! To ensure that the patient s back is at eye-level, the. ! If the sagittal curves can be corrected by bending

Transcription

1 Generlized skeletl normlities (VII) (Apert nd Polnd syndromes, Arthrogryposis etc.) Disloctions of the shoulder Growth disturnces of the upper extremities Pnner s disese Osteochondrosis dissecns of the cpitellum Luntomlci Neuromusculr disorders of the upper extremity Primrily spstic prlyses Primrily flccid prlyses Frctures of the upper extremities Scpulr frctures Clviculr frctures Proximl humerl frctures Humerl shft frctures Elow frctures Suprcondylr humerl frctures Epicondylr humerl frctures Trnscondylr humerl frctures Rdil hed nd neck frctures Olecrnon frctures Elow disloctions Rdil hed disloctions (Monteggi lesions) Forerm shft frctures Distl forerm frctures Frctures of the crpl ones Frctures of the metcrpls nd phlnges Tumors of the upper extremities 522

2 Exmintion of the ck 3.1 Spine, trunk Exmintion of the ck History Trum history: Hs trum occurred? If so: When did the trum occur? Wht ws the ptient doing (sport, plying, norml routine)? Direct or indirect trum? Pin history : Where is the pin locted (neck, upper thorcic spine, lower thorcic spine, lumr spine, lumoscrl spine)? When does it occur? Is it relted to loding or movement, or does it lso occur t rest (e.g. while sitting) or even t night? If so, does the pin occur only while chnging position, or does the pin cuse the ptient to wke up t night? Does the pin occur on ending down or strightening up gin? Does the pin lso rdite to the legs? Does the pin occur on coughing or sneezing? Sports history Wht sports does the ptient prctice outside school? If spondylolysis is suspected sk specificlly out the following ctivities: gymnstics, figure skting, llet, jvelin-throwing. If Scheuermnn disese is suspected sk specificlly whether the ptient is involved in cycle rcing or rowing. Neurologicl symptoms Is leg wekness present nd, if so, since when? Are there prolems of micturition or defection? Inspection After the git nlysis ( Chpter 2.1.3), the stnding ptient s ck is inspected from ehind.! To ensure tht the ptient s ck is t eye-level, the exminer himself should not stnd ut preferly sit on chir of the pproprite height ( Fig. 3.1). Inspection from ehind We oserve the position of the shoulders, the height of the scpule nd prticulrly the symmetry of the wist tringles. We look for pigmenttion over the spinous processes, especilly over the lumr spine, s this cn e n indiction of (usully pthologicl) kyphosis in this re. A (hiry) nevus in this re cn e sign of n intrspinl nomly. Inspection from the side We ssess the sgittl curves nd estlish posturl type : norml (physiologicl) ck, hollow ck (incresed thorcic kyphosis nd lumr lordosis), fully rounded ck (kyphosis extending down to the lumr re), hollow-flt ck (hyperlordosis of the lumr spine with reduced kyphosis of the thorcic spine, common in smll children), flt ck (reduced kyphosis of the thorcic spine nd lordosis of the lumr spine; Fig. 3.2).! If the sgittl curves cn e corrected y ending ckwrds or forwrds, then posturl vrints re involved rther thn (fixed) pthologicl chnges. N.B.: ewre of overdignosis nd overtretment! We oserve whether ventrl or dorsl overhng is present ( Fig. 3.3) nd the extent of the pelvic tilt ( Fig. 3.4). Fig Not like this! During exmintion in the stnding position the ptient s ck should e t the eye level of the exminer, who should therefore e seted. Smll children my need to stnd on ox so tht the ilic crest is t the exminer s eye level. The child must e undressed down to the underpnts. The dignity of the child or dolescent must e preserved. Girls who hve reched puerty should lso e llowed to wer their rssiere. Otherwise, ll items of clothing, including socks, should e removed.

3 Spine, trunk 3 A verticl line from the center of the shoulders should pss through the center of the nkle. The forwrd nd downwrd pelvic tilt is pprox. 30 in reltion to the horizontl. A reduction in this tilt is n indiction of lumr kyphosis (e.g. in lumr Scheuermnn disese) or of spondylolisthesis. In order to ssess posture-relted muscle performnce, Mtthiss hs proposed the rm-rising test. The child is sked to stnd s stright s possile nd rise his rms nd keep them in horizontl position. He should try nd mintin this position for 30 seconds. A child or dolescent with norml posturl cpcity is le to mintin this position, in contrst with child with posturl wekness ( Fig. 3.5). We now sk the child to end down s fr s possile while keeping the knees perfectly stright. We now mesure the finger-floor distnce (FFD; Fig. 3.6). Normlly, children nd dolescents should e le to touch the floor with their fingertips or even plce the whole plm of their hnd on the floor. If this is not possile, we mesure the distnce from the fingertips to the floor in Fig Ventrl nd dorsl overhng: A verticl line from the center of the shoulders flls in front of or ehind the center of the nkle c d e Fig. 3.2 e. Posturl types : norml ck, hollow ck, c rounded ck, d hollow-flt ck, e flt ck Fig Pelvic tilt : The forwrd nd downwrd pelvic tilt in reltion to the horizontl is normlly pprox c Fig. 3.5 c. Arm-rising test ccording to Mtthiss : The child is sked to stnd s stright s possile nd rise his rms nd keep them in horizontl position. He should try to mintin this position for 30 seconds. A child or dolescent with norml posturl performnce is le to mintin this position (), in the cse of posturl wekness this posture is lost (), while child with extremely wek muscles cnnot even dopt the upright posture (c)

