The Sanders classification system fails to meet all of the criteria required for an appropriate classification scheme. In this system the calcaneus is divided into three segments: proximal (body including the tuberosity and posterior facet), middle (sustentaculum tali with the middle facet and sulcus), and distal (anterior process including the anterior facet and the cuboidal facet). Target Content: In this study, the results indicated that the Sanders classification system has greater reliability for fractures at the extreme of the spectrum, but has poor reliability in discriminating between fractures in the midrange of the classification scheme [8]. (skill of easier complexity level), has completed on the Preparatory Tasks, and has Self-Mastered to 80%. Daftary, A., et al. The calcaneus is the most commonly fractured tarsal bone, accounting for 2% of all fractures that present to the emergency department [18]. The authors of that randomized controlled trial performed operative treatment on patients with 3 mm of articular displacement based on axial and coronal CT imaging of the posterior facet [3]. 2011;32:861-866. 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. 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. They demonstrated moderate interobserver agreement ( = 0.48) and greater agreement ( = 0.55) when Sanders subclasses were excluded. Essex-Lopresti P. The mechanism, reduction technique, and results in fractures of the os calcis. She occasionally takes acetaminophen, but the pain does not limit sport activities. MRI of the cervical, thoracic and lumbar spine. 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. A 12-year-old female is referred to the office by a community orthopaedic surgeon concerned that her shoulders appear to be at different heights. A standing PA and lateral radiograph is shown in Figures A and B. dart mixin inheritance; hand tenon cutter; cia directorate of operations interview 21. Although widely used since its introduction in 1993, the Sanders classification has several noted limitations. These are the top 50 streamed songs of Spotify as of today! Crosby LA, Fitzgibbons T. Computerized tomography scanning of acute intra-articular fractures of the calcaneus. 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]. For each of these "Steps" the surgeon rates his Self-mastery on the scale listed below. Take notes and highlight so you don't forget what you learned. Line C corresponds to the medial edge of the posterior facet of the talus, separating the sustentaculum from the posterior facet. Adolescent Idiopathic Scoliosis is a coronal plane spinal deformity which most commonly presents in adolescent girls from ages 10 to 18. how you move up the learning curve. A series of Core Videos will help residents take what they are reading, 11. Skimmed the topic briefly and skimmed 50% of questions once, Read entire topic and did all questions once, Read entire topic and did all questions at least twice, Presented topic to other residents or taught at grand rounds. This was intended to aid in surgical decision-making by demonstrating that outcomes as assessed with the Maryland Foot Score deteriorated as the number of articular fragments increased. What is the most appropriate treatment and expected outcome given her age and degree of scoliosis? 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. In patients with adolescent idiopathic scoliosis, bracing is indicated in which of the following conditions: Any patient with a curve of greater than 25 degrees, A 11- year-old boy boy with a Cobb angle curve of 50 degrees, A premenarchal girl with a Cobb angle curve of 30 degrees, A growing child with 6 degrees of progression with a 12 degree curve. Therefore, you are at 60%. recommended operative management of displaced intraarticular fracture of the calcaneus, but their clinical results did not correlate with the proposed classification scheme [15]. This may demonstrate that even if surgeons agree on how to classify a fracture according to this scheme, they may still disagree on how the patient should be treated. 2019 02;477 (2):467-471. Sanders, R., et al. J Foot Ankle Surg. The Sanders Maturity Scale, based on a left hand radiograph, has been shown to be the best predictor of the curve acceleration phase of growth. Thank you. The advent of CT in the 1980s revolutionized the characterization and management of calcaneal fractures, leading to a better understanding of the fracture anatomy. 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. Get new journal Tables of Contents sent right to your email inbox, The Association of Bone and Joint Surgeons, February 2019 - Volume 477 - Issue 2 - p 467-471, Classifications in Brief: Sanders Classification of Intraarticular Fractures of the Calcaneus, Articles in PubMed by Jos H. Jimnez-Almonte, MD, MS, Articles in Google Scholar by Jos H. Jimnez-Almonte, MD, MS, Other articles in this journal by Jos H. Jimnez-Almonte, MD, MS. Create subspecialty exams from a pool of 5000 orthobullets and AAOS SAE questions. 