20. Imaging demonstrates a T9 failure of formation with contralateral segmentation failure, A 13-year old female Risser 2, with AIS and a Cobb angle of 27 degrees. A total of 120 biology teachers was chosen as a . And I am glad because the song is a great song. Mastery Trigger: Have never seen this article, and therefore you are at 0%. Read full article carefully and reviewed References. 12. Furthermore, because most calcaneal fractures occur during the peak earning years of men who perform labor for a living, the economic implications of poorly treated calcaneal fractures can also be substantial [12]. Shows the % of polls that you have voted on and added supporting evidence. What would be the most common complication with this type of spinal column osteotomy? Epub 2020 Sep 16. 1988;91:507-515. Also, the descriptive utility of the Sanders classification relies on the inclusion of these fracture subclasses. Adolescent Idiopathic Scoliosis is a coronal plane spinal deformity which most commonly presents in adolescent girls from ages 10 to 18. Type C are articular fractures with dislocation. Surgeons and clinicians should be aware of the limitations regarding the interobserver and intraobserver reliability for this system. Clinical Orthopaedics and Related Research neither advocates nor endorses the use of any treatment, drug, or device. James O Sanders 1 , Joseph G Khoury , Shyam Kishan , Richard H Browne , James F Mooney 3rd , Kali D Arnold , Sharon J McConnell , Jeanne A Bauman , David N Finegold Affiliation 1 Department of Orthopaedics and Rehabilitation, University of Rochester, 601 Elmwood Avenue, Rochester, NY 14624, USA. [22] were the first to use information garnered from CT imaging to classify calcaneal fractures. Clinical Orthopaedics and Related Research: Schematic illustrates the Sanders classification of intraarticular fractures of the calcaneus in coronal and axial CT cross-sections with the widest undersurface of the posterior facet of the talus. The French surgeon described two types of fracture mechanisms: an avulsion injury resulting from muscular pull and a crushing injury. A 13-year old female, Risser 3, with adolescent idiopathic scoliosis (AIS) and a Cobb angle of 55 degrees, A 5-year old male, with juvenile idiopathic scoliosis (JIS) and a Cobb angle of 55 degrees, A 2-year old female with infantile idiopathic scoliosis (IIS), a flexible curve with a Cobb angle of 35, and a RVAD of 25, A 7-year-old with a progressive spinal deformity. Line C corresponds to the medial edge of the posterior facet of the talus, separating the sustentaculum from the posterior facet. J Bone Joint Surg Br. The Sanders classification is a reliable and reproducible system and should be in the armamentarium of surgeons who treat adolescent idiopathic scoliosis. An MRI showed no spinal cord abnormalities. Observation with repeat radiographs in 6 months, Bracing with a thoraco-lumbar-sacral orthosis, Posterior spinal fusion with instrumentation, Anterior and posterior spinal fusion with instrumentation. (OBQ12.176) (OBQ20.15) Figure A is the radiograph of a 55-year-old female who is a poorly-controlled diabetic with neuropathy and peripheral vascular disease (PVD) that underwent ankle open reduction internal fixation (ORIF) two years ago at an outside facility. Click on the Selfmastery wheel for EACH "Tested" article to advance based on scale below. She is two years post-menarcheal. [13] did not specify the degree of articular incongruity but did recommend surgical management in patients with 3 mm of articular displacement [13]. Multiple studies have demonstrated only fair-to-moderate reliability; therefore, this shortcoming greatly limits the application of this system to communicate with other physicians, to guide the treatment algorithm, and to anticipate prognosis. Lines A and B separate the calcaneus into medial, central and lateral columns. Jimnez-Almonte, Jos H. MD, MS; King, John D. MD; Luo, T. David MD; Aneja, Arun MD, PhD; Moghadamian, Eric MD, J. H. Jimnez-Almonte, J. D. King, A. Aneja, E. Moghadamian, Department of Orthopaedic Surgery, University of Kentucky, Lexington, KY, USA, T. D. Luo, Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA, J. H. Jimnez-Almonte, Department of Orthopaedic Surgery, University of Kentucky, 740 S Limestone, K403, Lexington, KY 40536-0284, USA, email: [emailprotected]. The Sanders classification is a system of categorizing intra-articular calcaneal fractures based on the number of articular fragments seen on the coronal CT image at the widest point of the posterior facet. Thank you. Examination reveals a mild right rib prominence during forward bending. In 1952, Essex-Lopresti [5] further distinguished intraarticular fracture patterns into two types (depending on the exit point of the secondary fracture line): tongue type and joint depression fractures. 