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Transient Synovitis Workup

  • Author: Christine C Whitelaw, MD; Chief Editor: Lawrence K Jung, MD  more...
 
Updated: Oct 11, 2015
 

Laboratory Studies

The following studies may be indicated in transient synovitis (TS):

  • CBC count: The white blood cell (WBC) count may be slightly elevated.
  • Erythrocyte sedimentation rate (ESR)
    • The erythrocyte sedimentation rate (ESR) may be slightly elevated. One study found that the combination of an ESR greater than 20 mm/h and/or a temperature greater than 37.5°C identified 97% of individuals with septic hip.[8]
    • Another study by Kocher et al used 4 independent predictors of septic arthritis to distinguish it from transient synovitis and the need for further workup.[9] They concluded that patients who were nonweightbearing and had a history of fever, an ESR greater than 40 mm/hr, and a WBC count greater than 12,000 cells/mm had a 99.6% predicted probability of septic arthritis. A 2014 retrospective multicenter study to assess the Kocher predictive algorithm found that because of the overlapping features of K kingae arthritis of the hip and transient synovitis in children younger than 3 years of age, Kocher predictive algorithm is not sensitive enough for differentiating between these 2 conditions. To exclude K kingae arthritis, blood cultures and nucleic acid amplification assay should be performed in young children presenting with irritation of the hip, even in the absence of fever, leukocytosis, or a high Kocher score.[10]
  • Luhmann et al applied these 4 criteria to their patient population and discovered a 59% predicted probability. [11] However, when they applied the 3 criteria of history of fever, a serum WBC count of greater than 12,000 cells/mm, and a previous health-care visit, they found a predicted probability of 71% that the patient had septic arthritis.
  • C-reactive protein
    • C-reactive protein (CRP) level rises within 6 hours after the onset of septic arthritis of the hip and peaks at 2 days.[12]
    • A CRP >2 mg/dL (>20 mg/L) has been found to be an independent risk factor strongly associated with septic hip arthritis.[13]
    • Adding in the CRP as a predictive factor, Jung et al found that patients with 4 of 5 predictors (body temperature >37ºC, ESR >20 mm/h, CRP >1 mg/dL, WBC >11,000/mL, and an increased hip joint space of >2 mm) had a high probability of having septic arthritis and were candidates for further study by MRI or joint aspiration.[14]
    • Singhal et al propose that a CRP value greater than 20 mg/L is the strongest independent risk factor for septic arthritis and that its inclusion within a predictive model eliminates the significance of other variables. They assert that the CRP and WBC count may be measuring a similar process so the relative strength of the CRP minimizes the importance of the WBC count. Their review of 311 records showed that only 2 factors (weight-bearing status and CRP >20 mg/L) were independent in differentiating septic arthritis from transient synovitis. Individuals with neither predictor had a less than 1% probability of having septic arthritis, but those with both had a 74% probability of having septic arthritis.[15]
  • Urinalysis and culture: Both of these tests should be normal.
  • Urine glycosaminoglycans: One study found a decreased level of urine glycosaminoglycans in patients who were diagnosed with Perthe disease, compared with those with transient synovitis and a control group.
  • Procalcitonin levels: These may be helpful in distinguishing between bacterial infections and inflammatory processes. Procalcitonin levels remain low during bouts of inflammatory disease but increase in septic arthritis and may be even more useful in distinguishing septic arthritis from osteomyelitis. [16]

Depending on the history, consider Lyme serology, antinuclear antibody, rheumatoid factor, HLA-B27, and tuberculosis skin testing.[7]

A study’s results suggest that most investigations performed during the initial work-up in patients suspected of transient synovitis of the hip are unnecessary and should routinely include only white blood cell count, C-reactive protein, erythrocyte sedimentation rate, and hip radiography and ultrasonography.[17]

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Imaging Studies

Radiographs exclude bony lesions (eg, occult fracture, osteoid osteoma) unless the child had onset of symptoms within 3 days, has no fever, appears well, and has only mildly restricted abduction without guarding against movement in other planes. Plain films may be normal for months after onset of symptoms. Medial joint space may be slightly wider in the affected hip (see the image below).

Widening of the joint space. Note that the space i Widening of the joint space. Note that the space is wider on the left side. Discrepancies greater than 1 mm indicate the presence of fluid.