4 Exmintion of the ck Fig Finger-floor distnce (FFD): The ptient ends down s fr s possile without ending the knees. The distnce etween the floor nd the fingertips is mesured. Norml vlue = 0 cm centimeters. However, this distnce is less n indiction of reduced moility of the ck thn of contrction of the hmstrings. With the ptient in forwrd-ending position we oserve whether the lumr lordosis is corrected nd whether the thorcic spine shows the right degree of kyphosis (correction of posturl curvture in the cse of hollow or flt ck). The ptient is now sked to clsp his hnds ehind his neck (to prevent the shoulders from eing pulled forwrd y the rms) nd try to look up t the ceiling without chnging the flexed position t the hip. Idelly, the ptient is held in this position with hnd plced t the pex of the kyphosis nd then sked to end ck (»look up t the ceiling«). We cn then oserve whether the thorcic kyphosis strightens out or whether fixed kyphosis is present (e.g. s in cse of thorcic Scheuermnn disese; Fig. 3.7). If the ltter is suspected, the condition of the pectorl muscles must lso e ssessed t the sme time. To this end, the shoulders of the erect ptient re pushed ckwrds y hnd. If the pectorl muscle is contrcted, the shoulder remins in front of the thorcic plne. Evlution of the ilic crest We plce extended index fingers on oth sides of the ilium nd extend nd duct the thums t right ngles, which then serve s pointers. We try to hold oth thums horizontlly ( Fig. 3.8). If one ilic crest is lower thn the other this will e reflected in the difference in the height of the thums. However, since it cn e difficult to estlish the precise difference, we plce ords under the shorter leg until the ilic crests on oth sides re t the sme level nd the two thums re likewise t the sme height. The thickness of the ords corresponds to the leg length discrepncy in centimeters. Fig Strightening of the kyphosis: While in forwrd-ending position the ptient clsps his hnds ehind his neck (to prevent the shoulders from eing pulled forwrd y the rms) nd tries to look up t the ceiling without chnging this flexed position t the hip. Idelly, the ptient is held in this position with hnd plced t the pex of the kyphosis nd then sked to end ck (»look up t the ceiling«). We cn then oserve whether the thorcic kyphosis is strightened out or whether fixed kyphosis is present Fig Height of the ilic crests : Extended index fingers re positioned on oth sides of the ilium. The thums re extended nd ducted t right ngles to serve s pointers. If one ilic crest is lower thn the other this will e reflected in the difference in the height of the thums. Bords re plced under the shorter leg until the ilic crests on oth sides re t the sme level nd the two thums re likewise t the sme height.

5 Spine, trunk! When mesuring leg length indirectly it is extremely importnt to ensure tht oth the knee nd hip joints re fully extended, unless this is rendered impossile ecuse of flexion contrctures. 3 Verticl lignment A cord with symmetricl weight is plced ginst the verter prominens, nd we ssess whether the weight is in line with the nl cleft or, if not, how mny fingerwidths it devites to the right or left ( Fig. 3.9). Exmintion of moility Exmintion of moility from ehind We exmine the mximum lterl inclintion of the stnding ptient s spine from ehind ( Fig. 3.10). We oserve whether the whole spinl column curves hrmoniously to the side or whether individul segments re fixed nd do not move with the rest of the spine (indiction of fixed scoliosis). The pelvis must e fixed in order to evlute trunk rottion. The rottion of the shoulder girdle in reltion to the frontl plne is mesured in degrees nd is est oserved from ove ( Fig. 3.11). The ptient is now sked to end forwrd until the thorcic spine forms the horizon. The symmetry of the thorx is ssessed. Protrusion of the ri cge on one side is termed ri prominence. Using protrctor (or if ville scoliometer or inclinometer ) we mesure the ngle etween the ri prominence nd the horizontl (the ltter cn e determined prllel to door or window frme in the exmintion room; Fig. 3.12). Fig. 3.10,. Lterl inclintion of the trunk: The ngle etween the verticl nd mximum lterl inclintion of the spine is estimted in degrees from ehind the stnding ptient (norml vlue: ). We oserve whether the whole spinl column ends hrmoniously to the side or whether individul segments re fixed nd do not move with the rest of the spine Fig Verticl lignment : A cord with symmetricl weight is plced ginst the verter prominens nd checked to see whether it is in line with the nl cleft or how mny fingerwidths it devites to the right or left Fig. 3.11,. Rottion of the trunk: With the pelvis fixed, the rottion of the shoulder girdle in reltion to the frontl plne is mesured in degrees nd is est oserved from ove. Norml vlue: 40 50

6 Exmintion of the ck Fig. 3.12,. Mesurement of ri prominence : The ptient ends forwrd until the thorcic spine forms the horizon. With protrctor, the ngle etween the horizontl (i.e. prllel to the door or window frme) nd the surfce of the ck is mesured. A simpler nd more ccurte mesurement is otined with n inclinometer with integrted spirit level nd notch in the center to void ny distortion of the mesurement cused y the projecting spinous process Fig. 3.13,. Hed rottion : Hed rottion to oth sides is mesured from ove with the ptient in sitting position. The rottion is stted in degrees mesured from the midline. It cn e mesured ctively (y sking the ptient to turn his hed) or pssively (y holding the sides of the hed with oth hnds nd turning to either side). Norml vlue: Oserve ny tensing of the sternocleidomstoid muscle t the sme time A ri prominence of more thn 2 together with horizontl pelvis is relile indiction of fixed rottion of the verterl odies. A ri prominence of 5 or more represents serious cse of scoliosis nd requires rdiogrphic investigtion. The ptient is now sked to continue ending forwrd until the lumr spine forms the horizon so tht we cn then identify ny lumr prominence. Here, too, it is importnt tht the pelvis is horizontl. If one leg is shorter thn the other, the leg length discrepncy must e corrected using ord of pproprite thickness. The lumr prominence is lso mesured with protrctor. An ngle of 5 or more requires x-ry exmintion. Exmintion of the moility of the cervicl spine The hed rottion to oth sides is idelly mesured from ove with the ptient in sitting position ( Fig. 3.13). The rottion cn e ctively (sk the ptient to turn his hed) or pssively (hold the sides of the hed with oth hnds nd turn to either side). We cn lso oserve ny tensing of the sternocleidomstoid muscle during this mneuver. If contrcture due to musculr (congenitl) torticollis is present, the muscle tenses on the side of the rottion movement. We then check lterl inclintion ( Fig. 3.14), which cn lso e mesured ctively or pssively. Here, too, the tensing of the sternocleidomstoid muscle is oserved. If contrcture is present, the muscle tenses when the hed is inclined to the opposite side. Finlly, inclintion nd reclintion re exmined. With the hed inclined forwrd the chin-sternum distnce is mesured. The ptient then ends his hed ck nd the ngle with the xis of the ody is estimted ( Fig. 3.15). Fig. 3.14,. Lterl inclintion of the hed: This cn e mesured ctively or pssively. The devition from the midline is stted in degrees. Norml vlue: Oserve ny tensing of the sternocleidomstoid muscle t the sme time Fig Inclintion of the hed: The chin-sternum distnce is mesured (in centimeters or fingerwidths; norml vlue: 0 cm). Reclintion: Estimte the ngle in reltion to the xis of the ody in degrees. Norml vlue: 40 60