3) ARTICLES - we will continue to select several articles, which may be a scientific articles or a section Humphrey et al. In 1931, Bhler described the first comprehensive calcaneal fracture classification scheme with eight fracture patterns based on plain radiographs, proposing two major groups: intraarticular and extraarticular [1, 2]. Mastery Trigger: Track and sort subjective comments. Did read the conclusion of Abstract & Bullets and highlighted some parts of it. Continue nocturnal bracing until skeletal maturity. Some error has occurred while processing your request. 3. Type III - Fractures involving articular surface. The simplest way to explain the Sanders Classification of calcaneal fractures. Master your subspecialty operative skills through topics, videos, quizzes, Technique Guide and Skillmaster. Fracture lines A, B, and C describe the position of the primary fracture line in relation to the posterior facet and the subtalar joint. of all the articles and have met specific Orthobullets inclusion criteria. J Foot Ankle Surg. Sync your program's lecture schedule with the Orthobullets 365-Day Core Curriculum. Skeletal maturity is an important variable in the progression of idiopathic scoliosis. Identify surgical skill deficiencies and adjust rotations schedule to ensure all residents meet their ACGME Patient Care Skills by graduation. Copyright 2022 Lineage Medical, Inc. All rights reserved. Int Orthop. Injury. They demonstrated moderate interobserver agreement ( = 0.48) and greater agreement ( = 0.55) when Sanders subclasses were excluded. 2003;42:21-23. Got question incorrect. Sanders et al. Subtypes include IIIAB, IIIAC, and IIIBC, according to the location of the two primary fracture lines. Ensure all residents meet their ACGME target levels for Patient Care. Line C corresponds to the medial edge of the posterior facet of the talus, separating the sustentaculum from the posterior facet. Target Content: This includes the Orthobullets "Steps" for each Skill. Subsequently, in 1975, Soeur and Remy [19] proposed a classification scheme based on the number of articular fragments and fracture displacement as determined on AP, lateral, and Harris axial heel views of the calcaneus. decreased pulmonary function in the future, to undergo an MRI to rule out any underlying neurologic pathology, as this is an abnormal curve, an increased risk of chronic back pain over her lifetime, this curve magnitude has the highest curve progression rate without operative intervention. Click on the Article Selfmastery Tool on Skill Articles per the scale listed above under articles. J Foot Ankle Surg. Track your residents though a Technique Guides & Skillmaster of 150+ procedures with videos, articles, quizzes and self-mastery tracking. to maintaining your privacy and will not share your personal information without Click on Selfmastery wheel for EACH OB and SAE Question associated with the topic to advance based on scale below. Answer the question correctly 3 times in a row to advance to 80%. (OBQ18.41) Take the pain out of ACGME reporting. Watched surgical "Step" and partially invovled (held retractor). Implement a structured curriculum including daily emails reviewing 500+ topics, daily key scientific articles, and monthly diagnostic Milestone exams. Thoracic curve coronal correction of > 40%, Thoracolumbar/lumbar curve coronal correction > 50%, Failure to maintain lumbar lordosis of > 45 degrees. treated differently - a question can still be a great educational tool even though it is a "bad question" from a diagnostic perspective. Pathoanatomic classification. Target Content: Each author certifies that his institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained. While you can learn a lot by reading on your own, didactic lectures from experts always highlights what Despite its widespread use, the value of this classification scheme has been a point of debate as a result of its limited reliability and validity. Sanders Classification (foothyperbook.com) Calcaneus Fracture Classification Images. 2005;87:205-208. She has no pain and has had no treatment up to this point. Increase faculty engagement by streamlining evaluations. Therefore, you are at 20%. In our opinion, only then is a resident ready to engage a faculy and have the most productive teaching/learning experience in the OR. Increase your OITE scores and pass the boards without stress by utilizing our Qbank of AAOS SAE questions and OB question! Got question correct and read the explanation and conclusion of the abstracts. However, intraobserver agreement was greater ( = 0.57) particularly when subclasses were excluded ( = 0.77) [12]. . 