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Transient Synovitis of the Hip

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Other Names

  • Transient Synovitis
  • Transitory Coxitis
  • Acute Transient Epiphysitis
  • Coxitis Fugax
  • Coxitis Serosa Seu Simplex
  • Phantom Hip Disease
  • Toxic Synovitis
  • Observation Hip

Background

  • This page describes Transient Synovitis (TS) of the Hip Joint, a benign, self-limited condition affecting children

History

  • First characterized by Lovett in 1892[1]

Epidemiology

  • Annual incidence estimated at about 0.2%[2]
    • Lifetime risk is roughly 3%
    • Risk of recurrence or relapse is estimated to be about 4%
  • Most commonly seen between ages 3 and 8[3]
    • In a Netherlands cohort, the mean age was 4.7[4]
    • Note there are case reports in adults
  • More common in males, with a a male:female ratio range from 1.7-2.8:1[5]
  • Bilateral involvement has been described, estimated incidence is 1-4% of cases[6]

Introduction

Illustration of transient synovitis of the hip[7]

General

  • Transient Synovitis (TS) a benign, self-limited condition affecting the hip joint
  • It is a common cause of hip pain in children
  • Diagnosis is one of exclusion, especially after ruling out Septic Arthritis
  • Pathophysiology remains largely unknown but typically thought to be viral
  • Treatment is mostly symptomatic with NSAIDS and observation

Etiology

  • The etiology of TS has not been clearly established
  • Viral Infection
    • Kastrissianakis et al found patients with TS more likely to have preceding viral symptoms of vomiting and diarrhea or upper respiratory infection[8]
    • Leibowitz et al found patients with TS have higher interferon concentrations and are more likely to be in an anti-viral state[9]
    • Direct links to specific viral candidates (parvovirus B-19 and human herpes simplex virus-6) have been unsuccessful
  • Other proposed etiologies
    • Trauma
    • Hypersensitivity/ Allergic Reaction
    • Bacterial Infection

Recurrence

  • Annual incidence of relapse is approximately 4%[10]
    • This is 20 fold increased risk over the general population

Risk Factors

  • Unknown

Differential Diagnosis

Differential Diagnosis Hip Pain

Clinical Features

Demonstration of the log roll test[11]

History

  • Typically acute onset of groin or thigh pain
  • Acute unwillingness to bear weight, +/- a limp
  • ROM limited
  • It's important to inquire about any preceding upper respiratory, gastrointestinal, genitourinary symptoms or recent trauma
  • Fever can be mildly present/ absent
  • Absence of trauma

Physical Exam: Physical Exam Hip

  • Child is typically not toxic appearing
  • Resting position or position of comfort may be slight flexion, abduction and external rotation[12]
  • Particularly sensitive to internal rotation
  • Normal exam of the ipsilateral knee and lower spine

Special Tests

Evaluation

Long axis sonogram of the hip demonstrates a distended joint capsule separated by an anechoic effusion[13]
MR images of a 7-year-old boy with transient synovitis of the right hip. a Coronal T2-W image shows grade 3 joint effusion without SI alteration of the bone marrow of the right hip. Grade 1 joint effusion is seen in the contralateral hip. b Coronal fat- suppressed, gadolinium-enhanced, T1-W SE image shows clear differentiation of an enhancing rim of the inflamed synovial membrane (arrows)[14]

Kocher Criteria

  • Algorithm from Kocher et al for predicting probability of septic arthritis[15]
    • Fever (Temp > 38.5°C)
    • Inability to bear weight
    • ESR > 40 mm/h
    • WBC > 12 x 10^6 cells/L
    • This PPV based on the presence of 1, 2, 3 and 4 criteria is 3.0, 40.0, 93.1 and 99.6%, respectively
  • CRP > 1 mg/dl (C-reactive protein ) has also been subsequently added to this algorithm
    • Caird et al: presence of 3, 4 and 5 factors PPV found to be 83, 93 and 98%, respectively[16]
  • Other studies have failed to reproduce these findings[17]
    • In children, Fever (Temp > 38.5°C) followed by elevated CRP were found to be the most significant predictors[18]
    • Singhal et al found CRP > 20 mg/dl was the strongest independent risk factor for septic arthritis[19]

Radiographs

  • Plain Radiographs Hip
    • Typically normal
    • Exclude other causes of hip pain
  • May show
    • Widening of the medial joint space

