prof. josaphine - diabetic upper limb

8/3/2019 Prof. Josaphine - Diabetic Upper Limb

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Diabetic Limb ProblemDiabetic Limb Problem

* Upper Limb Presentation* Upper Limb PresentationDr. Josephine WingDr. Josephine Wing--yukyuk IpIp

Division Chief Division Chief

Division of Hand & Foot SurgeryDivision of Hand & Foot Surgery

Department of Department of OrthopaedicsOrthopaedics && TraumatologyTraumatology

Queen Mary HospitalQueen Mary Hospital

The University of Hong KongThe University of Hong Kong



Diabetic hand infectionDiabetic hand infection

DM hand is currently not generallyDM hand is currently not generally

classified as common complicationclassified as common complicationof DM as in foot problemsof DM as in foot problems

Western literature: (1999) 10%Western literature: (1999) 10%

incidence of DM hand infection thatincidence of DM hand infection thatrequires hospital admission; which isrequires hospital admission; which iscomparable to foot infectioncomparable to foot infection

PathoPatho--mechanism similar to footmechanism similar to foot



The HandThe Hand

Similar anatomy to foot, developSimilar anatomy to foot, develop

from limb budfrom limb bud

Different functional demand: ADL &Different functional demand: ADL &

workwork

Closer to the heart:Closer to the heart: vascularityvascularity isis

better, less extensive skin necrosisbetter, less extensive skin necrosis

Nerve cells with shorter axon: LessNerve cells with shorter axon: Less

prone to significant sensory deficit &prone to significant sensory deficit &

motor deficitmotor deficit



Predisposition to infection inPredisposition to infection in

diabetic limbdiabetic limb High blood sugar levelHigh blood sugar level

Impaired immune responseImpaired immune response Loss of protective sensation, less so in handLoss of protective sensation, less so in hand – –

less chance of unaware bacterialess chance of unaware bacteria innoculationinnoculation &&tissue damagetissue damage

Motor deficit resulting in deformities, lessMotor deficit resulting in deformities, lesscommon in handcommon in hand

Rapid progression of infection along tendonsRapid progression of infection along tendons

Further tissue necrosis & infectionFurther tissue necrosis & infection

Septic thrombosis: digital, metatarsal moreSeptic thrombosis: digital, metatarsal morefrequent/ rarely metacarpalfrequent/ rarely metacarpal

Gangrene of tissueGangrene of tissue



Diabetic hand with intrinsicDiabetic hand with intrinsic

minus deformitiesminus deformities



The handThe hand Organ to contact outside worldOrgan to contact outside world

The most distal part is most prone to injuryThe most distal part is most prone to injuryi.e. the digiti.e. the digit

Special anatomy:Special anatomy: fascialfascial layers connectinglayers connecting

skin and underlying boneskin and underlying bone Many deep spaces ,multiple compartmentsMany deep spaces ,multiple compartments

in pulpin pulp

Infection raise compartment pressure, proneInfection raise compartment pressure, pronetoto ischaemiaischaemia & necrosis, underlying bone& necrosis, underlying bone

undergoesundergoes osteomyelitisosteomyelitis



Subcutaneous infectionSubcutaneous infection

-- delay exploration may requiredelay exploration may requireproximal amputationproximal amputation



Special demand of handSpecial demand of hand – –

motion, mo0tion, motionmotion, mo0tion, motion

The hand toleratesThe hand toleratesimmobilization poorlyimmobilization poorly

Adhesion between tissueAdhesion between tissue

layers develop easily: nolayers develop easily: nomanman’’s lands land

Stiff digit affects overallStiff digit affects overall

functionfunction



Distal digital amputation stillDistal digital amputation still

has good function, the key ishas good function, the key isgood rehabilitationgood rehabilitation



