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==Overview==
==Overview==
Patients with [[scoliosis]] usually appear normal. Physical examination of patients with scoliosis is usually remarkable for [[shoulder]] asymmetry, waist-line asymmetry, [[thoracic wall]] or [[breast]] asymmetry, and truncal decompensation.


==Physical Examination==
==Physical Examination==
{| align="right"
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[[File:Scoliosis physical exam.jpg|300px|thumb|none|Scoliosis physical findings.[https://commons.wikimedia.org/w/index.php?curid=36219861 Source: By https://wellcomeimages.org/indexplus/obf_images/8c/4f/9ae55eeb2f2735757102bb251795.jpg]]]
|}
Physical examination of patients with [[scoliosis]] is usually remarkable for [[Shoulder|shoulde]]<nowiki/>r asymmetry, waist-line asymmetry, [[thoracic wall]] or [[breast]] asymmetry, and truncal decompensation.<ref>{{cite book | last = Kapoor | first = Sudhir | title = Orthopaedic clinics spine : with video demonstration | publisher = CBS Publishers & Distributors | location = New Delhi | year = 2008 | isbn = 8123915993 }}</ref><ref name="pmid19030463">{{cite journal| author=Janicki JA, Alman B| title=Scoliosis: Review of diagnosis and treatment. | journal=Paediatr Child Health | year= 2007 | volume= 12 | issue= 9 | pages= 771-6 | pmid=19030463 | doi= | pmc=2532872 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19030463  }} </ref><ref>Azar, F., Canale, S., Beaty, J. & Campbell, W. (2017). Campbell's operative orthopaedics. Philadelphia, PA: Elsevier. Page: 1898-2028.</ref>
===Appearance of the Patient===
*Patients with [[scoliosis]] usually appear well.
*[[Tanner stage|Tanner staging]] done to predict magnitude of curve progression.
===Vital Signs===
Patients with [[scoliosis]] and other complications may have:
*[[Hypertension|High blood pressure]] due to [[pulmonary hypertension]] and [[cor pulmonale]]
===Skin===
===Skin===
* [[Skin]] for [[Café au lait spot|café au lait]] spots indicative of [[neurofibromatosis]]
*[[Skin]] for [[Café au lait spot|café au lait]] spots indicative of [[neurofibromatosis]]
*[[Spina bifida]] as evidenced by a [[dimple]], hairy patch, [[lipoma]], or [[hemangioma]]
 
===HEENT===
*HEENT examination of patients with [[scoliosis]] is usually normal.
 
===Neck===
*Neck examination of patients with [[scoliosis]] is usually normal. But, patients may have lateral bending of their neck due primary or secondary curve.
*when [[scoliosis]] is complicated with [[pulmonary hypertension]], it's physical findings may include:
**Prominent 'a' wave: due to forced atrial contraction
**Prominent 'v' wave: later if [[Tricuspid regurgitation|tricuspid regurgitation]] develops with [[right ventricular failure]]
**Elevated [[JVP]]: can be present if [[right ventricular failure]] develops
**Postive [[Kussmaul's sign]]: [[JVP]] elevation during inspiration (the opposite of what normally happens) because of [[right ventricular failure]]


===Extremities===
===Lungs===
* Uneven [[hip]] and [[shoulder]] levels
Patients with [[scoliosis]] and other complications may have:
* Unequal distance between arms and body
*[[Thoracic cavity|Chest wall]] or [[breast]] asymmetry is seen
* The feet for cavovarus deformity
*Decreased [[breast sounds]] upon auscultation of the [[lung]]


