Hand Osteomyelitis Huda

Osteomyelitis of The
Hand
• Osteomyelitis of the hand is
relatively uncommon, representing
1% – 6% of all hand infections
• 70% in single bone
INTRODUCTION
• 38% distal phalanx, proximal
phalanx and metacarpal
Pinder R, Barlow G. Osteomyelitis of the hand. J Hand Surg Eur Vol. 2016 May;41(4):431-40. doi: 10.1177/1753193415612373. Epub 2015 Oct 19. PMID: 26482914.
Sendi, P., A. Kaempfen, I. Uçkay, and R. Meier. 2020. “Bone and Joint Infections of the Hand.” Clinical Microbiology and Infection 26, no. 7 (July): 848–56.
https://doi.org/10.1016/j.cmi.2019.12.007.
Dargan, Dallan, Matthew Wyman, Dominic Ronan, Mark Heads, and Dave Partridge. 2021. “This Is a Repository Copy of A Microbiological Analysis of 210 Cases of
Hand Osteomyelitis . White Rose Research Online URL for This Paper : Version : Published Version Article : Dargan , D ., Wyman , M ., Ronan , D . et Al . ( 4 More
Authors ) ( 2021 ) A Microbiological ISSN 2590-1702 Clinical Infection in Practice A Microbiological Analysis of 210 Cases of Hand Osteomyelitis.”
• Although most cases are not urgent, less
common, severe infections of hand require
urgent identification and management.
Why is it • Early identification and treatment are
Important? essential to achieve optimal outcomes.
• A missed or delayed diagnosis can result in
amputation or death.
Koshy, John C. et al. 2018. Hand Infections Current Concepts. J Hand Surg Am. February 2018
Pathophysiology
• Not every wounds become

infected, it determined by
quartet factors
• Frequent causes – neglected
wound
• Human bite – the most
common single mechanism
Belcher, H.J.C.R., Clare, T.D., 2003. (iv) Hand Infections. Curr Orthop 17, 28–43. https://doi.org/https://doi.org/10.1054/cuor.2002.0318
Direct Inoculation (ST trauma, OF or
surgery)
Spreading from adjacent focus

(abscess, septic arthritis, flexor sheath
Pathophysiology infection)
Hematogenous spread (rare but

common in male children)
Pinder R, Barlow G. Osteomyelitis of the hand. J Hand Surg Eur Vol. 2016 May;41(4):431-40.
doi: 10.1177/1753193415612373. Epub 2015 Oct 19. PMID: 26482914.
Percentage
Trauma Spreading Hematogen
5%
15%
Pathophysiology
80%
Pinder R, Barlow G. Osteomyelitis of the hand. J Hand Surg Eur Vol. 2016 May;41(4):431-40.
doi: 10.1177/1753193415612373. Epub 2015 Oct 19. PMID: 26482914.
ETIOLOGY
Culture Results in OM Patients with
Arterial Calcification
1. Mixed 38%
2. Enterobacterales 22%
3. Mixed Gram +ve 17%
Culture Results in OM Patients
without Arterial Calcification
4. MSSA 32%
5. Mixed 24%
6. Mixed Gram +ve 15%
ETIOLOGY
In another study, culture results in OM
patients with arterial calcification
2. MSSA 18%
3. Pseudomonas 16%
In another study, culture results in OM

patients without arterial calcification
4. MSSA 37%
5. CoNS 20%
However resistance is on the rise.
Community Acquired Infections Nosocomial Infections
(E.Coli & Klebsiella) (Pseudomonas / Acinteobacter)
ESBL resistance to ALL Resistance to Imipenem,

Cephalosporins in Indonesia Meropenem, Doripenem in APAC
R
R (25%)
(25% - 50%) R
(70%)
9
*Adapted from ANSORP Study, 2011 *Adapted from COMPACT Study, 2011
Comparison Between ESBL and MRSA:
2010 and 2012, in Surabaya
50
45
40
35
30
25
20
15
25,6% 27%
10 19,2%
15,5%
5
0
2010 2012
ESBL MRSA
TRIAD DIAGNOSE
Clinical Microbiological
Radiological
examination confirmation of
changes
findings infection
Clinical Findings
• Prolonged time intervals from trauma and from

