Presented by Damon Jones, MD
Resident, Department of Pediatrics
Is there a clinical tool to determine the likelihood of a patient having transient synovitis versus septic arthritis of the hip?
Method developed by Kocher in 1999 to help differentiate septic arthritis from transient synovitis for children presenting with a hip effusion on ultrasound:
- History of fever; WBC > 12,000; ESR > 40; Refusal to bear weight
- 0/4 Criteria met = < 0.2% chance of having septic arthritis
- 4/4 Criteria met = 99.6% chance of having septic arthritis
- Substituting CRP > 2 for the ESR changes the likelihood of having septic arthritis to 87% with 4/4 criteria being met
Luhmann did a retrospective study on 163 patients at St. Louis Children’s 1992-2000:
- Using Kocher Criteria, only 59% of patients who met 4/4 criteria had true septic or presumed septic arthritis
- Suggested that patients would refuse to bear weight, regardless of cause of pain
- Proposed alternative criteria: Fever > 38.5, WBC >12k, and prior visit to health care provider
Is there a link between transient synovitis occurring after a viral infection?
Blockey et al. British Medical Journal, 1968
- No significant increase in viral titre levels
- Suggested minor trauma to be a more likely cause
Talot et al. Journal of Bone and Joint Surgery, 1993
- Increased interferon levels in both blood and synovial fluid, suggestive of viral infection at or time of or just prior to the onset of symptoms
Kastrissianakis et al. Eur J of Emergency Med, 2011
- Case-control, compared TS to broken legs, found patients with TS were more likely to have a history of URI and AGE symptoms within the last 4 weeks
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Singhal R, Perry DC, Khan FN, Cohen D, Stevenson HL, James LA, Sampath JS, Bruce CE. 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.
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