7 Spine, trunk 3 Schoer mesurement The Schoer test is used to determine the moility of the spine in the sgittl plne nd involves mesurement of the stretching of the skin over the thorcic nd lumr spine. An initil mrk is mde over spinous process S1 nd second mrk 10 cm ove the first. The distnce etween these skin mrks increses s the ptient ends forwrd, reching mximum of cm. Thorcic spine: A mrk is mde over spinous process C7, nd second mrk is mde 30 cm elow this. As the ptient ends forwrd the distnce etween the two increses y 2 3 cm ( Fig. 3.16). The mximum reclintion of the spine is mesured s shown in Fig We oserve whether the ptient complins of pin round the lumoscrl junction (indiction of spondylolysis). Plption We plpte the spinous processes nd estlish whether pin is elicited on pressure, percussion or virtion. To check pin on virtion we grsp the spinous processes etween forefinger nd thum nd move them ck nd forth. If the ptient finds this pinful, prticulrly round the lumoscrl junction, this is n importnt indiction of possile spondylolysis. We plpte the prverterl muscles to ssess whether these re strong, norml or wek, plpte ny pinful res of muscle hrdening (myogeloses) nd check for tenderness over the muscle ttchments. The trnsverse processes cn lso e felt y deep plption. During plption, the skin moisture, temperture nd elsticity of the skin re ssessed nd ny dermogrphic urticri noted. Heel-drop test The ptient is sked to stnd on tiptoe nd the exminer rests his hnds on the ptient s shoulders. The ptient is now sked to drop onto his heels while the exminer simultneously presses down on the shoulders. This mneuver will elicit ny virtion-relted pin in the spine cused y inflmmtion, tumors or hernited disks. Ilioscrl joints We check for pin on pressure or percussion nd pin on compression from the side nd sgittlly. Mennell sign : In disorders of this joint, pin is elicited if the hip on the sme side is overextended. Neurologicl exmintion A complete exmintion of the ck ( Tle 3.1) lso includes t lest cursory investigtion of the neurologicl sttus. A very rough (nd quick) indiction of motor disorder cn e otined y checking the ptient s ility to wlk on tiptoes or on heels. The most importnt spects of the neurologicl exmintion from the orthopedic stndpoint re descried in chpter Brief overview of spinl sttus (e.g. in mss screening or if the child is eing seen specificlly for ck prolem): Inspection from ehind, Height of the ilic crests, Finger-floor distnce, Ri prominence, lumr prominence on forwrd ending? Wlking on tiptoes nd heels. Fig Schoer sign. Lumr spine: Mke n initil mrk over spinous process S1 nd second mrk 10 cm ove this. The distnce etween these skin mrks increses s the ptient ends forwrd, reching mximum of cm. Thorcic spine: A mrk is mde over spinous process C7, nd second mrk is mde 30 cm elow this. As the ptient ends forwrd the distnce etween the two increses y 2 3 cm Fig Reclintion of the trunk: The mximum reclintion of the spine is mesured s the ngle etween the upper ody s verticl xis nd the frontl plne. Norml vlue: 30 60

8 Rdiogrphy of the spine Tle 3.1. Exmintion protocol for the ck Exmintion position Exmintion Questions I. Wlking Movement pttern? Limping? Atxi? Neurologicl lesion? II. Stnding from ehind III. Stnding from the side IV. Stnding with flexed ck from ehind From the side Position of the shoulders? Scpule symmetricl? Spine stright? Ilic crests horizontl? Glutel folds symmetricl? Wist tringles symmetricl? Plumline in the center? Pigmenttion over spinous processes? Hrdening of prverterl muscles? (if necessry exmine on the lying ptient s well) Pin on percussion/virtion of the verterl odies? (if necessry exmine on the lying ptient s well) Shoulders pulled forwrd? Sgittl curves? Trnsition etween front/ck Spine stright? Ri hump >5 Lumr prominence >5 FFD? Cn the thorcic kyphosis e strightened out? Scoliosis? Plexus presis? Sprengel deformity? Winged scpul? Sprengel deformity? Scoliosis? Leg length discrepncy? Hip condition? Scoliosis? Severe scoliosis? Lumr kyphosis? Myogelosis (muscle spsm)? Tumor? Infection? Spondylolysis? Contrcture of the pectorlis muscles? Scheuermnn s disese? Contrcture of psos or hmstrings? Scoliosis? Thorcic scoliosis? Lumr scoliosis? Contrcture of hmstrings? Thorcic Scheuermnn s disese? V. Moility Lterl inclintion of the hed? Hed rottion? Reclintion/Inclintion of hed? Lumr pin on reclintion? (if necessry exmine on the lying ptient s well) Torticollis? Torticollis? Klippel-Feil syndrome? Spondylolysis? Rdiogrphy of the spine The following stndrd spinl x-rys re recorded: Cervicl spine, AP nd lterl: The ptient cn either stnd or lie down for the AP x-ry of the cervicl spine. The centrl x-ry em is trgeted on the 4th cervicl verter (t the level of the Adm s pple) nd is inclined towrds the hed t n ngle of ( Fig left). For the lterl x-ry, the ptient cn either stnd, sit or lie down, nd hold his hed up stright in neutrl position. The centrl em is trgeted horizontlly on C4 (chin height; Fig right). Trnsuccl x-ry of the dens : For the specilist dens x-ry the ptient is plced on his ck with the hed in the neutrl position. With the ptient s mouth opened s wide s possile, the centrl em is verticlly ligned with the center of the open mouth ( Fig. 3.19). While the x-ry is recorded, the ptient is sked to sy»h«, cusing the tongue to press ginst the floor of the mouth therey preventing its shdow from eing projected onto verterl odies C1 nd C2. The dens, xis, lterl msses of the tls nd the tlntoxil joints will e clerly visile on the resulting x-ry. Functionl x-rys of the cervicl spine from the side during mximum inclintion nd reclintion: If instility or ligmentous injury is suspected, the cervicl spine is x-ryed (on the wke ptient) from the side, while the ptient is sitting up nd during mximum inclintion nd reclintion ( Fig. 3.19). Thorcic spine, AP nd lterl: The AP nd lterl x-rys of the thorcic spine should, if possile, e recorded while the ptient is stnding. For the AP view, the centrl em is trgeted perpendiculrly onto point pprox. 3 cm ove the xiphoid process of the sternum. For the lterl x-ry of the thorcic spine, the ptient is sked to rise his rms. The centrl em is trgeted horizontlly t the level of the 6th thorcic verter nd tilted towrds the hed t n ngle of out 10. The resulting x-ry shows the verterl odies nd the interverterl disks viewed from the side ( Fig. 3.20). Lumr spine, AP nd lterl The AP nd lterl x-rys of the lumr spine should likewise e recorded while the ptient is stnding. For

