Abstract Introduction The high incidence of transient synovitis in early childhood makes it the first suspected pathology in a limping child. Trauma, which has long been regarded as a causative factor for transient synovitis, may be underestimated in a non-cooperative toddler. After excluding most serious conditions, such as septic arthritis, a speculative diagnosis of transient synovitis can be made, and this can easily mask a subtle musculoskeletal injury. Case presentations We report the cases of three Caucasian patients (two boys, aged 20-months- and three-years-old, and one girl, aged two-years-old), with tibial torus and toddler's fractures which were late-diagnosed due to an initial misdiagnosis of transient synovitis of the hip. Conclusion In a non-cooperative child musculoskeletal trauma can be mistaken as a simple causative factor for transient synovitis of the hip and this can easily prevent further investigation for a possible subtle musculoskeletal injury of the lower extremities. Our experience with the presented cases suggests the need to be more vigilant in the differential diagnosis of transient synovitis in young children.</p

Aksel Seyahi

Burak Altıntaş

C Nnadi

CM Illingworth

CP Sainsbury

G Fabry

JS Dunbar

Kevin Hardinge

KLG Mills

M Padman

MB Hermel

Mehmet Demirhan

MS Caird

P Yagupsky

RB Dzioba

Serkan Uludag

SU Fischer

TT Do

Y Uziel

English

PubMed

Springer - Publisher Connector

CASE REPORT Open Access
Tibial torus and toddler’s fractures misdiagnosed
as transient synovitis: a case series
Aksel Seyahi1*, Serkan Uludag1, Burak Altıntaş1 and Mehmet Demirhan2
Abstract
Introduction: The high incidence of transient synovitis in early childhood makes it the first suspected pathology in
a limping child. Trauma, which has long been regarded as a causative factor for transient synovitis, may be
underestimated in a non-cooperative toddler.
After excluding most serious conditions, such as septic arthritis, a speculative diagnosis of transient synovitis can be
made, and this can easily mask a subtle musculoskeletal injury.
Case presentations: We report the cases of three Caucasian patients (two boys, aged 20-months- and three-years-
old, and one girl, aged two-years-old), with tibial torus and toddler’s fractures which were late-diagnosed due to
an initial misdiagnosis of transient synovitis of the hip.
Conclusion: In a non-cooperative child musculoskeletal trauma can be mistaken as a simple causative factor for
transient synovitis of the hip and this can easily prevent further investigation for a possible subtle musculoskeletal
injury of the lower extremities.
Our experience with the presented cases suggests the need to be more vigilant in the differential diagnosis of
transient synovitis in young children.
Introduction
Toddler’s fracture is a subtle, non-displaced fracture of
the tibia in children, aged between nine-months-old to
three-years-old. The child presents with an acute onset
of limp or refusal to bear weight on the leg. Toddlers
may be unable to localize pain or give a history. They
are also usually uncooperative during the physical exam.
Clinical signs of a toddler’s fracture can be subtle with
non-specific physical findings of local injury.
Transient synovitis (TS) of the hip is one of the most
common causes of hip pain and limping during early
childhood [1-4]. This benign condition is a clinical diag-
nosis, which is confirmed by excluding potentially more
severe disorders, such as septic arthritis, osteomyelitis,
slipped femoral epiphysis and Perthes’ disease. Septic
arthritis is the first, and occasionally the main condition
that most clinicians would like to exclude, due to its
devastating course [5,6]. However trauma, which has
commonly been mentioned as a causative factor, has
probably been underestimated in the differential diagno-
sis of this frequent entity [3,4,7-11].
We describe three cases of tibial torus and toddler’s
fractures. The initial misdiagnosis of TS of the hip
delayed the true diagnosis.
Case presentations
Case #1
A 20-month-old Caucasian boy presented with acute left
sided lower extremity pain and limping. He was not
cooperative and his parents did not mention a history of
trauma. He held his hip in flexion and external rotation.
No swelling and no signs of inflammation were
observed. On physical examination, he had no particu-
larly tender zone, but a generalized referred pain to the
entire lower extremity with passive rotations of the left
hip. A low-grade fever of 37.2°C was present and his
erythrocyte sedimentation rate (ESR) was 12 mm/hour.
The anteroposterior and frog leg radiographs of the pel-
vis were normal, and a probability of TS was suspected.
Anti-inflammatory therapy with ibuprofen suspension
(100 mg orally twice a day) was administered and the
child was discharged to return later for a follow up.
* Correspondence: aseyahi@gmail.com
1American Hospital, Department of Orthopaedics and Traumatology,
Istanbul, Turkey
Full list of author information is available at the end of the article
Seyahi et al. Journal of Medical Case Reports 2011, 5:305
http://www.jmedicalcasereports.com/content/5/1/305 JOURNAL OF MEDICAL
CASE REPORTS
© 2011 Seyahi et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
Two days after his initial presentation, the child
returned with the same symptoms and no relief. On re-
examination there was moderate swelling and local ten-
derness at the lateral aspect of the knee. A whole lower
extremity radiograph showed a metaphyseal torus frac-
ture of the left tibia (Figure 1). The boy was treated
