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SEMINAR

DISABILITIES AND DEFORMITIES IN LEPROSY

Presenter: Shivendra Jha


Moderator: Dr Nidhi Shah
Time:8:05 AM /14-6-20117
Introduction
Leprosy is not merely infection of nerves or skin its consequences extend far beyond the lives
of individuals their families and society. Every year thousands of patients develop nerve
damage as a result of leprosy. The number of new cases reported globally in 2015 was
2,11,973, 2.9 new cases per 100 000 people . SEAR accounted for 74% of the global new
case load , number of new cases with G2D was 8572, In Nepal, 3053 new cases is present of
which 433% of new leprosy cases presented with Grade-2 disability in a year.
The Global Leprosy Strategy 20162020: Accelerating towards a leprosy-free world 2" was released
in April 2016, where 3 key targets have been agreed by all national programmes:
a) zero G2D among children diagnosed with leprosy
b) the reduction of new leprosy cases with G2D to <1 case per million population and
c) zero countries with legislation allowing discrimination on the basis of leprosy
Etiology, pathology, management for understanding and treating diseases has been
inadequate in the context of leprosy or any other chronic and disabling disorder. To
understand better rehabilitation scientist developed "Three-tier consequences of diseases"
of which the three tier being Impairment, Disability, and Handicap.
Terminology
Impairment a scientific term denoting "any loss or abnormality of psychological,
physiological or anatomical structure or function" resulting from the
diseases or disorder and this visible impairment and visible
consequences of impairment are seen as deformities and
disfigurement.

Disability any restriction or lack of ability to perform an activity in the manner


or within the range considered normal for a human
being.

Handicap a disadvantage for a given individual that limits or prevents the


fulfillment of a role that is normal

Course of diseases
Leprosy Nerve damage (primary impairment) Ulcers(secondary
impairment/deformity) walking difficulty (activity
limitation/disability)loss of job (participation restriction/handicap)
loss of social status(dehabilitation) forced to leave
home(destitution)

WHO Classification and Grading

Grade Degree of impairment Included Excluded

Hands and feet

0 No sensory impairment, Scars of healed ulcers, when


no visible impairment sensation is normal
1 Sensory impairment present, Scars of healed ulcers, when Scars of healed ulcers when
no visible impairment sensation is impaired sensation is present
Hands or feet following Minor skin cracks
successful reconstructive surgery
Muscle weakness without
clawinga
2 Visible impairments present Ulcers, severe cracks,
severe atrophya

Eyes

0 No eye impairment; no
visible or vision impairment
b
1 Eye impairment present Absence of (regular) Corneal sensation testing19
(vision: > 6/60) blink
2 Severe visual impairment Unable to count ngers at 6 m Facial impairments due to
(vision: < 6/60) Lagophthalmos lepromatous leprosyc
Corneal opacities, uveitis19

Risk factors are:-


1) Type of Leprosy- more extensive and highly bacilliferous types (lepromatous and
boderline type) carry a high risk then less extensive and relatively lowly bacilliferous
type (tuberculoid and indeterminate type) if not treated early.
2) No. of nerve trunk involved- more than three nerve trunk involvement increases the
risk manifold, risk of impairment also increases with the number of nerve trunk
thickened in the patient because in a patient having involvement of many nerves
trunk, even if some nerves escape others may get damaged.
3) Attack of reaction and neuritis increases the risk.
4) Duration of active diseases- longer the disease remains untreated, greater the risk of
disability.
5)Dapsone monotherapy
6)Leprosy granuloma itself directly contribute to impairment or disfigurement, early
regression of the granuloma after specific treatment may reverse the
diseases processes

Nerve Involvement
Nerve damage occurs in two settings-
In skin lesion small dermal sensory and autonomic nerve fibres supplying dermal and
subcutaneous structures are damaged
Involving Peripheral nerve trunks usually those which are superficial or are in fibrocasseous
tunnels are involved leading to dermato sensory loss and dysfunction
of muscles.