9 Spine, trunk 3 Fig Recording lterl nd AP x-rys of the cervicl spine. (fter [1]) Fig. 3.19,. Recording cervicl spine x-rys. Rdiogrphic technique for the trnsuccl view of the dens, Functionl lterl x-rys of the cervicl spine in mximum reclintion (left) nd inclintion (right) Fig Recording thorcic spine x-rys, lterl (left) nd AP (right). (fter [1]) Fig Recording lumr spine x-rys, lterl (left) nd AP (right). (fter [1])

10 Rdiogrphy of the spine the AP view, the centrl em points perpendiculrly, t the level of the ilic crests, onto the center of the domen. For the lterl x-ry, the centrl em is trgeted on L3 t the ptient s wist level ( Fig. 3.21). In dolescents, wide cssettes should e used so tht the ilic crest is included in the x-ry (so tht the remining growth potentil cn e ssessed). Thorcolumr junction, lterl: For this x-ry the centrl em is trgeted on T12. Lumoscrl junction, lterl: For this x-ry the lterl em pth is centered on L5. Olique x-rys of the lumoscrl junction: For the olique x-rys of the lumr spine, the ptient lies on his side on the exmintion tle nd then turns 45 to the right so tht the smll verterl joints on the right re viewed (similrly, rising the left side will enle the fcet joints on the left to e viewed). The centrl em is trgeted verticlly onto the center of L3 ( Fig. 3.22). See Fig nd 3.69 for exmples nd explntions. Whole spine, AP nd lterl: With children nd younger dolescents it is possile to depict the whole spine on single norml cssette. The centrl em points to T12. If deformities re present, this overview is more useful for evluting the sttics of the spine thn individul imges of the thorcic nd lumr spine. Here, too, wide cssettes should e used so tht the ilic crest is included in the x-ry. For full-grown ptients the spine must e x-ryed using comined films in specil cssettes. Since the distnce from the x-ry tue is considerle, this not only hs n dverse effect on imge qulity, ut lso involves high dose of rdioctivity. We only record such x-rys in exceptionl cses. CT of the spine : CT is extremely useful in frctures for reveling frgments in the spinl cnl. They re lso effective for identifying introsseous tumors. Myelo-CT : Myelo-CT hs lrgely superseded the conventionl myelogrm when it comes to viewing ny impediment in the spinl cnl resulting from neurologicl lesion. Angiogrm : Angiogrms cn e recorded conventionlly, s MR ngiogrms or, using more recent technique, s CT ngiogrms, which produce the est view of the lood vessels. Such imges re required in certin tumors or for depicting the rtery of Admkiewicz prior to verterectomies. MRI of the spine: The MRI scn is used for cses of inflmmtion nd tumors (primrily for the imging of the soft tissue components) nd for reveling intrspinl nomlies efore scoliosis opertions (prticulrly for congenitl scolioses). Bone scn : The technetium scn is useful for reveling smll tumors tht re not clerly depicted with conventionl imging techniques (e.g. osteolstoms) or in the serch for metstses. Ultrsound scns: Ultrsound scns re recorded in cses of suspected spinl scess or serom. Reference 1. Greenspn (2003) Skelettrdiologie. Urn & Fischer, Munich Jen Fig Positioning of the ptient nd trgeting of the centrl em in olique x-rys of the lumoscrl junction (fter [1])

