This document discusses reconstructive surgery for complications of leprosy, including lagophthalmos (eyelid paralysis), foot drop, and claw hand. It describes the causes and assessment of these conditions and outlines surgical procedures to restore function, such as temporalis muscle transfer for lagophthalmos and tibialis posterior transfer for foot drop. The goals of reconstructive surgery in leprosy are to restore function and form, prevent further disability, and facilitate rehabilitation.
Deformities in leprosy Dr Manasa Shettisara JanneyManasa Janney
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.
Dr. Ankur Mittal's presentation discusses stenosing tenosynovitis, also known as trigger finger. The anatomy of the flexor tendon sheath and pulley system is described. Trigger finger occurs when a thickened flexor tendon catches on the A1 pulley, most commonly in the ring finger. Conservative treatments include splinting, steroid injections, and exercises, while surgery involves open or percutaneous release of the A1 pulley. Postoperative care focuses on early mobilization while avoiding complications like nerve damage or bowstringing. Surgical synovectomy may be required in rheumatoid patients to address underlying synovitis.
Foot drop is the inability to lift the front part of the foot. It can be caused by injuries or conditions that damage the common peroneal nerve. Symptoms include difficulty lifting the foot and dragging the toes. Treatment depends on the underlying cause but may include bracing, nerve stimulation, tendon transfers, or joint fusions. The goal is to improve mobility and gait.
Paraplegia is a spinal cord injury that paralyzes the lower limbs, caused by damage to the spinal cord and nervous system. It affects movement in the trunk, legs, and pelvic region. Causes include spinal fractures, tumors, infections, and trauma. Paraplegia is categorized as complete or incomplete based on the extent of movement loss. Complications include pressure sores, urinary issues, muscle tightness, osteoporosis, and respiratory problems. Physiotherapy focuses on prevention of complications, strengthening, stretching, mobility training, and achieving independence through exercise and assistive devices.
This document discusses radial nerve palsy, which is an injury to the radial nerve resulting in impaired nerve function and causing wrist drop. Wrist drop is the characteristic clinical sign where the wrist hangs flaccidly and cannot be extended. Causes of radial nerve palsy include sleeping with one's arm compressed (e.g. Saturday night palsy from falling asleep with one's arm on a chair or bar), compression from walking with a crutch (crutch palsy), or from another person sleeping on one's arm (honeymoon palsy). Radial nerve palsy results in weakness of wrist and finger extension and grip. Treatment involves reducing pain, increasing range of motion, and restoring
Deformities in leprosy Dr Manasa Shettisara JanneyManasa Janney
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.
Dr. Ankur Mittal's presentation discusses stenosing tenosynovitis, also known as trigger finger. The anatomy of the flexor tendon sheath and pulley system is described. Trigger finger occurs when a thickened flexor tendon catches on the A1 pulley, most commonly in the ring finger. Conservative treatments include splinting, steroid injections, and exercises, while surgery involves open or percutaneous release of the A1 pulley. Postoperative care focuses on early mobilization while avoiding complications like nerve damage or bowstringing. Surgical synovectomy may be required in rheumatoid patients to address underlying synovitis.
Foot drop is the inability to lift the front part of the foot. It can be caused by injuries or conditions that damage the common peroneal nerve. Symptoms include difficulty lifting the foot and dragging the toes. Treatment depends on the underlying cause but may include bracing, nerve stimulation, tendon transfers, or joint fusions. The goal is to improve mobility and gait.
Paraplegia is a spinal cord injury that paralyzes the lower limbs, caused by damage to the spinal cord and nervous system. It affects movement in the trunk, legs, and pelvic region. Causes include spinal fractures, tumors, infections, and trauma. Paraplegia is categorized as complete or incomplete based on the extent of movement loss. Complications include pressure sores, urinary issues, muscle tightness, osteoporosis, and respiratory problems. Physiotherapy focuses on prevention of complications, strengthening, stretching, mobility training, and achieving independence through exercise and assistive devices.
This document discusses radial nerve palsy, which is an injury to the radial nerve resulting in impaired nerve function and causing wrist drop. Wrist drop is the characteristic clinical sign where the wrist hangs flaccidly and cannot be extended. Causes of radial nerve palsy include sleeping with one's arm compressed (e.g. Saturday night palsy from falling asleep with one's arm on a chair or bar), compression from walking with a crutch (crutch palsy), or from another person sleeping on one's arm (honeymoon palsy). Radial nerve palsy results in weakness of wrist and finger extension and grip. Treatment involves reducing pain, increasing range of motion, and restoring
This document discusses foot drop, which is the inability to lift the front part of the foot. It can be caused by nerve injuries, neurological conditions, muscle weakness, or injuries. Symptoms include difficulty lifting the foot and dragging it when walking. Treatment depends on the underlying cause but may include bracing, physical therapy, nerve stimulation, or surgery to repair nerves or transfer tendons.
Disabilities and deformities in leprosy patients and managementdalal8
This document discusses disabilities and deformities that can occur in leprosy patients. It defines key terms like impairments, deformities, and defects. It describes risk factors for deformities like type and extent of leprosy, number of involved nerves, and duration of untreated disease. Common types of deformities are specific deformities from local infection and paralytic or anesthetic deformities from nerve damage. Nerve involvement is discussed, including the stages of involvement and commonly affected nerves. Guidelines are provided for managing nerve damage, neuritis, and abscesses. Common hand problems in leprosy patients are also summarized.
Cranial nerve assessment..Simple and Easy to perform for medics and Physiothe...pawan1physiotherapy
Cranial Nerve Assessment is a crucial step in neurological assessment. By following the simple theoretical aspects it can be made on your fingertips....here is an try to make the stuff easier for you....
This document provides an overview of leprosy (Hansen's disease), including:
- It is caused by Mycobacterium leprae bacteria and primarily affects the nerves and skin.
- Symptoms include discolored skin lesions and loss of sensation which can lead to injuries.
- It is classified based on severity and can be diagnosed via skin biopsy or smear.
- Treatment involves long-term multi-drug antibiotic regimens.
- Surgical procedures and orthotic devices can help address deformities caused by nerve damage.
The document provides information about ulnar nerve injury, including its course through the upper limb, branches and sensory/motor supply. Causes of injury include compression at sites like the elbow (cubital tunnel syndrome) and wrist (Guyon's canal syndrome). Signs and symptoms involve sensory loss and weakness of hand muscles. Clinical tests assess functions like pinching. Investigations include EMG, nerve conduction studies and imaging. Claw hand deformity can occur with severe ulnar nerve injury.
This document provides information on periarthritis shoulder (PA) and adhesive capsulitis/frozen shoulder (FS). It discusses the anatomy of the shoulder joint and describes PA and FS as conditions characterized by pain and progressive limitation of shoulder movement. It outlines the typical stages of FS, risk factors, clinical features, investigations, and management approaches. Management involves a multimodal approach including medications like NSAIDs, physical therapy focusing on range of motion exercises and strengthening, and in severe cases joint injections or surgery.
This document provides information about poliomyelitis (polio), including:
- Polio is caused by poliovirus and mainly affects children, causing paralysis in rare cases.
- It was first described in the late 1700s and caused epidemics in the late 1800s.
- The virus infects the intestine and can invade the nervous system, destroying motor neurons and causing muscle weakness or paralysis.
- Types of polio include spinal and bulbar polio, affecting different areas of the spinal cord or brainstem.
