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DOI:10.2214/AJR.06.0672
AJR 2007; 188:W94-W95
© American Roentgen Ray Society

MRI of Diabetic Cheiroarthropathy

Geetika Khanna and Polly Ferguson

Carver College of Medicine University of Iowa Iowa City, IA 52242



 
WEB—This is a Web exclusive article.

Diabetic cheiroarthropathy, or "stiff-hand syndrome," is characterized by painless limitation of mobility of the small joints of the hands. Although a well-described entity in the endocrine and rheumatology literature, the imaging findings of diabetic cheiroarthropathy have been described in only one article, to our knowledge, and that article focused on the sonography findings [1].

A 14-year-old girl was referred to the pediatric rheumatology service at our hospital with a 1-year history of inability to straighten her fingers. She had been diagnosed with juvenile arthritis at an outside facility and was started on antiinflammatory drugs without symptomatic relief. Her history was remarkable for a 3-year history of poorly controlled type 1 diabetes.


Figure 1
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  		Fig. 1A —14-year-old girl with type 1 diabetes and stiff hands. Coronal T2-weighted images with fat saturation of left (A) and right (B) hands show thickening and edema of synovial sheath along flexor tendons of all five digits, extending from wrist to phalanges. Flexion deformity of hands prevented inclusion of digits on same coronal plane.

 


Figure 2
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  		Fig. 1B —14-year-old girl with type 1 diabetes and stiff hands. Coronal T2-weighted images with fat saturation of left (A) and right (B) hands show thickening and edema of synovial sheath along flexor tendons of all five digits, extending from wrist to phalanges. Flexion deformity of hands prevented inclusion of digits on same coronal plane.

 


Figure 3
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  		Fig. 1C —14-year-old girl with type 1 diabetes and stiff hands. Axial T1 fat-saturation gadolinium-enhanced images of left (C) and right (D) hands show thickening of flexor digitorum superficialis (white arrow, D) and flexor digitorum profundus (black arrow, D) tendons with surrounding synovial inflammation (arrowhead, C). Extensor tendons are unremarkable.

 


Figure 4
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  		Fig. 1D —14-year-old girl with type 1 diabetes and stiff hands. Axial T1 fat-saturation gadolinium-enhanced images of left (C) and right (D) hands show thickening of flexor digitorum superficialis (white arrow, D) and flexor digitorum profundus (black arrow, D) tendons with surrounding synovial inflammation (arrowhead, C). Extensor tendons are unremarkable.

 
At physical examination, she was unable to straighten her fingers but had no joint warmth, erythema, or swelling. Laboratory studies were normal for inflammatory markers, but she had evidence of poorly controlled diabetes with a hemoglobin A1c value ranging from 8.2% to 9.2% (normal, 4.8-6%).

A diagnosis of diabetic cheiroarthropathy was suspected, and MRI examination was recommended to exclude juvenile idiopathic arthritis. MRI showed thickening of the flexor digitorum tendons bilaterally with edema and enhancement of the tendon sheaths (Figs. 1A, 1B, 1C, and 1D). A diagnosis of diabetic cheiroarthropathy was confirmed, and strict glycemic control was recommended.

Microangiopathic complications of diabetes such as neuropathy, nephropathy, and retinopathy are well-recognized sequelae of poorly controlled diabetes. However, a related microvascular disease, diabetic cheiroarthropathy, is underrecognized even though it has been reported to occur in up to 35% of patients with type 1 diabetes [2]. Diabetic cheiroarthropathy generally develops in patients who are between 10 and 20 years old [3]. The two clinical signs useful in the evaluation of this entity are the "prayer sign" and the "tabletop sign." The prayer sign is positive when the patient is unable to approximate the palmar surface of the fingers when raising the hands as if in prayer. When asked to lay the palms flat on a tabletop, if the patient is not able to touch the palmar surface of the fingers to the table, then findings are positive for the tabletop sign. Both signs were positive in our patient.

The sonography findings of diabetic cheiroarthropathy are thickening of the flexor tendon sheaths and subcutaneous tissues [1]. The MRI findings of diabetic cheiroarthropathy have not been previously described. In our patient, MRI showed thickening and enhancement of the flexor tendon sheaths. Other causes of tendon sheath inflammation include trauma, collagen vascular diseases, and infection.

Patients with diabetic cheiroarthropathy are at high risk for developing other microvascular complications. In a study by Rosenbloom et al. [2], the prevalence of proteinuria and retinopathy was 11% in diabetic patients without diabetic cheiroarthropathy versus 50% in diabetic patients with diabetic cheiroarthropathy. Proposed causes of diabetic cheiroarthropathy include increased nonenzymatic glycosylation of collagen, increased cross-linkage of collagen, and microangiopathy. Other musculoskeletal complications of type 1 diabetes include Dupuytren's contractures and carpal tunnel syndrome in the hands and myonecrosis [4].

Diabetic cheiroarthropathy is primarily a clinical diagnosis and the imaging findings are nonspecific, but in the appropriate clinical setting the diagnosis of diabetic cheiroarthropathy should be suggested. Recognition of this entity is important because it is reversible and is a marker of other microvascular complications. With the increasing use of MRI for the evaluation of suspected arthritis, radiologists are more likely to encounter this entity.


References
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 References
 

  1. Ismail AA, Dasgupta B, Tanqueray AB, Hamblin JJ. Ultrasonographic features of diabetic cheiroarthropathy. Br J Rheumatol1996; 35:676 -679[Abstract/Free Full Text]
  2. Rosenbloom AL, Silverstein JH, Lezotte DC, Richardson K, McCallum M. Limited joint mobility in childhood diabetes mellitus indicates increased risk for microvascular disease. N Engl J Med1981; 305:191 -194[Abstract]
  3. Rosenbloom AL. Skeletal and joint manifestations of childhood diabetes. Pediatr Clin North Am1984; 31:569 -589[Medline]
  4. Cagliero E, Apruzzese W, Perlmutter GS, Nathan DM. Musculoskeletal disorders of the hand and shoulder in patients with diabetes mellitus. Am J Med 2002;112:487 -490[CrossRef][Medline]

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