TRANSIENT MONOARTICULAR
SYNOVITIS
Transient
synovitis, also known as toxic synovitis, is a common cause of limping in
children. It is a diagnosis of exclusion, because septic arthritis and
osteomyelitis of the hip must be excluded
Etiology and
Epidemiology
The etiology of
transient synovitis is uncertain, but possible causes are viral illness and
hypersensitivity. Approximately 70% of children diagnosed with transient
synovitis have an upper respiratory tract viral infection in the preceding 7 to
14 days. Biopsies have revealed nonspecific synovial hypertrophy. Hip joint
aspirations, when necessary, are negative for bacterial culture or signs of
bacterial infection.
The mean age at onset is 6 years, with a range of 3 to 8 years. It is twice as common in male children.
The mean age at onset is 6 years, with a range of 3 to 8 years. It is twice as common in male children.
Clinical Manifestations
and Evaluation
The patient
or family will describe an acute onset of pain in the groin/hip, anterior
thigh, or knee. Irritation of the obturator nerve can cause referred pain in
the thigh and knee when the pathology is at the hip. Patients with transient
synovitis are often afebrile, walk with a painful limp, and have normal to
minimally elevated white blood cell count and erythrocyte sedimentation rate
compared with bacterial diseases of the hip (Table 199-1). Table 197-3 lists
the differential diagnosis of a limping child.
Anteroposterior and frog-leg radiographs of the hip are usually normal. Ultrasonography may reveal a small joint effusion. A bone scan may help differentiate transient synovitis from a septic process.
Anteroposterior and frog-leg radiographs of the hip are usually normal. Ultrasonography may reveal a small joint effusion. A bone scan may help differentiate transient synovitis from a septic process.
Differences Between Bacterial Infection and Transient Synovitis
Bacterial Infection* Transient Synovitis
Septic arthritis
Osteomyelitis of hip
Fever-temperature >38.5 °C Afebrile
Leukocytosis Normal WBC count
ESR >20 mm/hour Normal ESR and CRP
Refusal to walk Painful limp
Hip held in external rotation, abduction, and flexion Hip held normally
Severe pain and tenderness Moderate pain and mild tenderness
*Examples: Septic arthritis, osteomyelitis of hip.
CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; WBC, white blood cell.
Treatment
The mainstay of treatment is bed rest and minimal weight bearing until the pain resolves. Nonsteroidal anti-inflammatory medication is usually sufficient to decrease pain. Limiting strenuous activity and exercise for 1 to 2 weeks following recovery is helpful. Follow-up will help ensure that there is no deterioration. Lack of improvement necessitates further evaluation for more serious disorders.
The mainstay of treatment is bed rest and minimal weight bearing until the pain resolves. Nonsteroidal anti-inflammatory medication is usually sufficient to decrease pain. Limiting strenuous activity and exercise for 1 to 2 weeks following recovery is helpful. Follow-up will help ensure that there is no deterioration. Lack of improvement necessitates further evaluation for more serious disorders.
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