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

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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

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⊡ 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

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⊡ 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.

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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

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