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Hip Transient Synovitis

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Ovid: 5-Minute Orthopaedic Consult

Editors: Frassica, Frank J.; Sponseller, Paul D.; Wilckens, John H.
Title: 5-Minute Orthopaedic Consult, 2nd Edition
> Table of Contents > Hip Transient Synovitis

Hip Transient Synovitis
Paul D. Sponseller MD
Basics
Description
  • Transient synovitis is characterized by the acute onset of monarticular hip pain, limp, and restricted hip motion.
  • It must be distinguished from septic arthritis.
  • Gradual but complete resolution over several days to weeks is the norm.
  • Synonyms: Toxic synovitis; Irritable hip
Epidemiology
  • Transient synovitis is the most common cause of hip pain in children.
  • It is a diagnosis of exclusion.
  • Transient synovitis of the hip can occur from 9 months of age to adolescence; most cases occur in children 3–8 years old (1–3).
  • The risk of a child having at least 1 episode of transient synovitis of the hip is 1–3% (3).
    • This risk is 3 times greater in patients with a stocky or obese physique (3).
  • Right and left involvement is essentially equal; concurrent bilateral involvement has not been reported.
  • Male:Female ratio is 2:1.
Incidence
  • Transient synovitis accounts for 0.5% of annual pediatric orthopaedic admissions (1).
  • The incidence is much lower among African Americans (2).
Risk Factors
  • Male gender
  • Upper respiratory infection or other active infection
Genetics
This condition is not genetic.
Etiology
  • The true cause is unknown; it appears to be an immune-mediated inflammation, not an infection.
  • It has been proposed that transient
    synovitis of the hip may be associated with active infection elsewhere,
    trauma, or allergic hypersensitivity (1,3).
  • Nonspecific upper respiratory infection,
    pharyngitis, and otitis media have been associated with the occurrence
    of transient synovitis in as many as 70% of cases (1,2).
  • An association is noted with minor trauma in up to 30%, and with allergic predisposition in up to 25% (3).
Associated Conditions
Legg-Calvé-Perthes disease (~1.5%) (3)
Diagnosis
Signs and Symptoms
  • An acute onset of unilateral hip pain occurs in an otherwise healthy child.
  • Pain usually is confined to the ipsilateral groin and hip area, but it may present as anterior thigh and knee pain.
  • Limp and antalgic gait are common, with some patients refusing to bear weight on the involved extremity.
  • The hip is held in a flexed and externally rotated position and has restricted ROM.
  • The patient may have a low-grade fever.
  • Laboratory values are nonspecific and are often within normal limits (4,5).
Physical Exam
  • The patient usually indicates unilateral hip pain confined to the ipsilateral groin, anterior thigh, or knee.
  • ROM often is decreased and painful.
  • The patient does not have as much pain as a patient with a septic hip.
    • If the hip ROM is tested slowly, it is usually at least 50% of normal.
  • While walking, patients often display a limp or an antalgic gait; some children refuse to walk (4,5).
  • Ipsilateral muscle atrophy is seen
    rarely, but when present, it implies a longstanding duration of
    symptoms, and a diagnosis other than transient synovitis should be
    considered.
Tests
Lab
  • Results are usually nonspecific and within normal limits, but they may help to rule out other diagnoses (1).
    • The peripheral white blood cell count is normal to slightly elevated.
    • The ESR averages 20 mm/hour but may be slightly higher.
    • Urinalysis, blood culture, rheumatoid factor, and Lyme titers and tuberculin skin test results are usually within normal limits.
    • Analysis of joint fluid for complement levels or other tests has been nonspecific.
Imaging
  • Radiography:
    • Plain films of the hip should include AP and lateral views.
  • In transient synovitis, these films are
    normal but may help rule out other diagnoses, such as
    Legg-Calvé-Perthes disease and SCFE (3,6–8).
  • Ultrasound may be useful to determine if
    an effusion exists, and to guide aspiration, if infection cannot be
    ruled out clinically.
  • MRI is needed only in cases of persistent pain, when infection has been excluded.
  • A bone scan often is not helpful because this condition is not a bony process.
Pathological Findings
  • Biopsy specimens have shown synovial hypertrophy secondary to nonspecific, nonpyogenic inflammatory reaction.
  • Hip joint aspirates have shown a culture-negative synovial effusion, usually 1–5 mL.
Differential Diagnosis
  • Transient synovitis of the hip is a diagnosis of exclusion (1,4,5).
  • Conditions to rule out include:
    • Pyogenic arthritis (4,5)
    • Osteomyelitis in the adjacent femoral neck or pelvis (4)
    • Tuberculous arthritis
    • Psoas abscess
    • Other muscle infection about the hip
    • Juvenile rheumatoid arthritis
    • Acute rheumatic fever
    • Legg-Calvé-Perthes disease (3,8)
    • Tumor
    • SCFE
    • Dislocation
    • SI joint infection
Treatment
General Measures
  • Transient synovitis usually has a limited duration of symptoms, averaging <7 days (2).
    • Most studies report complete resolution
      of all signs and symptoms with no immediate residual clinical or
      radiographic abnormalities.
    • Long-term studies have shown mild radiographic changes in the involved hip.
  • Traction and routine joint aspiration are not always needed.
    • If traction is used, it is to promote rest and comfort.
    • The hip should be in ~30° of flexion to avoid increasing intra-articular pressure.
  • The important point in management of this
    condition is to establish the diagnosis: Pyogenic arthritis must be
    excluded, on clinical grounds or with laboratory tests.
  • Treatment is directed at rapidly resolving the underlying inflammatory synovitis with its symptoms.

