Examkin

Question

Difficulty: EasyOrthopedic Surgery

A 5-year-old boy is brought to the clinic by his parents because of a right-sided limp that began this morning. The parents note that he had a mild upper respiratory infection about a week ago, which has completely resolved. He is currently reluctant to bear full weight on his right leg but will take a few steps with a noticeable limp. His temperature is 37.5°C (99.5°F), blood pressure is 95/60 mm Hg, and pulse is 98/min. On physical examination, the child appears well and comfortably plays with a toy on the exam table. His right hip is held in slight flexion and external rotation. There is mild discomfort during passive internal rotation of the right hip, but no overlying erythema, warmth, or swelling.

Laboratory studies reveal:
TestResult
Leukocyte count8,200/μL
Erythrocyte sedimentation rate14 mm/h
C-reactive protein0.6 mg/dL

Radiographs of the pelvis and both hips show no abnormalities. Which of the following is the most appropriate next step in management?

  1. Administration of oral ibuprofen and close clinical observationAnswer
  2. B
    Ultrasound-guided aspiration of the right hip joint
  3. C
    Initiation of empiric intravenous ceftriaxone and vancomycin
  4. D
    Immediate surgical arthrotomy and joint irrigation
  5. E
    Application of a Pavlik harness and routine follow-up

Answer

Administration of oral ibuprofen and close clinical observation
The correct answer provides the standard treatment for transient synovitis, which consists of supportive care with nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, rest, and close clinical observation. This patient's clinical presentation—a recent viral infection, low-grade temperature, normal inflammatory markers, and well-appearing status—strongly supports transient synovitis rather than septic arthritis. According to the Kocher criteria, the lack of high fever, normal leukocyte count, and normal erythrocyte sedimentation rate make septic arthritis highly unlikely, negating the need for invasive procedures or antibiotics.

Step-by-Step Solution

1
Evaluate the patient's acute limp and history of recent viral illness.
Identifies classic risk factors for transient synovitis of the hip.
To form an initial differential diagnosis that includes transient synovitis, septic arthritis, and Legg-Calvé-Perthes disease.
2
Apply the Kocher criteria for pediatric septic arthritis to the clinical data.
The patient has 0 out of 4 predictors (no fever >38.5°C, normal WBC, normal ESR, able to bear some weight).
To objectively differentiate between a benign reactive process (transient synovitis) and a surgical emergency (septic arthritis).
3
Select the most appropriate management based on the likely diagnosis of transient synovitis.
Supportive care with NSAIDs and observation is chosen.
Because the risk of septic arthritis is extremely low, invasive testing or treatments are deferred in favor of symptomatic relief.

Key Concept

Transient synovitis is the most common cause of acute hip pain in children aged 3-8 years and is diagnosed clinically by ruling out septic arthritis using the Kocher criteria; management consists of NSAIDs and observation.
Rate this question

Topics

Orthopedic Surgery

More questions from this topic