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Diagnosis is typically by medical imaging. The degree of kyphosis can be measured by Cobb's angle and sagittal balance.
Kyphosis can be graded in severity by the Cobb angle. Also, "sagittal balance" can be measured. The sagittal balance is the horizontal distance between the center of C7 and the superior-posterior border of the endplate of S1 on a lateral radiograph. An offset of more than 2.5 cm anteriorly or posteriorly is considered to be abnormal.
The risk of serious complications from spinal fusion surgery for kyphosis is estimated to be 5%, similar to the risks of surgery for scoliosis. Possible complications include inflammation of the soft tissue or deep inflammatory processes, breathing impairments, bleeding, and nerve injuries. According to the latest evidence, the actual rate of complications may be substantially higher. Even among those who do not suffer from serious complications, 5% of patients require reoperation within five years of the procedure, and in general it is not yet clear what one would expect from spine surgery during the long-term. Taking into account that signs and symptoms of spinal deformity cannot be changed by surgical intervention, surgery remains to be a cosmetic indication. Unfortunately, the cosmetic effects of surgery are not necessarily stable.
Scheuermann's disease is self-limiting after growth is complete, meaning that it generally runs its course and never presents further complication. Typically, however, once the patient is fully grown, the bones will maintain the deformity. For this reason, there are many treatment methods and options available that aim to correct the kyphosis while the spine is still growing, and especially aim to prevent it from worsening.
While there is no explanation for what causes Scheuermann's Disease, there are ways to treat it. For decades there has been a lot of controversy surrounding treatment options. For less extreme cases, manual medicine, physical therapy and/or back braces can help reverse or stop the kyphosis before it does become severe. Because the disease is often benign, and because back surgery includes many risks, surgery is usually considered a last resort for patients. In severe or extreme cases, patients may be treated through an extensive surgical procedure in an effort to prevent the disease from worsening or harming the body.
In Germany, a standard treatment for both Scheuermann's disease and lumbar kyphosis is the Schroth method, a system of specialized physical therapy for scoliosis and related spinal deformities. The method has been shown to reduce pain and decrease kyphotic angle significantly during an inpatient treatment program.
Pectus excavatum requires no corrective procedures in mild cases. Treatment of severe cases can involve either invasive or non-invasive techniques or a combination of both. Before an operation proceeds several tests are usually to be performed. These include, but are not limited to, a CT scan, pulmonary function tests, and cardiology exams (such as auscultation and ECGs). After a CT scan is taken, the Haller index is measured. The patient's Haller is calculated by obtaining the ratio of the transverse diameter (the horizontal distance of the inside of the ribcage) and the anteroposterior diameter (the shortest distance between the vertebrae and sternum). A Haller Index of greater than 3.25 is generally considered severe, while normal chest has an index of 2.5. The cardiopulmonary tests are used to determine the lung capacity and to check for heart murmurs.
Gibbus deformity is a form of structural kyphosis typically found in the upper lumbar and lower thoracic vertebrae, where one or more adjacent vertebrae become wedged. Gibbus deformity most often develops in young children as a result of spinal tuberculosis and is the result of collapse of vertebral bodies. This can in turn lead to spinal cord compression causing paraplegia.
In addition to tuberculosis, other possible causes of gibbus deformity include pathological diseases, hereditary and congenital conditions, and physical trauma to the spine that results in injury. Gibbus deformity may result from the sail vertebrae associated with cretinism (the childhood form of hypothyroidism), mucopolysaccharidosis (MPS), and certain congenital syndromes, including achondroplasia. Because most children with MPS I (Hurler Syndrome) also exhibit symptoms of a gibbus deformity, the latter can possibly be used to identify the former.
Gibbus deformity is included in a subset of structural kyphosis that is distinguished by a higher-degree angle in the spinal curve that is specific to these forms of kyphosis. Other conditions within this subset include Pott’s disease and Scheuermann kyphosis, but gibbus deformity is marked by an especially sharp angle. Viewed from behind, the resulting hunchback is more easily seen when bending forward. A kyphosis of >70° can be an indication of the need for surgery and these surgeries can be necessary for children as young as two years old, with a reported average of 8 years of age.
