1
|
Benoit J, El Khalifi S, Saoudi C, De Jorna C, Dubos F. Transient synovitis of the hip: Development and validation of a new diagnostic algorithm. Acta Paediatr 2024; 113:1396-1403. [PMID: 38366676 DOI: 10.1111/apa.17144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 01/24/2024] [Accepted: 01/26/2024] [Indexed: 02/18/2024]
Abstract
AIM To develop and validate an algorithm to rapidly distinguish transient synovitis (TS) of the hip from differential diagnoses without additional tests. METHODS This retrospective cohort study included all children admitted for non-traumatic limping in the emergency department at Lille University-Hospital between 2016 and 2020. The gold standard was a definitive diagnosis at follow-up visit. All variables associated with acute limping in children were analysed in univariate and multivariable analyses. An algorithm was then developed using recursive partitioning and validated internally on a subset of patients. RESULTS There were 995 patients included (mean age 5.3 years; males 63%); 337 had a TS including 210 confirmed at follow-up visit and 354 another diagnosis. After multivariable analysis, the relevant variables for distinguishing between TS and differential diagnoses were: age 3-10 years, absence of fever, absence of local inflammation, sudden onset of limping on awakening. An algorithm combining these variables was developed (n = 297) and validated internally (n = 175) for children >12 months with limping for ≤10 days, with a specificity of 98.2% and a positive likelihood ratio of 19.6. No serious differential diagnoses were missed. CONCLUSION Use of this algorithm enables the diagnosis of TS without additional tests and without missing serious differential diagnoses.
Collapse
Affiliation(s)
- Justine Benoit
- Pediatric Emergency Department and Infectious Diseases, CHU Lille, Lille, France
| | - Siham El Khalifi
- Pediatric Emergency Department and Infectious Diseases, CHU Lille, Lille, France
| | - Colin Saoudi
- Pediatric Emergency Department and Infectious Diseases, CHU Lille, Lille, France
| | - Claire De Jorna
- Pediatric Emergency Department and Infectious Diseases, CHU Lille, Lille, France
| | - François Dubos
- Pediatric Emergency Department and Infectious Diseases, CHU Lille, Lille, France
- ULR2694 METRICS: évaluation des technologies de santé et des pratiques médicales, Univ. Lille, Lille, France
| |
Collapse
|
2
|
Lipshaw MJ, Walsh PS. Transient synovitis of the hip: Current practice and risk of misdiagnosis. Am J Emerg Med 2022; 61:1-6. [PMID: 35994972 DOI: 10.1016/j.ajem.2022.08.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 08/04/2022] [Accepted: 08/09/2022] [Indexed: 10/31/2022] Open
Abstract
INTRODUCTION Transient synovitis (TS) is a common and benign cause of hip pain in children, but must be distinguished from more serious entities such as septic arthritis, osteomyelitis, and pyomyositis. Our objectives were to determine the risk of missed bacterial musculoskeletal infection and rates of diagnostic testing in children diagnosed with TS. METHODS We performed a cohort study using the Pediatric Heath Information System of children 1-10 years diagnosed with TS in the ED. We determined rates of missed bacterial musculoskeletal infection (defined as a new diagnosis of septic arthritis, osteomyelitis, or pyomyositis within 14 days of initial ED visit). We described the initial diagnostic evaluation and ED management of children diagnosed with TS and variability between sites. RESULTS We analyzed 6419 encounters from 37 hospitals. 62 (1.0%, 95%CI: 0.7-1.2%) children were diagnosed with a missed bacterial musculoskeletal infection. Children with missed infection were younger than those without (median age 2.6 vs. 4.6 years, p < 0.01). Serum laboratory testing was performed in 76% of encounters with minimal variation across sites. There was significant variation in the rates of hip ultrasound by site (2 to 92%), which has increased in use over time (from 42% in 2016 to 62% in 2021). CONCLUSION In this large observational study, missed bacterial musculoskeletal infection in children diagnosed with TS was rare but more common in younger children. The optimal combination of bloodwork and radiographic testing, especially ultrasound, to distinguish TS from more serious disease remains unclear.
