1) Leprosy causes deformities through direct tissue infiltration, nerve damage, and secondary to anesthesia. Nerve damage in leprosy can impair sensation, motor function, or both. 2) Common deformities in leprosy include claw hand, claw toes, foot drop, and plantar ulcers. Deformities occur most often in the hands and feet. 3) Management of leprosy deformities focuses on early detection of nerve damage, prompt treatment to prevent further damage, rehabilitation to prevent disability, and management of existing deformities and injuries.

1. Deformities in Leprosy
and management
DR MANASA S J, 2ND YR PG STUDENT, DEPT OF DVL, CHAFB

2. Introduction
• Leprosy feared for its unsightly disabilities and deformities
•If leprosy had not caused deformities & disabilities- it would not have been a
dreaded disease
•Socioeconomic dehabilitation in leprosy  deformities
•Nerve damage  deformities

3. Basics
Impairment- Any loss or abnormality of psychological, physiological or
anatomical structure or function
Ex: loss of sensation due to nerve involvement
Deformity- Visible alteration in the form, shape or appearance of the body due
to impairment produced by disease process
Ex: claw hand, loss of eyebrows etc.
Disability- Any restriction or lack of ability (resulting from impairment) to
perform an activity considered normal for a human being
Ex: difficulty in walking due to foot-drop

4. Basics
Handicap- Disadvantage resulting from an impairment or disability that limits or
prevents fulfillment of a role that is normal depending on patient’s age and sex
as well as relevant social and cultural factors
Examples: inability to earn a living on account of disability or needing help in
performing activities of daily life

5. DEFORMITIES

6. Causation
1. Direct infiltration of tissues
2. Nerve damage
3. Secondary to anesthesia

7. Causation
1. Direct infiltration of tissues
2. Nerve damage
3. Secondary to anesthesia

8. Nerve damage
•Only bacillus known to infect peripheral nerves
•Peripheral nerves consist of sensory, motor and autonomic nerve fibres
•Nerve involvement may be partial or total, i.e., only sensory impairment or both
sensory and motor impairment, autonomic fibres are generally involved in both
cases

9. Stages of nerve involvement
(i)Stage of parasitization: Transition phase between "disease" and "non-disease“
States; M. leprae found inside Schwann cells,yet no host tissue response
(ii) Stage of tissue response: Persistence and multiplication of the bacilli
eventually evokes a tissue response which is initially non-specific or
indeterminate but,becoming specified
(iii) Stage of clinical infection: Nerve gets thickened and becomes clinically
regonizable as such

10. Stages of nerve involvement
(iv) Stage of nerve damage: Neural functional deficit becomes clinically demonstrable .Nerve
damage is reversible at this stage
(v) Stage of nerve destruction: Conducting elements are totallydestroyed and collagenized.
Caseation and cold abscess formation may occur in tuberculoid leprosy

11. Various deformities in leprosy

12. Factors associated with deformities

13. Factors associated with deformities

14. Types
1. Specific deformities
•Local infection or infiltration with M.leprae
•Most often seen in face (Ex: Loss of eyebrows, nasal deformity), less often in
hands (Ex: banana fingers, reaction hand deformities) and occasionally in feet
2.Paralytic deformities
• Damage to motor nerves
•Seen most often in hands (Ex: Claw fingers), less often in feet (Ex: Claw toes,
drop foot) and occasionally in face (Ex: Lagopthalmos, facial palsy)

15. Types
3.Anaesthetic deformities
•Neglected injuries in parts rendered insensitive because of damage to sensory
nerves
•Found most often on feet and hand (ex. Ulceration, shortening of digits ,
mutilation and skeletal disorganization of foot)

16. Grading

17. Deformities of hands

18. Ulnar nerve(C8,T1)
•Medial cord
•Posterior to medial epicondyle
•Pierces two heads of FCU
•Muscular branches,Palmar & dorsal cutaneous
branches
•At wrist, superficial to flexor retinaculum
•Enters the hand via Guyon’s canal
•Terminates into supfl(palmaris br.)& deep branches
(hypothenar, interossei, medial 2 lumbricals, Add.
pollicis, Flexor pollicis brevis-deep head)