2014;45:11171120. (SAE07PE.98) Figure A shows the pre-operative plan and surgical technique for this procedure. Unfortunately, there is a "sea" of evidence, and it can be difficult and time-consuming to choose what is important to read. Although widely used since its introduction in 1993, the Sanders classification has several noted limitations. Foot Ankle Int. In the treatment of thoracolumbar idiopathic scoliosis using an anterior single rod technique with interbody cages, which of the following variables has been associated with pseudoarthrosis. However, the Sander classification system does not have a direct correlation with the patients treatment [17]. 2003;128:517-528. Regarding operative treatment, as the fracture line goes lateral to medial, the operative view and the ability to obtain an anatomic reduction become more difficult [1, 13]. Operative Surgery, Based on Normal and Pathological Anatomy. 2021 Mar;52(3):616-624. Malgaine JF. Check the "Mark Skill as Read" under each Step. Analytics to improve Physician Development. This classification scheme uses the ABC classification regularly used for long bone fractures, which is organized into three hierarchical types with 27 subgroups. Other studies, however, have demonstrated that the level of training and experience of the observers did not correlate with observer reliability and reproducibility [1, 7, 12]. A resident should reach a Level 4 by the time he graduates from residency. A girl who is Risser 4, Sanders 7, with a 30 degree curve. Therefore, this system does not account for fracture displacement in the sagittal or axial planes relative to the widest undersurface of the posterior facet of the talus. 2022 University of Washington | Seattle, WA, Sanders Classification of Calcaneal Fractures, Winquist and Hansen Classification of Femoral Fractures, Seinsheimer Classification of Femoral Condylar Fractures, Schatzker Classification of Tibial Plateau Fractures, Ruedi and Allgower Classification of Pilon Fractures, Danis Weber Classification of Ankle Fractures, Lauge Hansen Classification of Ankle Fractures, Hawkins Classification of Talar Fractures, Regardless of the number of fracture fragments. (OBQ06.35) Crosby LA, Fitzgibbons T. Computerized tomography scanning of acute intra-articular fractures of the calcaneus. A 12-year-old female presents with a left thoracic rib prominence. Learning topics is best accomplished in layers. Despite the popularity of the Sanders classification, multiple studies have demonstrated that this scheme lacks the reproducibility to be considered ideal and its reliability has not consistently demonstrated superiority over other classification systems. robert mealy funeral home. Questions are a "poor-mans" version of case-based learning, which is the best way to learn to apply medical knowledge, how much does va pay for erectile dysfunction 2021 kaeya wine Enhance your operative skills through Self Mastery Skillmaster tracker, and Technique Guide. Number represents % of total requred Skill Tasks completed. Now highlight the key tested concept in the explanation and highlight the key clinical findings in the conclusion of the referenced article abstracts to advance to 60%. Injury. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request. Orthobullets Team Spine - Adolescent Idiopathic Scoliosis; Listen Now 24:40 min. Foot Ankle Int. A new classification system. This work was performed at the University of Kentucky, Lexington, KY, USA. A 13-year-old girl is referred to the orthopedic clinic for evaluation of scoliosis. SKILL COMPLEXITY LEVEL: Our surgical Skills, are broken down into 5 levels of complexity and may email you for journal alerts and information, but is committed J Orthop Trauma. [13] was to describe intraarticular calcaneal fractures with an emphasis on guiding restoration of the articular surface from a lateral surgical approach. . (OBQ12.70) 3 types. Mastery Trigger: Classification Conveniently the Salter-Harris types can be remembered by the mnemonic SALTR. Lines A and B separate the calcaneus into medial, central and lateral columns. Professionalism & Rotation Evaluations Accurate ACGME levels AND summative faculty feedback the residents want. Furey A, Stone C, Squire D, Harnett J. Os calcis fractures: analysis of interobserver variability in using