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 Table of Contents  
ORIGINAL ARTICLE
Year : 2013  |  Volume : 3  |  Issue : 2  |  Page : 124-127

Tropical diabetic hand syndrome: Surgical management and proposed classification


1 Department of Traumatic and Orthopaedic Surgery, Ahmadu Bello University, Zaria, Nigeria
2 Department of Internal Medicine, Ahmadu Bello University, Zaria, Nigeria
3 Department of Department of Medicine, Specialist Hospital Dutse, Nigeria

Date of Web Publication13-Dec-2013

Correspondence Address:
Yau Z Lawal
Department of Traumatic and Orthopaedic Surgery, Ahmadu Bello University, Zaria
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-9596.122931

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  Abstract 

Introduction: Hand complications of diabetes mellitus are rare compared to those in the foot. They occur in the ratio of 1:20 in our observations. We managed 36 patients with tropical diabetic hand syndrome and propose a classification for the disease that will allow communication between physicians and prognostication.
Materials and Methods: Patients with hand infections and background diabetes mellitus were admitted. Their age, sex and occupations were noted. A clinical diagnosis was made and drained. Wound swab for culture was taken. Wounds were generally serially debrided at bed side with wound being allowed to granulate over time to be subsequently closed by split thickness skin graft.
Results: Thirty six patients were studied. Based on their clinical diagnosis, they were classified into three (I,II,III) groups in increasing order of severity. The classification correlated with the type and severity of the disease. It also guided the choice of appropriate treatment.
Conclusion: Based on our findings, tropical diabetic hand syndrome was classified and prognosticated based on the degree of soft tissue and bone involvement. The classification allows for communication with other physicians.

Keywords: Diabetes mellitus, hand infections, deep palmar space abcess, Osteomyelitis, gangrene


How to cite this article:
Lawal YZ, Ogirima MO, Dahiru IL, Girei BA, Salisu MB. Tropical diabetic hand syndrome: Surgical management and proposed classification. Arch Int Surg 2013;3:124-7

How to cite this URL:
Lawal YZ, Ogirima MO, Dahiru IL, Girei BA, Salisu MB. Tropical diabetic hand syndrome: Surgical management and proposed classification. Arch Int Surg [serial online] 2013 [cited 2024 Mar 19];3:124-7. Available from: https://www.archintsurg.org/text.asp?2013/3/2/124/122931


  Introduction Top


Diabetic hand conditions are rare compared to the diabetic foot disease, which is ubiquitous. There is an increase in the prevalence of diabetes in the sub-Saharan region of Africa, northern Nigeria inclusive. With it comes the increased rates of diabetic hand conditions amongst other complications of diabetes like retinopathy, renal failure, and hypertension. [1] This is in keeping with the global trend of increase in diabetes mellitus and obesity, urbanization, physical inactivity, and aging. [2],[3],[4] Estimates of current and future global prevalence have been published. [2],[3]

A high index of suspicion and blood glucose measurement will help identify majority of these patients. Amongst those patients whose diabetic status is known, it was observed that those with body mass index greater than 25 and those with peripheral neuropathy have been found to be more at risk of developing diabetic hand diseases. Other conditions like trauma, poor glycemic control, type 2 diabetes, female gender, and late presentation to the hospital have been put forward as risk factors. [4],[5],[6],[7],[8] Although normoglycemic individuals develop hand infections, diabetics have more frequent and severe incidents compared to the general population. [5],[6],[7],[8] The mechanism for the development of diabetic foot disease is neuropathy followed by infection and subsequent healing of the infection the failure of which leads to ulceration.

In the diabetic hand syndrome, infections are easily controlled if seen early and ulcerations and gangrenes are therefore rare. Mechanical use in background neuropathic hands in the absence of infection does not frequently lead to ulceration. Early records of diabetic and hand complications were documented in 1977 in the United States and in 1984 in Africa. [4] The spectrum of diseases seen by the orthopedic surgeon in patients with diabetes occurs in the general population. However, the course taken is not as severe with osteomyelitis, gangrene, and severe deformities as possible outcomes. The term diabetic hand syndrome has been put forward as an all encompassing term to describe these conditions. [6],[7],[8] This term however has not received wide usage and the pathologies are described loosely as hand infections. Based on our experience in dealing with this condition, we described a course of management and propose a new classification for diabetic hand conditions.


  Materials and Methods Top


The study was conducted at the Ahmadu Bello University Teaching Hospital, Zaria, and the Federal Medical Center Katsina, northern Nigeria. Between September 2009 and February 2013, all diabetic patients referred to the authors with hand infections, abscesses, osteomyelitis, and gangrenes involving the upper extremity were prospectively managed and followed-up. Age, sex, nature, extent of disease, body mass index, serum glucose level, and presence of peripheral neuropathy using modified Semmes-Weinstein monofilaments were documented. Wound swabs for microbiological cultures were taken. Superficial infections were treated with empirical antibiotics pending the outcome of culture. Deep abscesses were drained and debrided under general anesthesia. The wounds were copiously lavaged with normal saline and hydrogen peroxide. They were subsequently dressed regularly with honey on the wards. Evolving necrotic tissues were serially debrided by the bedside. No tourniquet was used in all patients. Soft tissue infection was controlled by empirical use of intravenous ceftriaxone, gentamycin, and metronidazole.