19. Median nerve(C5-T1)
•Medial and lateral cords
•Crosses brachial artery(lateral to medial)
•Enters anterior comptmnt of forearm 
Muscular branches
•Travels between FDP and FDS
• In forearm,AIN, Palmar cutaneous nerve
• Enters hand via carpal tunnel
•Terminates into Recurrent branch(thenar
muscles) & Palmar digital branch (cut. & lateral
2 lumbricals)

20. Radial nerve(C5-T1)
•Posterior cord
•Posterior to axillary artery
•Muscular branches- triceps brachii
•Radial groove
•Anteriorly over lateral epicondyle of
humerus
•Terminates into deep branch (posterior
comptmnt of forearm) & superficial
branch (sensory)

21. Sensory supply

22. Motor paralytic deformities
•Common
•Destruction of motor fibres in the major nerve trunk
• MC nerve- Ulnar nerve
•Less commonly,combined paralysis of ulnar and median nerves
•Median nerve- affected at the level of forearm

23. Ulnar nerve paralysis
•Partial or ulnar claw hand
•High ulnar palsy : muscles of the forearm(FCU, FDP)
•Low ulnar palsy: small muscles of hand
•Extensors pull MP joints in extension bringing about compensatory flexion
at PIP joints
•Only ulnar nerveulnar claw
•Ulnar and partial median nerve subtotal claw
•Ulnar and median nerves total claw

24. CLAW HAND

26. Ulnar nerve paralysis
Deformities:
• Clawing: hyperextension –MCP; flexion-IPJ.
• Flattening of hypothenar eminence
• Depression over dorsum of thumb (wasting of dorsal interosseous muscle)
Disability:
• Difficulty in typing, eating rice with hand & coin slips off the finger
• Fine work with delicate manipulation –difficult
• Weakening of power grip (paralysis of adductor pollicis)

27. Median nerve paralysis
•Simian hand
•Thumb does not lift off the palm to
oppose other digits
•Paralysis of abductor pollicis brevis and
opponens pollicis

28. Triple palsy
•Damage above the level of elbow
•Paralysis of all muscles in back of forearm
•Claw hand is abolished, because of paralysis of digital extensors
•Wrist drop- When pt is asked to keep wrist & fingers straight ,with forearm
stretched & pronated –difficult to actively lift wrist
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29. WRIST DROP

30. Non specific deformities
•Banana finger- Heavy infiltration of skin followed by atrophy & deposition of fat
•Shortening of fingers- Fragmentation and resorption of terminal phalanx
•Reaction hand- Foci of acute inflammation occur and eventually resolve with
dense fibrosis & crippling effects
•Twisted finger – Bizarre deformity in reactions, osteoporosis & pathological #

31. Deformities of feet

32. Sciatic nerve(L4-S3)
•Lumbosacral plexus
•Enters gluteal region via greater sciatic foramen
•It emerges inferior to piriformis
•Enters posterior thigh by passing deep to long
head of biceps femoris
•In thigh, muscular branches (hamstrings &
adductor magnus)
•At apex of popliteal fossa, bifurcates into tibial
and common fibular nerves

33. Tibial nerve(L4-S3)
•Popliteal fossa
•Muscular branches
•Branches contributing towards sural
nerve
•Passes posteriorly and inferiorly to
themedial malleolus, through tarsal
tunnel
•Cutaneous innervation to the heel
•Terminates into medial & lateral
plantar nerves

34. Common peroneal nerve(L4-S3)
•Cutaneous branches
•Wraps around the neck of fibula
•Terminates into superficial fibular and deep fibular nerves

35. Sensory supply

36. Motor paralytic deformities
1.Claw toes-paralysis of intrinsic muscles ,supplied by medial plantar nerve
-ulceration of tip of toes, under the metatarsal head
2.Foot drop- Paralysis of common peroneal nerve at neck of fibula
- Paralysis of dorsiflexor and evertors of foot
- C/F high stepping gait
- Ulcers over toe tips
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37. FOOT DROP

38. Anaesthetic deformities
Neuropathic disorganisation of foot
•Disruption of the skeletal structure caused by neurological deficit
•Disruption of Forefoot: common ,neither progressive nor any complications
•Mid foot or Hind foot: progressive disorganisation leading to serious disability
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39. •Causes: septic disorganisation
: aseptic /traumatic disorganisation
•Prognosis poor when degenerative disorganisation coupled with extensive
infection
•Amputation- best treatment
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40. Neuropathic plantar ulcer
•Insensitive sole injured from outside
•Dry anaesthetic skin develops fissure &
cracks
•Stress & strain on forefoot
•Loss of arches of foot

