Bone and joint infections of the hand

Bone and Joint Infections of the Hand

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Emergency Recognition: Hand infections can rapidly progress to permanent disability, amputation, or systemic sepsis. Early recognition and aggressive management are critical for preserving function and preventing complications.

Introduction & Australian Epidemiology

Bone and joint infections of the hand represent a spectrum of conditions including septic arthritis, osteomyelitis, and tenosynovitis that can result in permanent functional impairment if not promptly and appropriately managed. These infections are more common in certain Australian populations, particularly those with high rates of trauma, diabetes, and injection drug use.

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Australian Context: Hand infections account for approximately 15-20% of all emergency department presentations for soft tissue infections. Rural and remote communities, particularly Aboriginal and Torres Strait Islander populations, have higher rates due to occupational hazards, delayed presentation, and limited access to specialist care.

Common Risk Factors

Penetrating trauma (animal bites, puncture wounds)
Human bites ("fight bite" over metacarpophalangeal joint)
Injection drug use
Diabetes mellitus
Immunocompromised states
Occupational exposure (fishing, farming, food handling)
Previous hand surgery or implants

High-Risk Populations

Aboriginal and Torres Strait Islander peoples
People who inject drugs
Workers in high-risk occupations
Elderly patients with comorbidities
Immunocompromised patients
Patients with peripheral vascular disease

Pathophysiology & Microbiology

Hand infections typically result from direct inoculation of bacteria through traumatic wounds, with subsequent spread through anatomical planes. The complex anatomy of the hand, including multiple fascial compartments and synovial spaces, facilitates rapid spread of infection and makes drainage challenging.

Common Pathogens by Clinical Context

Clinical Context	Common Pathogens	Special Considerations
Cellulitis/Soft tissue	Staphylococcus aureus, Streptococcus pyogenes	MRSA common in ATSI communities and PWID
Human bite	Eikenella corrodens, S. aureus, anaerobes	Polymicrobial, high morbidity
Animal bite	Pasteurella spp., S. aureus, Capnocytophaga	Consider rabies/tetanus prophylaxis
Fresh water exposure	Aeromonas spp., Pseudomonas spp.	Rapidly progressive
Salt water/marine	Vibrio spp., Mycobacterium marinum	Consider atypical mycobacteria
Injection drug use	S. aureus (including MRSA), Streptococcus spp.	Higher rates of MRSA and complications

Clinical Presentation & Diagnostic Criteria

Clinical presentation varies by anatomical location and severity. Early recognition of specific patterns is crucial for appropriate management and prevention of complications.

Mild

Superficial Infection

Limited cellulitis, minimal systemic symptoms

Outpatient management possible

Moderate

Deep Space/Joint Involvement

Septic arthritis, tenosynovitis, deep abscess

Hospital admission often required

Severe

Necrotising/Systemic

Necrotising fasciitis, osteomyelitis, sepsis

Emergency surgical intervention

Specific Clinical Syndromes

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Kanavel's Signs (Flexor Tenosynovitis): 1) Tenderness along flexor tendon sheath, 2) Finger held in slight flexion, 3) Pain with passive extension, 4) Fusiform swelling of finger. All four signs indicate surgical emergency.

Septic Arthritis

Joint swelling, erythema, warmth, severe pain with movement. May have limited range of motion and joint effusion.

Osteomyelitis

Deep bone pain, swelling, may have sinus tract. Often insidious onset, particularly in diabetics.

Flexor Tenosynovitis

Kanavel's four signs present. Requires urgent surgical intervention to prevent tendon necrosis.

Necrotising Fasciitis

Severe pain out of proportion to examination, skin changes, systemic toxicity. Surgical emergency.

Investigations

Investigations should be targeted based on clinical presentation and severity. Microbiological diagnosis is essential for directed therapy, particularly in severe infections or when resistant organisms are suspected.