onset of visible inflammation can indicate the
infection has expanded to bone
• Clinical signs of hand osteomyelitis :
1. pain and focal tenderness
2. erythema,
3. Swelling
4. functional impairment
5. may mimic a soft tissue infection
Sendi, P., A. Kaempfen, I. Uçkay, and R. Meier. 2020. “Bone and Joint Infections of the Hand.” Clinical Microbiology and Infection 26, no. 7 (July): 848–56. https://doi.org/10.1016/j.cmi.2019.12.007.
Radiography
• Plain radiographs
• osteolysis (70%)
• osteopenia (10%)
• osteosclerosis (10%)
• periosteal reaction (10%)
• sequestrum/involucrum
formation (5%)
• CT-Scan or MRI may perform if
needed
Koshy, John C. et al. 2018. Hand Infections Current Concepts. J Hand Surg Am. February 2018
Radiography
• Plain radiography has low
sensitivity and specificity for
detecting acute osteomyelitis.
• First two weeks of infection onset
will have a normal radiograph
An undisplaced 5th metacarpal shaft fracture ((a), arrow).
• In chronic osteomyelitis, a Repeating X-ray 16 days later, given the persistent pain, revealed rarefaction of 4th
sequestrum may be visible on and 5th carpometacarpal (CMC) joints consistent with osteomyelitis and septic
arthritis (b, arrow).
plain radiographs as a focal X-ray-following washout and introduction of antibiotic-impregnated cement
sclerotic lesion with a lucent rim spacer (arrow).
Lim, Wanyin, Christen D. Barras, and Steven Zadow. 2021. “Radiologic Mimics of Osteomyelitis and Septic Arthritis: A Pictorial Essay.” Radiology Research and Practice 2021, no. May (May): 1–18. https://doi.org/10.1155/2021/9912257.
Lee, Yu Jin, Sufi Sadigh, Kshitij Mankad, Nikhil Kapse, and Gajan Rajeswaran. 2016. “The Imaging of Osteomyelitis.” Quantitative Imaging in Medicine and Surgery 6, no. 2 (April): 184–98. https://doi.org/10.21037/qims.2016.04.01.
Microbiological
Confirmation of
Infection
• Erythrocyte Sedimentation
Rate (ESR), C-Reactive Protein
(CRP), and white cell count are
contributed little to the
diagnosis of osteomyelitis
• Blood culture may need to
confirm the specific organism
Microbiological Confirmation of Infection
Traumatized Metalworks/Prosthesis
1. Mixed 29% 1.MSSA 52%
2.Mixed 13%
2. MSSA 27%
3.CoNS 9%
3. CoNS 13% Human/Animal Bites
Abscess 4. MSSA 33%
4. MSSA 27% 5. Mixed 24%
6. Streptococcus sp. 10%
5. Mixed 23%
Burn
6. Mixed Gram +ve 15% 7. Mixed gram + ve 37%
Ulcer 8. MSSA 25%
7. Mixed 24% 9. Mixed 13%
8. MSSA 21% Spontaneous
10.Mixed gram + ve 25%
11.Streptococcus sp. 13%
Ischemia 12.CoNS 12%
10.Mixed 31 % Hematogenous
11.Enterobacterales 23% 13.MSSA 40%
12.MSSA 13% 14.Enterobacterales 20%
15.Fungi 20%
• Transient synovitis
• Trauma, including non-accidental injury
DIFFERENTI
• Inflammatory conditions
AL • Pyogenic myositis
DIAGNOSES • Discitis
• Malignancy
•Wong M, Williams N, Cooper C. Systematic Review of Kingella kingae Musculoskeletal Infection in Children: Epidemiology, Impact and Management Strategies. Pediatr
Health, Medicine and Therapeutics 2020:11
AIM
Correlate aetiologies
and comorbidities
Identify organisms with patterns of
Present the
associated with polymicrobial
microbiological
arterial calcification infections and types
organisms cultured
on plain x-ray of organisms and
review empirical
therapy.
Dargan, Dallan, Matthew Wyman, Dominic Ronan, Mark Heads, and Dave Partridge. 2021. “This Is a Repository Copy of A Microbiological Analysis of 210 Cases of Hand Osteomyelitis . White Rose Research
Online URL for This Paper : Version : Published Version Article : Dargan , D ., Wyman , M ., Ronan , D . et Al . ( 4 More Authors ) ( 2021 ) A Microbiological ISSN 2590-1702 Clinical Infection in Practice A
Microbiological Analysis of 210 Cases of Hand Osteomyelitis.”
MANAGEMENT
CONSERVATIVE? SURGERY?
MANAGEMEN
T
ALGORHYTM
Dargan, Dallan, Matthew Wyman, Dominic Ronan, Mark Heads, and Dave Partridge. 2021. “This Is a Repository Copy of A Microbiological Analysis of 210 Cases of Hand Osteomyelitis . White Rose Research Online URL for This Paper : Version : Published Version
Article : Dargan , D ., Wyman , M ., Ronan , D . et Al . ( 4 More Authors ) ( 2021 ) A Microbiological ISSN 2590-1702 Clinical Infection in Practice A Microbiological Analysis of 210 Cases of Hand Osteomyelitis.”
• Before sequestrum formation, acute
osteomyelitis can sometimes be successfully
WHEN TO DO treated medically.
SURGICAL • Periosteal or intramedullary aspiration can
MANAGEME yield the offending organisms.
• However, even in the acute stages, most
NT? surgeons prefer debridement and cortical
windowing followed by antibiotic treatment
Abrams, Reid A et al. 1996. Hand Infections: Treatment Recommendations for Specific Types. J Am Acad Orthop Surg 1996;4:219-230
SURGICAL MANAGEMENT PLAYS 2
ROLE
To get a specimen for To debride the necrotic

