Transient Synovitis of the Hip
- 1 Other Names
- 2 Background
- 3 Pathophysiology
- 4 Risk Factors
- 5 Differential Diagnosis
- 6 Clinical Features
- 7 Evaluation
- 8 Classification
- 9 Management
- 10 Rehab and Return to Play
- 11 Complications
- 12 See Also
- 13 References
- Transient Synovitis
- Transitory Coxitis
- Acute Transient Epiphysitis
- Coxitis Fugax
- Coxitis Serosa Seu Simplex
- Phantom Hip Disease
- Toxic Synovitis
- Observation Hip
- This page describes Transient Synovitis (TS) of the Hip Joint, a benign, self-limited condition affecting children
- The diagnosis is one of exclusion, especially after ruling out Septic Arthritis
- First characterized by Lovett in 1892
- Annual incidence estimated at about 0.2%
- Lifetime risk is roughly 3%
- Risk of recurrence or relapse is estimated to be about 4%
- Most commonly seen between ages 3 and 8
- In a Netherlands cohort, the mean age was 4.7
- Note there are case reports in adults
- More common in males, with a a male:female ratio range from 1.7-2.8:1
- Bilateral involvement has been described, estimated incidence is 1-4% of cases
- Pathophysiology remains largely unknown but typically thought to be viral
- Viral Infection
- Kastrissianakis et al found patients with TS more likely to have preceding viral symptoms of vomiting and diarrhea or upper respiratory infection
- Leibowitz et al found patients with TS have higher interferon concentrations and are more likely to be in an anti-viral state
- Direct links to specific viral candidates (parvovirus B-19 and human herpes simplex virus-6) have been unsuccessful
- Other proposed etiologies
- Hypersensitivity/ Allergic Reaction
- Bacterial Infection
- Fractures And Dislocations
- Muscle and Tendon Injuries
- Ligament Injuries
- Pediatric Pathology
- Transient Synovitis of the Hip
- Developmental Dysplasia of the Hip (DDH)
- Legg-Calve-Perthes Disease
- Slipped Capital Femoral Epiphysis (SCFE)
- Avulsion Fractures of the Ilium (Iliac Crest, ASIS, AIIS)
- Ischial Tuberostiy Avulsion Fracture
- Avulsion Fractures of the Trochanters (Greater, Lesser)
- Apophysitis of the Ilium (Iliac Crest, ASIS, AIIS)
- Typically acute onset of groin or thigh pain
- Unwillingness to bear weight, +/- a limp
- ROM limited
- It's important to inquire about any preceding upper respiratory, gastrointestinal, genitourinary symptoms or recent trauma
- Physical Exam: Physical Exam Hip
- Resting position or position of comfort may be slight flexion, abduction and external rotation
- Special Tests
- Algorithm from Kocher et al for predicting probability of septic arthritis
- 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
- Other studies have failed to reproduce these findings
- Plain Radiographs Hip
- Typically normal
- Exclude other causes of hip pain
- May show
- Widening of the medial joint space
- Rapidly able to evaluate joint space
- Helpful to distinguish TS from septic arthritis
- MRI with IV contrast has a NPD of 88.9%
- 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
- Findings supporting TS
- Contralateral joint effusion
- Has been used and suggested
- Limited applicability in the diagnosis of TS
- If there is an effusion present, consider Hip Arthrocentesis under US guidance
- Findings that support septic arthritis
- WBC > 50 x10^9/L
- Positive gram stain
- Not applicable
- 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
- 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
- There are case reports for refractory cases
- Arthroscopic debridement
Rehab and Return to Play
- No specific rehabilitation is typically required
Return to Play
- When asymptomatic and able to run pain free
- Legg-Calve-Perthes Disease
- Sports Medicine Review Hip Pain: https://www.sportsmedreview.com/by-joint/hip/
- ↑ Lovett RW, Morse JL. Transient or ephemeral form of hip-disease, with a report of cases. Boston Med Surg J 1892; 127:161–163.
- ↑ 2.0 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.
- ↑ 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.
- ↑ 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.
- ↑ Fischer SU, Beattie TF. The limping child: epidemiology, assessment, and outcome. J Bone Joint Surg Br 1999; 81:1029–1034.
- ↑ 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.
- ↑ Kastrissianakis K, Beattie TF. Transient synovitis of the hip: more evidence for a viral aetiology. Eur J Emerg Med 2010; 17:270–273.
- ↑ Leibowitz E, Levin S, Torten J, Meyer R. Interferon system in acute transient synovitis. Arch Dis Child 1985; 60:959–962.
- ↑ 9.0 9.1 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.
- ↑ 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.
- ↑ 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.
- ↑ 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
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ Connolly LP, Connolly SA. Skeletal scintigraphy in the multimodal assessment of young children with acute skeletal symptoms. Clin Nucl Med 2003; 28:746–754.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
John Kiel on 23 September 2020 23:17:35
5 October 2022 13:10:15
Lower Extremity | Pediatrics | Hip | Acute