Diabetic hand syndrome

History, Prevalence and Assessment of Limited Joint Mobility, from Stiff Hand Syndrome to Diabetic Foot Ulcer Prevention: A Narrative Review of the Literature

BACKGROUND

Limited Joint Mobility (LJM) is a dreaded complication of Diabetes Mellitus (DM). During the last half century, LJM has been studied in patients of different age because it has been considered useful for the monitoring of a patient's condition and for the prevention of vascular disease and diabetic foot.

OBJECTIVES

The main aims of this review are to describe the relationship between DM and joint mobility as well as its prevalence and assessment. We have also investigated the role of LJM in the development of diabetic foot ulcers.

METHODOLOGY

An in-depth literature search was conducted to identify studies that examined the prevalence and characteristics of LJM in patients with DM of different types, age, durations and chronic complications.

RESULTS

Many factors (therapy improvements, population characteristics and different evaluation methods) concur to hinder an exact assessment of the prevalence of LJM. However, it has been confirmed that LJM is widespread among patients with DM and may affect more than two-thirds of them in addition to being a major risk factor for foot ulcer. Its role in the monitoring of a patient's condition is also important for the definition of risk thresholds such as in patients with diabetic foot. The efficacy of exercise therapy for the treatment of LJM, also in patients at risk of foot ulcer, has not been discussed.

CONCLUSION

Difficulties encountered in the definition of the prevalence of LJM may hinder its study and the establishment of preventive interventions. However, LJM plays a key role in the monitoring of patients, especially those at risk for ulcer.

Musculoskeletal disorders of the hand in type 2 diabetes mellitus: prevalence and its associated factors

AIM

To assess the prevalence of musculoskeletal disorders of the hand among adult patients with type 2 diabetes mellitus (T2DM) and their relation to disease duration, glycemic control and microvascular complications.

METHODS

A cross-sectional study was conducted at the National Center for Diabetes, Endocrinology and Genetics in Amman, Jordan.

RESULTS

One thousand patients with T2DM were included in this study (mean age 57.8 ± 9.5 years, 52.2% females and 47.8% males). Hand disorders were seen in 69.5% of patients, limited joint mobility (LJM) was the most prevalent (63.1%) condition followed by Dupuytren's contracture (DC) (18.6%). Trigger finger, thick skin and carpal tunnel syndrome (CTS) were found in 7.2%, 6.2% and 5.5% of patients, respectively. One disorder was seen in 45.4% of patients, two in18.2%, three in 4.9%, four in 0.9%, while only 0.1% of patients had all disorders. Female gender, age over 60 years and long duration of diabetes were associated with hand abnormalities. Hypertension was significantly associated with DC while retinopathy was associated with increased odds of thick skin, DC and CTS with P-values 0.037, < 0.005 and 0.002, respectively.

CONCLUSION

Hand disorders are very common in T2DM. Female gender, old age, duration of diabetes, retinopathy and hypertension were significantly associated with hand disorders in T2DM.

[Hand and endocrine diseases]

The whole of hormones likely influence state of hands, modifying colouring and trophicity of the skin and having influence on its muscular, tendineous, osseous, articular components. Thus state of the hands contributes to the recognition of the endocrine diseases: hot and moist hands of the Graves' disease, dry, cold and infiltrated hands in myxoedema, pale and fine hands of hypopituitarism, broad and thick hand of acromegaly, brachymetacarpia in the pseudohypoparathyroidism… Diabetes exposes particularly to tendineous and articular retractions, to whitlows and ungual mycosis.

Impact of obesity and diabetes on arthritis: An update

The incidence of obesity and diabetes has been increased with alarming rate in recent years and became a common problem around the globe including developing as well as in developed countries with incalculable social costs. Obesity and type 2 diabetes are two common co-morbidities occur together. Obesity and diabetes is closely associated with many diseases, osteoarthritis, hypertension, certain form of cancer, sleep-breathing disorders and coronary heart disease. Impacts of obesity and diabetes (insulin resistance) on arthritis have been seen in patients that we associated with combination of various factors like increased availability of high- energy foods, genetic susceptibility and decreased physical activity in modern society. Arthritis is becoming pandemic around the globe and its occurrence with obesity and diabetes has been observed more common than ever. Combination of these two chronic conditions makes these diseases more vulnerable for human health. Till now very limited information is established about the pathological and mechanistic correlation among these health ailments. In this review article we aimed to survey the literature covering the influence of obesity and diabetes on arthritis pathology and tried to establish correlation with these diseases.