Collapse
Affiliation(s)
- Matthew J Lipshaw
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Patrick S Walsh
- Section of Emergency Medicine, Children's Hospital of Wisconsin, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| |
Collapse
|
3
|
Heylen CE, Docquier PL, Dumitriu D. Transient synovitis of the hip : is systematic radiological screening necessary for the detection of Perthes disease? Acta Orthop Belg 2021. [DOI: 10.52628/87.2.09] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Current imaging guidelines in Belgium advise a systematic X-ray screening of the hips after an episode of transient synovitis of the hip, in order to detect Perthes disease. The aim of this study was to analyze whether systematic radiological screening is necessary for all children or whether the X-ray indication could be guided by clinical symptoms.
A retrospective single center study including all children with the diagnosis of transient synovitis of the hip between 2013 and 2018 was performed. 242 patients with the diagnosis of one or more transient synovitis episodes were included, 102 of whom underwent a follow up X-ray. Persistence or recurrence of symptoms were recorded for all patients, as well as the results of follow-up hip X-rays. 12 children did not remain symptom-free after the episode of transient synovitis. Of these patients 10 had a normal follow-up X-ray and 3 were diagnosed with Perthes disease. 1 patient of those 3 had a normal X-ray but was diagnosed with Perthes disease on MRI. Of the children which remained symptom-free after the episode of transient synovitis, none were diagnosed with Perthes disease afterwards.
A follow-up X-ray to exclude Perthes disease after a diagnosis of transient hip synovitis appears to be necessary only in patients with persistent or recurrent symptomatology.
Collapse
|
4
|
Gravel CA, Lynn AQ, Hannon M, Miller AF, Neal JT, Neuman MI, Vieira RL. Yield of Plain Radiography in Addition to Ultrasound Among Children with Hip Pain. J Emerg Med 2021; 61:376-380. [PMID: 34176687 DOI: 10.1016/j.jemermed.2021.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/22/2021] [Accepted: 04/26/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Children with limp or hip pain often undergo radiographs and ultrasound as part of their initial evaluation. Previous research suggests that hip radiography may have limited utility, and early use of ultrasound may safely reduce the use of radiographs. OBJECTIVES We sought to assess the utility of radiography in addition to ultrasound by evaluating the rate of bony abnormalities present on hip radiographs among children with and without effusion on ultrasound. We also assessed the agreement of point-of-care and Radiology-performed ultrasounds for the detection of effusion. METHODS This is a retrospective cohort study of children presenting to a pediatric emergency department with acute atraumatic limp or hip pain. Data from patients who received both hip ultrasound and hip radiography as part of their evaluation were analyzed. We included both point-of-care and Radiology-performed hip ultrasounds. RESULTS We identified 134 patients who received both hip ultrasound and hip radiographs. Sixty-eight patients (51%) had a hip effusion present on ultrasound and none of these had bony abnormalities on radiography (0%, 95% confidence interval 0-5.3%). Of the 66 patients (49%) who had no effusion on hip ultrasound, 2 patients were found to have a bony abnormality (3%, 95% confidence interval 0.4-10.5%). For patients who received both point-of-care and Radiology-performed ultrasound, the overall agreement for diagnosis of effusion was 92.6% (kappa = 0.82). CONCLUSIONS We observed that no children with an effusion on ultrasound had bony pathology on plain radiography, suggesting that the routine performance of hip radiography may not be indicated in all children. Future studies are needed to evaluate the negative predictive value of effusion in larger numbers of patients with known bony abnormalities.
