Transient_Synovitis_Flashcards
What is transient synovitis also referred to as?
Irritable hip.
How does transient synovitis generally present?
As acute hip pain following a recent viral infection.
What is the commonest cause of hip pain in children?
Transient synovitis.
What is the typical age group for transient synovitis?
3-8 years.
What are the features of transient synovitis?
Limp/refusal to weight bear, groin or hip pain, a low-grade fever in a minority of patients. High fever should raise the suspicion of other causes such as septic arthritis.
What does NICE Clinical Knowledge Summaries suggest for excluding septic arthritis and other serious diagnoses in children with a limp?
Fever is a red flag, indicating the need for urgent specialist assessment. Children may be monitored in primary care (with a presumptive diagnosis of transient synovitis) if the child is aged 3-9 years, well, afebrile, mobile but limping, and has had the symptoms for less than 72 hours.
What is the management for transient synovitis?
Transient synovitis is self-limiting
Management
Bed rest
Analgesia: Pain relief can be achieved with paracetamol or NSAIDs
Usually resolves after a few days
what condition do you need to rule out even is suspecting transient synovitis?
RULE OUT septic arthritis: consider joint aspiration and blood cultures if likely
summarise transient synovitis
Transient synovitis
Transient synovitis is sometimes referred to as irritable hip. It generally presents as acute hip pain following a recent viral infection. It is the commonest cause of hip pain in children. The typical age group is 3-8 years.
Features
limp/refusal to weight bear
groin or hip pain
a low-grade fever is present in a minority of patients
high fever should raise the suspicion of other causes such as septic arthritis
NICE Clinical Knowledge Summaries help us with the difficult task of excluding septic arthritis and other serious diagnoses in children who present with a limp. They suggest:
fever is a red flag, indicating the need for urgent specialist assessment
children may be monitored in primary care (with a presumptive diagnosis of transient synovitis) ‘If the child is aged 3-9 years, well, afebrile, mobile but limping, and has had the symptoms for less than 72 hours
Transient Synovitis (AKA irritable hip)
Need to RULE OUT septic arthritis: consider joint aspiration and blood cultures if likely
Management
Transient synovitis is self-limiting,
Bed rest
Pain relief can be achieved with paracetamol or NSAIDs
Usually resolves after a few days
A 9-year-old boy presents to the general practitioner with his father complaining of right hip pain.
His father explains that he had the ‘flu’ a few weeks ago.
His observations are as follows: he is alert, heart rate 78 bpm, respiratory rate 18 breaths/min, temperature 38.3ºC, blood pressure 118/76 mmHg, oxygen saturations, 99% on room air.
What is the most appropriate management?
Discharge with 5 days of oral antibiotics
Discharge with pain relief
Reassure and discharge
Refer for same-day assessment
Refer routinely to orthopaedics
Refer for same-day assessment
If a child with a limp/hip pain has a fever they should be referred for same-day assessment, even if a diagnosis of transient synovitis is suspected
The child is likely to have hip pain due to transient synovitis secondary to a previous illness, such as the flu.
Discharging with oral antibiotics is not indicated as the patient is likely to have transient synovitis, which is managed conservatively. Antibiotics may be indicated if the patient was showing signs of a septic joint.
Discharging with pain relief is not appropriate. Although a septic joint is unlikely in this case, it has not been completely ruled out so the patient will need to be assessed by orthopaedics before they can be discharged.
Reassurance and discharge is incorrect. The patient will need formal assessment due to their current fever, and recent history of illness, and cannot be discharged before this occurs.
It is very important to refer a child with hip pain for same-day assessment if they have a fever, as to exclude the possibility of the child having a septic joint.
Routine referral to orthopaedics is not appropriate as this might take a very long time and the child will need urgent assessment.
A 6-year-old boy is brought to the emergency department by his mother due to pain in his left hip. He has been complaining of pain and is reluctant to weight bear on his left leg. He has a normal range of movement in both legs. His mother says that he has been generally unwell with coryzal symptoms for the last few days and he currently has a temperature of 37.8 ºC.
What is the most likely diagnosis?
Juvenile idiopathic arthritis (JIA)
Perthes disease
Septic arthritis
Slipped upper femoral epiphysis (SUFE)
Transient synovitis
Transient synovitis
Transient synovitis is most commonly seen in children aged 3-8 years
This patient is most likely to have transient synovitis of the hip (the most common cause of hip pain in children). He has the typical presentation of acute onset hip pain associated with a viral infection and a low-grade fever. Additionally, he still has a normal range of movement in the affected leg, despite the pain.
JIA is an important cause of joint pain in children, however, it tends to affect medium-sized joints such as the knees or ankles rather than the hip. The pain also needs to have lasted for more than 3 months for a diagnosis to be made, whereas this patient has had an acute onset of symptoms.