- Treatment focuses on rest, physiotherapy, orthotics, tendon transfers and arthrodesis to correct deformities from muscle imbalances.
This document summarizes photochemotherapy with psoralens, also known as PUVA therapy. PUVA therapy combines the use of oral or topical psoralens followed by exposure to ultraviolet A radiation. It results in beneficial therapeutic effects for conditions like psoriasis through controlled phototoxic reactions. The document describes the types of psoralens used, pharmacokinetics, dosing, administration methods like baths or soaks, indications, contraindications, and combination therapies for PUVA.
The document discusses using Z-plasty techniques to treat post-burn scar contractures and pilonidal sinus. Z-plasty involves reorienting scar tissue to lengthen it and correct deformities. The author describes using Z-plasty on 10 cases of scar contractures and 5 cases of pilonidal sinus. It resulted in scar lengthening and zero recurrence of pilonidal sinus with less hospital stay compared to other techniques. The document concludes that Z-plasty is a versatile technique for general surgeons to manage linear scar contractures and pilonidal disease.
Nerve conduction studies test the function of motor and sensory nerves by measuring nerve conduction velocity. Small electrical stimuli are applied to nerves while recordings are made from muscles. Abnormalities may indicate conditions like peripheral neuropathy or radiculopathy. The test evaluates nerves like the median and ulnar nerves and can help diagnose disorders affecting the peripheral nervous system.
The document provides information on performing a sensory examination, including testing superficial sensations like pain, temperature, and touch. It also describes evaluating deep sensations such as proprioception, vibration, and kinesthesia. Finally, it discusses assessing combined cortical sensations including stereognosis, graphesthesia, and two-point discrimination. The examination involves testing various areas of the body using specific tools and techniques, and having the patient respond verbally or by physical demonstration to identify sensations.
This document summarizes fluidotherapy, a dry heating modality. It transfers heat to the body through convection using a cabinet containing heated air and finely ground cellulose particles. This creates a fluid-like medium allowing limbs to float and exercises to be performed. Key effects include increased blood flow, pain relief and improved range of motion. It is used to treat distal extremities for conditions like pain, swelling and post-operative rehabilitation. Contraindications include fever, anesthesia or severe circulatory issues. Advantages include ease of use and allowing some active exercise in a comfortable, dry environment.
Tennis elbow, also known as lateral epicondylitis, is an inflammation of the tendons on the outside of the elbow caused by repetitive motions like tennis, volleyball, or computer use. It causes pain on the outside of the elbow and weakness when grasping. Resting the elbow and avoiding aggravating activities for 2-3 weeks is the first treatment, along with icing, anti-inflammatory medication, and exercises to maintain flexibility and strength once healing begins.
1. The document defines normal human gait and its components, including gait terminology, the gait cycle, and muscle actions during stance and swing phases.
2. Six key determinants that minimize the displacement of the center of gravity during gait are described: pelvic rotation, pelvic tilt, knee flexion, ankle dorsiflexion/plantarflexion, step width, and arm swinging.
3. Methods for analyzing gait such as observational, photographic, force plate, electromyography, and energetics studies are outlined. Common pathological gaits and their causes are also listed.
This document provides information on ankylosing spondylitis (AS), including its etiology, pathogenesis, pathology, symptoms, tests, treatment, and physiotherapy management. AS is an inflammatory arthritis that primarily affects the axial skeleton. It has unknown cause but is associated with the genetic marker HLA-B27 in most cases. Symptoms begin with pain in the sacroiliac region and lower back and can progress to fusion of the vertebrae. Treatments include medications like NSAIDs and TNF inhibitors, as well as regular physiotherapy focusing on exercises, hydrotherapy, electrotherapy, and education to maintain mobility and function.
This document discusses Sudeck's osteodystrophy, also known as complex regional pain syndrome (CRPS). It defines CRPS as a chronic progressive disease characterized by disproportionate regional pain and abnormalities in sensory, motor, and autonomic nervous system function. It describes three stages of CRPS based on dystrophic and atrophic changes. Treatment involves prevention, non-operative approaches like physical therapy, nerve stimulation, nerve blockade, and in some cases surgical sympathectomy. The goal is to reduce pain and limit progression of the chronic condition.
This document provides information on peripheral nerve injuries, including the structure of nerves, classifications of nerve injuries, common sites of injury for specific nerves like the ulnar and radial nerves, clinical features of injuries, and treatment approaches. It details Seddon's and Sunderland's classifications of nerve injuries, which range from neurapraxia to neurotmesis depending on the severity of axonal and neural sheath damage. Specific injuries like ulnar nerve entrapment at the elbow or Guyon's canal are discussed. Both non-surgical and surgical treatment options are presented.
This document discusses Thyroid Eye Disease (TED), a common orbital disorder associated with thyroid dysfunction. It covers the epidemiology, pathology, clinical features, evaluation, and management of TED. Some key points:
- TED is an autoimmune condition causing inflammation and swelling of extraocular muscles and orbital tissues. It is seen in Graves' disease and Hashimoto's thyroiditis.
- Symptoms include eye irritation, bulging eyes (proptosis), and impaired eye movement. Signs include eyelid retraction, proptosis, and restrictive extraocular muscle involvement.
- Evaluation involves assessing thyroid function and signs of orbital involvement. Severity is classified using Werner's or EUGO
This document provides information on disabilities and deformities that can occur in leprosy patients. It discusses terminology used to describe impairments, deformities, and defects. It outlines risk factors for deformities and describes specific, paralytic, and anesthetic deformities that can arise. The WHO classification system for grading impairments in hands/feet and eyes is presented. Details are given on nerve involvement in leprosy and management of neuritis. Common problems in hands like ulcers and deformities are covered, along with foot issues like ulcers and drop foot. Management of various deformities affecting face and eyes is summarized. The GPAS scale for assessing daily activities is briefly described, and economic rehabilitation is mentioned.
This document discusses foot drop, which is the inability to lift the front part of the foot. It can be caused by nerve injuries, neurological conditions, muscle weakness, or injuries. Symptoms include difficulty lifting the foot and dragging it when walking. Treatment depends on the underlying cause but may include bracing, physical therapy, nerve stimulation, or surgery to repair nerves or transfer tendons.
Disabilities and deformities in leprosy patients and managementdalal8
This document discusses disabilities and deformities that can occur in leprosy patients. It defines key terms like impairments, deformities, and defects. It describes risk factors for deformities like type and extent of leprosy, number of involved nerves, and duration of untreated disease. Common types of deformities are specific deformities from local infection and paralytic or anesthetic deformities from nerve damage. Nerve involvement is discussed, including the stages of involvement and commonly affected nerves. Guidelines are provided for managing nerve damage, neuritis, and abscesses. Common hand problems in leprosy patients are also summarized.
Cranial nerve assessment..Simple and Easy to perform for medics and Physiothe...pawan1physiotherapy
Cranial Nerve Assessment is a crucial step in neurological assessment. By following the simple theoretical aspects it can be made on your fingertips....here is an try to make the stuff easier for you....
This document provides an overview of leprosy (Hansen's disease), including:
- It is caused by Mycobacterium leprae bacteria and primarily affects the nerves and skin.
- Symptoms include discolored skin lesions and loss of sensation which can lead to injuries.
- It is classified based on severity and can be diagnosed via skin biopsy or smear.
- Treatment involves long-term multi-drug antibiotic regimens.
- Surgical procedures and orthotic devices can help address deformities caused by nerve damage.
