3. Introduction
MS complaint more frequent
Metabolic change in CV tissue
Glycolysation of proteins
Microvascular abnormality
Accumulation of extracellular matrix and soft
tissue
More seen in longstanding type I
Some complications have direct association
4. Pathogenesis:
An increase in non-enzymatic glycosylation
of collagen fiber
Increase collagen crosslink
Resistant to enzymatic digestion
Increase in hydration mediated by aldolase
reductase pathway
Increased formation Advanced Glycosylation
End product (AGEs)
5. Pathogenesis:
AGEs causes micro and macro vascular
complications
AGEs result from early glycolysation
Accumulate in tissue
Damage extra and intra cellular proteins
There are receptors on cell surface for AGEs
belong to IG receptors
Signaling lead to cell dysfunction
AGEs decrease vascular elasticity
12. Hand
Diabetic cheiroathrophaty or diabetic stiff hand or
limited mobility joint syndrome:
8% to 50% all type I DM,45%-70% type II
Associated and predictor of other complication
Thick, tight, waxy skin, begin in MCP&PIP 5
Like systemic sclerosis
Limited joint mobility( finger flex and extend)
13. Cheiroarthropathy
Lack of following differentiated from Scledrema:
Raynuads’ phenomena, dermal atrophy, telangiectasia
and autoantibodies
Nail fold capillaroscopic change may be seen
Both type I and type II have higher prevalence
retinopathy and nephropathy
17. Hand: Trigger finger
Catching sensation or locking phenomena
Pain in affected finger
Thumb, then third and forth
5%-36% type I, II (2% normal)
Palpable nodule overlying MCP joint
Thickening along the affected flexor tendon
Prevalence related to duration of DM
TF in 3 or more finger highly suggestive for DM
18.
19.
20. Trigger Finger
Treatments:
1-Change of activity
2- Splint
3- Use of NSAIDs with caution
4- CS injection
5- In severe case surgery
21. Hand: Dupuytren’s contracture
Thickening, shortening, fibrosis of palmar facia
Nodule along the facia
causes flexion contractures of the finger
Usually fourth but may be seen II to V fingers
16% to 42% of all DM more in eldery
May be seen in early stage
Prevalence more in longstanding DM
25. Dupuytren’s contracture
Treatments:
1- Intralesional injection of CS
2- Surgery
3- Physical therapy
4- Some studies show benefit from injection of
collagenase Colstridium Histolyticum
26. Hand: Carpal Tunnel syndrome
20% of diabetic patients more in women
More in obbes
Median nerve entrapment
Caused by diabetic-induced connective tissue
alteration
HX & PE
Tinel’s sign, Phalen’s test
In dubious case Electrophysiological studies helpfull
27.
28.
29. Carpal tunnel syndrome
Treatments:
1- Splint, NSAIDs
2- Injection CS: response may be temporary and
poorer in DM
3- Release surgery: post operative recovery is worse
30. Shoulder: Frozen shoulder
Frozen shoulder or adhesive capsulitis
Most common shoulder involvement
10-29% diabetic patients, bilateral, elderly
Stiffness Glenohumeral joint
Reversible contraction joint capsule
See in hyperthyroidism, Addison and Parkinson
31.
32. Adhesive capsulitis
Progressive and painful manner
Pain at night initially
Three phase:(a) Pain (b) Stiffness (c) Recovery
Diagnostic criteria by Pal: Shoulder pain at least one
month, impossibility lying's one shoulder, limited
active and passive movement
Decreased range of motion in abduction and external
rotation then internal rotation
35. Shoulder: Calcific shoulder
tendonitis
Three times more frequent in DM (type II)
Coexist with adhesive capsulitis
Deposit Ca hydroxy apatite
Ca depostion in rotator cuff tendons
60% asymptomatic
36. Sohulder:Reflex sympathetic
dystrophy
Shoulder-hand synd or complex regional pain synd
Pain from shoulder to hand
Swelling of affected limb
Skin change: hair growth, shiny skin, color, temperature
Increased sensitivity to pain and touch
Vasomotor instability
Transit patchy osteoporosis
37.
38.
39. Feet: Charcot’s arthropathy
Diabetic osteoarthropathy
Rare: 0.1% to 0.4%
Both type DM
Average duration 15 years
Advanced peripheral neuropathy
40. Feet: Charcot’s arthropathy
Loss of sensation in involved joint
Inadvertent microtrauma to joint
Consecutive degenerative change
Severe destruction, lytic joint changes
Most affect pedal bones
41. Feet: Charcot’s arthropathy
Erythema, swelling, hyperpimentation
Purpura, soft tissue ulcer
Joint loosening, instability, joint deformity
Often no history of trauma
42.
43. Feet: Charcot’s arthropathy
Diagnosis: based on radiographic findings
Symptoms often milder than view of X-ray
X-raysubluxation, bone fragment, osteolysis
Periosteal reaction, deformity, ankylosis
44.
45. Feet: Charcot’s arthropathy
CT sacn is insensitive
MRI and bone scintigraphy adjuncts X-ray
DD: Inflammatory, degenerative, infections, tumors,
DVT
47. Muscle: Diabetic muscle infarction
Rare condition
Spontaneous infraction with no history of trauma
Patients with long history of poorly controlled DM
More in insulin requiring patients
Most patients show microvascular complications like
neuropathy, retinopathy, nephropathy
48. Muscle: Diabetic muscle infarction
Acute onset of pain and swelling on affected M
Over days to weeks
Usually thigh or calf
Varying degree of tenderness
CPK may be normal or increased
49.
50. Muscle: Diabetic muscle infarction
D&D: Tumor, muscle infection/abscess, localized
myositis, osteomyelitis, thrombosis
CT Scan in insensitive
MRI show high signals in muscle in T2
When incisional muscle biopsy?
Only to rule out infection and malignancy
(culture for atypical organisms)
Treatments: rest, analgesic
51.
52.
53. Diffuse Skeletal Disease
Diffuse idiopathic skeletal hyperostosis(DISH)
Metaplastic calcification of spinal ligament
Osteophyte formation
Disc space, sacroiliac and facet joint: normal
Thoracic spine most commonly affected
May be accompanied by generalized calcification of other
ligament
54. Diffuse Idiopathic Skeletal
Hyperostosis
Unknown etiology
IN DM patients more than normal
Association with type II DM
More in obese patients
Pain is not prominent symptoms
Complaint stiffness in neck and back
Decreased range of motion
55.
56.
57. Other disease with DM
Osteoporosis: controversy, risk of Fx increased
Osteoarthritis
Hyperurecemia