A 16-year-old girl comes to the office due to her posture. The patient is a competitive diver and has difficulty maintaining a handstand on the diving platform due to the tendency to "lean sideways." She also "leans to the side" when trying to stand up straight. The patient has no other symptoms or medical conditions. She takes no medications and has no allergies. Her last menstrual period was 2 weeks ago. Height and weight are at the 50th percentile. The patient is alert and engaging. The neck is supple. The lungs have good air entry in all fields. Breast and pubic hair are Tanner stage 5. Forward bend test reveals a right rib prominence that is not relieved by placing a block under the contralateral foot. Achilles and patellar deep tendon reflexes are 2+. Posteroanterior and lateral spine x-rays reveal a Cobb angle of 17 degrees, indicating mild scoliosis. Which of the following is true about management of this patient?

Question

A 16-year-old girl comes to the office due to her posture.  The patient is a competitive diver and has difficulty maintaining a handstand on the diving platform due to the tendency to "lean sideways."  She also "leans to the side" when trying to stand up straight.  The patient has no other symptoms or medical conditions.  She takes no medications and has no allergies.  Her last menstrual period was 2 weeks ago.  Height and weight are at the 50th percentile.  The patient is alert and engaging.  The neck is supple.  The lungs have good air entry in all fields.  Breast and pubic hair are Tanner stage 5.  Forward bend test reveals a right rib prominence that is not relieved by placing a block under the contralateral foot.  Achilles and patellar deep tendon reflexes are 2+.  Posteroanterior and lateral spine x-rays reveal a Cobb angle of 17 degrees, indicating mild scoliosis.  Which of the following is true about management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c0c5_7905_8f63_b7795ef308bb_MD0005_00 Scoliosis, or lateral curvature of the spine, is typically idiopathic and occurs most commonly in adolescents during periods of rapid growth. A thoracic or lumbar prominence is present on the forward bend test. Limb length discrepancy is excluded if back asymmetry does not correct with block placement under the shorter leg, as in this case. Posteroanterior and lateral x-rays of the spine confirm the diagnosis. Management of adolescent idiopathic scoliosis is determined by the risk for progression, which depends on skeletal maturity (ie, growth potential remaining) and the degree of the curvature (ie, Cobb angle). Skeletal maturity is reflected by the pubertal status, which can help in estimating the remaining growth potential. By Tanner stage 5, this postmenarcheal patient has completed puberty, undergone epiphyseal fusion, and likely reached her full growth potential. Because curve progression is minimal to nonexistent once skeletal maturity is reached, treatment is generally unnecessary, and no follow-up is required for mild/moderate scoliosis (Cobb angle <40 degrees, as in this patient). Cobb angle (Choice A) Monitoring for progression with serial imaging is appropriate for mild scoliosis until skeletal maturity is reached; age alone does not determine management. Monitoring this patient's mild scoliosis is unnecessary because she is skeletally mature with a low risk of progression. (Choice B) Bracing the back helps reduce the risk of curve progression and the need for surgery in skeletally immature patients. However, it is ineffective in those with minimal growth potential, such as this patient who has completed puberty. (Choice D) Orthopedic referral for surgical evaluation is required for severe scoliosis (Cobb angle ≥40 degrees) at high risk for progression and complications, such as chronic back pain, neurologic symptoms, and pulmonary compromise. In contrast, this patient has mild scoliosis and no other symptoms. Educational objective: Mild adolescent idiopathic scoliosis in a skeletally mature patient has a low risk for progression and does not require treatment or follow-up. References: Adolescent idiopathic scoliosis: diagnosis and management. (http://www.ncbi.nlm.nih.gov/pubmed/24506121)

A 16-Year-Old Girl Comes to the Office Due to Her