Introduction

Background
Transient synovitis (TS) is the most common cause of acute hip pain in
children aged 3-10 years. The disease causes arthralgia and arthritis
secondary to a transient inflammation of the synovium of the hip.
Pathophysiology
Biopsy reveals only nonspecific inflammation and hypertrophy of the
synovial membrane. Ultrasonography demonstrates an effusion that
causes bulging of the anterior joint capsule. Synovial fluid has increased
proteoglycans.
Frequency
United States
Little data are available regarding the frequency of this illness. However,
excluding infections and trauma, transient synovitis is one of the most
common causes of joint pain in the pediatric age group.
Mortality/Morbidity
The possible etiologic relationship between transient synovitis and LeggCalv-Perthes disease (LCP) is controversial. Although some children with
transient synovitis may develop LCP, whether persistence of increased
intraarticular pressure eventually causes avascular necrosis or whether
patients may have a synovitis that occurs before detection of femoral
head collapse is not fully known. Approximately 1.5% of patients with
transient synovitis develop LCP. Coxa magna, osteoarthritis, or
recurrences may occur.
Sex
Transient synovitis affects boys twice as often as girls.
Age
Transient synovitis most frequently occurs when individuals are aged 3-10
years; however, transient synovitis has been reported in a 3-month-old
infant and in adults. Nonetheless, children outside the typical age group
are unlikely to have transient synovitis. Some teenagers with enthesitisassociated arthritis are initially diagnosed erroneously with toxic synovitis
when they first present with hip pain.
Clinical
History

Hip pain: Unilateral hip or groin pain is the most common report;
however, some patients with transient synovitis (TS) may report
medial thigh or knee pain. Guidelines for chronic hip pain have been
established.1

Crying at night: Very young children with transient synovitis may

have no symptoms other than crying at night; however, a careful
examination should reveal some degree of an antalgic limp.
Recent infection: Recent history of an upper respiratory tract
infection, pharyngitis, bronchitis, or otitis media is elicited from
approximately half of patients with transient synovitis.
Limp: Some patients with transient synovitis may not report pain
and may present with only a limp. Guidelines for diagnosis and
treatment in children with a limp have been established.2
Fever: Children with transient synovitis are usually afebrile or have
a mildly elevated temperature; high fever is rare.

Physical

Hip
o
o

o
o
o

During physical examination, hold the hip in flexion with

slight abduction and external rotation.
Examination of the individual with transient synovitis usually
reveals mild restriction of motion, especially to abduction and
internal rotation, although one third of patients with transient
synovitis demonstrate no limitation of motion.
The hip may be painful even with passive movement.
The hip may be tender to palpation.
The most sensitive test for transient synovitis is the log roll,
in which the patient lies supine and the examiner gently rolls
the involved limb from side to side. This may detect
involuntary muscle guarding of one side when compared to
the other side.

Knee
o
o

The knee of the individual with transient synovitis may have

decreased range of motion only as it may include hip motion.
Any effusion or joint abnormality within the knee should
suggest another disease process.

Causes
No definitive cause of transient synovitis is known, although the following
have been suggested:

Patients with transient synovitis often have histories of trauma,

which may be a cause or predisposing factor.
One study found an increase in viral antibody titers in 67 of 80
patients with transient synovitis.
Postvaccine or drug-mediated reactions and an allergic disposition
have been cited as possible causes.

Differential Diagnoses
Arthritis,
Juvenile
Juvenile
Osteomyelitis

Idiopathic
Rheumatoid

Septic
Arthritis
Arthritis

Other Problems to Be Considered

Avascular
Fracture
Gonococcal
Lyme
Rheumatic
Soft
Tumor or malignancy

necrosis
arthritis
arthritis3
tissue

arthralgias
injury

Workup
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)
o
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
37.5C identified 97% of individuals with septic hip.4
o
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.5 They concluded that patients
who were nonweightbearing and had history of fever, an ESR
greater than 40 mm/h, and a WBC count greater than 12,000
cells/mm had a 99.6% high predicted probability of septic
arthritis.
o
Luhmann et al applied these 4 criteria to their patient
population and discovered a 59% predicted probability.6
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
o
C-reactive protein (CRP) level rises within 6 hours after the
onset of septic arthritis of the hip and peaks at 2 days.7
o
A CRP >2 mg/dL (>20 mg/L) has been found to be an
independent risk factor strongly associated with septic hip
arthritis.8
o
Adding in the CRP as a predictive factor, Jung et al found that
patients with 4 of 5 predictors (body temperature >37 C,
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.9
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.10

Imaging Studies

Anteroposterior and lateral radiography of the pelvis

o 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.
o Plain films may be normal for months after onset of
symptoms.
o Medial joint space may be slightly wider in the affected hip
(see
Media
file
1).

