R. SNEKAVALLIROLL NO - 73

INTRODUCTION

LEPROSY - FOREMOST CAUSE OF DEFORMITY & CRIPPLING

25% OF PATIENT - NOT TREATED AT AN EARLY STAGE DEVELOP ANAESTHESIA & DEFORMITIES OF HAND & FEET

THREE TIER CONSEQUENCES OF LEPROSY

IMPAIRMENT

DISABILITYHANDICAP

IMPAIRMENT –ANATOMIC, PHYSIOLOGIC,

PSYCHOLOGIC ABNORMALITIES OR LOSES RESULTING FROM DISEASE OR DISORDERDISABILITY –

IMPAIRMENTS – PROBLEMS – AFFECTED INDIVIDUALS – CERTAIN TASKS & ACTIVITIES – NORMAL FOR PERSONS AGE, SEX, TRAINING – BECOME DIFFICULT OR IMPOSSIBLE

THIS DIFFICULTY – INABILITY – CARRY OUT TASK - DISABILITY

HANDICAP –DISADVANTAGES WHICH MAKE

DISABLED INDIVIDUALS UNABLE TO DISCHARGE THEIR SOCIAL OBLIGATIONS

DEFORMITY & DISABILITY IN LEPROSY

RISK FACTORSTYPE OF LEPROSY DURATION OF ACTIVE DISEASE NUMBER OF NERVE TRUNKS

INVOLVED

THREE KINDS OF DEFORMITIES

DEFORMITY

SPECIFIC PARALYTIC ANAESTHETIC

LOCAL LEPROSY RELATED

PATHOLOGY

COMMON IN FACE

DAMAGE TO MOTOR NERVES

COMMON IN HAND

DAMAGE TO SENSORY NERVES AND LOSS OF

SENSIBILITY

COMMON IN FEET

DEFORMITY MAY BE DUE TO DISEASE PROCESS eg. LOSS OF

EYEBROWS

PERIPHERAL NERVE DAMAGE - PARALYSIS OF MUSCLES eg. CLAW HAND

RESULTING FROM INJURIES TO HAND AND FEET eg. MUTILATION OF HAND & FEET

DEFORMITIES OCCURING IN LEPROSY

NERVE STAGES OF NERVE INVOLVEMENT

STAGE OF PARASITIZATIONSTAGE OF HOST RESPONSESTAGE OF CLINICAL INVOLVEMENTSTAGE OF NERVE DAMAGESTAGE OF NERVE DESTRUCTION

PERIPHERAL NERVES AFFECTED

SUPERFICIALLY LOCATED DERMAL NERVE TWIGS

CUTANEOUS NERVESNERVE TRUNKS LOCATED DEEP TO

THE DEEP FASCIAUPPER LIMB – ULNAR NERVE

THICKENINGLOWER LIMB – COMMON PERONEAL

NERVE

MODES OF ONSET AND PROGRESSQUIET NERVE PARALYSISEPISODIC ONSET & SALTATORY

PROGRESSCATASTROPHIC MODE OF ONSETNERVE DAMAGE OF LATE ONSET

ACUTE NEURITIS – SEVERE PAIN & TENDERNESS

ENL NEURITISNERVE ABSCESS

COLD ABSCESS HOT ABSCESS

CASEOUS NECROSIS OF NERVE FASCICLES

BT,TT

ENL RELATED NEURITIS

FACE MASK FACEFACIES LEONINA

SAGGING FACELOSS OF EYEBROWS (SUPERCILIARY

MADAROSIS)

LOSS OF EYELASHES (CILIARY MADAROSIS)

