Periarticular hand joint limitation syndromes in diabetes.

“Clear and precise definitions of disease, and the application of such names to them as are expressive of their true and real nature, are of more consequence than they are generally imagined to be: Untrue or imperfect ones occasion false ideas; and false ideas are generally followed by erroneous practice.” Percival Pott (1714-1788) The importance of accurate taxonomy for the under-standing of pathological processes, appropriate therapy, prognostication, and research data acquisition cannot be better stated after more than 200 years of medical progress. Despite this inarguable requirement, a plethora of terms have been used for complications of diabetes associated with finger joint contracture not involving the articular sur-face (1). Multiple designations have been used to denote the same condition, and widely disparate conditions have appeared under the same rubric. Stiff hand syndrome (2,3), diabetic hand syndrome (4,5), diabetic cheiroarthropathy (6), Rosenbloom syndrome (7-9), limited joint mobility (10), scleroderma-like syndrome (11), and digital sclerosis (12) have all been used to describe the unique limitation of hand and frequently other joints with associated thick tight waxy skin initially described in young patients with type 1 diabetes and later recognized to occur at all ages and with all forms of diabetes (1,10). The nonspecific nature of the terms stiff hand syndrome, diabetic hand syndrome, and limited joint mobility has contributed to their expan-sive use as an umbrella for several or all of the diabetes-related conditions resulting in finger joint limitation (5). Understanding the problems with the use or misuse of these terms in the literature is necessary to minimize the taxonomic confusion. In 1957, Lundbaek described “stiff hands in long-term diabetes” in 5 older adults with 40+ years duration of type 1 diabetes with contractures of all the fingers with pares-thesias, pain aggravated by movement, stiff hard skin over the palms, and arterial calcifications noted on radiography of the hands (2). Only a single case report of the syndrome has subsequently been published, suggesting that it may be an exceptional aggregation of diabetes complications affecting the hand (see Table 1), rather than a distinct entity. “Diabetic hand syndrome” was applied by Jung et al (4) to a group of adults having limitations involving all of the fingers with neuropathic pain and interosseous and palmar muscular atrophy. There was delayed nerve transmission in the forearm and in the median and ulnar nerves, with wide variability in severity. The condition may be confused with the carpal tunnel syndrome that results from entrap-ment of the median nerve within the carpal tunnel at the wrist, resulting in paresthesias of the thumb, index finger, and little finger, with pain that is often worse at night. Importantly, finger contractures do not occur with the car-pal tunnel syndrome. The involvement of both the ulnar and median nerve in the diabetic hand syndrome indicates intrinsic neuropathy, rather than entrapment, precluding anticipated improvement with carpal tunnel syndromesurgery (4). Although pain and muscle atrophy, as well as the exclusive adult distribution, distinguish the diabetic hand syndrome from the unique pediatric and adult limited joint mobility, diabetic hand syndrome has been considered synonymous with limited joint mobility (5). Also, “the diabetic hand” has been used as a general term to include any of the conditions affecting the hand in diabetes, such as Dupuytren disease, flexor tenosynovitis, shoulder-hand