A 12-year-old girl is brought to the office for a preventive health maintenance examination. The patient's mother has noticed that over the last few months, her daughter "seems to sit sideways" and does not sit up straight when asked. The patient occasionally takes acetaminophen in the morning due to mild "aches and pains." She fractured her left femur in a horse-riding accident at age 8. Height and weight are at the 75th and 50th percentiles, respectively. Physical examination shows a well-appearing, nondysmorphic girl. Forward bend test demonstrates a right thoracic prominence that measures a 9-degree angle of trunk rotation and does not improve when a block is placed under the left foot. Flexion of the lumbar spine is normal and the patient is able to touch her toes. Lower extremity strength is normal. Patellar and Achilles deep tendon reflexes are 2+. Gait is normal.
Which of the following is the best next step in management of this patient?

Question

A 12-year-old girl is brought to the office for a preventive health maintenance examination.  The patient's mother has noticed that over the last few months, her daughter "seems to sit sideways" and does not sit up straight when asked.  The patient occasionally takes acetaminophen in the morning due to mild "aches and pains."  She fractured her left femur in a horse-riding accident at age 8.  Height and weight are at the 75th and 50th percentiles, respectively.  Physical examination shows a well-appearing, nondysmorphic girl.  Forward bend test demonstrates a right thoracic prominence that measures a 9-degree angle of trunk rotation and does not improve when a block is placed under the left foot.  Flexion of the lumbar spine is normal and the patient is able to touch her toes.  Lower extremity strength is normal.  Patellar and Achilles deep tendon reflexes are 2+.  Gait is normal.
Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c0c3_f261_8f63_0343ebe5e1ab_MD0005_00 Adolescent idiopathic scoliosis is the most common type of scoliosis. During puberty, a period of rapid growth, the spine may grow asymmetrically, resulting in a lateral curvature of the spine. Patients may present with poor posture; however, scoliosis is often otherwise asymptomatic and identified incidentally on routine examination. A thoracic or lumbar prominence on forward bend test is the most sensitive examination finding for scoliosis. To estimate the severity of curvature, a scoliometer is placed sequentially along the spine, measuring the angle of trunk rotation. Spinal rotation ≥7 degrees (or ≥5 degrees in overweight children) may suggest clinically significant scoliosis. Abnormal scoliometry or obvious deformity on examination necessitates posteroanterior and lateral x-rays of the spine to confirm the diagnosis. scoliometer (Choice A) MRI of the spine is indicated when a secondary cause of scoliosis (eg, tumor, spina bifida) is suspected based on red flags such as significant pain (eg, that limits activity or wakes the patient up at night), rapidly progressive scoliosis, or neurologic deficits (eg, weakness, abnormal reflexes). None of these findings are present in this patient. (Choice B) Reassurance is appropriate if the angle of trunk rotation is <7 degrees. However, this patient's 9-degree rotation requires further evaluation. (Choice C) X-ray of the spine is required prior to initiating treatment. A back brace may be appropriate depending on the degree of scoliosis seen on x-ray; however, physical therapy is not typically beneficial. (Choice D) This patient's past femur fracture puts her at increased risk for leg-length discrepancy. Although leg-length discrepancy may also present with a thoracic prominence on forward bend test and may be evaluated by femur x-ray, the thoracic prominence should correct by placing a block under the contralateral foot, a finding not seen in this patient. Educational objective: Adolescent idiopathic scoliosis is characterized by lateral curvature of the spine in an otherwise healthy adolescent. A thoracic or lumbar prominence on forward bend test is indicative of scoliosis, and a scoliometer angle of rotation ≥7 degrees requires additional evaluation with an x-ray of the spine. References: Optimal management of idiopathic scoliosis in adolescence. (http://www.ncbi.nlm.nih.gov/pubmed/24600296)

A 12-Year-Old Girl Is Brought to the Office for a Preventive