Pectus excavatum is initially suspected from visual examination of the anterior chest. Auscultation of the chest can reveal displaced heart beat and valve prolapse. There can be a heart murmur occurring during systole caused by proximity between the sternum and the pulmonary artery.
Lung sounds are usually clear yet diminished due to decreased base lung capacity.
Many scales have been developed to determine the degree of deformity in the chest wall. Most of these are variants on the distance between the sternum and the spine. One such index is the "Backer ratio" which grades severity of deformity based on the ratio between the diameter of the vertebral body nearest to xiphosternal junction and the distance between the xiphosternal junction and the nearest vertebral body. More recently the "Haller index" has been used based on CT scan measurements. An index over 3.25 is often defined as severe. The Haller index is the ratio between the horizontal distance of the inside of the ribcage and the shortest distance between the vertebrae and sternum.
Chest x-rays are also useful in the diagnosis. The chest x-ray in pectus excavatum can show an opacity in the right lung area that can be mistaken for an infiltrate (such as that seen with pneumonia). Some studies also suggest that the Haller index can be calculated based on chest x-ray as opposed to CT scanning in individuals who have no limitation in their function.
Pectus excavatum is differentiated from other disorders by a series of elimination of signs and symptoms. Pectus carinatum is excluded by the simple observation of a collapsing of the sternum rather than a protrusion. Kyphoscoliosis is excluded by diagnostic imaging of the spine, where in pectus excavatum the spine usually appears normal in structure.
FAI-related pain is often felt in the groin, but may also be experienced in the lower back or around the hip. The diagnosis, often with a co-existing labral tear, typically involves physical examination in which the range of motion of the hip is tested. Limited flexibility leads to further examination with x-ray, providing a two-dimensional view of the hip joints. Additional specialized views, such as the Dunn view, may make x-ray more sensitive. Subsequent imaging techniques such as CT or MRI may follow producing a three-dimensional reconstruction of the joint to evaluate the hip cartilage, demonstrate signs of osteoarthritis, or measure hip socket angles (e.g. the alpha-angle as described by Nötzli in 2-D and by Siebenrock in 3-D). It is also possible to perform dynamic simulation of hip motion with CT or MRI assisting to establish whether, where, and to what extent, impingement is occurring.
There is no consensus on what degree of angulation justifies a diagnosis, an incline between 15° and 30° is typical. A similar-sounding term, camptodactyly, is a fixed flexion deformity of a digit.
Presence at birth is extremely rare and associated with other congenital anomalies such as proximal femoral focal deficiency, fibular hemimelia or anomalies in other part of the body such as cleidocranial dyastosis. The femoral deformity is present in the subtrochantric area where the bone is bent. The cortices are thickened and may be associated with overlying skin dimples. External rotation of the femur with valgus deformity of knee may be noted. This condition does not resolve and requires surgical management. Surgical management includes valgus osteotomy to improve hip biomechanics and length and rotational osteotomy to correct retroversion and lengthening.
X-Ray
Bubbly lytic lesion / Ground glass
Imaging tests. Computerized tomography or magnetic resonance imaging scans may be used to determine how extensively your bones are affected.
Bone scan. This test uses radioactive tracers, which are injected into your bloodstream. The damaged parts of your bones take up more of the tracers, which show up more brightly on the scan.
Biopsy. This test uses a hollow needle to remove a small piece of the affected bone for laboratory analysis.
Generally, no treatment is required for idiopathic presentation as it is a normal anatomical variant in young children. Treatment is indicated when it persists beyond 3 and a half years old. In the case of unilateral presentation or progressive worsening of the curvature, when caused by rickets, the most important thing is to treat the constitutional disease, at the same time instructing the care-giver never to place the child on its feet. In many cases this is quite sufficient in itself to effect a cure, but matters can be hastened somewhat by applying splints. When the deformity arises in older patients, either from trauma or occupation, the only permanent treatment is surgery, but orthopaedic bracing can provide relief.