Nerve involvement in leprosy can be said to occur in 5 stages:--


First two are recognized histologically while next three by clinical examination
Stages of Nerve Involvement
1. Parasitization: is the earliest stage of nerve involvement in leprosy. The bacilli have
entered the nerve and are located in the epineurium, perineurium or inside the fascicles,
within the Schwann cells particularly. Bacilli are less and there is hardly any host
response to the presence of organism suggesting that the host has not yet recognized the
invader.
2. Tissue response: persistence and multiplication of the bacilli to some specific level appear
to be needed for the induction of host response. In individual with full protective
immunity the bacilli are destroyed and are successfully eliminated by the host response.
3. Clinical involvement: continued tissue response leads to increased granuloma formation
in the affected nerve with the accumulation of cells along with reactive thickening of the
investments of the nerve. The nerve becomes noticeably thickened and recognized as
such in clinical examination. Often there is some local tenderness with or without pain or
other positive sensory phenomena relating to the affected nerve. However, at this stage no
clinically recognizable neural deficit is evident by routine clinical examination.
4. Nerve damage: In this stage nerve damage is reached to the state where the conducting
elements in the affected nerves are damaged to such extent that the routine clinical
examination reveals a definite deficit. The small non myelinated 'C' fibers (pain and
temperature from deeper structure) and thinly myelinated A-delta fibers (pain and
temperature from superficial structure) mediated autonomic and sensory function is
impaired earlier, causing loss of sweating, thermanesthesia and loss of perception of pain.
Later the thicker myelinated fiber mediated sensory function like touch and pressure are
affected
5. Nerve destruction: is the end stage of the nerve damage. The affected nerve is destroyed
and converted into scar. In tuberculoid type of leprosy the destruction may be restricted to
one fascicles or even one part of fascicles .Further in this type of leprosy the destruction
may be followed by caseous degeneration which may progress to cold abscess. In
lepromatous and near lepromatous type the nerve is replaced by collagen which may
undergo hyalinization.

Specific nerve involvement:


Ulnar Nerve is affected just proximal to the elbow is easily palpable behind medial
epicondyle. Enlargement is just above the medial epicondyle and often
continues as a fusiform segment higher up in tuberculoid leprosy cases
and as general thickening in lepromatous type.
Median Nerve is affected just above the wrist but difficult to palpate unless grossly
enlarged. Tenderness on pressing firmly at proximal wrist crease can
be elicited.

Radial Nerve Main trunk is affected in very few cases. When affected it can be rolled
as thickened cord in humeral groove, in the arm.

Sural nerve can be palpated on the back of leg, running along the lower portion of
Achilles tendon.

Lateral popliteal nerve at the neck of fibula,When affected can be palpated extending
proximally towards popliteal fossa in its course

Posterior Tibial nerveis palpated just behind the medial malleolus

Categorization of patient according to Nerve Function Deficit (NFD) and


Clinical neuritis
Nerve Function Deficit Clinical Neuritis
Absent Present

Absent A B

Present C D

Category Apatients-Patent is taught how to look for signs and symptoms of neuritis.
Category B patients-(Neuritis +, no NFD)
Start Prednisolone 40-80 mg daily 4 wks
taper dose 5mg/wk upto 30mg2-3 wks and then taper it.
In BT leprosy cases (neuritis due to RR), if there is no significant
improvement in the clinical condition within 48-72 hrs then
immediate surgical decompression is required so that
haemperfusion to nerve can be improved and permit the drug to
reach the compressed segment
In BL and LL cases (neuritis due to ENL), thalidomide is very
useful and should be given if possible or one can wait for six weeks
or even longer

Category C patients- (No neuritis,NFD+)


Clinically, one may assume that the nerve trunk has the potential to
recover if NFD is
- of recent onset - < 6 months involvement
-incomplete- some sensibility is there
-and if no severe muscle wasting is present
If NFD considered reversible:- prednisolone 30mg 4 wks then
tapered off over 30 days.
If NFD not recent:- prevent secondary impairement.
Category D patients:-(NFD +, neuritis+)
Prednisolone 40-80 mg daily 2-3 wks reduce to maintenance dose
in 3-4wks
Maintenance dose 30mg daily 8-10 wks
If there is no improvement in neuritis within 3-7days then surgical
decompression is required.
To accelerate resolution of inflammation:-
1- Splint affected nerve in slightly stretched position
2-Supportive therapy like analgesics
3- Short wave or microwave diathermy

Others -integrity of sensory and motor function should be assessed daily to start with
and progressively less often so that one will be able to recognize the onset of
nerve damage

Nerve abscess is cold abscess occurring in a damaged fascicle usually in


Tuberculoid Leprosy, Occasionally, hot abscess occurs in ENL related neuritis

Management:--
If nerve shows no NFD: wait and watch, there is no urgency but nerve function should
be monitored closely drain abscess only if risk of sinus formation is there.
If nerve is considered irrecoverably damaged: same as above.
If NFD is considered likely to recover: drain the abscess, mopping out the necrotic
contents, gently removing adherent slough, evacuate and excise the abscess.

