Aust. Radiol. (1976),
U, 270
Forearm Bone Destruction in Lep:osy HILARY SKENE-SMITH, MRCP, FFR Department of Radiology, University Hospital, Kuala Lumpur, Malaysia
Bone changes in leprosy are common and can be classified as: ( 1) Specific bone lesions - due to direct lepromatous involvement. ( 2 ) Non-specific lesions due to the effects of trauma and infection in an anaesthetic part. (Paterson, 1975, 1961, 1964, Enna et al., 1971, and Lechat, 1962.) The non-specific changes are the most common and usually affect the digits (Enna et al., 1971). Involvement of the tarsal bones occurs often and this is related to weight bearing. However, non-specific changes affecting more proximal bones are rare (M4ller-Christenssen 1961; Karat, Karat & Foster, 1968), and the gross destruction of the wrist and forearm bones in the case presented here is related to the patient’s refusal to accept treatment. CASEREPORT L.C.Y., a Chinese male was born in 1914 and admitted to Sungei Buloh Leprosarium in 1953 with borderline leprosy. In 1958 a left below-knee amputation was performed for persistent ulceration and infection of his foot. His left upper limb was first known to be infected in 1962 when an ulcer was present and this was scraped. In 1963 a sinus developed and was incised. Ulceration of the right foot, hand and elbow also developed and peisisted, and by 1965 the left wrist appeared clinically to be ‘disarticulated‘. The patient persistently refused to consider further treatment, until 1972 when his right patella became infected. By this time his left wrist and forearms were no longer ulcerated but the stump of the hand had no bony attachment to the forearm. Since then he has had further episodes of infection but not involving the left upper limb. He manages to live with the help of three friends and moves around with the aid of
270
FIGURE I-Left
forearm. 1965.
Australasian Radiology, Vol. X X , No. 3. September, 1976
FOREARM BONE DESTRUCTION IN LEPROSY
FIGURE ?-Left
forearm. 1972.
crutches. He has been provided with splints to support his hand.
RADIOLOGICAL FEATURES
Left Forearm When first examined in 1965 the digits had bten destroyed, apart from small remnants of the proximal phalanges. The wrist showed soft A u.ctrulasiuii R a d i o l o p . Vol. XX. N o . 3 . Septenther. 1976
FIGUR? 3-1-eft
forearm. 1973.
tissue swelling, b m y ankylosis and marked destruction of the distal radius and ulna with associated periosteal new bone formation (Figure I ). The changes are those of old infection and neuropathy involving the digits and distal carpus with active infection of the forearm bones and proximal carpus. 27 I
HILARY SKENE-SMITH shows sclerosis and destruction due to advanced neuropathic change (Figure 4).
CONCLUSION This case shows the progressive bone destruction, which can occur in an anaesthetic limb following infection. This destruction has occurred over 10 years and although there has been no evidence of infection for 6 years, the bone reabsorption has continued and is remarkable for its extent and involvement of both forearm bones. The loss of digits is not uncommon in leprosy, nor is the neuropathic change in the foot, although it is especially marked in this patient.
ACKNOWLEDGEMENTS My thanks are due to Dr. M. K. Bhojwani, Director, Malaysia National Leprosy Control Scheme for permission to publish this case and to Miss Janet Low for typing the manuscript.
REFERENCES FIGURE
&Right
foot. 1972.
By 1972, there was no evidence of active infection, but the distal forearm bones were represented by only a thin sliver of bonc. The carpal and metacarpal joints had ankylosed ( Figure 2). Re-examination a year later showed further reabsorption of the forearm bones, but again without evidence of infection (Figure 3). Right Foot Bone reabsorption and bony ankylosis with loss of digits is also present. Main weight bearing and movement occurs at the ankle joint, which
272
‘Paterson, D. E. (1955): ‘‘Radiological Bone Changes and Angiographic Findings in Leprosy.” Journul of the Faculty of Radiologists. VII, 35-56. ‘Paterson, D. E. (1961) in Tropical Radiology by Middlemiss, William Heinemann Medical Books Ltd., 21-37.
“Paterson, D. E. (1964) in Cochrane & Davey. Leprosy in Theory and Practice. John Wright and Sons Ltd., Bristol. ‘Enna, C. D., Jacobson, R. R. and Rausch, R. 0. ( 1971) : “Bone Changes in Leprosy.” Radiology, 100, 295-306.