The document provides information about ulnar nerve injury, including its course through the upper limb, branches and sensory/motor supply. Causes of injury include compression at sites like the elbow (cubital tunnel syndrome) and wrist (Guyon's canal syndrome). Signs and symptoms involve sensory loss and weakness of hand muscles. Clinical tests assess functions like pinching. Investigations include EMG, nerve conduction studies and imaging. Claw hand deformity can occur with severe ulnar nerve injury.
This document provides information on periarthritis shoulder (PA) and adhesive capsulitis/frozen shoulder (FS). It discusses the anatomy of the shoulder joint and describes PA and FS as conditions characterized by pain and progressive limitation of shoulder movement. It outlines the typical stages of FS, risk factors, clinical features, investigations, and management approaches. Management involves a multimodal approach including medications like NSAIDs, physical therapy focusing on range of motion exercises and strengthening, and in severe cases joint injections or surgery.
This document provides information about poliomyelitis (polio), including:
- Polio is caused by poliovirus and mainly affects children, causing paralysis in rare cases.
- It was first described in the late 1700s and caused epidemics in the late 1800s.
- The virus infects the intestine and can invade the nervous system, destroying motor neurons and causing muscle weakness or paralysis.
- Types of polio include spinal and bulbar polio, affecting different areas of the spinal cord or brainstem.
- Treatment focuses on rest, physiotherapy, orthotics, tendon transfers and arthrodesis to correct deformities from muscle imbalances.
This document summarizes photochemotherapy with psoralens, also known as PUVA therapy. PUVA therapy combines the use of oral or topical psoralens followed by exposure to ultraviolet A radiation. It results in beneficial therapeutic effects for conditions like psoriasis through controlled phototoxic reactions. The document describes the types of psoralens used, pharmacokinetics, dosing, administration methods like baths or soaks, indications, contraindications, and combination therapies for PUVA.
The document discusses using Z-plasty techniques to treat post-burn scar contractures and pilonidal sinus. Z-plasty involves reorienting scar tissue to lengthen it and correct deformities. The author describes using Z-plasty on 10 cases of scar contractures and 5 cases of pilonidal sinus. It resulted in scar lengthening and zero recurrence of pilonidal sinus with less hospital stay compared to other techniques. The document concludes that Z-plasty is a versatile technique for general surgeons to manage linear scar contractures and pilonidal disease.
Nerve conduction studies test the function of motor and sensory nerves by measuring nerve conduction velocity. Small electrical stimuli are applied to nerves while recordings are made from muscles. Abnormalities may indicate conditions like peripheral neuropathy or radiculopathy. The test evaluates nerves like the median and ulnar nerves and can help diagnose disorders affecting the peripheral nervous system.
The document provides information on performing a sensory examination, including testing superficial sensations like pain, temperature, and touch. It also describes evaluating deep sensations such as proprioception, vibration, and kinesthesia. Finally, it discusses assessing combined cortical sensations including stereognosis, graphesthesia, and two-point discrimination. The examination involves testing various areas of the body using specific tools and techniques, and having the patient respond verbally or by physical demonstration to identify sensations.
This document summarizes fluidotherapy, a dry heating modality. It transfers heat to the body through convection using a cabinet containing heated air and finely ground cellulose particles. This creates a fluid-like medium allowing limbs to float and exercises to be performed. Key effects include increased blood flow, pain relief and improved range of motion. It is used to treat distal extremities for conditions like pain, swelling and post-operative rehabilitation. Contraindications include fever, anesthesia or severe circulatory issues. Advantages include ease of use and allowing some active exercise in a comfortable, dry environment.
Tennis elbow, also known as lateral epicondylitis, is an inflammation of the tendons on the outside of the elbow caused by repetitive motions like tennis, volleyball, or computer use. It causes pain on the outside of the elbow and weakness when grasping. Resting the elbow and avoiding aggravating activities for 2-3 weeks is the first treatment, along with icing, anti-inflammatory medication, and exercises to maintain flexibility and strength once healing begins.
1. The document defines normal human gait and its components, including gait terminology, the gait cycle, and muscle actions during stance and swing phases.
2. Six key determinants that minimize the displacement of the center of gravity during gait are described: pelvic rotation, pelvic tilt, knee flexion, ankle dorsiflexion/plantarflexion, step width, and arm swinging.
3. Methods for analyzing gait such as observational, photographic, force plate, electromyography, and energetics studies are outlined. Common pathological gaits and their causes are also listed.
This document provides information on ankylosing spondylitis (AS), including its etiology, pathogenesis, pathology, symptoms, tests, treatment, and physiotherapy management. AS is an inflammatory arthritis that primarily affects the axial skeleton. It has unknown cause but is associated with the genetic marker HLA-B27 in most cases. Symptoms begin with pain in the sacroiliac region and lower back and can progress to fusion of the vertebrae. Treatments include medications like NSAIDs and TNF inhibitors, as well as regular physiotherapy focusing on exercises, hydrotherapy, electrotherapy, and education to maintain mobility and function.
This document discusses Sudeck's osteodystrophy, also known as complex regional pain syndrome (CRPS). It defines CRPS as a chronic progressive disease characterized by disproportionate regional pain and abnormalities in sensory, motor, and autonomic nervous system function. It describes three stages of CRPS based on dystrophic and atrophic changes. Treatment involves prevention, non-operative approaches like physical therapy, nerve stimulation, nerve blockade, and in some cases surgical sympathectomy. The goal is to reduce pain and limit progression of the chronic condition.
This document provides information on peripheral nerve injuries, including the structure of nerves, classifications of nerve injuries, common sites of injury for specific nerves like the ulnar and radial nerves, clinical features of injuries, and treatment approaches. It details Seddon's and Sunderland's classifications of nerve injuries, which range from neurapraxia to neurotmesis depending on the severity of axonal and neural sheath damage. Specific injuries like ulnar nerve entrapment at the elbow or Guyon's canal are discussed. Both non-surgical and surgical treatment options are presented.
This document discusses Thyroid Eye Disease (TED), a common orbital disorder associated with thyroid dysfunction. It covers the epidemiology, pathology, clinical features, evaluation, and management of TED. Some key points:
- TED is an autoimmune condition causing inflammation and swelling of extraocular muscles and orbital tissues. It is seen in Graves' disease and Hashimoto's thyroiditis.
- Symptoms include eye irritation, bulging eyes (proptosis), and impaired eye movement. Signs include eyelid retraction, proptosis, and restrictive extraocular muscle involvement.
- Evaluation involves assessing thyroid function and signs of orbital involvement. Severity is classified using Werner's or EUGO
This document provides information on disabilities and deformities that can occur in leprosy patients. It discusses terminology used to describe impairments, deformities, and defects. It outlines risk factors for deformities and describes specific, paralytic, and anesthetic deformities that can arise. The WHO classification system for grading impairments in hands/feet and eyes is presented. Details are given on nerve involvement in leprosy and management of neuritis. Common problems in hands like ulcers and deformities are covered, along with foot issues like ulcers and drop foot. Management of various deformities affecting face and eyes is summarized. The GPAS scale for assessing daily activities is briefly described, and economic rehabilitation is mentioned.
Leprosy is a chronic infectious disease caused by Mycobacterium leprae bacteria. It primarily affects the skin and nerves. There are three main types - tuberculoid, lepromatous, and borderline. Symptoms include pale skin lesions and numbness or damage to nerves. Diagnosis involves clinical examination, slit skin smears, and biopsies. Treatment involves multidrug therapy over 6-12 months depending on type. Complications include reactions and disability from nerve damage. Prevention focuses on early detection and treatment to limit transmission and disability. Rehabilitation aims to reduce disability impacts and promote independence.