Assessment

Assess and record the risk status of the patient


Not all leprosy patients will develop disabilities and deformities. Some are more likely to
develop them than others. Of these, some will be in great danger of developing further
problems and will require urgent specific action. Therefore the risk status of all patients at the
start of the disability prevention programme and all new patients thereafter should be
assessed
by clinical examination and questioning, as outlined below.
1. Ask for history of any previous problems:
- eye problems;
- hand problems;
- foot problems;
- nerve problems;
- reactions.
2. Examine for presence of any problems:
-loss of sensibility in hands or feet;
-thickening of nerve trunks (number of nerve trunks involved, level of tenderness)
-deformities of hands or feet;
-changes in eyes;
- weakness of eyelid muscles.
3. Consider the overall picture:
-type of disease;
-extent of disease;
- other factors, e.g. occupation, treatment.

"In danger" group.


Patients who have already developed some impairments and disabilities are in great danger of
developing new disabilities as well as worsening of existing ones and need urgent specific
action. If any of the following characteristics are present, the patient should be assigned to the
"in danger" group.

Characteristic Comment
Past or present eye problem Danger of eye damage and loss of sight
Weakness of eyelid muscles
Anaesthesia of hand (palmar surface) Danger of damage to hand
Past or present ulceration or crack in
hand
Deformities in hand

Anaesthesia of sole Danger of damage to foot


Drop-foot or other deformities in foot
Past or present ulcer or crack in sole
Acute or subacute neuritis of a nerve Danger of permanent damage
trunk nerve
Incomplete or recent neural deficit

"At-risk" group. Patients who have not yet developed impairments or disabilities but who
show any of the following characteristics should be assigned to the "at-risk" group. Such
patients are more likely to develop problems and disabilities than those in the "low-risk"
group and need to
be monitored. Remember that, in many cases, the risk of nerve damage is greater during the
first 6-12 months after starting anti-leprosy treatment.

Characteristic Comment

Multibacillary leprosy

Increased risk of damage to eyes, hands, feet and


nerves
Multiple skin patches
and their consequences group , patients with extensive
Three or more thickened
nerve trunks
disease, many nerve trunks thickened, or a history of
Moderate or severe
reactions, and patients who are pregnant
tenderness of a nerve
trunk compared with
patients in the "low-risk"

Pregnancy (with or without


thickened nerve trunk)

"Low-risk" group. Patients with the following characteristics and patientswho are not
included in either of the two previous categories should be assigned to the "low-risk" group.
The likelihood of disability is low in these patients and they need only occasional checking.

Assess and record the disability status


The disability status of the patient must also be assessed periodically. In these assessments,
check the following:
State of eyes: eyelids; cornea; conjunctiva; pupils; vision; muscles of the eyelids.
State of nerve trunks:
- ulnar nerves at elbow and wrist;
- median nerves at elbow and wrist;
- common peroneal nerves behind knee;
- posterior tibial nerves behind ankle.
State of hands and feet: sensibility; ulcers, skin cracks, scars and callosities;
deformity; muscle strength.
Record the results in a special disability chart and compare them with theprevious findings.
Patients in the "in danger" group will need immediate attention.
Deformities in leprosy
Types of deformities
Specific Deformities:- arise due to local infection with M. lepra like loss of eyebrows, nasal
deformities (face>hands=feet)
Paralytic Deformities:- result from damage to motor nerves like claw finger, foot drop,
facial palsy. (hands>feet>face)
Anesthetic deformities:- results from insensitivity because of damage to sensory nerves like
ulceration, mutilation (feet>hands>face)
Arise due to tissue infiltration and nerve damage

a) Tissue infiltration loss of eyebrows


Depressed nose
Wrinkled skin of face
Commonly seen in lepromatous leprosy

b) Nerve Claw hand which is usually chronic


Due to leprosy neuritis and reactions
Affects peripheral nerves at a particular site resulting in paralysis.

