Hansens Chronic Polyarthritis in a Child.

BACKGROUND: Musculoskeletal manifestations of leprosy are often underdiagnosed and under-reported. CASE CHARACTERISTICS: An 11-year old girl with leprosy presented with deforming symmetric polyarthritis with raised inflammatory parameters and erosion on imaging. OBSERVATION: The patient was diagnosed to have Hansens chronic polyarthritis and treatment started with non-steroidal anti inflammatory drugs and methotrexate. MESSAGE: Hansen chronic polyarthritis is a rare differential of juvenile chronic arthritis in children.

Correction of the claw hand.

Intrinsic paralysis can be the manifestation of a variety of pathologic entities (stroke, cerebral palsy, Charcot-Marie-Tooth, muscular dystrophy, leprosy, trauma, cervical disease, and compressive and metabolic neuropathies). Patients present with a spectrum of clinical findings dependent on the cause and severity of the disease. The 3 main problems caused by intrinsic weakness of the fingers are clawing with loss of synchronistic finger flexion, inability to abduct/adduct the digits, and weakness of grip. Clawing is defined as hyperextension of the metacarpophalangeal joints and flexion of the interphalangeal joints. This article describes the clinical evaluation and surgical treatment options for claw hand.

Factors affecting functional outcome of surgical correction of claw hand in leprosy.

The objective of this paper is to study the results and the factors that impact the results of claw hand surgery in leprosy. 110 patients who underwent claw hand correction between 2002 and 2006 were followed up and studied. Brand's criteria for objective assessment and a visual analog scale for subjective assessment were used. The factors studied were age, sex, clinical, duration of paralysis, long flexor tightness, degree of contracture and type of surgery. Objective assessment showed Excellent or Good results in 76.6%, Fair in 20% and Poor in 3.4%. Subjective assessment showed that 80.8% were fully satisfied or satisfied. Regression analysis showed that age, degree of contracture,duration of paralysis and long flexor contracture were seen as significant factors impacting results of claw hand correction.

Claw-finger correction in leprosy using half of the flexor digitorum superficialis.

The commonest paralytic deformity in leprosy is the claw deformity of the fingers. Many surgical procedures have been described and are practiced to correct this deformity, but none is free from complications. A modification of the Zancolli lasso operation in which only half of the flexor digitorum superficialis tendon of the middle finger was used as the motor is described and a comparative study of this and the conventional procedure was carried out in 70 hands in 70 patients. The results suggest that the modification is technically simpler, with comparable results to those of the conventional procedure and fewer complications.

Comparative evaluation of effectiveness of different motor muscles in modified lasso procedure for correction of finger clawing.

A retrospective study was carried out to compare the effectiveness of different muscles as motors in modified lasso procedures for correction of finger clawing in leprosy. It was observed that palmaris longus and extensor carpi radialis longus were more suitable than the flexor digitorum superficialis. In some patients, removal of superficialis is associated with complications which could not be predicted before surgery. Extensor carpi radialis longus has advantages over palmaris longus in selected cases.

Surgical reconstruction of irreversible ulnar nerve paralysis in leprosy.

Twenty-five patients with irreversible leprotic ulnar nerve palsy having undergone lumbrical replacement with two different tendon transfer techniques were assessed 6-120 months after surgery. Nineteen patients were reconstructed with the flexor digitorum four-tail procedure (FDS-4T), and six with Zancolli's lasso procedure (ZLP). Mean paralysis times were 103 months for FDS-4T, and 68 months for ZLP. Mean age of the patients was 36 years (21-57). Grip strength measurements, improvement in active range of motion at the PIP joints, patients' ability to open and close their hands fully, as well as sequence of phalangeal flexion, were noted. Mean grip strength measurements during follow-up were 76% of the contralateral extremity in the FDS-4T group and 82% in the ZLP group. Comparison of the follow-up grip strength with the preoperative value revealed 1% improvement in the FDS-4T group and 20% in the ZLP group. Claw hand deformity was completely corrected in 12 patients in FDS-4T group, and in five patients in the ZLP group. Residual flexion contracture remained in five patients after surgery. Swan-neck deformity subsequently developed in seven fingers. Age, sex, mean follow-up and surgical technique did not relate statistically to the functional outcome. However, preoperative extensor lag of the PIP joint and mean paralysis time significantly affected the functional outcome. ZLP was found to be a more effective procedure in restoring grip strength, whereas FDS-4T was more effective in correcting claw hand deformity.