X-ray of the affected wrist is required if a fracture is suspected. Anteroposterior (AP), lateral, and oblique views can be used together to describe the fracture. X-ray of the uninjured wrist should also be taken to determine if there are any normal anatomic variations. Investigation of a potential distal radial fracture includes assessment of the angle of the joint surface on lateral X-ray (volar/dorsal tilt), the loss of length of the radius from the collapse of the fracture (radial length), and congruency of the distal radioulnar joint (DRUJ). Displacement of the articular surface is the most important factor affecting prognosis and treatment. CT scan is often performed to further investigate the articular anatomy of the fracture, especially if surgery is considered. MRI can be considered to evaluate for soft tissue injuries, including damage to the TFCC and the interosseous ligaments.
Bunion can be diagnosed and analyzed by plain projectional radiography. The "hallux valgus angle" (HVA) is the angle between the longitudinal axes of the proximal phalanx and the first metatarsal bone of the big toe. It is considered abnormal if greater than 15–18°. The following HVA angles can also be used to grade the severity of hallux valgus:
- Mild: 15–20°
- Moderate: 21–39°
- Severe: ≥ 40°
The "intermetatarsal angle" (IMA) is the angle between the longitudinal axes of the first and second metatarsal bones, and is normally less than 9°. The IMA angle can also grade the severity of hallux valgus as:
- Mild: 9–11°
- Moderate: 12–17°
- Severe: ≥ 18°
A cubitus varus deformity is more cosmetic than limiting of any function, however internal rotation of the radius over the ulna may be limited due to the overgrowth of the humerus. This may be noticeable during an activity such as using a computer mouse.
The diagnosis of the cause of a limp is often made based on history, physical exam findings, laboratory tests, and radiological examination. If a limp is associated with pain it should be urgently investigated, while non-painful limps can be approached and investigated more gradually. Young children have difficulty determining the location of leg pain, thus in this population, "knee pain equals hip pain". SCFE can usually be excluded by an x-ray of the hips. A ultrasound or x-ray guided aspiration of the hip joint maybe required to rule out an infectious process within the hip.
Treatment for children with Blount's disease is typically braces but surgery may also be necessary, especially for teenagers. The operation consists of removing a piece of tibia, breaking the fibula and straightening out the bone; there is also a choice of elongating the legs. If not treated early enough, the condition worsens quickly.
Diagnosis may be evident clinically when the distal radius is deformed but should be confirmed by X-ray.
The differential diagnosis includes scaphoid fractures and wrist dislocations, which can also co-exist with a distal radius fracture. Occasionally, fractures may not be seen on X-rays immediately after the injury. Delayed X-rays, X-ray computed tomography (CT scan), or Magnetic resonance imaging (MRI) will confirm the diagnosis.
The treatment of FAI varies. Conservative treatment includes reducing levels of physical activity, anti-inflammatory medication and physiotherapy. Physical therapy may optimize alignment and mobility of the joint, thereby decreasing excessive forces on irritable or weakened tissues. It may also identify specific movement patterns that may be causing injury.
Due to the frequency of diagnosis in adolescents and young adults, various surgical techniques have been developed with the goal of preserving the hip joint. Surgery may be arthroscopic or open, peri-acetabular or rotational osteotomies being two common open surgical techniques employed when an abnormal angle between femur and acetabulum has been demonstrated. These primarily aim to alter the angle of the hip socket in such a way that contact between the acetabulum and femoral head are greatly reduced, allowing a greater range of movement. Femoral sculpting may be performed simultaneously, if required for a better overall shape of the hip joint. It is unclear whether or not these interventions effectively delay or prevent the onset of arthritis. Well designed, long term studies evaluating the efficacy of these treatments have not been done.