Factors to determine infected nerve will be paralyzed or not (BRAND)


1. No of nerve fibers in the nerve trunk
2. The depth of location of the nerve from the body surface
3. Immunological status of the patient

Loss of sensation due to nerve damage is 10 impairment & grade I disability


Claw hand is 10 impairment & grade II disability (visible consequence)
20deformities are Joint stiffness
Volar skin contractures in the hands
Ulcers due to anesthesia, injury & neglect of self
care
Absorption & shortening of fingers & toes.
Hand Problems in Leprosy Patients
Hands are affected because of damage to nerves supplying them or directly affected
by reactional process(especially in BL, LL).
Ulnar nerve is affected most often than others.
In BL,LL cases usually Glove type extensive acral anesthesia occurs without
significant motor involvement.
Therefore loss of sensibility in palm doesnt necessarily indicate damage to nerve
trunk, as it may also result from destruction of dermal nerve twigs.
Muscle weakness is sure sign of damage of nerve trunk.

Impairment Direct consequences Late consequences


Damage to somatic Loss of sensibility Anesthetic deformities
sensory fibres (ulcers, shortening of digits.)

Damage to motor fibres Muscle paralysis Contracture

Damage to sudomotor Dry skin Deep cracks, hand infections


autonomic fibers

Lepra reaction Inflammatory edema, Severe fixed deformities


osteoporosis, bone (specific deformities,bizzare deformities)
destruction,pathological
fractures

Sensory loss lead to:-


-Loss of perception of pain and heat which deprives the hand of its protective mechanism.
- Motor activities become clumsy and difficult because muscle action is not fine tuned
-Frequently injuries results in anesthetic deformities(shortening of digits).

Dryness of Palmar skin :-


-Lack of sweating
-Cracks at digital creases

Specific Deformities of hand:-


a) Banana Fingers: due to heavy infiltration of skin and subcutaneous tissue of finger
followed by atrophy of the skin and deposition of fat under the
skin
b) Shortening of fingers: due to resorption and fragmentation of most o the terminal
phalanx
c) Non paralytic claw hand :skin and subcutaneous tissue of dorsum of hand is site of
moderate to severe chronic inflammation, leads to healing,
scaring and fibrosis(localized scleroderma),which
also cause to pull the digits back to cause swan neck deformity,
pathological fracture

d) Reaction Hand: when hand is involved in reactional states


Foci of acute inflammation develops which eventually resolves
with dense fibrosis.
Foci may be located in dorsal skin, s/c adipose tissue, in small
muscles or in small bones.
Rx. Start systemic corticosteroids therapy(30 mg),
Initially hand is rested using splint in functional position
Wax baths
Active movements after subsiding acute phase
Paralytic deformities of hand:-
A) Paralytic claw finger
Ulnar palsy leads to:-
Ulnar claw hand(hyper extended MCP and flexed PIP joints)
Loss of adduction and abduction
Combined Ulnar and Median nerve palsy:-
all intrinsic muscles are paralyzed
complete claw hand
handling of objects become very difficult

Management surgical
Lasso's operation
Providing an independent flexor for the MCP joints (insertion of a transformed tendon)

Brands' operation (muscle tendon transfer)


radial wrist extensor tendon is lengthened and transferred to run through the palm& reach
the extensor expansion on the dorsum of the finger.

Modified Burnell's procedure


Flexor superficialis transfer (particularly useful in fingers with residual contracture at the
proximal IP joints)

Srinivasan procedure (extensor diversion)


A tendon graft is used for diverting the part of the extending forces at the MCP joint
anteriorly.

Zancolli procedure (flexor pulley advancement)


Anterior capsular shortening at the MCP joint could with flexor pulley advancement to
increase flexing force at this jt.