EYE

CORNEAL ULCERSACUTE IRITISCORNEAL OPACITY

LAGOPTHALMOS

BLINDNESS

EARNODULES ON THE EAR

ELONGATED LOBULESEAR DEFORMITIES

NOSE

PERFORATED NOSEDEPRESSED NOSESUNKEN NOSE DEFROMITY

HANDULNAR CLAW HAND –

ULNAR NERVE INVOLVEMENT

HYPEREXTENSION - METACARPO - PHALANGEAL JOINT & FLEXION -PROXIMAL & THE DISTAL INTER-PHALANGEAL JOINTS

DUE TO PARALYSIS OF LUMBRICALS – SUPPLY BY ULNAR NERVE

WRIST DROP – RADIAL NERVE

PALSY WRIST - PALMAR

FLEXION - WEAKNESS OF DORSIFLEXORS

EXTENSOR MUSCLES OF THE FOREARM AND THE HAND

APE THUMB DEFORMITY -

MEDIAN NERVE PARALYSIS OF

OPPONENS POLLISIS MUSCLE

TOTAL CLAW HAND – ULNAR & MEDIAN NERVE INVOLVEMENT

HOLLOWING OF INTROSSEOUS SPACES & SWOLLEN HAND

FEET

FOOT DROP –COMMON PERONEAL NERVE

INVOLVEMENTPLANTAR FLEXION DUE TO

WEAKNESS OF THE DORSIFLEXORS

FOOT DROP

PLANTAR ULCER -DUE TO NERVE INVOLVEMENT -

ANAESTHESIA

CLAWING OF TOESABSORPTION OF TOESCOLLAPSED FOOTSWOLLEN FOOT AND CALLOSITIES

ABSORPTION OF TOES

OTHER DEFORMITIES

GYNAECOMASTIAPERFORATION OF PALATEACUTE EPIDIDYMO ORCHITIS

GRADING

HANDS & FEET -GRADE 0 - NO ANAESTHESIA & NO

VISIBLE DEFORMITYGRADE 1 – ANAESTHESIA BUT NO

VISIBLE DEFORMITYGRADE 2 – VISIBLE DEFORMITY

DAMAGE PRESENT

GRADING

EYE -GRADE 0 – NO EYE PROBLEM, NO

EVIDENCE OF LOSS OF VISIONGRADE 1 – EYE PROBLEM DUE TO

LEPROSY PRESENT BUT VISION NOT AFFECTED

GRADE 2 – SEVERE VISUAL IMPAIRMENT, LAGOPTHALMOS, IRITIS, CORNEAL OPACITY

INTERVENTIONS

FIRST LEVEL -

Primary, secondary & psychological impairment

Anti-leprosy treatment, health education, supportive social action

SECOND LEVEL –

Reversible disability preventive measures

Early recognition and treatment

THIRD LEVEL –

Permanent irreversible disabilities

Physiotherapy, corrective measures, provision of appliances

FOURTH LEVEL –

Disability & handicap

Rehabilitation measures

FIFTH LEVEL –FOR THE DESTITUTESRESCUE, RESTORE & REHABILITATE

MANAGEMENT

NERVE DAMAGE CAUSES 3 LEVELS OF PROBLEMS – ONE LEADING TO THE NEXT

LEVEL 1 LEVEL 3LEVEL 2

LEVEL 1 LEVEL 2 LEVEL 3

OFTEN OFTEN PREVENTABLE WITH PREVENTABLE WITH

MEDICAL MEDICAL TREATMENT OF TREATMENT OF

LEPROSY BEFORE LEPROSY BEFORE THERE IS NERVE THERE IS NERVE

DAMAGEDAMAGE

OFTEN PREVENTABLE OFTEN PREVENTABLE WITH PROTECTIVE EYE WITH PROTECTIVE EYE

AND SKIN CARE AND AND SKIN CARE AND EXERCISE TO KEEP EXERCISE TO KEEP FULL MOVEMENT OF FULL MOVEMENT OF

JOINTSJOINTS

OFTEN PREVENTABLE OFTEN PREVENTABLE WITH CAREFUL EARLY WITH CAREFUL EARLY

TREATMENT OF SORES, TREATMENT OF SORES, BURNS AND INFECTIONSBURNS AND INFECTIONS

A Person with leprosy gets a

blister

It does not hurt. So keeps walking until blister bursts -

infected

Still without pain - infection Still without pain - infection gets deeper and attacks the gets deeper and attacks the

bonebone

Bone is destroyed - foot becomes Bone is destroyed - foot becomes more and more deformed.more and more deformed.