If excess fluid is present or the patient has early Legg-Calvé-Perthes (LCP) disease, plain radiography may reveal an increase in the teardrop distance (ie, distance between the medial acetabulum and ossified part of the femoral head). Compared with the other side, this distance should be the same or within 1 mm. One half to two thirds of patients with transient synovitis may have an accentuated pericapsular shadow.

In one study, as many as 58% of patients with transient synovitis had the Waldenström sign (ie, lateral displacement of the femoral epiphyses with surface flattening). Other studies have reported a positive obturator sign in established incidents of transient synovitis. This is a prominent shadow caused by the soft tissues that overlie the interpelvic aspect of the acetabulum. Radiography may reveal diminution of the definition of soft tissue planes around the hip joint or slight demineralization of the bone of the proximal femur, particularly in the metaphyseal region.

Although extremely accurate for detecting an intracapsular effusion, ultrasonography does not assist in determining the cause and is used best to guide hip aspiration. An effusion is present if ultrasound demonstrates capsular distension greater than 2 mm. Occasionally, the radiologist can differentiate between transient synovitis and early LCP on the basis of effusion rather than synovial membrane thickening. However, ultrasonography cannot rule out osteomyelitis or soft tissue infection.

In settings in which routine aspirations of effusions is not performed, an MRI may help physicians differentiate transient synovitis from septic arthritis.[18] A study by Lee et al found that septic arthritis demonstrated signal intensity alterations in the bone marrow of the affected hip. Yang et al confirmed this finding in a study on 49 patients with transient synovitis and 18 patients with septic arthritis.[19] He demonstrated not only the statistically significant finding of signal intensity in the bone marrow, but also found signal intensity alterations and contrast enhancement of the soft tissue in patients with septic arthritis. Furthermore, the statistically significant findings in the patients with transient synovitis included contralateral (asymptomatic) joint effusions and the absence of signal intensities in the bone marrow. Both diseases showed ipsilateral effusions with synovial thickening and enhancement.

Dynamic contrast-enhanced MRI findings can be used to diiferentiate septic arthritis from transient synovitis in the joint.[20]

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Other Tests

Bone scintigraphy demonstrates mildly elevated uptake; however, bone scintigraphy may also reveal a transient decrease in uptake of technetium 99m phosphate. Bone scintigraphy does not help the physician differentiate etiologies.

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Procedures

Perform aspiration with ultrasonographic guidance in all individuals in whom ultrasonography has exhibited evidence of an effusion and any of the following predictive criteria are present:

  • Temperature greater than 99.5°F
  • ESR greater than or equal to 20 mm/h
  • Severe hip pain and spasm with movement

The aspirate should assist the physician in differentiating transient synovitis from septic arthritis. The physician can confirm 30-50% of septic arthritis incidents with Gram stain. In individuals with septic arthritis, the WBC count varies (25,000-250,000/mcL); however, in these individuals, the WBC count consistently demonstrates 90% polymorphonuclear cells. Also, in persons with septic arthritis, the glucose is often less than 40 mg/dL or is markedly different from the serum glucose.

In one study, 36 children with an effusion underwent aspiration with ultrasonographic guidance. The Gram stain identified 1 child with an acute infection. The 35 children with a negative Gram stain were sent home with no further complications.

In another study published by Skinner et al, 25 children with a clinical diagnosis of transient synovitis were observed.[21] They all had a joint effusion by ultrasound, but no aspiration was performed. The mean age of the patient population was 6 years, the average size of the effusions was 9 mm, and the distribution between the sides affected was equal. They found that by 2 weeks postdiagnosis, all patients were pain and limp free. The effusions, although still present in some, were decreasing in size. They concluded that transient synovitis is benign and can be treated with supportive therapy.

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Contributor Information and Disclosures
Author

Christine C Whitelaw, MD Clinician, Department of Pediatrics, Division of Emergency Medicine, University of Louisville School of Medicine

Christine C Whitelaw, MD is a member of the following medical societies: American Academy of Pediatrics, Kentucky Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Kenneth N Schikler, MD Professor, Department of Pediatrics, Director, Divisions of Pediatric Rheumatology and Adolescent Medicine, University of Louisville School of Medicine and Kosair Children's Hospital; Professor (Part-time), Department of Pediatrics, University of Kentucky College of Medicine

Kenneth N Schikler, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Rheumatology, Society for Adolescent Health and Medicine, Childhood Arthritis and Rheumatology Research Alliance

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Thomas JA Lehman, MD FAAP, FACR, Clinical Professor of Pediatrics, Department of Pediatrics, Division of Pediatric Rheumatology, Weill Cornell Medical College; Chief, Hospital for Special Surgery

Thomas JA Lehman, MD is a member of the following medical societies: PM American Allergy Society

Disclosure: Nothing to disclose.