B) Paralytic claw thumb:


aim is to restore the ability to lift the thumb of palm (abduct the
thumb and take it across the palm in the position of apposition
Management: Brands operation
C) Wrist drop (triple nerve paralysis):
Management; aim of surgery
-to stabilize the wrist in the position of extension
-stabilize the fingers in extension at MCP joint
-correct the claw finger deformity and disability
-stabilize the thumb in extension in the plane of the palm
-stabilize the thumb in abduction in the plane perpendicular to the palm

MXA) Muscle transfer procedure available


Pronator teres to extensor carpi radialisbrevis to obtain wrist
extension
Flexor carpi radialis to extensor digitoriumcommunis to obtain
digital extension
Palmaris longus to Extensor Pollicis longus to obtain extension
of thumb
Felxor carpi radialis to extensor digitoruim communis to obtain
extension of thumb.
Flexor superficialis tendon transfer to extensor expansion of
fingers for correcting intrinsic zero disability
Transfer to flexor superficialis tendon to thumb to restore
abduction of the thumb.
B) Arthodesis Wrist in extension followed by tendon transfer to the fingers

Prevention and Management


Care of Insensitive Hand:-
A. Skin care practices:-
daily soaking hands in water for 15 min.
rubbing palms vigorously each against each other
in case of sole there is excessive hyperkeratosis so we can use rough
surface of stones or coarse brick
apply liquid parraffin or vegetable oil
ulcer and fissure if present is need to be sealed with sticking plasters
(adhesive strips coated with zinc oxide)
hard callus and corns need to be softened using keratolytic ointment 5%
salisylic acid
B. Injury care practices:-
injury consciousness: frame of mind of watchful awareness of the
potential for injury in any activity or task
precaution against burns while cooking
using utensils with insulated handles
daily inspection of hands ,protective gloves
using bulky bandages in case injury occurs
habit of automatic inspecting their insensitive hands, after any task
and observe any sign of fresh injury as such cuts, redness, blisters,
bruising, swelling
small wound which are not gapping should be cleaned well with
soap and water, any foreign body should be removed and should be
kept covered clean and dry
part should be wrapped well and rested completely in an elevated
position over some pillows for 72 hours
if not healed in 72 hrs seek medical advice

C. Joint care procedure


massaging the digits daily using vegetable oils keep skin soft and
supple
passive stretching of bent digits to straighten them up
assistive active exercise to extend the finger joint to their full
extent after stabilizing the MCP joint in flexion
patient advised to wear knuckle duster splint during the rest of day
and keep opening out he finger
if contracture developed: serial splinting in which permissible level
of passive stretching forces are maintained by splint, finger is
opened out very slightly by a few degree only using steady force
and maintained at this position by apply plaster of paris cast for 72
hrs
use of dynamic splint :rubber gutter splint to provide continuous
stretching force

D) Exercise:- press hand(flexed at MCP) against thigh and open flexed fingers with
other hand, take a soft rubber ball for squeezing
- In recent onset deformity, splints should be used. Four main types of
splints are used:-( delivered by H Workers)
Adductor Band splint(in splayed fingers)
Finger Loop Splint(maintain lumbricals in
position and strengthen small muscles of hand)
Opponens Loop Splint
Gutter Splint(in late cases with stiffness)
E) Grip Aid:- used after advanced deformities like absorption and amputation.
- Epoxy resins Grip Aids- applied on articles of work
- Instant Grip aid kit- immediate benefit in daily work
F) Physiotherapy
Foot Problem In Leprosy Patients
A) Paralytic deformity
1) Foot drop:--
About 1-5% of leprosy patients develop due to damage to lateral popliteal nerve.
Paralysis of anterior group of muscles give rise to foot drop giving characteristic stepping
gait inwhich the outer part of forefoot make 1st contact to the ground and then rest of foot
slap down on ground. Paralysis lateral muscle group gives rise to loss of eversion which
normally transfer the body wt from lateral to medial part of foot hence leads to overloading
on outer part.

Rx
-If paralysis is recent; manage under Nerve Care therapy
-If paralysis is of >1 year duration; it is satisfactorily corrected by anterior
transposition of tibialis posterior tendon (Srinivasan operation)
-If surgical intervention is contraindicated; foot drop appliances like strap,
stops or springs are used which hold the foot at right angle, use drop foot
brace or toe raising device, exercise to prevent contracture of calf muscle
as such squatting or forward bending exercise
2) Claw deformity of Toe:-
Indicate plantar intrinsic muscle paralysis which increase the risk of ulceration under the
metatarsal head and the tip of the toes
Rx
oil massage
passive toe straightening exercise
dorsalizing the long flexor tendon distal to metatarsal phalyngeal
joint
arthrodesis of PIP joint
dorsal migration of toe with fixed hyperextension at
metacarpophalyngeal joint