PREVENTION OF INJURY FOR PERSONS WITH LOSS OF FEELING&

STRENGTHEYE – EYE DAMAGE – COMES FROM NOT

BLINKING ENOUGH, BECAUSE OF WEAKNESS OR LOSS OF FEELING

BLINKING - EYES WET AND CLEAN. PERSON DOES NOT BLINK WELL, OR HIS EYES ARE RED, THEN ADVICE -

TO WEAR SUNGLASSES WITH SIDE SHADES, AND MAY BE SUN HAT

CLOSE EYES TIGHTLY – DAY- ESPECIALLY WHEN DUST BLOWS

ROLL THE EYEBALLS UP AS YOU TRY TO CLOSE EYES TIGHT

KEEP EYES CLEAN. WASH WELL AROUND EYES, KEEP

FLIES AND DIRTY HANDS AWAY

NERVE

ACUTE NEURITIS – ANTI-REACTION THERAPY – STEROIDS & ANALGESICS, SEDATIVES

ENL NEURITIS – THALIDOMIDELOCAL MEASURES – SPLINTING OF

THE PART PHYSICAL THERAPY – WAX BATH,

SHORTWAVE OR MICROWAVE DIATHERMY

SURGICAL DECOMPRESSION OF NERVE TRUNKS

INDICATION - MEDICAL & AUXILLARY TREATMENT

FAILED

PROCEDURE - RELEASE EXTERNAL COMPRESSING

FACTOR DIVIDE EPINEURIUM RELIEVE THE FASCICLES FROM BEING

STRANGULATED BY THE SCLEROSED EPINEURIUM

NERVE ABSCESSCOLD ABSCESS – SURGICAL

INTERVENTION – DRAINING THE ABSCESS – MOPPING – NECROTIC CONTENT – REMOVING ADHERENT SLOUGH – EXCISING THE ABSCESS

HOT ABSCESS – SURGERY RARE

HANDS

SPECIAL CARE WHEN WORKING WITH HANDS OR COOKING MEALS

NEVER PICK UP A PAN OR OTHER OBJECT THAT MIGHT BE HOT, WITHOUT FIRST PROTECTING HAND WITH A THICK GLOVE OR FOLDED CLOTH

AVOID WORK THAT INVOLVES HANDLING SHARP OR HOT OBJECTS.

DO NOT SMOKE

USE TOOLS WITH SMOOTH, WIDE HANDLES, OR WRAP CLOTH AROUND HANDLES

FOR A PERSON WITH WEAK OR DEFORMED FINGERS - HOLD A TOOL OR UTENSIL - YOU CAN MOLD HANDLE TO THE SHAPE OF THE PERSON’S CLOSED HAND.

FEET

AVOID GOING BAREFOOT. USE SHOES OR SANDALS

LEARN TO TAKE SHORT STEPS

INJURY CAREEYES –

CLOSE EYES OFTEN. IF NECESSARY USE A SIMPLE EYE PATCH

IF EYE GETS INFECTED - ANTIBIOTIC EYE OINTMENT- LOWER LID WITHOUT TOUCHING THE EYE

HANDS AND FEET

IF YOU HAVE A CUT OR SORE, KEEP THE INJURED PART VERY CLEAN AND AT REST UNTIL IT HAS HEALED COMPLETELY

TAKE CARE NOT TO INJURE THE AREA AGAIN

THINGS TO DO EVERY DAY EXAMINE HANDS AND FEET CAREFULLY OR

SOMEONE ELSE EXAMINE THEM. LOOK FOR CUTS, BRUISES THORNS, SPOTS

OR AREAS ON THE HANDS AND FEET THAT ARE RED, HOT, SWOLLEN OR SHOW THE START OF BLISTERS

IF YOU FIND ANY OF THESE – REST THE HANDS OR FEET - SKIN IS COMPLETELY NORMAL AGAIN

IF THE SKIN GETS DRY AND CRACKS - SOAK FEET DAILY - WATER - 20 MIN

THEN RUB COOKING OIL, VASELINE, OR LANOLIN HAND CREAM INTO THEM

DO STRETCHING EXERCISES - KEEP COMPLETE RANGE OF MOTION IN THE JOINTS

CONTINUED DAILY CARE, MOST DEFORMITIES OF LEPROSY CAN BE PREVENTED

PREVENTION OF CONTRACTURES AND DEFORMITIES

EYE

HANDLOSS OF FEELING MAKES

PREVENTION MORE DIFFICULTEXERCISES TO PREVENT FIXED

CLAWING OF THE HANDS CAN BE DONE BY GENTLY STRAIGHTENING THE FINGERS

SPLINTAGE

NERVE INJURED SPLINT USED

RADIAL NERVE PALSY COCK-UP SPLINT

ULNAR NERVE PALSY KNUCKLE BENDER SPLINT

COMMON PERONEAL NERVE INVOLVEMENT

FOOT DROP SPLINT

COCK - UP SPLINT

KNUCKLE BENDER SPLINT

FOOT DROP SPLINT

GOOD EXERCISE TO PREVENT ‘TIPTOE’ CONTRACTURES WITH ‘FOOT DROP’ IS TO STRETCH THE HEEL CORDS BY LEANING FORWARD AGAINST A WALL OR BY SQUATTING WITH HEELS ON THE GROUND

