1. S
Stiff Joint Syndrome in
Diabetes: a Potential for
Difficult Airway
Keara Laffey, SRNA
Case Western Reserve University/Cleveland Clinic
OSANA Fall Meeting
September 13, 2015

2. Objectives
S State the incidence and pathology of Stiff Joint Syndrome
S Discuss the incidence of difficult laryngoscopy in patients
with long standing DM as it relates to Stiff Joint
Syndrome
S Describe two screening tools to assess for difficult
laryngoscopy in the diabetic patient and understand how
to interpret the results

3. Diabetes Statistics
S International Diabetes Federation
S Worldwide 387 million living with diabetes worldwide, 8.3%
S 1/12 people with diabetes worldwide
S American Diabetes Association
S 29.1 million Americans, 9.3% of population
S 86 million Americans have pre-diabetes
S By 2050 1 in 3 Americans will have diabetes if the current
trend continues

4. Diabetes in Surgery
S 25%-50% require surgery
S Most common endocrine abnormality in
surgical population
S Higher morbidity and mortality
S Often undiagnosed

5. Complications of Diabetes
SAtherosclerosis
SNephropathy
SNeuropathy
SStiff Joint Syndrome

6. Stiff Joint Syndrome
S First described by Dr. Arlan Rosenbloom in 1974
S Also referred to as Diabetic Cheiroarthropathy or Limited
Joint Mobility
S Most common, earliest occurring complication of Type 1
DM, also frequent occurrence in Type 2 DM
S Linked to duration and control of diabetes

7. Stiff Joint Syndrome
S Patient Characteristics
S Joint contractures
S Begins in fifth finger and progresses radially
S Thick, tight, waxy skin
S Short stature
S Microvascular complications
S Symmetrical
S Painless, non-disabling

8. Stiff Joint Syndrome
S Prevalence
S Up to 50% of Type 1 DM
S As high as 75% of Type II DM
S Causes
S Chronic hyperglycemia  glycosylation  increased
protein-protein cross-linkage  clinical stiffness
S Microvascular disease  hypoxia  cellular hyperplasia

9. Stiff Joint Syndrome
SDiagnosis
SGoniometry
SPrayer Sign
SPalm Print Test

11. Grade 0 Grade 1
Grade 2 Grade 3

13. Research
S Diabetes and difficult laryngoscopy
Hogan et al., 1988; Reisssel et al., 1990; Erden, 2003
S Difference between Type I DM and Type II DM
Arkkila et al., 1997
S Predictive value of Palm Print Test vs Mallampati,
thyromental distance, and head extension
Vani, Kamath, and Naik, 2000; George and Jacob, 2003
S Sensitivity of Palm Print Test and Prayer Sign
Sachdeva, 2013; Mahmoodpoor et al., 2013; Hashim and Thomas, 2014

14. Airway Assessment
S Palm Print Test
S Highly Sensitive 75%-98%
S Highly Specific 73%-96%
S Prayer Sign
S Less sensitive 29.6%-54%
S Moderate-highly specific 55%-

15. Significance
S Problems in Anesthesia
S Unexpected difficult intubation
S Altered nerve monitoring
S Decreased lung elasticity

16. Summary
S Future research guiding practice
S Addition of tests to pre-operative assessment
S Inclusion of new knowledge into practice

17. References
S Arkkila, P., Kantola, I., & Viikari, J. (1997). Limited Joint Mobility in NonñInsulin Dependent
Diabetic (NIDDM) Patients: Correlation to Control of Diabetes, Atherosclerotic Vascular Disease,
and Other Diabetic Complications. Journal of Diabetes and Its Complications, 11.4, 208-217.
Retrieved August 11, 2015, from PubMed.
S Barash, P.G., Cullen, B.F., Stoelting, R.K., Cahalan, M.K., Stock, M.C., and Ortega, R. (2013).
Clinical Anesthesia (7th ed.). Philadelphia, PA: Lippincott, Williams & Wilkins and Wolters Kluwer
Health.
S Erden, V. (2003). Relationship of difficult laryngoscopy to long-term non-insulin-dependent
diabetes and hand abnormality detected using the 'prayer sign' British Journal of Anaesthesia,
159-160. doi:10.1093/bja/aeg583
S Fast Facts: Data and Statistics About Diabetes. American Diabetes Association, Mar. 2015. Web.
13 Aug. 2015.
S George, S.P., and Jacob, R. "Predictability of Airway Evaluation Indices in Diabetic Patients."
Indian Journal of Anesthesia 47.6 (2003): 476-78. PubMed. Web. 11 Aug. 2015
S Hines, R.L., and Marschall, K.E. (2012). Stoeltings Anesthesia and Co-Existing Disease (6th ed.).
Philadelphia, PA: Elsevier.