Sanders classification. Tibiofibular syndesmosis intact or only partially torn, but no widening of the distal tibiofibular articulation. Sanders Classification of Calcaneal Fractures Use coronal image with the widest undersurface of the posterior facet of the talus. Therefore, this system does not account for fracture displacement in the sagittal or axial planes relative to . Schepers T, van Lieshout EM, van Ginhoven TM, Heetveld MJ, Patka P. Current concepts in the treatment of intra-articular calcaneal fractures: results of a nationwide survey. ACGME Patient Care Levels derived from cumulative Point-of-Care Grades on a 1000+ competency-based skill evaluations. Questions work best in repetition, where you see the question over and over again, 1. Injury. She denies pain. 13. Sanders RW. History. (2012). 17. She was noncompliant with her immediate postoperative weight-bearing instructions and went on to fixation failure. The most appropriate treatment would be? The 'Risser sign' is one of the most commonly used markers for skeletal maturation and growth potential in patients with adolescent idiopathic scoliosis. Our selfmastery system allows residents to track their selfmastery on each step of a skill. This techniques allows for which of the following: (OBQ13.138) Strengthen your subspecialty knowledge and stay current on the literature through our annual fellowship-specific Subspecialty Study Plans. A Personalized Adaptive Learning System added to the premium content of Virtual Curriculum. These systems are useful tools for describing and classifying ankle injuries along with the Weber classification. An analysis of inter- and intra-observer variability. In: Coughlin MJ, Saltzman CL, Anderson RB, eds. Type Description; I: Nondisplaced posterior facet: II: . She has 5 of 5 motor strength in all muscles groups in her lower extremities and symmetric patellar and Achilles reflexes. 0000044467 00000 n Diagnosis is made with plain elbow radiographs. 20 January, 2011. This is an AAOS Self Assessment Exam (SAE) question. A mother and her 16-year-old daughter present to your clinic because the daughter has noticed asymmetries in her back. The Salter-Harris classificationwas proposed by Salter and Harris in 1963 1 and at the time of writing (June 2016) remains the most widely used system for describing physeal fractures. Observation and referral to an endocrinologist. Finally, the Sanders classification has not been shown to be more reproducible or reliable than other calcaneal classification systems such as the Zwipp, Essex-Lopreti, or Crosby classification [7, 9, 16]. Diagnosis is made with full-length standing PA and lateral spine radiographs. (OBQ12.178) Only Orthobullets "Tested" articles count as target content. A competency based surgical skill training & evaluations system that is mobile, user-friendly, and improved technical training. Mastery Trigger: The Sanders classification is a system of categorizing intra-articular calcaneal fractures based on the number of articular fragments seen on the coronal CT image at the widest point of the posterior facet. Lower Extremity Schatzker Classification of Tibial Plateau Fractures A very useful tutorial on this topic can be found here. Currently all cases linked to a topic count as target cases. A 12-year-old girl who is 3 months postmenarchal undergoes full-time brace treatment for scoliosis. Please try after some time. J Foot Ankle Surg. learn more efficiently by decreasing redundancy in the future. He should have reached a Level 5 by the time he has completed his fellowship. Observer C Observer D Measurement 1Measurement 2Measurement 1Measurement 2 Sanders Classification N % n % n % n % 1 4 8.7 5 10.9 0 0.0 0 0.0 2A 2 4.3 5 10.9 11 23.9 15 32.6 evidence, and to think critically. At age 15, after 3 years of bracing, a repeat posteroanterior radiograph is obtained, now revealing a right thoracic curve measuring 11 degrees and the left lumbar curve measuring 19 degree, and Risser 4. Which statement best represents the indicated course of action in this patient? Click the PEAK Tracker below to see how you rate mastery of different learning activities. Now read the Abstract itself and make some highlights there to advance to 40%. References: Enhance and align your medical knowledge training with our Core Curriculum and stay on the same page as your residents. (OBQ11.49) Click on the Topic Selfmastery wheel to advance based on the scale below. Make sure residents reach their ACGME Patient Target levels through our competency-based skill tracking and evaluation system. On Adams forward bending, she measures 6 