Orthopedic Prometric MCQs - Chapter 3 Part 10

Scheuermannâ s kyphosis may affect any region of the thoracic spine; it also may affect the thoracolumbar junction or the lumbar spine. Endplate irregularity, wedging of three vertebrae, narrowing of disk space, and Schmorls nodes are characteristic of Scheuermanns kyphosis.

This patient is too skeletally mature to benefit from bracing. Bracing is not likely to change the natural history of the curve at maturity. Surgery is indicated if a patient experiences pain or dissatisfaction with the appearance of the back. Otherwise, the natural history is benign and observation is indicated.

Patients with Scheuermannâ s kyphosis have no decrease in pulmonary function compared to controls; however, they have increased severity of back pain, seek jobs with lower activity levels, and have more thoracic back pain and less trunk extension. They also have a 30% incidence of scoliosis of less than 35°.

Compression of the posterior column is the principal method of correcting Scheuermannâ s kyphosis. Compresssion is usually achieved by resecting portions of the elongation.

Brace treatment for Scheuermannâ s kyphosis is successful in decreasing the kyphosis, usually permanently, by 10° to 20° if worn properly. A patientâ s Risser sign must be below 3. Because this patient has a Risser sign of 1, bracing is appropriate treatment. The Milwaukee brace is the most effective type of brace for kyphosis. However, the Boston brace is also somewhat effective in treating patients with Scheuermannâ s kyphosis because it corrects the compensatory lordosis and stimulates active correction of the thoracic curve.

This radiograph shows two fractures in different stages of healing. Note the old femur fracture at the top of the field. No evidence of decreased cortical thickness, diaphyseal thinning, or bowing suggests OI. The physis of the distal femur and proximal femur show no signs of rickets. The presence of fractures rather than periosteal reaction make C affeyâ s disease unlikely. The fractures in scurvy are more commonly located in the physis. The diagnosis of nonaccidental injury should be made only after performing a thorough patient history and physical.

Repair of a spondylolytic defect is usually a successful procedure for relieving symptoms. Repair is not indicated in patients older than 35 years of age. Repair should not be done if there is a significant slip over a grade 1 at most or if the patient has minimal, tolerable symptoms or has symptoms complicated by a degenerative disk at the same level.

Asymptomatic spondylolisthesis occurs in approximately 5% of the pediatric population. Slips of up to grade 1 develop in at least one third of patients with asymptomatic spondylolisthesis. Most patients with asymptomatic spondylolisthesis are minimally symptomatic or asymptomatic. The patient presented in this scenario may be allowed to play football as long as he understands that he may develop symptoms.

A study was conducted to monitor the development of L5 spondylolysis in patients from birth to 6 years of age. The study showed that no cases of L5 spondylolysis were present at birth in any of the patients. The majority of the patients developed L5 spondylolysis by the time they had reached 6 years of age. A 45-year follow-up study showed that none of the 30 patients had more than a 40% slip and that only 1 patient required fusion.

As spondylolisthesis progresses to a high grade, the fifth lumbar vertebra shifts forward into a kyphotic position termed a slip angle. The slip angle can reach a value of more than 30° and results in verticalization of a patients sacrum to decrease force on the involved vertebra.

Klippel-Trnaunay-Weber syndrome is a constellation of varicose veins, cutaneous nevus, and an increase in the length or width of the involved limb. Seizure disorder is a feature of von Hippel- Lindau disease.

Epiphyseal osteochondroma is also known as Trevorâ s disease. Epiphyseal osteochondroma is localized to a specific region of the body, unlike multiple osteochondroma, which affects the entire body. Epiphyseal osteochondroma and multiple osteochondroma are unrelated disorders.

The term osteochondrosis refers to symptomatic disorders involving cartilage growth. Cartilage affected by osteochondrosis may be epiphyseal, physeal, or apophyseal. Gorhamâ s disease is not an example of osteochondrosis. Gorhams disease is a lymphatic disorder known as disappearing bone disease.