Carpal tunnel syndrome: a review of the recent literature

Carpal Tunnel Syndrome (CTS) remains a puzzling and disabling condition present in 3.8% of the general population. CTS is the most well-known and frequent form of median nerve entrapment, and accounts for 90% of all entrapment neuropathies. This review aims to provide an overview of this common condition, with an emphasis on the pathophysiology involved in CTS. The clinical presentation and risk factors associated with CTS are discussed in this paper. Also, the various methods of diagnosis are explored; including nerve conduction studies, ultrasound, and magnetic resonance imaging.

Rheumatic manifestations of diabetes mellitus

DM is associated with various musculoskeletal manifestations. The strength of this relationship varies among the various musculoskeletal disorders; the associations are based mostly on epidemiologic data. For most of these conditions, definitive pathophysiologic correlates are lacking.Hand and shoulder disorders occur more frequently than other musculoskeletal manifestations of DM. Recognition of the association between DM and shoulder adhesive capsulitis, DD, and stenosing flexor tenosynovitis facilitates their correct diagnosis in the setting of DM and prompt initiation of appropriate treatment, which may include optimizing glycemic control. Conversely, awareness and identification of the characteristic musculoskeletal manifestations of DM may facilitate earlier diagnosis of DM and initiation of glucose-lowering therapy to retard the development of diabetic complications.Much less has been published about the musculoskeletal complications of DM than about its micro- and macrovascular complications. Prospective case-control cohort studies are needed to establish the true prevalence of musculoskeletal complications of DM and the metabolic syndrome, especially in this era of tighter glycemic control.The potential relationship between DM and the development of OA needs to be clarified in large, prospective, case-control cohort studies. The effect on musculoskeletal manifestations of various therapeutic regimens to manage DM should be studied prospectively. Treatment regimens for some musculoskeletal conditions associated with DM, such as DISH, should be studied in larger prospective, randomized,controlled clinical trials.At the molecular level, further studies are warranted to clarify the potential contribution of AGEs and adipokines to the development of OA and diabetic musculoskeletal syndromes, such as shoulder adhesive capsulitis, DD, stenosing flexor tenosynovitis, and LJM. Identification of such molecular targets for therapy would promote the development of additional treatments for these and other rheumatic diseases.

Reduced myelinated nerve fibre and endoneurial capillary densities in the forearm of diabetic and non-diabetic patients with carpal tunnel syndrome

The underlying basis of carpal tunnel syndrome (CTS) and the basis of its increased incidence in diabetes are unknown. We have quantified pathology in an uncompressed nerve (posterior interosseous nerve, PIN) in the forearm between diabetic and non-diabetic patients with CTS and control subjects. In an age- and gender-matched series, 26 diabetic patients with CTS and 20 non-diabetic patients with CTS underwent biopsy of the PIN at the time of surgical carpal tunnel release. Control subjects consisted of ten PIN biopsies taken postmortem and three biopsies taken at the time of wrist surgery. We found PIN myelinated nerve fibre density significantly reduced in diabetic (mean 5,373/mm2 [95% confidence interval, 4,835–5,911]) and non-diabetic (6,617/mm2 [5,697–7,537]) patients with CTS compared to control subjects (9,109/mm2 [7,967–10,250], P < 0.001). Furthermore, diabetic patients had a significantly lower density than non-diabetic patients (P < 0.03). Endoneurial capillary density was also reduced in diabetic (58/mm2 [50–66]) and non-diabetic (67/mm2 [55–78]) patients compared to control subjects (86/mm2 [72–101], P < 0.02) with no difference between diabetic and non-diabetic patients with CTS. Our results suggest that a reduction in myelinated nerve fibre and capillary densities may predispose patients, particularly those with diabetes, to develop CTS.