1975;57:413-421. Which statement best represents the indicated course of action in this patient? Within that study, the mean interobserver value was 0.41 among 10 orthopaedic traumatologists with 5 years of postresidency experience [8]. Both improved when the subclassification scheme was removed ( = 0.33 and = 0.45, respectively). The patient represented by which Figure would be expected to have the highest risk of progression of an idiopathic scoliotic curve? Please try after some time. is most relevant in clinical practice. Questions work best in repetition, where you see the question over and over again, [22] were the first to use information garnered from CT imaging to classify calcaneal fractures. 9. Increase your OITE scores and pass the boards without stress by utilizing our Qbank of AAOS SAE questions and OB question! Interobserver and intraobserver reliability of two classification systems for intra-articular calcaneal fractures. Track your residents though a Technique Guides & Skillmaster of 150+ procedures with videos, articles, quizzes and self-mastery tracking. IIA - Both ligaments (conoid and trapezoid) attached to the distal fragment. Click on the Video Selfmastery wheel to advance based on the scale below. Observation with a 100% chance of progression to >50 deformity, Rigid TLSO for 2 hours/day with a 75% decrease in the need for surgery, Rigid TLSO for 13 hours/day with a 50% decrease in the need for surgery, Rigid TLSO for 24 hours/day with a 100% decrease in the need for surgery. A Personalized Adaptive Learning System added to the premium content of Virtual Curriculum. She was noncompliant with her immediate postoperative weight-bearing instructions and went on to fixation failure. (OBQ12.176) Only Orthobullets "Tested" articles count as target content. Team Orthobullets (D) Trauma - Calcaneus Fractures Flashcards (55) Cards . Which of the following methods of determining skeletal maturity correlates most closely with the curve acceleration phase for children with idiopathic scoliosis? james_sanders@urmc.rochester.edu PMID: 18310704 Several studies have demonstrated that reliability declines substantially when subclassification is used. Sanders et al.s [13] original description of intraarticular calcaneal fracture classification was based on coronal and axial CT cross-sections with the widest undersurface of the posterior facet of the talus (Fig. 12. (OBQ12.70) Mastery Trigger: Even if the correct answer is outdated, it is important to know that historically a condition was 2014;53:47-51. Three-dimensional computed tomography is not indicated for the classification and characterization of calcaneal fractures. Shortly, only "Core Videos" that 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]. Teaching cases are the "cadillac" of learning to apply medical knowledge, the latest evidence, Results using a prognostic computed tomography scan classification. Give resident summative faculty feedback on the ACGME core competencies at the end of each rotation using a modern mobile platform. Sanders R. Displaced intra-articular fractures of the calcaneus. Therefore, you are at 80%. (1979). Leverage easy-to-use ACGME reporting functionality, including automated end-of-rotation summative evaluations for ACGME Milestones (MK, PC, and Prof.). IIB - Conoid torn, trapezoid attached to the distal fragment. A new classification system. (OBQ06.35) Zwipp H, Baumgart F, Cronier P, Jorda E, Klaue K, Sands AK, Yung SW. Integral classification of injuries (ICI) to the bones, joints, and ligamentsapplication to injuries of the foot. Questions are a "poor-mans" version of case-based learning, which is the best way to learn to apply medical knowledge, Injury. By focusing faculty teaching effort on your target "sweet spot" skills, we believe we can greatly accelerate 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. This techniques allows for which of the following: (OBQ13.138) 2021 Mar;52(3):616-624. When compared to normal controls, adults with untreated idiopathic scoliosis and a Cobb angle of greater than 60 degree at the time of skeletal maturity have a higher rate of which of the following? 3) ARTICLES - we will continue to select several articles, which may be a scientific articles or a section [17] evaluated reliability with 12 observers: six orthopaedic traumatologists and six radiologists who specialized in trauma and musculoskeletal radiology. The simplest way to explain the Sanders Classification of calcaneal fractures. J Bone Joint Surg Br. It became the pillar for understanding calcaneus fractures, preoperative planning, and predicting patient prognosis. 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. Type 1 fractures are minimally displaced and are not depicted. 6,600+Free Board Style Questions in modern Qbank, 5,000+Referenced Journal Articles with 100s of PDFs, 1,300+Educational Presentation and Technique Videos, 2,500+ Shared Cases with million physician votes & comments. 