FOOT WEAR USED IN LEPROSY

WELL – FITTED UPPER PART THAT DOES NOT RUB AND HAS PLENTY OF TOE ROOM

A SOFT INNERSOLE ABOUT 1 CM THICK

A TOUGH UNDER-SOLE, SO THORNS, NAILS AND SHARP ROCKS DONOT INJURE FOOT

FOOTWEAR SHOULD BE ACCEPTABLE AND NOT LOOK STRANGE SO THAT THE PERSON WILL USE IT

THINGS TO BE AVOIDED

PLASTIC SHOES OR SANDALSSOFT-SOLED SANDALS OR THONGS

THAT THORNS CAN PASS THROUGH

USING NAILS TO FASTEN HEELS AND SOLES

POSSIBLE WAYS TO GET FOOTWEAR

CONTACT A LEPROSY HOSPITAL WITH A FOOTWEAR WORKSHOP. THEY CAN MAKE SANDALS IF YOU SEND A TRACING OF THE FOOT

CHECK THE MARKET. YOU MAY FIND A CANVAS SHOE OR TENNIS SHOE THAT ALREADY HAS A GOOD INSOLE

OR THEY CAN PUT SOFT INSOLES INTO THE SHOES

MAKE SPECIAL FOOTWEAR. FOR THE INNER SOLE, YOU CAN USE A SOFT SPONGE SANDAL OR THONG OR BUY MICROCELL RUBBER WHICH IS SOFT BUT FIRM.

FOR THE UNDER SOLE YOU CAN USE A PIECE OF OLD CAR TIRE.

FOR PERSONS WHO HAVE DEVELOPED SORE ON THEIR FOOT - FOOT SUPPORT HERE MAY HELP TAKE PRESSURE OFF THE BALL OF THE FOOT AND PREVENT NEW SORES.

TO PREVENT SORES – A SOFT, HEAT-MOLDABLE FOAM PLASTIC CALLED ‘PLASTAZOTE’.

LACES SHOULD BE AVOIDED. IN THAT CASE VELCRO IS AN IDEAL ALTERNATIVE

FOR PERSONS WITH A ‘DROP FOOT’, A BRACE OR LIFT CAN HELP PREVENT SORES AND INJURIES

GET A BRACE OR SUPPORT AT A REHABILITATION WORKSHOP OR MAKE A SPECIALLY-FITTED, WELL-PADDED PLASTIC BRACE

MAKE A SIMPLE DEIVICE TO HOLD THE FOOT UP

ORTHOPAEDIC SURGERY AND PLASTIC SURGERY

PARALYSED FINGERS – STRAIGHTENED BY TAILED GRAFT OF BRAND - PLANTARIS TENDON

DROPPED FOOT – TRANSVERSE TIBIALIS POSTERIOR MUSCLE

CLAWED HAND AND TOES – TRIPLE ARTHRODESIS

CHRONIC PLANTAR ULCERATION – REMOVAL OF DAMAGED META-TARSAL WITH EXCISION OF THE ULCER

GROSS DEFORMITY OR BONE DESTRUCTION – BELOW KNEE AMPUTATION

WHEN TREATMENT IS COMPLETED CONGRATULATE THE PATIENT

THANK FAMILY / FRIENDS FOR THEIR SUPPORT REASSURE THAT MDT COMPLETELY CURES

LEPROSY ANY RESIDUAL LESIONS WILL FADE AWAY

SLOWLY SHOW THEM HOW TO PROTECT ANAESTHETIC

AREAS / DISABILITIES ENCOURAGE TO COME BACK IN CASE OF ANY

PROBLEM TELL THAT THEY ARE WELCOME TO BRING

OTHER MEMBERS OF FAMILY OR FRIENDS FOR CONSULTATION

REMOVE THE PATIENT’S NAME FROM THE TREATMENT REGISTER

BIBLIOGRAPHY

JOPLINGHASTINGSPARK MAHESHWARI SNELL’S CLINICAL ANATOMY INTERNET