Bone and joint infections of the hand

Bone and Joint Infections of the Hand

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Emergency Presentation: Hand infections can rapidly progress to sepsis, osteomyelitis, or permanent disability. Prompt recognition and treatment are critical for preserving function.

Clinical Presentation

MILD

Early Infection

Localised pain, swelling, warmth. Normal range of motion. No systemic symptoms.

Outpatient management

MODERATE

Established Infection

Significant pain, restricted movement, regional lymphadenopathy. Possible low-grade fever.

Urgent specialist review

SEVERE

Deep/Systemic Infection

Severe pain, marked swelling, inability to move joints, systemic toxicity, fever >38°C.

Emergency admission

Common Pathogens

Infection Type	Common Pathogens	Risk Factors
Acute septic arthritis	Staphylococcus aureus (including MRSA), Streptococcus species	Penetrating trauma, diabetes, immunocompromise
Chronic osteomyelitis	S. aureus, Pseudomonas aeruginosa, Enterobacter species	Previous surgery, open fractures, chronic wounds
Human bite wounds	Streptococcus viridans, Eikenella corrodens, anaerobes	Fight bite, clenched fist injury
Animal bites	Pasteurella multocida (cats), mixed flora	Cat/dog bites, particularly deep puncture wounds

Initial Assessment

Clinical History

Mechanism of injury, timing, systemic symptoms, immunocompromise, diabetes, previous infections

Physical Examination

Inspect for wounds, swelling, erythema. Assess range of motion, tendon function, neurovascular status

Imaging

X-ray (initial), ultrasound for joint effusion, MRI if osteomyelitis suspected

Investigations

ESSENTIAL

Blood cultures

If systemic symptoms or fever present

ESSENTIAL

Joint aspiration/tissue culture

Pre-antibiotic if possible. Include anaerobic cultures for bite wounds

AVAILABLE

FBC, CRP, ESR

Inflammatory markers. CRP >100 mg/L suggests severe infection

REFERRAL

MRI with contrast

If osteomyelitis suspected or poor response to treatment

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MRSA Risk: Consider MRSA in healthcare workers, nursing home residents, IV drug users, or areas with high community-acquired MRSA prevalence (particularly remote Indigenous communities).

First-Line Antibiotic Therapy

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Flucloxacillin

First-line for S. aureus

Adult Dose 2 g IV q6h OR 500 mg PO q6h

Paediatric 50 mg/kg IV q6h (max 2 g/dose)

Duration 2-6 weeks depending on severity

PBS Status ✔ PBS General Benefit

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Cephalexin

Keflex® · Oral alternative

Adult Dose 500 mg PO q6h

Paediatric 25 mg/kg PO q6h

Advantage Good oral bioavailability

PBS Status ✔ PBS General Benefit

MRSA Coverage

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Vancomycin

First-line IV for MRSA

Adult Dose 25-30 mg/kg IV loading, then 15-20 mg/kg q8-12h

Monitoring Trough levels 15-20 mg/L for serious infections

Renal Adjustment Reduce dose if CrCl <50 mL/min

PBS Status ⚠ PBS Restricted

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Lincomycin

Oral MRSA option

Adult Dose 600 mg PO q8h

Advantage Good bone penetration

Side Effects C. difficile risk, GI upset

PBS Status ✔ PBS General Benefit

Bite Wound Coverage

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Amoxicillin-clavulanate

Augmentin® · Broad spectrum

Adult Dose 875/125 mg PO q12h OR 1.2 g IV q8h

Coverage S. aureus, Pasteurella, anaerobes

Human Bites First-line for polymicrobial infections

PBS Status ✔ PBS General Benefit

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Doxycycline + Metronidazole

Penicillin allergy alternative

Doxycycline 100 mg PO q12h

Metronidazole 400 mg PO q8h

Coverage Gram-positive, anaerobes, atypicals

References

1. Therapeutic Guidelines Limited. eTG complete [Internet]. Melbourne: Therapeutic Guidelines Limited; 2024. Antibiotic; Bone and joint infections.

2. Australian Commission on Safety and Quality in Health Care. AURA 2021: third Australian report on antimicrobial use and resistance in human health. Sydney: ACSQHC; 2021.

3. Patzakis MJ, Wilkins J, Brien WW, Carter VS. Infected versus sterile malunion of the tibia. Clin Orthop Relat Res. 1991;(269):193-201.

4. 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-e46.

5. Osmon DR, Berbari EF, Berendt AR, et al. Diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2013;56(1):e1-e25.

6. Australian Government Department of Health. Pharmaceutical Benefits Scheme [Internet]. Canberra: Australian Government; 2024 [cited 2024]. Available from: https://www.pbs.gov.au/

7. Zimmerli W, Trampuz A, Ochsner PE. Prosthetic-joint infections. N Engl J Med. 2004;351(16):1645-1654.

8. Australian Institute of Health and Welfare. Aboriginal and Torres Strait Islander Health Performance Framework 2020 report. Cat. no. IHPF 2. Canberra: AIHW; 2020.

9. RHDAustralia (ARF/RHD writing group), National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand. Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease (2nd edition). 2012.

10. Mathews CJ, Weston VC, Jones A, Field M, Coakley G. Bacterial septic arthritis in adults. Lancet. 2010;375(9717):846-855.

11. Kremers HM, Nwojo ME, Ransom JE, Wood-Wentz CM, Melton LJ 3rd, Huddleston PM 3rd. Trends in the epidemiology of osteomyelitis: a population-based study, 1969 to 2009. J Bone Joint Surg Am. 2015;97(10):837-845.

12. Australian Group on Antimicrobial Resistance. Staphylococcus aureus sepsis outcome programme (ASSOP) annual report 2021. Commun Dis Intell. 2022;46.

13. Lew DP, Waldvogel FA. Osteomyelitis. Lancet. 2004;364(9431):369-379.

14. Australian National Antimicrobial Resistance Surveillance System. NARMS annual report 2021. Canberra: Department of Health and Aged Care; 2022.

15. Spellberg B, Lipsky BA. Systemic antibiotic therapy for chronic osteomyelitis in adults. Clin Infect Dis. 2012;54(3):393-407.

16. Australian Medicines Handbook Pty Ltd. Australian medicines handbook. Adelaide: Australian Medicines Handbook Pty Ltd; 2024.

17. McNeil JC, Sommer LM, Baker CJ, et al. Impact of bone and joint infections in childhood: a systematic review and meta-analysis. J Pediatric Infect Dis Soc. 2021;10(1):31-41.

18. Royal Children's Hospital Melbourne. Clinical Practice Guidelines: Osteomyelitis and septic arthritis [Internet]. Melbourne: RCH; 2021 [updated 2021 Oct; cited 2024]. Available from: https://www.rch.org.au/clinicalguide/

19. Australian Commission on Safety and Quality in Health Care. National Safety and Quality Health Service Standards. 2nd ed. Sydney: ACSQHC; 2017.

20. Turnidge JD, Kotsanas D, Munckhof W, et al. Staphylococcus aureus bacteraemia: a major cause of mortality in Australia and New Zealand. Med J Aust. 2009;191(7):368-373.