4% (116/3049) L 2 . Did surgical "Step" start to finish under close supervision. Orthobullets; This article about Orthopedic surgery is a stub. Make a strong impression on your sub-internship, Get a head start on your orthopaedic knowledge in preparation for residency, Increase your OITE scores by having access to both Academy SAE questions and Orthobullets Virtual Curriculum questions, Identify your areas of strength and weakness with our monthly diagnostic Milestone exams, Enjoy unlimited access to our study plans, including OITE and CORE Curriculum, Use our topic and technique guide mastery tracking to help guide your learning efforts, Prepare for ABOS Part I with access to AAOS SAE and OB Virtual Curriculum questions, Our monthly Milestone exams can act as a dress rehearsal for ABOS Part I, Transition from CORE Curriculum to ABOS Part I 215-Day Study Plan a proven method to prepare for ABOS Part I, Use our topic & technique tracking to make sure you've covered and mastered all the reequired topics and procedural skills you'd like to acquire prior to graduation, Create custom subspecialty exams, using Orthobullets and SAE questions, Choose our annual 365-Day study plan to guide your learning, Master all your subspecialty procedures using technique guides and Skillmaster, Use our 5000 question Qbank to prepare for the maintenance of certification exam, which includes both AAOS SAE and Orthobullets questions, Stay up-to-date on the literature and be in sync with your residents using CORE, Earn 100% of your Category 1 PRA MOC and SAE credits, Use our MOC Study plans to guide your study efforts, Simply use our annual CORE Curriculum to stay on top of the literature, Earn 100% of CME and SAE Credits with our MOC study plans, Stay up-to-date with the latest scientific articles. described this phenomenon as akin to a split-depression tibial plateau fracture. Generate ACGME Medical Knowledge levels through testing data, rather than through expensive and inefficient faculty evaluations. Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. based on the number of articular fragments seen on the coronal CT image at the widest point of the posterior facet. The pain is worse after prolonged sitting and after carrying a heavy backpack at school. In our opinion, only then is a resident ready to engage a faculy and have the most productive teaching/learning experience in the OR. (OBQ04.144) 0 0% pdf Classifications in Brief: Sanders Classification of Intraarticular Fractures of the Calcaneus. specific "core" cases that have been through a specific editorial process and have a certain teaching objective. Sanders RW. Take the pain out of ACGME reporting. 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. Increase in type number denotes increasing severity, reflecting an increase in energy imparted to the bone at the time of injury and also an increasingly worse prognosis 1. 0000044467 00000 n Diagnosis is made with plain elbow radiographs. Classification [ edit] See also [ edit] Foot fracture References [ edit] Orthobullets This article about Orthopedic surgery is a stub. "Tested Articles" represent a small subset 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. Enhance your operative skills through Self Mastery Skillmaster tracker, and Technique Guide. Fractures of the Calcaneus: A Review with Emphasis on CT. Radiographics 25: 1215-1226. Currently all cases linked to a topic count as target cases. History. As the number of intraarticular fragments increases, the ability to obtain a satisfactory reduction and achieve a good-to-excellent outcome decreases. Spine Infections, Tumors, & Systemic Conditions. Target Content: Type II fractures are displaced two-part fractures of the posterior facet with one primary fracture line that can be accompanied by one or more accessory fracture lines that do not involve the posterior articular facet. Validity studies have demonstrated improved inter- and intraobserver reliability when the Sanders classification system is used without the subclassification that it was originally described with [6, 9], but this subclassification is one of the key components that makes this system an improvement over earlier classification schemes. 1993;290:87-95. Long-term (1020 years) outcomes reported by Sanders [12] in a subsequent study demonstrated that Type III fractures had a higher risk for subtalar arthrodesis (18 of 38 [47.4%]) compared with Type II fractures (13 of 70 [18.6%]). [9] evaluated reliability using two residents, two foot and ankle fellows, and four fellowship-trained orthopaedic surgeon observers at two different time points. LEVEL OF EVIDENCE: Level III. A 12-year-old female presents with a left thoracic rib prominence. They include: (OBQ18.41) What risk factor is most associated with progression of idiopathic scoliosis to a curve requiring surgery? Their scheme, similar to previous classification systems based on radiographs, divided the entire calcaneus into a total of five possible fragments. evidence, and to think critically. INJURY We recognize some of the AAOS SAE questions are dated and need improvement. (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. - Post - Orthobullets PMID: 30664605 Clin Orthop Relat Res. Target Content: For information on cookies and how you can disable them visit our Privacy and Cookie Policy. 