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[IP] Re Diabetic cheiroarthropathy

Re Diabetic cheiroarthropathy- Cheiro refers to digits (fingers or toes) and
Arthro to joints.  It's sort of like arthritis and neuropathy all in one
 In 1984  a particular severe bout of gastroparesis  landed me in the
hospital several times, my gastroenterologist  thought I had scleroderma.
because of my waxy hands, totally impassive, unlined face which made me look
younger than my years,
distended esophagus etc.  I had already had multiple surgeries for tendon
releases in both hands over the years.  The posssibility that I might have
scleroderma nearly finished me off.
I was paralyzed with fear which added new symptoms to an already complicated

Eventually it was all sorted out and I just had to adapt to each REAL
complication. The thing with cheiroarthropathy is  that I can't do anything
with my hands for an extended period.  The surgeries have helped but can't
stop the degenerative process.   Swelling, stiffness, numbness  are all
unpredictable.  This week I couldn't change the batteries in my pump by
myself which freaked me out.  Usually I manage quite well.
In cold, damp  weather I can't use a key to unlock the front door, zip up my
coat etc.  It's all temporary I know, but unnerving.  I can't type fast
enough to go to chat rooms either so I gave that up.  :-(

By the way it took about twenty years for the progression of my
cheiroarthropathy to reach its actual stage, so I hope that younger
diabetics will benefit  from all that has been learned over the years.  Also
that FEAR is probably the worst unspoken complication of diabetes , can
mimic a lot of illnesses and send doctors and patients on a wild goose

Here is an excerpt from  an article I found at Diabetic-Lifestyle.com  I
wish I had read that years ago.

. "Diabetic cheiroarthropathy, also known as diabetic stiff hand syndrome or
limited joint mobility, is found in 8-50% of all people with type 1 diabetes
and is also seen in those with type 2 diabetes. The prevalence increases
with duration of diabetes and this condition is associated with and
predictive of other diabetic complications.

This syndrome is characterized by thick, tight, waxy skin reminiscent of
scleroderma. Limited joint range of mobility (inability to fully flex or
extend the fingers) and sclerosis of tendon sheaths are also present. The
underlying cause is thought to be multifactorial. Increased glycosylation of
collagen in the skin and periarticular tissue, decreased collagen
degradation, diabetic microangiopathy, and possibly diabetic neuropathy are
thought to be some of the contributing factors. Flexion contractures of the
fingers may develop at advanced stages. One indication of the presence of
this condition is known as the "prayer sign". this is patients' inability to
press their palms together completely without a gap remaining between
opposed palms and fingers. The specific treatment of diabetic
cheiroarthropathy (other than optimizing glycemic control) is unknown.

Flexor tenosynovitis (or trigger finger) is another frequent diabetic
complication of the hands. People complain of a catching sensation or
locking phenomenon that may be associated with pain in the affected fingers.
Examination shows a palpable nodule, usually in the overlying
metacarpophalangeal joint, and thickening along the affected flexor tendon
sheath on the palmar aspect of the finger and hand. Also, the locking
phenomenon may be reproduced with either active or passive finger flexion.
This complication is thought to have the same pathogenisis as diabetic
cheirarthropathy, and its prevalence is similarly related to the duration of

Initial treatment involves injecting local corticosteroids into the tendon
sheath. If this is unsuccessful, patients will most likely need to be seen
by a hand surgeon for a minor operation that can provide permanent relief.
This operation consists of a small transverse incision just distal to the
flexion crease over the metacarpal head, which exposes the flexor tendons
and sheath. A complete longitudinal incision along the thickened fibrous
tendon sheath relieves the constriction and allows the finger to move

Dupuytren's contracture results from a thickening, shortening, and fibrosis
of the palmar fascia. Nodule formation along the fascia is seen. Flexion
contractures of the fingers may result, usually at the fourth finger, but
sometimes involving any of the second through fifth digits. Dupuytren's
contracture has been reported in 16-42% of diabetic patients. Its
pathogenesis is thought to be the same as that for cheiroarthropathy. The
prevalence of this condition increases with disease duration, but may also
may also be seen early in the course of diabetes. Varied success has been
reported with local cortico-steroid injections. Surgical intervention may be
needed for severe cases.

Carpal tunnel syndrome (CTS) is seen in up to 20% of diabetic patients. Its
specific relationship to diabetes is thought to be a median nerve entrapment
caused by the diabetes-induced connective tissue changes mentioned above.
The prevalence of CTS in diabetic persons generally increases with duration
of the disease. CTS is usually diagnosed based on history and clinical
findings. Classically, people complain of burning, paresthesis, or sensory
loss in the median nerve distribution (the first three fingers as well as
the radial half of the fourth finger). They may also complain of pain in the
same area, often with radiation proximally into the forearm and arm. The
pain may awaken people from sleep and is aggravated by activities involving
wrist flexion or extension, such as holding a newspaper or book, typing,
driving, or using a knife and fork.

Tinels' sign (tapping over the median nerve on the volar aspect of the
wrist) may be helpful in diagnosis but it is not universally positive. A
positive Tinels' sign produces paresthesias distally in the hand. Phalen's
test (the wrist flexion test) may also assist in diagnosis, but like
Tinel's, it is somewhat variable. Patients are asked to flex both wrists so
that the dorsal of both hands are touching and hold that position for 30-60
seconds. A positive Phalen's test consists of paresthesias being reproduced
in the hand with this maneuver. it is also important to examine patients for
possible motor weakness by median nerve compression. Assessing thinner
muscle strength and examining the hand for the presence of the muscle
atrophy do this. It is important that clinicians intercede in CTS before the
development of this type of atrophy. Diabetic patients may have paresthesias
caused by underlying peripheral neuropathy, and these two entities must be
differentiated. Electromyogram/nerve conduction velocity (EMG/NCV) testing
can confirm the diagnosis of CTS in uncertain cases and can also help to
localize the site of entrapment.

Management of CTS is the same for diabetic patients as for nondiabetic
patients. Conservative treatment is tried initially for early or mild cases,
using volar wrist splints (particularly at night) with or without
nonsteroidal anti-inflammatory drugs (NSAIDs). Ergonomic adjustment of
computer workstations should be made when appropriate. Local corticosteroid
injection of the carpal tunnel may be tried as well. Patients with severe or
refractory cases, as well as those with thenar atrophy or progressive
neurological changes on serial EMG/NCV testing, should be sent for
definitive therapy with surgical release of the transverse carpal ligament
by a hand surgeon"
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