Basics
Description
Transient inflammatory process resulting in arthralgia and arthritis (especially affecting the hip) and occasionally rash precipitated by an exposure to an infectious agent � �
Epidemiology
- Any age at risk
- Common in ages 3 " �10 years
- Males affected 1.5 times more commonly
Risk Factors
Genetics
No specific associations � �
Pathophysiology
A type III hypersensitivity reaction mediated by immune complex deposition within the skin and joint spaces � �
Etiology
Usually viral (especially upper respiratory but also enterovirus) � �
Diagnosis
History
- Preceding viral syndromes
- Day care
- Relatively rapid onset of symptoms, with refusal to bear weight, in a non " �toxic-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.
- Pitfalls
- Distinctions 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
- CBC
- Usually mild leukocytosis
- Erythrocyte sedimentation rate (ESR)
- Usually midrange elevation (35 " �50 mm/h)
Imaging
- Radiography
- Usually normal findings or demonstrates small effusion
- No evidence of periosteal changes
- Ultrasound
- Affected hip joints may have demonstrable effusions.
- MRI
- Normal 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
- Infection
- Lyme disease
- Septic arthritis
- Tuberculosis
- Gonorrhea
- Environment
- Trauma (fracture or soft tissue injury)
- Slipped capital femoral epiphysis
- Avascular necrosis
- Tumors
- Immunologic
- Juvenile idiopathic arthritis
- Spondyloarthropathy
- Psychological
- Psychogenic limp
- Imitative 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 " �3 weeks of a tapering course of NSAIDs are effective.
Additional Treatment
General Measures
Pitfalls � �
- 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 " �48 hours � �
Patient Monitoring
Ongoing synovitis despite therapeutic levels of NSAIDs or any bony change indicates need to change diagnosis. � �
Prognosis
Excellent, although on occasion, patients will experience recurrence of symptoms with subsequent viral syndromes or if there is an underlying spondyloarthropathy. � �
Complications
Questionably associated with subsequent avascular necrosis of femoral head and coxa magna � �
Additional Reading
- Del Baccaro � �MA, Champoux � �AN, Bockers � �T, et al. Septic arthritis versus transient synovitis of the hip: the value of screening laboratory tests. Ann Emerg Med. 1992;21(12):1418 " �1422. � �[View Abstract]
- Do � �TT. Transient synovitis as a cause of painful limps in children. Curr Opin Pediatr. 2000;12(1):48 " �51. � �[View Abstract]
- Luhmann � �SJ, Jones � �A, Schootman � �M, 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 " �962. � �[View Abstract]
- Taekema � �HC, Landham � �PR, Maconochie � �I. Towards evidence based medicine for paediatricians: distinguishing between transient synovitis and septic arthritis in the limping child " �how useful are clinical prediction tools? Arch Dis Child. 2009;94(2):167 " �168. � �[View Abstract]
- Uziel � �Y, Butbul-Aviel � �Y, Barash � �J, et al. Recurrent transient synovitis of the hip in childhood: long-term outcome among 39 patients. J Rheumatol. 2006;33(4):810 " �811. � �[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.