Collapse
Affiliation(s)
- Cynthia A Gravel
- Division of Emergency Medicine, Boston Children's Hospital Harvard Medical School, Boston, Massachusetts
| | - Alex Q Lynn
- Midwestern University Arizona College of Osteopathic Medicine, Glendale, Arizona
| | - Megan Hannon
- Division of Emergency Medicine, Boston Children's Hospital Harvard Medical School, Boston, Massachusetts,; Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Andrew F Miller
- Division of Emergency Medicine, Boston Children's Hospital Harvard Medical School, Boston, Massachusetts
| | - Jeffrey T Neal
- Division of Emergency Medicine, Boston Children's Hospital Harvard Medical School, Boston, Massachusetts
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital Harvard Medical School, Boston, Massachusetts
| | - Rebecca L Vieira
- Division of Emergency Medicine, Boston Children's Hospital Harvard Medical School, Boston, Massachusetts,; Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
5
|
Vial S. COXALGIA EN NIÑOS MENORES DE 10 AÑOS. REVISTA MÉDICA CLÍNICA LAS CONDES 2021. [DOI: 10.1016/j.rmclc.2020.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
|
6
|
Thompson M, Johnson T, Koberlein G. Radiologic Evaluation of the Child with a Limp. Pediatr Ann 2020; 49:e395-e402. [PMID: 32929515 DOI: 10.3928/19382359-20200821-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
A child presenting with a limp can present a diagnostic challenge to pediatricians. Clinical presentation, age, and history all contribute to the initial differential diagnosis; however, imaging plays a key role in the ultimate diagnosis, and the correct imaging study is essential to save time and health care expenses. This article will present a few of the more common causes of a limp and the recently updated imaging recommendations from the American College of Radiology to aid in final diagnosis. [Pediatr Ann. 2020;49(9):e395-e402.].
Collapse
|
7
|
Lázaro Carreño M, Fraile Currius R, García Clemente A. Non-traumatic limping in Paediatric Emergencies: Epidemiology, evaluation and results. Rev Esp Cir Ortop Traumatol (Engl Ed) 2018. [DOI: 10.1016/j.recote.2017.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
|
8
|
Lázaro Carreño MI, Fraile Currius R, García Clemente A. Non-traumatic limping in Paediatric Emergencies: Epidemiology, evaluation and results. Rev Esp Cir Ortop Traumatol (Engl Ed) 2017; 62:127-133. [PMID: 29138043 DOI: 10.1016/j.recot.2017.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 09/21/2017] [Accepted: 10/04/2017] [Indexed: 10/18/2022] Open
Abstract
INTRODUCTION Non-traumatic limping is a common reason for consultation in paediatric emergencies. Although transient synovitis of the hip (TS) is the most frequent diagnosis, there are cases of limping secondary to serious pathologies. The aim of this review is to describe the variables related to non-traumatic limp that come to the paediatric emergency department to establish the best management protocol, making the most of resources and speeding up emergency care. MATERIAL AND METHOD A prospective study was conducted, selecting all children less than 15 years old who consulted aspaediatric emergencies for non-traumatic limping during the 2014. Clinical variables, complementary examinations and diagnoses were collected in the emergency room consultation and 6 months after the consultation RESULTS: During 2014, 146 patients (0.69% of the emergencies) were included in the non-traumatic limping study. Four cases of severe limping were diagnosed: 2 leukaemias, 1 septic arthritis and 1 acetabular bone tumour. The most frequent diagnosis was TS (53.16%). At 6 months, 135 children (92.4%) had resolved lameness. The diagnosis was changed in 9 children (6.1%). Children with TS had fewer days of evolution, and 77% were between 3 and 10 years old. Children with a final diagnosis of severe pathology had a limp for longer, fever and did not weight bear on ambulation. CONCLUSIONS In limping of probable hip origin, at the ages of between 3 and 10, without fever or systemic symptoms and of less than one week's onset, it is possible to make a clinical diagnosis of TS limiting the use of complementary examinations.
