7. Musculoskeletal Problems of Children 173 BC E SEVERITY OF SPONDYLOLISTHESIS SLIP ANGLE D C B A 5 1 2 3 4 90Њ 31Њ Fig. 7.10. Spondylolysis, and spondylolisthesis (right). (A) Radiographic representation of an abnormal elongation (grey- hound sign) of the pars interarticularis, or the “neck” of a scotty dog (arrow). Other defects, such as sclerosis or lysis in the pars, are best visualized in this “neck.” (From Lillegard and Kruse, 50 with permission.) (B) “Scotty dog.” A ϭ superior articular process (ear); B ϭ pedicle (eye); C ϭ pars interarticularis (neck); D ϭ lam- ina (body); E ϭ inferior articular process (front leg). (C) Severity of spondylolisthesis and slip angle. interarticularis) of L5. Sclerosis of the opposite pars may be present. A standing spot lateral view of L5-S1 allows accurate assessment of a possible slip. Scoliosis is commonly associated with spondylolisthesis. Bone scans show increased activity on one or both sides in symptomatic spondylolysis but are not routinely required. If asymptomatic, no treatment is required, and there is no need to limit contact sports. For a mildly symptomatic patient, temporary reduction of activity is all that is needed. If symptoms are alleviated, progressive activity is permitted. Symptoms that are sudden in onset, traumatically induced, or do not resolve with rest do heal—much as any fracture would heal—after 10 to 12 weeks of immobilization in a plastic body jacket or a Boston-type spinal orthosis. In general, once symptoms resolve, the child can resume normal activities, although advice regarding return to rigorous spine-bending athletic events (gym- nastics, diving, downed lineman in football) is controversial (see Chapter 10). With spondylolisthesis, if slippage is less than 30% and symptoms are minimal, treatment is conservative. With persistent pain unre- sponsive to treatment or slippage more than 30% to 50%, spinal fusion is recommended. Such fusion is generally at the L5-S1 level and includes L4 if slippage is more than 50%. 44 Idiopathic Scoliosis Idiopathic scoliosis is defined as lateral deviation of the spine of more than 10 degrees (measured by the Cobb method), 45 with structural change and without congenital anomalies of the vertebrae. It is inher- ited in an autosomal-dominant manner with variable penetrance or a multifactorial condition. It occurs in approximately 2% of the popu- lation. Normally, only about one fifth to one sixth of this group require treatment. 46 Scoliosis is a painless condition usually identified by shoulder, scapular, or pelvic asymmetry during school screening or routine physical examination. Forward bending (Adam’s) testing is done with the child standing straight and bending forward with palms together and knees straight. Truncal asymmetry, most commonly right rib prominence, may be seen. Any limb length irregularity should be noted and corrected by placing blocks under the short leg and level- ing the pelvis prior to examination. Neurological examination is nor- mal. Initial radiological evaluation consists of standing PA and lateral spine films on a long cassette to include the pelvis. The curve is meas- ured using the Cobb method 45 (Fig. 7.11). If a structural curve of 10 174 Mark D. Bracker et al. to 20 degrees is identified, orthopedic referral is recommended. Painful scoliosis or an atypical curve pattern (apex left thoracic) is indicative of possible underlying neurological problems, such as syringomyelia or spinal cord lesion, and is probably not idiopathic scoliosis. The risk of curve progression is higher in young children, in those with large curves or double curves, and in girls. Bracing is usually ini- tiated for curves of more than 20 degrees with documented progres- sion and growth remaining or for curves initially 30 degrees or more. Curves of more than 45 to 50 degrees are usually not amenable to bracing, so surgery is recommended, as the risk of continued progres- sion after skeletal maturity is high in this group. 46 Scheuermann’s Disease Scheuermann’s disease (juvenile kyphosis) is defined as an abnormal increase in thoracic kyphosis (normal 20–40 degrees) during puberty with at least 5 degrees of anterior wedging of at least three or more adjacent vertebrae. It is to be distinguished from postural round back, which is more flexible and lacks radiographical changes in the verte- brae. 47 The etiology is unclear, but a familial incidence is noted in 30% to 48% of cases. It occurs in about 1% of the population and is more common in boys. Clinically, it is possible to distinguish two forms of juvenile kypho- sis. Thoracic Scheuermann’s disease has an apex of the curve at T7–9, 7. Musculoskeletal Problems of Children 175 OBSERVATION COBB ANGLE 0 - 25Њ 25Њ - 45Њ > 45Њ BRACE SPINAL FUSION Fig. 7.11. Measuring the Cobb angle and treatment of idiopathic scoliosis. 176 Mark D. Bracker et al. and thoracolumbar Scheuermann’s disease has an apex at T11-12. Cosmetic deformity is often the chief complaint. Pain is usually aching and occurs more commonly with the thoracolumbar form. Radiographs should include standing posteroanterior and lateral scoliosis films. Hyperextension lateral films help to determine the flexibility of the curve. Radiographs show irregularity of the vertebral endplates, anterior wedging of 5 degrees or more of three or more adjacent vertebrae, Schmorl’s nodes, and increased kyphosis meas- ured between T4 and T12 by the Cobb method. Kyphosis may worsen during the growing period. Curves of 40 to 60 degrees may be treated by a trial of hyperextension exercises if the curve is supple and demonstrates active correction. Curves of 60 to 75 degrees are treated with a Milwaukee brace or underarm orthosis with a breastplate. Bracing is begun if the vertebral end plates are not fused to the vertebral body, with full-time wearing for 6 to 12 months and then part-time (about 16 hours/day) for 6 months or until the end plate fuses. Bracing is less effective for curves of more than 65 to 75 degrees or after skeletal maturity. Surgery may be indicated for cosmesis, progressive deformity despite bracing, or intractable pain. No long-term cardiopulmonary problems have been identified. 