Carpal Bone Osteomyelitis after IV Drug Abuse

Introduction: Carpal bone osteomyelitis was a rare problem until the recent epidemic of intravenous drug abuse and we now frequently treat abscesses of the hand and wrist. Delayed presentation with suppurative wrist arthritis and carpal bone infections is common in our institution. There is scant guidance literature (PubMed) about human carpal osteomyelitis so we present our experience to these challenging infections.

Materials and Methods: From 2015 to 2018, (732) patients presented to our Level 1 Trauma Center with severe infections of the hand, wrist or forearm. Lacerations, animal bites, injection of illegal substances (IVDA) led to infections severe enough to require admission and intravenous antibiotics, with or without surgical I&D. Nine (9) IVDA patients were found to have wrist joint infections that presented as or developed into developing osteomyelitis of one or more carpal bones. Cellulitis was initially treated with high dose antibiotics but with demonstrated osteo aggressive intraoperative I&D, and sequential irrigating wound VAC dressings were employed. Imaging including MRI and wrist CT scan were useful in diagnosing ambiguous bony involvement. Debridement of infected bone was required. Definitive IV antibiotics based on culture results was instituted for 6-10 weeks in most cases.

Results: All osteomyelitis patients achieved resolution of infection and had stable wrists. The scaphoid bone was most often infected (4), lunate (2), trapezium (2) and multiple bones (1). All osteomyelitis patients at last follow-up had stiffness but comparable to comminuted carpal fracture patients. Four patients had pain requiring management by the pain clinic, two patient were completely asymptomatic and three were lost to follow-up. Two patients with lunate resections underwent late proximal row carpectomy.

Conclusions:
1) Carpal bone osteomyelitis infection of hand is becoming a significant problem with rising IV drug abuse.

2) Carpal bone infections can be treated with a high degree of antimicrobial success using, aggressive ostectomy, irrigating NPWT, coupled with stabilization. Lunate resection often requires proximal row carpectomy.

3) Carpal osteomyelitis treatment can salvage the wrist and hand, but pain and stiffness is a usual outcome in this challenging population.