Ultrasound

  • Rapidly able to evaluate joint space
    • Can reliably exclude/include the presence of an effusion[20]
    • It has been suggested that an absence of a joint effusion excludes septic arthritis
    • Note that Zamzam et al found several cases of false-negative US studies that delayed care in their patient population[21]

MRI

  • Helpful to distinguish TS from septic arthritis
    • MRI with IV contrast has a NPD of 88.9%[22]
  • Findings supporting septic arthritis
    • Signal intensity abnormalities in the bone marrow
    • Decreased perfusion at the femoral epiphysis on fat suppressed gadolinium-enhanced coronal T-weighted images[23]
  • Findings supporting TS
    • Contralateral joint effusion

Bone Scintography

  • Has been used and suggested
  • Limited applicability in the diagnosis of TS[24]

Hip Arthrocentesis

  • If there is an effusion present, consider ultrasound guided arthrocentesis
  • Findings that support septic arthritis
    • WBC > 50 x10^9/L
    • Positive gram stain

Classification

  • Not applicable

Management

Nonoperative

  • Observation
  • Rest
  • NSAIDS
    • Kermond et al in an RCT found Ibuprofen reduced duration of symptoms from 4.5 days to 2 days[25]
  • Hip Arthrocentesis
    • In addition to diagnostic value, fluid aspiration has a therapeutic/ palliative effect
    • Wingstrand et al noted effusion recurred in 1 day in 11/13 patients[12]

Operative

  • Indications
    • There are case reports for refractory cases[26]
  • Technique
    • Arthroscopic debridement

Rehab and Return to Play

Rehabilitation

  • No specific rehabilitation is typically required

Return to Play

  • When asymptomatic and able to run pain free

Prognosis and Complications

Prognosis

  • TS is a self limited condition that resolves spontaneously
    • Typically in 3-10 days without any specific treatment
  • In patients with previous diagnosis of TS, recurrence remains a risk
    • Uziel et al found recurrence risk was 69, 13 and 18% in years 1, 2 and 3 following the initial diagnosis[27]

Complications

  • Legg-Calve-Perthes Disease
    • Incidence is up to 3% following an episode of TS[2], in general population it is 0.9/100,000 patients
    • Mukamel et al combined data from 10 studies and also found an increased risk[28]
    • Kallio et al was not able to reproduce these findings[29]

