Abstract
Objectives:
Transient Synovitis (TS) is an inflammation of the synovium and a common cause of acute hip pain in pediatric patients that must be differentiated from another urgent disease of the hip. Although TS is a common condition, it is rarely diagnosed. According to a study in Netherland, the average annual incidence of TS and lifetime risk of development has been estimated at 0.2 and 3%. Transient synovitis commonly occurs in childhood aged between three and ten years. The development of TS has been shown to predispose to an increased chance for relapse, with an annual incidence of recurrence estimated at 4%.2,3 It is an exclusion diagnosis when a broad differential diagnosis, ranging from benign conditions to surgical emergencies had examined carefully. The purpose of this case report is showing effective therapy with minimal diagnostic procedures and treatment.
Case presentation:
In this presented case, a seven years old boy complained severe pain felt in the right hip, thigh, and knee, also reluctance to walk or bearing weight on the affected leg. The history of trauma (fall) previously is confirmed. Other histories of disease or surgery are denied. The vital sign within normal limits, and the appearance of the hip and legs not showing any deformity, swelling, or redness. The patient rejected to move the affected leg actively, with lessening the range of motion (ROM) passively due to pain. The patient shows a positive FABER (Patrick) Test. Laboratory findings show normal leukocyte, hemoglobin, erythrocyte, erythrocyte sedimentation rate (ESR), platelets, and C-Reactive Protein (CRP). Plain radiograph of the hip, femur, and hip frog lateral position were obtained, and showed no abnormalities, except a subtle widening of affected joint space. The joint aspiration wasn’t performed since there was no sign of infection on the affected joint, and the following parenteral corticosteroid therapy shows good results. There were no C-Arm image intensifier modalities available at the hospital to support the possibility of a hip arthrography. Also, there was no appropriate probe for ultrasound examinations of the joint. We managed to do the parenteral therapy followed by enteral therapy. Intravenous injection of Dexamethasone 0,3 mg/kg/ 6 hours a day were given for 3 days, followed with oral Dexamethasone 0,2 mg/kg/ 6 hours a day for 4 days. The therapy then tappered with 0,1 mg/ kg twice a day for 2 days, then 0,1 mg/kg once for 2 days.
The complaints on hip, thigh, or knee pain were subsided on the third day of therapy, then completely resolved on the fifth day. The patient was discharged on the fifth day. The patient evaluated within four weeks after therapy in the outpatient clinic. The plain radiograph on the fourth week shows no bone resorption to ruled out the possibility of Legg Clave Perthes Disease (LCPD).
Discussion:
Over the years, various researchers have proposed several possible etiologies of Transient Synovitis including trauma, hypersensitivity, and perhaps most notably infections of both viral and bacterial origin. The cardinal sign of TS is restriction of all movement with pain at the extremes of the range in all directions. The Patrick test (also known as the FABER test for Flexion, Abduction and External Rotation) is performed by having the patient flexed the leg with the thigh abducted and externally rotated. Diagnosis of TS may be complicated by the absence of specific laboratory markers, negative laboratory tests, as well as the fact that pain originating from the knee or lumbar spine must be excluded.5 We managed to give him intravascular Dexamethasone injection. Corticosteroids are inherently short, intermediate, or long-acting, and this generally corresponds with their anti-inflammatory potency, including increased transcription of anti-inflammatory genes, inhibition of expression of multiple inflammatory genes including cytokines, enzymes.The most important differential diagnosis inpatient with the irritable hip is Septic Arthritis (SA) and Legg Calve Perthes Disease (LCPD). Whereas transient synovitis is self-limiting, SA needs urgent decompression of the hip. Delays in treatment increase the risk of complications, including osteonecrosis of the capital femoral epiphysis, osteomyelitis, chondrolysis, systemic sepsis, and secondary osteoarthritis. Whereas LCPD is a pediatric form of osteonecrosis that ultimately heals but will cause femoral head and acetabular deformities. Transient synovitis was diagnosed based on the patient’s history of the acute irritable hip with a normal vital sign and no sign of inflamed hip, with decreased ROM of the affected hip on physical examination. Laboratory findings were within normal limits and radiograph findings only showed subtle widening of affected joint space.
Conclusion:
Transient synovitis is a common cause of childhood acute hip pain but rarely diagnosed. Diagnosis of TS is an exclusion after other diseases had examined carefully due to unspecific laboratory and radiograph findings. Parenteral corticosteroid therapy has shown good outcomes to manage TS.