degrees. Watched surgical "Step" but not involved. how you move up the learning curve. Inaccurate reductions can result in substantial deformity, functional impairment, disability, and chronic pain; however, even when anatomic reduction is achieved, pain and disability may still follow, because the high loads experienced by the articular cartilage may predispose even well-reduced fractures to subsequent posttraumatic arthritis. Classification Philadelphia, PA, USA: Elsevier Inc; 2014:2041-2100. Type B are intraarticular fractures with at least half of the articular surface within the regular confines of the joint. What is the next step in management? Discontinuation of bracing as she has reached skeletal maturity. They also incorporated the number of affected joint facets and the degree of soft tissue damage into a 12-point scoring system that was of prognostic relevance [11]. How PASS is a win for everyone on the team Residents Chief Residents Fellows Program Coordinators So, this is the other Imagine Dragons song that is listed here in the top 50 . In addition, intraobserver reliability for selecting operative treatment based on this classification system has been shown to be moderate, whereas interobserver reliability has been shown to be fair at best [20]. Save your CCC team 120+ FTE hours doing ACGME evaluations via our automated platform. For more information, please refer to our Privacy Policy. Tracking tools monitor your progress and help you Copyright 2022 Lineage Medical, Inc. All rights reserved. Categories: Orthopedic . Attempts to validate the Sanders classification have demonstrated, at best, fair interobserver reliability and fair-to-moderate intraobserver reliability [8, 9, 16, 17, 21]. 2002;84:1733-1744. Aghnia Farda N, INJURY 2021 Pubmed Journal Website BACKGROUND: Classification of the type of calcaneal fracture on CT images is essential in driving treatment. 1). Have never seen surgical "Step" performed. 2019 02;477 (2):467-471. 18. Classification Edit. She occasionally takes acetaminophen, but the pain does not limit sport activities. Fractures of the Calcaneus: A Review with Emphasis on CT. Radiographics 25: 1215-1226. Radiologists in the same study demonstrated an interobserver value of 0.43 without subclasses, which decreased to 0.30 with subclasses [17]. Zwipp et al. 6. as they are updated by experts in the field over the coming months. A detailed neurological examination reveals no abnormalities. Medial malleolus may be fractured or deltoid ligament may be torn. In today's world of medicine, having a firm grasp of the evidence is essential to take good care of patients. Epidemiology Incidence most common type of scoliosis incidence of 3% for curves between 10 to 20 When the head moves a lot ('owl'), not much classification improvement is attained by estimating eye pose on top of head pose.On the other hand, when the head stays still and only the eyes move ('lizard'), classification accuracy increases significantly from adding in eye pose.Examples of the two strategies are shown in Fig. 19. Did surgical "Step" independently and comfortably without supervision. Therefore, you are at 80%. (OBQ04.144) Highlighting and taking notes allows residents to document what they learned for future reference. Which of the following methods of determining skeletal maturity correlates most closely with the curve acceleration phase for children with idiopathic scoliosis? Clearly identify and document residents who have deficiencies. J Bone Joint Surg Am. ORTHO BULLETS Join now Login 602ms Topics Trauma General Trauma Evaluation High-Yield Topics Evaluation, Resuscitation & DCO Open FX Management Adult Knee Trauma Radiographic Evaluation Gustilo Classification Tscherne Classification Trauma Scoring Systems Specific Presentations Compartment Syndrome Infection Upper Extremity Shoulder Humerus Elbow These are the top 50 streamed songs of Spotify as of today! [13] described their classification system as the rational extension of the fracture patterns identified by Soeur and Remy [19]. Open reduction and internal fixation] [in German]. For information on cookies and how you can disable them visit our Privacy and Cookie Policy. The purpose of this study is to determine the correlation between the Risser and Sanders systems, and to determine if one system can be used to predict the stage of the other. Figures A-E are radiographs showing varying stages of skeletal maturity. On this page: Article: Classification; Reference: Schatzker, J., et al. What is the most appropriate treatment and expected outcome given her age and degree of scoliosis? more