Transient Synovitis
Assume that any child with a fever who presents with refusal to walk has septic arthritis or osteomyelitis until proven otherwise. Transient synovitis is a diagnosis of exclusion - Cameron Gettel
image by: Lori Olsen Everson
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Acute limping in children
One of the most common reasons for acute limping is Transient Synovitis, also named ‘A-septic Arthritis’. This condition, representing a viral infection in a large joint, is most common between 3 and 10 years of age, with a mean age of 6 years. It occurs more frequently in boys and in vast majority of cases is unilateral (>90%).
Children are usually symptomatic for 24-48 hours before their parents seek advice from a health care provider. They may limp or not bear weight on the affected leg. They may have a low grade fever, albeit most patients are a-febrile. The hip is the most common joint involved in the process.
One of the key elements in illness history, that help with…
Resources
Kocher Criteria
Distinguishes septic arthritis from transient synovitis in a child with an inflamed hip.
Pediatric Nontraumatic Hip Pathology
Transient synovitis is the most common diagnosis among patients with nontraumatic pediatric hip complaints.
Approach to the Pediatric Limp
Minor trauma is the most common etiology for a limp, with the median age being 4 years, boys outnumbering girls 2:1, and localization typically to the hip. In those that deny history of trauma, the most common diagnosis is transient synovitis, with 77% having a benign cause without requiring surgical intervention or hospital admission.
Transient Synovitis or Septic Arthritis? Evaluating the Kocher Criteria
Both present with an atraumatic, acutely irritable hip sometimes with associated limp, fever, refusal to bear weight, limited ROM, and/or joint effusion on x-ray and ultrasound. It is imperative to differentiate the two as the treatment and course of the two diseases are very different.
Transient Synovitis vs Septic Arthritis of the Hip
TS is an inflammation of the joint space, classically following a URI, with a benign clinical course. SA is an infectious arthritis associated with poor outcomes with diagnostic delays, including osteonecrosis, growth arrest, and sepsis. Both can both present as an atraumatic, acutely irritable hip with progressive signs of fever, limp, refusal to bear weight, limited range of motion, and abnormal labs. This overlap makes them difficult to differentiate.
Acute limping in children
When children with a limp present to you, always consider the possibility of septic arthritis.
StatPearls
TS most commonly presents as acute unilateral limb disuse ranging from nonspecific hip pain or subtle limp to a refusal to bear weight. Depending on the age of the patient, the history may only be significant for the child or infant becoming increasingly agitated or crying more often than at baseline. Therefore, heightened clinical suspicion is warranted in younger pediatric patients and infants.
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