Types of Infection inTypes of Infection in

diabetic limbdiabetic limb

CellulitisCellulitis

ParonychiaParonychia

PulpPulp

Web spaceWeb space

TenosynovitisTenosynovitis

Plantar Plantar spaces:medial,lateral,centralspaces:medial,lateral,central

Palmar Palmar

spaces:spaces:

thenar thenar

,,

hypothenar hypothenar

, mid, mid

--

palmar palmar

OsteomyelitisOsteomyelitis

Septic arthritisSeptic arthritis



PParonychiaaronychia

common infectioncommon infection



Pulp infection (Felon)Pulp infection (Felon)

•Special anatomy for firm

contact with objects, multiplesensory end organs

•Septa connecting bone to

skin•Multiple tight compartments

•High compartment pressure

•Prone to septic embolism &

grangrenous changes early



Pulp infection resulting in pulpPulp infection resulting in pulp

gangrene, earlygangrene, early fasciotomyfasciotomy &&drainage may salvage itdrainage may salvage it



Web space infectionWeb space infection

need volar & dorsal incision for need volar & dorsal incision for drainagedrainage



TenosynovitisTenosynovitis

Exploration with radicalExploration with radicaldebridement along the tendondebridement along the tendon

must be done before tendonmust be done before tendonnecrosis to preserve functionnecrosis to preserve function



MidMid--palmar palmar space infectionspace infection

Late presentation as it startedLate presentation as it startedwith edematous hand onlywith edematous hand only



Thenar Thenar space infectionspace infection



OsteomyelitisOsteomyelitis arising fromarising from

pulp infectionpulp infection



Septic arthritisSeptic arthritis



Hong Kong Chinese DiabetesHong Kong Chinese DiabetesPrevalencePrevalence

DM is 11%, around 700,000DM is 11%, around 700,000(700,000)(700,000)

DM hand: expect significant No.,DM hand: expect significant No.,

but no epidemiological data atbut no epidemiological data atpresentpresent

((KoKo GTC et al.GTC et al. TwoTwo- - hour post hour post - - glucose loading glucose loading plasma glucose is the main determinant for the plasma glucose is the main determinant for the progression from impaired glucose tolerance to progression from impaired glucose tolerance todiabetes mellitus in Hong Kong Chinese (letter)diabetes mellitus in Hong Kong Chinese (letter)..Diabetes Care 1999;22: 2096Diabetes Care 1999;22: 2096--2097.)2097.)



Analysis of hand infectionAnalysis of hand infection

cases 2006cases 2006--20102010

Retrospective reviewRetrospective review Protocol:Protocol:

-- Rest in boxing glove, elevationRest in boxing glove, elevation

in hospitalin hospital



-- Broad spectrum IV antibiotics coveringBroad spectrum IV antibiotics covering

gramgram-- and anaerobes : initiallyand anaerobes : initially AmpicillinAmpicillin++

CloxacillinCloxacillin ++ GentamycinGentamycin

-- Aggressive early debridement if there isAggressive early debridement if there is

pus collection or symptoms of infectionpus collection or symptoms of infection

not resolving within 24 hoursnot resolving within 24 hours

-- Liberal reLiberal re--exploration at intervals tillexploration at intervals till

clearance of infection, early decision onclearance of infection, early decision on

digital amputationdigital amputation

-- Early intervention by hand therapists toEarly intervention by hand therapists to

regain hand functionregain hand function



Features of hand infection inFeatures of hand infection in

DM compared with nonDM compared with non--DMDM

More rapid in progressionMore rapid in progression More extensive involvementMore extensive involvement

More severe tissue involvementMore severe tissue involvement Frequently mixed organisms, gramFrequently mixed organisms, gram

negative organisms Vs gram positivenegative organisms Vs gram positive

organisms in nonorganisms in non--DMDM



Epidemiological dataEpidemiological data

37 patients37 patients Average age 62(23Average age 62(23--87)87)

Male: 24 (64%), female: 13(36%)Male: 24 (64%), female: 13(36%)

Diagnosis of DM:Diagnosis of DM:--knownknown

-- previously unknown, diagnosed after 1previously unknown, diagnosed after 1stst

episode of hand infectionepisode of hand infection

Insulin injection:10Insulin injection:10 Oral medication 27, 5 need to switch toOral medication 27, 5 need to switch to

insulin injection during hospital stayinsulin injection during hospital stay



AetiologyAetiology

Trauma 10(27%)Trauma 10(27%) Fish fin injury 8(22%)Fish fin injury 8(22%)