with a long leg plaster cast for four weeks. Retrospective
questioning of the parents revealed a history of an
unknown period of care under the supervision of his
nursemaid.
Case #2
A three-year-old Caucasian boy presented to a local
pediatric polyclinic with acute hip pain and difficulty
in bearing weight on his left leg. The child had no
fever (36.5°C) and his CRP was negative. Radiographic
examination of his hip did not reveal any pathology
and a diagnosis of TS was made. Bed rest and anti-
inflammatory therapy with acetaminophen (120 mg
orally, twice a day) was started. He did not improve
after six days of treatment, and he was referred to our
institution with a suspected diagnosis of an early-onset
Perthes disease. On his re-examination, aside from the
painful hip rotations, there was local tenderness and
swelling in the left leg and passive flexion and exten-
sion of the ankle was painful. An entire-leg radiograph
of the lower extremity revealed a subtle non-displaced
oblique fracture of the left tibia (Figure 2). After the
application of a long leg cast, his symptoms subsided
dramatically. The fracture healed at the end of the fifth
week. Retrospective questioning of the parents con-
firmed that the patient had a history of losing his foot-
ing when running with the dog.
Case #3
A two-year-old Caucasian girl presented to our emer-
gency room with acute right-sided lower extremity pain
and limping. She had stumbled the same morning she
was admitted, and her parents noticed her limping late
in the afternoon. She was initially evaluated by the
emergency room physician and then consulted by a
pediatrician in attendance. She held her hip in flexion
and no local tenderness was observed. On physical
examination, she had a generalized pain which referred
to the entire lower extremity and abduction and internal
rotation of the hip was limited. She had a slight fever of
37.4°C, her CRP was negative (1.6 mg/L) and her ESR
was 8 mm/hour. With the initial diagnosis of TS, she
was given an anti-inflammatory (ibuprofen, 100 mg
orally, three times a day) and bed rest was advised.
She had a slight improvement of her symptoms in the
first week. Two weeks after her initial visit, she was eval-
uated in our orthopedic outpatient clinic because of her
persisting symptoms. There was local tenderness and
swelling on her right leg and passive flexion and exten-
sion of the ankle was painful. A whole lower extremity
radiograph showed peri-osteal new bone formation sug-
gesting the healing of a toddler’s fracture (Figure 3).
The patient healed uneventfully after two additional
weeks of immobilization and she had no complaint
Figure 1 Whole lower extremity radiograph showed a
metaphyseal torus fracture of the left tibia (arrow).
Figure 2 Whole-leg radiograph of the lower extremity revealed
a subtle non-displaced oblique tibia fracture which was only
seen on the lateral view (arrow).
Seyahi et al. Journal of Medical Case Reports 2011, 5:305
http://www.jmedicalcasereports.com/content/5/1/305
Page 2 of 4
during her follow-up examination three months after
her initial admission.
Discussion
Toddler’s fracture was described by Dunbar in 1964 as a
subtle, non-displaced fracture of the tibia in children,
nine months to three years of age [12]. The child pre-
sents with an acute onset of limp or refusal to bear
weight on the leg. Toddlers are unsteady and they may
fall with a twist, or they may have gotten their foot
caught and fallen. The fall is generally unwitnessed by
the parents who will be unsure of an injury. Clinical
signs of a toddler’s fracture can be subtle with non-spe-
cific physical findings of local injury. Radiologic signs
can also be subtle, as in the presented cases. The frac-
ture may only be seen on the oblique views.
TS of the hip, is an inflammation and swelling of the tis-
sues around the hip joint. It is accepted as the most com-
mon cause of sudden hip pain in children. The diagnosis
of TS is inevitably speculative and retrospective. The simi-
larities between TS and other more serious diseases makes
the diagnosis difficult. The differential diagnosis includes,
but is not limited to, the conditions listed in Table 1.
Difficulty in bearing weight on a leg, characteristic of
an acute onset of a limp, suggests the diagnosis of TS
[2,3,8,9,13-15] While limitation of internal rotation is
the most common finding, referred pain in the knee can
occasionally be the predominant complaint [4]. In the
reported cases, passive rotations of the hip joint, tested
with 90 degrees of hip and knee flexion, were painful.
The reactions of the children were probably due to the
leg pain which was obviously triggered by this maneuver
(Figure 4).
Figure 3 Lower extremity radiograph showed periosteal new
bone formation suggesting healing of a toddler’s fracture.
Table 1 Differential diagnosis of acute hip pain and limp
• Septic arthritis
• Perthes disease
• Juvenile rheumatoid arthritis
• Discitis
• Psoas abscess
• Stress fracture
• Overuse syndrome
• Rheumatic fever
• Proximal femoral osteomyelitis
• Kawasaki syndrome
• Gaucher disease
• Tumor (Ewing, osteoid osteoma, osteogenic sarcoma, acute
lymphocytic leukemia)
• Serum sickness
• Slipped capital femoral epiphysis
• Tuberculosis
Figure 4 During the examination of the hip rotations the shear
forces acting on the leg (arrows) can elicit pain in an injured
tibia and this can be mistaken as a hip tenderness.
Seyahi et al. Journal of Medical Case Reports 2011, 5:305
http://www.jmedicalcasereports.com/content/5/1/305
Page 3 of 4
The difficulties in taking history and evaluation in a