Collapse
Affiliation(s)
- M I Lázaro Carreño
- Servicio de Pediatría, Sección Urgencias Pediátricas, Hospital Clínico Universitario de Valencia, Valencia, España.
| | - R Fraile Currius
- Servicio de Pediatría, Sección Urgencias Pediátricas, Hospital Clínico Universitario de Valencia, Valencia, España
| | - A García Clemente
- Servicio de Pediatría, Sección Urgencias Pediátricas, Hospital Clínico Universitario de Valencia, Valencia, España
| |
Collapse
|
9
|
|
10
|
Abstract
"Limp" is a common complaint of children presenting to the emergency department or physician's office. For most patients presenting with limp, the diagnosis and management can be completed in the physician's office or emergency department by gathering a detailed history, performing a careful physical examination, and requesting a few laboratory and imaging studies. This article reviews common causes of atraumatic limp in children and discusses the evaluation and management of these conditions.
Collapse
|
11
|
Thornton MD, Della-Giustina K, Aronson PL. Emergency department evaluation and treatment of pediatric orthopedic injuries. Emerg Med Clin North Am 2015; 33:423-49. [PMID: 25892730 DOI: 10.1016/j.emc.2014.12.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Orthopedic injuries in children are unique when compared to those of adults because of the physiologic differences, especially the growth plates, stronger periosteum, and dynamic state of growth. The approach to the orthopedically injured child requires a gentle yet thorough focus with consideration of the growth plates as a primary area of weakness and growth when the child sustains an injury. Understanding the developmental stages of bones is paramount to being able to manage any injuries. Finally, what appears to be a benign injury may portend more serious issues, because nonaccidental trauma must always be considered in the evaluation of the injured child.
Collapse
Affiliation(s)
- Matthew D Thornton
- Department of Emergency Medicine, Bay State Medical Center, 759 Chestnut Street, Springfield, MA 01199, USA
| | - Karen Della-Giustina
- Department of Emergency Medicine, Bridgeport Hospital, 267 Grant Street, Bridgeport, CT 06610, USA.
| | - Paul L Aronson
- Department of Pediatric Emergency Medicine, Yale New Haven Childrens Hospital, 100 York Street, Suite 1F, New Haven, CT 06511, USA
| |
Collapse
|
12
|
Sarwar ZU, DeFlorio R, Catanzano TM. Imaging of Nontraumatic Acute Hip Pain in Children: Multimodality Approach With Attention to the Reduction of Medical Radiation Exposure. Semin Ultrasound CT MR 2014; 35:394-408. [DOI: 10.1053/j.sult.2014.05.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
13
|
Abstract
Transient synovitis is a benign, self-limiting condition that is diagnosed after the exclusion of more serious causes of acute hip pain in children. Although its etiology remains unclear, it is largely believed to be viral in nature. Transient synovitis typically presents as an acute onset of thigh pain with a limp or an unwillingness to bear weight. It can be distinguished from similar conditions by the absence of fever, as well as unremarkable bloodwork (WBC, CRP, ESR), radiographs, and hip aspiration. Conservative treatment and observation are the mainstay of management. Resolution of symptoms generally occurs by 1 week and may be accelerated by NSAIDs. Although numerous papers have emerged over the years with an effort to advance our understanding, many questions remain about its pathomechanics, etiology, and how to exclude other more serious conditions that present similarly.
Collapse
|
14
|
Bomer J, Klerx-Melis F, Holscher HC. Painful paediatric hip: frog-leg lateral view only! Eur Radiol 2013; 24:703-8. [DOI: 10.1007/s00330-013-3038-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Revised: 09/09/2013] [Accepted: 09/19/2013] [Indexed: 11/28/2022]
|
15
|
Murias S, Remesal A, Quiles M, Merino R. Características de los pacientes con cojera en Reumatología. An Pediatr (Barc) 2012; 76:290-3. [DOI: 10.1016/j.anpedi.2011.10.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2011] [Revised: 10/05/2011] [Accepted: 10/27/2011] [Indexed: 01/24/2023] Open
|