Pediatric Primary Care Case Studies (130 page)

Naproxen and ibuprofen are the most frequently prescribed nonsteroidal anti-inflammatory drugs (NSAIDs) used for children. NSAIDs may shorten the duration of symptoms (Whitelaw & Schikler, 2008). In a randomized clinical trial, ibuprofen was found to shorten the duration of symptoms in cases of mild transient synovitis of the hip (Kocher, 2004). In cases of severe transient synovitis, medications such as ibuprofen or acetaminophen may need to be avoided so that symptoms of septic arthritis will not be masked (Kocher). The most important factor in the drug therapy is to make sure the parent/caretaker is giving the medication in the correct dose at the prescribed intervals. NSAIDs should be administered with food to avoid gastrointestinal upset. The parent/caretaker needs to understand that they are giving the medication for the anti-inflammatory effects so the medication needs to be given around the clock, not just when the child has pain or fever.

When do you want to see this child back?

Diagnosis of an infected hip is especially difficult in the early phase. The physiologic response to early bacterial infection is quite variable, and serum indicators of inflammation can be within normal range (Luhmann et al., 2004). Follow-up in 12 to 24 hours is crucial to check for changes in the child’s condition.

24-Hour Follow-Up

Tyler is seen in the clinic the next morning. According to his mother he has been afebrile and slept through the night. She has given him the prescribed ibuprofen every 6 hours. He is sitting on his mother’s lap looking at a picture book. When he is examined he still has some hip irritability and guarding, but is more cooperative than on the previous exam. An appointment is made to return to the clinic in 1 week with instructions to call if the child develops fever or increased pain. The mother is instructed to continue administering the ibuprofen for inflammation until the next visit.

One week later Tyler is seen in the clinic. He is sitting on the floor playing with a truck. His mother states it has been difficult to keep him from running around and playing with his brothers. He has been afebrile. On examination he has no complaints of pain or
guarding, with range of motion of the hip. He is able to ambulate without a limp. At this time, you instruct the mother to discontinue the ibuprofen and to let him resume his normal activity. She is to return to the clinic if he becomes febrile or has hip pain.

Tyler’s mother asks you if there are any long-term effects that she should watch for.

How will you answer her question?

The parent should be informed about the following expected outcomes:

   Transient synovitis requires systematic treatment and typically resolves without complication (Shah, 2005).

   Patients with transient synovitis usually experience marked improvement in 24–48 hours.

   Two thirds to three fourths of patients usually experience complete resolution in 2 weeks.

   The recurrence rate is 4–17%; most recurrences develop within 6 months.

   There is no increased risk for chronic juvenile arthritis.

   There is a slightly increased risk for developing osteoarthritis later in life (Whitelaw & Schikler, 2008).

Key Points from the Case

1. History with an analysis of the presenting symptoms and a physical exam are key to making the proper diagnosis.

2. Review of the causes of acute limping in the child identifies the differential diagnosis that must be considered.

3. Know the key radiographs and laboratory values that are needed to make the correct diagnosis.

4. Management and follow-up care of toxic synovitis are critical points to discuss with the parents.

REFERENCES

Adler, B. (2008).
Slipped capital femoral epiphysis.
Retrieved June 2, 2009, from
http://emedicine.medscape.com/article/413810-overview

Beach, C. B., & Ficke, J. (2007).
Limping child.
Retrieved June 2, 2009, from
http://emedicine.medscape.com/article/1258835-overview

Caird, M., Flynn, J. M., Leung, L., Millman, J., D’Italia, J., & Dormans, J. (2006). Factors distinguishing septic arthritis from transient synovitis of the hip in children. A prospective study.
Journal of Bone and Joint Surgery, 88
(6), 1251–1257.

Fordham, G., Gunderman, R., Blatt, E. R., Bulas., D., Coley, B. D., Poderberesky, D., et al. (2007). American College of Radiology ACR appropriateness criteria: limping child: ages 0–5 years
American College of Radiology.
Retrieved June 2, 2009, from
http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=11598&nbr=6011

Junnila, J., & Cartwright, V. (2006a). Chronic musculoskeletal pain in children: part I. Initial evaluation.
American Family Physician, 74
(1), 115–122.

Junnila, J., & Cartwright, V. (2006b). Chronic musculoskeletal pain in children: part II. Rheumatic causes.
American Family Physician, 74
(2), 293–300.

Kocher, M. (2004). Ibuprofen shortened time to symptom resolution in children with transient synovitis of the hip.
Journal of Bone and Joint Surgery, 86
(2), 439.

Kocher, M., Mandiga, R., Zurkowski, D., Barnewold, C., & Kasser, J. (2004). Validation of a clinical prediction rule for the differentiation between septic arthritis and transient synovitis of the hip in children.
Journal of Bone and Joint Surgery, 86
(8), 1629–1635.

Luhmann, S., Jones, A., Schootman, M., Gordon, J. E., Schoenecker, P., & Luhmann, J. (2004). Differentiation between septic arthritis and transient synovitis of the hip in children with clinical predictive algorithms.
Journal of Bone and Joint Surgery, 86
(5), 956–962.