IRRITABLE HIP

Transient synovitis (irritable hip)

• Transient synovitis is the most common cause
of acute hip pain in children aged 3-8 years.
• The disease causes arthralgia and arthritis
secondary to a transient inflammation of the
synovium of the hip.
 Transient synovitis (irritable hip)
• Affects boys twice as often as girls.
• Usually it is a diagnosis of exclusion, once
trauma and infection are excluded
 Symptoms
• Unilateral hip or groin pain is the most
common symptom.
• Limp.
• Recent history of an upper respiratory tract
infection in 50% of patients.
 Symptoms
• Usually afebrile or have a mildly elevated
temperature.
• Very young children with transient synovitis
may have no symptoms other than crying at
night.
 Signs
• Hip kept in flexion with slight abduction and
external rotation.
• some may have mild restriction of motion,
especially to abduction and internal rotation
 Signs
• The hip may be painful with passive
movement and 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.
 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
• Perthes’ disease
• Slipped epiphysis
• Tuberculous synovitis
• Juvenile chronic arthritis
• Septic arthritis
 Investigations
• Usually to rule out other diagnoses.
• WBC, ESR and CRP are usually elevated in
septic arthritis.
• XRAYS: can exclude bony lesions.
• Ultrasound guided aspiration of the effusion.
Sign of effusion :
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.
 Management
• Apply heat and massage .
• 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.
 Management
• Advise the patient with transient synovitis to
avoid full unrestricted activity until the limp
and pain have resolved.
• Non-steroidal anti-inflammatory drugs
(NSAIDs).
 Prognosis
• Usually marked improvement within 24-48
hours.
• Two thirds to three fourths of patients have
complete resolution within 2 weeks.
 Prognosis
• The remainder may have less severe
symptoms for several weeks.
• The recurrence rate is 4-17%; most
recurrences develop within 6 months.
Legg-Calvé-Perthes disease -coxa
plana
 Legg-Calvé-Perthes disease
• Legg-Calvé-Perthes disease (LCPD) is the name given to
idiopathic osteonecrosis of the capital femoral epiphysis
in a child.
 Legg-Calvé-Perthes disease
• Usually ages 4-10yo
• As early as 2yo, as late as teens
• Boys:Girls= 4-5:1
• Bilateral 10-12%
• No evidence of inheritance
 Pathogenesis
• Up to 4 years
Metaphyseal vessels,lateral epiphyseal
vessels,scanty vessels from ligamentum teres
Between 4-7 years,femoral head
depends entirely on the lateral
epiphysael vessels.

• 7 years old
Vessels of ligamentum teres has developed
 Pathogenesis
• Lateral epiphyseal vessels situated in the
retinacula makes them susceptible to
streching and pressure from an effusion.The
precipitating cause is an effusion into the hip
joint following:
 Pathogenesis
• Idiopathic
• Slipped capital femoral epiphysis
• Trauma
• Steroid use
• Sickle-cell crisis
• Synovitis
• Congenital dislocation of the hip.
 Pathogenesis
Stage 1:BONE DEATH
Episodes of ischemia leads to part of bony
femoral head dies, x-ray looks normal but it
stops enlarging.
 Pathogenesis
Stage 2:REVASCULARIZATION AND REPAIR
New blood vessels enter the necrotic area and
new bone is laid down on the dead
trabeculae, x-ray-increased in density.If only
part of the epiphysis is involved & the repair is
rapid bony architecture is completely
restored.
 Pathogenesis
Stage 3:DISTORTION AND REMODELLING
If large part of the bony epiphysis is damaged &
the repair process is slow, epiphysis may
collapse and growth of the head and neck will
be distorted
Epiphysis ends up flattened(coxa plana),flat and
enlarged(coxa magna) and the femoral head
will be incompletely covered by the
acetabulum.
 Clinical Features
• Male
• 4-8 years old
• Hip pain, may be referred to the medial aspect
of the ipsilateral knee or to the lateral thigh.
 Clinical Features
• All ROM are limited
• The quadriceps muscles and thigh soft tissues
may undergo atrophy
• The hip may develop adduction flexion
contracture
 Clinical Features
• The patient may have an antalgic gait with
limited hip motion.
• Passive range of motion are limited, especially
internal rotation and abduction.
• Children can have a trendelenburg gait
resulting from pain in the gluteus medius
muscle.
 Investigation
• Plain radiograph
– Hip radiographs, anteroposterior and frog-leg
lateral views of the pelvis to establish the
diagnosis.
– Initial radiographs can be normal,
 Investigation
• Plain radiograph
– Early changes-increased density of the bony
epiphysis and widening of the joint space.
– Late changes-flattening,fragmentation and lateral
displacement of the epiphysis with rarefraction at
the metaphysis.
 Catterall classification
• Group I
– Epiphysis retains its height.
– Less then half the nucleus is sclerotic
• Group II
– Some collapse of central portion
– Upto half the nucleus is sclerotic
• Group III
– Most of the nucleus is involved with sclerosis, fragmentation
and collapse of head
• Group IV
– Whole head is involved.
– Nucleus is flat, dense and metaphyseal resorption is marked
 Head at risk signs
• Progressive uncovering of the epiphysis
• Calcification in the cartilage lateral to the
ossific nucleus
• Radiolucent area at the lateral edge of the
bony epiphysis (Gage’s sign)
• Severe metaphyseal resorption.
 Herring classification
The herring classification addresses the integrity
of the lateral pillar of the femoral head.
• A: there is no loss of height in the lateral one
third of the head and there is little density
change.
• B: there is a lucency and less than 50% loss of
lateral height.
• C: there is a more than 50% loss of lateral
height.
 Investigation
• CT scan: allow early diagnosis of bone
collapse and also demonstrate subtle changes
in the bone trabecular pattern.
• Ultrasonography :preliminary diagnosis of
transient synovitis of the hip and the onset of
CP.Hip effusion with capsular distension is well
depicted on sonographic images.
• MRI: allows more precise localization of the
femoral head.
 Treatment
• Skin traction as long as the hip is
painful(usually takes 3 weeks)
• Further treatment is taken by assessment of
the prognostic value:
 • Good prognosis
Good prognosis Poor prognosis
• 1)Onset under age 6
• • Onset under age 6 • Age over 6 years old
2)Partial involvement of
• Partialfemoral
involvement
headof • Involve the whole femoral
femoral head head
• 3)Absence of
• Absence of metaphyseal • Severe metaphyseal
metaphyseal involvement
involvement rarefraction
• • Normal
4)Normal femoral
femoral headhead • Lateral displacement of
shape shape
femoral head

No•active
No active Tx needed
Tx needed Containment
 Treatment
• Containment means keeping the femoral head
well seated within the acetabulum
• Can be achieved by:
1) Holding the hips widely abducted in plaster
or removable splint.(at least will take a year).
2) Varus osteotomy of the femur or innominate
osteotomy of the pelvis.
 Guidelines to treatment
• Under 6 years:
– Symptomatic
 Guidelines to treatment
• 6 – 8 years:
– Bone age at or below 6 years
• Lateral pillar group A,B = symptomatic
• Lateral pillar group C = Abduction brace.
– Bone age over 6 years
• Group A B = abduction brace / osteotomy
• Group c = outcome not affected by treatment
 Guidelines to treatment
• 9 years and older:
– Operative containment