41. Distribution of plantar ulcer
Forefoot-79%, midfoot-7%, hind foot 14%
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42. Stages
1. Threatened Ulcer
2. Concealed ulcer- Necrosis blister
3. Overt ulcer

43. Deformities of face
NON PARALYTIC & PARALYTIC

44. Madarosis -super ciliary & ciliary
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45. •Corrugations-deepening of
skin markings
•Leonine facies (sagging
face)
•Premature senile
appearance
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46. External ear infiltration
megalobule(Buddha ear)
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47. Rat bitten appearance of ear : irregular
& scalloped due to loss of skin & bits
of cartilage
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48. •Infiltration of the nasal structure-
sunken nose deformity
•Negligence of nasal hygiene-myiasis
•Septal perforation
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49. Eyes
•Eyelids-infiltrated & thickened, nodular Conjuctivitis, scleritis, episcleritis,
superficial punctate keratitis
•Iris pearls: deposits of tightly packed bacilli within the swollen macrophages (slit
lamp)
•Secondary cataract ,Glaucoma,Ciliary staphyloma
Mouth
•Hard palate perforation
•Upper incisor teeth missing-part of skull changes ( Facies Leprosa – named by
Moller Christensen)
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50. Paralytic deformities
Upper facial palsy- facial nerve
(zygomatic branch)
-Lagophthalmos-upper eyelid
-Ectropion-lower eye lid
-Exposure keratitis
Lower facial palsy (buccal &
mandibular branch):
-drooping of angle of mouth to
affected side
-obliteration of nasolabial fold
-dribbling of saliva
-unable to purse lips/whistle
Trigeminal nerve - sensory loss
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51. Lagophthalmos with ectropion

52. Other deformities
Larynx
•Vocal cords : fibrotic form ,ulcerative form leading to hoarseness
• glottis narrowed- stridor
Genitalia
•testicular atrophy-altered sexual hair pattern/altered sexual functions
Gynaecomastia

53. Management

54. Management
•Prevention of primary deformity
•Early detection of nerve damage &
prompt Rx(Rest, MDT, Steroids,
Thalidomide, Splints)
•Surgical decompression of nerve
indicated if
Intractable pain,Nerve abscess,
Entrapment of nerve
•Reablement- Splints, active and
passive excercises, Reconstructive
surgery
•Prevention of secondary deformity
•Skin care procedure
•Injury care procedure
•Joint care procedure
•Mx of ulcers
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55. Skin care
•Absence of sweating dry, brittle, cracks
•Insensitive skin ignorance  deep chronic infection
•Daily soaking of hands in water-15 min
•Rubbing palms vigorously to remove superficial keratin layer
•Smear with liquid paraffin, neem or castor oil
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56. Injury care
•Preventing or promptly attending to them if they do occur
•Injury consciousness & protective behaviour
•Protective covering of hand with thick towel/glove or using utensils with
insulated handles
•Habit of inspecting limbs daily(cuts,blisters.hot spots)
•Cover with bulky bandage &rest for 24-72 hrs, consult medical advice if doesn’t
subside
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57. Joint care
•Mobile, supple, free from contracture
•Daily oil massage
•Repeated passive stretching
•Serial splinting

58. Splints
• Circular splints
• Thumb web splints
• Gutter splint
• Functional splint
• Dynamic splint
• Walking plastic cast
• Namasivayan’s splint( Hand splint Galavanised iron wire inserted into rubber tubing for
‘Intrinsic muscle paralysis of the hand’)

59. Adductor splint for abductor deformity of little finger
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60. Opponens splint for ape thumb deformity & first web space contracture
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61. Cock up splint

62. Finger loop splint

63. Knuckle bender splint

64. Immobilisation

65. Corrective surgeries
•Restoration of normal appearance
•Improvement in function of hand
•Preoperative preparation- Assessment of deformity, disability, integrity of
extensor apparatus
-Prevent & release contractures
-Muscle training
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66. Claw hand
•Lasso insertion(independent flexor)
•Zancolli’s operation(Volar capsule shortening) augment flexion forces
at MCP jt
•Srinivasan’s operation(extensor diversion)
•Bunnel’s operation(FDS)
•Brand operation(ECRL) augments extension
forces at PIP jt
•Antia (PL)

