Review Question - QID 105429

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Transient Synovitis of Hip Treatment Medical QID: 105429 (M2.OR.14.31)

QID 105429 (Type "105429" in App Search)

A 7-year-old boy presents with right hip pain for the past 2 days. He reports gradual onset of pain and states it hurts to walk. He had a recent cold last week but is otherwise healthy. His temperature is 98.2°F (36.8°C), blood pressure is 107/70 mm Hg, pulse is 90/min, respiratory rate is 19/min, and oxygen saturation is 98% on room air. Physical exam reveals no swelling or warmth surrounding the joint. The patient is sitting with the right hip flexed, abducted, and externally rotated. Passive range of motion of the hip causes discomfort. The patient is able to ambulate but states it hurts. An initial radiograph of the hip is unremarkable. The patient's CRP is 0.10 mg/L. Which of the following is the best next step in management of this patient?

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Arthrocentesis

1/44

Ibuprofen

68%

30/44

MRI

3/44

Prednisone

18%

8/44

Vancomycin and piperacillin-tazobactam

0/44

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This patient is presenting with mild hip pain after a viral illness without any systemic illness or severe symptoms suggesting a diagnosis of transient synovitis of the hip which can be managed symptomatically (ibuprofen).

Transient synovitis of the hip is most commonly seen in boys between the ages of 5-10. The etiology of this condition is unknown; however, it is thought that an autoimmune reaction after a viral infection, allergic reaction, or trauma is the etiology. It is a diagnosis of exclusion and other more serious conditions must be ruled out. A normal leukocyte count and ESR/CRP help differentiate transient synovitis from septic arthritis though the overall clinical presentation should be considered when differentiating these 2 diagnoses. A radiograph will appear normal in transient synovitis of the hip. Typical treatment is rest and NSAID therapy which often improves the symptoms associated with transient synovitis of the hip.

Incorrect Answers:
Answers 1: Arthrocentesis would be indicated to rule out septic arthritis which presents with a red, hot, and tender joint with extreme pain elicited with passive range of motion. This patient's benign exam, preceding viral illness, and normal CRP suggest against this diagnosis.

Answer 3: MRI can be used to image for pathologies such as Legg-Calves-Perthes disease or osteomyelitis; however, it is not indicated in patients with a classic history for transient synovitis of the hip. This test would be ordered for these diagnoses after a plain radiograph had been performed.

Answer 4: Prednisone is a steroid which may tamper down inflammation in conditions such as gout or transient synovitis of the hip; however, steroids have many side effects and should not be used first line in management of these conditions. Symptomatic control with ibuprofen and rest is all that is needed for this patient's condition.

Answer 5: Vancomycin and piperacillin-tazobactam are broad-spectrum antibiotics that could be given for septic arthritis; however, these would be given after arthrocentesis had been performed.

Bullet Summary:
The treatment of transient synovitis of the hip is symptom control only with rest, ice, and ibuprofen.

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