11 Spine, trunk Cn the»nut croissnt«1 e strightened out y dmonitions? or: To wht extent is ent ck cceptle? Posturl prolems in dolescents» The ody is the visile mnifesttion of the soul. (Christin Morgenstern, Steps) «The ck mirror of the soul? Prents concerns out the posture or the shpe of the ck of their offspring re one of the commonest resons for visit to the peditricin or the orthopedist. Their worries re essentilly ttriutle to two min fctors: On the one hnd they re worried tht n non-correctle deformity of the spine might result from the poor posture, s n expression of some sinister frme of mind. On the other hnd, it is generlly known fct tht ck pin is one of the commonest conditions suffered in dulthood nd one tht might possily e prevented y pproprite mesures tken during childhood nd dolescence. But why re prents so worried out their child s ppernce, prticulrly in reltion to ck prolems, even though the ck is usully covered y clothing nd thus less exposed thn, sy, the fce or the hnds? The ck hs specil symolic significnce in linguistic usge nd is, to prticulrly gret extent, the»visile mnifesttion of the soul«, s Christin Morgenstern puts it. A»good«posture for the spine is»upright«, just s person s chrcter cn e descried s»upright«. This lso reflects the reltionship etween truth nd dishonesty. 1 Nut croissnt: term used in Switzerlnd for croissnt filled with nuts. The expression»nut croissnt figure«is commonly used in Switzerlnd to refer to prticulrly drooping, kyphotic posture. But terms ssocited with the ck cn lso hve other connottions. Politicins who dopt prticulr stndpoint nd do not lwys chnge their opinion to mtch the previling mood re sid to show»ckone«. But there re lso others who re so thick-skinned tht they cn live without ckone. Prticulrly strongwilled people re descried s»unending«. If their will is roken we sy tht it is»ent«to the will of nother. People with lot of prolems re»weighed down y worries«until they eventully»collpse under the lod«. Those who wish to ingrtite themselves with others»ow nd scrpe«. Those with huge dets re»lid low«nd person who refuses tke responsiility for his own mistkes nd ccept the consequences my try nd»plce ll the lme on someone else s shoulders«. So we cn see how terms connected with the ck nd spine cn lso e used to descrie emotion-provoking ctivities nd properties tht re closely relted to person s stte of mind. Linguists re unle to explin whether the lnguge ctully cretes this link etween physicl posture nd mentl outlook. We lso find»crooked«chrcters in literture. Victor Hugo, in prticulr, mde hunchck the led chrcter in two of his works: Qusimodo in Notre-Dme de Pris nd the court jester in Le Roi s muse. The ltter ply ws used s the sis for Giuseppe Verdi s fmous oper Rigoletto. And the French poet Pul Févl hs hunchck s the min chrcter in Le Bossu. But in these literry exmples the hunched ck does not represent the mnifesttion of sinister soul. Quite the opposite, since they re kind-herted sensitive individuls who hve een disdvntged y nture nd rutlly exploited y others ecuse of their inility to defend themselves. But while the ody is indisputly n expression of the soul, the connections re much more multilyered nd complex thn suggested y the vernculr lnguge. Viewed t superficil level, nture cn lso e t vrince with linguistic usge. Thus, prents lwys wnt their child to dopt s stright posture s possile. But the drooping nd loutish posture of the dolescent is precisely n expression of the desire not to»end«to the will of his prents. Economic significnce of ck pin Lumr ck pin is one of the commonest conditions suffered y dults nd the numer one reson for lost productivity. Thus, ccording to one epidemiologicl study, 66% of employees stted tht they hd suffered ck pin in the previous 12 months [5]. And even group of individuls in their twenties (Swiss recruits nd soldiers) showed prevlence of 69% for lumr ck pin [7]. An Americn study showed tht 11% of men nd 9.5% of women visited generl prctitioner ecuse of lumr ck pin [3]. In the USA, the loss of ernings is estimted

12 Cn the»nut croissnt«e strightened out y dmonitions? t round 10 illion dollrs [8]. In Switzerlnd, too, ck pin is the second commonest cuse of disility, fter ccidents. A high prevlence of lumr ck pin, t 48.2%, hs een reported for industril workers in Russi [9], indicting tht ck pin is not specilty of the West, lthough it is clerly much more serious prolem in industril ntions thn in the developing world. The significnce of ck pin evidently tends to prllel the degree of industriliztion. In Omn, the demnd for ck tretment hs risen drmticlly since the oil oom [2], finding tht is lso of mjor economic significnce. According to Cndin sttisticl survey, pproximtely 30% of the totl mount pid in 1981 s compenstion for loss of ernings in the form of disility pensions ws pid to ck ptients [1]. The pin frequently strts t young ge, nd round hlf of dolescents complin of occsionl ck pin [10] ( Chpter ). For ll of the resons outlined ove, it is perfectly understndle tht prents re worried out wht could hppen to their children s cks in future. Evolution of upright wlking nd posture Humns re unique mong ll living cretures in exhiiting n erect posture. While primtes evidently developed the mechnism for mintining the trunk in n upright position t very erly stge, only humns re cple of stnding nd wlking upright on two legs for prolonged periods. This species-specific ipedl, erect posture freed up the hnds so tht humns could use these for tsks other thn locomotion. In fct, this discriminting use of the hnd ws proly the very first evolutionry step. A secondry consequence of the discovery tht hnds could e used not just for locomotion ws the development of the rin nd upright wlking. The use of hnds s tools nd lso the use of tools with the hnds ws therefore the first step in the evolution of mn, some 5 million yers go, from primte to homo erectus, the precursor of tody s homo spiens. This upright posture cused the eyes to e shifted forwrds, therey widening the field of vision nd eventully producing inoculr, stereoscopic vision. Compred to qudrupeds nd the climing nthropoid pe, humns hve etter visul, coustic nd tctile sptil orienttion. From the phylogenetic stndpoint, the doption of n erect posture in humns did not simply involve rottion of 90 t the hip, ut primrily round the lumoscrl junction s result of the cuneiform shpe of the 5th lumr nd 1st scrl vertere. The scrum is the resting point out which this erect posture is chieved. The development of the upright posture requires specilly-shped spinl column. The doule-s-shped humn spine differs from the single-s-shped spine of the qudruped in its dditionl lumr lordosis. Although this lumr lordosis is not solutely essentil for n upright posture, it cme out primrily for functionl resons. The S shpe of the spine is the optiml design for the corresponding dynmic lods. The cervicl nd lumr lordosis, nd lso the thorcic kyphosis, ct like linked elstic springs. Any mjor devitions from these functionlly-dpted curves in the spine re mechniclly inpproprite nd result in dverse loding conditions. The upright posture lso hs implictions for other orgns s well s the spine. Thus the ilic wing in humns is much wider thn in qudrupeds, since it hs to help crry the internl orgns. The detorsion of the femorl neck during growth is nother phenomenon specific to humns. In fct, humns hve pid very derly for this unique dvntge of n upright posture nd hve evidently not yet completely come to terms with this evolutionry step. Mn s unique erect posture not only contriutes to his specil dominnt role in nture, t the sme time it hs ecome direct potentil disese fctor whose implictions cnnot yet e fully grsped. Posturl development in children The phylogenetic development of the ck is imitted during mturtion from the fetus to the child nd then from the child to the dult. In the uterus, the fetus is in flexed position nd the spinl column is completely kyphotic. The neonte lso holds the shoulders, elows, hips nd knees in flexion, cusing the spine, prt from the cervicl section, to e held in kyphosis, s is lso the cse Posturl development from the fetus, vi the infnt nd toddler, to the child