Median nerve palsy following claw finger correction in leprosy: effect of M. leprae or a consequence of surgery.

Median nerve palsy, though not a frequent occurrence after claw finger correction, does exist as a post-operative complication after claw finger correction. A retrospective study was carried out to examine the occurrence of post-operative median palsy, in cases of isolated ulnar palsy, where the transferred motor tendon was routed through the carpal tunnel. We noted that six patients developed median nerve palsy following claw finger correction. Median palsy developed at different times after surgery--the "early onset" type developing within three weeks post-operatively, "reactional" type developed when patient was undergoing physiotherapy exercises and learning to use the transfer and "delayed insidious" type presenting six months or more after operation. We could not succeed to get the true prevalence of such occurrences because all the operated hands could not be re-examined.

Intertester reliability of manual muscle strength testing in leprosy patients.

This study reports the results of a study on the intertester reliability of manual muscle strength testing in leprosy patients with confirmed motor function loss of at least one nerve. Three testers graded the muscle strength of 72 patients in random order. Both hands and feet were graded. Strength was graded on a modified Medical Research Council Scale (9 points, 5, 4+, 4, 3+, 3, 2+, 2, 1, 0). The following movements were tested for strength: little finger and index finger abduction, intrinsic position of all four fingers, thumb abduction and opposition, foot dorsiflexion and eversion and extension of the big toe. The weighted kappa statistic was used to calculate the chance-corrected percentage of agreement between observers. Overall agreement for each of the 11 tests appeared to be good or very good (0.61-1.00). However, when data for hands or feet with normal strength or complete paralysis were excluded from the analysis, the reliability of the remaining mid-range scale was not acceptable (kappa 0.55-0.88, direct agreement range 11-41%). While the reliability of this scale could possibly be improved by special training, we feel that, for the evaluation of nerve function for leprosy patients with (suspected) nerve function loss, the extended 9-point VMT scale should only be used when direct intra- or intertester agreement is more than 80%.

Joshi External Stabilising System (JESS) in proximal interphalangeal joint (PIP) contractures in leprosy.

The authors present their experience in the use of the JESS (Joshi External Stabilising System) for correction of proximal interphalangeal joint (PIP joint) contracture deformity in 68 fingers. The use of the JESS has made this surgery easier, faster in releasing contractures and it has given better correction than the methods so far used by the same authors, like capsulotomy, local flaps and free skin grafting. The procedure is simple and has no serious side effects; it can be repeated if need be. The JESS is easy to apply, economical, reliable, reusable, well accepted by the patient. Compared to the other distractors made in USA and Europe, the JESS has an added advantage in that it costs so very much less (US $5-10), that our leprosy hospitals can afford it. In our patients, we have achieved full extension in 75% and good extension in 10.3% of the cases. These figures are much better than what was possible, in the past, with local flaps and free skin grafting. With those procedures we had excellent results in only 53% of the cases and poor result in 28%.

[The metacarpophalangeal stabilization test and its value in surgery of the leprous hand]. / L'épreuve de stabilisation métacarpo-phalangienne, intérêt en chirurgie de la main lépreuse.

In a claw hand with ulnar-nerve and median-nerve paralysis, if the digits are stabilized to prevent over-extension at the metacarpophalangeal joints, the long extensor alone could fully extend all phalanges. From the proximal interphalangeal stiffness evaluated by this test (on more than 200 claw hands operated on 20 years ago) I propose a simple therapeutic scheme for palliative surgery.

[Volar flexion of the fingers. Its value in diagnosis of leprous paralysis of the intrinsic muscles of the fingers and in the study of the results of palliative interventions]. / La flexion en volet des doigts. Son intérêt dans le diagnostic des paralysies lépreuses des muscles intrinséques des doigts et l'étude des résultats des interventions palliatives.

