Osteomyelitis of the hand after a human bite

Hand Osteomyelitis: A Systematic Review of the Literature and Recommendations for Diagnosis and Management

Hand osteomyelitis is a complex condition to diagnose and treat, with an opportunity to improve care through organization of existing evidence. The literature was systematically searched for series of hand osteomyelitis between 1990 and 2022 for evidence regarding diagnosis and treatment, to formulate recommendations. Twenty-one series reported at least 5 cases of hand osteomyelitis in adults, with a total of 666 cases. Surgical debridement is central to treatment and oral antibiotics are sufficient for individuals without diabetes, renal or vascular disease, after debridement and resolution of associated sepsis. A 4- to 6-week duration of antibiotic therapy according to organism sensitivities is recommended, or a 2-week course after amputation. Delayed presentation is common and if over 6 months is associated with high amputation rates. Hand osteomyelitis with renal failure is associated with systemic complications. Reconstruction options include antibiotic-eluting spacers, osteosynthesis or arthrodesis, vascularized bone or adipose, regional soft tissue coverage and silicone implant arthroplasty.Level of Evidence: IV.

Effects of Mouthguards on Skin Damage In Vitro Study

OBJECTIVE

 Mouthguards can prevent and reduce orofacial sports traumas, which occur to the players themselves. However, the effect of mouthguards on skin damage has not been clarified. The present study's purpose was to examine whether the mouthguard can reduce or prevent skin damage caused by teeth (including the difference in mouthguard thickness).

MATERIALS AND METHODS

 Pigskins, artificial teeth, and Ethylene-vinyl acetate (EVA) mouthguard blanks with 1.5- and 3.0-mm thickness were employed. Each of the two type mouthguards was produced in 10 replicates. Mouthguard incisal thickness and collision touch angle were measured on a PC using imaging software. A pendulum-type machine was used to apply impact. Strain gauges attached to the tooth and impacted plate were used to measure mouthguards' effect on impact stress. Also, a microscope was used to observe the after impacted skin condition, and the extent of damage was assessed as a score.

RESULTS

 The pigskin was ruptured in without mouthguard (NOMG) with presenting the highest damage score, whereas the complete rupture was not seen in the 1.5 mm MG, but the damage of the skin (defeat) was observed. No tissue change was found with the 3 mmMG. In both the flat plate and impact tooth strain, no significant difference was observed between NOMG and 1.5 mmMG. However, 3 mmMG had a significantly smaller value than the other two conditions. These results are likely to be strongly influenced by the mouthguard incisal thicknesses and collision touch angles differences.

CONCLUSION

 The present study results clarified that two different thickness mouthguards reduced the skin damage, and the thicker mouthguard showed more effectiveness. Therefore, mouthguards may prevent the wearer's stomatognathic system's trauma and avoid damage to the skin of other athletes they are playing with. This effect seems to be an essential basis for explaining the necessity of using mouthguards for others besides full-contact sports.

[Osteitis/Osteomyelitis of the Hand and Wrist]

Osteomyelitis of the hand and wrist is uncommon compared to the infections of the long bones but not rare. There is poor evidence on many answers to questions concerning this disease. This includes careful consideration of the prevalence, pathogenesis, microbiology, diagnostic methods and the conservative, medical and surgical treatment. The emergence of the disease can subdivided in post-traumatic, postoperative, spread from contiguous infections and hematogenous. The individual patient-specific risk must be considered. Early diagnosis and correct management are essential to preserve bony structures and the articular function of the hand. A two-step surgical procedure is usually necessary, but uncertainties about the optimal treatment are still existing. Satisfactory control rates of the infection and successful bone reconstructions can be achieved. But complications, a limited range of motion and amputations of finger parts can still not be avoided in all cases.