===Neurologic===
===Heart===
* Slow nerve action (in some cases)
Patients with [[scoliosis]] and it's late complications such as [[pulmonary hypertension]] and [[cor pulmonale]] include physical findings:<ref name="isbn0-7295-3905-9">{{cite book |author=Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP |title=Clinical Examination: A Systematic Guide to Physical Diagnosis |publisher=Churchill Livingstone |location=Edinburgh |year=2009 |pages= |isbn=0-7295-3905-9 |oclc= |doi= |accessdate=}}</ref><ref name="isbn0-07-055417-X">{{cite book |author=Alexander, R. McNeill; Hurst, J. Willis; Schlant, Robert C. |title=The Heart, arteries and veins |publisher=McGraw-Hill, Health Professions Division |location=New York |year=1994 |pages= |isbn=0-07-055417-X |oclc= |doi= |accessdate=}}</ref><ref name="isbn0-7020-2993-9">{{cite book |author=Clark, Michael; Kumar, Parveen J. |title=Kumar and Clark's clinical medicine |publisher=Elsevier Saunders |location=St. Louis, Mo |year=2009 |pages= |isbn=0-7020-2993-9 |oclc= |doi= |accessdate=}}</ref>
* Abdominal reflexes
*'''Left [[parasternal heave]]'''
* Muscle tone for [[spasticity]]
**Due to hyperdynamic right ventricle
*'''Palpable [[P2]]'''
**Correlates with severity of the disease
*'''Ausculation'''
**First and second heart sound (S1,S2)
***Loud P2 component of S2: this is due to the forceful closure of the valve because of increased pulmonary pressure. It can be heard mostly in the pulmonary area (upper right sternal border). If it is evident at the [[Apex of the heart|cardiac apex]], this indicates more severe disease. It is best appreciated on inspiration.
**'''Splitting of S2'''
***Narrowed splitting of S2: in chronic [[pulmonary hypertension]], [[pulmonary artery]] compliance decreases leading to earlier [[pulmonary valve]] closure and narrowed splitting.
***Widened splitting of S2: widened splitting may occur later if right ventricular failure or bundle branch block develops.
**'''Extra Heart Sounds'''
***S4: due to [[right ventricular hypertrophy]] and therefore reduced compliance secondary to [[pulmonary hypertension]]. It is increased with [[Inhalation|inspiration]].
***S3: if [[Right heart failure|right ventricular failure]] develops. Increased with [[inspiration]].
**'''Additional Sounds'''
***Systolic pulmonary ejection click: increased with [[inspiration]]
**'''Murmurs'''
***Ejection [[midsystolic murmur]]: increased with [[inspiration]]
***[[Diastolic murmurs|Diastolic murmur]] (Graham-Steele murmur): indicates pulmonary regurgitation
***Pansystolic [[murmur]]: indicates [[tricuspid regurgitation]] and developing [[Right heart failure|right ventricular failure]]


===Others===
===Abdomen===
* Asymmetric size or location of breast in females
*Abdominal examination of patients with [[scoliosis]] is usually normal
* Uneven musculature on one side of the spine
*Flank fullness may be seen
* A [[rib]] "hump" and/or a prominent [[shoulder blade]], caused by rotation of the ribcage in [[thoracic]] scoliosis
 
===Genitourinary===
*Genitourinary examination of patients with [[scoliosis]] is usually normal. But, in [[neuromuscular scoliosis]], patient may present with bowel and bladder [[incontinence]].
 
===Neuromuscular (Spine)===
*Patient is usually oriented to persons, place, and time
 
====Gait====
*Patients usually walk with bipedal unassisted [[Gait (human)|gait]].
*Some patients with neuromuscular scoliosis walk with a spastic [[Gait (human)|gait]].
 
====Palpation====
*No local rise in temperature
*[[Tenderness]] is usually not present.
*Head may be centered or tilted away from pelvis
*[[Shoulders]] asymmetry
*[[Scapula|Scapular]] asymmetry with one scapula being farther away from the the mid-line
*[[Spinous process]] are deviated away from mid-line
*Lateral curvature of the [[spine]], with curve described in terms of convexity directed to right or left
*Paraspinal muscle spasm may be present
*[[Rib]] razor hump is usually present
*Posterior Superior Iliac spine (PSIS) asymmetry seen
*Anterior Superior Iliac spine (ASIS) asymmetry seen
*List and step are usually not present
*Sagittal balance (Head in line with sacrum) may be disturbed
*[[Sinuses]] and tuft of hair may be present
*Flank fullness may be seen
 
====Movement====
*[[Flexion]] and [[extension]] are usually affected
* Lateral flexion and rotation helps to identify [[rigidity]] of the curve
 
====Flexibility Test====
*Lateral bending test are usually affected
*[[Traction (orthopedics)|Traction]] test are usually abnormal
*Prone position test are usually abnormal 
 
====Neurological====
*Motor
**Motor [[Muscle weakness|weakness]] may be seen
**[[Spasticity]] and rigidity may be seen depending on level of involvement
**Sensory
***Fine touch and crude touch may be lost
***[[Hypoesthesia]] may be seen
***Postion sense and vibration may be disturbed
***Two point discrimination may be lost
**Reflexes
*** Hypo or Hyper [[reflexia]] may be seen depending on level of involvement
***[[Clonus]] may be seen
**Coordination
***[[Motor coordination|Coordination]] may be affected when scoliosis is associated with CNS involvement such arnold-chiari malformation
 
