Lepr Rev (2014) 85, 74 – 80
Reconstructive surgery in children to correct ulnar
claw hand deformity due to leprosy
G MANIVANNAN*, PREMAL DAS**,
G KARTHIKEYAN* & ANNAMMA S JOHN***
*Occupational therapist, TLM Community Hospital Naini,
Allahabad, Uttar Pradesh, India
**Surgeon & Superintendent, TLM Community Hospital Naini,
Allahabad, Uttar Pradesh, India
***Research Co-ordinator, The Leprosy Mission Trust India,
CNI Bhavan, New Delhi, India
Accepted for publication 11 May 2014
Summary
Objectives: To study the impact of tendon transfer surgery for ulnar claw hand
correction in children with leprosy.
Subjects and Methods: All the children who underwent reconstructive surgery
for ulnar nerve paralysis during the period 2007 to 2012 were included in the
study. Unassisted angle, grasp contact, pinch contact and functional assessment
were the main outcome measures. All the surgical procedures were performed by the
same surgeon and pre- and post-operative therapy protocol was same for all the
patients. A common surgical audit form was used to record assessments for all
the patients.
Results: In this case series, 82 hands of 79 patients with ulnar paralysis were
included. All the children had lasso surgery. In 83% of hands, flexor digitorum
superficialis of middle or ringer finger was used, while in the remaining patients
palmaris longus or extensor carpi radialis longus with fascia lata graft was used as
the motor tendon. The unassisted angle decreased in all the patients, indicating
correction of claw fingers. Hand function improved after surgery and it showed steady
progress during follow-up.
Conclusion: The deformity due to leprosy in the hands of children is a tragedy as
it hampers the use of hands in daily routine activities, school work and other
social interactions. Tendon transfer surgery should be done on children to correct
established clawed fingers as it yields good results and helps in facilitating hand
function to complete daily activities and lead a normal life.
Correspondence to: G Manivannan, Occupational Therapist, The Leprosy Mission Hospital, Naini, Allahabad –
211 008, Uttar Pradesh, India (e-mail: manibot_2001@yahoo.com, tlmnaini@tlmindia.org)
74
0305-7518/14/064053+07 $1.00
q Lepra
Reconstructive surgery for leprosy in children
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Introduction
The National Leprosy Elimination Programme (NLEP) 2012-2013 report indicates that
134,752 new cases of leprosy were detected in India during the year. This gives an Annual
New Case Detection Rate (ANCDR) of 10·78 per 100,000 population. The NLEP report also
shows that a total of 13,387 of these were new child cases, giving a Child Case rate of
1·07/100,000 population. The number of new child cases with Grade II disability were 4,650,
which shows the new child disability rate of 3·72/million population.1
Ulnar nerve paralysis is the most common impairment in leprosy causing deformities and
deficiencies which can be identified by specific tests and signs.2,3,4 The pattern observed on
children was similar to the findings of the 2005 study done by Kar et al. in SLR&TC
Karigiri.5 The muscle imbalance that results from ulnar nerve paralysis creates the
characteristic claw hand, due to hyperextension at the metacarpophalangeal (MCP) joints and
flexion at the proximal interphalangeal (PIP) joints.6 As a result, hand function is
compromised and impedes the execution of daily activities.7 The consequence of this easily
visible disability on children would be manifold as it hinders the physical, social and
academic development of the child. The aim of reconstructive surgery on the hand, as in
adults,8,9 is to increase the capabilities of the child for activities of daily living (ADL),
academic development and to restore normality adequately to accelerate the child’s
integration into the school and society.
Lasso surgery for intrinsic replacement, using the Flexor Digitorum Sublimus (FDS) of
the middle or ring finger, the palmaris longus or extensor carpi radialis longus with fascia lata
graft, has been a standard procedure for correcting clawed fingers in leprosy.10,11 To the best
of our knowledge, the benefit of reconstructive surgery on children with deformities of the
hand was not reported earlier. This paper aims to study the impact of tendon transfer to
correct the ulnar claw deformity of leprosy in children.
