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DIABETES MELLITUS

Introduction

Diabetes mellitus (DM) is impaired insulin secretion and peripheral insulin resistance that results in hyperglycemia. Early symptoms include polyuria, polyphagia, and blurred vision. Later complications include vascular disease, peripheral neuropathy, and vulnerability to infection. The patient is diagnosed via plasma glucose measurements, and complications can be minimized with adequate glycemic control. Patients with DM are at higher risk for several hand disorders, including carpal tunnel syndrome (CTS), Dupuytren’s disease (DD), trigger finger, and limited joint mobility (LJM). Collectively, these conditions are known as “diabetic hand,” because they occur so frequently in patients with DM. Thus, hand surgeons should obtain a detailed history and ask their patients about DM. If surgery is required, glycemic control during the procedure is imperative, as intraoperative hyperglycemia increases the risk of cardiovascular and respiratory problems, as well as infection. Post-operative glycemic control is just as crucial. Patients with DM are at higher risk of surgical complications and DM can have a negative effect on postsurgical outcomes.
 

Pathopysiology

  • The exact pathophysiology of hand conditions associated with DM is not known.
  • Proposed hypotheses all relate to the mechanisms by which DM occurs.

Incidence and Related Conditions

  • CTS
    • Incidence is 11–21% in the diabetic population
    • CTS is more severe and less responsive to surgical release in patients with DM
  • DD
    • Incidence is 11–63% in the diabetic population, which is 2–8 times higher than in the nondiabetic population
    • In patients with DM, DD predominantly affects the ring and middle fingers; in nondiabetic patients, DD predominantly affects the ring and little fingers
  • Trigger finger
    • Prevalence is 20% in the diabetic population and 2% in the general population
    • Multiple fingers are involved in ≤60% of diabetic patients
    • Responds less well to corticosteroid injection and more often requires surgery
  • LJM
    • Incidence is 8–75% in the diabetic population
    • LJM occurs mainly in the hands, but can extend to the wrist and upper extremity
    • LJM is associated with Type 1 DM
  • Peripheral Vascular Disease
    • Radiocephalic fistulas in patients with radial artery Mönckernerg calcification had worse clinical outcomes when compared to ESRD diabetics with healthy distal arm vessels 3
  • Hand weakness
    • In patients with DM, grip strength and pinch strength are reduced, and these effects are independent of potentially comorbid DD, trigger finger, and LJM
    • There is no direct association between hand weakness and patient age, duration of DM, or DM control
ICD-10 Codes

  • DIABETES MELLITUS

    Diagnostic Guide Name

    DIABETES MELLITUS

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    DIABETES MELLITUS    
    - TYPE I    
      - NO COMPLICATIONSE10.9   
      - MONONEUROPATHYE10.41   
      - POLYNEUROPATHYE10.42   
      - PERIPHERAL CIRCULATORY COMPLICATION W/ GANGRENEE10.52   
      - PERIPHERAL CIRCULATORY COMPLICATION W/O GANGRENEE10.51   
    - TYPE II    
      - NO COMPLICATIONSE11.9   
      - MONONEUROPATHYE11.41   
      - POLYNEUROPATHYE11.42   
      - PERIPHERAL CIRCULATORY COMPLICATION W/ GANGRENEE11.52   
      - PERIPHERAL CIRCULATORY COMPLICATION W/O GANGRENEE11.51   

