angle between a vertical line passing thr ough the
vertebral body and the axis of the rib is measur ed on both the c
onvex and concave sides. If the difference (γ) between the two
angles is 20° or more, the scoliosis is very likely t o be the pr
ogressive form rather than a spontaneously correcting scoliosis