What to assess and document

1. Clarify basic history
   • Exact age, birth history, developmental milestones
   • Onset and progression of spinal curve
   • Previous spine radiographs, Cobb angle, MRI, brace/cast treatment
   • Family history, syndromic features, prior cardiac/renal investigations
2. Bedside inspection
   • Supine/prone only if PICU team considers it safe.
   • Curve location and direction: thoracic, thoracolumbar, lumbar; left versus right.
   • Trunk shift, shoulder/pelvic asymmetry, rib prominence, truncal shortening.
   • Skin markers of occult dysraphism: midline hairy patch, deep sacral dimple, hemangioma, lipoma, sinus.
   • Chest wall/rib anomalies, especially fused or absent ribs.
   • Dysmorphism or signs of syndromic/neuromuscular disease.
3. Neurologic examination
   • Spontaneous symmetric movement of all limbs, tone, power where feasible.
   • Deep tendon reflexes, plantar responses, clonus.
   • Sensory response if assessable.
   • Perineal/sacral function and bowel/bladder history when clinically appropriate.
   • Look specifically for signs of tethered cord, syrinx, or other neural-axis pathology.
4. Musculoskeletal examination
   • Neck motion and torticollis.
   • Hip abduction and instability, limb lengths, foot deformities.
   • Contractures, joint laxity, muscle wasting or spasticity.
   • If the child is stable enough, assess flexibility of the curve gently. Do not force correction.
5. Review imaging rather than repeat imaging now
   • AP and lateral whole-spine radiographs, preferably prior films, for:
     • Cobb angle and serial progression
     • Vertebral formation/segmentation defects, hemivertebra, unsegmented bar
     • Rib anomalies
     • Sagittal alignment
   • In true infantile idiopathic scoliosis, assess Mehta rib-vertebral angle difference (RVAD) on the AP film. An RVAD below 20 degrees tends to be associated with resolving curves, whereas a larger value suggests higher progression risk. Campbell notes that infantile idiopathic scoliosis occurs before age 3 and many curves resolve, but progressive curves can rapidly deform the thorax and impair pulmonary function. Campbell's Operative Orthopaedics, 15th ed., lines 6245-6265, 6275-6287.
   • If congenital scoliosis is suspected, check if a whole-spine MRI has been done, once medically stable. Neural-axis anomalies are common even with a normal clinical neurologic exam. POSNA congenital scoliosis guidance recommends MRI as part of initial assessment in congenital scoliosis.
6. Associated-system work-up
   • Because congenital vertebral defects can coexist with other anomalies, confirm:
     • Echocardiography/cardiology evaluation, already highly relevant here due to cyanotic CHD
     • Renal ultrasonography and renal function
     • Genetic/pediatric review if dysmorphic, syndromic, or multiple congenital anomalies are present.

Suggested orthopedic opinion for this referral

Child with early-onset scoliosis, currently medically unstable/ill with cyanotic CHD and pneumonia. Bedside examination should document curve pattern, congenital vertebral/rib anomalies, cutaneous dysraphism markers, and neurologic status. No acute orthopedic intervention is indicated during active pneumonia/PICU care unless there is neurologic deterioration or another urgent musculoskeletal issue. Review prior whole-spine AP/lateral radiographs for Cobb angle, vertebral morphology and progression; obtain/plan full-spine MRI after cardiopulmonary stabilization if congenital or progressive scoliosis is suspected. Arrange serial pediatric spine follow-up.

Escalate urgently if present

• New weakness, asymmetric limb movement, hyperreflexia/clonus, or bowel/bladder dysfunction
• Severe rigid kyphosis, rapidly progressing deformity, or suspected spinal infection
• Evidence of respiratory restriction attributable to major thoracic deformity, though the immediate respiratory problem here is likely dominated by pneumonia and cyanotic heart disease.