Diabetic Limb Problem * Upper Limb Presentation

Dr. Josephine Wing-yuk Ip Division Chief Division of Hand & Foot Surgery Department of Orthopaedics & Traumatology Queen Mary Hospital The University of Hong Kong

Diabetic hand infection

DM hand is currently not generally classified as common complication of DM as in foot problems Western literature: (1999) 10% incidence of DM hand infection that requires hospital admission; which is comparable to foot infection Patho-mechanism similar to foot

The Hand
Similar anatomy to foot, develop from limb bud Different functional demand: ADL & work Closer to the heart: vascularity is better, less extensive skin necrosis Nerve cells with shorter axon: Less prone to significant sensory deficit & motor deficit

Predisposition to infection in diabetic limb

High blood sugar level Impaired immune response Loss of protective sensation, less so in hand less chance of unaware bacteria innoculation & tissue damage Motor deficit resulting in deformities, less common in hand Rapid progression of infection along tendons Further tissue necrosis & infection Septic thrombosis: digital, metatarsal more frequent/ rarely metacarpal Gangrene of tissue

Diabetic hand with intrinsic minus deformities

The hand
Organ to contact outside world The most distal part is most prone to injury i.e. the digit Special anatomy: fascial layers connecting skin and underlying bone Many deep spaces ,multiple compartments in pulp Infection raise compartment pressure, prone to ischaemia & necrosis, underlying bone undergoes osteomyelitis

Subcutaneous infection - delay exploration may require proximal amputation

Special demand of hand motion, mo0tion, motion

The hand tolerates immobilization poorly Adhesion between tissue layers develop easily: no mans land Stiff digit affects overall function

Distal digital amputation still has good function, the key is good rehabilitation

Types of Infection in diabetic limb

Cellulitis Paronychia Pulp Web space Tenosynovitis Plantar spaces:medial,lateral,central Palmar spaces: thenar, hypothenar, midpalmar Osteomyelitis Septic arthritis

Paronychia
common infection

Pulp infection (Felon)

Special anatomy for firm contact with objects, multiple sensory end organs Septa connecting bone to skin Multiple tight compartments High compartment pressure Prone to septic embolism & grangrenous changes early

Pulp infection resulting in pulp gangrene, early fasciotomy & drainage may salvage it

Web space infection need volar & dorsal incision for drainage

Tenosynovitis Exploration with radical debridement along the tendon must be done before tendon necrosis to preserve function

Mid-palmar space infection Late presentation as it started with edematous hand only

Thenar space infection

Osteomyelitis arising from pulp infection

Septic arthritis

Hong Kong Chinese Diabetes Prevalence

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

DM hand: expect significant No., but no epidemiological data at present

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

Analysis of hand infection cases 2006-2010

Retrospective review Protocol: - Rest in boxing glove, elevation in hospital

Broad spectrum IV antibiotics covering gram- and anaerobes : initially Ampicillin+ Cloxacillin + Gentamycin Aggressive early debridement if there is pus collection or symptoms of infection not resolving within 24 hours Liberal re-exploration at intervals till clearance of infection, early decision on digital amputation Early intervention by hand therapists to regain hand function

Features of hand infection in DM compared with non-DM

More rapid in progression More extensive involvement More severe tissue involvement Frequently mixed organisms, gram negative organisms Vs gram positive organisms in non-DM

Epidemiological data
37 patients Average age 62(23-87) Male: 24 (64%), female: 13(36%) Diagnosis of DM: -known - previously unknown, diagnosed after 1st episode of hand infection Insulin injection:10 Oral medication 27, 5 need to switch to insulin injection during hospital stay

Aetiology
Trauma Fish fin injury Animal bite Cannula site infection Post-operation infection Unknown 10(27%) 8(22%) 2(5.4%) 1(2.7%) 1(2.7%) 13(35%)

Acute on chronic nail infection 2(5.4%)

Severity of infection
Superficial involving skin & subcutaneous tissue Deep involving fascia, tendon, muscle, bone & joint

Pathological diagnosis
Subcutaneous abscess 15(40.5%) Felon 9(24.3%) Tenosynovitis 5(13.5%) Osteomyelitis 2(5.4%) Necrotizing fasciitis 2(5.4%) Septic arthritis 1(2.7%)

Length of hospital stay

Superficial: 9.6 days Deep: 15.54 days P=0.002

Micro-organisms
Mixed growth Gram positive Gram negative Fungus No growth 15 (41%) 8 (22%) 4 (11%) 2 (5%) 8 (22%)

Most common organisms in mixed growth: Staphlcoccus, Klebsiella

No. of operation
Single operation: 37.8% Multiple operations: 62.2% Flap coverage of distal digit to preserve length was not always preferred as it may delay rehabilitation

Digital amputation
6/37 :16% Early decision to hasten rehabilitation 4 with mixed growth, 2 with single/no identifiable organism 5/6 started with pulp infection Reported amputation rate in literature:1238%; depends heavily on management concept

Digital amputation was performed after 1st debridement confirmed that multiple procedures to preserve length will end up with poorer function

Key points in management

Proper glycaemic control to decrease immunopathy Immobilization during acute infection in pressure dressing (boxing glove) to slow down spread and control edema Early aggressive antibiotic management to cover mixed growth Aggressive exploration & radical repeated debridement to control infection Digital amputation should be considered early if the digit is not able to achieve reasonable function start hand rehabilitation early: at day of presentation, keep non-infected parts mobile

Thank you
E mail: wyip@hkucc.hku.hk