microbiological culture and infected tissue
GUIDELINES FOR MANAGEMENT OF HAND
OSTEOMYELITIS
Suspect osteomyelitis if:
 Radiological evidence of osteolysis or periosteal reaction
 Discharging sinus over bone
 At surgical removal of infected metalwork
 Clinical soft tissue infection with exposed bone
 Open fracture with soft tissue infection
Initial management
 Bloods: FBC, U&E, CRP. Add Uric Acid, Glucose/HbAIC if indicated
 X-ray
 Swab for microbiology
 List for urgent debridement, washout & bone biopsy (within 72 hours)
Initial antibiotics
 Assess for red flag signs of sepsis that require admission and IV antibiotics-discuss individual cases with microbiology
 Unless the patient is clinically unwell:
o Do not start antibiotics until patient has had a bone biopsy.
o If patient already on antibiotics, withhold for 72 hours prior to biopsy
If chronic osteomyelitis, withhold for
Wong M, Williams N, Cooper C. Systematic Review of Kingella kingae Musculoskeletal Infection in Children: Epidemiology, Impact and Management Strategies. Pediatr Health, Medicine and Therapeutics 2020:11
GUIDELINES FOR MANAGEMENT OF HAND
OSTEOMYELITIS
Surgical management
 Bone biopsy for microbiology (ideally 2 or more samples]& histology
 Separate instruments and pots for each sample
 Thorough washout & debridement of all non-viable tissue
 Commence antibiotics once biopsies have been taken (see below)
 Post-op ×-ray before discharge if significant debridement of bone
Post-surgical antibiotics
 Total of 6 weeks antibiotics usually required
 Discuss all cases with microbiology
 Uncomplicated cases/well patients, pending definitive cultures, start with:
o 1st line:Flucloxacillin
o Penicillin allergic: Doxycycline
o Human or animal bite: Co-amoxiclav
Follow up
 Hand surgery review 3-5 days (ward attender or consultant clinic) to:
o Assess for clinical improvement - escalate to senior if not improving.
o Check culture results and adjust antibiotics accordingly - discuss with
o microbiologist and document clearly in clinical record.
o This can be at a dressing clinic but patient must see a doctor.
 Consultant review (operating consultant if available) at:
o Week 2 -chase enrichment cultures, repeat FBC & CRP
 Week 6 -review off antibiotics, x-ray on arival
Wong M, Williams N, Cooper C. Systematic Review of Kingella kingae Musculoskeletal Infection in Children: Epidemiology, Impact and Management Strategies. Pediatr Health, Medicine and Therapeutics 2020:11
Algorithm for
Internal Fixation
with Osteomyelitis
• Bony reconstruction should perform
after infection had resolved
• In more severe or chronic, stabilize
SURGICAL using external fixator in the first stage
and bone reconstruction at a second
MANAGEME stage (at least 4-6 weeks later)
NT • Antibiotic spacer can be used to prevent
fibrous tissue invasion and induces a
surrounding membrane.
• Bone reconstruction-using morcelized
autologous cancellous bone graft
SURGICAL
MANAGEMENT
Multiple deep tissue specimens are
more preferred than a swabs
If clean wound can be closed, or leave

it open to allow drainage
Delay soft tissue closure until the

infection resolved
• Adequate bone penetration and high oral
bioavailability are preferred
• doxycycline, fluoroquinolones, linezolid,
and rifampicin
ANTIBIOTIC • Combinations of antibiotics used when treating
implant-associated infections.
S • Important factor to consider :
• Patient allergy/intolerance
• Safety
• The complexity of required monitoring
• Regime
• Local Prescribing factor
• Mader et al. (1997) applied the Cierny–Mader
Classification to parenteral (intravenous)
antibiotic management with varying lengths
for each stage :
ANTIBIOTIC • Stage I : initial 4 weeks after first
S debridement, followed by a possible further
4 weeks if recurrent infection
• Stage II : a 2 week course after
debridement and soft tissue cover
• Stage III & IV : a 4 to 6 week course after
the last major debridement
• Regular surveillance is essential, if
there is no improvement then re-
exploration should be considered
• Rehabilitation should start as early as
AFTER CARE AND possible
OUTCOME • Several complication followed :
• Pain and tenderness
• Stiffness and contracture
• Compartment syndrome
• Amputation
• Death
Belcher, H.J.C.R., Clare, T.D., 2003. (iv) Hand Infections. Curr Orthop 17, 28–43. https://doi.org/https://doi.org/10.1054/cuor.2002.0318
THANK YOU

Hand Osteomyelitis Huda

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Hand Osteomyelitis Huda

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Osteomyelitis of The

• Not every wounds become

Spreading from adjacent focus

Hematogenous spread (rare but

In another study, culture results in OM

ESBL resistance to ALL Resistance to Imipenem,

• Prolonged time intervals from trauma and from

To get a specimen for To debride the necrotic

If clean wound can be closed, or leave

Delay soft tissue closure until the

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