12/11/2019. Level of Evidence III, Diagnostic Studies. A 12-year-old girl who is Risser stage 3 has had intermittent mild midback pain for the past 4 weeks. Click on the Selfmastery wheel for EACH "Tested" article to advance based on scale below. However, we still think they should be taken as they included valuable tested concepts. This work was performed at the University of Kentucky, Lexington, KY, USA. They were the first to correlate clinical outcomes with a CT-based classification scheme [4]. Readers are encouraged to always seek additional information, including FDA approval status, of any drug or device before clinical use. Classification Edit. learn more efficiently by decreasing redundancy in the future. Mastery Trigger: 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. Int Orthop. robert mealy funeral home. Reference: Schatzker, J., et al. Schepers et al. Adduction- tilts medial talus upwards. . and see the relevance in clinical practive. Although widely used since its introduction in 1993, the Sanders classification has several noted limitations. Have never seen surgical "Step" performed. Track and sort subjective comments from comments by faculty in multiple locations. Type IV fractures involve three or more primary fracture lines, resulting in four or more articular fragments with severe comminution (Fig. 10. Identify areas of improvement and track improvement. Most calcaneal fractures are caused by high-energy mechanisms, where concentrated axial loading forces from the heel drive the talus distally into the calcaneus. Currently we only have videos for one procedure posted. Surgeons and clinicians should be aware of the limitations regarding the interobserver and intraobserver reliability for this system. Tracking tools monitor your progress and help you [13] argued that by solely using a lateral surgical approach, one may address both calcaneal articular and body disruptions. Got question incorrect. Abstract. Competency-based Point-of-Care Competency-based Point-of-Care Evaluations for specific skills with well-defined educational objections. This reflects the prognostic value of the classification scheme, because there is good correlation with fracture type and clinical result [1, 13]. Get unlimited access to study plans, including OITE, ABOS, and CORE Curriculum. Bhattacharya R, Vassan UT, Finn P, Port A. Sanders classification of fractures of the os calcis. Mastery Trigger: unless you have done your homework. By continuing to use this website you are giving consent to cookies being used. A competency based surgical skill training & evaluations system that is mobile, user-friendly, and improved technical training. more effectively with tools like highlighting and personal notes. Copyright 2022 Lineage Medical, Inc. All rights reserved. berkeley castle estate. We will do our best to make sure a PDF is provided. The authors also stated that the Sanders ABC subclassification of calcaneal fractures that refers to the location of the primary fracture line was useful for surgical planning but was not prognostic for posterior facet articular reduction nor for restoring the calcaneocuboid joint. J Foot Ankle Surg. An analysis of inter- and intra-observer variability. An MRI showed no spinal cord abnormalities. Shoe Size monitoring. Type I - Minimally displaced / interligamentous. Orthobullets has done the hard work of filtering for the evidence of which you need to be aware. 10/16/2019. The Sanders classification system is specific for intraarticular calcaneal fractures and requires the use of CT images in the coronal plane adjusted to a perpendicular plane to the normal position of the posterior facet of the talus. She has no back pain and no neurologic symptoms. Watched surgical "Step" but not involved. Did surgical "Step" independently and comfortably without supervision. 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. 2014;28:551-563. 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! Perhaps the most widely articulated criticism of the Sander classification is its inconsistent reproducibility among orthopaedic surgeons and other clinicians [18]. 2021, 2021 Orthopaedic Trauma & Fracture Care: Pushing the Envelope, 29th Orthopaedic Trauma - What We Need to Know in 2017, Calcaneal Fractures- What's New? 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. . Open reduction and internal fixation] [in German]. Therefore you are at 20% for trying. Sanders et al. acetabular fracture causes symptoms diagnosis treatment. 7. 5. May 6th, 2018 - The enzyme kinetics page discusses the classification function and regulation of the biochemical catalysts Lippincott Pharmacology Review Collection of best April 29th, 2018 - Books from lippincott series are always the best standard books for medical students Want to learn pharmacology download lippincott pharmacology pdf here Number represents % of total requred Skill Tasks completed. Anatomic articular reduction verified by CT scan at 1 year was greatest for Type II fractures (86%) compared with Type III (60%) and Type IV (0%) fractures. The Sanders classification system is specific for intraarticular calcaneal fractures and requires the use of CT images in the coronal plane adjusted to a perpendicular plane to the normal position of the posterior facet of the talus. Calcaneus fracture classification systems have evolved since Malgaine [10] first described them in 1843, before the advent of roentgenography. We plan on releasing 1-2 Technique Videos per month. Classification Although it appears complicated, it is actually only a four-type classification (odd-numbered types) with each type having a subtype which includes ulnar styloid fracture (these are the even-numbered types): type I: transverse metaphyseal fracture includes both Colles and Smith fractures as angulation is not a feature Mastery Trigger: Click on the Step Selfmastery Tool to advanced based on the scale below. 