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Despite today’s extraordinary technology and doctors’ seemingly endless years of training, sometimes the only way doctors can sort out what’s wrong with a sick child is to figure out what it isn’t wrong. They call it “a diagnosis of exclusion.”
“How’s that leg doing?” asks Dr. David Goo, M.D., Children’s Healthcare of Atlanta.
Last night, 5-year-old William Pruett started limping. Today, he can’t move his leg.
“There was no history of trauma other than a remote history a few days ago of him jumping off a wall, but there were no symptoms at the time and he had no findings of tenderness or limp before that evening,” says Goo.
The doctor says the pain could be anything.
“It can represent infection, trauma, a broken bone, a sprained ankle, a splinter in the foot. It can represent leukemia, it can represent problems in the buttocks area or under the toenails,” says Goo.
“The main pain is when we rotate his leg in or out. We can bend it and the knee looks fine … but that’s really where it hurts,” says Goo.
Goo orders X-rays of Williams’s leg and reviews them.
“And that allowed us to see if there was any fluid in the hip, if there was any problem in the bone and also if there were any broken bones or fractures. We did not see anything. We also checked him for infection. Infection can be seen in the blood stream. Sometimes we will see an elevation of the white blood cell count or an elevation of some of the inflammatory markers -- what we call the sedimentation rate or the C-reactive protein. Fortunately for William, all of those were negative,” says Goo.
After everything else is ruled out, the doctor says he is pretty sure it’s toxic synovitis. Toxic synovitis typically occurs prior to puberty and often is preceded by a low-grade fever.
“Transient synovitis or toxic synovitis is inflammation of the lining of the joint. The synovial lining is the type of lining that is inside your joints and it allows your joints to move on each other without rubbing, without pain. You can get an inflammation of the synovial lining and sometimes this occurs in the hip. Typically, it’s between the ages of 3 and 8 and most often it’s boys compared to girls. We have no idea why. So, William fit directly into this category,” says Goo.
The illness is temporary. It will heal on its own as long as William follows the doctor’s orders.
“I’d rather that he didn’t walk on it, because that’s going to cause even more inflammation of the hip. Give him the anti-inflammatory around the clock. I don’t want you to stop. I want you to give it around the clock because that will give the synovial lining a chance to heal,” says Goo.
Tips for Parents: - Transient synovitis of the hip joint is a condition that occurs in childhood and can cause hip pain. The cause of transient synovitis is not well understood, but it may be related to a viral illness the child has or has had. (Jonathan Cluett, M.D.)
- Transient synovitis causes inflammation and pain around the hip joint. The symptoms tend to begin quickly over one to three days, and usually resolve over the next several days. The following symptoms are common in children with transient synovitis of the hip: (Jonathan Cluett, M.D.)
- Pain with movement of the hip
- Hip and knee pain
- Difficulty walking or a limp
- Holding the hip flexed and rotated
- Fever
- Bacterial infections of the hip joint are more serious, and may require surgery to treat the infection. Therefore, any child with hip pain or a limp must be carefully assessed by a doctor to determine the cause of their symptoms. (Jonathan Cluett, M.D.)
- The most important aspect of treatment is time. Some mild anti-inflammatory medication can help to alleviate pain, and rest for a few days will help as well. The child should be watched by a parent or responsible caregiver to ensure the condition does not worsen. In addition, regular temperature checks are important. (Jonathan Cluett, M.D.)
- Children who have transient synovitis of the hip usually recover completely. Children with transient synovitis of the hip should follow-up with their doctor to ensure all of the symptoms have resolved. (Jonathan Cluett, M.D.)
References:
- Dr. Jonathan Cluett, M.D.
- Children’s Healthcare of Atlanta
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