Antibiotics were changed if the culture proves insensitive to them. Only 19.4% of tissue cultures were positive for Staphylococcus aureus. The remaining 80.6% were sterile probably from earlier use or misuse of antibiotics. Osseous infection was prevented by the incision and drainage of abscesses and intensive antibiotic therapy. Wounds were dressed with honey until maturation of granulation tissue. This was followed by bedside split thickness skin graft for wounds 5 cm 2 or less in size as described. The rate of graft take was more than 90% in all wounds treated. Passive and active physiotherapy were continued while the graft incorporated.

Ulcers were allowed to granulate gradually. This was then covered by STSGs. Wounds <5 cm 2 had bedside STSG. While this treatment is being given, elevation of the limb, early active and passive physiotherapy was commenced to facilitate the rehabilitation.


  Results Top


Thirty-six patients with hand conditions and background diabetes mellitus were seen during the study period. All had type 2 diabetes mellitus and were being managed on oral hypoglycemic agents. The patients were broadly classified into three groups (I-III) based on the degree of severity of their disease and prognosis.

Group I: Hand infections limited to skin, subcutaneous tissues muscles, and the web spaces in between metacarpals including the space of Parona (61.1%) [Figure 1].
Figure 1: Diabetic with deep palmar abscess

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Group II: Infections involving deep tendons, bones, and joints including osteomyelitis but no gangrene (25%).

Group III: Digital and hand gangrene (13.9%) [Figure 1] and [Figure 2].
Figure 2: A diabetic with digital gangrene and infection extending into the space of Parona. He had forearm amputation

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Fifteen patients had cellulitis needing only antibiotic therapy, elevation of the affected hand, and early physiotherapy accounting for 68.1% of group I. Physiotherapy was passively and actively done according to the ability of the patient. Seven patients had web space infections accounting for 39.1% requiring incision and drainage in addition to antibiotics and early physiotherapy. Nine patients had deep thenar and hypothenar space infections requiring incision and drainage and serial wound dressing with honey. One of the deep abscesses group developed chronic osteomyelitis of the second terminal phalanx requiring amputation. Of these eight patients, five developed a cicatrizing ulcer in the dorsum and volar aspect of the hands requiring bedside split thickness skin grafting. The average size of the ulcers was 4 cm 2 .

Five patients had fulminant hand infection leading to digital gangrenes with one requiring amputation at the wrist joint.

There were seven women and 29 men in the study with M:F ratio of 4:1. The average age was 47 years. The average body mass index for male patients was 20 and 22 for females. The average fasting serum glucose level of our patients was 9 mmol. There were 30 diabetic foot diseases to every one hand disease seen by us (ratio 30:1).

Staphylococcus aureus was isolated in seven patients accounting for 19.4% positive culture rate. The rest of the patients had sterile culture. Antibiotics therapy has been commenced in all the patients before they were seen by the orthopedic surgeon. Functional outcome of the reconstruction procedures were assessed by the surgeon. All patients reported satisfactory outcome although they desired for more, except for the one forearm amputee. Cosmetic outcome was not assessed in our patients with main trust being function. The average cost of treatment was $250 with a range of $120-1,000. No mortality was reported in any of the patients studied.


  Discussion Top


Diabetic hand infections and other complications were until recently, not common in our environment. The diabetic hand syndrome is not of infectious origin. It comprises of limitation in joint mobility, Duputyren's contracture and trigger finger. The tropical diabetic hand syndrome is a form of advanced necrotizing fasciitis in which in addition to soft tissue, the bones and digits are affected leading to gangrene. It has been our observation that there are thirty diabetic foot diseases to every one hand disease seen by us (ratio 30:1).

