Acute transient tenosynovitis of the hip is the most common cause of hip pain in children less than 10 years of age (peak, 3 to 6 years). There is a boy-to-girl predominance that is variously described as 3:2 to 5:1. The right hip is somewhat more commonly affected than the left, and the condition is bilateral in 5 percent of cases. The etiology of the condition is not known, although trauma, viral and bacterial infection, and allergy (hypersensitization) have been proposed by authors to explain the condition.
Symptoms may be acute or gradual in onset. There may be a history of recent upper respiratory symptoms offered by the parent. Considering the age group, such an association is probably best interpreted casually. The child complains of pain in the anteromedial or anterolateral thigh and knee. The gait is antalgic. Tenderness is elicited upon palpation of the anterior hip, and range of motion is limited by the discomfort. The child's systemic temperature is normal or minimally elevated. The child does not appear toxically ill.
The peripheral WBC and ESR are usually normal. If performed, tuberculin skin tests, rheumatoid factor titers, and antistreptococcal antibodies titers are negative. Radiographs of the hip are either normal or demonstrate mild to moderate hip effusion ( Fig 132-5). There are no bone changes associated with the condition.
FIG. 132-5. Widening of the joint space, indicating an effusion, is a nonspecific finding seen in children with toxic tenosynovitis, Legg-Calve-Perthes disease, suppurative arthritis, and hemarthrosis.
The differential diagnosis includes SCFE and other hip fractures, Legg-Calve-Perthes disease, and suppurative arthritis of the hip. Less common differential considerations include rheumatic fever, juvenile rheumatoid arthritis, and, rarely, tuberculosis of the hip.
If the peripheral WBC and ESR are substantially elevated and a hip effusion is noted on the radiograph, a diagnostic arthrocentesis should be performed to exclude suppurative arthritis. Consideration should be given to open irrigation of the hip joint in the operating room by an orthopedic consultant after obtaining samples of synovial fluid for laboratory studies (Gram stain, aerobic and anaerobic cultures, and acid-fast bacilli stain and culture). The synovial fluid in transient tenosynovitis of the hip is clearly transudative, will have negative stains for microorganisms, and will yield sterile cultures.
If further differentiation of transient tenosynovitis of the hip from Legg-Calve-Perthes disease is necessary, a technetium-99m bone scan or a magnetic resonance imaging (MRI) scan will confirm the absence of avascular necrosis of the femoral head. This aspect of the diagnostic workup can be performed in the ambulatory setting.
Admission to hospital is necessary only for management of SCFE, other hip fractures, and septic arthritis of the hip. Once these diagnostic considerations are effectively eliminated, the child with suspected transient tenosynovitis of the hip can be managed as an outpatient. Weight bearing is eliminated, and anti-inflammatory agents are recommended until the child's hip is painless and range of motion returns to normal (3 to Z days). Some authors recommend an additional period of rest (Z to 10 days) after symptoms have resolved. Antibiotics are of no value; glucocorticoids are not recommended.
Various authors have noted an association between transient tenosynovitis of the hip and the subsequent development of Legg-Calve-Perthes disease, ranging from 0.5 to 10 percent. It remains unclear whether the association is one of cause and effect or misdiagnosis of early Legg-Calve-Perthes disease. Follow-up clinical evaluations of patients with a diagnosis of transient tenosynovitis of the hip should occur at 2 weeks with the child's primary care physician. Subsequent clinical elevations (possibly to include radiographs) are performed by the primary care physician at 2 months and 6 months after the initial episode.
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