Perthes disease is an important cause of hip pain to rule out in children as it is due to avascular necrosis of the femoral head. While it is common in boys aged 4-8 years it tends to have a progressive symptom onset over a few weeks and would also have a reduced range of movement associated with it. This patient has had an acute symptom onset and has a normal range of movement in both hips.
Septic arthritis is the most important differential to rule out in this case. It would tend to present with a generally unwell child with a high temperature (as opposed to the mild pyrexia present in this case). The child would also have severely restricted joint movements and likely unable to weight bear on the affected joint.
SUFE is not likely to be the cause of this patient’s symptoms. It tends to present in older children (aged 10-15 years) who are overweight. It can present with acute symptoms but is more typically associated with chronic symptoms and tends to have reduced internal rotation of the hip while it is flexed. This patient has had acute symptoms and has a normal range of movement in both hips
A 2-year-old boy is brought to his GP as his mother has noted him limping over the past day. He is up to date with his vaccinations and has no past medical history, although he did have symptoms of a cold several days ago.
On examination, he looks well. His temperature is 38.3ºC, his heart rate is 110 beats per minute, his respiratory rate is 25 breaths per minute and his saturations are 100% on air. There is no redness, swelling or erythema to his hip joint and he allows slight movement of the hip, although becomes upset with excessive movement.
What is the most appropriate management?
Arrange a routine hip ultrasound
Arrange bilateral hip x-rays
Manage conservatively with analgesia and safety-netting
Refer for a same-day hospital assessment
Refer routinely to paediatric orthopaedics
Refer for a same-day hospital assessment
If a child with a limp/hip pain has a fever they should be referred for same-day assessment, even if a diagnosis of transient synovitis is suspected
The age of the child, the fact he is well (other than his temperature, his observations are within normal limits for his age), his recent cold and the examination findings (i.e. some restricted movement but a normal looking joint without significant restriction) all point towards a diagnosis of transient synovitis, the most common cause of hip pain in children. Although this is a self-limiting condition managed with analgesia only, any child with limp/hip pain who also has a fever should be referred for same-day assessment to rule out septic arthritis. In secondary care, the Kocher criteria use a combination of signs and symptoms (fever and non-weight bearing) and blood tests (ESR and white cell count) to determine the likelihood of a septic joint.
Arrange a routine hip ultrasound is not correct. This would be the investigation of choice to screen for developmental dysplasia of the hip (DDH). DDH presents in newborns and those with risk factors (e.g. breech presentation) are screened with ultrasound at six weeks. DDH would not be a cause of new, acute hip pain in an older child. USS may also be used to investigate a ? septic joint and could guide drainage. However, this would not be done routinely. Immediate investigation and treatment of a suspected septic joint are required to reduce morbidity and mortality.
Bilateral hip x-rays are not required. These are the investigation modality of choice for suspected Perthes’ disease. This would present less acutely, is not associated with a viral infection and is more common in slightly older children.
Manage conservatively is appropriate management for transient synovitis. However, there is a low threshold for children with suspected transient synovitis to be referred to secondary care, given the differential of septic arthritis. As this child has a temperature, they should first be seen in secondary care.
A routine referral to paediatric orthopaedics is not required for transient synovitis (which is self-limiting) or the differential of septic arthritis (which needs urgent inpatient investigation).
A 2-year-old child comes to the emergency department with a 2 day history of right knee pain and irritability. She had recently recovered from a viral respiratory tract infection and is apyrexial and asymptomatic now.
On examination, the joint is painful to move but not hot or erythematous, and she is able to weight bear. Blood results show the following
What is the likely diagnosis?
Septic arthritis
Transient synovitis
Juvenile idiopathic arthritis
Psoriatic arthritis
Osteochondritis dissecans
Transient synovitis
Kocher’s criteria is used to assess the probability of septic arthritis in children
Kocher’s criteria is used to assess the probability of septic arthritis in children using 4 parameters:
Non-weight bearing - 1 point
Fever >38.5ºC - 1 point
WCC >12 * 109/L - 1 point
ESR >40mm/hr
The probabilities are calculated thus:
0 points = very low risk
1 point = 3% probability of septic arthritis
2 points = 40% probability of septic arthritis
3 points = 93% probability of septic arthritis
4 points = 99% probability of septic arthritis
This girl scores 0, and with a history of recent viral infection, the likely culprit is transient synovitis.
Juvenile idiopathic arthritis (JIA) is more likely to give a polyarticular presentation with systemic features, including fever and rashes.
There is no indication of psoriasis in the presentation, making psoriatic arthritis unlikely.
Osteochondritis dissecans occurs when small segments of articular cartilage and bone come loose into the joint due to reduced blood supply. It tends to present in older children with a more insidious onset.