B) Anesthetic deformities
PLANTAR ULCERATION:--
- found in 10% of patients
-manifestation of sensory motor deficit
-mostly in front part of sole in MTP joint
-augmented by infection through fissures and paralysis
of feet muscles(which counter the stress while walking)

Stages of ulceration
i. Threatened Ulceration (dorsal puffiness, deep tenderness)
ii. Concealed ulceration (destruction of soft tissues has occurred)
iii. Overt ulceration (necrosis blister open & exposed)

Types of Ulcer
Acute ulcer Frankly infected, swollen and hyperemic, copious discharge, base
covered with dirty slough
Chronic ulcer indolent ulcer with hyperkeratotic edges, scanty discharge, hard
fibrosed base with floor covered with unhealthy granulation tissue
Complicated ulcer Infection spread to deeper structure may lead to muscle paralysis, gas
gangrene, septicemia, osteomyelitis, septic arthritis, septic
tenosynovitis
Recurrent ulcer appears repeatedly

Plantar ulceration: Distribution

Forepart of the sole (ball of the foot) 70-90%


Medial aspect 30-50% occurring in relation to great toe, under proximal phalanx of big toe
and 1st metatarsal head.
Mid-lateral border of sole & heel 5-10%
Tips of the toe 1-5%
Central part of sole ulcerates when the tarsus is disorganized with collapse of the arch of foot.

Causes of Ulceration (pathogenesis)


i. Walking on insensitive feet (which also suffer from small muscle paralysis)
ii. Infection following a penetrating injury to the insensitive feet.
iii. Infection through a deep fissure in the dry insensitive sole or though a minute crack
assistant with corn/ callosity in the sole

Risk of ulceration is increased in insensitive feet by a factor of 10-12 when there is intrinsic
muscle paralysis with loss of sensibility.

Mx.
ACUTE
-absolute bed rest no weight bearing, walking or standing
-limb elevation to prevent further tissue damage and permit the resolution of traumatic
inflammation
-if necrotic blister present avoid breaking of blister if felt necessary the blister may be
covered with sterile gauze
-Eusol bath, irrigation & dressing
-Remove slough
-Start antibiotics (treat information)

CHRONIC:
Aim:-to protect the ulcer during walking and to allow it to heal without interference
-plaster cast
-Protective foot wears
-Foot care practices: skin care, injury care, walking care
-superficial ulcer: strips of zinc oxide coated adhesive plaster laid directly
on the ulcer to cover it entirely
-large ulcer: split thickness graft then encasing the leg in plaster cast
-complicated ulcer: debridement where floor is curetted, sequestra are
removed
-Splinting of knee Rest to inflamed nerve, result in quicker healing &
dropped foot should be supported to hasten recovery
Stretching calf muscle
Prevention:--
Protective footwear:-(type depends on state of foot)
Feet with only sensory loss (no muscle paralysis), footwear should have tough
outer sole, should not rub against toes. Eg using automobile tyre side pieces.
-Any footwear can reduce the pressure upto 25%
-Appropriate footwear should have outer sole of
15-18mm thick and soft inner sole 18-22mm.
-Iron nails and buckles are to be avoided.
-Raja Model is most suitable one.