See Also

Internal

External

References

  1. ↑ Lovett RW, Morse JL. Transient or ephemeral form of hip-disease, with a report of cases. Boston Med Surg J 1892; 127:161–163.
  2. ↑ 2.0 2.1 Landin LA, Danielsson LG, Wattsga° rd C. Transient synovitis of the hip. Its incidence, epidemiology and relation to Perthes’ disease. J Bone Joint Surg Br 1987; 69:238–242.
  3. ↑ Baskett A, Hosking J, Aickin R. Hip radiography for the investigation of nontraumatic short duration hip pain presenting to a children’s emergency department. Pediatr Emerg Care 2009; 25:78–82.
  4. ↑ Krul M, van der Wouden JC, Schellevis FG, van Suijlekom-Smit LW, Koes BW. Acute non-traumatic hip pathology in children: incidence and presentation in family practice. Fam Pract 2010; 27:166–170.
  5. ↑ Fischer SU, Beattie TF. The limping child: epidemiology, assessment, and outcome. J Bone Joint Surg Br 1999; 81:1029–1034.
  6. ↑ Ehrendorfer S, LeQuesne G, Penta M, Smith P, Cundy P. Bilateral synovitis in symptomatic unilateral transient synovitis of the hip: an ultrasonographic study in 56 children. Acta Orthop Scand 1996; 67:149–152.
  7. ↑ Image courtesy of hip-knee.com
  8. ↑ Kastrissianakis K, Beattie TF. Transient synovitis of the hip: more evidence for a viral aetiology. Eur J Emerg Med 2010; 17:270–273.
  9. ↑ Leibowitz E, Levin S, Torten J, Meyer R. Interferon system in acute transient synovitis. Arch Dis Child 1985; 60:959–962.
  10. ↑ Landin, LENNART A., LARS G. Danielsson, and C. E. C. I. L. I. A. Wattsgard. "Transient synovitis of the hip. Its incidence, epidemiology and relation to Perthes' disease." The Journal of Bone & Joint Surgery British Volume 69.2 (1987): 238-242.
  11. ↑ Wilson, John J., and Masaru Furukawa. "Evaluation of the patient with hip pain." American family physician 89.1 (2014): 27-34.
  12. ↑ 12.0 12.1 Wingstrand H, Egund N, Carlin NO, Forsberg L, Gustafson T, Sunde´n G. Intracapsular pressure in transient synovitis of the hip. Acta Orthop Scand 1985; 56:204–210.
  13. ↑ Pauroso, S., et al. "Transient synovitis of the hip: Ultrasound appearance. Mini-pictorial essay." Journal of Ultrasound 14.2 (2011): 92-94.
  14. ↑ Yang, Wan Jik, et al. "MR imaging of transient synovitis: differentiation from septic arthritis." Pediatric radiology 36 (2006): 1154-1158.
  15. ↑ Kocher MS, Zurakowski D, Kasser JR. Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence based clinical prediction algorithm. J Bone Joint Surg Am 1999; 81:1662–1670.
  16. ↑ Caird MS, Flynn JM, Leung YL, Millman JE, D’Italia JG, Dormans JP. Factors distinguishing septic arthritis from transient synovitis of the hip in children. A prospective study. J Bone Joint Surg Am 2006; 88:1251–1257.
  17. ↑ Luhmann SJ, Jones A, Schootman M, Gordon JE, Schoenecker PL, Luhmann JD. Differentiation between septic arthritis and transient synovitis of the hip in children with clinical prediction algorithms. J Bone Joint Surg Am 2004; 86-A:956–962
  18. ↑ Sultan J, Hughes PJ. Septic arthritis or transient synovitis of the hip in children: the value of clinical prediction algorithms. J Bone Joint Surg Br 2010; 92:1289–1293.
  19. ↑ Singhal R, Perry DC, Khan FN, Cohen D, Stevenson HL, James LA, et al. The use of CRP within a clinical prediction algorithm for the differentiation of septic arthritis and transient synovitis in children. J Bone Joint Surg Br 2011; 93:1556–1561.
  20. ↑ Yabunaka K, Ohue M, Morimoto N, Kitano N, Shinohara K, Takamura M, et al. Sonographic measurement of transient synovitis in children: diagnostic value of joint effusion. Radiol Phys Technol 2012; 5:15–19.
  21. ↑ Zamzam MM. The role of ultrasound in differentiating septic arthritis from transient synovitis of the hip in children. J Pediatr Orthop B 2006; 15: 418–422.
  22. ↑ Kim EY, Kwack KS, Cho JH, Lee DH, Yoon SH. Usefulness of dynamic contrast-enhanced MRI in differentiating between septic arthritis and transient synovitis in the hip joint. Am J Roentgenol 2012; 198:428–433.
  23. ↑ Kwack KS, Cho JH, Lee JH, Cho JH, Oh KK, Kim SY. Septic arthritis versus transient synovitis of the hip: gadolinium enhanced MRI finding of decreased perfusion at the femoral epiphysis. Am J Roentgenol 2007; 189:437–445.
  24. ↑ Connolly LP, Connolly SA. Skeletal scintigraphy in the multimodal assessment of young children with acute skeletal symptoms. Clin Nucl Med 2003; 28:746–754.
  25. ↑ Kermond S, Fink M, Graham K, Carlin JB, Barnett P. A randomized clinical trial: should the child with transient synovitis of the hip be treated with nonsteroidal anti-inflammatory drugs? Ann Emerg Med 2002; 40:294–299.
  26. ↑ Shetty VD, Shetty GM. Arthroscopic view of transient synovitis of the hip joint: a case report. Knee Surg Sports Traumatol Arthrosc 2009; 17: 1003–1005.
  27. ↑ Uziel Y, Butbul-Aviel Y, Barash J, Padeh S, Mukamel M, Gorodnitski N, et al. Recurrent transient synovitis of the hip in childhood. Long term outcome among 39 patients. J Rheumatol 2006; 33:810–811.
  28. ↑ Mukamel M, Litmanovitch M, Yosipovich Z, Grunebaum M, Varsano I. Legg–Calve–Perthes disease following transient synovitis. How often? Clin Pediatr (Phila) 1985; 24:629–631.
  29. ↑ Kallio P, Ryo¨ ppy S, Kunnamo I. Transient synovitis and Perthes’ disease. Is there an aetiological connection? J Bone Joint Surg Br 1986; 68:808–811.
Created by:
John Kiel on 23 September 2020 23:17:35
Authors:
Last edited:
12 May 2025 17:34:27
Categories:
Lower Extremity | Pediatrics | Groin | Hip | Acute
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