Trigger Finger (Diabetic cheiroarthropathy)

P.Bamila

SeenaRajsekar

Dept. of Podiatry

Trigger finger or the stiff hand syndrome, is a frequent occurrence in people with diabetes.

Diabetes can affect the musculoskeletal system in a variety of ways. The metabolic changes in diabetes such as  glycosylation of proteins; microvascular abnormalities with damage to blood vessels and nerves; and collagen accumulation in skin and periarticular structures result in changes in the connective tissue.

Hands are a target for several diabetes-related complications. Diabetic cheiroarthropathy, also known as diabetic stiff hand syndrome or limited joint mobility syndrome, is found in 40–50% of all patients with type 1 diabetes and is also seen in people with type 2 diabetes. The longer the duration of diabetes, the greater is the occurrence.

 This condition is related to and predictive of other diabetic complications.

Contractures of the fingers known as flexion, may develop when the problem reaches advanced stages.

One of the most noticeable signs of trigger finger is the formation of the prayer sign. This is when the person is unable to completely close the gap between palms together and is an indicator of stiff-hand syndrome. 

Also, many people complain of a locking or catching sensation accompanied by pain in the fingers.

Cause and Risk factors for developing trigger finger:

• Trigger finger is more common in women than in men. 
• It occurs most frequently in people who are between the ages of 40 and 60 years of age. 
• Trigger finger is more common in people with certain medical problems, such as diabetes because of increased glycosylation of collagen in the skin and periarticular tissue, decreased collagen degradation, diabetic microangiopathy, and possibly diabetic neuropathy and rheumatoid arthritis. 
• Trigger finger may occur after activities that strain the hand. 

Symptoms

• Symptoms of trigger finger usually start without any injury, although they may follow a period of heavy hand use. Symptoms may include:
• A tender lump in the palm 
• Swelling 
• Catching or popping sensation in finger or thumb joints 
• Pain when bending or straightening the finger 

Stiffness and catching are likely to be worse after periods of inactivity, such as when you wake up in the morning. The fingers will often loosen up after some movement.

Examination:

• Trigger finger is usually diagnosed through X-rays.
• On examination a palpable nodule, usually in the area overlying the metacarpophalangeal joint, and thickening along the affected flexor tendon sheath on the palmar aspect of the finger and hand.
• The locking phenomenon may be reproduced with either active or passive finger flexion.
• Prayer sign of trigger finger.

Treatment:

• Rest. 
• Splinting. Wearing  a splint to keep the affected finger in an extended position for up to six weeks ,helps to rest the joint,
• Physical therapy-Exercises to improve motion, strength, and endurance in the wrist and hand are recommended.

• Avoiding repetitive gripping.
• Soaking in warm water/ice
• Soft tissue mobilization/massage /wax therapy
• Ultrasound therapy
• Phonophoresis
• Stretching-As the pain and irritation begin to ease, the muscles and other soft tissue can be gently stretched to allow the finger or thumb to bend without clicking or catching.
• Isometrics/ergonomics 
• Nonsteroidal anti-inflammatory drugs (NSAIDs).
• Steroids.
• Percutaneous trigger finger release.
• Surgery 
• Good glycemic control

Ultrasound, nanoparticle may help people with diabetes avoid the needle

Researchers at North Carolina State University and the University of North Carolina at Chapel Hill have developed a new nanotechnology-based technique for regulating blood sugar in people with diabetes that allows them to control insulin release with an injectable nano-network and portable ultrasound device.

This technique may give patients the ability to release insulin painlessly using a small ultrasound device,in contrast to the current practice of multiple insulin injections each day. 

Dr. Zhen Gu, senior author of a paper on the research and an Assistant Professor in the joint biomedical engineering program at NC State and UNC-Chapel Hill is hopeful that this is a big step towards a more painless method of maintaining healthy blood sugar levels in people with diabetes.

In this technique biocompatible and biodegradable nanoparticles made  of poly lactic-co-glycolic acid (PLGA) and filled with insulin are injected into a patient’s skin. Each of the PLGA nanoparticles is given either a positively charged coating made of chitosan (a biocompatible material normally found in shrimp shells), or a negatively charged coating made of alginate (a biocompatible material normally found in seaweed). When mixed together, the positively and negatively charged coatings are attracted to each other by electrostatic force to form a nano-network. Once injected into the subcutaneous layer of the skin, that nano-network holds the nanoparticles together and prevents them from dispersing throughout the body.

The coated PLGA nanoparticles are also porous. Once in the body, the insulin begins to diffuse from the nanoparticles . The electrostatic force of the nano-network keeps most of the insulin in the subcutaneous layer of the skin thereby creating a dose of insulin waiting to be transported into the bloodstream.

Using the new technology developed by Gu’s team, a person with diabetes can use a small, handheld device to apply focused ultrasound waves to the site of the nano-network that  releases the insulin into the bloodstream.

The researchers believe the technique works because the ultrasound waves excite microscopic gas bubbles in the tissue, temporarily disrupting nano-network in the subcutaneous layer of the skin. The disruption pushes the nanoparticles apart, thus relaxing the electrostatic force being exerted on the store of insulin which in turn allows the insulin to begin entering the bloodstream. This process is accelerated by the effect of the ultrasound waves pushing on the insulin.

When the ultrasound is removed, the electrostatic force reasserts itself and pulls the nanoparticles in the nano-network back together. The nanoparticles then diffuse more insulin to replace the insulin.

Proof-of-concept testing in laboratory mice with type 1 diabetes shows that with this technique there isa quick release of insulin into the bloodstream, and that the nano-network contains enough insulin to regulate blood glucose levels for up to 10 days.

According to Jin Di, lead author and a graduate student in Gu’s research laboratory, when the insulin finishes, a new nano-network is injected and the earlier nano-network dissolves and is fully absorbed into the body in a few weeks.

“This advance will certainly give millions of people with diabetes worldwide hope that better days are ahead,” says Dr. John Buse, director of UNC-Chapel Hill’s Diabetes Care Center and deputy director of UNC-Chapel Hill’s NIH Clinical and Translational Sciences Award. “We must work to translate these exciting studies in the lab to clinical practice.”

The paper, “Ultrasound-Triggered Regulation of Blood Glucose Levels Using Injectable Nano-Network,” is published online in Advanced Healthcare Materials and was selected as a cover article. The paper was co-authored by Jennifer Price, an undergraduate in the joint biomedical engineering program; Dr. Xiao Gu, of Yangzhou University; and Dr. Xiaoning Jiang, an associate professor of mechanical engineering at NC State.

Source:
(http://news.ncsu.edu/)
North Carolina State Univ.