OSTEOMYELITIS (UPPER EXTREMITY)

Osteomyelitis is a rare bone infection. Once considered incurable, current treatments can be successful with removal of infected and necrotic bone and intravenous (IV) antibiotics. Common infection sites are growth plates of the arms and legs in children and the vertebrae and hips in adults. Osteomyelitis of the hand is rare and usually caused by direct inoculation (eg, penetrating trauma and postsurgical infection). It can also be caused by spread from adjacent tissue, the blood stream, or an infected prosthetic joint. Initially, signs and symptoms of osteomyelitis can be vague or absent. A high degree of suspicion is necessary, because osteomyelitis can spread to adjacent joints and cause septic arthritis, or involve soft tissues and form subcutaneous abscesses progressing to ulcerating lesions. An infectious disease specialist should be part of the medical team. Treatment almost always entails a medical-surgical combination approach.^1-4

Pathophysiology^1-4

• Most cases of osteomyelitis are caused by Staphylococcus (70–90%).
• Osteomyelitis due to inhalation of aerosolized spores from the fungus Coccidioides immitis (endemic to the American Southwest, Mexico, and South America) has been reported.
• Although disseminated C. immitis is rare (<1% of all infections), 10–30% of patients have osseous involvement, and a distal location is common.
• Osteomyelitis due to the fungus Blastomyces dermatitidis (endemic Midwestern, North Central, and Southeastern parts of the United States) also has been reported. Osseous involvement occurs in 25–50% of patients.
• Infection with group B Streptococcus in non-pregnant adults is increasing.
• Other microbes that have been associated with osteomyelitis include:
  • Viridans streptococci
  • Eikenella corrodens
  • Escherichia coli
  • Kingella kingae
  • Pasteurella multocida
  • Pseudomonas

Incidence and Related Conditions

• Osteomyelitis of the hand is rare and occurs in 6-10% of those patients with severe hand infections.
• Incidence of osteomyelitis in children has recently increased.  
• Hand hematogenous osteomyelitis is more common in children
• Risk factors for osteomyelitis include:
  • Severe bone fracture or deep puncture wound (eg, animal bite)
  • Surgery to repair bones or replace joints
  • Implanted orthopedic hardware
  • Blood circulation disorders (eg, diabetes, peripheral artery disease, sickle cell disease)
  • Use of IV lines or catheters (eg, dialysis machine tubing, urinary catheters)
  • IV drug abuse
  • Immunocompromised patients are at higher risk

Differential Diagnosis

• Acute calcium deposition
• Acute nonspecific flexor tenosynovitis
• Brown recluse spider bites
• Cellulitis
• Crystalline deposition disease (eg, gout, pseudogout)
• Foreign-body reactions
• Fracture
• Pyogenic granuloma
• Rheumatic fever
• Rheumatoid arthritis

The typical patient, most likely a child or an adult aged >50 years, may present with complaints of recent-onset pain, swelling, or discomfort in the hand or upper extremity. There may be recent fever or chills. The patient is unlikely to be able to pinpoint a specific precipitating event. Because there is a variety of risk factors for infection and possible osteomyelitis, the patient must be thoroughly questioned about (for example) recent travel, camping trips, previous surgery, blood circulation disorders, and implanted hardware. If symptoms are not of recent onset, then the differential diagnosis will narrow, as osteomyelitis is associated with rapid, aggressive progression. If a wound is chronic, patient factors such as smoking, compliance, associated medical comorbidities, and immunosuppression may be affecting wound healing. 

• Incomplete debridement
• Nerve injury
• Difficulty maintaining the hand in a functional position postsurgery to avoid negative effects on quality of life
• Chronic infection despite treatment
• Amputation

• Hand and wrist osteomyelitis infections are uncommon.³
• Outcomes vary widely according to the bacterium involved. Relapse rates can be as high as 78% in patients with osteomyelitis due to C. immitis.  
• Patient compliance is critical in managing chronic wounds.
• Other cases resolve satisfactorily (wound healing and full ROM) with surgical debridement and antifungal therapy. 

• The gold standard for diagnosis is bone biopsy with characteristic pathology and positive culture.
• Nonsurgical cure is occasionally achieved in acute osteomyelitis, but should not be routinely attempted.
• Single-use, portable negative-pressure wound therapy systems may achieve adequate seal and suction without immobilizing the hand, leading to improved patient compliance.
• C. immitis fungal infection is particularly difficult to manage because:
  • There are no pathognomonic chest X-ray findings.
  • Any symptoms usually manifest as those of a nonspecific upper respiratory tract infection.
  • Disseminated coccidioidomycosis immitis can cause bone infection.

New Article

1. Ahlawat S, Corl FM, LaPorte DM, et al. MDCT of hand and wrist infections: emphasis on compartmental anatomy. Clin Radiol 2017;72(4):338.e1-9. PMID: 28065641
2. Sheedy CA, Snyder SB. Clinician-performed ultrasound in identifying osteomyelitis of the hand. J Emerg Med 2014;47(5):e121-3. PMID: 25214178
3. Burns J, Moore E, Maus J, Rinker B.  Delayed idiopathic hardware - associated osteomyelitis of the scaphoid.  J Hand Surg Am 2019; 44(2):162.e1-e4.
4. Koshy JC, Bell B.  Hand infections.  J Hand Surg Am 2019; 44(1):46.54.

Reviews

1. Chan E, Bagg, M. Atypical hand infections. Orthop Clin North Am 2017;48(2):229-40. PMID: 28336045
2. Pinder R, Barlow G. Osteomyelitis of the hand. J Hand Surg Eur Vol 2016;41(4):431-40. PMID: 26482914

Classics

1. Michaeli D. Osteomyelitis with special reference to the hand. Prog Surg 1979;16:38-43. PMID: 375310
2. Borgia CA. An unusual bone reaction to an organic foreign body in the hand. Clin Orthop Rel Res 1963;30:188-93. PMID: 5889002