====Rib Hump====
*Adam's forward bending test makes the hump prominent
 
====Measurement====
*Hump height
*[[Chest expansion]] is usually decreased
*[[Limb length discrepancy]] may be present
*Truncal height is measured in standing and sitting position, which is usually abnormal
*Scoliometer is used to measure the curve
 
====Special Test====
*'''Straight leg raising (SLR) test''' may be positive
**Test:
***Patient in supine position with [[knee]] and [[Hip (anatomy)|hip]] in [[extension]]
***Elevate the patient's leg in air, so the hip gets gradually flexed with knees in extension
***Presence of radiating pain in the leg between 30-70 degrees of hip flexion indicates a positive test
*'''Cross SLR''' is usually absent
**Test:
***Patient in supine position with [[knee]] and [[Hip (anatomy)|hip]] in [[extension]]
***Elevate the patient's contralateral leg in air, so the hip gets gradually flexed with knees in extension
***Presence of radiating pain in the ipsilateral leg indicates a positive test
*'''Lassegue test''' may be positive
**Test:
***Patient in supine position with [[knee]] and [[Hip (anatomy)|hip]] in [[extension]]
***Elevate the patient's leg in air, so the hip gets gradually flexed with knees in extension
***If radiating pain present in the legs between 30-70 degrees of hip flexion, then slightly lower down the angle of flexion at the hip and dorsiflex the ankle
***Presence of radiating pain in the leg again indicates a positive test
*'''Bowstring test''' may be positive
**Test:
***Patient in supine position with [[knee]] and [[Hip (anatomy)|hip]] in [[extension]]
***Elevate the patient's leg in air, so the hip gets gradually flexed with knees in extension
***If radiating pain present in the legs between 30-70 degrees of hip flexion, then slightly bend the kneewhich will relieve the symptoms
***Apply digital pressure in popliteal fossa over the posterior aspect of sciatic nerve
***Reproduction of radiating pain indicates nerve compression
 
*'''Femoral stretch''' '''test''' may be positive
**Test:
***Patient in prone position with [[knee]] bend to 90 degrees and [[Hip (anatomy)|hip]] in [[extension]]
***Grasp the lower end of the [[femur]] and extend the [[Hip (anatomy)|hip]]
***Presence of pain on the anterior aspect suggests [[Spinal cord compression|compression]] of the [[femoral nerve]]
 
====Extremities====
*Feet may show cavovarus deformity


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
[[Category:Orthopedics]]
[[Category:Skeletal disorders]]
[[Category:Rheumatology]]
[[Category:Disease]]


[[Category:Needs content]]
[[Category:Needs content]]

Latest revision as of 16:08, 10 December 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rohan A. Bhimani, M.B.B.S., D.N.B., M.Ch.[2]

Overview

Patients with scoliosis usually appear normal. Physical examination of patients with scoliosis is usually remarkable for shoulder asymmetry, waist-line asymmetry, thoracic wall or breast asymmetry, and truncal decompensation.

Physical Examination

Scoliosis physical findings.Source: By https://wellcomeimages.org/indexplus/obf_images/8c/4f/9ae55eeb2f2735757102bb251795.jpg

Physical examination of patients with scoliosis is usually remarkable for shoulder asymmetry, waist-line asymmetry, thoracic wall or breast asymmetry, and truncal decompensation.[1][2][3]

Appearance of the Patient

Vital Signs

Patients with scoliosis and other complications may have:

Skin

HEENT

  • HEENT examination of patients with scoliosis is usually normal.

Neck

Lungs

Patients with scoliosis and other complications may have:

Heart

Patients with scoliosis and it's late complications such as pulmonary hypertension and cor pulmonale include physical findings:[4][5][6]

Abdomen

  • Abdominal examination of patients with scoliosis is usually normal
  • Flank fullness may be seen

Genitourinary

Neuromuscular (Spine)

  • Patient is usually oriented to persons, place, and time

Gait

  • Patients usually walk with bipedal unassisted gait.
  • Some patients with neuromuscular scoliosis walk with a spastic gait.