young child, the natural association with trauma, and
referred pain are all important factors complicating the
differential diagnosis of TS in early childhood. The pre-
sented young children with toddler’s fractures were
unable to localize pain or give a history. They were
uncooperative during the physical examination.
Trauma has been commonly mentioned as a causative
factor for TS [3,4,7-11]. It has been reported to have
occurred in, as high as, 17% to 30% of the patients [4].
Local contusion to the hip is thought to set up a self limit-
ing chemical synovitis which resolves as the hematoma is
reabsorbed. Trauma history can be considered as a natural
preceding condition in TS. This can prevent a thorough
investigation for a probable subtle musculoskeletal injury.
While it is difficult to assess the accuracy of published
reports on TS, which is obviously an excluding one, the
high rates (up to 30%) of trauma history can be due to
several missed diagnoses of musculoskeletal injuries.
Finally, we should also mention the probability of the
co-existence of TS in the reported cases. While our
patients had limited and painful hip rotation at their initial
evaluation, it is not clear if this was due to leg pain or an
accompanying TS in the hip. Steady relief was observed in
their symptoms after immobilization of the leg.
Conclusion
In non-cooperative young children, musculoskeletal
trauma can be mistaken as a simple causative factor for
TS of the hip which can easily preclude further investi-
gation for a possible subtle musculoskeletal injury of the
lower extremities.
Our experience with the presented cases suggests the
need to be more vigilant in the differential diagnosis of
TS in early childhood. We believe that a detailed history
should be taken from the parents and that a musculos-
keletal injury should always be considered, even with a
minor trauma history.
Consent
Written informed consent was obtained from all three
patient’s parents for publication of these case reports
and any accompanying images. A copy of the written
consent is available for review by the Editor-in-Chief of
this journal.
Author details
1American Hospital, Department of Orthopaedics and Traumatology,
Istanbul, Turkey. 2Istanbul University, Istanbul Faculty of Medicine;
Department of Orthopedics and Traumatology, Istanbul, Turkey.
Authors’ contributions
All authors read and approved the final manuscript. AS wrote the abstract,
introduction, and discussion sections. SU wrote the case report section. BA
reviewed the literature, prepared the figures and participated in writing the
case reports. MD revised the manuscript and gave final approval of the
version to be published.
Competing interests
The authors declare that they have no competing interests.
Received: 2 February 2011 Accepted: 13 July 2011
Published: 13 July 2011
References
1. Fabry G: Clinical practice: the hip from birth to adolescence. Eur J Pediatr
2010, 169:143-148.
2. Fischer SU, Beattie TF: The limping child: epidemiology, assessment and
outcome. J Bone Joint Surg Br 1999, 81:1029-1034.
3. Illingworth CM: Recurrences of transient synovitis of the hip. Arch Dis
Child 1983, 58:620-623.
4. Do TT: Transient synovitis as a cause of painful limps in children. Curr
Opin Pediatr 2000, 12:48-51.
5. Yagupsky P: Differentiation between septic arthritis and transient
synovitis of the hip in children. J Bone Joint Surg Am 2005, 87:459, author
reply 459-60.
6. Caird MS, Flynn JM, Leung YL, Millman JE, D’Italia JG, Dormans JP: Factors
distinguishing septic arthritis from transient synovitis of the hip in
children. A prospective study. J Bone Joint Surg Am 2006, 88:1251-1257.
7. Hermel MB, Sklaroff DM: Roentgen changes in transient synovitis of the
hip joint. AMA Arch Surg 1954, 68:364-368.
8. Mills KLG: Transitory Synovitis of the Hip in Children. Postgrad Med J 1964,
40:190-192.
9. Dzioba RB, Barrington TW: Transient monoarticular synovitis of the hip
joint in adults. Clin Orthop Relat Res 1977, , 126: 190-192.
10. Padman M, Scott BW: Irritable hip and septic arthritis of the hip.
Orthopaedics and Trauma 2009, 23:153-157.
11. Sainsbury CP, Newcombe RG, Essex-Cater A: Irritable hips: relationship
with trauma. Lancet 1986, 1:220.
12. Dunbar JS, Owen HF, Nogrady MM, McLeese R: Obscure tibial fracture of
infants the toddler’s fracture. J Canad Assoc Radiol 1964, 15:136-144.
13. Hardinge Kevin: The etiology of transient synovitis of the hip in
childhood. J Bone Joint Surg Br 1970, 52:100-107.
14. Uziel Y, Butbul-Aviel Y, Barash J, Padeh S, Mukamel M, Gorodnitski N, Brik R,
Hashkes PJ: Recurrent transient synovitis of the hip in childhood.
Longterm outcome among 39 patients. J Rheumatol 2006, 33:810-811.
15. Nnadi C, Chawla T, Redfern A, Argent J, Fairhurst J, Clarke N: Radiograph
evaluation in children with acute hip pain. J Pediatr Orthop 2002,
22:342-344.
doi:10.1186/1752-1947-5-305
Cite this article as: Seyahi et al.: Tibial torus and toddler’s fractures
misdiagnosed as transient synovitis: a case series. Journal of Medical
Case Reports 2011 5:305.
Submit your next manuscript to BioMed Central
and take full advantage of: 
• Convenient online submission
• Thorough peer review
• No space constraints or color figure charges
• Immediate publication on acceptance
• Inclusion in PubMed, CAS, Scopus and Google Scholar
• Research which is freely available for redistribution
Submit your manuscript at 
www.biomedcentral.com/submit
Seyahi et al. Journal of Medical Case Reports 2011, 5:305
http://www.jmedicalcasereports.com/content/5/1/305
Page 4 of 4


