Pediatric Differential Diagnosis: Toxic Synovitis

Sometime in the past year, I saw an interesting pediatric hip pain case. He was referred by a close family friend, with onset of left sided, sharp hip pain. He was unable to weight bear without significant pain, and when it was tolerable, his gait was antalgic. Most of the time, he could not walk.

History revealed the boy recently had the flu with fever, and physical examination revealed

Standing with left hip in external rotation - moderate toe out, also during gait, severely antalgic
Limited and painful left hip pain in all planes (DP)
DP empty end feel hip motion in all planes
Lumbar screen unable to be completed - at least a repeated motions exam in standing
Various lumbar positions (loading/gapping) of the left side had no effect on the constant hip pain
MMT unable to be tested due to increase in resting pain of 5/10 to 8/10 sharp pain

Since there was no history of injury or change of activities, and the patient was overall a healthy young, athletic boy, I told the mother he should see his pediatrician. The pediatrician diagnosed him with Toxic Synovitis and prescribed antibiotics due to patient also having strep throat. His hip pain cleared up along with his sore throat and he was back to school, running, and playing within 1 week.

From kidshealth.org

About Toxic Synovitis

Toxic synovitis (also known as transient synovitis) is a common cause of hip pain and limping in children. Doctors don't know its exact cause, but many kids develop it after having a viral infection (such as a cold or diarrhea). Because of this, some doctors think that toxic synovitis is caused by substances produced by the body's immune system to fight the infection.

Toxic synovitis can happen at any age, but is most common in kids between 3 and 8 years old. It's also more common in boys.

Sometimes toxic synovitis can be confused with septic arthritis, or infectious arthritis, a more serious condition caused by a bacterial infection that invades the joints and can cause long-term joint damage. Doctors can rule out septic arthritis or other conditions through a physical exam and diagnostic tests.
Symptoms

When kids have toxic synovitis, the pain starts suddenly and usually is only on one side of the body. Other signs to look for:

a recent viral infection, such as a cold or stomach virus
low-grade fever (up to 101°F [38°C])
limping with toes turned outward, the knee bent or straightened
walking on tiptoes
hip discomfort that happens after a long period of resting the joint (such as sitting in a car or at a desk, or watching TV)
knee or thigh pain with no hip pain
in younger children, crying
in some cases, a refusal to walk

In babies, the most common signs of toxic synovitis are abnormal crawling and crying, and they may cry in situations where their hip joints are being moved, such as diaper changes.

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