'Punch' actinomycosis causing osteomyelitis of the hand

Osseous actinomycosis usually results from direct invasion of bone from adjacent soft-tissue infection. Involvement of the jaw and vertebral column has been frequently reported, but involvement of the bones of the wrist or hand is rare. A patient with osteomyelitis of the distal right first metacarpal bone due to Actinomyces israelii following a punch injury during fisticuffs is described. Review of similar cases revealed a striking association of this type of infection with punch injuries; hence the term, punch actinomycosis. Analysis of the pus in these infections typically reveals sulfur granules; strict anaerobic conditions must be employed to culture the etiologic agent, A israelii. Management of individual cases should include surgical débridement combined with high-dose parenteral penicillin, followed by long-term penicillin therapy, orally.