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Transient Synovitis of the Hip

Transient synovitis of the hip
Objectives
  1. Define transient synovitis
  2. Describe presenting symptoms and natural history of transient synovitis
  3. Describe the differentiation of transient synovitis from septic arthritis

Discussion points
  1. Should all "irritable hips" be evaluated with ultrasonography?
  2. Should patients with suspected transient synovitis undergo hip aspiration?

Discussion
Transient synovitis of the hip is one of the most commonly seen hip disorders in children. It is most commonly seen in children younger than age 8. Anterior groin or thigh pain accompanied by limp or reluctance/ refusal to weightbear are the usual presenting symptoms. Restricted hip motion is noted, particularly abduction and internal rotation. An effusion without capsular thickening can be noted on ultrasound. The natural history is benign, usual complete resolution is noted in a week or less. No treatment is necessary. Recurrence is not rare, mostly within 6 months. A viral etiology has been suspected on the basis of increased blood interferon in children with transient synovitis, although no viral antibodies were found in two recent studies looking for them.

The two major clinical problems associated with transient synovitis have dealt with its possible association with subsequent development of Legg-Calvé-Perthes syndrome, and the differentiation of transient synovitis from septic arthritis. A number of follow-up studies are now available, some of which could detect no relationship with subsequent acquisition of Legg-Calvé-Perthes syndrome, or a subsequent incidence of 1-2%. Thus, most, but not all authors discount the need for routine follow-up of children with transient synovitis after acute symptoms have resolved. The intraarticular pressure accompanying toxic synovitis is below arteriolar pressure in the position of comfort, it is raised dramatically with extension and internal rotation.

Kocher has recently analyzed data on children with septic arthritis and transient synovitis, and concluded there were 4 major predictors to study -history of fever, non weight-bearing, ESR > 40mm/ hr, and WBC > 12.000. If one predictor was present, the predicted probability of septic arthritis was 3%, for two -40%, for 3 -93%, and for 4 -99%. Obviously, the definitive diagnosis is dependent on aspiration of the hip joint. Another described approach was to aspirate the hip as an outpatient, and defer admission for toxic synovitis. However, McGoldrick found ultrasound less discriminating than physical assessment, comforting to those of us who are believers in the value of the physical exam.

With the rapid clinical resolution of transient synovitis, aspiration for other than diagnostic purposes is recommended only by Kesteris who felt it further shortened the clinical course.

References
  1. Briggs RD, Baird KS, Gibson PH. Transient synovitis of the hip joint. Journal of the Royal College of Surgeons of Edinburgh 1990; 35( 1): 48-50.
  2. Eich GF, Superti-Furga A, Umbricht FS, Willi UV. The painful hip: evaluation of criteria for clinical decision-making. European Journal of Pediatrics 1999; 158( 11): 923-8.
  3. Fink AM, Berman L, Edwards D, Jacobson SK. The irritable hip: immediate ultrasound guided aspiration and prevention of hospital admission. Archives of Disease in Childhood 1995; 72( 2): 110-3; discussion 3-4.
  4. Futami T, Kasahara Y, Suzuki S, Ushikubo S, Tsuchiya T. Ultrasonography in transient synovitis and early Perthes' disease. Journal of Bone & Joint Surgery -British Volume 1991; 73( 4): 635-9.
  5. Haueisen DC, Weiner DS, Weiner SD. The characterization of "transient synovitis of the hip" in children. Journal of Pediatric Orthopedics 1986; 6( 1): 11-7.
  6. Illingworth CM. Recurrences of transient synovitis of the hip. Archives of Disease in Childhood 1983; 58( 8): 620-3.
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  8. Kesteris U, Wingstrand H, Forsberg L, Egund N. The effect of arthrocentesis in transient synovitis of the hip in the child: a longitudinal sonographic study. Journal of Pediatric Orthopedics 1996; 16( 1): 24-9.
  9. Kocher MS, Zurakowski D, Kasser JR. Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence-based clinical prediction algorithm. Journal of Bone & Joint Surgery -American Volume 1999; 81( 12): 1662-70.
  10. Landin LA, Danielsson LG, Wattsgard C. Transient synovitis of the hip. Its incidence, epidemiology and relation to Perthes' disease. Journal of Bone & Joint Surgery -British Volume 1987; 69( 2): 238-42.
  11. Leibowitz E, Levin S, Torten J, Meyer R. Interferon system in acute transient synovitis. Archives of Disease in Childhood 1985; 60( 10): 959-62.
  12. Lockhart GR, Longobardi YL, Ehrlich M. Transient synovitis: lack of serologic evidence for acute parvovirus B-19 or human herpesvirus-6 infection. Journal of Pediatric Orthopedics 1999; 19( 2): 185-7.
  13. McGoldrick F, Bourke T, Blake N, Fogarty E, Dowling F, Regan B. Accuracy of sonography in transient synovitis. Journal of Pediatric Orthopedics 1990; 10( 4): 501-3.
  14. Robben SG, Lequin MH, Diepstraten AF, den Hollander JC, Entius CA, Meradji M. Anterior joint capsule of the normal hip and in children with transient synovitis: US study with anatomic and histologic correlation. Radiology 1999; 210( 2): 499-507.
  15. Sharwood PF. The irritable hip syndrome in children. A long-term follow-up. Acta Orthopaedica Scandinavica 1981; 52( 6): 633-8.
  16. Terjesen T, Osthus P. Ultrasound in the diagnosis and follow-up of transient synovitis of the hip. Journal of Pediatric Orthopedics 1991; 11( 5): 608-13.
  17. Vegter J. The influence of joint posture on intra-articular pressure. A study of transient synovitis and Perthes' disease. Journal of Bone & Joint Surgery -British Volume 1987; 69( 1): 71-4.
  18. Zeharia A, Reif S, Ashkenazi S. Lack of association of transient synovitis of the hip joint with human parvovirus B19 infection in children. Pediatric Infectious Disease Journal 1998; 17( 9): 843-4.
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