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
1. 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.
2. 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. 3. 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.