Syndactyly in constriction band syndrome is a fenestrated syndactyly, is incomplete, and has slits between the digits proximally. Syndactyly in constriction band syndrome is also not complex because the bones are not fused.

An ultrasound of the abdomen is indicated for patients with idiopathic hemihypertrophy to determine the development of Wilms tumor. Children with idiopathic hemihypertrophy have an increased incidence of Wilmsâ tumor. C hildren require periodic monitoring, and they should have an abdominal ultrasound 2 to 3 times per year until 8 years of age.

Patients with idiopathic hemihypertrophy require periodic monitoring to determine the risk of Wilms tumor. The best method to monitor patients with idiopathic hemihypertrophy is a renal ultrasound two to three times per year until the patient is 8 years of age.

The second ray is most commonly used to treat patients with macrodactyly of the foot. The third ray is the next most commonly used ray in treating patients with macrodactyly of the foot.

Macrodactyly displays overgrowth that is greatest plantarly and distally. Plantar overgrowth causes the sole to become convex plantarly and the toes to become dorsiflexed.

Almost all cases of congenital pseudarthrosis involve the right clavicle. C ases of congenital pseudarthrosis involving the left clavicle often coexist with dextrocardia. Patients with pseudarthrosis of the clavicle respond well to standard orthopedic treatment, unlike patients with congenital pseudarthrosis of the tibia.C orrect Answer: Dextrocardia

This patient demonstrates signs of early reflex sympathetic dystrophy. She may later develop osteopenia, a positive bone scan, and contracture. Physical therapy is the best treatment for reflex sympathetic dystrophy in this case because it will increase the patients range of movement and her tolerance to touch. Multimodality therapy is also required to treat reflex sympathetic dystrophy. Analgesics may be appropriate treatment for the patient and can be supplemented by antidepressants, if needed. Repeated regional block treatment is recommended for patients with established cases of reflex sympathetic dystrophy.

The classic Sorensen criteria define Scheuermann's kyphosis by the presence of anterior wedging of greater than 5 degrees in at least three consecutive vertebral bodies.

Bracing is typically indicated for progressive Scheuermann's kyphosis between 50 and 75 degrees in skeletally immature patients with significant remaining growth.

Operative treatment, typically a posterior spinal fusion, is indicated for Scheuermann's kyphosis >75 degrees, especially in skeletally mature patients or those with intractable pain.

Scheuermann's kyphosis is characterized by a structural, rigid deformity that does not correct upon hyperextension, whereas postural kyphosis is flexible and will fully correct.

Type II Scheuermann's involves the thoracolumbar or lumbar spine, frequently lacking the classic cosmetic deformity, and is often seen in athletic adolescents subjected to heavy axial loading.

Schmorl's nodes are intraosseous disc herniations commonly seen in Scheuermann's disease due to weakened vertebral endplates and disordered ossification.

The image highlights anterior wedging of multiple vertebral bodies and endplate irregularities, which are the hallmark radiographic features of Scheuermann's kyphosis.

To minimize the risk of distal junctional kyphosis, the lower instrumented vertebra (LIV) must include the first lordotic disc space, ensuring it is the sagittal stable vertebra.

Junctional kyphosis, either proximal or distal to the construct, is the most common complication and is frequently related to improper selection of fusion levels.

Histologically, Scheuermann's disease is characterized by disorganized endplate cartilage and defective ossification, predisposing the spine to disc herniation and wedging.

Extending the fusion construct to include the proximal end vertebra of the kyphotic curve, or one level proximal to it, is a standard strategy to prevent proximal junctional kyphosis.

Pain in Scheuermann's disease is typically described as a non-radiating, dull ache located directly over the apex of the thoracic or thoracolumbar kyphosis.

Mild scoliosis, usually measuring 10 to 20 degrees, is observed in approximately 20% to 30% of patients presenting with Scheuermann's kyphosis.