The clinical picture of the painful diabetic shoulder--natural history, social consequences and analysis of concomitant hand syndrome

Sixty diabetic patients with shoulder pain were followed in order to trace the natural history of the disease. The triad of painful shoulder, hand syndrome and restricted hip joint mobility was strongly correlated to the duration of diabetes and retinopathy. Painful shoulder with restricted mobility (58%) and tendinitis (28%) predominated. Hand syndrome was found in 62% and restricted hip joint mobility in 42%. Ninety percent of painful shoulders with restricted mobility had difficulties in the activities of daily living in the acute phase. There was functional limitation of shoulder mobility in 17% of painful shoulders with restricted mobility at the end of the study. The duration of diabetes and the duration of shoulder symptoms were correlated. In 25%, working capacity was affected by the painful shoulder. A serious risk of developing shoulder symptoms persisting for more than 2 years was associated with insulin treatment, diabetes lasting more than 10 years, proliferative retinopathy and painful shoulder with restricted mobility.

The painful diabetic shoulder

Different types of shoulder affection were studied in 62 diabetic patients with shoulder pain. Three groups of shoulder joint disorder were found: painful shoulder with restricted mobility (62%), tendinitis without mobility restriction (27%), and a small group with mixed diagnoses. Sixty per cent had hand symptoms and 38% had restricted mobility of their hip joints. High frequencies of retinopathy and neuropathy were found. Affection of the shoulder joint was seen with almost the same frequency in insulin-dependent as in non-insulin-dependent patients, but after a shorter duration of diabetes in the latter. A group of patients with the triad shoulder pain, hand symptoms and restricted mobility of the hip joints had a significantly higher frequency of proliferative retinopathy than patients with shoulder pain only. The long duration of diabetes, the high frequency of insulin treatment and classical late complications indicate that diabetic patients with painful shoulder and restricted mobility are suffering from clinically advanced diabetes mellitus.

Treating trigger finger in diabetics using excision of the ulnar slip of the flexor digitorum superficialis with or without A1 pulley release

The purpose of this study was to evaluate the results of excision of the ulnar slip of the flexor digitorum superficialis tendon, with or without A1 pulley release, for the treatment of trigger finger in diabetic patients. We performed a retrospective review with long-term follow-up examinations. Short-term data was obtained on 18 consecutive patients (37 fingers). Long-term information was collected on 14 of these patients (24 fingers) at an average of 48 months after surgery. Short-term follow-up revealed average proximal interphalangeal joint (PIP) flexion of 81 degrees . One patient had slight residual triggering. At long-term follow-up, 93% of patients were completely or very satisfied with the procedure. Total active finger motion averaged 218 degrees , and PIP extension deficit averaged less than 5 degrees . Pinch strength was equal to the contralateral corresponding finger. There were no significant complications. One finger had minimal residual triggering. In conclusion, this procedure is a safe and effective treatment for the often-difficult problem of stenosing flexor tenosynovitis in the diabetic patient.

Musculoskeletal disorders in diabetes mellitus: an update

Diabetes mellitus (DM) is associated with several musculoskeletal disorders. The incidence of DM and the life expectancy of the diabetic patient have both increased, resulting in the increased prevalence and clinical importance of musculoskeletal alterations in diabetic subjects. The exact pathophysiology of most of these musculoskeletal disorders remains obscure. Connective tissue disorders, neuropathy, vasculopathy or combinations of these problems, may underlie the increased incidence of musculoskeletal disorders in DM. The development of musculoskeletal disorders is dependent on age and on the duration of DM; however, it has been difficult to show a direct correlation with the metabolic control of DM. Most of these disorders can be diagnosed clinically, but some radiological examination may help, especially in differential diagnosis. No specific treatment is available, and treatments used in the general population are also recommended for diabetic subjects. Infectious complications affecting the musculoskeletal system are common in DM subjects, and these, possibly life-threatening, complications should be systematically discussed.

Musculoskeletal manifestations of diabetes mellitus

Rheumatic complaints are common in patients with diabetes. Maintaining good glycaemic control by exercise, diet, and medication improves or prevents the development of rheumatic conditions.