COMPLICATIONS OF LEPROSY & ITS MANAGEMENTKushal kumar
This document discusses leprosy (Hansen's disease), including its types, symptoms, complications, treatment, and rehabilitation. It covers the types of leprosy reactions (Type I and II), as well as the specific reaction erythema nodosum leprosum. Disabilities caused by leprosy are described, including paralytic deformities and anesthetic deformities. The adverse effects of anti-leprotic drugs are listed. It also summarizes the milestones of India's National Leprosy Eradication Program and concludes by stating that modern medicine has cured most of the world of leprosy, though it remains a problem in some undeveloped countries.
This document discusses Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and erythema multiforme (EM). It defines SJS and TEN as rare, life-threatening diseases caused by extensive keratinocyte cell death. SJS is distinguished from TEN based on the extent of epidermal detachment. The document outlines risk factors, pathogenesis, clinical features, investigations, differential diagnosis, management including wound care, and complications of SJS, TEN and EM. Management involves discontinuing causative drugs, fluid and electrolyte replacement, nutritional support, wound dressing, and in some cases corticosteroids, cyclosporine or IV immunoglobulins. Progn
carpal tunnel syndrome and dupuytren diseaserohit raj
The document discusses carpal tunnel syndrome and Dupuytren's disease. It defines the conditions, describes the anatomy involved, and discusses causes, clinical presentation, diagnostic tests, and treatment options. For carpal tunnel syndrome, it notes the median nerve is compressed in the carpal tunnel. For Dupuytren's disease, it indicates involvement most commonly occurs in the ring finger due to thickening of the palmar fascia. Surgical treatments for both conditions include open or endoscopic release of compressed structures.
This document summarizes carpal tunnel syndrome (CTS), including its anatomy, pathogenesis, etiology, symptoms, clinical tests, treatments, and other related topics. It describes how CTS is caused by compression of the median nerve as it passes through the carpal tunnel. Common causes include repetitive hand motions, anatomical abnormalities, medical conditions like diabetes or hypothyroidism. Clinical tests for diagnosing CTS include Phalen's test and Tinel's sign. Treatments may involve splinting, corticosteroid injections, surgery such as open or endoscopic carpal tunnel release. De Quervain's tenosynovitis and tuberculous tenosynovitis are also summarized.
This document discusses Graves' disease and its management. Some key points:
- Graves' disease most commonly affects females ages 40-44 and males ages 45-49. Symptoms include eye protrusion, double vision, and eye pain or pressure.
- Assessment involves measuring eye protrusion, eye muscle function and signs of inflammation. Disease severity is classified as mild, moderate or severe.
- Treatment depends on severity but may include anti-thyroid medications, steroids, radiation therapy, surgery to decompress the orbit or correct eye muscle imbalances, and eyelid surgery.
- Management aims to control thyroid function, reduce inflammation and symptoms, and correct structural issues like eye protrusion and double vision. Care must
This presentation describes all clinical aspects about primary open angle glaucoma ......
you can watch the illustrated video presentation at the following link : https://youtu.be/eA44Pu4l8Ow
This document presents a case report of a 57-year-old male who presented with sudden painless diminution of vision in his right eye for 2 days and gradual vision loss in both eyes over the past 12-13 days. His medical history includes hypertension and recently diagnosed diabetes. On examination, he was found to have a non-ischemic central retinal vein occlusion in both eyes with macular edema in his right eye. He received intravitreal injections of bevacizumab and was advised to follow up in 1 month. At follow up visits, his vision improved and macular edema resolved with further injections. He was advised to continue regular follow ups to monitor for complications.
This case involves a 57-year-old male with newly diagnosed multiple myeloma. He was started on induction therapy with bortezomib, lenalidomide and dexamethasone. After developing neuropathy and thrombocytopenia, his doses were adjusted according to guidelines. An autologous stem cell transplant was performed after successful harvest with cyclophosphamide mobilization. He was then maintained on lenalidomide. Over time, he developed complications including renal impairment, osteonecrosis of the jaw, and a secondary head and neck tumor, requiring adjustments to his therapy. Upon confirmed relapse, the best next treatment option presented is to restart lenalidomide at 10mg daily.
1) Diabetic peripheral neuropathy (DPN) affects around 70% of diabetics and can lead to foot ulcers and amputation. Symptoms include neuropathic pain, numbness, and autonomic dysfunction.
2) DPN results from damage to small and large nerve fibers caused by hyperglycemia. Clinical tests assess sensation of touch, vibration, temperature.
3) Treatment focuses on pain management with pregabalin, duloxetine, or tapentadol, as well as glycemic control and vitamins B1, B6, and B12 to aid nerve regeneration. The goals are symptomatic relief and halting nerve damage progression.
This 55-year-old diabetic man likely has carpal tunnel syndrome (CTS) involving the median nerve. He presents with sensory loss in the lateral 3 1/2 fingers and thenar wasting, indicating stage IV disease. Provocative tests like Phalen's and Tinel's signs would help diagnose CTS. Given the advanced stage, he requires surgical release of the transverse carpal ligament to decompress the median nerve.
Thyroid eye disease (TED) is an autoimmune inflammatory disorder affecting the eye muscles and surrounding tissues. It is commonly associated with Graves' disease. Symptoms include eye pain, swelling of eyelids, and issues with eye movement. Examination may reveal eyelid retraction, proptosis, and restrictive myopathy. Management involves medications like steroids to reduce inflammation during active phases, with surgery to correct eye muscle issues and proptosis during inactive phases. The goal is to improve symptoms, eye health, and appearance.
1) Systemic sclerosis is a disorder of connective tissue that causes hardening and tightening of the skin. It occurs more often in females and peaks between ages 40-50.
2) There are two main types: limited cutaneous which mainly affects the skin, and diffuse cutaneous which has more severe internal organ involvement.
3) Symptoms include thickened skin, especially on the hands, as well as Raynaud's phenomenon and potential lung, heart, kidney, or gastrointestinal complications. Management focuses on treating specific organ involvement and symptoms.
TED (thyroid eye disease) or Graves' ophthalmopathy is an autoimmune disorder where the eyes and area around the eyes become inflamed and swollen. It is commonly associated with Graves' hyperthyroidism but can also occur in euthyroid or hypothyroid patients. Common symptoms include eye dryness, pain, and bulging of the eyes. Signs include eyelid retraction, muscle weakness, and in severe cases, optic nerve compression. Treatment involves supportive care, medications like steroids to reduce inflammation, and in some cases orbital decompression surgery or eye muscle surgery to correct muscle weakness and eye alignment issues.
Complex Regional Pain Syndrome and other pain syndromes tulsimd
A 35-year-old woman complains of burning pain in her left arm and hand for 6 months following a wrist sprain while playing volleyball. Her left hand is colder than the right and her fingertips are blue. She meets criteria for complex regional pain syndrome (CRPS), which causes continuing pain disproportionate to any injury along with changes to skin temperature, color, and swelling. CRPS is diagnosed using Budapest criteria and treated with a multidisciplinary approach including medications, nerve blocks, psychotherapy, and physical rehabilitation.