Palpation

  • No local rise in temperature
  • Tenderness is usually not present.
  • Head may be centered or tilted away from pelvis
  • Shoulders asymmetry
  • Scapular asymmetry with one scapula being farther away from the the mid-line
  • Spinous process are deviated away from mid-line
  • Lateral curvature of the spine, with curve described in terms of convexity directed to right or left
  • Paraspinal muscle spasm may be present
  • Rib razor hump is usually present
  • Posterior Superior Iliac spine (PSIS) asymmetry seen
  • Anterior Superior Iliac spine (ASIS) asymmetry seen
  • List and step are usually not present
  • Sagittal balance (Head in line with sacrum) may be disturbed
  • Sinuses and tuft of hair may be present
  • Flank fullness may be seen

Movement

Flexibility Test

  • Lateral bending test are usually affected
  • Traction test are usually abnormal
  • Prone position test are usually abnormal

Neurological

  • Motor
    • Motor weakness may be seen
    • Spasticity and rigidity may be seen depending on level of involvement
    • Sensory
      • Fine touch and crude touch may be lost
      • Hypoesthesia may be seen
      • Postion sense and vibration may be disturbed
      • Two point discrimination may be lost
    • Reflexes
      • Hypo or Hyper reflexia may be seen depending on level of involvement
      • Clonus may be seen
    • Coordination
      • Coordination may be affected when scoliosis is associated with CNS involvement such arnold-chiari malformation

Rib Hump

  • Adam's forward bending test makes the hump prominent

Measurement

  • Hump height
  • Chest expansion is usually decreased
  • Limb length discrepancy may be present
  • Truncal height is measured in standing and sitting position, which is usually abnormal
  • Scoliometer is used to measure the curve

Special Test

  • Straight leg raising (SLR) test may be positive
    • Test:
      • Patient in supine position with knee and hip in extension
      • Elevate the patient's leg in air, so the hip gets gradually flexed with knees in extension
      • Presence of radiating pain in the leg between 30-70 degrees of hip flexion indicates a positive test
  • Cross SLR is usually absent
    • Test:
      • Patient in supine position with knee and hip in extension
      • Elevate the patient's contralateral leg in air, so the hip gets gradually flexed with knees in extension
      • Presence of radiating pain in the ipsilateral leg indicates a positive test
  • Lassegue test may be positive
    • Test:
      • Patient in supine position with knee and hip in extension
      • Elevate the patient's leg in air, so the hip gets gradually flexed with knees in extension
      • If radiating pain present in the legs between 30-70 degrees of hip flexion, then slightly lower down the angle of flexion at the hip and dorsiflex the ankle
      • Presence of radiating pain in the leg again indicates a positive test
  • Bowstring test may be positive
    • Test:
      • Patient in supine position with knee and hip in extension
      • Elevate the patient's leg in air, so the hip gets gradually flexed with knees in extension
      • If radiating pain present in the legs between 30-70 degrees of hip flexion, then slightly bend the kneewhich will relieve the symptoms
      • Apply digital pressure in popliteal fossa over the posterior aspect of sciatic nerve
      • Reproduction of radiating pain indicates nerve compression
  • Femoral stretch test may be positive

Extremities

  • Feet may show cavovarus deformity

References

  1. ↑ Kapoor, Sudhir (2008). Orthopaedic clinics spine : with video demonstration. New Delhi: CBS Publishers & Distributors. ISBN 8123915993.
  2. ↑ Janicki JA, Alman B (2007). "Scoliosis: Review of diagnosis and treatment". Paediatr Child Health. 12 (9): 771–6. PMC 2532872. PMID 19030463.
  3. ↑ Azar, F., Canale, S., Beaty, J. & Campbell, W. (2017). Campbell's operative orthopaedics. Philadelphia, PA: Elsevier. Page: 1898-2028.
  4. ↑ Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP (2009). Clinical Examination: A Systematic Guide to Physical Diagnosis. Edinburgh: Churchill Livingstone. ISBN 0-7295-3905-9.
  5. ↑ Alexander, R. McNeill; Hurst, J. Willis; Schlant, Robert C. (1994). The Heart, arteries and veins. New York: McGraw-Hill, Health Professions Division. ISBN 0-07-055417-X.
  6. ↑ Clark, Michael; Kumar, Parveen J. (2009). Kumar and Clark's clinical medicine. St. Louis, Mo: Elsevier Saunders. ISBN 0-7020-2993-9.

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