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.