A 60-year-old woman presented with painful, sclerotic hands and fingers due to progressive cutaneous scleroderma. She was started on a compounded topical cream containing ketamine, baclofen, gabapentin, verapamil, and pentoxifylline, which provided significant pain relief and improved sensation within a month. At a 6-month follow up, she had been largely weaned off opioid pain medications. The customized treatment targeted the pathophysiology of the condition and helped manage her debilitating symptoms.
The document discusses several neuromuscular disorders including cerebrovascular accident, epilepsy, Bell's palsy, Parkinson's disease, and multiple sclerosis. It covers the etiology, clinical presentation, investigations, management, and dental considerations for treating patients with these conditions. Special precautions are needed during dental procedures to minimize stress and prevent injury due to issues like paralysis, seizures, tremors, spasticity, and altered sensation or swallowing.
Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Osteoporosis - Definition , Evaluation and Management .pdfJim Jacob Roy
Osteoporosis is an increasing cause of morbidity among the elderly.
In this document , a brief outline of osteoporosis is given , including the risk factors of osteoporosis fractures , the indications for testing bone mineral density and the management of osteoporosis
These lecture slides, by Dr Sidra Arshad, offer a simplified look into the mechanisms involved in the regulation of respiration:
Learning objectives:
1. Describe the organisation of respiratory center
2. Describe the nervous control of inspiration and respiratory rhythm
3. Describe the functions of the dorsal and respiratory groups of neurons
4. Describe the influences of the Pneumotaxic and Apneustic centers
5. Explain the role of Hering-Breur inflation reflex in regulation of inspiration
6. Explain the role of central chemoreceptors in regulation of respiration
7. Explain the role of peripheral chemoreceptors in regulation of respiration
8. Explain the regulation of respiration during exercise
9. Integrate the respiratory regulatory mechanisms
10. Describe the Cheyne-Stokes breathing
Study Resources:
1. Chapter 42, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 36, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 13, Human Physiology by Lauralee Sherwood, 9th edition
One health condition that is becoming more common day by day is diabetes.
According to research conducted by the National Family Health Survey of India, diabetic cases show a projection which might increase to 10.4% by 2030.
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1. "Leprosy work is not merely medical relief; it is transforming frustration of life into joy
of dedication, personal ambition into selfless service"
Mahatma Gandhi
3. History of Leprosy
• 1893: Doctor Armaur Hansen of Norway discovers
M. Leprae bacilli
• 1950s: Doctors begin using Dapsone to treat
leprosy
• Since 1982, Multi-Drug Therapy has made a
huge impact
4. Epidemiology
• 80% of the worldwide cases are found in five
countries, namely India, Mynamar,
Indonesia, Brazil and Nigeria.
5.2 million in 1985
8.05lakhs in 1995
7.53lakh at the
end of 1999
2.13lakhs in 2008
6. WORLD STATUS
• Elimination of leprosy as a public health
problem is defined as a prevalence rate of less
than one case per 10,000 persons.
• Use of MDT reduced the disease burden
dramatically.
7. INDIA
• 4,00,000 new cases per year
• The prevalence of leprosy - 52 per 10,000 in
1981 to 2.4 per 10,000 in July 2004.
• No primary prevention
• MDT is the only intervention
• July 2004 - 2.4 lakhs leprosy cases on record
8. LEPROSY
• A chronic infectious disease of the peripheral nerve,
skin, and mucus membrane of URT
• Cause - Mycobacterium leprae
and M. lepromatosis
• An intracellular, acid fast bacterium , is aerobic and
rod-shaped.
Every year January 27 is World Leprosy Day
9. Mode of infection
• Human-to-human via nasal discharge (droplet
infection )
• Three other species can carry and (rarely)
transfer M. leprae to humans: chimpanzees,
mangabey monkeys, and nine-banded
armadillos.
10. OTHER MODES OF TRANSMISSIONS
1. Contact through the skin (rare).
2. Arthropod-born infection (rare).
3. Through placenta and milk.
11. Signs and Symptoms
First symptoms :
Numbness
loss of temperature sensation
As the disease progresses :
The sensations of touch
Pain
Eventually deep pressure are
decreased or lost.
15. Indeterminate leprosy :Hypopigmented patch, sensation normal, no
palpable peripheral nerve and slit skin smear negative.
Indeterminate Leprosy (IL)
16. Tuberculoid leprosy: Two hypopigmented patches, hypoasthetic
well defined borders, palpable peripheral nerve and SSS negative.
Tuberculoid Leprosy (TL)
29. DEFINITIONS
IMPAIRMENT : The loss/ abnormality of the
anatomical / physiological , structure/function.
DEFORMITY : Visible alteration in the form, shape
or appearance of the body due to impairment
produced by the disease.
DISABILITY : Lack of ability to perform an activity
considered normal for a human being.
30. DISABILITIES
▫ Late diagnosis and late treatment with MDT
▫ Advanced disease (MB leprosy)
▫ Leprosy reactions which involve nerves
▫ Lack of information on how to protect insensitive
parts
Only about 10-15% of leprosy affected person
develop significant deformities and disabilities.
31. 1) SPECIFIC DEFORMITIES:
▫ Local infection with
M.Leprae
▫ Most often in the face -
facies leprosa
▫ Less often in the hand and
only occassionly in the
feet.
32. 2) Paralytic deformities:
• Due to damage to motor
nerve
• Most often in the hand(claw
finger)
• Less often in the feet
• Occassionly in the face
(lagopthalomos, facial palsy)
33. 3)Anesthetic deformity :
- Occur as a consequence of neglected
injuries
- in part rendered insensitive b/c of
damage to sensory nerve.
- Found most often on the feet and
hand(ulceration, scar contrature,
shortening of digits & skeletal
disorganization of foot)
34. WHO Grade 0 Grade 1 Grade 2
EYES Normal vision,
lid gap &
blinking.
Corneal reflex
weak
Reduced vision
Lagophthalmos
HANDS Normal
sensation &
m.power.
Loss of feeling
in the palm
Visible damage
i)wounds
ii)claw hand
iii)Loss of tissue
FEET Normal
sensation &
m.power.
Loss of feeling
in the sole
Visible damage
i)wound
ii)foot drop
iii)loss of tissue.
35. Peripheral nerves
Sensory Motor Autonomic
Hypoaesthesia/
anaesthesia
Muscle
paralysis
Lack of sweating &
sebum
Ulcers Ulnar nerve Claw hand
Radial nerve Wrist drop
Lt. popliteal Foot drop
Post. tibial Claw toes
Facial n lagophthalmous
Dry skin
Cracked skin
Ulcers
36. RECONSTRUCTIVE SURGERY
Aims:
• Restore function and form as far as possible
• Prevent further disability
• Rehabilitation process.
Note: Not all patients are suitable.
37. • The reconstructive possible for:
▫ Lagophthalmos
▫ Foot-drop
▫ Ulnar/median paralysis (fingers and thumb)
▫ Collapsed nose
Successful outcome depends on
• Pre and post-operative physiotherapy
• Ability of patients to learn to use new ability
38. CRITERIA FOR REFERRAL FOR RCS
Criteria have been grouped into three categories:
• Social and motivation
• Physical
• Leprosy treatment
39. SOCIALAND MOTIVATIONALCRITERIA
• Patients who benefit socially, occupationally or
economically
• Potential to make a difference to patients’acceptance in
their society
• Patients must be well motivated for their own health and
follow instructions
• The surgery involves loss of economic activity for a
period of several months.