Methodology
The Leprosy Mission Community Hospital at Naini, Allahabad district in Uttar Pradesh, India
is a Referral Centre for leprosy, recognised by the Government of India and has been
managing leprosy complications since 1876. About 300 tendon transfers for correcting
deformities are done at the hospital each year. The operations are done for established
deformities of longer than 6 months duration. The centre has an excellent medical records
system and each patient has a unique registration number, facilitating the recording of every
detail at baseline and during follow-up. All medical records were computerised in 2007.
All patients less than 14 years of age who underwent claw hand correction during the
period 2007 to 2012 have been included in this study. Patients who had an associated median
nerve deficit were excluded. During this period, a total of 82 claw hand corrections were done
on 79 patients of this group. Apart from basic demographic details and clinical data on
leprosy, the ulnar claw hand was assessed in terms of unassisted angles, grip contact, pinch
contact, functional activities like opening and closing a jar, buttoning big and small sized
buttons, fastening a zip, and simulated counting of money. The unassisted angles were
measured using a standard procedure with a goniometer.
Grip contact measures the number of phalanges in contact with a standard wooden
cylinder; Pinch contact measures the pulp contact of thumb, index and middle finger during
76
G. Manivannan et al.
tripod pinch. Functional activities are assessed by measuring the frequency of performing a
particular task within a fixed time. The results of these assessments are available for preoperative status, after completion of post-op physiotherapy, as well as at a later follow-up.
Associated problems and post-operative complications are also recorded. All the assessments
were done by an Occupational therapist, Physiotherapist or physio-technician, each with
experience in therapy for reconstructive surgery, and were recorded on a surgical audit form.
All surgical procedures were done by the same surgeon. The pre- and post- operative
physiotherapy programs were the same for all patients.
SURGICAL PROCEDURE
The insertion of the tendon slips for lasso is through the a1 and proximal part of a2 (a2A)
pulleys of each of the four digits. This slip is then looped over the pulley and tied to itself with
nylon and sutured with cotton. The motor tendon is usually the flexor digitorum superficialis
(FDS) of the ring finger or middle finger. Less frequently, the palmaris longus (PL) or
extensor carpi radialis longus (ECRL) tendon are used with a facia lata graft.
PRE AND POST-OPERATIVE PHYSIOTHERAPY MANAGEMENT
Pre – operative therapy focuses on teaching isolated contraction of the tendon to be
transferred. The patient is taught active and passive extension exercises of the proximal
interphalangeal joint to make the fingers mobile. Serial cylindrical finger cast, gutter splint,
outrigger splints were applied when required to correct soft tissue contractures.
Post-operatively, a below elbow Plaster of Paris cast is applied which incorporates a
volar slab. This cast is to immobilise the wrist in the neutral position, metacarpophalangeal
joints at 90 degrees and interphalangeal joints straight (lumbrical position). The patient is
discharged on the 3rd post-operative day.
The plaster is removed on the first day of the 4th week. Post-operative re-education is
provided in a staged manner for the next 3 weeks.
During the 4th week, the patient practices the isolated meta-carpophalangeal joint flexion
and extension exercises. The volar slab is retained for night use for the initial 3 days. The
MCP joint full extension is achieved at the end of the 4th week. During the 5th week, flexion
and extension exercises for the proximal and distal interphalangeal joints and grasp activities
are introduced. During the 6th week, the patient has functional training like writing, fine
manipulation, activities of daily living (ADL) and then discharged from therapy.
Results
The age of the children ranged from 7 to 14 years with a mean (SD) age of 12 (2) years and
41% of them were female. The mean (SD) duration of deformity was 17 (10) months.
55 (67%) of them had lasso procedure using the ring finger FDS tendon, 13 (16%) with Middle
finger FDS and 14 (17%) with PL or ECRL tendon with a facia lata graft. Sixty children had
multibacillary leprosy and 22 had paucibacillary leprosy. The mean (SD) follow up was at 2 (1)
months after discharge for the 1st follow up and at 10 (7) months for the final follow up.