18. S Hogan, K., Rusy, D., & Springman, S. (1988). Difficult Laryngoscopy and Diabetes Mellitus. Anesthesia
& Analgesia, 67, 1162-1165. Retrieved July 12, 2015, from PubMed.gov
S Infante, J., Rosenbloom, A., Silverstein, J., Garzarella, L., & Pollock, B. (2001). Changes in frequency
and severity of limited joint mobility in children with type 1 diabetes mellitus between 1976-78 and 1998.
The Journal of Pediatrics, 138(1), 33-37. doi:10.1067/mpd.2001.109710
S Kadoi, Y. (2010). Anesthetic considerations in diabetic patients. Part I: Preoperative considerations of
patients with diabetes mellitus. Journal of Anesthesia. Japanese Society of Anesthesiologists, 24, 739-
747. doi:10.1007/s00540-010-0987-1
S Larkin, M.E., Barnie, A., Braffett, B.H., Cleary, P.A., Diminick, L., Harth, J.,...(2014). Musculoskeletal
Complications in Type 1 Diabetes. Diabetes Care 37.7, 1863-869. Retrieved August 11, 2015 from
PubMed.
S Mahmoodpoor, Ata, Hassan Soleimanpour, Kavous Shahsavari Nia, Jafar Rahimi Panahi,
Mohammadreza Afhami, Samad EJ Golzari, and Karim Majani. "Sensitivity of Palm Print, Modified
Mallampati Score and 3-3-2 Rule in Prediction of Difficult Intubation." International Journal of Preventive
Medicine 4.9 (2013): 1063-1069. PubMed. Web. 11 Aug. 2015
S Nagelhout, J.J., and Plaus, K.L. (2014). Nurse Anesthesia (5th ed.). Philadelphia, PA: Elsevier.

19. S Reissell, E., R. Orko, E-L. Maunuksela, and Lindgren, L. "Predictability of Difficult Laryngoscopy in Patients with
Long-term Diabetes Mellitus." Anaesthesia 45.12 (1990): 1024-027. PubMed. Web. 11 Aug. 2015.
S Sachdeva, K., Singh, A., Kathuria, S., Kaul, T., Rupinder, M., Bajwa, N., & Singh, P. (2005). Prediction of Difficult
Laryngoscopy in Diabetics by Palm Print and Interphalangeal Gap. Journal of Anesthesiology Clinical Pharmacology,
21(3), 261-264. Retrieved August 14, 2015, from PubMed.gov
S Salzarulo, H., & Taylor, L. (1986). Diabetic ìStiff Joint Syndromeî as a Cause of Difficult Endotracheal Intubation.
Anesthesiology, 64, 366-367. Retrieved July 20, 2015, from PubMed.gov
S Silverstein, J., Gordon, G., Pollock, B., & Rosenbloom, A. (1998). Long-term glycemic control influences the onset of
limited joint mobility in type 1 diabetes. The Journal of Pediatrics, 132(6), 944-947. Retrieved July 16, 2015, from
PubMed.gov
S Thomas, M., and Hashim, K.Y. "Sensitivity of Palm Print Sign in Prediction of Difficult Laryngoscopy in Diabetes: A
Comparison with Other Airway Indices." Indian Journal of Anaesthesia Indian J Anaesth 58.3 (2014): 298-302.
PubMed. Web. 11 Aug. 2015.
S Vani V V, Kamath S K, Naik L D. The palm print as a sensitive predictor of difficult laryngoscopy in diabetics: a
comparison with other airway evaluation indices. J Postgrad Med 2000;46:75