Infections of Deep Hand and Wrist Compartments

The human hand is the most exposed part of the body to highest risk for injuries, loss of the skin integrity, and to the inoculation of bacteria, most commonly Staphylococcus aureus, Streptococcus β-haemolytic, and gram-negative. In case of an infection, the mobile anatomical structures and the synovial membranes in close proximity to each other may spread the pus towards deep spaces and compartments. Mild early infections without an abscess formation may respond to antibiotics, but at more advanced stage, erythema, swelling, stiffness, and severe pain may ensue. Abscess formation will cause debilitating pain, fever, systemic symptoms, and even sepsis. Necrotizing infections may threaten not only the limb, but also patient's life. Therefore, an initially "trivial" hand injury should never be neglected, as it might turn into a deep space infection, which must be treated immediately with drainage, wound debridement, and i.v. antibiotics. Delay in diagnosis and inadequate initial management might rapidly lead to abscess formation, destruction of the gliding surfaces and the normal anatomy, and irreparable functional deterioration.

Extensor Tendon Injuries in the Athlete

An athlete's hands are susceptible to a variety of acute and cumulative traumas depending on their chosen sport. Depending on the timing of the injury, the immediate requirements of the athlete, and future aspirations, treatment strategies may need individual customization. This article offers a brief review of the anatomy and complex function of the extensor mechanism, discusses the etiologies of various extensor injuries, and outlines the multiple treatment options and expected outcomes.

Infections of the hand: an overview

Infections of the hand are common entities that are frequently encountered by orthopaedic surgeons and primary care physicians.

A high clinical suspicion and a thorough medical history with information about the social and working history of the patients, correct identification of the type and cause of the infection, and prompt initiation of appropriate treatment by the infectious diseases physicians and orthopaedic surgeons are required.

Late diagnosis and inappropriate treatment may be a significant cause of morbidity for the hand and mortality for the patients. This article reviews the clinical spectrum and microbiology of the most common infections of the hand, and discusses the current concepts for their treatment. The aim is to increase the awareness of the treating physicians of the diagnosis and management of infections in the hand.

Cite this article: EFORT Open Rev 2019;4:183-193. DOI: 10.1302/2058-5241.4.180082

Predicting Amputation and Multiple Debridements in Tooth Knuckle Injuries

BACKGROUND

Tooth knuckle injuries can be expensive to treat and may necessitate amputation in some cases. Several limitations exist in the literature regarding our knowledge around the factors predicting amputation and the need for multiple debridements in treating this injury.

METHODS

A historic cohort study of 321 patients treated for tooth knuckle injuries was undertaken. Twenty-one demographic, clinical and laboratory variables were collected. Two outcome measurements were collected - the need for amputation and the need for more than one surgical debridement. A multivariate logistic regression was performed to determine the relationship between the predictor variables and the outcome measurements.

RESULTS

Of the 321 patients examined, 1.6% required amputations and 25% required multiple debridements. Osteomyelitis was found to be a major predictor for amputation in these patients (OR = 35). Delayed presentation (OR = 1.1) and diabetes (OR = 2.6) were found to significantly increase the risk of requiring multiple debridements.

CONCLUSIONS

Our models were able to predict what patients were at the greatest risk for amputation and multiple debridement. Reducing rates of osteomyelitis and delays in presentation may help reduce the incidence of amputation and reoperation in this injury.

Care of Infectious Conditions in an Observation Unit

Infectious conditions such as skin and soft tissue infections (SSTIs), Urogenital infections and peritonsillar abscesses frequently require care beyond emergency stabilization and are well-suited for short term care in an observation unit. SSTIs are a growing problem, partly due to emergence of strains of methicillin-resistant S. aureus (MRSA). Antibiotic choice is guided by the presence of purulence and site of infection. Purulent cellulitis is much more likely to be associated with MRSA. Radiographic imaging should be considered to aid in management in patients who are immunosuppressed, have persistent symptoms despite antibiotic therapy, recurrent infections, sepsis or diabetes.