40. PHYSICAL CRITERIA:
• Age: 15 -45 years
• Duration of muscle paralysis -at least one year and
preferably not longer than 3 years.
• Suppleness of the joints
• Physiotherapy or surgery can reverse some
contractures
• No infection of the skin
41. LEPROSY TREATMENT CRITERIA
• Completed the scheduled course of MDT or at least for 6
months
• Free from reactions and symptomatic neuritis for at least
6 months.
• Should not have had lepra reaction during the past 6
months unless the surgery is for neuritis.
• No tenderness of any major nerve trunk in the limbs.
42. 𝑪𝒐𝒏𝒅𝒊𝒕𝒊𝒐𝒏𝒔 𝒕𝒉𝒂𝒕 𝒓𝒆𝒒𝒖𝒊𝒓𝒆 𝒔𝒖𝒓𝒈𝒊𝒄𝒂𝒍 𝒊𝒏𝒕𝒆𝒓𝒗𝒆𝒏𝒕𝒊𝒐𝒏:
IRREVERSIBLE CLAW HAND Ulnar / median paralysis
FOOT DROP Lateral popliteal nerve
CLAW TOES Posterior tibial nerve
LAGOPHTHALMOS Facial nerve.
Irrespective of age lid gap (>6mm)
WRIST DROP Radial nerve
RECURRENT WOUNDS OF HANDS AND
FEET
Sequestrum removal.
CATARACT Cataract in one or both eyes with
Visual acuity < 6/60
GYNAECOMASTIA Testicular and liver damage
MADROSIS Graft from scalp or temporal artery
island flap
SAGGING OF FACE/ MEGA LOBULE Destruction of elastic/ collagen fibres in
dermis
NASAL DEFORMITY Invasion and destruction of nasal tissue
especially nasal septum.
43. PRIORITIES for reconstructive surgery
• High priority - Lagophthalmos
• Feet are usually considered the next priority
followed by hands
• Surgery is most beneficial - when the disease is
stable, MDT is established, and the muscle
paralysis is not likely to progress or to recover.
45. Involvment of the ophthalmic division of the (5th.) trigeminal nerve
Corneal sensation imparment
Patients ignore injuries
keratitis, conjunctivitis and ulcers
Involvment of zygomatic & temporal braches of the (7th.) facial nerve.
Lagophthalmos
Unable to close the eye (unblinking stare)
46. How is lagophthalmos assessed?
• Observe the Frequency and Extent of
Blinking
• Ask the Patient to Close the Eyes 'As in
Sleep'
• Ask the Patient to Close the Eyes Tightly
47. • Duration of lagophthalmos ≤ 6 months:
prednisolone 40mg/day slowly reducing over
12 weeks
• Duration of lagophthalmos > 6 months with
eyelid gap < 6 mm: Conservative treatment,
e.g. sunglasses, 'think blink‘
• Duration of lagophthalmos > 6 months with
eyelid gap ≥ 6 mm: eyelid surgery
55. FOOT DROP
• Due to damage of common peroneal nerve
• Paralysis for more than six months to one year-
corrective surgery is advised.
• Orthotic device - Short leg iron with a foot-drop stop
• Stretching exercises - To prevent shortening of the
Tendo- Achilles.
56. Diagnosis
• High stepping gait
• Sitting on a high stool with the leg hanging down
free - unable to lift the foot
Aim of surgery
• To restore active dorsiflexion of the foot.
• By Tibialis posterior transfer
57. PREREQUISITES
• Foot fitness for corrective surgery
• Foot fitness for Tibialis posterior transfer
• Functioning of Peroneus muscle
• Check for tightness of tendo Achilles
• Teach the patient isolated contraction of
the Tibialis posterior muscle
61. Post-operative management
• Limb elevation for 72 hours
• Walking heel is given on fourth day
• Follow up after 3 weeks
• Physical therapy and exercises for re-educating
the transferred muscle are then started
62. Re-education exercises
First week Patient practices contracting the
Tibialis posterior muscle, with gravity
eliminated
Second week Patient does exercises against gravity
Third week Patient starts standing and then
walking in a walkway with parallel
bars for support and partially bearing
weight on the foot.
Fourth week Patient is allowed full weight-bearing
and practises walking with a ‘heel to
toe’ gait without support
63. Transfer of the Peroneous longus
tendon to the toe extensors
• Paralysis of only the anterior group of muscles
(dorsiflexors) and the peroneal muscles are of
normal strength
• Tendon of Peroneus longus is tranferred to
restore dorsiflexion of the foot.
66. Complications
• Infection
• Adhesion
• Tension of the transferred tendon may be unequal
• Post-operative inversion/eversion deformities of the foot
• The Tibialis posterior may have become paralysed -
Medial popliteal neuritis.
70. Types of claw hand
• Complete : Involving all digits and resulting from
combined Ulnar and Median Nerve palsy
• Incomplete : Involving only ulnar 2 digits as in
isolated Ulnar Nerve palsy
71. Modified Bunnell’s procedureFirst week
Flexing the PIP joint of the middle finger in
isolation and ALL the fingers would be now
flexing at the MCP joints.
Second week
Fingers should attain the 'intrinsic' position
(MCP joints in flexion and IP joints in
extension) by contracting the transferred
muscle
Third week Slow and increasing active flexion of the IP
joints
Fourth week Usage of hand in minor activities of daily
living not requiring much power
75. RADIAL NERVE PALSY
• The patient loses the ability to extend the wrist,
fingers and thumb, movements that are essential
for functional grasp.
• Three main goals when treating radial nerve palsy.
• Restoration of finger (MCPJ) extension,
• Restoration of thumb extension,
• Restoration of wrist extension.
82. 1 Tips of toes 1st and 2nd degree claw deformity of toes
2 Dorsal knuckle of toes Claw toes and friction from uppers of shoes
3 Proximal phalanx of big toe Poor quality of scar
4 Under MTP joints 3rd degree claw-toes deformity, poor quality
of scar
5 Under Ist MTP joint Sesamoiditis, scar adherent to sesamoids,
severe forefoot
deformities, poor quality of scar
6 Middle of sole Tarsal disorganization with collapse of the
longitudinal
arch of the foot
7 Front part of heel Collapse of calcaneum
8 Heel pad Poor quality of scar
Pathology involving calcaneum
9 Sides of the heel Chronic osteitis of calcaneum
10 Over lateral malleolus Chronically infected bursa
Poor quality of scar
84. DEGREE OF DEFORMITY DESCRIPTION
1st degree deformity Deformity is mobile
Toes can be actively straightened
2nd degree deformity Flexion contractures develop at the interphalangeal
joints,esp PIP
Toe cannot be straightened even passively at these
joints
3rd degree deformity Proximal phalanx of the toe gets drawn up
progressively
Gets dislocated and comes to lie on top of the head
of the metatarsal
Tip of the toe does not contact the ground
First degree corrected by transferring the Flexor digitorum
longus tendon to the extensor expansion distal to
the metatarsophalangeal joint
Second degree arthrodesis of the proximal interphalangeal joints
of the toes in the straight position.
Third degree reposition the toes in front of the metatarsals and
retain them there.
TREATMENT
85. SCAR REVISION PROCEDURES
• Scar excision and direct closure
• Closure using local flaps
▫ Rotation flap
▫ Bipedicle flap
▫ Closure with filleted toe flap
86. MEGALOBULE
NASAL DEFORMITY:
• Ant & antero-inferior part is commonly
involved
• Nose loses its mucosal lining and its skeletal
support - ‘SUNKEN NOSE’.
