Transient synovitis of the hip

Transient synovitis of the hip

1. Transient synovitis of the hip

2. Transient synovitis of the hip represents one of the most common cause of pain in hip in childhood. Acute onset on monarticular hip pain, limp in a child without any systemic illness classically represents Transient synovitis . Also referred as irritable hip, observation hip, toxic synovitis, transitory coxitis, coxitis serosa.

3. etiology Exact etiology is not known. Most popular hypotheses active infection, trauma, allergic hypersensitive. Nonspecific upper respiratory tract infection associated in 70% cases. Biopsy specimens from hip of patient with transient synovitis demonstrates synovial hypertrophy secondary to “nonspecific nonpyogenic inflammatory reaction”. Aspiration of hip joint reveals, cuttore-negative synovial effusion. Usually 1 to 3 ml.

4. INCIDENCE Most common cause of pain in hip in children. No right or left predominance of involvement is reported, but bilateral involvement never noted. Male to female ratio is 2:1.

5. CLINICAL PRESENTATION AGE: 3 to 18 years. ACUTE ONSET: - Unilateral hip pain without any systemic illness, pain confined to ipsilateral groin and hip region associated with limp and antalgic gait. Involved extremity is held in flexion and external rotation. Range of movements are restricted, mainly abduction and internal rotation. Associated flexion contracture and protective muscle spasm is noted. Low grade temperature.

6. If there is ipsilateral muscle atrophy, it indicated long standing disease and thus excludes transient synovitis The extremity is held in flexion and external rotation, and there is decreased rang of motion, especially abduction and internal rotation.

7. INVESTIGATION Laboratory values are usually within normal limits. Radiographic studies are not helpful in diagnosis, but they prove helpful to exclude other clinical conditions of hip with similar presentation. Ultrasonography can be very useful in documenting the presence of an effusion in the hip joint, and is more sensitive than plain films in detecting hip effusion. MRI is extremely sensitive to alterations in the bone marrow that may represent pathology. Aspiration of the hip joint should be performed if septic arthritis is suspected.

8. DIFFERENTIAL DIAGNOSIS Tuberculosis arthritis- septic arthritis presents with more severe pain and marked limitation of motion of the hip because of the pain. If the diagnosis is not clear from the history, physical examination, and radiography hip aspiration should performed, preferably with fluoroscopy or ultrasonography guidance. Pyogenic arthritis or associated osteomyelitis : child is systemically ill with high fever, pain is more intense symptoms does not improve with rest rather they progresses. Total count and ESR will be raised. Aspiration of hip joint reveals purulent fluid.

9. Juvenile rheumatoid arthritis, perthe’s disease tuberculous arthritis , synovitis is of insidious onset. Range of motion of affected hip is restricted to a lesser degree as compared to in transient synovitis. Radiographic factors are diagnostic in perthes disease and tuberculous arthritis. In acute rheumatic fever, synovitis occurs 2 to 4 weeks after streptococcal infection, joint pain is migratory and may be associated with carditis, rheumatic nodule or transient rash. Plain radiograph shows displacement or blurring of peri-articular fat pads in all patients with acute septic arthritis.

10. Radiographic findings Plain x rays are normal. They are useful in excluding other clinical conditions. USG useful in joint effusion and to know the natural history of ds . (but 29% pt has no effusion, hence not diagnostic.) Bone scan shows transient decrese in perfusion in early stages of disease, but return to normal spontaneously.

11. Natural history Transient synovitis means ‘ synovitis for limited period’. Average duration is 10 days, less than 1 week in 67% pts and less than 4 weeks in 88% pts. In most cases, complete resolution of signs and symptoms with no immediate rsidual or clinical abnormalities occurs.

12. treatment TOC: Strict bed rest and NWB on affected side till synovitis subsides, later avoid all srenous activities. If limp persists, continue bed rest or ambulation with PWB is advised till return of normal gait. Skin traction not recommended routinly but should be used in patients with recurrent symptoms. Position of rest for limbs and joints. No therapeutic value of joint aspiration, only diagnostic value. NSAIDs for pain relief.