[Dupuytren's contracture and diabetes mellitus]

The literature suggests that the frequency of Dupuytren's disease is ten times greater in diabetes than in the general population. We have studied 42 diabetic patients with a contracture of the palmar fascia. Dupuytren's contracture can be considered a complication of diabetes and of the local neurovascular changes since both are often associated. The contracture is usually not severe in diabetes, is nodular in form, and usually crushes the palmar surface of the long and ring fingers. It is usually well tolerated by the patients and surgery is rarely indicated, particularly in view of the advanced age of many patients. In caring for patients with Dupuytren's disease, surgeons should also rule out the presence of diabetes with appropriate test.

A commentary on 10 years of aldose reductase inhibition for limited joint mobility in diabetes

This investigation examines the clinical response to long-term treatment of the diabetic syndrome of limited joint mobility (LJM) using an aldose reductase inhibitor (ARI) in comparison to historical controls, and proposes a potential role of aldose reductase (AR) genotype and expression in the clinical response to ARI. Clinical parameters, including quantitative hand movement and electromyogram, were followed over a decade of continuous ARI treatment with sorbinil (400 mg/day) in two patients with insulin-dependent diabetes mellitus (IDDM) and severe compromising LJM, and compared to the published 10-year prospective investigation of untreated IDDM diabetic patients with LJM. Both subjects were homozygous for the Z-2 AR allele (A-C)23 that has been linked with microvascular complications of DM. Cellular AR mRNA/beta-actin ratios for both treated patients while on ARI therapy were approximately one-half the value observed in untreated patients with the complications of nephropathy or neuropathy. This is the longest reported experience of ARI intervention for any diabetic complication, documenting sustained correction of LJM, lack of side effects, and a potential molecular basis for the therapeutic response.

Limited joint mobility of the ankle in diabetic patients with cutaneous sensory deficit

Limited joint mobility (LJM) of the ankle joint was measured in 48 diabetic patients classified into three groups: Insulin-dependent diabetes mellitus (IDDM = 15), non-insulin diabetes mellitus (NIDDM = 12) and patients with cutaneous sensory deficit in the foot (CD = 21). Specifically, plantar flexion, dorsiflexion and total range of motion was measured on both feet using goniometric techniques during active and passive movement conditions. No significant bilateral differences were established, therefore values for the right foot were used for statistical analyses. Diabetic patients were matched to 48 non-diabetic controls for age, weight and gender factors. A Semmes-Weinstein monofilament test was used on both feet to assess the integrity of cutaneous sensitivity in all patient and control subjects. Cutaneous sensory deficit patients (CD) had monofilament values greater than two standard deviations below control group mean values. There were no significant differences between the monofilament test values for the IDDM and NIDDM patients and control group data. LJM results indicated both plantar flexion and range of motion in CD patients under active and passive movement conditions were significantly reduced compared to control group data. No differences were observed for any pairwise comparisons between the IDDM and NIDDM groups compared to controls. The data is discussed in terms of the interaction between LJM in the foot and type of diabetic classification.

Connective tissue and joint disease in diabetes mellitus

Connective tissue is ubiquitous and subject to alterations that result in changes in the extracellular matrix of vessels and tissues leading to the long-term complications of diabetes. This article reviews only those abnormalities of interstitial connective tissue involving skeleton, joints, skin, and periarticular tissues. Abnormalities in the skin and periarticular tissues result in syndromes limiting joint movement, including limited joint mobility, Dupuytren disease, flexor tenosynovitis, carpal tunnel syndrome, stiff-hand syndrome, and shoulder-hand reflex dystrophy. Of these, only limited joint mobility and stiff-hand syndrome occur exclusively in patients with diabetes. In all of these conditions, advanced glycation end products are thought to form as a result of nonenzymatic reaction of glucose with proteins, causing stiffening.

Diabetes and trigger finger

Trigger finger is a stenosing tenovaginitis in which there is a constriction of the annular sheath associated with a nodule in the digital flexor tendon. Clinically this can present as triggering or snapping of the nodule as it passes through the tight constricting tendon sheath. Although many triggering fingers settle spontaneously, and others respond to local anesthetic and steroid injection, others require surgical decompression. The association between diabetes and trigger finger, although not widely known, has been described and forms part of the "diabetic hand syndrome". We studied 100 adult patients in the group that required surgery. Eighteen of the 100 patients were diabetic with six insulin dependent diabetics (IDDM) and 12 non-insulin dependent diabetics (NIDDM). In the current climate of day case surgery this has significant implications both for the management of known diabetics as well as the preoperative detection of those with the condition.

