Musculoskeletal conditions are seen commonly in the family physician’s office. This edition of FP EssentialsTM will address four musculoskeletal conditions in children: foot deformities, scoliosis, overuse injuries, and juvenile idiopathic arthritis.
The FP EssentialsTM monograph should be approximately 10,000 words in length, divided into four sections of approximately 2,500 words each, plus a preface, key practice recommendations, a maximum of 15 tables and figures, recommended readings, and references. The monograph should focus on what’s new in each topic and should answer the key questions listed for each section. Each section should begin with an illustrative case, similar to the examples provided, with modifications to emphasize key points. The references listed below include information that should be considered in preparation of this edition of FP EssentialsTM. However, these references are only a useful starting point that should be used to identify additional information to review.
Musculoskeletal Conditions in Children
Section One: Foot Deformities: Current Concepts in Diagnosis and Management of Clubfoot and Intoeing
Example case: You are performing a newborn examination of a 1-day-old girl in the hospital with the mother present. The mother’s prenatal course was normal and the infant was delivered at term without complications. The mother’s only concern is that the newborn’s feet are turned in.
Key questions to consider:
Key questions to consider:
- What are the differences among metatarsus adductus, metatarsus varus, and clubfoot?
- How are metatarsus adductus and varus initially managed? What are the typical prognoses for each of these? When is treatment initiated and how long is treatment typically required?
- How is clubfoot initially managed? What conservative (nonsurgical) treatments are available for clubfoot? How effective is conservative therapy?
- What is the Ponseti method? What are the advantages of this method compared to traditional methods?
- What are the indications for surgery for clubfoot? How effective are the surgical therapies?
- What conditions cause intoeing after the neonatal period? At what ages are you most likely to see internal tibial torsion and increased femoral anteversion? How are these managed? What are the typical prognoses for each of these?
Initial references to consider:
- Abbas M, Qureshi OA, Jeelani LZ, et al. Management of congenital talipes equinovarus by Ponseti technique: a clinical study. J Foot Ankle Surg. 2008;47(6):541-545.
- Cosma D, Vasilescu D, Vasilescu D, et al. Comparative results of the conservative treatment in clubfoot by two different protocols. J Pediatr Orthop B. 2007;16(5):317-321.
- Sass P, Hassan G. Lower extremity abnormalities in children. Am Fam Physician. 2003;68(3):461-468. Erratum in Am Fam Physician. 2004;69(5):1049.
Section Two: Scoliosis Update
Example case: Allison, a 12-year-old girl, is brought to your office by her mother Wendy for a well-child evaluation. Wendy says Allison’s back seems to be uneven. Allison does not have back pain and is otherwise well. Her examination is normal except for back asymmetry noted on a forward flexion test. X-rays reveal a 35-degree lateral curvature of the spine.
Key questions to consider:
Key questions to consider:
- Are there effective screening strategies for scoliosis, and is screening recommended?
- How is scoliosis diagnosed?
- What are the treatment options for scoliosis? How do these options vary based on the degree of spinal curvature and patient age at diagnosis?
- What activities/exercise are encouraged or should be avoided in children with scoliosis?
- What are the advantages and disadvantages of continuous versus part-time bracing?
- When should children be referred for surgical treatment? What types of surgery currently are used?
- What can children and their families expect as typical outcomes of treatment?
Initial references to consider:
- McIntire KL, Asher MA, Burton DC, et al. Treatment of adolescent idiopathic scoliosis with quantified trunk rotational strength training: a pilot study. J Spinal Disord Tech. 2008;21(5):349-358.
- Negrini S, Zaina F, Romano M, et al. Specific exercises reduce brace prescription in adolescent idiopathic scoliosis: a prospective controlled cohort study with worst-case analysis. J Rehabil Med. 2008;40(6):451-455.
- Grivas TB, Rodopoulos GI, Bardakos NV. Night-time braces for treatment of adolescent idiopathic scoliosis. Disabil Rehabil Assist Technol. 2008;3(3):120-129.