2014;45:11171120. 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. 2009;48:156-162. A girl who is Risser 4, Sanders 7, with a 30 degree curve. Implement a structured curriculum including daily emails reviewing 500+ topics, daily key scientific articles, and monthly diagnostic Milestone exams. The posteroanterior radiograph (Figure A ) taken at that time reveals a right thoracic curve measures 28 degrees, and the left lumbar curve measures 23 degrees. Make sure residents reach their ACGME Patient Target levels through our competency-based skill tracking and evaluation system. Prepare for surgical skills by reading the basic outline of the skill steps 1. 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]. An isolated long-segment instrumented posterior spinal fusion is considered in which of the following clinical situations? We know surgeons can teach themselves most surgical skills by passive observation and trying on their own. As a junior resident you should focus on presentation and nonoperative treatment. Read full article briefly with focus on Discussion and Conclusion. All of the following should be performed as part of her evaluation EXCEPT: (SBQ09SP.17) 1952;39:395-419. This classification scheme uses the ABC classification regularly used for long bone fractures, which is organized into three hierarchical types with 27 subgroups. 15. Lauder et al. Target Content: Figure A shows her radiograph with a 32 curve. Lines A and B separate the calcaneus into medial, central and lateral columns. DeFi For You is a peer-to-peer platform where you can loan against NFTs and. (2012). The French surgeon described two types of fracture mechanisms: an avulsion injury resulting from muscular pull and a crushing injury. Fracture Classification System Zone 1: Avulsion or "Pseudo-Jones" fracture Proximal tubercle (rarely enters 5th tarsometatarsal joint) Caused when bony fragment is detached by ligament or other connective tissue Typically long plantar ligament, lateral band of plantar fascia, or contraction of peroneus brevis Zone 2: Jones fracture therefore, whenever possible, avoid fusion to L4 and L5, it is almost never required to fuse to the pelvis in idiopathic scoliosis, screw insertional torque correlates with resistance to screw pullout, segmental pedicle screw fixation allows increased coronal plane correction while lessening the need for anterior releases, better correction while saving lumbar fusion levels, increased risk of pseudarthrosis when thoracic hyperkyphosis is present, typically fuse from end vertebra to end vertebra, monitoring with somatosensory-evoked potentials (SSEPs) and/or motor-evoked potentials (MEPs) is now the standard of care, motor-evoked potentials can provide an intraoperative warning of impending spinal cord dysfunction, neurologic event defined as drop in amplitude of > 50%, if neurologic injury occurs intraoperatively consider, check hemoglobin and transfuse as necessary, remove instrumentation if the spine is stable, increased risk with kyphosis, excessive correction, and sublaminar wires, presents as late pain, deformity progression, and hardware failure, an asymptomatic pseudarthrosis with no pain and no loss of correction should be observed, attempt I&D with maintenance of hardware if not loose and within 6 months, early fatigability and back pain due to loss of lumbar lordosis, rare now that segmental instrumentation addresses sagittal plane deformities, decreased incidence with rod contouring in the sagittal plane and compression/distraction techniques, treat with revision surgery utilizing posterior closing wedge osteotomies, anterior releases prior to osteotomies aid in maintenance of correction, rotational deformity of the spine created by continued anterior spinal growth in the setting of a posterior spinal fusion, can occur in very young patients when PSF is performed alone and the anterior column is allowed continued growth, avoided by performing anterior diskectomy and fusion with posterior fusion in very young patients, compression of 3rd part of duodenum due to narrowing of the space between SMA and aorta, SMA arises from anterior aspect of aorta at level of L1 vertebrae, presents with symptoms of bowel obstruction in first postoperative week, associated with electrolyte abnormalities, height percentile <50%; weight percentile < 25%, late rod breakage can signify a pseudarthrosis, increased incidence of acute and chronic pain in adults if left untreated, curves > 90 are associated with cardiopulmonary dysfunction, early death, pain, and decreased self image. 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