Transient Synovitis of the

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Transient synovitis is a self-limited, nonspecific, inflammatory disease, typically affecting the hips in children aged between 3 and 10 years. Boys are affected much more commonly than girls. It occurs frequently after a respiratory tract infection. Erythrocyte sedimentation rate and white blood cell count are mostly normal. Other terms for the condition include irritable hip syndrome, observation hip, transitory arthritis, transitory coxitis, and simple serous coxitis. The etiology is not yet established, but a viral infection or hypersensitivity reaction to

Transitory Hip Synovitis

Fig. 8.2A-C Transient synovitis. A Anteroposterior radiograph of painful left hip in a 14-year-old boy shows distension of the joint capsule (small arrows) and thickening of the obturator muscle (large arrow). B Sonogram shows moderate widening of the joint space with effusion (between crosses). C Anterior pinhole scan portrays subtle but clearly defined tracer uptake in the subchondral zone of the femoral head denoting synovial inflammation (arrowheads)

Fig. 8.2A-C Transient synovitis. A Anteroposterior radiograph of painful left hip in a 14-year-old boy shows distension of the joint capsule (small arrows) and thickening of the obturator muscle (large arrow). B Sonogram shows moderate widening of the joint space with effusion (between crosses). C Anterior pinhole scan portrays subtle but clearly defined tracer uptake in the subchondral zone of the femoral head denoting synovial inflammation (arrowheads)

Transient Coxitis

infection elsewhere in the body is considered to be a likely cause.

The basic radiographic abnormality is capsular distension with the displacement of the capsular fat line (Fig. 8.2A). This sign is observed in only a fraction of patients; in the majority the study is not informative. Ultrasonography is readily available and extremely useful for the direct, real-time demonstration of synovial effusion (Fig. 8.2B).

The tracer uptake in transient synovitis is usually mild or moderate at most, barely delineating the femoral head and the acetabular fossa on ordinary scintigraphs. Pinhole scintigraphy, however, can detect even an extremely subtle increase in uptake. The detectability of the lesion can be further raised when the healthy hip is used as a reference. Increased sub-chondral bone uptake in synovitis is accounted for by increased blood flow through the anastomotic vascular channels induced by hyperemia in the inflamed synovium (Rosenthall 1987). Scintigraphic findings differ according to the amount of effusion present within the diseased joint. When the amount is small to moderate the subchondral bone in the femoral head accumulates tracer, giving rise to a capped appearance (Fig. 8.2C) and when the amount is large uptake may become reversed to photopenia due to the elevated intracapsular

Photopenia

Fig. 8.3A, B Photopenic presentation of acute synovitis. A Anterior pinhole scan of painful left hip in a 10-year-old boy shows absence of tracer uptake in the femoral epiphysis due to elevated intracapsular pressure (open arrow). B Follow-up anterior pinhole scan taken after tapping shows instant return of uptake with increased sub-chondral uptake (arrow)

Fig. 8.3A, B Photopenic presentation of acute synovitis. A Anterior pinhole scan of painful left hip in a 10-year-old boy shows absence of tracer uptake in the femoral epiphysis due to elevated intracapsular pressure (open arrow). B Follow-up anterior pinhole scan taken after tapping shows instant return of uptake with increased sub-chondral uptake (arrow)

Ischemic Epiphysis

Fig. 8.4 Transient ischemia in synovitis. Anterior pinhole scan of the left hip in a 16-year-old boy with limping gait shows an ill-defined photopenia in the lateral aspect of the femoral head (open arrow), designating focal bone ischemia incidental to increased intracapsular pressure. Note increased uptake in the medial aspect pressure (Fig. 8.3A). The photopenia can instantly revert to normal or be slightly increased by rebound after needle aspiration (Fig. 8.3B). Obviously, the extent of photopenia parallels the amount of effusion; the smaller the effusion the milder is the photopenia (Fig. 8.4). It is to be mentioned that the tracer uptake in transient synovitis is usually much less intense than in an infective arthritis (see Section 8.2.1). In the great majority of cases, simple bed rest brings recovery in a few days, and the recovery can be confirmed by pinhole scintigraphy or sonography.

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