13 Spine, trunk 3 with qudrupeds. Flexion contrctures of up to 30 re physiologicl. At lter stge, the neck, ck nd femorl extensors re the first to e strengthened, providing the infnt with hed control. After few months the y is lso cple of sitting up, leit with totl kyphosis of the ck. At this stge the lumr lordosis is still lcking, which is physiologicl finding during this period efore the strt of wlking. Once the y strts wlking, the lumr lordosis itself strts to develop. But this process does not fully prllel the strengthening of the muscles, nd hyperlordosis usully forms t this stge s result of grvity cting on the ventrl side. In toddlers this hyperlordosis is often not compensted y hyperkyphosis of the thorcic spine, resulting in the scenrio of the»hollow ck«. This type of posture in the toddler is chrcterized y the physiologicl wekness of the muscles nd the generl lxity of the ligments tht is typicl of the constitution t this stge. The toddler s ck shpe only develops into the dult shpe shortly efore puerty, lthough this shpe is still dependent on the stte of the muscles. In the elderly, the spine gin resemles the kyphotic picture of the infnt ( Fig. 3.23). An importnt chrcteristic feture of the infnt is the symmetricl tonic neck reflex. The persistence of this reflex cn led to n symmetricl development of the muscles nd the condition known s resolving infntile scoliosis. Resolving infntile scoliosis is single rcshped curvture of the whole spine resulting from the symmetricl tone of the muscles. The curvture is ssocited with little rottion nd occurs with left- or rightsided convex curve with equl frequency. If the child is Fig Posturl cycle (the old mn returns to the kyphotic posture of the fetus) held y the hed nd feet, the opposite side cn e mde to curve. Resolving infntile scoliosis used to e much more common in the pst, nd is rrely encountered nowdys. This is possily ttriutle to the trend (fter 1970) of plcing the infnt in the prone position. More recently (since pproximtely 1992), the prone position is eing ndoned following the discovery tht sudden infnt deth syndrome occurs more frequently in the prone position thn the supine position. We hve, however, not seen n increse in resolving infntile scoliosis since then. Therefore there must e other etiologicl fctors (e.g. genetic intermixture?). The prognosis for resolving infntile scoliosis is very good, s lmost ll of these curvtures dispper during the first yer of life. This did not lwys used to e the cse. Some cses of pprently resolving infntile scoliosis persisted nd developed into progressive idiopthic infntile scoliosis, condition tht used to e prticulrly common in Gret Britin [6]. The oservtion tht the difference etween the ngle mde y the ris nd the spine when seen from the side is greter in the progressive forms thn in cses tht spontneously resolve themselves mens tht the progressive forms cn e detected t n erly stge ( Chpter 3.1.4). The condition of progressive infntile scoliosis hs lmost disppered even in Scotlnd, where the condition ws prticulrly common. While the progressive form of the disese hs n extremely poor prognosis, resolving infntile scoliosis is not ssocited with ny long-term sequele. It is completely unrelted to idiopthic dolescent scoliosis, nd ptients with history of resolving infntile scoliosis show no incresed risk of developing idiopthic dolescent scoliosis in lter life. Posturl types in the dolescent Posture is influenced y the following fctors: The shpe of the ony skeleton The shpe is determined y genetic fctors (the mother:»his fther hs exctly the sme crooked ck«). The position of the scrum, which in turn is dependent on the pelvic tilt, lso plys n importnt role. The steeper the scrum, the less pronounced the sgittl curvtures (lordosis nd kyphosis). Ligmentous pprtus Posture cn e ctive or pssive. If our muscles re not ctivted, then we simply»hng«from our ligments. Such posture cn est e dopted y overstretching the hips, sticking out the tummy, positioning the lumr spine in hyperlordosis nd tilting the upper ody ckwrd to offset the forwrd shifting of the center of grvity. If the center of grvity is shifted forwrd or ckwrd we tlk of ventrl or dorsl overhng ( Chpter 3.1.1). This posture cnnot e dopted pssively, however, since it is unstle nd must e compensted for y muscle ctivity.