Chief Editor

Lawrence K Jung, MD Chief, Division of Pediatric Rheumatology, Children's National Medical Center

Lawrence K Jung, MD is a member of the following medical societies: American Association for the Advancement of Science, American Association of Immunologists, American College of Rheumatology, Clinical Immunology Society, New York Academy of Sciences

Disclosure: Nothing to disclose.

References
  1. Cook PC. Transient synovitis, septic hip, and Legg-Calvé-Perthes disease: an approach to the correct diagnosis. Pediatr Clin North Am. 2014 Dec. 61 (6):1109-18. [Medline].

  2. Fabry G. Clinical practice: the hip from birth to adolescence. Eur J Pediatr. 2010 Feb. 169(2):143-8. [Medline].

  3. Krul M, van der Wouden JC, Schellevis FG, van Suijlekom-Smit LW, Koes BW. Acute non-traumatic hip pathology in children: incidence and presentation in family practice. Fam Pract. 2010 Apr. 27(2):166-70. [Medline].

  4. [Guideline] American College of Radiology, Expert Panel on Musculoskeletal Imaging. Chronic hip pain. ACR Appropriateness Criteria. 2003. [Full Text].

  5. Kastrissianakis K, Beattie TF. Transient synovitis of the hip: more evidence for a viral aetiology. Eur J Emerg Med. 2010 Oct. 17(5):270-3. [Medline].

  6. [Guideline] Fordham L, Gunderman R, Blatt ER, et al. Limping child--ages 0-5 years. ACR Appropriateness Criteria. 2007. [Full Text].

  7. Houghton KM. Review for the generalist: evaluation of pediatric hip pain. Pediatr Rheumatol Online J. 2009 May 18. 7:10. [Medline]. [Full Text].

  8. Del Beccaro MA, Champoux AN, Bockers T, Mendelman PM. Septic arthritis versus transient synovitis of the hip: the value of screening laboratory tests. Ann Emerg Med. 1992 Dec. 21(12):1418-22. [Medline].

  9. Kocher MS, Mandiga R, Zurakowski D, et al. Validation of a clinical prediction rule for the differentiation between septic arthritis and transient synovitis of the hip in children. J Bone Joint Surg Am. 2004 Aug. 86-A(8):1629-35. [Medline].

  10. Yagupsky P, Dubnov-Raz G, Gené A, Ephros M. Differentiating Kingella kingae Septic Arthritis of the Hip from Transient Synovitis in Young Children. J Pediatr. 2014 Sep 9. [Medline].

  11. 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 May. 86-A(5):956-62. [Medline].

  12. Kallio MJ, Unkila-Kallio L, Aalto K, Peltola H. Serum C-reactive protein, erythrocyte sedimentation rate and white blood cell count in septic arthritis of children. Pediatr Infect Dis J. 1997 Apr. 16(4):411-3. [Medline].

  13. Caird MS, Flynn JM, Leung YL, et al. Factors distinguishing septic arthritis from transient synovitis of the hip in children: a prospective study. The Journal of Bone and Joint Surgery. June 2006. 88-B:1251-1257. [Medline].

  14. Jung ST, Rowe SM, Moon ES, et al. Significance of Laboratory and Radiologic Findings for Differentiating between Septic Arthritis and Transient Synovitis of the Hip. Journal of Pediatric Orthopedics. June 2003. 23:368-372. [Medline].

  15. 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 Nov. 93(11):1556-61. [Medline].

  16. Butbul-Aviel Y, Koren A, Halevy R, et al. Procalcitonin as a Diagnostic Aid in Osteomyelitis and Septic Arthritis. Pediatric Emergency Care. December 2005. 21:828-832. [Medline].

  17. Dubois-Ferrière V, Belaieff W, Lascombes P, de Coulon G, Ceroni D. Transient synovitis of the hip: which investigations are truly useful?. Swiss Med Wkly. 2015. 145:w14176. [Medline].

  18. Lee SK, Suh KJ, Kim YW, et al. Septic arthritis versus transient synovitis at MR imaging: preliminary assessment with signal intensity alterations in bone marrow. Radiology. 1999 May. 211(2):459-65. [Medline].