Reconstructive surgery for leprosy in children
77
Table 1. Comparison of the Mean (standard deviation) of unassisted angle at different stages of assessment
Angles in degrees
Pre (82)
Index Finger
Middle Finger
Ring Finger
Little Finger
34
37
66
69
(21)
(27)
(29)
(23)
Post (82)
2
2
2
4
1st follow-up (52)
Final follow-up (40)
2 (4)
1 (4)
1 (3)
4 (7)
2 (4)
2 (4)
1 (3)
4 (7)
(5)
(6)
(5)
(7)
The Mean (SD) unassisted angle is shown in Table 1. This shows the correction of the
deformity at the completion of post operative therapy which is maintained at the follow up
assessments.
The impact of duration of deformity on Reconstructive surgery (RCS) outcome is shown
in Table 2. The results of surgery in terms of unassisted angle are better when the duration of
deformity is shorter. In three patients, surgical soft tissue release with full thickness skin graft
of the proximal inter-phalangeal joints for the little finger had to be done. Other secondary
deformities such as hooding (six hands) and long flexor contractures (three hands) were also
prevalent in patients of longer duration of deformity.
The impact of duration of follow-up on outcome of reconstructive surgery is shown in
Table 3. There was no statistical significance of follow-up duration on the unassisted angles.
Table 4 compares the functional improvement of hand before and after surgery. There is
an improvement in performing specific tasks after correction of deformity which improves
further with subsequent follow-ups.
Table 5 shows the impact of age on outcome in terms of unassisted angles. There is no
statistically significant difference between the groups.
Discussion
Development of visible deformity in children due to leprosy is unfortunate, especially
considering that timely intervention can prevent disability.5,12 Children with leprosy often
report late due to a lack of awareness and by then they may have established deformities.
Additionally, children with leprosy are prone to a high risk of developing deformities as
compared to the rest of the population.5,13Although nerve function impairment can be treated
conservatively if detected within 6 months, delay necessitates surgical intervention.
Table 2. Impact of duration of deformity on unassisted angles measured at discharge from post-operative
physiotherapy
Duration of deformity
Angles in degrees
Index finger
Middle finger
Ring finger
Little finger
Average
,1 year (49)
1–2 years (22)
.2 years (11)
P value
2 (5)
2 (6)
1 (3)
2 (4)
1 (4)
2 (5)
1 (2)
2 (3)
6 (8)
3 (3)
2 (5)
4 (9)
6 (12)
10 (14)
5 (9)
1·000
0·374
0·016
0·002
0·026
78
G. Manivannan et al.
Table 3. Impact of duration of follow-up on un-assisted angles
Duration of follow-up
Angles in degrees
Index Finger
Middle Finger
Ring Finger
Little Finger
Average
,6 months (20)
1
1
1
6
2
6–12 months (10)
.12 months (10)
P value
3 (5)
1 (3)
2 (3)
3 (5)
2 (3)
2 (4)
3 (5)
1 (3)
3 (4)
2 (3)
0·398
0·411
0·662
0·426
1·000
(3)
(4)
(3)
(9)
(4)
Reconstructive surgery (RCS) in leprosy has a significant role in restoring normal
appearance and function of the hand in adults,8,10 and can have the same impact on children
by enabling them to live normal lives in the family, school and society. In this study we have
highlighted the effect of RCS on children with established visible deformities in terms of
correction of deformity and improvement of hand function.
In this case series 84% of hands had lasso surgery using FDS of either middle or ring
fingers. The remaining hands had hypermobile proximal inter-phalangeal joints in which
removal of FDS was not favoured as it may cause intrinsic plus deformity.14 Hence, for the
motor tendon, Palmaris Longus (PL) or Extensor Carpi Radialis Longus (ECRL) were used
with a fascia lata graft. The unassisted angle, which indicates inadequate functioning of
lumbricals and interossei supplied by the ulnar nerve, was drastically reduced after post
operative physiotherapy. This enables the patients to straighten their fingers, thus improving
appearance and removing a major contributory factor for stigma.