Teeth syndrome: diagnosis, complications and management

Teeth syndrome or fight bite is a specific entity in hand surgery that is little known. It includes infectious complications of the hand following a fist against the teeth. Neglected or misdiagnosed this injury frequently leads to serious complications that could compromise the function of the hand. A retrospective study was performed on 20 patients treated for teeth syndrome at our department, during a period of 12 years (January 2003 to April 2015). All young adults with a mean age of 28 years and a significant male predominance. The dominant side was involved in 15 patients. Lesions were divided into 4 cases of simple dorsal wounds facing the MP joint, 8 cases of dorsal hand cellulitis, and 8 cases of arthritis and osteoarthritis of the metacarpophalangeal (MP) joint of the long fingers. The index was the most affected finger. Treatment consisted in debridement of necrotic tissues, stabilization with external fixation for arthritis, skin reconstruction was performed secondarily. Result was assessed as good in 60% of cases. Clenched fist injuries to the mouth (teeth syndrome or fight bite) are known as being the worst human bites. Usually treated as minor injuries, without realizing a breach of the joint capsule, a lesion of the extensor tendon, or a contamination by oral flora. Any patient with a wound near the joint of the hand and was involved in a fight, need an appropriate evaluation and a specialized treatment to avoid serious complications.

The management of clenched fist 'fight bite' injuries of the hand

We present a prospective study outlining the management of clenched fist 'fight bite' injuries. Over a 4-year period all patients with such injuries had surgical exploration with further débridements as necessary. For metacarpophalangeal joint injuries, a midline tendon-splitting approach was used. For proximal interphalangeal joint injuries, an approach was made between the lateral band and central slip of the extensor mechanism. A total of 147 patients with 159 joint injuries were treated, with 130 metacarpophalangeal joint and 29 proximal interphalangeal joint injuries. The joint was penetrated in 96% of joints overall. The number of débridements ranged from two to eight. Twenty patients defaulted within 1 week of surgery and were not included in the analysis of the results. All patients with metacarpophalangeal joint injury had satisfactory or good outcomes. A total of 42% of patients with proximal interphalangeal joint injuries had poor results, four requiring amputation and one a fusion. The tendon-splitting approach to the metacarpophalangeal joint allows excellent access and avoids damage to the sagittal bands and consequent instability of the extensor mechanism.

Acute hand infections

The continued emergence of antibiotic-resistant bacteria and the development of only a few new classes of antibiotics over the past 50 years have made the treatment of acute hand infections problematic. Prompt diagnosis and treatment are important, because hand stiffness, contractures, and even amputation can result from missed diagnoses or delayed treatment. The most common site of hand infections is subcutaneous tissue and the most common mechanism is trauma. An immunocompromised state, intravenous drug abuse, diabetes mellitus, and steroid use all predispose to infections.

Knee Osteochondritis Dissecans Treated by the AO Hook Fixation System: A Four Year Follow-Up of an Alternative Technique

Surgical fixation is recommended for stable osteochondritis dissecans (OCD) lesions that have failed nonoperative management and for all unstable lesions. In this study we set out to describe and evaluate an alternative method of surgical fixation for such lesions. Five knees with unstable OCD lesions in four male adolescent patients with open physes were treated with the AO Hook Fixation System. The outcome was evaluated both clinically and with three separate outcome systems (IKDC 2000, KOOS, Lysholm) at one and a mean four year follow-up. We demonstrated excellent clinical results in all patients. At four years, all scoring systems demonstrated statistically significant improvement when compared to the preoperative status. Our study suggests that the AO Hook Fixation System is an alternative method of surgical intervention with comparable medium term results with other existing modes of fixation and the added biomechanical advantage of the absence of distracting forces during hardware removal.

Mammalian bite injuries to the hand and their management

Bite wounds are a common form of hand injury with the potential to lead to severe local and systemic sequelae and permanent functional impairment. Mammalian bite wounds may be caused by a variety of animal class and species; injuries resulting from dogs, cats and humans are the most widely discussed and reported in the literature. Bite wounds may be contaminated with aggressive pathogens and the anatomical vulnerability of structures within the hand means that without early recognition and treatment with irrigation and antibiotics, alongside a low index of suspicion for deep structural involvement requiring formal surgical exploration and washout, the consequences of such injuries can be disastrous. We review the literature and discuss the epidemiology, pathophysiology and microbiology relating to these injuries, as well as clinical aspects including signs, symptoms, and management.