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Clinical Presentation Photos and Related Diagrams
  • Limited joint mobility secondary to diabetes with positive Prayer sign. Positive sign secondary to joint stiffness and contractures especially in the PIP joints.
    Limited joint mobility secondary to diabetes with positive Prayer sign. Positive sign secondary to joint stiffness and contractures especially in the PIP joints.
Symptoms
Patients typically will report numbness and tingling consistent with CTS. The peripheral neuropathy ["in stocking glove distribution] in addition to CTS act as a double crush phenomenon.
Patients also complain of catching and locking of finger(s) consistent with trigger finger. This should be evaluated for associated stiffness of limited joint mobility and any baseline joint contractures.
Typical History
  • Preoperative planning: determine blood glucose or HbA1c level to help identify patients who may be at risk for complications
    • Pursue medical optimization before hand surgery
    • Poor glycemic control is defined as HbA1c >9% (blood glucose 170–249 mg/dL)
    • The Society for Ambulatory Anesthesia recommends an intraoperative blood glucose level ≤180 mg/dL 
Positive Tests, Exams or Signs
Work-up Options
Images (X-Ray, MRI, etc.)
Imaging Related to Diabetes
  • Calcified arteries in elder diabetic patient
    Calcified arteries in elder diabetic patient
Treatment Options
Conservative
  • Cortisone injections are commonly used to treat CTS, trigger finger, LJM and other conditions; however, there is risk of hyperglycemia after injections in DM patients and only moderate benefit
    • Some studies have shown that the increase in blood glucose is transient and most likely to occur in patients with Type 1 DM and in those taking insulin
    • Patients receiving corticosteroids should perform vigilant glucose monitoring for up to 2-5 days post-injection.
    • The physician must always weigh the benefits against the risks.
Operative
  • In DM patients, first-line oral hypoglycemic medications are typically stopped the morning of hand surgery; short-acting insulin can be substituted as needed
  • Patients with Type 1 DM and moderate-to-severe Type 2 DM are treated with insulin based on glucose monitoring.
    • Short-acting insulin: stop the morning of surgery
    • Long-acting or premixed insulin: administer half the usual dose the night before surgery due to NPO status prior to surgery,
  • Blood glucose levels should be monitored at least every 2 hours
  • Insulin pumps: no change
  • Consider prophylactic pre-operative antibiotics in diabetic patients 
Complications
  • Higher post-operative rates of pneumonia, urinary tract infection, and sepsis in patients with DM
  • There is an increased risk of infection in patients with DM
Outcomes
  • Hyperglycemia can impair immune function, alter vascular permeability, and affect metabolic reactions—all of which can lead to inferior surgical outcomes.
  • CTS:
    • In patients who undergo carpal tunnel release, outcomes may be poorer in patients with DM than in those without DM.
    • Specifically, there is a correlation between CTS surgery and the development of TD.
  • Trigger finger:
    • Conservative management is less successful in DM patients
  • Steroid injection has a 44–50% success rate in DM patients versus 60% in nondiabetics
    • Release outcomes are less favorable in patients with DM
  • LJM:
    • Notable improvement after intra-sheath steroid injections in the diabetic hand
Key Educational Points
  • Surgeons should make preoperative adjustments to oral hypoglycemic medications and insulin regimens to avoid intraoperative hypoglycemia and adverse metabolic states.
  • Schedule surgery in the early morning to decrease the risk of hypoglycemia while fasting.
  • Elective procedures for patients with poorly controlled diabetes (HbA1c >9%) can be postponed. 
  • Diabetic patient's with CTS and TF are less likely to respond to conservative treatment.
  • Diabetic patients that receive a cortisone injection require glycemic monitoring for up to 5 days after injection.
References

New Articles

  1. Grandizio LC, Beck JD, Rutter MR, et al. The incidence of trigger digit after carpal tunnel release in diabetic and nondiabetic patients. J Hand Surg Am 2014;39(2):280-5. PMID: 24360881
  2. Stepan JG, London DA, Boyer MI, Calfee RP. Blood glucose levels in diabetic patients following corticosteroid injections into the hand and wrist. J Hand Surg Am 2014;39(4):706-12. PMID: 24679910
  3. Georgiadis, GS, Georgakarakos EI, Antoniou GA, et al. Correlation of pre-existing radial artery macrocalcifications with late patency of primary radiocephalic fistulas in diabetic hemodialysis patients. J Vasc Surg 2014; 60 (2): 462-70

Reviews

  1. Kang JR, Yao J. Perioperative management of diabetic patients undergoing hand surgery. J Hand Surg Am 2015;40(5):1028-31. PMID: 25911211
  2. Brown E, Genoway KA. Impact of diabetes on outcomes in hand surgery. J Hand Surg Am 2011;36(12):2067-72. PMID: 22123050

Classics

  1. Chammas M, Bousquet P, Renard E, et al. Dupuytren's disease, carpal tunnel syndrome, trigger finger, and diabetes mellitus. J Hand Surg 1995;20(1):109-14. PMID: 7722249
  2. Griggs SM, Weiss A-P C, Lane LB, et al. Treatment of trigger finger in patients with diabetes mellitus. J Hand Surg 1995;20(5):787-9. PMID: 8522745
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