14 Cn the»nut croissnt«e strightened out y dmonitions? Muscles The stte of the muscles hs considerle influence on our posture. Strong muscles with good tone cn mintin n ctively erect posture throughout the dy. The condition of the muscles depends prtly on constitutionl fctors nd prtly on the trining sttus. But one other fctor needs to e tken into ccount in reltion to the growing ody: The muscles, together with the skeleton, undergo sustntil length growth ut re unle to increse in width to the sme extent. Consequently, certin muscle wekness is physiologicl in the growing child. Only on completion of the growth phse cn the»muscle corset«e trined nd uilt up in the optiml wy. Posturl insufficiency is frequently ssocited with n intoeing git nd reduced hip flexion [4]. Pelvic tilt The pelvic tilt is closely relted to the steepness of the scrum. Strightening the pelvis reduces the lumr lordosis nd thus the thorcic kyphosis s well ( Fig. 3.24, 3.25). Influence of the psyche Posture is not constnt ntomicl feture of n individul. Aprt from constitutionl fctors, posture represents snpshot tht depends not only on musculr ctivity ut, to very gret extent, on psychologicl sttus. As previously mentioned, linguistic usge lso highlights this link. A stte of mind chrcterized y joy, hppiness, success, self-confidence, trust nd optimism tends to ffect the erect posture nd the ssocited efficient posturl pttern. By contrst, worries, conflicts, depression, filures nd feelings of inferiority produce precisely the opposite effect nd promote poor posturl ptterns. Another specil fctor comes into ply in dolescents: Puerty is stge of life mrked y internl conflicts ssocited with finding one s own personlity. Since n importnt element in this process is the loosening of the ond with the prents, certin protesting posture in respect of the prents cn e considered physiologicl. Since stright posture is usully considered the idel y prents, the internl protest ginst the prents world mnifests itself in the form of n often ostenttiously poor posture (prticulrly while sitting). The poor posture resulting from the physiologicl muscle wekness of the growing ody is further emphsized y»csul«sitting. The more frequently the prents dmonish their child with»sit up stright«, the quicker he or she resumes the»nut croissnt«position. It is striking to oserve how children with very pronounced kyphotic posture re very frequently withdrwn nd hve one very dominting prent. When such dolescents re questioned out their symptoms or prolems during the consulttion, the A A Fig Norml pelvic tilt with forwrd/cudl inclintion of the pelvis y pprox. 20 Fig Cncelltion of the pelvic tilt nd consequent reduction of the lumr lordosis nd the thorcic kyphosis Adolescents often deliertely dopt seted posture tht goes ginst their prents ides out good posture... mother or fther will constntly reply on their ehlf. It is noticele tht the child is clerly overwhelmed y the mother or fther. But other prolems cn lso cuse dolescents to dopt very kyphotic posture, e.g. if femle unconsciously tries to concel her rests y hunching her shoulders forwrd nd folding her rms in front of her. Some girls re unle to ccept the growth of

15 Spine, trunk 3 their own rests. This is prticulrly pprent if the girl hs very dominnt mother who herself hs lrge rests. But lso funnel or keeled chest cn cuse the girl to dopt permnently kyphotic posture in the unconscious desire to concel this prt of her ody. Socil spects Not every socil clss or er hs the sme conception of the idel posture. Since ncient times, sttues nd pintings hve tended to present the idel of n upright posture. In Europen royl dynsties, stiff posture ws often promoted y constrining the individul in rce. But the socil notions of the idel posture hve chnged since then, nd the idels of the modern ge re frequently chrcterized y mrkedly»csul«posture. As lredy mentioned, posture represents»snpshot«. Every individul cn dopt vriety of postures. The stnding posture cn e sudivided into the following stges ( Fig ): hitul posture, pssive posture, ctively strightened posture. We cn lso distinguish etween constitutionl posturl types (norml ck, hollow ck, rounded ck, flt ck, hollow-flt ck, chpter 3.1.1). The clssifiction of the first 4 ck shpes dtes ck to the 19th century (Stffel 1889 [2]). These re physiologicl vrints with essentilly no pthologicl significnce. We hve dded the 5th ck shpe since it is reltively common physiologicl vrint, prticulrly in children. Insted of»norml ck«perhps we should rther refer A A A Fig Hitul posture posture Fig Pssive posture Fig Actively strightened posture to hrmonious ck. Using the term»norml ck«cn esily give the impression tht the other ck shpes re norml, which is certinly not the cse y definition, since these re, fter ll, types of posture. We only spek of pthologicl shpe if there is fixed hyperkyphosis of the thorcic spine, permnent sence of lumr lordosis or even kyphosis in this re. The investigtion of the correctility or fixtion of individul segments is descried in chpter Pthologicl significnce of poor posture Whether»posturl dmge«ctully exists is mtter of considerle dispute. Since ck symptoms re common in dults nd hve lso incresed over the pst few decdes, the discussion of this suject is highly topicl. Unfortuntely there is scrcity of scientificlly-estlished hrd fcts nd, on the other hnd, widely diverging opinions sed on sujective impressions. However, numer of fctors in recent yers hve thrown some light on the suject. Vrious widely-held trditionl views first need to e corrected somewht: The development of structurl scoliosis hs nothing to do with posture. A poor posture cnnot induce idiopthic dolescent scoliosis. Scoliosis is known to result from discrepncy etween the growth of the verterl ody nteriorly nd the growth of the posterior elements, resulting primrily in lordosis. Adolescents with scoliosis re therefore conspicuously stright nd erect, nd lso often very keen on sport. The lterl curvture develops s result of the rottion of the verterl odies nd hs nothing to do with posture ( Chpter 3.1.4). A leg length discrepncy my possily promote lumr scoliosis. This is definitely the cse with uncompensted differences of more thn 2 cm. Whether it pplies for differences of less thn 2 cm is controversil, nd it is possile tht the leg length discrepncy only influences the direction of the scoliosis rther thn its development. Of the physiologicl posturl types, prt from the hrmonious posture, the hollow ck hs much etter prognosis thn the flt ck. Although the flt ck is the esthetic idel, the future prospects in terms of susequent symptoms re much worse for the flt ck thn for ck with mrkedly sgittl curves, given the poorer shock-soring properties of the former. Lumr disk dmge occurs more frequently with this ck shpe nd is lso often ssocited with pin. The prolem rises primrily from the kyphosing of the lumr spine. The lck of lordosis shifts the center of grvity forwrd, which mens tht the lumr prverterl muscles hve to work hrder to mintin posture. The kyphosing of the lumr spine is lso often very pronounced during sitting.