• POST NASAL EPITHELIAL INLAY
GRAFTING OF GILLES
• Elongated ear lobe hangs down lose.
• Corrected by excising the infero-medial segment of
lobule using curved incision(cresent wedge resection)
88. COMMUNITY BASED REHABILITATION
• Aims to overcome activity limitation and
participation restriction and thus improving QOL for
disabled.
89.
90. REFERENCES
• IAL Textbook of LEPROSY by Hemanta Kumar
• Essential Surgery in Leprosy by H Srinivasan
• Campbell’s textbook of Orthopaedics
• Internet
Editor's Notes
Leprosy has existed since biblical times
Once thought hereditary
1893: Doctor Armaur Hansen of Norway discovers M. Leprae bacilli
1950s: Doctors begin using Dapsone to treat leprosy
1982: Leprosy develops resistance to Dapsone; the World Health Organization recommends multi-drug treatment
Leprosy is a disease of developing countries but affects all races.
Registered cases of leprosy have fallen from 5.2 millions worldwide in 1985 to below one million in 1998; and by 2008 it is about 2 lakhs.{WHO}
80% of the worldwide cases are found in five countries, namely India, Mynamar, Indonesia, Brazil and Nigeria.
Elimination of leprosy as a public health problem is defined as a prevalence rate of less than one case per 10,000 persons. The target was achieved on time and the widespread use of MDT reduced the disease burden dramatically.
Every year around 4,00,000 new cases of leprosy occur in India and India contributes about 80% of the global leprosy case load.
The prevalence of leprosy has come down from 52 per 10,000 in 1981 to 2.4 per 10,000 in July 2004.
There is no primary prevention for leprosy.
Multidrug therapy is the only intervention available against the disease.
As of July 2004 there were about 2,40,000 leprosy cases on record in India.
It is a chronic infectious disease of the peripheral nerve, skin, and mucus membrane of the URT(nasal mucosa).
Caused by Mycobacterium leprae and M. lepromatosis
An intracellular, acid fast bacterium , is aerobic and rod-shaped.
Although human-to-human transmission via nasal discharge (droplet infection) is the primary source of infection, three other species can carry and (rarely) transfer M. leprae to humans: chimpanzees, mangabey monkeys, and nine-banded armadillos.
Early signs and symptoms of leprosy are very subtle and occur slowly (usually over years).
First symptoms :
Numbness and loss of temperature sensation (cannot sense very hot or cold temperatures)
As the disease progresses :
The sensations of touch, then pain, and eventually deep pressure are decreased or lost.
Two types of classifications:
Ridley Jopling classification based on Host Immunity
WHO classification based on Bacterial load
Usually a single Hypopigmented macule / patch
Sensation normal
The peripheral nerves normal.
Slit skin smear negative.
Usually single or <5 Hypopigmented patches
Well defined borders.
Sensation markedly imparied.
Enlarged peripheral nerve.
Slit skin smear negative
Borders are well defined, sensory impairment marked and split skin negative to 1+
Satellite lesions are seen
Borders are less defined, sensory impairment moderate and split skin 2+ to 3+
sensory impairment slight and split skin 4+
Very numerous ill defined lesions.
(macules, patches, papules,and nodules).
Symmetrically distributed allover the body
Loss of eyebrows and eyelashes.
No sensory impairments in lesions .
Peripheral nerves symmetrically enlarged.
Slit skin smear always positive.
Clinical Examn – Hypopig patches, loss of senssation and thickened nerves
SSS – from ear lobules, calculate Bactreriological and Morphological indices
Skin Bx- To differentiatebetween Tuber Lepr from Lepro Leprosy
Other drugs
Ethionamide and protionamide
Quinolones
Minocycline
Clarithromycin
1) SPECIFIC DEFORMITIES:
- b/c of local infection with M.Leprae
- seen most often in the face; facies leprosa(loss of eyebrow,nasal deformity), less often in the hand and only occassionly in the feet.
Social and motivational criteria:
•All patients who will benefit socially, occupationally or economically should be considered.
•It should have the potential to make a difference to patients’acceptance in their society and their family and to improve their socio-economic situation.
•Patients must be well motivated to participate in essential pre and postoperative physiotherapy.
•The surgery involves loss of economic activity for a period of several months.
Leprosy treatment criteria
•The patient should’ve completed the scheduled course of MDT OR at least for 6 months
•Free from reactions and symptomatic neuritis for at least 6 months.
•Should not have had lepra reaction during the past 6 months unless the surgery is for neuritis.
•No tenderness of any major nerve trunk in the limbs.
Priorities for reconstructive surgery
Operations for lagophthalmos are usually considered as a high priority because of the possibility of secondary damage to the eye.
Feet are usually considered the next priority followed by hands, but this may depend on the needs of individual patients.
For most patients there is a period of a few years in which surgery is most likely to be beneficial.
It starts when the disease is stable (free of reactions and neuritis), MDT is established, and the muscle paralysis is not likely to progress or to recover.
A hockey-stick incision, in front of the tragus. A skin flap is reflected forwards and downwards exposing the fascia covering the temporalis muscle. (Fig. 2)Two parallel and vertical incisions, are made in the temporalis fascia which are extended upwards for 4 mm. on to the periosteum covering the parietal bone. The inclusion of the periosteal tag is very important as it serves as the common link between the muscle and its fascia. The muscle fibres start from the periosteum and the fascial fibres merge into the periosteum. Therefore, the fascial strip remains attached to the muscle slip through the periosteal tag and does not come off on pulling. (Fig. 3) This portion of the temporalis fascia is freed from the muscle up to the level of periosteum and reflected upwards And split longitudinally into two equal halves (Fig. 4). Two parallel verticle incisions are now made on the muscle deep to the bone along the line of the original fascial incision and the linking periosteum is lifted by blunt dissection (Fig. 5-1) The muscle slip with the strips of fascia attached to it through the periosteal tag is then reflected down (Fig. 5-2). Subcutaneous tunnels are made with closed artery . (Fig. 6)The fascial strips are then taken round the upper and lower lid margins to the medial canthus where they are crossed, and firmly anchored to the medial palpebral ligament by. The patient is told that he will be able to reduce the width of the palpebral fissure still further by clenching his teeth.
Technique:
First determine the length of join required as shown in figure A
After administering an anaesthetic
Incise to a depth of 2 mm along the grey line of outer one third of both lid margins.
Join the two lids by inserting mattress sutures through rubber tubing about 5 mm away from the eyelashes.
These are the pre and post op pictures of lagophthalmos following temporalis muscle transfer.
Foot-drop occurs in leprosy patients because of damage to the common peroneal nerve
When the paralysis has been present for more than six months to one year and when the paralysed anterior and lateral group of leg muscles are severely atrophied, it is taken as irreversible and corrective surgery is advised.
Corrective surgery can be delayed to suit the patient's convenience. In the meantime, an appropriate orthotic device, such as a short leg iron with a foot-drop stop , as well as stretching exercises are given to prevent shortening of the tendo Achilles.
The pt walks with a ‘Hstepping gait
Asking the pt to Sit on a high stool or couch with the leg hanging down free, the patient is unable to lift the foot or toes.
Aim of surgery
The aim of surgery is to restore active dorsiflexion of the foot so that the gait becomes normal.
