Osteomyelitis of the hand and wrist

Hand anatomy and special features of bone infections

The bones of the hand (phalanges, metacarpals/metacarpals, carpal bones) are finely structured and are surrounded by tendons, joint capsules and fine vessels. Although their good blood circulation promotes healing, it can also allow an infection to spread quickly - especially if the soft tissue infection is inadequately treated or after an injury.

• Short paths between skin, tendon sheaths and bones: Germs easily reach depths.
• Small compartments: Swelling increases pressure, reduces blood flow and promotes tissue damage.
• Close to the joint: Osteomyelitis can quickly turn into septic arthritis - an emergency.

Typical pathogens are Staphylococcus aureus (including MRSA), streptococci; Eikenella corrodens for human bites and Pasteurella multocida for animal bites. After operations or with implants, biofilm-forming skin germs can also be involved.

Causes and risk factors

• Open injuries: bites, punctures and cuts, nail bed infections (paronychia), panaritium.
• Post-operative or post-traumatic: after fractures, plate/screw osteosynthesis, external fixators.
• Hematogenous (via the bloodstream): v. a. in children or if there is an existing infection elsewhere.
• Soft tissue abscesses near bones or joints that break through.

• Risk factors:
• Diabetes mellitus and circulatory disorders
• Smoke
• Immunosuppression (e.g. cortisone, rheumatism therapies, HIV)
• Rheumatoid arthritis, chronic skin diseases
• Previous infections or implants

Acute osteomyelitis usually begins within a few days to weeks of the triggering event. Inadequately treated infections can become chronic: Sequestrums (dead bone material) and fistula tracts develop.

Symptoms: How to recognize osteomyelitis of the hand

• Local pain, tenderness over a bone or joint
• redness, warmth, swelling; Possibly discharge of pus
• Pain when moving, limited function, protective posture
• Fever, chills (not always present)
• In chronic cases: persistent or recurring pain, fistula formation, instability

Warning signs: increasing pain, new fever, rapidly increasing swelling or restricted movement of the finger/wrist. If joint involvement is suspected (severe pain at rest, severe pain when moving), there is a need for urgency.

Diagnostics: step by step

If the condition is stable, it may make sense to withhold antibiotics until the sample is taken so as not to falsify the pathogen diagnosis. If the course is severe or sepsis is suspected, immediate antibiotic therapy has priority.

Conservative therapy: antibiotics and immobilization first

In acute osteomyelitis without evidence of necrotic bone or abscess, primary conservative treatment may be sufficient. The aim is to quickly reduce the bacterial load, relieve pain and maintain function.

• Antibiotic therapy: initially calculated (e.g. against staphylococci and streptococci), then targeted according to antibiogram. Total duration is often 4-6 weeks, depending on the findings and course.
• Application: often initially intravenously, later oral continuation possible (depending on the active ingredient and absorption).
• Immobilization: briefly using a splint to relieve pain, then early functional mobilization as soon as acceptable.
• Pain management: anti-inflammatory and analgesic medications as needed.
• Treatment of underlying diseases: e.g. B. Blood sugar control, nicotine stop.

Close follow-up (clinic, CRP, imaging if necessary) is important. If pain, fever or inflammation persists, surgical repair must be considered.

Surgical therapy: When tissue needs to be repaired and stability needs to be ensured

Surgery is indicated if abscesses, fistulas, dead bone (sequestrum), unstable fractures or implant-related biofilm are present. The goal is thorough debridement, removal of non-viable tissue and, if necessary, restoration of stability.

• Debridement and Sequestrectomy: Removal of necrotic bone and infected soft tissue.
• Sampling: multiple deep tissue samples for culture and histology.
• Stabilization: temporary splinting, Kirschner wires, miniplates or external fixation - depending on the bone and defect.
• Local antibiotic carriers: absorbable carriers (e.g. calcium sulfate) or chains; Selection individually.
• Soft tissue coverage: if necessary, plastic coverage (flap) to create stable, well-supplied conditions.
• Follow-up treatment: targeted intravenous and then oral antibiotic therapy over several weeks.

In the case of implant-associated infections, depending on the situation, maintenance with aggressive debridement and biofilm-effective antibiotics is attempted or a staged approach with removal and later replacement is chosen. We make decisions individually after weighing up the risks and benefits.

Rehabilitation and everyday life: Maintain function, avoid stiffness

After the acute phase, early functional hand therapy is crucial to restore mobility, strength and fine motor skills. Immobilization should be as short as possible and as long as necessary.

• Physiotherapy and occupational therapy: mobilization that is gentle on the joints, scar care, tendon gliding.
• Load build-up: gradually depending on pain and stability, clear exercise plans.
• Splint supply: individually adapted, often as a removable functional splint.
• Ability to work and play sports: depending on job, infection control and stability – individual approval.

The course of therapy is checked regularly. If there are signs of renewed inflammation (increasing pain, redness, warmth), medical attention should be sought promptly.

Possible complications and prognosis

• Chronification with fistula formation and recurring attacks
• Bone instability, defects, pathological fractures
• Joint involvement with consequential damage and stiffness
• Tendon adhesions, scar problems, sensory disorders
• Rare: spread of infection (sepsis) – emergency

The prognosis depends on the speed of diagnosis, the spectrum of pathogens, the tissue situation and concomitant illnesses. A consistent, interdisciplinary approach improves the chances of stable infection control and good function - guarantees are not possible.

Differential diagnoses: What else is possible

• Septic arthritis (joint infection)
• Severe soft tissue infections (panaritium, cellulitis, flexor tenosynovitis)
• Gout/pseudogout
• Rheumatoid or psoriatic arthritis
• Fracture/stress fracture, aseptic bone necrosis
• Tumorous or granulomatous diseases (e.g. TB)

Prevention and aftercare

• Clean and disinfect hand wounds early and seek medical attention for deeper injuries.
• Always take bite injuries seriously: often early antibiotics and a tetanus check.
• Treat fractures in a stable manner and observe wound checks.
• Address risk factors: good blood sugar control, quitting smoking.
• After osteomyelitis: clinical and laboratory follow-up, graduated loading program.

Special situations: children, diabetes, implants

Hematogenous osteomyelitis is more common in children; it can manifest itself with non-specific complaints. A quick clarification is important to protect growth plates.

People with diabetes or arterial circulatory disorders have an increased risk of complicated disease. Good metabolic control and soft tissue management are particularly important here.

Biofilm formation plays a role in implants (plates, screws, wires). The decision between maintaining or removing an implant depends on stability, soft tissue situation, spectrum of pathogens and duration of the infection.

When should you seek medical attention?

• Severe pain, increasing redness/swelling in the hand
• Fever, chills or general feeling of being unwell
• Drainage of pus, formation of fistulas, foul smell from a wound
• After bite injuries, v. a. in the event of a cat or human bite
• After fracture/surgery with new pain or redness

If you experience acute warning signs, seek medical help immediately. In Hamburg you can reach our practice centrally at Dorotheenstrasse 48, 22301 Hamburg.

Your orthopedics in Hamburg

We treat infections of the hand and wrist with a structured, guideline-oriented concept. Appointments can be made easily online or by email. Address: Dorotheenstraße 48, 22301 Hamburg.