A patient with leprosy can lose the feeling in his hands suddenly during a lepra reaction, so that he complains of an immediate numbness, or so slowly that he hardly notices it. When this happens, neglected bruises, blisters, and cuts cause scars that progressively destroy the pulps of his fingers. Painless cigarette burns are a common presentation. To prevent this happening he must learn how not to injure himself. Persuade him that it is the injury to his hands which leads to wounds, and not the disease itself. If he fails to care for his fingers, and presents you with a severely disabled hand, there is little you can do, except to maintain such mobility as he has with physiotherapy. Patients are usually able to use their deformed hands quite well, and don't like having their fingers amputated.
Tendon transfers and arthrodeses are sometmes helpful, and a Z-plasty can be done to widen the web of the thumb, but these are all expert tasks.
Severe hand infections are common in leprosy patients, and usually present late. You will see abscesses (8.1), osteomyelitis (8.16), tenosynovitis (8.12), and gangrenous fingers.
HANDS [s8]IN LEPROSY Protect a patient's hands during hard work, either by making sure he wears protective gloves, or by adapting the handles of the tools he uses. He is more likely to consent to wear gloves, than to use modified tools. If he smokes (persuade him not to) he must use a cigarette holder. Make sure that his insensitive hands are soaked and oiled in the same way as his feet (30.5).
If the flexor surface of his finger cracks, don't let it heal with a short scar which will be likely to reopen when it is stretched[md]splint it straight while it heals. Use plaster strengthened with a stiff longitudinal wire, or a short length of stiff plastic hose pipe, cut with a tongue which projects into his palm. Observe his finger carefully for blueness. Initially, remove splints at night, until you are sure they are not occluding his circulation.
If the dorsum of his hand is scarred, so that his MP joints become hyperextended, severe disability will result. This can happen as the result of a lepra reaction, when a thick sheet of inflammatory tissue scars and perhaps ulcerates. Put his hand through a full range of movement daily during the reaction to keep it mobile. Later, a skilled surgical release may be possible.
If he has severely deformed finger(s), such as a terminal phalanx bent to 90[de], consider amputation or, better, an arthrodesis with shortening of the bones to allow for the contracted tissue on the front of the joint. If his fifth finger is badly deformed, remove it with half its metacarpal (75- 28). Its absence will hardly be noticed.
If paralysis is acute (within 3 months, and perhaps up to 6 months, but certainly no more), he has probably had a lepra reaction, and so has some hope of recovery. Give him full antileprosy treatment and steroids for 6 to 12 weeks. Splint his hand in the position of function (75.3) at night, and be sure he moves it by day. Ensure that all the joints of his hand are put through their full range daily, using the exercises D, and E, in Fig. 30-3.
If his ulnar nerve is acutely involved, rest his arm in a sling with his elbow at 90[de], and put his whole arm through its full range of motion at least once a day.
If his lumbricals are involved, he is in danger of developing a claw hand, so teach him the exercises in F, and G, Fig. 30-3.
If his median nerve is involved, his thumb web may need stretching. Ask him to grasp the distal end of its metacarpal (not its phalanges), and pull it away from his fingers (not shown).
If paralysis is chronic and slowly progressive, recovery is unlikely, so ask him to do the exercises in Fig. 30-3. A paralysed hand is more useful if it is mobile rather than stiff, and is less likely to be damaged at work.
INFECTIONS [s7]IN LEPROUS HANDS (common) Watch for heat and swelling. Tenderness is often absent and fluctuation is too late to be useful. His first complaint may be painful glands in his axilla. The same principles apply as in normal hands (Chapter 8), with one great difference[md]the pain which prevents a normal person from using his infected hand cannot protect an anaesthetic one. So make sure that a leprosy patient rests his infected hand, and apply a splint to make sure he does. Apply it in the position of safety (75.3) with his MP joints flexed, his IP joints almost fully extended, and his thumb abducted, as if he were holding a tennis ball.
CAUTION ! Antibiotics without rest are a waste of time, money and his fingers!
If infection starts as a macerated skin crease in a paralysed finger, splint it with a posterior splint in just sufficient extension to open out the finger and expose it to the air. If a posterior splint is difficult, use a palmar one. If there is any discharge, give him an antibiotic also.
If you feel rough bone at the base of an ulcer or sinus in his hand, and pus oozes from a joint he has osteomyelitis or septic arthritis (8.15).
If you feel rough bone at the bottom of a sinus over the tip of his finger, he has osteomyelitis of his terminal phalanx. If only part of a phalanx is dead, allow dead bone to separate spontaneously. Otherwise, you are likely to open the joint, and he will lose more finger length. If most of a phalanx is dead, disarticulate the joint and remove the base.
If he has septic arthritis, aim for a fibrous arthrodesis, or a bony ankylosis. Splint his hand and fingers as nearly as possible in the position of function (7.16), and give him an antibiotic. Immobilize his infected joint for at least 4 to 6 weeks after the infection is controlled, and the ulcer healed, while putting all his other joints through their full range of movement daily. If splinting one finger is difficult, you may be justified in splinting it with one of its neighbours (75-14), depending on their condition. Curette dead bone and granulations, and pack the cavity with hypochlorite (''Eusol) or sugar (57.3) to encourage sequestra to discharge and granulations to fill the cavity. An ankylosis usually takes 12 weeks and a fibrous arthrodesis 6 to 8 weeks.
If his septic arthritis does not heal, excise the joint. Make a dorsal incision, remove the joint surfaces, and any dead tissues, and splint the joint in a position of function (75.3). Pack the cavity that remains, and allow it to heal by granulation. Keep the joint splinted in the position of function, and wait 12 weeks for an ankylosis.
If he has septic tenosynovitis, it is likely to be the result of spread from a pulp infection. Splint his hand in the position of function. If drainage is not free make a further opening in his middle palmar crease.
If he has a grossly swollen hand, with pitting oedema of the dorsum, and obliteration of the concavity of his palm, he has a midpalmar space infection[md]see Section 8.9.
Fig. 30-3 HANDS AND FEET IN LEPROSY. A, a patient inspecting his anaesthetic feet to find early wounds and ''hot spots'. He is soaking them, and is about to rub them with oil. The exercises shown here are for acute and chronic paralysis, and will prevent a hand like (B) from becoming a stiff claw hand (C) which physiotherapy cannot cure. Instruct him like this: D, ''[...]rest the back of your hand on your thigh, or on a table padded by a cloth. E, use your other hand to rub your fingers as straight as they will go, taking care not to crack any weak skin. F, cup your knuckle joints in your other palm and keep them firmly bent. G, then straighten the end two joints of your fingers, as firmly as you can. H, and I, use your other hand to straighten the end joint of your thumb, as straight as it will go. Pull gently and firmly, as if you were trying to lengthen your thumb, but don't pull it backwards. J, and K, rest the little finger side of your hand on your thigh. Use your other hand to support the back of your thumb firmly (to keep its MP joint flexed), then straighten the end joint of your thumb as firmly as you can[...]' After Watson Jean M, ''Preventing Disability in Leprosy', The Leprosy Mission International, with kind permission.