Practice Based Learning: Is there a clinical tool to determine the likelihood of a patient having transient synovitis versus septic arthritis of the hip?

Damon Jones, MD

Presented by Damon Jones, MD
Resident, Department of Pediatrics
Emory University

Clinical question:

Is there a clinical tool to determine the likelihood of a patient having transient synovitis versus septic arthritis of the hip?

Key Points:

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

Clinical question:

Is there a link between transient synovitis occurring after a viral infection?

Key Points:

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

References:

Blockey NJ, Porter BB. Transient synovitis of hip. A virological investigation. Br Med J. 1968 Nov 30;4(5630):557-8. 

Davidson D, Letts M, Khoshhal K. Pelvic osteomyelitis in children: a comparison of decades from 1980-1989 with 1990-2001. J Pediatr Orthop. 2003 Jul-Aug;23(4):514-21. 

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. 

Klein JD, Leach KA. Pediatric pelvic osteomyelitis. Clin Pediatr (Phila). 2007 Nov;46(9):787-90. Epub 2007 Jul 19. 

Kocher MS, Zurakowski D, Kasser JR. Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence-based clinical prediction algorithm. J Bone Joint Surg Am. 1999 Dec;81(12):1662-70. 

Kocher MS, Lee B, Dolan M, Weinberg J, Shulman ST. Pediatric orthopedic infections: early detection and treatment. Pediatr Ann. 2006 Feb;35(2):112-22. 

Luhmann SJ, Jones A, Schootman M, Gordon JE, Schoenecker PL, Luhmann JD. 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.

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. 

Tolat V, Carty H, Klenerman L, Hart CA. Evidence for a viral aetiology of transient synovitis of the hip. J Bone Joint Surg Br. 1993 Nov;75(6):973-4. 

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