Chapter 105

• Toxic synovitis of the hip is an inflammatory process that often follows an upper respiratory infection. The disorder is usually seen in children between the ages of 3 and 6 years of age. The most common complaint is a refusal to walk.
• In the absence of fever, an elevated white blood cell count, or elevated erythrocyte sedimentation rate, septic joint is unlikely and the diagnosis of transient synovitis can be made without obtaining joint fluid.
• Systemic lupus erythematosus (SLE) is an autoimmune inflammatory disease that affects multiple organ systems. Fifteen to twenty percent of cases of SLE begin in childhood or adolescence.
• Therapy for SLE is directed primarily at ameliorating the underlying inflammatory process. NSAIDs, glucocorticoids, immunosuppressants, and biologic agents are treatment options.
• The diagnosis of acute rheumatic fever (ARF) is made by utilizing a combination of clinical and laboratory findings summarized in the revised Jones criteria.
• Patients with suspected ARF are admitted to the hospital. Penicillin is indicated to eradicate any residual carriage of group A β-hemolytic Streptococcus.
• Spondyloarthropathies include enthesitis-related arthritis (formerly known as juvenile ankylosing spondylitis), psoriatic arthritis, inflammatory bowel disease–related arthropathies, and reactive arthritis.
• Enthesitis-related arthritis is a rheumatic disorder that can present in later childhood or adolescence. The disorder is predominantly characterized by involvement of the sacroiliac joints and lumbar spine, but patients may also have peripheral arthritis.
• The treatment of reactive arthritis is with anti-inflammatory agents: the role of antibiotic treatment is unclear; however, it may be helpful if Chlamydia trachomatis is the inciting infection.
• In juvenile idiopathic arthritis (JIA), polyarticular disease involves more than four joints and rheumatoid factor may be present or absent.
• Pauciarticular JIA involves four or fewer joints. Leg joints are most commonly affected, but hip involvement is unusual.
• Systemic onset JIA occurs throughout childhood. Intermittent spiking fever may be the initial manifestation of disease.
• The treatment of JIA consists of aggressive therapy with NSAIDs. For pauciarticular disease, intra-articular steroids may be used. Systemic steroids, cytotoxic drugs, and biological medications may also be effective.

Transient synovitis, also known as toxic synovitis, is the most common cause of hip pain in childhood.1 It is a self-limited inflammatory condition caused by a nonpyogenic inflammatory response of the synovium. Its peak incidence is between 3 and 6 years of age. Transient synovitis of the hip affects boys more commonly than girls and has a slight predilection for the right side. Less than 5% of cases are bilateral. Though most commonly affecting the hip, transient synovitis can also affect the knee. The etiology of transient synovitis is unknown. Current theories imply an association with active or recent infection, trauma, or allergic hypersensitivity. At least half the children with transient synovitis have or recently have had an upper respiratory illness.2

In transient synovitis, hip or groin pain is the most common initial symptom, but referred pain to the medial aspect of the thigh or knee is found in 10% to 30% of patients. ...

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