67. •Claw thumb: abductor- opponens replacement operation, Brand’s, Snow Fink
•Triple nerve palsy- multiple tendon transfer operation
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68. CLAW HAND CORRECTION BY TENDON TRANSFER
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69. Lower limb deformities
Foot drop
•Early cases: spontaneous recovery-surgery deffered –1yr
•Established cases: tibialis posterior tendon transfer(circumtibial/interosseus
route)
Claw toe
•Flexor digitorum tendon transfer
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70. Facial deformities
•Lagophtholmos: lateral tarsorraphy
temporalis transfer
•Very severe cases: lower lid shortened& retensioned using procedure of
palpebroplasty
•Nose: first stage: postnasal inlay
second stage: cantilever bonegraft for nasal support
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71. Lateral tarsorraphy

72. Rhinoplasty

73. Facial deformities
•Eyebrows:reconstruction- free graft of hair bearing skin,island scalp pedicle graft
micro follicular hair grafting
•Ears: reduction auriculoplasty
•Face: rhytidectomy/face lift procedures
Others:
•Gynaecomastia-mastectomy by websters technique
•Para phimosis- circumcision
•External meatal stenosis- periodic dilatation/meatotomy
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74. Secondary deformities
Education
Prevention and treatment of injuries
Use eyes in compensation to loss of sensation
Grip aids, Protective footwear
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75. Plantar ulcer
1)STAGE OF THREATENED ULCERATION:
-foot should be rested in a splint
-no wt bearing on the affected foot
2)STAGE OF NECROSIS BLISTER:
-blister is padded well
-if danger of breaking open,it is snipped & sealed with adhesive plaster and a
below knee POP
-cast removed after 3 wks & asked to use protective footwear

76. ACUTE ULCER:
-absolute bed rest
-elevate the foot
-Eusol bath,irrigation,dressing
-limit surgery to drinage proced
-antibiotic if needed
-treat as chronic ulcer after acute phase subsides

77. 1) CHRONIC SIMPLE :
-Scraping floor of the ulcer
-sticking plaster or vaseline gauze
dressing
-below knee POP cast or bulky
dressing
-protective footwear+foot care
training
2) CHRONIC COMPLICATED:
-Ulcer debridement
-physiological rest by below
knee POP cast
-protective footwear on POP
removal
-corrective deformity,if necessary
-identify other complication
& treat accordingly
-skin graft of large ulcer

78. RECURRENT:
- improve quality of scar(scar revision using exision and suture
local flap,distant flap,free flap)
- reduce load on scar by footwear modification or corrective surg
-eradicate infection

79. Protective footwear
• should have a tough outer sole that will resist penetration by
thorn,nails,glass
• itself doesnt have any nails
• upper/straps and buckle should not rub against the toes or cause undue
pressure
• MCR(microcellular rubber ) m/c used for reducing the stress generated
during walking

80. MCR Footwear

81. Foot care practice
1.Infected ulcer/Cracks
2.Wounds/injury
3.Weakness/paralysis
•Clean with soap & water
•Rest & apply antiseptic dressing
•Apply cooking oil/Vaseline
•Soak in water
•Clean and apply clean bandage
•Protect when working/cooking
•Oil massage
•Exercises

82. TROPHIC ULCER
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83. Grip Aids
•Indications –Grossly deformed hand with loss of fingers, fixed contractures, loss
of sensory input, total fixed claw hand
•Made up of – epoxy resin putty grip aids
•Fitted to any tool / utensils
• Adheres to any surface
•Washable and autoclaved
•Improve grip & protect skin from abrasion and ulcer
•Improves quality of life
•Disadvantage – not suitable for heating
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85. Rehabilitation
•Physical & mental restoration
•Able to resume their place in the home, society & industry
•Education of the patient, his family & the public
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86. References
IAL textbook of leprosy
Hastings textbook of leprosy
Handbook of leprosy- Jopling
BD Chaurasia textbook of anatomy
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87. “Leprosy work is not merely medical relief;
it is transforming frustration of life into joy of dedication, personal ambition into
selfless service...”
Mahatma Gandhi
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