Rheumatic pains of previously undiagnosed diabetic subjects

To identify the early diabetic musculoskeletal symptoms of previously undiagnosed diabetic subjects, a case-control study was carried out. The cases and controls were recruited from a population aged 55 years. Questions concerning the symptoms were asked before the 2-h oral glucose tolerance tests (OGTT). The results show that pain in the right hand was the most prominent symptom among the diabetic women. Pains in the left hand and the shoulders in the diabetic women and pains in the right knee and the right hip joint in the diabetic men tended to be more prevalent than the corresponding symptoms in the controls. The highest prevalence of most musculoskeletal pains occurred in the highest tertile of 2-h OGTT values among women. The conclusion is that the hand pain is closely associated with the development of diabetes and may give clues to an early diagnosis of diabetes in a middle-aged population.

Incidence of microvascular complications in type 1 diabetic subjects with limited joint mobility: a 10-year prospective study

Previous cross-sectional studies have shown a significant correlation between limited joint mobility (LJM) and the microvascular complications of Type 1 diabetes, but whether LJM precedes and, therefore, may be regarded as an early marker for complications is unknown. Twenty-two Type 1 diabetic patients (10 male/12 female; diabetes duration at follow-up 20.1 +/- 1.3 (SEM) years) with LJM, and 22 subjects matched for age, sex, and duration of diabetes, without LJM were observed over a 10-year period. Both groups were free of retinopathy and negative for 'dipstick' proteinuria at baseline. After 10 years, of 22 patients with LJM, 10 had developed background and 3 proliferative retinopathy compared with 9 and 1 control subjects, respectively. Microalbuminuria (20 < or = albumin excretion rate < 200 micrograms min-1) was present in 3 and macroalbuminuria (albumin excretion rate > or = 200 micrograms min-1) in 2 of LJM patients compared with 6 and 1 control subjects, respectively. Ankle and toe vibration perception thresholds, HbA1, mean HbA1 (a mean of serial HbA1 measurements obtained during the 10-year follow-up period), and arterial blood pressure did not differ between the two groups (p > 0.05). At 10-year review, 9 of the control subjects had developed LJM of whom 4 had retinopathy and 4 microalbuminuria. Thus, while LJM may be another 'chronic complication' of diabetes, its presence does not appear to predict those at increased risk of developing microvascular complications.

Limited joint mobility in insulin dependent childhood diabetes

Limited joint mobility (LJM), beginning typically in the fifth finger and moving radially, affecting interphalangeal, metacarpal-phalangeal, and large joints, is the earliest clinically apparent complication of diabetes in childhood and adolescence. It is painless and not disabling. Approximately 50% of post-adolescent patients with more than 5 years duration of diabetes are affected, with age being more important than duration of diabetes, as is the case with other complications. Growth failure is more frequent in the presence of LJM, although correlations with diabetic control have not been found. Variations in frequency in various reports, including high prevalence in controls or relatives, appear to be related to the quality of the examination; simple inspection with hands pressed flat on the table top or together in the prayer position is inadequate; passive extension must be performed. Although differential diagnosis from other conditions causing limitation of the fingers in diabetes would appear simple, LJM has been confused with other conditions which can be distinguished by the presence of pain or paresthesias, neurologic findings, disability, finger-locking, swelling, muscle atrophy, palmar skin or fascial thickening, absence of typical distribution, calcification of the vessels and, particularly, the age group affected. That the periarticular thickening found on examination and demonstrated on roentgenograms reflects generalized abnormalities is suggested by association with thick tight waxy skin, decreased pulmonary function, and association with retinopathy, nephropathy, and neuropathy, independently of duration of diabetes.(ABSTRACT TRUNCATED AT 250 WORDS)