Tibial torus and toddler's fractures misdiagnosed as transient synovitis: a case series

Crossref

Journal of Medical Case Reports

Abstract Introduction The high incidence of transient synovitis in early childhood makes it the first suspected pathology in a limping child. Trauma, which has long been regarded as a causative factor for transient synovitis, may be underestimated in a non-cooperative toddler. After excluding most serious conditions, such as septic arthritis, a speculative diagnosis of transient synovitis can be made, and this can easily mask a subtle musculoskeletal injury. Case presentations We report the cases of three Caucasian patients (two boys, aged 20-months- and three-years-old, and one girl, aged two-years-old), with tibial torus and toddler's fractures which were late-diagnosed due to an initial misdiagnosis of transient synovitis of the hip. Conclusion In a non-cooperative child musculoskeletal trauma can be mistaken as a simple causative factor for transient synovitis of the hip and this can easily prevent further investigation for a possible subtle musculoskeletal injury of the lower extremities. Our experience with the presented cases suggests the need to be more vigilant in the differential diagnosis of transient synovitis in young children.</p

Altıntaş Burak

Uludag Serkan

Seyahi Aksel

Demirhan Mehmet

Directory of Open Access Journals

Clinical practice: the hip from birth to adolescence.

Differentiation between septic arthritis and transient synovitis of the hip in children.

Dormans JP: Factors distinguishing septic arthritis from transient synovitis of the hip in children. A prospective study.

Essex-Cater A: Irritable hips: relationship with trauma. Lancet

Hashkes PJ: Recurrent transient synovitis of the hip in childhood. Longterm outcome among 39 patients.

Irritable hip and septic arthritis of the hip. Orthopaedics and Trauma

Obscure tibial fracture of infants the toddler’s fracture.

Radiograph evaluation in children with acute hip pain. J Pediatr Orthop

Recurrences of transient synovitis of the hip. Arch Dis Child

Sklaroff DM: Roentgen changes in transient synovitis of the hip joint. AMA Arch Surg

TF: The limping child: epidemiology, assessment and outcome.

The etiology of transient synovitis of the hip in childhood.

Transient synovitis as a cause of painful limps in children. Curr Opin Pediatr

Transitory Synovitis of the Hip in Children. Postgrad Med J

TW: Transient monoarticular synovitis of the hip joint in adults. Clin Orthop Relat Res

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3142521

Tibial torus and toddler's fractures misdiagnosed as transient synovitis: a case series

Abstract

Similar works

Full text

Available Versions

Springer - Publisher Connector

Crossref

Directory of Open Access Journals