Insensitive feet(with intrinsic muscle paralysis):-


- these require a resilient, non collapsing, shock absorbing insole that will
dampen the impact during walking
-Microcellular rubber is most suitable.
In certain case where greater reduction of pressure is required; add metatarsal
bar obliquely across the outer sole about 2.5cm proximal to metatarsal head or
molding the insole so that pressure can be distributed evenly over entire
plantar surface.
Certain orthosis like fixed ankle brace can also be used that may transfer a part
of load to leg.
Foot Care Practices: similar to those done for hand as such skin care, injury care and walking
care
Walking care: -reduce walking
-use alternate mode of transport as such bicycle, carts or buses
-restricting walk to within "SAFE LIMIT"
-protective foot wear as mentioned earlier
Deformities of Face
Most of deformities on face occurs due to infiltration of facial skin but paralytic
deformities can also occur(in borderline leprosy).
Deformities are :-
1) loss of eyebrows(madarosis)
Rx: replacing the bald eyebrow with hair bearing skin from nearby scalp
ie, mastoid area of scalp or skin flap from temproparaital scalp
2) mega lobules of ear(Buddha ear)
Rx: reduction of ear lobe by crescent wedge resection removing much
from infero medial segment of ear lobe
3 premature senility:
-stretching of skin due to heavy infiltration lead to loss of elastic tissue and
when infiltration regresses skin become redundant
Rx: face lift operation in which the skin of face tightened by removing part
of the facial skin and resecting
4) Sunken Nose: due to infiltration in nasal mucosa in LL, granuloma formed which
erodes the supporting bony structure of nose.
Rx: nasal lavage and smearing through mucosa with liquid paraffin
-collapsed nose: split thickness grafting and providing rigid support by
bone graft or internal prosthesis
Eye Problem
More commonly in BL and LL type leprosy.
Occurs due to:-
-Direct invasion- leprous conjuctivitis, scleritis andchoroidal nodule.
-Acute iridocyclitis- due to immune complex deposition
-paralysis of eyelid muscles and lagophthalmos, epiphora ectropion,
entropion
-trigeminal nerve : loss of corneal sensation leads to exposure keratitis
and corneal ulceration.
Management-
-using spectacles, goggles or eyeshades.
-artificial tears and cover eyes during sleep
-treating ac iridocyclitis using topical corticosteroids
-surgical intervention for lagophthalmos by temporalis transfer procedure of
gill or tarsorrhaphy or lid straightning procedure
Splint in facial palsy-
- use adhesive tape strips so that lower lid is not sagging due to gravity
and angle of mouth is not deviated
Gynecomastia: embarrassing enlargement of breast in males, usually bilateral due to hormonal
imbalances because of testicular and liver damage
Rx: Webster's operation (mastectomy)
Disabilities and Deformities which can develop in leprosy patient (overall)

organ specific deformities motor paralytic anesthetic miscellaneous


deformities deformities deformity
face Nodulation, loss of facial Lagopthalmos, facial Anosmia Paresthesia, loss of
hair in males, nasal defect- palsy taste, crocodile tear
full thickness loss of nasal syndrome, nasal
wall, depressed dorsal crusting and blockage
crest, alar deformities,
facial wrinkle
Eyes Loss of eyebrow blurring due to complicated cataract,
corneal ectropion and
abrasion entropion, loss of
vision
Ears Sagging of ear lobules, Rat
bitten appearance of helix
Larynx Hoarseness of voice

Hard and Palatal perforation nasal speech


Soft
palate
Hands Reaction hand, Frozen ulnar claw hand, ulnar anesthesia paresthesia, pain, loss
hands, Twisted fingers, median claw hand, of grip power
intrinsic plus finger wrist drop, Z thumb,
contracture of thumb
Feet Frozen foot, twisted toes clawing of toes, drop ulcer, warty out growth on
foot partial or absorption, the dorsum of foot,
complete disorganization chronic lymphedema
of foot
Skin Scarring due to recurrent
reaction
Testes Testicular atrophy gynaecomastia,
gynecothelia,impotence
sterility

Rehabilitation
The basic concepts behind rehabilitation are that the persons affected with leprosy
should be restored back to normal social life or as near as possible.
Rehabilitation means restoration of economic productivity leading to economic
independence
Rehabilitation in the field of leprosy requires greater efforts than the rehabilitation in
other types of disabled persons because of the question of social acceptance
The task of removing public fear and at the same time maintaining public concern
and interest may be difficult but not impossible
Efforts to create a broad interest in the social problems of leprosy afflicted are
beginning to yield good results
Appropriate economic rehabilitation is provided eg sewing machines, handcrafts,
carpentry, kits for bicycle repair etc.

CBR(community based rehabilitation)


- aims to overcome activity limitation and participation restriction and thus improving
QOL for disabled

Delivery of CBR Services


Person with disabilities and their family motivated and facilitated by
community workers

Community members and resources mobilized by field workers and their


supervisors

Local programme management networking with local organization to


maximize access to available skills and services

Skills and resources of rehabilitation personnel usually available at


specialist referral centers and increasingly in other hospital
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3.J Infect Dev Ctries2015;9(3):232-238.doi:3855/jidc.5431
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H Srinivasan
5.Park K. Parks Textbook of Preventive and Social Medicine.
6.IndianJ Dermatol Venereol Leprol 2012;78:328-34.
7.WHO/ILEP technical guide on community based rehabilitation and leprosy-2017
8. WHO Weekly epidemiological record , sep 2016