effectively with tools like highlighting and personal notes. Perhaps the most widely articulated criticism of the Sander classification is its inconsistent reproducibility among orthopaedic surgeons and other clinicians [18]. - e.g., so you got an MRI in the ER and the patient is alert and oriented, so what is your next step in management? Mastery Trigger: have a certain educational value and quality control will count in this counter. Gustilo-Anderson classification grade 1: clean wound <1 cm in length grade 2: wound 1-10 cm in length without extensive soft-tissue damage, flaps or avulsions grade 3: extensive soft-tissue laceration (>10 cm) or tissue loss/damage or an open segmental fracture open fractures caused by farm injuries injuries requiring vascular intervention A competency based surgical skill training & evaluations system that is mobile, user-friendly, and improved technical training. Mastery Trigger: The angle formed by extending the fracture line upwards to meet an imaginary horizontal line drawn through the transtubercular (iliac crest) plane on AP film is described as "Pauwels' angle." Multiple studies [13, 14] have also highlighted the utility of the system as a prognostic tool to assist the surgeon in counseling the patient with respect to expected outcomes. Therefore, you are at 40%. 2009;48:156-162. Ensure a higher quality of care in the OR by identifying which residents are ready for advanced procedures. You can't expect to do any surgical skill, for instance cutting the femoral neck in a THA, It became the pillar for understanding calcaneus fractures, preoperative planning, and predicting patient prognosis. Give resident summative faculty feedback on the ACGME core competencies at the end of each rotation using a modern mobile platform. Most intraarticular calcaneus fractures are treated surgically, but it is challenging because of associated soft tissue damage, primary cartilage damage resulting from the impact at the time of the injury, complex fracture configuration with numerous articular fragments, and a steep learning curve required before obtaining consistent and predictable results with operative fixation. as that is captured under the Skill component of Peak. This website uses cookies. You can rate this topic again in 12 months. Sanders R, Vaupel ZM, Erdogan M, Downes K. Operative treatment of displaced intraarticular calcaneal fractures: long-term (10-20 years) results in 108 fractures using a prognostic CT classification. 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Type in at least one full word to see suggestions list, Authors' Preferred Technique: Temporary Internal Distraction for Severe Scoliosis - Daniel Badin MD, Frederick Mun BS BA, David L. Skaggs MD MMM, Paul D. Sponseller MD MBA, Correction of Adolescent Idiopathic Scoliosis - Kenneth R. Kato, MS, Lindsay M. Andras, MD, Kenneth D. Illingworth, MD, David Skaggs, MD, MMM, 2019 Orthopaedic Summit Evolving Techniques, Pathogenesis of AIS: Braces & Monitoring: You Can Do It! 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Aghnia Farda N, 10. . Type IV fractures involve three or more primary fracture lines, resulting in four or more articular fragments with severe comminution (Fig. Third-degree fractures were highly comminuted, and as such, they could not be classified. Tried to teach surgical "Step" to another surgeon. Results using a prognostic computed tomography scan classification. Clin Orthop Relat Res(290): 87-95. Traumatic Spondylolisthesis of Axis (Hangman's Fracture), Cervical Lateral Mass Fracture Separation, Extension Teardrop Fracture Cervical Spine, Clay-shoveler Fracture (Cervical Spinous Process FX), Chance Fracture (flexion-distraction injury), Osteoporotic Vertebral Compression Fracture, Ossification Posterior Longitudinal Ligament, DISH (Diffuse Idiopathic Skeletal Hyperostosis), Atlantoaxial Rotatory Displacement (AARD), Pediatric Intervertebral Disc Calcification, Pediatric Spondylolysis & Spondylolisthesis. CONCLUSIONS: : The Sanders Classification System showed good intraobserver reliability, but interobserver reproducibility below the ideal level, both among experienced and less experienced observers. Level of Evidence III, Diagnostic Studies. What risk factor is most associated with progression of idiopathic scoliosis to a curve requiring surgery? Humphrey CA, Dirschl DR, Ellis TJ. Lauder et al. Just like you need a "spotter" when benching 20lbs more than ever before, you need to engage faculty Our Bullets* App syncs with Peak so you can learn 1) STEPS - reading the Orthobullets "Steps" of a skill that have been created by orthobullets. 