  19. Yang WJ, Im SA, Lim GY, et al. MR imaging of transient synovitis: differentiation from septic arthritis. Pediatr Radiol. 2006 Nov. 36(11):1154-8. [Medline].

  20. Kim EY, Kwack KS, Cho JH, Lee DH, Yoon SH. Usefulness of dynamic contrast-enhanced MRI in differentiating between septic arthritis and transient synovitis in the hip joint. AJR Am J Roentgenol. 2012 Feb. 198(2):428-33. [Medline].

  21. Skinner J, Glancy S, Beattie TF, Hendry GM. Transient Synovitis: is there a need to aspirate hip joint effusions?. European Journal of Emergency Medicine. 2002. 9:15-8. [Medline].

  22. Kermond S, Fink M, Graham K, Carlin JB, Barnett P. A randomized clinical trial: should the child with transient synovitis of the hip be treated with nonsteroidal anti-inflammatory drugs?. Ann Emerg Med. 2002 Sep. 40(3):294-9. [Medline].

  23. Saulsbury, Frank T. MD. Lyme Arthritis presenting as Transient Synovitis of the Hip. Clinical pediatrics. October 2008. 47:8333-835. [Medline].

  24. Topoz I, Manole MD. Limping in toddlers: pelvic abscess presenting with transient synovitis picture. J Emerg Med. 2011 Dec. 41(6):623-6. [Medline].

  25. Caird MS, Flynn JM, Leung YL, et al. Factors distinguishing septic arthritis from transient synovitis of the hip in children: a prospective study. The Journal of Bone and Joint Surgery. June 2006. 88-B:1251-1257. [Medline].

  26. Cassidy JT, Petty RE. Textbook of Pediatric Rheumatology. 3rd ed. 1995. 505.

  27. Chung SM. Diseases of the developing hip joint. Pediatr Clin North Am. 1986 Dec. 33(6):1457-73. [Medline].

  28. Connolly LP, Connolly SA. Skeletal scintigraphy in the multimodality assessment of young children with acute skeletal symptoms. Clin Nucl Med. 2003 Sep. 28(9):746-54. [Medline].

  29. Eggl H, Drekonja T, Kaiser B, Dorn U. Ultrasonography in the diagnosis of transient synovitis of the hip and Legg-Calve-Perthes disease. J Pediatr Orthop B. 1999 Jul. 8(3):177-80. [Medline].

  30. Fink PC, Dufort JE, Smith-Wright D. Orthopedic disorders. Pediatric Emergency Medicine. 1996. 937.

  31. Hart JJ. Transient synovitis of the hip in children. Am Fam Physician. 1996 Oct. 54(5):1587-91, 1595-6. [Medline].

  32. Haueisen DC, Weiner DS, Weiner SD. The characterization of "transient synovitis of the hip" in children. J Pediatr Orthop. 1986 Jan-Feb. 6(1):11-7. [Medline].

  33. Keenan GF. Transient synovitis. The Five Minute Pediatric Consult. 1997. 736.

  34. Kermond S, Fink M, Graham K, Carlin JB, Barnett P. A randomized clinical trial: should the child with transient synovitis of the hip be treated with nonsteroidal anti-inflammatory drugs?. Ann Emerg Med. 2002 Sep. 40(3):294-9. [Medline].

  35. Koop S, Quanbeck D. Three common causes of childhood hip pain. Pediatr Clin North Am. 1996 Oct. 43(5):1053-66. [Medline].

  36. Robben SG, Lequin MH, Diepstraten AF, et al. Anterior joint capsule of the normal hip and in children with transient synovitis: US study with anatomic and histologic correlation. Radiology. 1999 Feb. 210(2):499-507. [Medline].

  37. Simon RR, Koenigsknecht SJ. Hip, pelvis, and thigh. Emergency Orthopedics: The Extremities. 1995. 421.

  38. Snider RK. Transient synovitis of the hip. Essentials of Musculoskeletal Care. 1998. 667-8.

  39. Wingstrand H. Transient synovitis of the hip in the child. Acta Orthop Scand Suppl. 1986. 219:1-61. [Medline].

  40. Yang WJ, Im SA, Lim GY, Chun HJ, Jung NY, Sung MS, et al. MR imaging of transient synovitis: differentiation from septic arthritis. Pediatr Radiol. 2006 Nov. 36(11):1154-8. [Medline]. [Full Text].

 
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Widening of the joint space. Note that the space is wider on the left side. Discrepancies greater than 1 mm indicate the presence of fluid.
 
 
 
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