16 Cn the»nut croissnt«e strightened out y dmonitions? The development of fixed kyphosis cn e influenced y posture. A permnent kyphotic posture cn trigger Scheuermnn disese during puerty. Although the prognosis in terms of symptoms is not d in Scheuermnn disese involving the thorcic region, it ecomes incresingly worse the further down one goes, nd lumr Scheuermnn disese is ssocited with very high risk of susequent chronic lumr ck pin. Usully the condition results in elimintion of the lumr lordosis, or even kyphosing in this re. This is extremely undesirle from the mechnicl stndpoint ecuse of the forwrd-shifting of the center of grvity. It hs to e offset y lordosing of the thorcic spine nd considerle posturl work y the prverterl muscles in the lumr re. The shock-soring properties of this type of spine re lso poor. Therpeutic options Of the fctors tht determine posture, we cn influence two in prticulr: the sttus of the muscles, possily the psychologicl fctors. All other prmeters re given nd we hve no wy of influencing them. As regrds the muscles, we should lwys er in mind tht certin mount of physiologicl muscle wekness is ssocited with growth.! Muscles cn only e strengthened y ctivity. Such ctivity must e undertken y the child or dolescent nd cnnot e imued into the child from the outside. Consequently, the crucil fctor in determining whether ctivity tkes plce or not is the child s motivtion. The surest wy of demotivting the child is to compel it to undertke n ctivity ginst its will. Since physicl therpy is not n ttrctive type of ctivity, it is pointless to prescrie months, or even yers, of physicl therpy, t the expense of helth insurnce funds, when the child is not remotely motivted. The outcome will e complete lck of ny effect on the muscles. Eqully questionle in my view re the»posturl physicl eduction lessons «provided in mny schools. Since ll students ttending such lessons re leled s those with»poor posture«the prticipnts re stigmtized from the outset. Since it is self evident tht such lessons re unlikely to motivte the students to keep ctive, it would e much more useful to encourge the dolescent to exercise within the context of sport tht ffords him or her certin mount of plesure. Although the type of sport selected is not ultimtely importnt, ctivities in which the rms re lso used re preferle. Swimming is est, of course, lthough other ll-sed sports such s sell, sketll or volleyll re extremely eneficil. Sports tht exercise the muscles on one side of the ody, e.g. tennis, re lso perfectly pproprite since, s lredy mentioned, there is no need to worry t ll out the possiility of scoliosis developing s result of the unilterl muscle tension. Even scoliosis ptients should e llowed to ply tennis. The importnt thing is the plesure gined from the sport. Pssive nd non-thletic children do not like tking prt in ll-sed sports ecuse they invrily lose. However, perhps such children cn e motivted to tke up swimming or possily ttend fitness center on regulr sis. This voids the prolem of their hving to constntly mesure themselves ginst their peers. One prticulr fctor tht promotes pssivity is the considerle mount of time spent sitting t school or in the home. The lumr spine tends to kyphose during pssive sitting. Certin useful mesures cn e tken to counter this tendency, even though these re implemented in only very smll proportion of schools: An inclined writing surfce reduces the kyphosing of the lumr spine during writing; the writing surfce should e positioned sufficiently high; ll chir lso promotes lordotic sitting nd stimultes the sitter to constntly perform slight compenstion movements; kneeling chir with support for the lower leg lso promotes lordotic sitting ( Fig. 3.29). Such ids promote hitul lordotic sitting posture tht produces positive effects in the long term. In theory, psychologicl fctors cn lso e influenced, lthough this is much more difficult. Since fixed hyperkyphosis of the thorcic spine is often indictive of conflict etween the dolescent nd prent, the doctor must proceed very cutiously. Psychologicl counseling cn prove worthwhile on occsion however. Another potentilly fruitful strtegy in motivting the dolescent to tke up sport is for him or her to meet other relevnt individuls who could serve s new positive models. In most cses, however, it cn e very difficult to explore often deepseted conflicts, prticulrly since oth sides (prents nd child) frequently dopt highly defensive ttitude. Wht is certin, however, is tht constnt dmonitions to sit up stright re counterproductive.! In other words, the question posed t the strt, i.e. whether the»nut croissnt«posture cn e strightened out y cjoling, cn e nswered resoundingly in the negtive. A permnent improvement in posture will only e chieved if the dolescent is motivted to tke prt in enjoyle ctivities. References 1. Andersson GB (1981) Epidemiologic spects on low-ck pin in industry. Spine 6: Derunner AM (1994) Orthopädie orthopädische Chirurgie. Huer, Bern

17 Spine, trunk 3 Fig e. Seted postures nd sitting ids: upright seted posture; drooping seted posture; c kyphotic seted posture; d influence of writing height nd slope of the writing surfce on seted posture; e ll chir c d e 3. Frymoyer JW, Pope MH, Costnz MC, Rosen JC, Goggin JE, Wilder DG (1980) Epidemiologic studies of low-ck pin. Spine 5: Ihme N, Olszynsk B, Lorni A, Weiss C, Kochs A (2002) Zusmmenhng der vermehrten Innenrottion im Hüftgelenk mit einer verminderten Beckenufrichtrkeit, der Rückenform und Hltung ei Kindern Git es ds so gennnte Antetorsionssyndrom? Z Orthop Ihre Grenzge 140: p Msset D, Mlchire J (1994) Low ck pin. Epidemiologic spects nd work-relted fctors in the steel industry. Spine 19: McMster MJ (1983) Infntile idiopthic scoliosis: Cn it e prevented? J Bone Joint Surg (Am) 65: Rohrer MH, Sntos-Eggimnn B, Pccud F, Hller-Mslov E (1994) Epidemiologic study of low ck pin in 1398 Swiss conscripts etween nd 1985 nd Eur Spine J 3: Rothmn RH, Simenone FA (1992) The spine. Sunders, Phildelphi 9. Toroptsov NV, Benevolensky LI, Krykin AN, Sergeev IL, Erdesz S (1995)»Cross-sectionl«study of low ck pin mong workers t n industril enterprise in Russi. Spine 20: Widhe T (2001) Spine: posture, moility nd pin. A longitudinl study from childhood to dolescence. Eur Spine J 10: p Idiopthic scolioses» While her elegnce in llet my ppel, the risk of scoliosis is very rel. «> Definition Condition involving lterl ending of the spine of >10 of unknown origin. There re two sic clinicl pictures of scoliosis: A rre form in which the deformity strts s erly s infncy or childhood (infntile or juvenile scoliosis). Boys nd girls re eqully ffected y this type. Scolioses t the thorcic level frequently hve their convexity to the left nd re ssocited with kyphosis. The more common dolescent form strts during puerty. Girls re minly ffected nd the thorcic form is lwys right convex. This type of scoliosis is usully ssocited with lordosis.