The assessment includes functional ability of the hand based on sample activities which
incorporates the components of hand functions like grasp, pinch and in-hand manipulation.15
The improvement in these activities can be generalized into daily routine activities. Post
operatively there was improvement in almost all the components evaluated in this study. This
demonstrates that the child can complete daily routine and academic activities without
difficulty after surgery and physiotherapy. Also, it is important that during the third week of
post-operative physiotherapy protocol, therapy related to activities of daily living and writing
tasks be included in occupational therapy to maximise the functional rehabilitation of
the hand.
Pre-operative physiotherapy and splints are essential6 to reduce all the secondary
impairments before being selected for surgery. Among the 82 patients, for three patients the
Table 4. Comparison of the Mean (standard deviation) of functional activities at various stages of assessment
Grasp contact (Number of phalanges touching the object)
Pinch contact (Number of phalanges in contact)
Opening and closing jar (Number of times)
Buttoning –small (Number of times)
Buttoning-big (Number of times)
Fastening Zip (Number of times)
Counting money (Total counted)
Pre Op
(82)
Post Op
(82)
10 (2)
3 (1)
4 (1)
4 (2)
3 (2)
8 (3)
21 (10)
13
3
4
5
4
9
22
(1)
(0·2)
(1)
(2)
(2)
(3)
(9)
First follow-up
(52)
13
3
5
6
4
10
24
(1)
(0·2)
(1)
(2)
(2)
(4)
(10)
Final follow-up
(40)
13 (1)
3 (0·2)
6 (2)
7 (2)
5 (2)
10 (4)
28 (17)
Reconstructive surgery for leprosy in children
79
Table 5. Comparison of unassisted angle at discharge versus age group
Age group in years
Index
Middle
Ring
Little
Average
Less than 10
N ¼ 20
More than 10
N ¼ 62
P value
1 (2)
1 (2)
2 (7)
4 (7)
2 (3)
2 (6)
2 (7)
2 (5)
4 (8)
3 (5)
0·141
0·212
0·878
0·813
0·346
contracture was not released with pre-operative physiotherapy and a surgical release of
proximal inter-phalangeal joint of little finger with skin graft was done along with the lasso
procedure.
There is a general concern that the longer duration of deformity could compromise the
outcome of the results. Therefore, in this study we have divided duration of deformity into
three groups as less than 1 year, 1– 2 years and more than 2 years and compared the unassisted
angle at discharge following post-operative physiotherapy. The results of surgery were better
when the children were operated on earlier, suggesting that awareness needs to be improved
and intervention done at the earliest.
Patients were grouped into three groups of less than 6 months, 6 – 12 months and more
than 12 months based on their duration of final follow-up. There was no statistical
significance between the groups in unassisted angle measurements, suggesting that the
correction of claw was maintained during follow-up.
Analysis was done to determine the impact of age on outcome in terms of unassisted angle
at discharge. They were divided into those more than and less than 10 years of age. There was
no statistical significance between the groups suggesting that the outcome is not influenced by
age. There was a drop in number of patients during follow-up. The main reason is that the
patients come from hundreds of kilometres away; once the deformity is corrected they do not
come back unless there are other leprosy complications.
Conclusions
The deformity in hands due to leprosy in children is a tragedy as it hampers the use of hands in
daily routine activities, school attendance and other social interactions. Tendon transfer
surgery should be done on children to correct established clawing of fingers as it yields good
results and helps in facilitating hand functions to complete daily routine and academic
activities. Delay in having surgery should be avoided as this compromises the results leading
to a life time of residual visible deformity.
Acknowledgements
We thank the staff in the physiotherapy department, medical records department and
operation theatre as well as the ward staff for their co-operation and compassionate services.
80
G. Manivannan et al.
Thank you to the patients for their co-operation during the procedure and physiotherapy as
well as travelling long distances for follow-up.
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