# A 12-year-old girl is brought to the clinic by her mother who noticed that her daughter's shoulders appear uneven when she wears tank tops. The nurse is conducting an initial assessment for possible idiopathic scoliosis. Which assessment finding would be most indicative of structural scoliosis?

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## 문제

A 12-year-old girl is brought to the clinic by her mother who noticed that her daughter's shoulders appear uneven when she wears tank tops. The nurse is conducting an initial assessment for possible idiopathic scoliosis. Which assessment finding would be most indicative of structural scoliosis?

## 보기

1. Uneven shoulder heights when standing upright
2. Hip asymmetry when standing in normal position
3. Unequal leg lengths measured from hip to ankle
4. Prominent rib hump visible during forward bend test **✔ 정답**

**정답: 4**

## 해설

The forward bend test (Adam's test) reveals a rib hump, indicating the rotational component of structural scoliosis. Other findings like shoulder or hip asymmetry are less specific and can occur in various conditions.

## 심화 해설

Clinical Context

In the assessment of a pediatric patient for suspected idiopathic scoliosis, the nurse must differentiate between postural (functional) deformities and fixed (structural) deformities. Idiopathic scoliosis is a three-dimensional spinal deformity involving lateral curvature and vertebral rotation . While visual asymmetry in the shoulders or hips can be suggestive, these findings can also occur due to poor posture or leg length discrepancies without true spinal pathology. The key pathognomonic sign of structural scoliosis is the manifestation of vertebral rotation, which becomes clinically visible as a rib prominence or hump during the forward bend test (Adam's test) [4].

Pathophysiology of the Rib Hump

Structural scoliosis is defined by a fixed lateral curvature coupled with rotation of the vertebral bodies. As the spine rotates, the attached ribs are displaced posteriorly on the convex side of the curve and anteriorly on the concave side. When the patient bends forward, this rotational deformity becomes accentuated, revealing a prominent rib hump or paraspinal muscle mass on one side of the thorax. This finding is the hallmark of structural scoliosis because it confirms the presence of vertebral rotation, which is absent in functional scoliosis [4].

Differential Analysis of Findings

The following table distinguishes the assessment findings to clarify why the rib hump is the most specific indicator:

| Assessment Finding | Clinical Interpretation | Specificity for Structural Scoliosis |
| --- | --- | --- |
| 1. Uneven shoulder heights | Common in both functional and structural scoliosis. Can result from muscle spasm, poor posture, or pelvic tilt without vertebral rotation. | Low |
| 2. Hip asymmetry | Often associated with pelvic obliquity. May be caused by leg length discrepancy or functional curvature rather than fixed spinal deformity. | Low |
| 3. Unequal leg lengths | This is a potential cause of functional scoliosis. A pelvic tilt from a short leg creates a compensatory curve that disappears when the leg length is corrected or the patient sits. It does not confirm a structural spinal deformity. | Very Low |
| 4. Prominent rib hump | Directly indicates vertebral rotation. This finding is pathognomonic for structural scoliosis and is the primary indicator measured by a scoliometer during screening [4]. | High |

Clinical Screening Application

School-based and clinical screening programs rely heavily on the Adam's forward bend test to detect structural deformities that require radiographic follow-up. While visual inspection for shoulder or hip asymmetry is part of the initial observation, these signs alone overestimate the presence of structural scoliosis . The forward bend test is essential because it allows the examiner to view the transverse plane deformity (rotation) that defines the condition. In the absence of a rib hump, asymmetries are more likely to be functional or related to non-spinal factors such as limb length inequality.

Early detection of the rib hump is critical because progressive curves during adolescent growth can lead to significant morbidity. The Cobb angle, the gold standard measurement for curve magnitude on radiography, quantifies the coronal plane deformity, but the clinical suspicion for obtaining that radiograph is triggered by the presence of rotation on the forward bend test .

References (research sources)

- [4]Prevalence and Classification of Scoliosis Among Female University Students in Saudi Arabia.Research articleAljohani MMA, Alshehri YS, Eweda RS. (2025) · DOI: 10.3390/healthcare13222894

## 임상 시나리오

Scoliosis Screening: Adam's Forward Bend TestIdentifying Structural vs. Functional Deformity
For a 12-year-old girl with uneven shoulders, the most indicative finding for structural scoliosis is a rib hump visible during the Adam's forward bend test. This sign confirms underlying vertebral rotation, which is absent in postural or functional curves.

Instruct the patient to bend forward at the waist with feet together, knees straight, and arms hanging freely. Observe the thorax from behind at eye level. A prominent rib hump on one side or an asymmetric paraspinal muscle mass is a positive test requiring referral.

CautionAsymmetrical shoulders or hips alone do not differentiate structural from functional scoliosis. Always perform the forward bend test to assess for fixed rotation before measuring leg lengths or attributing findings to posture.

## 핵심 개념

- **Structural Scoliosis** — A fixed, three-dimensional spinal deformity involving lateral curvature and vertebral rotation that does not correct with posture changes.
- **Adam's Forward Bend Test** — A screening test where the patient bends forward at the waist; a rib hump indicates vertebral rotation characteristic of structural scoliosis.
- **Vertebral Rotation** — The twisting of vertebrae on their axis in structural scoliosis, causing posterior rib displacement on the convex side of the curve.
- **Functional Scoliosis** — A reversible lateral spinal curvature caused by conditions like leg length discrepancy or muscle spasm, lacking fixed vertebral rotation.
- **Rib Hump** — A visible prominence of the ribs on one side of the thorax during forward bending, the hallmark sign of structural scoliosis.

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