This is achieved by re-routing the tendon of Tibialis posterior muscle to run in front of the ankle to work as a dorsiflexor
Fitness of foot for corrective surgery
Corrective surgery should not be performed when plantar ulcers or, if tarsal disorganization is present in the affected foot.
Fitness of foot for Tibialis posterior transfer
Tibialis posterior testing done by asking the patient to sit on a stool with the affected leg lying across the opposite thigh with the medial border of the foot facing upwards. Now, ask the patient to lift the foot vertically upwards towards the ceiling
As the foot is being lifted we can see and feel the tendon of Tibialis posterior becoming more
prominent and moving just behind and proximal to the medial malleolus. If the muscle is weak, this operation is contraindicated
Functioning of PERONEUS MUSCLE
Assess the Peroneus longus and brevis by resisting the eversion of the foot.
TPT Need not be done in patients who have paralysis of only the anterior group of muscles (dorsiflexors) and both peroneal muscles (evertors) are normal.
Checking for tightness of tendo Achilles
There is no tightness if the foot makes an angle of 70° or less with the leg
If tightness is present – Lengthening should be done before TPT
Teach the patient isolated contraction of the Tibialis posterior muscle
The procedure is"two tailed transfer of Tibialis posterior tendon to Extensor hallucis (EHL) and digitorum longus (EDL) tendons“
the tendon of Tibialis posterior muscle is detached from its insertion at Navicular bone and brought out through the lower leg incision.
The tendon of Extensor halluc is longus (EHL) & Extensor digitorum longus (EDL) are exposed and
The TP tendon brought out and split into two "tails"
The two tails of TP tendon are re-routed subcutaneously , anterior to the ankle joint and sutured to EHL and EDL tendons resp by Making a slit in the recipient tendon and passing the transferred slip through it.
The foot is carefully bandaged and a below-the-knee POP cast, with the foot in dorsiflexion and neutral version is applied
The leg is kept elevated for 72 hours. On the fourth day, a walking heel is given.
The patient discharged and followed up after 3 weeks
Divide the Peroneus brevis and Peroneus longus close to their insertion.
Now suture the distal stump of Peroneus longus tendon to the Peroneus brevis tendon.
Withdraw the peroneous longus tendon in the leg wound and split it longitudinally into two slips.
The rest of the operation is similar to TPT, except that the route of the new dorsiflexor now is anterolateral and not anteromedial.
Technique
Make a transverse incision to overlie the tendo Achilles, 3 cm above its calcaneal insertion and another similar incision 8 cm more proximally
Through the lower incision cut the medial half of the tendon.
Similarly, cut the lateral half through the upper incision.
Now forcibly dorsiflex the foot up to 70° and the tendon undergoes a Z lengthening.
These are Pre and post op pictures of foot drop of L foot following tib post transfer
Infection
Adhesion of transferred tendon to the adjacent structures
Tension of the transferred tendon may be too loose or too tight
Post-operative inversion/eversion deformities of the foot
The muscle ( Tibialis posterior ) may have become paralysed during the post-operative period when the leg is in POP cast due to Medial popliteal neuritis.
SURGERY Mod Bunnels -The principle - to re-route the Flexor superficialis tendon of one finger to the extensor expansion of the four fingers such that it mimics the paralysed intrinsic muscles
First week
The patient is asked to flex the PIP joint of the middle finger in isolation and ALL the fingers would be now flexing at the MCP joints. The interphalangeal joints are immobilized in extension by individual POP cylindrical splints.
Second week
The same regimen as in the first week is followed except that now the fingers should attaining the 'intrinsic' position (MCP joints in flexion and IP joints in extension) by contracting the transferred muscle. At the end of the week the patient should be able to do this without the use of finger splints.
Third week
Slow and increasing active flexion of the IP joints is now encouraged together with the main movement caused by the transfer.
Fourth week
The regimen is similar to that of the third week except that the patient is now encouraged to use the hand in minor activities of daily living not requiring much power. The patient should not perform heavy work for another two months.
Zancolli lasso insertion technique is indicated in hands with long slender hypermobile fingers showing significant hyperextension at the proximal interphalangeal joint ,in which , if the motor tendon is inserted in the extensor expansion, hyperextension at the PIP joint becomes worse.
Here the FDS is passed through the A1 pulley, then sutured back onto itself, resulting in improved MCPJ flexion while avoiding PIPJ hyperextension.
When only the ulnar nerve is paralysed the Adductor pollicis becomes paralysed giving rise to weakness of grip . Adduction is still carried out using the Extensor pollicis longus muscle. Combined paralysis of ulnar and median nerves results in paralysis of all the small muscles of the thumb, viz., Abductor pollicis brevis, Flexor pollicis brevis, Opponens pollicis and Adductor pollicis. Giving rise to the deformity of "claw thumb"
Superficialis opponensplasty using ring finger FDS can be done for restoration of opposition in low median nerve palsy.
Extensor Indices Proprius opponensplasty can be done for restoration of opposition in high median nerve palsy.
The patient loses the ability to extend the wrist, fingers and thumb, movements that are essential for functional grasp.
There are three main goals when treating radial nerve palsy.
restoration of finger (MCPJ) extension,
restoration of thumb extension,
and in cases of high radial nerve palsy, restoration of wrist extension.
Wrist extension
The most accepted method for restoring wrist extension after high radial nerve injury is the Pronator teres to ECRB transfer.
Thumb extension
For thumb extension,The palmaris longus (PL) or the ring finger flexor digitorum superficialis (FDS) are often used to join with Ext pollicis longus
Finger MCP extension
Finger MCPJ extension can be re-established by transferring the FCR or FCU tendon to the EDC
Bacterial parasitization of peripheral nerves is a unique feature that is characteristic of leprosy. In most instances, the resulting neural lesion remains as a granuloma, but in a few cases the granuloma may soften and develop into an 'abscess.'
Progression to abscess formation is most commonly seen in patients with tuberculoid leprosy. Rarely, may also develop in other types of leprosy
PLANTAR ULCERS (SYN. TROPHIC ULCERS)
They occur mainly because of the repeated stresses generated during walking which destroy the subcutaneous fatty tissue at the stressed sites, with subsequent breakdown of the skin.
often seen in the fore-part of the sole in the metatarsophalangeal joint region .Plantar ulcers are classified as acute and chronic ulcers. Chronic ulcers may be simple or complicated
SIMPLE CHRONIC ULCER -Is an acute ulcer which, under treatment has reached the healing stage; or,chronic non-healing ulcer. Having an hyperkeratotic heaped up margins The floor of the ulcer is made up of pale granulation tissue
COMPLICATED CHRONIC ULCER- Is one which presents with unhealthy granulation and deep sinus tracks leading to an underlying bone, joint or tendon sheath
Treatment- ULCER DEBRIDEMENT, POSTERIOR TIBIAL DECOMPRESSION
Which is done in some patients whose ulcer does not heal readily because of poor blood flow through the foot in whom the posterior tibial artery is the main source of arterial supply which is compressed by the grossly enlarged posterior tibial nerve.
In such cases, decompression of the posterior tibial neurovascular bundle relieves the pressure on the artery, improves the blood flow and brings about the healing of the ulcer.
Damage to Post. Tibial nerve behind ankle in leprosy causes paralysis of the plantar intrinsic muscles
Without which the Ext dig longus and Flex digit long and brevis act unapposed causing Extension of Metatarsophalangeal joint and flexion at Prox and Dist IP joints.
The resulting deformty leads to very high pressures on the tissues under the metatarsophalangeal joint region during walking leading to ulceration