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Activity
  • Bed rest until initial acute pain resolves
  • Weightbearing after pain resolves and full ROM returns, followed by a period of refraining from strenuous activities
Special Therapy
Physical Therapy
  • Usually not necessary
  • Parents can moderate child’s activity adequately.
Medication
First Line
  • Anti-inflammatory drugs:
    • Some experts believe these medications
      should be withheld to avoid masking an infection, but others believe
      they may have diagnostic value in speeding the natural resolution of
      inflammatory symptoms.
Follow-up
Prognosis
The prognosis is good because transient synovitis is self-limiting, without any clinically significant sequelae.
Complications
  • 1 study has reported that
    Legg-Calvé-Perthes disease or AVN of the femoral head may develop
    several months after an episode of transient synovitis of the hip (3).
    • This finding probably represents a delay in establishing the correct diagnosis.
Patient Monitoring
  • A physician should be available for re-evaluation at all times until the possibility of infection is excluded.
  • The child should be re-examined in ~1–2
    weeks to determine return of motion before resuming full weightbearing
    and normal activity.
  • Parents should bring the child back if symptoms recur or increase.
References
1. Dobbs MB, Morcuender JA. Other conditions of the hip. In: Morrissy RT, Weinstein SL, eds. Lovell and Winter’s Pediatric Orthopaedics, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006: 1126–1155.
2. Haueisen DC, Weiner DS, Weiner SD. The characterization of “transient synovitis of the hip” in children. J Pediatr Orthop 1986;6:11–17.
3. Landin
LA, Danielsson LG, Wattsgard C. Transient synovitis of the hip. Its
incidence, epidemiology and relation to Perthes’ disease. J Bone Joint Surg 1987;69B:238–242.
4. Kocher
MS, Mandiga R, Murphy JM, et al. A clinical practice guideline for
treatment of septic arthritis in children. Efficacy in improving
process of care and effect on outcome of septic arthritis of the hip. J Bone Joint Surg 2003;85A:994–999.
5. Kocher
MS, Mandiga R, Zurakowski D, et al. Validation of a clinical prediction
rule for the differentiation between septic arthritis and transient
synovitis of the hip in children. J Bone Joint Surg 2004;86A:1629–1635.
6. Johnson K, Haigh SF, Ehtisham S, et al. Childhood idiopathic chondrolysis of the hip: MRI features. Pediatr Radiol 2003;33:194–199.
7. Kay
RM. Slipped capital femoral epiphysis. In: Morrissy RT, Weinstein SL,
eds. Lovell and Winter’s Pediatric Orthopaedics, 6th ed. Philadelphia:
Lippincott Williams & Wilkins, 2006:1085–1124.
8. Weinstein
SL. Legg-Calvé-Perthes syndrome. In: Morrissy RT, Weinstein SL, eds.
Lovell and Winter’s Pediatric Orthopaedics, 6th ed. Philadelphia:
Lippincott Williams & Wilkins, 2006:1039–1083.
Miscellaneous
Codes
ICD9-CM
727.0 Synovitis
Patient Teaching
  • Transient hip synovitis is a self-limiting process without major consequences.
  • Some authorities have suggested an
    increased incidence of later Legg-Calvé-Perthes disease in such
    patients, but this finding has not been proven conclusively.
FAQ
Q: Do all patients with transient synovitis require aspiration of the hip?
A:
No. Although the essence of management is to rule out infection, in
many cases this goal can be accomplished clinically by noting that
transient synovitis involves a more mild degree of guarding, more mild
elevation of infection and inflammatory markers. Most often, patients
with transient synovitis will be able to bear some weight on the
involved side.
Q: If aspiration is needed to rule out infection, where and how should it be done?
A:
Aspiration requires sedation. It should be done with imaging
(ultrasound or fluoroscopy) to be certain that the aspirate is from the
hip joint. A radiologist or orthopaedic surgeon may perform this
procedure. Anterior, medial, or lateral approaches are used. Fluid
should be sent for cell count with differential and culture.

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