Cheiroarthropathy and long term diabetic complications in Nigerians

Two hundred and fifty six consecutively ambulant diabetic patients attending a Nigerian diabetic clinic for the presence of cheiroarthropathy were examined using standard criteria. Forty eight (19%) had limited joint mobility of the hand, a prevalence higher than the 4% (2/56) observed in a non-diabetic population matched for age and sex. Limited joint mobility was twice as prevalent in the insulin treated (16/50, 32%) than in the non-insulin dependent (32/206, 16%) diabetics. Indices such as age, duration of diabetes, and glycaemic control (as assessed by integrated blood glucose concentration over the previous 12 months and glycated haemoglobin (HbA1c concentrations) were the same in the diabetics with and without limited joint mobility. The prevalence of cataracts (18/48, 38%) and background retinopathy (8/48, 17%) was higher in diabetics with limited joint mobility than in those without (respectively 6-9% and 5-6%); hypertension, peripheral neuropathy, and foot ulcers, however, were about equally common in the two groups of diabetics (with and without limited joint mobility). Nephropathy appeared commoner in diabetic subjects without limited joint mobility. Our results confirm previous observations in Caucasians of an increased prevalence of limited joint mobility in diabetes, especially those receiving insulin treatment, and also showed that limited joint mobility could predict the presence of retinopathy and cataracts in those diabetics. Neuropathy and hypertension were not commoner in our diabetics with limited joint mobility (unlike in the Caucasian population), suggesting that racial factors may underlie the predictive value of limited joint mobility in diabetic microangiopathy.

Limitation of finger joint mobility in diabetes mellitus

Diabetes mellitus, both insulin dependent and non-insulin dependent, is associated with limitation of joint mobility of the fingers, which can be due to connective tissue changes, neuropathy, vasculopathy, or combinations of these problems. Distinct clinical problems include Dupuytren disease, flexor tenosynovitis, carpal tunnel syndrome (diabetic hand), stiff hand syndrome, shoulder-hand syndrome (reflex dystrophy) and limited joint mobility (LJM). Stiff hand and LJM syndromes are only seen with diabetes; the others have distinct clinical characteristics in those with diabetes compared to the nondiabetic presentation. LJM is of particular interest because it is common in young patients and associated with an increased risk for the serious complications of nephropathy and retinopathy.

Hand abnormalities are associated with the complications of diabetes in type 2 diabetes

Limited finger joint mobility, Dupuytren's contracture, and the complications of diabetes were assessed in 233 Type 2 diabetic patients. Limited joint mobility was present in 34% and Dupytren's contracture in 26%. The prevalence of limited joint mobility and Dupuytren's contracture increased with duration of diabetes and with age. Logistic regression analysis showed that, after allowing for age and duration of diabetes, limited joint mobility was independently associated with Dupuytren's contracture (odds ratio 5.7, 95% CI 2.0-16.4) and retinopathy (odds ratio 3.1, CI 1.5-6.4). Dupuytren's contracture was independently associated with vision-threatening retinopathy (odds ratio 2.6, CI 1.1-6.4), limited joint mobility (odds ratio 2.5, CI 1.3-4.8), and foot ulceration (odds ratio 4.9, CI 1.4-16.4). Both Dupuytren's contracture and limited joint mobility were associated with peripheral neuropathy but neither hand abnormality was associated with neuropathy independently of other complications of diabetes. The association of connective tissue abnormalities in the hand with the complications of diabetes suggests that similar factors may be contributing to their pathogenesis.

[Tunnel syndromes and blood glucose anomalies]

The fasting blood glucose was studied in 406 patients with carpal tunnel syndrome. We found 3.3% patients with diabetes mellitus and 15% with abnormal blood glucose levels. A prospective study was performed in 36 patients (oral glucose tolerance test, and blood lipid parameters). 45% of the patients in this group had an abnormal OGTT and 52% presented with hyperlipoproteinemia.

Diabetic hand syndrome

Diabetic hand syndrome is a condition affecting about 30% of patients with insulin-requiring juvenile diabetes. Characteristic findings in this syndrome are mild- to- moderately severe joint contractures of the fingers, particularly at the proximal interphalangeal joints in the ring and small fingers, and thickening of the skin of the dorsum of the hand. There is no evidence of palmar fascial thickening or Dupuytren's contracture. Occasionally other joints may be involved, such as the wrists, elbows, hips, knees, and toes. In the case presented in this report light and electron microscopic studies showed that the disease presents aspects similar to those of other "fibrotic diseases" as described by Kisher and Speer. Surgical treatment was only partially beneficial in this patient.