48,49 References 1. Karoll LA. Rotational deformities in the lower extremities. Curr Opin Pediatr 1997;9:77–90. 2. Engel FM, Staheli LT. The natural history of torsion and other factors influencing gait in early childhood. Clin Orthop 1974;99: 12–17. 3. Wells L. 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Gerberg LF, Micheli LJ, Nontraumatic hip pain in active children: a crit- ical differential. Phys Sports Med 1996;24:69–74. 53. Peck DM. Apophyseal injuries in the young athlete. Am Fam phys 1995;51:1891–5. 7. Musculoskeletal Problems of Children 179 [...]... predicts the risk of osteoporotic fractures in postmenopausal women. 26 These markers include indices of bone resorption such as serum and urine levels of C- and N-telopeptide, and indices of bone formation such as osteocalcin and bone-specific alkaline phosphatase These markers of bone turnover may be particularly 1 86 Paula Cifuentes Henderson and Richard P Usatine Table 8.2 Indications for Bone Mineral Density... Engl J Med 1998;339:292–9 16 Bassey EJ, Rothwell MC, Littlewood JJ Pre- and post-menopausal women have different bone mineral density responses to the same high impact exercise J Bone Miner Res 1998;13:1805–13 17 Dawson B, Harris SS, Krall EA Effect of calcium and vitamin D supplementation on bone density in men and women 65 years of age or older N Engl J Med 1997;337 :67 0 6 18 NIH Consensus Development... body weight history in the occurrence and recovery of osteoporosis in patients with anorexia nervosa: evaluation by dual x-ray absorptiometry and bone metabolic markers Eur J Endocrinol 1998;139:2 76 83 20 Consensus Development Conference Diagnosis, prophylaxis and treatment of osteoporosis Am J Med 1993;94 :64 6–50 21 Nattiv A Osteoporosis: its prevention, recognition, and management Family Pract Recert... Osteoporosis Prevention Study Maturitas 2000; 36( 3):181–93 32 Komulainen MH, Kroger H, Tuppurainen MT, et al HRT and Vit D in prevention of non-vertebral fractures in postmenopausal women; a 5 year randomized trial Maturitas 1998;31(1):45–54 33 Torgerson DJ, Bell-Syer SEM Hormone replacement therapy and prevention of nonvertebral fractures: a meta-analysis of randomized trials JAMA 2001;285:2891–7 34 Ettinger... women with osteoporosis treated with raloxifene: results from a 3-year randomized clinical trial JAMA 1999;282 :63 7–45 35 Karpf DB, Shapiro DR, Seeman E Prevention of nonvertebral fractures by alendronate: a meta-analysis JAMA 1997;277:1159 64 36 Saag KG, Emkey R, Schnitzer TJ, et al Alendronate for the prevention and treatment of glucocorticoid-induced osteoporosis GlucocorticoidInduced Osteoporosis Intervention... decrease of the bone density.25 The ultimate goal is to prevent vertebral and hip fractures The most thoroughly studied and most widely used technique to measure BMD is the dual-energy x-ray absortiometry (DEXA) scan This is considered to be the gold standard screening test to measure the BMD of the hip and spine It is less expensive and involves less radiation exposure than the quantitative computed tomography... enough vegetables and fruits, and have a high intake of low-calcium/high-phosphorus beverages like sodas These beverages have a negative effect on calcium balance Laboratory Assessment If the history and physical exam suggests secondary causes of osteoporosis, the physician should consider tests such as thyroid-stimulating hormone (TSH), parathyroid hormone (PTH), calcium, vitamin D, urine N-teloptide, complete... assessment Prevention and Treatment Nonpharmacological Nonpharmacological therapy for prevention and treatment of osteoporosis includes adequate dietary intake of calcium and vitamin D, weight-bearing exercise, fall precautions, no smoking, and avoidance of excessive alcohol intake These steps should be started early in life and continued through menopause because BMD peaks at about age 35 and then begins... women and will reduce the risk of fractures.27 The effect is not strong enough to recommend calcium alone for osteoporosis prevention Table 8.3 Optimal Calcium Intake Population Infants, children, and young adults 0 6 Months 6 12 Months 1–10 years 11–24 years Adult women Pregnant and lactating Ͻ24 years Ͼ24 years Premenopausal 25–49 years Postmenopausal 50 64 years On estrogen Not on estrogen 65 years... prevention and treatment of postmenopausal osteoporosis Endocrinol Pract 19 96; 2(2):157–71 useful if obtained prior to starting treatment and then repeated in 3 to 6 months to measure the response Despite the fact that these markers may identify changes in bone remodeling, they do not predict fracture risk These tests are very expensive and are not recommended for screening or as the first-line studies . evaluation and prognosis in Legg-Calv - Perthes disease. Clin Orthop 1980;150: 16 22. 36. Herring JA. The treatment of Legg-Calve-Perthes disease. J Bone Joint Surg 1994;76A(3):448–57. 37. McAndrew. women. 26 These markers include indices of bone resorption such as serum and urine levels of C- and N-telopeptide, and indices of bone formation such as osteocalcin and bone-specific alka- line. 1994;76A(3):448–57. 37. McAndrew MP. Weinstein SL. A long-term follow-up of Legg-Calve- Perthes disease. J Bone Joint Surg 1984 ;66 A (6) : 860 –9. 38. Osgood RB. Lesions of the tibial tubercle occurring