A 2011 study analyzing current surgical methods for management of symptomatic femoral acetabular impingement (FAI), suggested that arthroscopic method had surgical outcomes equal to or better than other methods with a lower rate of major complications when performed by experienced surgeons.
Sprengel's deformity (also known as high scapula or congenital high scapula) is a rare congenital skeletal abnormality where a person has one shoulder blade that sits higher on the back than the other. The deformity is due to a failure in early fetal development where the shoulder fails to descend properly from the neck to its final position. The deformity is commonly associated with other conditions, most notably Klippel-Feil syndrome, congenital scoliosis including cervical scoliosis, fused ribs, the presence of an omovertebral bone and spina bifida. The left shoulder is the most commonly affected shoulder but the condition can be bilateral, meaning that both shoulders are affected. About 75% of all observed cases are girls. Treatment includes surgery in early childhood and physical therapy. Surgical treatment in adulthood is complicated by the risk of nerve damage when removing the omovertebral bone and when stretching the muscle tissue during relocation of the shoulder.
The scapula is small and rotated so that its inferior edge points toward the spine. There is a high correlation between Sprengel's deformity and the Klippel-Feil syndrome. Sometimes a bony connection is present between the elevated scapula and one of the cervical vertebrae, usually C5 or C6. This connection is known as the omovertebral bone.
A skeletal survey is useful to confirm the diagnosis of achondroplasia. The skull is large, with a narrow foramen magnum, and relatively small skull base. The vertebral bodies are short and flattened with relatively large intervertebral disk height, and there is congenitally narrowed spinal canal. The iliac wings are small and squared, with a narrow sciatic notch and horizontal acetabular roof. The tubular bones are short and thick with metaphyseal cupping and flaring and irregular growth plates. Fibular overgrowth is present. The hand is broad with short metacarpals and phalanges, and a trident configuration. The ribs are short with cupped anterior ends. If the radiographic features are not classic, a search for a different diagnosis should be entertained. Because of the extremely deformed bone structure, people with achondroplasia are often "double jointed".
The diagnosis can be made by fetal ultrasound by progressive discordance between the femur length and biparietal diameter by age. The trident hand configuration can be seen if the fingers are fully extended."
Another distinct characteristic of the syndrome is thoracolumbar gibbus in infancy.
More common cause: primary defect in endochondral ossification of the medial part of the femoral neck.
Excessive interuterine pressure on the developing fetal hip.
vascular insult.
Faulty maturation of the cartilage and metaphyseal bone of the femoral neck.
Clinical feature: presents after the child has started walking but before six years of age. Usually associated with a painless hip due to mild abductor weakness and mild limb length discrepancy.
If there is a bilateral involvement the child might have a waddling gait or trendelenburg gait with an increased lumbar lordosis. The greater trochanter is usually prominent on palpation and is more proximal. Restricted abduction and internal rotation.
X-ray: decreased neck shaft angle, increased cervicofemoral angle, vertical physis, shortened femoral neck decrease in femoral anteversion. HE angle (hilgenriener epiphyseal angle- angle subtended between a horizontal line connecting the triradiate cartilage and the epiphysisn normal angle is <30 degrees.
Treatment:
HE angle of 45–60 degrees observation and periodic follow up.
Indication for surgery :HE angle more than 60 degrees, progressive deformity, neckshaft angle <90 degrees, development of trendelenburg gait
Surgery: subtrochantric valgus osteotomy with adequate internal rotation of distal fragment to correct anteversion
common complication is recurrence. If HE angle is reduced to 38 degrees less evidence of recurrence
post operative spica cast is used for a period of 6–8 weeks.
Coxa vara is also seen in Niemann–Pick disease.
First options for treatment are conservative, using hot or cold packs, rest and NSAID's at first. If no improvement is made, a splint or brace can be used to keep the deviated arm straight. When none of the conservative treatments work surgical intervention is designated.
Due to a developmental arrest there is an abnormal alignment of the joint surfaces at either interphalangeal joint causing angulation in the plane of the palm. The finger may be slightly bent or have a very prominent bend.