Bite injuries to the hand - review of the literature

Patients presenting to the emergency department with bite injuries to the hand sustain them through a number of causes including domesticated as well as stray animal bites, and human bites commonly sustained as a result of violence. The nature of the injuries sustained can be very deceptive. A small tooth mark on the exterior can be a fulminant infection in the tissues deeper down. Tendon injuries, fractures of the metacarpals and phalanges and management of the wound are critical issues faced by a surgeon in dealing with such patients. Similarly the less common bite injuries to the hand, often with disastrous and sometimes fatal complications, do also present to the emergency department. A high incidence of suspicion is needed in dealing with these injuries effectively. In our article we discuss the common as well as uncommon causes of bite injuries to the hand and their management. In addition to reviewing the literature to ascertain the management of such injuries, we also discuss interesting and rare case reports.

Reversible and Irreversible Peri-implant Lesions: Report and Etiopathogenic Analysis of 7 Cases

The purpose of this report is to review the aberrations in the integration process of cylindrical endosseous implants, though such aberrations are seldom observed. These issues are treated according to the following scheme: (1) infectious lesions, which consist of peri-implantitis, intraosseous infectious foci, and septic voids; (2) transitory lesions; (3) lesions related to occlusal overload; and (4) healing defects. In this report, we illustrate these categories with patient histories and discuss the clinical findings and etiopathogenies.

Low risk of infection in selected human bites treated without antibiotics

To assess the need for antibiotics in low-risk human bite wounds, a prospective, double-blind, placebo-controlled study involving 127 patients presenting with low-risk human bite wounds over 2 years to a 40,000 visit per year major academic ED was performed. Low-risk bites penetrated only the epidermis and did not involve hands, feet, skin, overlying joints, or cartilaginous structures. Exclusion criteria included age less than 18 years, puncture wounds, immunocompromise, allergy to penicillin or related compound, or bites greater than 24 hours old. Patients were randomly assigned to receive either a cephalexin/penicillin combination or placebo. One hundred twenty-five patients completed the study. Infection developed in 1 of 62 patients receiving placebo (1.6%, 95% confidence interval CI, 0-7.3%). Infection developed in 0 of 63 patients receiving the cephalexin/penicillin combination (0%, 95% CI, 0-4.6%). Antibiotic treatment of some low-risk human bite wound could be unnecessary. Infection rates appear similar in low-risk human bite wounds whether treated with antibiotics or placebo.

Primary repair of a flexor tendon after a human bite

Successful uncomplicated primary closure of a human bite injury of the hand with simultaneous zone II flexor tendon injury has not been previously reported to our knowledge. We report the case of a man who was bitten on his left ring and right middle and index fingers. He was treated with antiseptic lavage, intravenous antibiotics, and operation. He had complete transsection of the flexor digitorum profundus at the middle phalanx. This was repaired primarily and he made a good recovery.

Infectious complications associated with toothpick injuries of the hand

PURPOSE

Although rare, hand injury caused by toothpicks can result in serious complications similar to hand injury produced by human biting. To emphasize its clinical significance this article describes a group of patients sustaining hand injury induced by toothpicks.

METHOD

Eight patients who developed cellulitis, abscess, septic arthritis, and/or pyogenic tenosynovitis of flexor tendons after toothpick injuries of the hand were treated at our hospital. Seven of them required admission for antibiotics and surgical treatment.