The three-point bending principle uses a posterior pad to apply an anteriorly directed force at or slightly below the curve's apex, countered by posteriorly directed forces anteriorly at the sternum and pelvis.

Modern all-posterior pedicle screw constructs achieve equivalent or superior deformity correction compared to historic methods, avoiding the significant pulmonary morbidity associated with an anterior thoracotomy.

The anterior longitudinal ligament (ALL) becomes significantly thickened and contracted in Scheuermann's disease, contributing to the rigidity of the kyphotic deformity.

Hyperlordosis in the cervical and lumbar regions is typically a flexible, compensatory response to the rigid thoracic kyphosis, allowing the patient to maintain their head centered over the pelvis.

Neurologic compromise is very rare in Scheuermann's disease. When it does happen, it is usually due to a compressive thoracic disc herniation or an epidural cyst located at the apex of the severe kyphosis.

Congenital kyphosis (Type I, failure of formation) has a high propensity for severe, rapid progression and neurologic compromise, often requiring early surgical intervention, unlike the more benign course of Scheuermann's.

Modern pedicle screw instrumentation provides highly rigid internal fixation, typically eliminating the need for any postoperative bracing or casting.

The Sorensen criteria for diagnosing Scheuermann's kyphosis require anterior wedging of greater than 5 degrees in at least three consecutive vertebrae. Additional common findings include Schmorl's nodes and endplate irregularities.

Bracing is indicated for skeletally immature patients (Risser 0-2) with a flexible Scheuermann's kyphosis measuring between 55 and 80 degrees. An extension orthosis like the Milwaukee brace should be worn 16-23 hours daily for optimal results.

To prevent distal junctional kyphosis, the distal fusion level must include the first lordotic disc, which corresponds to the sagittal stable vertebra. Stopping short of this level leaves the construct vulnerable to progressive kyphosis below the fusion.

Type II Scheuermann's disease affects the thoracolumbar or lumbar spine and usually presents in adolescent athletes involved in heavy lifting or repetitive trauma. It causes loss of normal lumbar lordosis and presents with mechanical back pain.

Type I congenital kyphosis (anterior failure of formation) results in a sharp, angular deformity with the highest propensity for rapid progression and spinal cord compression. Early surgical intervention (posterior fusion in situ) is often required.

While adults with untreated Scheuermann's kyphosis have higher rates of back pain and cosmetic concerns, long-term studies show no significant difference in severe disability, neurologic compromise, or occupational limitations compared to controls.

Type I congenital kyphosis has a high rate of progression and neurologic risk. In young children (under age 3-5) with curves <50 degrees, early in situ posterior spinal fusion is the treatment of choice to halt progression.

A slipped vertebral apophysis (apophyseal ring fracture) typically occurs in adolescents when disc material herniates through the unossified ring apophysis, displacing it posteriorly into the spinal canal. It is often mistaken for a simple disc herniation.

To compensate for the rigid hyperkyphosis in the thoracic spine and maintain a horizontal gaze, patients will typically develop hyperlordosis in both the cervical and lumbar spine.

Failure to extend the proximal fusion level to include the proximal end vertebra (typically T2 or T3) in Scheuermann's kyphosis significantly increases the risk of proximal junctional kyphosis (PJK).

The proximal fusion level should be the proximal end vertebra of the kyphosis, which is usually T2 or T3. Stopping lower (e.g., T4 or T5) leaves the patient highly susceptible to proximal junctional kyphosis.

Schmorl's nodes occur when the intervertebral disc (nucleus pulposus) herniates vertically through a weakened or defective cartilaginous endplate into the cancellous bone of the vertebral body.

Overcorrection of the kyphotic deformity alters spinal biomechanics aggressively and is a major independent risk factor for the development of proximal junctional kyphosis (PJK). Correction to high-normal ranges (40-50 degrees) is preferred.