Essential

Blood Cultures

Two sets before antibiotics in moderate-severe infections. Available in all Australian hospitals.
Essential

Wound Swab/Aspirate

Deep tissue or joint aspirate preferred over superficial swabs. Include anaerobic culture for bite wounds.
Available

Plain Radiographs

Two views of affected area. Available in all facilities. May show soft tissue swelling, gas, or bony changes in chronic infections.
Available

Full Blood Count

Leucocytosis may indicate systemic infection. Available in all laboratories.
Available

Inflammatory Markers

CRP, ESR useful for monitoring response. Procalcitonin may help differentiate bacterial from viral infection.
Referral

MRI

Gold standard for osteomyelitis diagnosis. Available in major centres, may require transfer from remote areas.
Specialist

Bone Biopsy

For definitive osteomyelitis diagnosis and culture. Requires specialist expertise and sterile technique.
Specialist

Joint Aspiration

Essential for septic arthritis diagnosis. Send for cell count, gram stain, culture, and crystal examination.

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Synovial Fluid Analysis: Septic arthritis: >50,000 WBC/μL with >75% neutrophils, positive gram stain in 50-70%, culture positive in 70-90%. Consider crystal arthropathy and other causes of sterile inflammation.

Risk Stratification & Severity Scoring

Risk stratification guides management decisions including need for hospitalisation, surgical intervention, and specialist consultation. Several factors indicate high-risk infections requiring aggressive management.

References

01
Pinder RM, Greyling M, Strydom A, et al. Hand infections: anatomy, types and spread of infection, investigations, and management. Bone Joint J. 2022;104-B(4):499-509.
02
Mathews CJ, Weston VC, Jones A, et al. Bacterial septic arthritis in adults. Lancet. 2010;375(9717):846-855.
03
Australian Commission on Safety and Quality in Health Care. Antimicrobial Stewardship in Australian Hospitals. Sydney: ACSQHC; 2018.
04
Kremers HM, Nwojo ME, Ransom JE, et al. Trends in the epidemiology of osteomyelitis: a population-based study, 1969 to 2009. J Bone Joint Surg Am. 2015;97(10):837-845.
05
Ostermann PA, Henry SL, Seligson D. The role of local antibiotic therapy in the management of compound fractures. Clin Orthop Relat Res. 1993;(295):102-111.
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Australian Institute of Health and Welfare. Australia's Health 2020: in brief. Cat. no. AUS 232. Canberra: AIHW; 2020.
07
Berbari EF, Kanj SS, Kowalski TJ, et al. 2015 Infectious Diseases Society of America (IDSA) clinical practice guidelines for the diagnosis and treatment of native vertebral osteomyelitis in adults. Clin Infect Dis. 2015;61(6):e26-46.
08
Department of Health. Pharmaceutical Benefits Scheme. Canberra: Australian Government Department of Health; 2024. Available from: https://www.pbs.gov.au
09
Spellberg B, Lipsky BA. Systemic antibiotic therapy for chronic osteomyelitis in adults. Clin Infect Dis. 2012;54(3):393-407.
10
RHDAustralia. The 2020 Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: RHDAustralia; 2020.
11
Zimmerli W, Trampuz A, Ochsner PE. Prosthetic-joint infections. N Engl J Med. 2004;351(16):1645-1654.
12
McNally MA, Ferguson JY, Lau AC, et al. Single-stage treatment of chronic osteomyelitis with a new absorbable, gentamicin-loaded, calcium sulphate/hydroxyapatite biocomposite: a prospective series of 100 cases. Bone Joint J. 2016;98-B(9):1289-1296.
13
Teterycz D, Ferry T, Lew D, et al. Outcome of orthopedic implant infections due to different staphylococci. Int J Infect Dis. 2010;14(10):e913-918.
14
Australian Medicines Handbook. Australian Medicines Handbook 2024. Adelaide: Australian Medicines Handbook Pty Ltd; 2024.
15
Chen CE, Ko JY, Pan CC. Results of vancomycin-impregnated cancellous bone grafting for infected tibial nonunion. Arch Orthop Trauma Surg. 2005;125(6):369-375.

Risk Factor	Low Risk	Moderate Risk	High Risk
Anatomical location	Superficial cellulitis	Deep space infection	Joint, bone, or tendon sheath
Systemic symptoms	None	Fever, malaise	Sepsis, organ dysfunction
Comorbidities	None	DM, PVD	Immunocompromised, ESRF
Wound characteristics	Clean laceration	Contaminated wound	Bite wound, foreign body