Animal bite 2(5.4%)Animal bite 2(5.4%) Acute on chronic nail infection 2(5.4%)Acute on chronic nail infection 2(5.4%)

CannulaCannula site infection 1(2.7%)site infection 1(2.7%)

PostPost--operation infection 1(2.7%)operation infection 1(2.7%)

Unknown 13(35%)Unknown 13(35%)



Severity of infectionSeverity of infection

SuperficialSuperficial – – involving skin &involving skin &subcutaneous tissuesubcutaneous tissue

DeepDeep – – involving fascia, tendon,involving fascia, tendon,

muscle, bone & jointmuscle, bone & joint



Pathological diagnosisPathological diagnosis

Subcutaneous abscess 15(40.5%)Subcutaneous abscess 15(40.5%) Felon 9(24.3%)Felon 9(24.3%)

TenosynovitisTenosynovitis 5(13.5%)5(13.5%) OsteomyelitisOsteomyelitis 2(5.4%)2(5.4%)

NecrotizingNecrotizing fasciitisfasciitis 2(5.4%)2(5.4%)

Septic arthritis 1(2.7%)Septic arthritis 1(2.7%)



Length of hospital stayLength of hospital stay

Superficial: 9.6 daysSuperficial: 9.6 days Deep: 15.54 daysDeep: 15.54 days

P=0.002P=0.002



MicroMicro--organismsorganisms

Mixed growth 15 (41%)Mixed growth 15 (41%) Gram positive 8 (22%)Gram positive 8 (22%)

Gram negative 4 (11%)Gram negative 4 (11%)

Fungus 2 (5%)Fungus 2 (5%)

No growth 8 (22%)No growth 8 (22%)

Most common organisms in mixed growth:Most common organisms in mixed growth:

StaphlcoccusStaphlcoccus,, KlebsiellaKlebsiella



No. of operationNo. of operation

Single operation: 37.8%Single operation: 37.8% Multiple operations: 62.2%Multiple operations: 62.2%

Flap coverage of distal digit to preserveFlap coverage of distal digit to preserve

length was not always preferred as itlength was not always preferred as it

may delay rehabilitationmay delay rehabilitation



Digital amputationDigital amputation

6/37 :16%6/37 :16% Early decision to hasten rehabilitationEarly decision to hasten rehabilitation

4 with mixed growth, 2 with single/no4 with mixed growth, 2 with single/no

identifiable organismidentifiable organism 5/6 started with pulp infection5/6 started with pulp infection

Reported amputation rate in literature:12Reported amputation rate in literature:12--38%; depends heavily on management38%; depends heavily on managementconceptconcept



Digital amputation was performedDigital amputation was performed

after 1after 1stst debridement confirmeddebridement confirmedthat multiple procedures tothat multiple procedures to

preserve length will end up withpreserve length will end up with

poorer functionpoorer function



Key points in managementKey points in management Proper Proper glycaemicglycaemic control to decreasecontrol to decrease

immunopathyimmunopathy

Immobilization during acute infection inImmobilization during acute infection inpressure dressing (boxing glove) to slowpressure dressing (boxing glove) to slowdown spread and control edemadown spread and control edema

Early aggressive antibiotic management toEarly aggressive antibiotic management to

cover mixed growthcover mixed growth Aggressive exploration & radical repeatedAggressive exploration & radical repeated

debridement to control infectiondebridement to control infection

Digital amputation should be consideredDigital amputation should be considered

early if the digit is not able to achieveearly if the digit is not able to achievereasonable functionreasonable function

start hand rehabilitation early: at day of start hand rehabilitation early: at day of

presentation, keep nonpresentation, keep non

--infected partsinfected parts

mobilemobile



Thank youThank youE mail:E mail:

[email protected]@hkucc.hku.hk

prof. josaphine - diabetic upper limb

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