Elsevier

Annals of Emergency Medicine

Volume 40, Issue 3, September 2002, Pages 294-299
Annals of Emergency Medicine

Pediatrics
A randomized clinical trial: Should the child with transient synovitis of the hip be treated with nonsteroidal anti-inflammatory drugs?*,**,

Presented at the Royal Australasian College of Physicians annual meeting, Perth, Australia, May 1999.
https://doi.org/10.1067/mem.2002.126171Get rights and content

Abstract

Study objective: The diagnosis of transient synovitis of the hip (“irritable hip”) is made frequently in the pediatric emergency department. We hypothesized that an anti-inflammatory agent (ibuprofen syrup) would shorten the duration of symptoms. Methods: Patients who were clinically diagnosed with transient synovitis of the hip in the ED between July 1997 and July 1998 were randomized in a double-blind, placebo-controlled trial to receive either ibuprofen syrup (10 mg/kg 3 times a day for 5 days) or placebo. There were stringent exclusion criteria, and patients were only included if there was a low index of suspicion of more serious pathology. All patients had a hip ultrasonography performed at enrollment and at day 7. Symptoms were monitored by the use of a parental diary and clinical review. Results: Forty patients were initially enrolled, but 4 patients were subsequently excluded, leaving 17 patients in the ibuprofen group and 19 in the placebo group. Although symptoms resolved in more than 80% (30 of 36) of patients in both groups by 7 days, the median duration of symptoms was shorter in the ibuprofen group (2 days compared with 4.5 days in the placebo group; P =.05 on Wilcoxon-Breslow test). The medication was well tolerated, with only minor gastrointestinal side effects being reported by 6 patients (4 ibuprofen and 2 placebo). Conclusion: In this small study, ibuprofen shortened the duration of symptoms in children with a clinical diagnosis of transient synovitis of the hip. [Ann Emerg Med. 2002;40:294-299.]

Introduction

Patients with transient synovitis of the hip (“irritable hip”) present frequently to the pediatric emergency department. Transient synovitis of the hip is a benign self-limiting condition most commonly occurring in children between the ages of 3 and 10 years. It causes pain on movement of the hip resulting from sterile inflammation of the joint and may cause limp or inability to walk. Resolution usually occurs spontaneously in less than 7 days, but the condition is distressing for both parents and children.1

The cause of transient synovitis of the hip remains unknown, and although infection (either acute or as a postinfectious phenomenon) has been postulated as a possible cause, no definitive agent has been identified.2, 3 There is some speculation regarding a link between transient synovitis and Perthes' disease of the hip, because a small number of patients in long-term studies subsequently develop Perthes' disease.3, 4 However, because most patients with transient synovitis of the hip do not develop this complication or demonstrate vascular insufficiency on radionuclide scanning,5 it may be that the conditions are not related but can occasionally present in a similar fashion.

There have been a number of articles published on methods to discriminate between transient synovitis of the hip and other more serious pathology.6, 7, 8, 9 There has been little published on the treatment aspects of transient synovitis of the hip or on the natural history in the short term.

Ibuprofen has been found to be safe and effective when used as an anti-inflammatory agent for children with other conditions.10, 11 This has led to our hypothesis that ibuprofen may shorten the duration of symptoms by reducing inflammation and by reducing pain in patients with transient synovitis of the hip. To date, to our knowledge, there have been no trials looking at the effectiveness and safety of nonsteroidal anti-inflammatory drugs (NSAIDS) in this condition, although they have been used by some clinicians.

Section snippets

Materials and methods

The study was conducted in a large pediatric ED between July 1997 and July 1998. All children with the clinical diagnosis of transient synovitis of the hip (apart from those presenting on weekends because of the difficulty in consistently obtaining an ultrasonographic scan within 24 hours) were eligible for enrollment. A clinical diagnosis was made on the basis of pain, limp, or both, with an examination revealing limitation of hip movement or pain localized by the child to the hip joint.

Results

Forty patients were enrolled over the 12-month period, but there were 4 patients who were excluded from the final analysis (Figure 1).

. Study summary. Patients not randomized because of presentation over the weekend (n=51); patients not randomized because of parental refusal (n=30). Patients excluded from final analysis (n=4).

One patient received placebo and was excluded when the ESR was noted the following day to be 60 mm/h. He was recalled and admitted for intravenous antibiotics, but the final

Discussion

Our study suggests that NSAIDS (in this case, ibuprofen) may hasten the recovery of patients with a clinical diagnosis of transient synovitis of the hip. Although the natural history of transient synovitis of the hip is resolution within 5 to 7 days,1 parents and children prefer resolution in the shortest possible time. Because both groups used paracetamol for pain relief, it is likely that the shorter duration in the ibuprofen group was a result of the anti-inflammatory effects.

Hip effusion

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*

Author contributions: SK and PB conceived and designed this study with advice from KG. SK and PB recruited patients and collected data. JC provided advice on study design and analyzed the data. MF coordinated ultrasonography and reviewed and reported on all ultrasonographic scans. SK drafted the manuscript, and all authors were involved substantially in its revision. SK takes responsibility for the paper as a whole.

**

Supported by a research grant from The Boots Company PLC, Melbourne, Victoria, Australia.

Address for reprints: Susan Kermond, MBBS, FRACP, 11 Canora Street, Blackburn South, Victoria 3130, Australia; 03 9899 1775;,E-mail [email protected]

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