- Weiss HR. Adolescent idiopathic scoliosis (AIS)—an indication for surgery? A systematic review of the literature. Disabil Rehabil. 2008;30(10):799-807.
- Maruyama T. Bracing adolescent idiopathic scoliosis: a systematic review of the literature of effective conservative treatment looking for end results 5 years after weaning. Disabil Rehabil. 2008;30(10):786-91.
- Negrini S, Fusco C, Minozzi S, et al. Exercises reduce the progression rate of adolescent idiopathic scoliosis: results of a comprehensive systematic review of the literature. Disabil Rehabil. 2008;30(10):772-785.
- Torre-Healy A, Samdani AF. Newer technologies for the treatment of scoliosis in the growing spine. Neurosurg Clin N Am. 2007;18(4):697-705.
- Danielsson AJ, Hasserius R, Ohlin A, et al. A prospective study of brace treatment versus observation alone in adolescent idiopathic scoliosis: a follow-up mean of 16 years after maturity. Spine (Phila Pa 1976). 2007;32(20):2198-2207.
Section Three: Common Overuse Injuries in Children and Adolescent Athletes
Example case: Eric, a 14-year-old boy, is brought to your office by his father Jim after the summer baseball season for elbow pain. The pain began several months ago and gradually increased throughout the season. Eric began pitching at age 11 years and throws 180 pitches/week. This season he has been practicing throwing curve balls.
Key questions to consider:
Key questions to consider:
- What are the differences in the skeletal structure of children compared with adults? How do those differences affect overuse injuries in children and adolescents?
- What are the most common overuse injuries seen in children and adolescents who participate in athletics?
- What activities are associated with overuse injuries of the shoulder or elbow? What are little leaguer’s shoulder and little leaguer’s elbow? At what age do these overuse injuries typically occur?
- What activities are associated with overuse injuries of the back? At what age do these overuse injuries typically occur?
- What activities are associated with Osgood-Schlatter disease? At what age do these injuries typically occur?
- What imaging studies are useful in the diagnosis of overuse injuries?
- What therapeutic strategies are recommended to manage overuse injuries?
- What strategies are effective in preventing or reducing overuse injuries?
- When can an activity be resumed by a child or adolescent with an overuse injury?
Initial references to consider:
- Soligard T, Myklebust G, Steffen K, et al. Comprehensive warm-up programme to prevent injuries in young female footballers: cluster randomised controlled trial. BMJ. 2008;337:a2469.
- Bloom OJ, Mackler L, Barbee J. Clinical inquiries. What is the best treatment for Osgood-Schlatter disease? J Fam Pract. 2004;53(2):153-156.
- Blankstein A, Cohen I, Heim M, et al. Ultrasonography as a diagnostic modality in Osgood-Schlatter disease. A clinical study and review of the literature. Arch Orthop Trauma Surg. 2001;121(9):536-539.
- Klingele KE, Kocher MS. Little league elbow: valgus overload injury in the paediatric athlete. Sports Med. 2002;32(15):1005-1015.
- Klein G, Mehlman CT, McCarty M. Nonoperative treatment of spondylolysis and grade I spondylolisthesis in children and young adults: a meta-analysis of observational studies. J Pediatr Orthop. 2009;29(2):146-156.
- Sanpera I Jr, Beguiristain-Gurpide JL. Bone scan as a screening tool in children and adolescents with back pain. J Pediatr Orthop. 2006;26(2):221-225.
Section Four: Juvenile Idiopathic Arthritis
Example case: Rebecca, a 16-year-old girl, is new to your practice. You learn from her medical history that she had juvenile arthritis. She was treated by an arthritis subspecialist from age 8 to 14 years. Her family moved and did not establish care for her in this area. She has not had many problems and she tells you she does not have arthritis anymore.