In diabetic foot disease, the mechanism of occurrence of ulceration is clear-cut. Neuropathy is followed by ulceration, and then neuro-arthropathy. This sequence is affected by subtle factors that, if dealt with appropriately will tip the disease process towards healing rather than ulceration. It is possible that the mechanism of disease is similar between diabetic hand and foot diseases. The somatic and sensory neuropathies that are commonly seen in diabetic foot disease are not present in diabetic hand disease. The occurrence of neuropathy is linked to glycemic control of the patient. The average fasting serum glucose level of our patients was 9 mmol compared to the desirable 5.0 mm/dl. [9] This is based on the findings in our series that 92% can recognize modified Semmes-Weinstein monofilaments, the recognition of which has been found to positively correlate with occurrence of neuropathic ulcers in diabetics. [9],[10] Wound cover has been a problem for diabetics who developed ulcers. We found out that bedside STSG has almost 100% success rate for wounds less than 5 cm 2 as described. [11] The presence of high serum glucose in the local environment is very important in diabetic hand disease. In 80% of the patients seen, a discernible traumatic incident leads to either an infection or straightforward ulceration. Majority are manual laborers who are at greater risk for hand injuries. All women affected are engaged in normal household chores that predispose to the development of hand infections. It has been reported that peripheral neuropathy and peripheral vascular disease may not be significant contributing factors in diabetic hand syndrome. Instruction on hand care will go a long way in reducing the risk of this syndrome and its complications. Infection is assumed to be a cardinal feature of diabetic hand syndrome. Our study found 19.4% positive culture rate of Staphylococcus aureus. Other studies reported mixed organisms. [5],[12],[13],[14],[15] From the orthopedic point of view, the most important thing is to control soft tissue infection, debride gangrenous tissues, prevent osteomyelitis, and cover ulcers followed by functional rehabilitation of the affected hand. To our knowledge, no previous classification or staging has been proposed for tropical diabetic hand syndrome. Mortality arising from tropical diabetic hand syndrome is rare, but the long-term effect and morbidity on the patient is enormous. This has been the observation of other authors on the matter. [16]


  Conclusion Top


The prevalence of diabetes mellitus and consequently its complications are set to increase in the near future. The pathology and care of the foot disease is well-established and has classifications allowing for prognostication and communication between physicians. This is not the same with diabetic hand syndrome which occurs less frequently and to the best of our knowledge has neither been staged nor classified. This manuscript has provided such classification, and probably generates further discussion on the matter.

 
  References Top

1.WHO. The Global Burden of Disease: 2004 Update. Geneva: World Health Organisation; 2004.  Back to cited text no. 1
    
2.Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: Estimates for the year 2000 and projection for 2030. Diabetes Care 2004;27:1047-53.  Back to cited text no. 2
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3.King H, Rewers M. Global estimates for prevalence of diabetes mellitus and impaired glucose tolerance in adults: WHO Ad Hoc Diabetes Reporting Group. Diabetes Care 1993;16:157-77.  Back to cited text no. 3
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4.King H, Aubert RE, Herman WH. Global burden of diabetes, 1995-2025: Prevalence, numerical estimates, and projections. Diabetes Care 1998;21:1414-31.  Back to cited text no. 4
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5.Akintewe TA, Odusan O, Akanji O. The diabetic hand - 5 illustrative case reports. Br J Clin Pract 1984;38:368-71.  Back to cited text no. 5
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6.Larkin JG, Frier BM, Ireland JT. Diabetes mellitus and infection. Postgrad Med J 1985;61:233-7.  Back to cited text no. 6
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7.Gill GV, Famuyiwa OO, Rolfe M, Archibald LK. Serious hand sepsis and diabetes mellitus: Specific tropical syndrome with western counterparts. Diabet Med 1998;15:858-62.  Back to cited text no. 7
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8.Abbas ZG, Lutale J, Gill GV, Archibald LK. Tropical diabetic hand syndrome: Risk factors in an adult diabetes population. Int J Infect Dis 2001;5:19-23.  Back to cited text no. 8
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9.Olomo PR, Cataland S, O'Dorisio TM, Casey CA, Smead WN, Simon SR. The Semmes-Weinstein monofilament as a potential predictor of foot ulceration in patients with non insulin dependent diabetes. Am J Med Sci 1995;309:76-82.  Back to cited text no. 9
    
10.The effect of intensive treatment of diabetes on the development and progression of long term complications in insulin dependent diabetes mellitus. The Diabetes Control and Complications Trial Research Group. N Eng J Med 1993;329:977-86.  Back to cited text no. 10
    
11.Lawal YZ, Ibrahim A. Bedside split thickness skin graft using a safety razor blade: a forgotten surgical art. Nig J Orth 2012;11:36-40.  Back to cited text no. 11
    
12.Tiwari S, Chauhan A, Sethi NT. Tropical diabetic hand syndrome. Int J Diabetes Dev Ctries 2008;28:130-1.  Back to cited text no. 12
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13.Archibald LK, Gill GV, Abbas Z. Fatal hand sepsis in Tanzanian diabetic patients. Diabet Med 1997;14:607-10.  Back to cited text no. 13
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14.Fitzgibbons PG, Weiss AP. Hand manifestations of diabetes mellitus. J Hand Surg Am 2008;33:771-5.  Back to cited text no. 14
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15.Centers for Disease control and Prevention (CDC). Tropical diabetic hand syndrome-Dar es Salam, Tanzania. 1998-2002. MMWR Morb Mortal Wkly Rep 2002;51:969-70.  Back to cited text no. 15
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16.Nthumba P, Cavadas PC, Landin L. The tropical diabetic hand syndrome: A surgical perspective. Ann Plast Surg 2013;70:42-6.  Back to cited text no. 16
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    Figures

  [Figure 1], [Figure 2]


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