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.
o

o
o

If excess fluid is present or the patient has early Legg-CalvPerthes (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 Waldenstrm 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.
Ultrasonography
o 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.
o 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.
MRI
o A study by Lee et al proposed that physicians may
differentiate transient synovitis from septic arthritis by
considering the results of an MRI. 11 This study found that
septic arthritis demonstrated signal intensity alterations in
the bone marrow of the affected hip.
o Yang et al confirmed this finding in a study on 49 patients
with transient synovitis and 18 patients with septic arthritis. 12
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.
o 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.
o

Other Tests

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

Procedures

Aspiration with ultrasonographic guidance

o Perform this procedure in all individuals in whom
ultrasonography has exhibited evidence of an effusion and
any of the following predictive criteria are present:
Temperature greater than 99.5F
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. 13
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.

Treatment
Medical Care

Apply heat and massage to individuals with transient synovitis (TS).

If the diagnosis of transient synovitis is equivocal or the patient is
uncomfortable, hospitalize for observation and traction. Home
treatment also can include traction. Skin traction of the hip in 45
of flexion minimizes intracapsular pressure.
Treatment with ibuprofen may shorten the duration of symptoms. 14

Activity

Advise bedrest for 7-10 days, allowing the patient to rest in a

position of comfort.
Advise the patient with transient synovitis not to bear weight on the
affected limb.
Advise the patient with transient synovitis to avoid full unrestricted
activity until the limp and pain have resolved.

Medication
Nonsteroidal anti-inflammatory drugs (NSAIDs)
These agents have analgesic, antiinflammatory, and antipyretic activities.
They act by inhibiting cyclooxygenase activity, which results in decreased
prostaglandin synthesis. Other mechanisms, such as inhibition of

leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity,

neutrophil aggregation, and various cell-membrane functions, may also
exist.
Naproxen and ibuprofen are the most frequently prescribed NSAIDs in
children, with a suspension form and safety and efficacy studies available.
The COX-2 inhibitors have not yet been studied adequately in the pediatric
population.

Naproxen (Aleve, Naprosyn, Anaprox)

NSAID that inhibits
prostaglandins.

cyclooxygenase,

thus

inhibiting

formation

of

thus

inhibiting

formation

of

Dosing
Interactions
Contraindications
Precautions

Adult
0.5-1 g/d PO divided bid
Pediatric
10-20 mg/kg/d PO divided bid
Dosing
Interactions
Contraindications
Precautions
Dosing
Interactions
Contraindications
Precautions
Dosing
Interactions
Contraindications
Precautions

Ibuprofen (Motrin, Advil)

NSAID that inhibits
prostaglandins.

cyclooxygenase,

Dosing
Interactions
Contraindications
Precautions

Adult
400 mg PO q4-6h, 600 mg q6h, or 800 mg q8h while symptoms persist;
not to exceed 3.2 g/d

Pediatric
30-40 mg/kg/d PO divided tid/qid
Dosing
Interactions
Contraindications
Precautions
Dosing
Interactions
Contraindications
Precautions
Dosing
Interactions
Contraindications
Precautions

Follow-up
Further Outpatient Care

Advise patients with transient synovitis (TS) to return in 12-24

hours for a repeat examination.
If significant symptoms persist for 7-10 days after the initial
presentation, consider other diagnoses.
Advise that all patients with transient synovitis have repeat
radiography within 6 months to exclude Legg-Calv-Perthes (LCP)
disease.

Inpatient & Outpatient Medications

Recommend nonsteroidal anti-inflammatory drugs (NSAIDs), such

as ibuprofen and naproxen. NSAIDs may shorten the duration of
symptoms.
A study performed on 36 children with transient synovitis showed
that those who took ibuprofen had a median duration of symptoms
for 2 days. The control group taking a placebo had a mean duration
of symptoms for 4.5 days.

Complications

Sequelae include coxa magna and mild degenerative changes of the

femoral neck.
o Coxa magna is observed radiographically as an overgrowth of
the femoral head and broadening of the femoral neck.
o Coxa magna leads to dysplasia of the acetabular roof and
subluxation.
o An incidence rate of coxa magna of 32.1% has been reported
in the first year following transient synovitis.
LCP disease develops in 1-3% of individuals with transient
synovitis.

Prognosis

Patients with transient synovitis usually experience marked

improvement within 24-48 hours.
Two thirds to three fourths of patients with transient synovitis have
complete resolution within 2 weeks. The remainder may have less
severe symptoms for several weeks.
The recurrence rate is 4-17%; most recurrences develop within 6
months.
No increased risk of juvenile chronic arthritis is known; however, a
slightly increased risk for later development of osteoarthritis may
be noted.

Patient Education

Advise parents and/or caregivers to initially check the temperature

of the patient with TS regularly and inform the physician of any
fever.
For excellent patient education resources, visit eMedicine's Foot,
Ankle, Knee, and Hip Center and Arthritis Center.

Miscellaneous
Medicolegal Pitfalls

Misdiagnosis of toxic synovitis and the resulting delay in treatment

of an infectious etiology or malignancy can be disastrous.
Early use of nonsteroidal anti-inflammatory drugs (NSAIDs) can
mask disease progression in septic joints.