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Synovitis, Toxic, Emergency Medicine


Basics


Description


  • Nonspecific inflammation and hypertrophy of the synovium with an effusion of the hip joint inchildren
  • It can affect any joint but most commonly affects the hip.
  • Disease process is self-limiting.
  • Most common cause of acute hip pain and a limp in children aged 3 " “10.
  • Also referred to as acute transient synovitis and irritable hip syndrome.
  • Age group most affected is 3 " “6 yr.
  • Male > female (2:1)
  • Right hip > left

Etiology


  • Cause of toxic synovitis is unknown.
  • Infectious etiology is suspected, because an upper respiratory infection precedes the symptoms of transient synovitis in ¢ ˆ ¼50% of cases.

Diagnosis


Signs and Symptoms


  • Unilateral hip pain
  • Pain in the anteromedial thigh and knee
  • Pain with weight bearing
  • Limp
  • Low-grade fever
  • Decreased range of motion (ROM) of the affected hip
  • Pain with ROM of the affected hip

History
  • Acute onset of unilateral hip pain
  • No history of trauma
  • Pain with ambulation
  • Recent upper respiratory infection

Physical Exam
  • Low-grade fever, usually <38.5 ‚ °C (101.3 ‚ °F)
  • High-grade fevers are more concerning for septic arthritis
  • Nontoxic appearing
  • Limited hip ROM due to pain
  • Hip is usually held in the flexed and externally rotated position for maximal comfort.

Essential Workup


  • Hip x-rays
  • AP pelvis
  • CBC, C-reactive protein (CRP), ESR if concerned for septic arthritis

Diagnosis Tests & Interpretation


Lab
CBC, CRP, ESR: ‚  
  • May be normal or elevated
  • An elevated white blood cell (WBC) count, CRP, or ESR alone does not differentiate toxic synovitis from septic arthritis or osteomyelitis.
  • If WBC count, CRP, and ESR are normal, more serious causes of hip pain are less likely.
  • If CRP <2 mg/dL and able to bear weight, more likely to be toxic synovitis

Imaging
  • Plain hip films (anteroposterior and frog-leg view):
    • Usually normal
    • May detect an effusion or other causes of hip pain
  • US to rule out joint effusion and to guide hip joint aspiration if required
  • MRI (rarely indicated):
    • Very useful in diagnosing Legg " “Calve " “Perthes (LCP) disease
  • Bone scan:
    • Used to differentiate LCP disease from toxic synovitis
    • Can detect osteomyelitis
    • The increased radiation is usually reserved for recurrent cases or cases in which the diagnosis is still in question.

Diagnostic Procedures/Surgery
Joint aspiration: ‚  
  • Not necessary if the patient is afebrile with a normal WBC count, CRP, and ESR
  • Abnormal joint fluid analysis indicates SA (see "Arthritis, Septic " )

Differential Diagnosis


  • SA
  • Osteomyelitis
  • Soft tissue infection
  • LCP disease
  • Slipped capital femoral epiphysis
  • Juvenile rheumatoid arthritis
  • Rheumatic fever
  • Chondrolysis
  • Gaucher disease
  • Osteosarcoma
  • Ewing sarcoma
  • Osteoid osteoma
  • Leukemia
  • Tuberculosis of the hip
  • Fracture
  • Lyme disease
  • Psoas abscess
  • Sickle cell crisis

  • 4 " “17% of children have a recurrent episode.
  • 10% of recurrent cases may be the presenting feature of a chronic inflammatory condition.
  • 2 " “10% of patients with toxic synovitis later develop LCP disease:
    • Suggested that toxic synovitis may represent an early stage of LCP disease.

Treatment


Pre-Hospital


  • Keep leg in position of comfort.
  • Treat with NSAIDs.

Ed Treatment/Procedures


  • Conservative treatment
  • Bed rest in position of comfort: Flexion and external rotation
  • Initiate NSAIDs
  • Apply heat to the area
  • Antibiotics and steroids are not indicated
  • Some authors recommend no weight bearing for 7 " “10 days following improvement and return of normal hip function, citing increased risk for recurrence.
  • Close follow-up is essential, with repeat radiographs due to association with LCP.

Medication


First Line
  • Ibuprofen: 200 " “600 mg (peds >6 mo old: 5 " “10 mg/kg/dose) PO q6h PRN
  • Naproxen: 250 " “500 mg (peds >6 mo old: 5 " “10 mg/kg/dose) PO BID PRN

Second Line
Acetaminophen: 500 mg (peds: 10 " “15 mg/kg, do not exceed 5 doses/24 h) PO/PR q4 " “6h, do not exceed 4 g/24 h ‚  

Follow-Up


Disposition


Admission Criteria
Patients with severe joint pain or a large effusion may require hospitalization for bed rest and analgesics. ‚  
Discharge Criteria
All patients who have had more serious causes of hip pain excluded and have been diagnosed with toxic synovitis can be discharged from the hospital with good follow-up. ‚  
Issues for Referral
Follow-up with an orthopedic surgeon in 1 " “2 wk for repeat evaluation. ‚  

Follow-Up


Follow-Up Recommendations


  • Return to the ED immediately for worsening pain in the hip or increasing fever.
  • Follow-up with pediatric orthopedic surgeon in 1 " “2 wk for repeat evaluation.
  • Patients should have repeat x-rays done in 6 mo to exclude LCP disease.

Pearls and Pitfalls


  • Most cases are diagnosed by history and physical exam alone with fever and weight bearing as key elements.
  • ¢ ˆ ¼50% of children have a history of a preceding viral illness.
  • NSAIDs help treat the pain and shorten the course of the illness.
  • Nearly all children recover from toxic synovitis within 2 wk and without sequelae.
  • ¢ ˆ ¼2 " “10% of children with toxic synovitis develop LCP disease.

Additional Reading


  • Caird ‚  MS, Flynn ‚  JM, Leung ‚  YL, et al. Factors distinguishing septic arthritis from transient synovitis of the hip in children. A prospective study. J Bone Joint Surg Am.  2006;88:1251 " “1257.
  • McCarthy ‚  JJ, Noonan ‚  KJ. Toxic synovitis. Skeletal Radiol.  2008;37:963 " “965.
  • Singhal ‚  R, Perry ‚  DC, Khan ‚  FN, et al. The use of CRP within a clinical prediction algorithm for the differentiation of septic arthritis and transient synovitis in children. J Bone Joint Surg Br.  2011;93(11):1556 " “1561.
  • Sultan ‚  J, Hughes ‚  PJ. Septic arthritis or transient synovitis of the hip in children: The value of clinical prediction algorithms. J Bone Joint Surg Br.  2010;92(9):1289 " “1293.

See Also (Topic, Algorithm, Electronic Media Element)


  • Arthritis, Septic
  • Hip Injury
  • Legg " “Calve " “Perthes Disease

Codes


ICD9


727.09 Other synovitis and tenosynovitis ‚  

ICD10


  • M67.351 Transient synovitis, right hip
  • M67.352 Transient synovitis, left hip
  • M67.359 Transient synovitis, unspecified hip
  • M67.35 Transient synovitis, hip

SNOMED


  • 202926002 Synovitis of hip (disorder)
  • 301864002 transient synovitis of hip (disorder)
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