Carpal tunnel release in patients with diffuse peripheral neuropathy

Sixty carpal tunnel decompressions were performed in 44 patients with combined carpal tunnel syndrome and peripheral neuropathy. Symptomatic improvement was obtained in 92% of the patients and complete relief of symptoms in 72%. We conclude that peripheral neuropathy is not a contraindication to carpal tunnel decompression.

Pathologic features of diabetic thick skin

Skin thickening simulating scleroderma, or progressive systemic sclerosis, has previously been reported in children and adults with insulin-dependent diabetes mellitus. We have studied eighty-nine patients with insulin-dependent diabetes mellitus and twenty-five normal control subjects. Clinical evidence of skin thickening (diabetic thick skin) was found in 22% of patients with insulin-dependent diabetes mellitus and in 4% of control subjects (p less than 0.05). Full-thickness skin biopsy specimens were taken from the forearm of nine patients with insulin-dependent diabetes mellitus and diabetic thick skin, four patients with insulin-dependent diabetes mellitus and clinically normal skin, four patients with progressive systemic sclerosis, and four normal control subjects. The sections stained with hematoxylin and eosin showed increased thickness of the dermis of the forearm skin in all diabetic patients. In diabetic thick skin the collagen bundles were large, disorganized, and separated by clear spaces. Small amounts of acid mucopolysaccharides were present in the upper reticular dermis of five patients with diabetic thick skin. Electron microscopy of the dermis showed capillary basement membrane thickening in Groups 1, 2, and 3. All patients with diabetic thick skin showed active fibroblasts and extensive collagen polymerization in the rough endoplasmic reticulum. Occasional collagen flowers were noted in all patients with diabetic thick skin. Measurements of 100 collagen fibers in the upper and lower reticular dermis of each biopsy specimen showed predominance of large fibers (greater than 60 nm) in Groups 1 and 2. Unlike scleroderma, diabetic thick skin resulted in small fiber sizes (less than 60 nm) only rarely, and bimodality of fiber sizes was not seen.(ABSTRACT TRUNCATED AT 250 WORDS)

Limited finger joint mobility in insulin-dependent and non-insulin-dependent Ethiopian diabetics

The prevalence of limited joint mobility (LJM) was studied in 110 insulin-dependent (IDDM) and 190 non-insulin-dependent (NIDDM) consecutive Ethiopian African diabetics and 300 age- and sex-matched controls at the Tikur Anbassa Teaching Hospital in Addis Ababa over a period of 18 months. Mean ages +/- S.D. of the IDDM, NIDDM, and controls were 35 +/- 9.9, 49.4 +/- 12.0, and 43.3 +/- 14.0 years, respectively. LJM was found in 44.5% of IDDM, 25.3% of NIDDM, and 6.7% of controls, being significantly commoner in IDDM than NIDDM (p less than 0.001) and in the diabetics than in controls (p less than 0.001). In IDDM those with LJM were significantly younger (p less than 0.05), had a higher prevalence of median fasting blood glucose (FBG) levels of 15 mmol/l and above (p less than 0.01), and retinopathy (p less than 0.05), but did not differ from those without LJM in duration of diabetes, or prevalence of neuropathy and nephropathy. In NIDDM those with LJM had a significantly longer duration of diabetes (p less than 0.005) and a higher prevalence of nephropathy (p less than 0.005), but did not differ from those without LJM in age at onset of diabetes, prevalence of neuropathy, and retinopathy or median FBG level.

Limited joint mobility in diabetes mellitus

The relationship of limited joint mobility and finger joint contractures in diabetics to age of onset, duration, and control of diabetes has not been established. We measured the mobility of metacarpophalangeal, wrist, elbow, and ankle joints and assessed the prevalence of finger joint contractures in 254 young diabetics and 110 controls. The presence of microvascular disease was assessed by ophthalmoscopy and urine analysis for proteinuria. An estimate of long-term diabetic control was obtained from a postal questionnaire. A generalised reduction in joint mobility was present in diabetics of all ages two years after diagnosis. The reduction in joint mobility in controls between the ages of 12 and 13 was exaggerated in the diabetics. Diabetics diagnosed before puberty were more severely affected than those with a postpubertal onset, independent of duration of diabetes. Finger joint contractures were a significant feature of longstanding diabetics (nine years or more duration) only.