Key questions to consider:
Key questions to consider:
- What is juvenile idiopathic arthritis (JIA)? What are the differences between this new classification and the old nomenclature of juvenile rheumatoid arthritis (JRA)?
- What are the current diagnostic criteria for different types of JIA? What are the common presenting signs and symptoms? Are laboratory or imaging studies helpful in making the diagnosis?
- What is the typical disease course for children with JIA? How is the severity of JIA determined and monitored? How often does JIA persist into adulthood? What are important issues as patients grow from childhood into adulthood?
- Which subspecialists and healthcare team members will family physicians work with in caring for patients with JIA?
- When in the course of JIA are drugs started? What drugs are being used clinically for JIA (methotrexate, etanercept [Enbrel], adalimumab [Humira], infliximab [Remicade], anakinra [Kineret], and others)? What are the side effects, drug interactions, contraindications, and costs of these drugs?
- What exercise recommendations are appropriate for children with JIA?
- In addition to the joints, what other systems are affected by JIA? Is any routine surveillance recommended for children with JIA?
- What effects on the parents/family of a child with a chronic illness, such as JIA, should be anticipated and addressed? What effects on the child should be anticipated and addressed?
Initial references to consider:
- Oen K, Tucker L, Huber AM, et al. Predictors of early inactive disease in a juvenile idiopathic arthritis cohort: results of a Canadian multicenter, prospective inception cohort study. Arthritis Rheum. 2009;61(8):1077-1086.
- Andrews NR, Chaney JM, Mullins LL, et al. The differential effect of child age on the illness intrusiveness—parent distress relationship in juvenile rheumatic disease. Rehabil Psychol. 2009;54(1):45-50.
- Prince FH, Geerdink LM, Borsboom GJ, et al. Major improvements in health-related quality of life during the use of etanercept in patients with previously refractory juvenile idiopathic arthritis. Ann Rheum Dis. 2009 Jul 5. [Epub ahead of print]
- Marvillet I, Terrada C, Quartier P, et al. Ocular threat in juvenile idiopathic arthritis. Joint Bone Spine. 2009;76(4):383-388.
- Geerdink LM, Prince FH, Looman CW, et al. Development of a digital Childhood Health Assessment Questionnaire for systematic monitoring of disease activity in daily practice. Rheumatology (Oxford). 2009;48(8):958-963.
- Halbig M, Horneff G. Improvement of functional ability in children with juvenile idiopathic arthritis by treatment with etanercept. Rheumatol Int. 2009 May 16. [Epub ahead of print]
- Russo RA, Katsicas MM. Clinical remission in patients with systemic juvenile idiopathic arthritis treated with anti-tumor necrosis factor agents. J Rheumatol. 2009;36(5):1078-1082.
- de Avila Lima Souza L, Gallinaro AL, Abdo CH, et al. Effect of musculoskeletal pain on sexuality of male adolescents and adults with juvenile idiopathic arthritis. J Rheumatol. 2009;36(6):1337-1342.
- Ringold S, Wallace CA, Rivara FP. Health-related quality of life, physical function, fatigue, and disease activity in children with established polyarticular juvenile idiopathic arthritis. J Rheumatol. 2009;36(6):1330-1336.
- Ruperto N, Lovell DJ, Cuttica R, et al. Long-term efficacy and safety of infliximab plus methotrexate for the treatment of polyarticular course juvenile rheumatoid arthritis: findings from an open-label treatment extension. Ann Rheum Dis. 2009 Apr 29. [Epub ahead of print]
- Consolaro A, Ruperto N, Bazso A, et al. Development and validation of a composite disease activity score for juvenile idiopathic arthritis. Arthritis Rheum. 2009;61(5):658-666.
- Cavallo S, Feldman DE, Swaine B, et al. Is parental coping associated with quality of life in juvenile idiopathic arthritis? Pediatr Rheumatol Online J. 2009;7:7.
FP Essentials™ Requests for Proposals
Musculoskeletal Conditions in Children