The Milwaukee brace works primarily via three-point bending. It applies anteriorly directed corrective force via a posterior pad situated just below the apex of the kyphosis, countered by posterior forces at the neck and pelvis.

This presentation describes postural kyphosis, characterized by a flexible deformity with no structural vertebral wedging. Management consists of reassurance and postural exercises; bracing or surgery is not indicated.

Historically, anterior release was recommended for curves >75 degrees. With powerful modern pedicle screw constructs, posterior-only approaches are standard unless the curve is exceptionally severe (>100 degrees) and highly rigid.

A Ponte osteotomy is a posterior column shortening osteotomy that involves wide resection of the spinous process, lamina, ligamentum flavum, and the bilateral facet joints to drastically increase posterior flexibility.

The primary histological defect in Scheuermann's disease is an abnormality in the cartilaginous endplate, characterized by disorganized cellularity, defective ossification, and focal defects allowing disc herniation (Schmorl's nodes).

Loss of MEPs indicates compromise to the anterior spinal cord (motor tracts), which can occur from over-shortening or distraction. The immediate first step is to release the corrective forces. MEPs are more sensitive to this specific ischemia than SSEPs.

Dystrophic curves in NF1 are highly aggressive and carry a massive risk of pseudarthrosis. They typically require robust stabilization with combined anterior and posterior spinal fusion to achieve successful arthrodesis.

The Sorensen criteria define classic Scheuermann's disease as anterior wedging of greater than 5 degrees in at least three consecutive vertebrae.

Sorensen's classic criteria for Scheuermann's disease requires anterior wedging of at least 5 degrees in three or more sequential adjacent vertebrae. This distinguishes it from postural kyphosis and normal variant spinal curves.

For a skeletally immature patient (Risser 0-2) with a flexible curve between 50 and 75 degrees, bracing is indicated. Because the apex is at T8 (T7 or below), a TLSO is effective; an apex above T7 would require a Milwaukee brace.

The lower instrumented vertebra (LIV) must include the sagittal stable vertebra (SSV) and the first lordotic disc space. Stopping short of the SSV significantly increases the risk of distal junctional kyphosis (DJK).

The image demonstrates Scheuermann's kyphosis with anterior wedging and Schmorl nodes. The primary histologic defect is abnormal enchondral ossification of the vertebral endplates, leading to weakened cartilage and subsequent herniation of the disc material.

Type II (Atypical or Lumbar) Scheuermann's disease, also known as Appellgren's, primarily involves the thoracolumbar or lumbar spine and is heavily associated with athletic activity and heavy lifting in adolescents. It tends to be more painful than classic thoracic Scheuermann's.

To prevent proximal junctional kyphosis, the proximal fusion level must incorporate the upper end vertebra of the kyphosis. Fusing short of this curve boundary leaves the patient vulnerable to progressive deformity above the construct.

Spondylolysis is observed at a higher rate in patients with Scheuermann's kyphosis. This is thought to be due to increased shear forces on the pars interarticularis resulting from the compensatory lumbar hyperlordosis.

The supine cross-table lateral radiograph with a hyperextension bolster placed under the apex of the curve best demonstrates the flexibility and correctability of the kyphosis.

Similar to idiopathic scoliosis, the amount of initial in-brace correction is highly predictive of final outcomes in Scheuermann's disease. Correction of at least 15 degrees or >40% in the brace correlates with a successful result.

Modern posterior-only approaches using rigid all-pedicle screw constructs and multiple posterior column (Ponte) osteotomies achieve equivalent or superior correction to combined AP approaches, while eliminating anterior approach-related morbidity.

Excessive correction of kyphosis can cause relative lengthening of the spinal column compared to the spinal cord, leading to cord traction or ischemia. Neurologic monitoring is critical during deformity correction.

The Sagittal Stable Vertebra (SSV) is determined by drawing a vertical plumb line from the posterior superior corner of the sacrum (S1). The most proximal vertebra bisected by this line is the SSV.