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Synovitis—Transient, Pediatric

Basics

Description

- Radiography - Usually normal findings or demonstrates small effusion - No evidence of periosteal changes

- Infection - Lyme disease - Septic arthritis - Tuberculosis - Gonorrhea

- Tumors - Immunologic - Juvenile idiopathic arthritis - Spondyloarthropathy

- Psychological - Psychogenic limp - Imitative limp

Transient inflammatory process resulting in arthralgia and arthritis (especially affecting the hip) and occasionally rash precipitated by an exposure to an infectious agent пїЅ пїЅ

Epidemiology

  • Any age at risk
  • Common in ages 3 " пїЅ10 years
  • Males affected 1.5 times more commonly

Risk Factors

Genetics

No specific associations пїЅ пїЅ

Pathophysiology

A type III hypersensitivity reaction mediated by immune complex deposition within the skin and joint spaces пїЅ пїЅ

Etiology

Usually viral (especially upper respiratory but also enterovirus) пїЅ пїЅ

Diagnosis

History

  • Preceding viral syndromes
  • Day care
  • Relatively rapid onset of symptoms, with refusal to bear weight, in a non " пїЅtoxic-appearing child
  • Recent nonspecific upper respiratory or GI infection

Physical Exam

  • General examination usually benign
  • Occasional low-grade fever
  • Child refuses to bear weight but may tolerate limited ranging of joint.
  • Effusions in peripheral joints are rare and usually small and evanescent.
  • PitfallsDistinctions between transient synovitis and a septic joint may be impossible.Extreme pain and guarding on passive ranging raises suspicion for septic joint.

Diagnostic Tests & Interpretation

Lab

  • CBCUsually mild leukocytosis
  • Erythrocyte sedimentation rate (ESR)Usually midrange elevation (35 " пїЅ50 mm/h)

Imaging

  • RadiographyUsually normal findings or demonstrates small effusionNo evidence of periosteal changes
  • UltrasoundAffected hip joints may have demonstrable effusions.
  • MRINormal signal intensity may help differentiate transient synovitis from septic hip.

Diagnostic Procedures/Other

  • Joint aspirate culture is usually not needed.
  • Be wary of contaminated joint aspiration cultures.
  • Up to 50% of infected joints are negative on culture.

Differential Diagnosis

  • InfectionLyme diseaseSeptic arthritisTuberculosisGonorrhea
  • Environment
  • Trauma (fracture or soft tissue injury)Slipped capital femoral epiphysisAvascular necrosis
  • Tumors
  • ImmunologicJuvenile idiopathic arthritisSpondyloarthropathy
  • PsychologicalPsychogenic limpImitative limp
  • Miscellaneous

Treatment

Medication

  • Usually responsive to NSAIDs such as ibuprofen (up to 10 mg/kg/dose q.i.d.)
  • Very rarely, a short course of oral steroids is necessary.Usually, 1 " пїЅ3 weeks of a tapering course of NSAIDs are effective.

Additional Treatment

General Measures

Pitfalls пїЅ пїЅ

  • Missing a septic hip or, alternatively, overinvestigating transient synovitis with invasive procedures
  • Avoid initiation of therapy until septic joint has been ruled out.

Ongoing Care

Follow-up Recommendations

Usually significant improvement in 24 " пїЅ48 hours пїЅ пїЅ

Patient Monitoring

Ongoing synovitis despite therapeutic levels of NSAIDs or any bony change indicates need to change diagnosis. пїЅ пїЅ

Prognosis

Excellent, although on occasion, patients will experience recurrence of symptoms with subsequent viral syndromes or if there is an underlying spondyloarthropathy. пїЅ пїЅ

Complications

Questionably associated with subsequent avascular necrosis of femoral head and coxa magna пїЅ пїЅ

Additional Reading

  • Del Baccaro пїЅ пїЅMA, Champoux пїЅ пїЅAN, Bockers пїЅ пїЅT, et al. Septic arthritis versus transient synovitis of the hip: the value of screening laboratory tests. Ann Emerg Med. 1992;21(12):1418 " пїЅ1422. пїЅ пїЅ[View Abstract]
  • Do пїЅ пїЅTT. Transient synovitis as a cause of painful limps in children. Curr Opin Pediatr. 2000;12(1):48 " пїЅ51. пїЅ пїЅ[View Abstract]
  • Luhmann пїЅ пїЅSJ, Jones пїЅ пїЅA, Schootman пїЅ пїЅM, et al. Differentiation between septic arthritis and transient synovitis of the hip in children with clinical prediction algorithms. J Bone Joint Surg Am. 2004;86-A(5):956 " пїЅ962. пїЅ пїЅ[View Abstract]
  • Taekema пїЅ пїЅHC, Landham пїЅ пїЅPR, Maconochie пїЅ пїЅI. Towards evidence based medicine for paediatricians: distinguishing between transient synovitis and septic arthritis in the limping child " пїЅhow useful are clinical prediction tools? Arch Dis Child. 2009;94(2):167 " пїЅ168. пїЅ пїЅ[View Abstract]
  • Uziel пїЅ пїЅY, Butbul-Aviel пїЅ пїЅY, Barash пїЅ пїЅJ, et al. Recurrent transient synovitis of the hip in childhood: long-term outcome among 39 patients. J Rheumatol. 2006;33(4):810 " пїЅ811. пїЅ пїЅ[View Abstract]

Codes

ICD09

  • 727.09 Other synovitis and tenosynovitis
  • 716.45 Transient arthropathy, pelvic region and thigh

ICD10

  • M67.30 Transient synovitis, unspecified site
  • M67.359 Transient synovitis, unspecified hip
  • M67.351 Transient synovitis, right hip
  • M67.352 Transient synovitis, left hip

SNOMED

  • 202924004 transient synovitis (disorder)
  • 301864002 transient synovitis of hip (disorder)

FAQ

  • Q: Are there any chronic sequelae from transient synovitis?
  • A: Not usually. This is generally a benign disease, but there is a questionable association with avascular necrosis of the femoral head.
  • Q: Is there an association with chronic arthritis?
  • A: No. There is no known increased risk for chronic arthritis in affected children unless this is the first manifestation of a spondyloarthropathy.