Introduction: Osteomyelitis and septic arthritis (SA) below the elbow are severe conditions affecting the function and viability of the hand. Factors predisposing to these conditions and parameters affecting prognosis are emphasized.

Material and Methods: In a 4 years period, 16 patients with SA (4) or osteomyelitis (12) were treated in a University Orthopaedic Department providing care to a rural population of 1.000.000, Nine had history of trauma in unhygienic environment, 3 had immunodeficiency and in 4 osteomyelitis was iatrogenic [previous fixation of fractures (3) and vein catheterization (1)]. SA was located in the wrist (2) and thumb joints (2) and osteomyelitis involved the radius (3), ulna (1), metacarpals (3) and phalanges (5). Ten patients received oral antibiotics in other centers. The mean delay from onset of symptoms to referral to our center was 22 days. Apart of antibiotics administration, surgical treatment included debridement and irrigation for SA and excision of necrotic bone, stabilization (external fixators), use of antibiotic beads and secondary bridging with bone graft for osteomyelitis. Additional procedures (amputations, arthrodesis) were also required in some cases.

Results: Cultures were positive in 9 of 16 cases [Staph. aureus (5) and enterobacter cloacae (3)]. Patients underwent multiple procedures (mean: 3.8) and 4 underwent amputation of a digit (2) and hand (2) due to the rapid extension of infection threatening and finally taking the lives of 2 elderly and immunosuppressed patients. Mean follow-up period of the 12 surviving and non-amputated patients was 18 months. Union was accomplished in all cases. Functional results were excellent or very good in 10 of 12 patients and good in 2 patients. All patients were satisfied and returned to their previous occupations.

Conclusions: Osteomyelitis and SA below the elbow was frequent in population living in unhygienic environment or working with soil. All cases received medical treatment with delay. Immunosuppressing conditions favored the extension of infection and threatened patients lives. Delay in treatment in combination to immunosuppression resulted to significant morbidity. Early treatment including surgical drainage, thorough debridement and antibiotic administration is necessary for elimination of skeletal infection and salvage of the hand and patients life.

Introduction: Suppurative conditions in closed cavities/tunnels require surgical drainage and irrigation for elimination of infection. The purpose of this study is to evaluate the pattern of extension of infections in hand compartments and the necessity for intraoperative and continuous postoperative catheter irrigation.

Material and Methods: Compartmental infections of the hand and wrist (CIHW) were diagnosed in 42 consecutive patients involving the flexor tendon sheaths (pyogenic flexor tenosynovitis) (28); the tip (3); the carpal tunnel (2); or extended to multiple compartments including the above mentioned and the thenar, midpalmar, web and Parona’s (9). Three patients had diabetes mellitus, 2 suffered from bites, 15 had penetrating injuries and 7 were working with animals or meat products. Fifteen were previously treated in other centers. After meticulous clinical evaluation to define all the involved compartments, all patients were treated with drainage of the respective compartments, sheath irrigation and appropriate antibiotics, whereas continuous postoperative catheter irrigation was used in 24. Hand therapy started the third postoperative day.

Results: Mean follow-up time was 20 months. The most common pathogen was S. aureus (14 patients) whereas cultures were negative in 15. Three patients received additional fungal treatment. Results were excellent or very good in 25 hands and good in 12 regaining full or near full ROM. Recurrence of infection in 4 (that were initially treated inadequately in other centers or had intraoperative sheath irrigation without postoperative continuous irrigation) necessitated a revision of the procedure with extensive debridement and continuous postoperative irrigation. Finally, 1 patient developed complex regional pain syndrome.

Conclusions: A high index of suspicion and profound knowledge of the anatomy is essential for early diagnosis and prompt surgical treatment of CIHW. Initially «benign» infections often extend in multiple compartments of the hand as a result of inadequate initial treatment. Intraoperative irrigation is not always adequate for the resolution of infection, especially in neglected cases or cases with underlying conditions. Early surgical debridement of all the involved compartments in combination to continuous postoperative irrigation, administration of appropriate antibiotics and precocious onset of hand therapy is the treatment of choice for these potentially debilitating, infectious conditions of the hand.