Active metacarpophalangeal flexion with simultaneous active extension of interphalangeal joints places the fingers in the position in preparation for prehension. This volar flexion of the fingers is due to the action of their intrinsic muscles, and this movement, which is irreplaceable, has been used by the author for the last twenty years as a specific exploratory test of intrinsic finger muscles. It can be investigated as an emergency procedure in cases of ulnar nerve wounds at the elbow or injury to the upper forearm before suture, and clearly demonstrates the presence of an ulnar claw hand. It is a very sensitive test since this position potentiates an ulnar claw hand in its early stage which would have passed unnoticed with fingers extended. This rapid examination is particularly valid during neurologic investigation of the hand in lepers in countries where this disease is endemic, and it forms part of the 10 tests that the author has selected for exploration, within 2 or 3 minutes, in a standing patient, of the facial, ulnar, median, superficial peroneal and posterior tibial nerves. The test is also the most effective evaluation criterion of palliative surgery for claw hand which to be considered as successful must restore volar flexion, as shown by a personal series of over 200 operated hands.

Correction of ulnar claw hand by a loop of flexor digitorum superficialis motor for lumbrical replacement.

The current dynamic procedures for correction of ulnar claw hand are extensor carpi radialis longus many tail graft, palmaris longus four finger many tail graft and extensor by pass operation. Each of these procedures takes a minimum of one and a half hours and needs extensive post operative re-education and training. These procedures employ a graft of plantaris tendon, fascia lata or extensor tendon, with the disadvantages of operating at another site and adhesion of grafts. The procedure described in this article obviates these disadvantages. The operation is simple to perform and has given good results even when performed at leprosy camps where no extensive re-education physiotherapy was available. This operation also tends to correct the reversal of transverse arch. The technique and observations are discussed in detail.

Internal stabilization in the thumb.

An analysis of the thumb as an articular chain, with the biarticular tendon displacement used as a model, is presented. Comparison of the extensor pollicis longus/flexor pollicis longus (EPL/FPL) tendon displacement ratios at the three joints, as determined from cadaver studies, shows that the thumb will be unstable, with a persistent tendency to extend at the carpometacarpal (CMC) joint and flex at the interphalangeal (IP) joint when it is under the exclusive control of the EPL and FPL muscles. In addition, according to the model, with stabilization of the CMC joint, the MCP joint will tend to extend and the IP joint will flex. Clinical data from thumbs of leprosy patients with thenar paralyses largely confirm these predictions and the validity of this approach in studying the functional behavior of the thumb.

The deformity of thumb in ulnar paralysis.

The flexion/extension angles at the Metacarpophalangeal and Interphalangeal joints of the thumb in position of rest and pinch were studied in 68 thumbs of ulnar paralysis. In two thumbs the flexor pollicis brevis was not paralysed. Twenty five normal thumbs were used as controls for comparison. During the resting position the metacarpophalangeal joints showed less flexion and interphalangeal joints more flexion than normal. During the pinch position metacarpophalangeal hyperextension and interphalangeal flexion -- the Z deformity was seen in about 60% while marked interphalangeal flexion was seen in all thumbs of ulnar paralysis. It is suggested that this muscular imbalance is likely to affect thumb joints in time because of abnormal stresses due to altered forces and this can be prevented by restoring the muscle balance by surgery.

Clinical features of paralytic claw fingers.

A study of 221 claw fingers of fifty-one leprosy patients with ulnar or combined ulnar and median-nerve paralysis showed that the severity of the deformity was determined mostly by the completeness of paralysis of intrinsci muscles, and to a lesser extent by the duration of paralysis. There was no predilection for severe deformity in any one finger. Recurrent dislocation of the extensor tendon from the knuckle of the metacarpophalangeal joint was observed mostly in fingers that were completely deprived of all intrinsic muscles. No satisfactory explanation could be found for this. Flexing the wrist facilitated opening of the claw finger, but the effect was more evident at the metacarphophalangeal joint than at the proximal interphalangeal joint.