Diabetes is a systemic disease with wide ranging manifestations due to defects in insulin production or organ receptor sensitivity to this critical hormone. It has profound effects on the cells comprising the circulatory, nervous and connective tissue systems. This widespread involvement of systems is expressed in the hand and diabetes patients often have symptoms that are due to these problems but go unrecognized.
Numbness or tingling in the fingers is often ignored until it becomes persistent or painful. This if often interpreted as neuropathy which occurs commonly in the foot. In the hand, this tingling, or “paresthesias”, is more often due to a nerve compression in the upper extremity. Most commonly, carpal tunnel syndrome is present, which is a median nerve compression at the wrist level. It is actually due more to inflammation of the surrounding flexor tendons, rather than direct pathology of the nerve itself.
Patients typically complain of numbness or tingling in the thumb or central fingers which is often worse at night and can cause difficulty sleeping. Chronic and severe compression of the nerve leads to weakness of the thumb with subsequent difficulty in many daily tasks.
The diagnosis of carpal tunnel syndrome
This diagnosis is usually made through a careful history and physical exam of the hand, and confirmed by nerve conduction studies which measure the electrical conduction of the median nerve through the wrist. The treatment initially consists of sleeping with a night splint which keeps the wrist in a neutral position, and high doses of vitamin B6. Anti-inflammatories may help as well, and in certain indications a cortisone injection in the wrist. However, the majority of cases with significant persistant symptoms will require a decompression of the carpal canal to take pressure off the median nerve. This has been traditionally done by an open incision, but can now be done endoscopically in a minor procedure with local anesthesia. Patients can use the hand immediately after the outpatient procedure, and only need to miss a minimum amount of work and can usually forego any therapy.
The cause of carpal tunnel syndrome is really a thickening and inflammation of the tendons that pass in the tunnel along with the delicate nerve. This same tendonitis deep in the wrist causes mechanical problems and pain farther along in the palm. Inflammation of these flexor tendons as they travel to the finger leads to pain in the palm of the hand with occasional “triggering” or catching of the tendon in the tunnel as the patient attempts to extend the finger after flexing.
The treatment of tendonitis
This treatment is quite simple, involving either reducing the tendon inflammation or opening the tunnel through which it passes. A corticosteroid injection along the tendon sheath is very effective, unless the patient experiences locking where the mechanical problem is more profound and requires a mechanical solution. A trigger finger release is done by a small incision in the palm and opening the tight sheath containing the tendon allowing it to glide once again. In isolated cases of trigger finger, we can even do this percutaneously, without making an incision. This is also done under local anesthesia, and the dressing is removed the very next morning by the patient themselves. Similar releases are done at the wrist level for DeQuervain’s tendonitis.
There is a common misconception that cortisone injections are harmful to patients, particularly diabetics. This is not the case when the injections are limited to several low dose injections spanned out over time and in different locations. This medication tends to stay in the local area injected and does not affect the patient systemically as in elevating blood sugar. Nevertheless, these pathologies often do not respond adequately to this conservative treatment, and the minor surgical procedures should be performed. This is commonly the scenario is other locations such as lateral epicondylitis (tennis elbow) or bursitis of the shoulder, where an arthroscopic excision of bursa can be done to alleviate and usually cure the problem.
Infection in the hand is another typical problem seen in diabetics.
The diabetic response to an infection is just one manifestation of how the hand and upper extremity is profoundly affected by this alteration in sugar metabolism. It is important that the patient as well as the primary physician have a good understanding of these conditions and to involve the hand surgeon at an early stage.
Please call (305) 227-4263 to request an appointment with Dr. Alejandro Badia.
Alejandro Badia, MD, FACS
Badia Hand to Shoulder Center