RESULTS

The 7 admitted patients required multiple debridements (3 times on average) to control infection and administer intravenous antibiotics for mixed aerobic and anaerobic infections showing in wound cultures. The average hospital stay for the 7 patients was 26 days. At follow-up evaluation, 4 patients had full recovery of hand function after various cutaneous flap resurfacing of the wounds or staged tendon reconstruction, whereas the remaining 4 patients had arthritis with flexion contracture of interphalangeal joints or persistent paresthesia of the finger.

CONCLUSIONS

Patients injured by contaminated toothpicks should be treated with antibiotics that inhibit the growth of both aerobic and anaerobic organisms immediately after these organisms have been identified from cultures. Moreover early surgical treatment might avoid complications and obtain satisfactory results.

Orthopedic pitfalls in the ED: fight bite

Clenched fist injuries to the mouth ("fight bite") are notorious for being the worst human bites. These are often treated as minor injuries, without the recognition that the joint capsule, the extensor tendon, or the deep fascial spaces may have been violated and contaminated with oral bacteria. Significant morbidity can result from late presentation or inadequate initial management. The emergency physician needs to remain vigilant for complications associated with closed fist injury. This review article examines the clinical presentation, diagnostic techniques, and management options applicable to the emergency physician in the treatment of fight bite.

Human bites of the hand: the Tasmanian experience

INTRODUCTION

The purpose of the present paper is to provide geographically representative information on the presentation, treatment and complications of human bites of the hand in Australia.

METHODS

A 5-year retrospective study was undertaken of patients treated at Royal Hobart Hospital for human bites of the hand. The variables evaluated included age, sex, hand involvement, anatomical distribution, presentation, operative findings, bacteriology, antibiotic use, X-ray findings, complications and compliance.

RESULTS

Thirty-five patients had human bites to the hand. All were male with a median age of 24 years. Most were clenched fist injuries with the middle metacarpophalyngeal joint being the most prone to injury. Patients presenting early had a high incidence of open joints and fractures but spent less time in hospital than late presenters, almost all who had infection complications. Compliance with treatment was found to be a major problem. Serious hand infections were not observed.

CONCLUSION

The treatment of human bites must be early, correct and comprehensive. The appropriate treatment is surgical exploration with debridement and lavage, appropriate antibiotic administration, hand elevation and initial immobilization. Poor compliance of patients in the present study was demonstrated by a high incidence of late presentation, self-discharge from hospital and loss to follow up, making assessment of outcomes difficult. Despite this there is an absence of serious hand infections reported in the literature and this may be due to the administration of antibiotics prior to referral.

Using an esterified hyaluronan fleece to promote healing in difficult-to-treat wounds

Hyaluronic acid enhances angiogenesis and promotes re-epithelialisation and scar formation. Two case studies illustrate how a dressing that creates a hyaluronan-rich environment at the wound surface achieved full healing in two patients with underlying physiological problems.

Osteomyelitis of the tubular bones of the hand

The records of 700 patients with hand infections were reviewed. Forty-six (6%) had osteomyelitis of the metacarpals or phalangeal bones. The cause was post-traumatic in 57%, postoperative in 15%, hematogenous in 13%, spread from contiguous infections in 9%, and unidentified in 6%. Twenty-two percent of the patients had vascular insufficiency and/or were immunocompromised. History, physical exam, plain x-rays, and open biopsy and culture were most helpful in establishing the diagnosis. Laboratory studies and bone scans were less helpful. Cultures were positive in 74% of patients, with a noteworthy number of mixed infections (35%) and gram-positive infections (35%). Gram-negative infections accounted for 15%, fungal infections for 12%, and mycobacterial infections for 3%. Surgical management varied from simple curettage to more elaborate staged reconstructions and/or arthrodeses. Despite provision of aggressive surgical care and use of appropriate antibiotics, the overall amputation rate was 39% (18/46). A delay of more than 6 months from onset of symptoms to diagnosis and definitive treatment led to amputation in 6 of 7 patients (86%), 2 of whom had squamous-cell carcinoma. Of the 12 patients who underwent more than 3 surgical procedures, 8 ultimately underwent amputation and 2 had marked disability.