Chronic osteomyelitis of the metacarpals. Report of a case

Chronic osteomyelitis of the hand is uncommon and affects the metacarpals in only 3% of cases. We report a case of chronic osteomyelitis involving two metacarpals, and we present a review of the relevant literature.

A 41-year-old man with a 5-year history of psoriatic arthritis was admitted for a swelling over the dorsum of the left hand. At admission, he was in good general health and had no fever. In addition to the swelling, he had synovitis of the right ankle and psoriasis over the hands and elbows. The spine and sacroiliac joints were normal to physical examination. The erythrocyte sedimentation rate was 110 mm/h, the C-reactive protein level was 48 mg/l, and the leukocyte count was 9600/mm3. A radiograph of the hands disclosed a bone-within-bone image in the second and third metacarpals of the left hand and arthritis of the left carpal joints. A fluid collection over the dorsum of the left hand was visualized by ultrasonography. Aspiration recovered serous fluid that contained no organisms by microscopic examination or culture. Investigations for tuberculosis and a serological test for HIV infection were negative. Computed tomography showed a florid periosteal reaction encasing the diaphyses of the second and third metacarpals and enclosing bony sequestra; abnormal carpal bone architecture and thickening of the soft tissues related to joint effusions were seen also. The diagnosis was chronic osteomyelitis of the metacarpals. Two antimicrobials active against staphylococci were given and the bony sequestra were removed surgically. Histological examination of the operative specimens showed nonspecific osteitis. After 3 months of treatment, the outcome was favorable.

Chronic osteomyelitis of the metacarpals is exceedingly rare but results in severe functional incapacitation and major social and economic burdens. Our case illustrates an unusual pattern with involvement of two metacarpals in the same hand. An early diagnosis followed by prompt treatment increases the likelihood of a favorable outcome.