5. incidence of 3% for curves between 10 to 20, 1:1 male to female ratio for small curves, cartilaginous plate that forms between the centrum and posterior neural arches, risk factors for progression (at presentation), > 25 before skeletal maturity will continue to progress, > 50 thoracic curve will progress 1-2 / year, > 40 lumbar curve will progress 1-2 / year, Risser 0 covers the first 2/3rd of the pubertal growth spurt, correlates with the greatest velocity of skeletal linear growth, is the best predictor of curve progression, if curve is >30 before peak height velocity there is a strong likelihood of the need for surgery, thoracic more likely to progress than lumber, double curves more likely to progress than single curves, five part classification to describe thoracic curve patterns and help guide surgeons implanting Harrington instrumentation, link to King-Moe classification (not testable), more comprehensive classification based on PA, lateral, and supine bending films, helps to decide upon which curves need to be included within the fusion construct, link to Lenke classification (not testable), patients often referred from school screening where a, 7 curve on scoliometer during Adams forward bending test, 7 correlates with 20 coronal plane curve, axial plane deformity indicates structural curve, can eliminate leg length inequality as cause of scoliosis, other important findings on physical exam, skin defects (hairy patches, dimples, nevi), rib rotational deformity (rib prominence), can suggest neural axis abnormalities and warrant a MRI, coronal balance is determined by alignment of, sagittal balance is based on C7 plumb from center of C7 to the posterior-superior corner of S1, between lines drawn vertically from lumbosacral facet joints, most proximal vertebrae that is most closely bisected by central sacral vertical line, rotationally neutral (spinous process equal distance to pedicles on PA xray), end vertebra is defined as the vertebra that is most tilted from the horizontal apical vertebra, the apical vertebraeis the disk or vertebra deviated farthest from the center of the vertebral column, best predictor of postoperative shoulder balance, should extend from posterior fossa to conus, purpose is to rule out intraspinal anomalies, left thoracic curve, short angular curve, apical kyphosis, a syrinx is associated with abnormal abdominal reflexes and a curve without significant rotation, Based on skeletal maturity of patient, magnitude of deformity, and curve progression, obtain serial radiographs to monitor for progression, only effective for flexible deformity in skeletally immature patient (Risser 0, 1, 2), goal is to stop progression, not to correct deformity, 50% reduction in need for surgery with compliant brace wear of at least 13 hours a day, poor prognosis with brace treatment associated with, noncompliant (effectiveness is dose-related), the number needed to treat (NNT) is four in highly compliant patients, predicts the risk of curve progression despite bracing to >50 degrees in Lenke type I and III curves, uses anteroposterior hand radiograph and curve magnitude to assess risk of progression despite bracing, can be used for all types of idiopathic scoliosis, remains gold standard for thoracic and double major curves (most cases), best for thoracolumbar and lumbar cases with a normal sagittal profile, young age (Risser grade 0, girls <10 yrs, boys < 13 yrs), recommended for 16-23 hours/day until skeletal maturity or surgical intervention deemed necessary (actual wear minimum 12 hours required to slow progression), Milwaukee brace (cervicothoracolumbosacral orthosis), Charleston Bending brace is a curved night brace, bracing success is defined as <5 curve progression, 6 or more curve progression at orthotic discontinuation (skeletal maturity), absolute progression to >45 either before or at skeletal maturity, or discontinuation in favor of surgery, <1cm change in height over 2 visits 6 months apart, fusion should include enough levels to adequately maintain sagittal and coronal balance while being as minimal as safely possible to preserve motion, typical fusion from proximal end vertebra to one or two levels cephalad to the stable vertebra, double and triple major curves fuse to the distal end vertebra, recommends one level above and two levels below the end vertebrae if these levels fall wilthin the stable zone, recommends fusion to the neutral vertebrae, recommends including all major curves in the fusion and minor curves that are not flexible or are kyphotic. 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