Carpal tunnel syndrome: a review

Compression of the median nerve in the crowded carpal tunnel is common and frequently incapacitating. Its causes and associated clinical conditions are multiple. Diagnosis is made by the typical history, three frequently positive physical signs at the wrist, and, if necessary by median nerve conduction velocity impairment. Most patients can be managed medically; when surgery is required it can be done usually without general anesthesia on an outpatient basis with gratifying results.

Skeletal and joint manifestations of childhood diabetes

The rheumatologic and skeletal manifestations of childhood diabetes have only recently been appreciated. This article reviews bone loss (osteopenia) in this population, and the differential diagnosis of the limited joint mobility commonly found in insulin-dependent diabetes in childhood.

Limitation of joint mobility (cheiroarthropathy) in adult noninsulin-dependent diabetic patients

Joint mobility was assessed in 80 consecutive adult noninsulin-dependent diabetic (NIDD) patients and 47 nondiabetic controls matched for age and sex. Impairment of mobility was observed in 36 NIDD patients but only 7 controls (p less than 0.01). There was no significant differences between diabetic patients with and without impaired mobility with regards to age, duration of diabetes, mean daily insulin dose, or overall diabetic control as assessed by the measurement of glycosylated haemoglobin (HbA1C). However, NIDD patients with impaired joint mobility had a significantly increased frequency of microvascular disease, as shown by retinopathy and/or nephropathy (42% versus 22%, p less than 0.05), were more often on insulin treatment (86% versus 63%, p less than 0.05) and more frequently had additional rheumatic disorders such as Dupuytren's contracture and osteoarthritis (36% versus 18%, p less than 0.05). In addition tight waxy skin over the phalanges was commonly associated with impaired mobility (58% versus 22%, p less than 0.01). Limitation of joint mobility was most prominent in the hands but caused no functional impairment. This finding may be an additional marker of microvascular disease in the adult diabetic patient.

Locomotor system disorders in diabetes mellitus. Increased prevalence of palmar flexortenosynovitis

Diabetes mellitus (DM) may be accompanied by a variety of locomotor system disorders including several hand syndromes. It has been suggested that palmar flexortenosynovitis (FTS) might be included among these hand syndromes, but no conclusive data have been available. Furthermore, recent studies have indicated that FTS may be a clue to previously undiagnosed impaired glucose tolerance. In the present study the prevalence of FTS among diabetics without inflammatory rheumatic disease was 11% compared with less than 1% (p less than 0.001) in a reference group. Thus, FTS could be included among the locomotor system disorders which are associated with DM.

Limited joint mobility in Type I diabetes mellitus

Forty-two of 115 patients with Type I (insulin dependent) diabetes were found to have limited joint mobility affecting mainly the small joints of the hands. The presence of joint abnormalities was related to duration of diabetes. Patients with limited joint mobility had a significantly higher incidence of proliferative retinopathy than patients with normal joint mobility and a similar duration of diabetes (P<0·001). Limited joint mobility appears to be an early marker for the development of microvascular complications in diabetes.

Rheumatic syndromes in endocrine disease

It is not widely appreciated that endocrine disease may present primarily as rheumatic syndromes, sometimes spectacular in onset, more commonly insidious and subtle, making their true recognition difficult. The underlying hormonal, biochemical, and metabolic events have understandable reflection in the structure and function of bone, joint, and muscle.

The rheumatologic manifestations of diabetes mellitus

The rheumatologic disorders associated with diabetes mellitus have been reviewed. From the evidence presented, it can be concluded that neuroarthropathy and osteolysis are definitely assoicated with diabetes. Ankylosing hyperostosis and periarthritis probably represent valid associations, and possible, but still unproven associations exist for gout, pseudogout, the carpal tunnel syndrome, osteoarthritis, Dupuytren's contracture and joint contractures. Despite the lack of a proven pathophysiologic basis these interrelationships may be clinically relevant. The discovery of one of these disorders may provide a clue to underlying glucose intolerance, and idabetics should be followed with the knowledge that they are at risk for the development of certain musculoskeletal problems.