“Karat, S., Karat, A. B. A. and Foster, R., (1968). “Radiological Changes in Bones of the Limbs in Leprosy.” Leprosy Review, 1938,3, 147-169. “Mdler-Christenssen, V. (1961): “Bone Changes in Leprosy.” Copenhagen: Ejnar Munksgaard, 33 and 43. ‘Lechat, M. F. (1962): “Bone Lesions in Leprosy.” International Journal of Leprosy, 30, 125-1 37.
Ausfralasian Radiology, Vol. XX,No. 3, September, I976
U, 270
Forearm Bone Destruction in Lep:osy HILARY SKENE-SMITH, MRCP, FFR Department of Radiology, University Hospital, Kuala Lumpur, Malaysia
Bone changes in leprosy are common and can be classified as: ( 1) Specific bone lesions - due to direct lepromatous involvement. ( 2 ) Non-specific lesions due to the effects of trauma and infection in an anaesthetic part. (Paterson, 1975, 1961, 1964, Enna et al., 1971, and Lechat, 1962.) The non-specific changes are the most common and usually affect the digits (Enna et al., 1971). Involvement of the tarsal bones occurs often and this is related to weight bearing. However, non-specific changes affecting more proximal bones are rare (M4ller-Christenssen 1961; Karat, Karat & Foster, 1968), and the gross destruction of the wrist and forearm bones in the case presented here is related to the patient’s refusal to accept treatment. CASEREPORT L.C.Y., a Chinese male was born in 1914 and admitted to Sungei Buloh Leprosarium in 1953 with borderline leprosy. In 1958 a left below-knee amputation was performed for persistent ulceration and infection of his foot. His left upper limb was first known to be infected in 1962 when an ulcer was present and this was scraped. In 1963 a sinus developed and was incised. Ulceration of the right foot, hand and elbow also developed and peisisted, and by 1965 the left wrist appeared clinically to be ‘disarticulated‘. The patient persistently refused to consider further treatment, until 1972 when his right patella became infected. By this time his left wrist and forearms were no longer ulcerated but the stump of the hand had no bony attachment to the forearm. Since then he has had further episodes of infection but not involving the left upper limb. He manages to live with the help of three friends and moves around with the aid of
270
FIGURE I-Left
forearm. 1965.
Australasian Radiology, Vol. X X , No. 3. September, 1976
FOREARM BONE DESTRUCTION IN LEPROSY
FIGURE ?-Left
forearm. 1972.
crutches. He has been provided with splints to support his hand.
RADIOLOGICAL FEATURES
Left Forearm When first examined in 1965 the digits had bten destroyed, apart from small remnants of the proximal phalanges. The wrist showed soft A u.ctrulasiuii R a d i o l o p . Vol. XX. N o . 3 . Septenther. 1976
FIGUR? 3-1-eft
forearm. 1973.
tissue swelling, b m y ankylosis and marked destruction of the distal radius and ulna with associated periosteal new bone formation (Figure I ). The changes are those of old infection and neuropathy involving the digits and distal carpus with active infection of the forearm bones and proximal carpus. 27 I
HILARY SKENE-SMITH shows sclerosis and destruction due to advanced neuropathic change (Figure 4).
CONCLUSION This case shows the progressive bone destruction, which can occur in an anaesthetic limb following infection. This destruction has occurred over 10 years and although there has been no evidence of infection for 6 years, the bone reabsorption has continued and is remarkable for its extent and involvement of both forearm bones. The loss of digits is not uncommon in leprosy, nor is the neuropathic change in the foot, although it is especially marked in this patient.
ACKNOWLEDGEMENTS My thanks are due to Dr. M. K. Bhojwani, Director, Malaysia National Leprosy Control Scheme for permission to publish this case and to Miss Janet Low for typing the manuscript.
REFERENCES FIGURE
&Right
foot. 1972.
By 1972, there was no evidence of active infection, but the distal forearm bones were represented by only a thin sliver of bonc. The carpal and metacarpal joints had ankylosed ( Figure 2). Re-examination a year later showed further reabsorption of the forearm bones, but again without evidence of infection (Figure 3). Right Foot Bone reabsorption and bony ankylosis with loss of digits is also present. Main weight bearing and movement occurs at the ankle joint, which
272
‘Paterson, D. E. (1955): ‘‘Radiological Bone Changes and Angiographic Findings in Leprosy.” Journul of the Faculty of Radiologists. VII, 35-56. ‘Paterson, D. E. (1961) in Tropical Radiology by Middlemiss, William Heinemann Medical Books Ltd., 21-37.
“Paterson, D. E. (1964) in Cochrane & Davey. Leprosy in Theory and Practice. John Wright and Sons Ltd., Bristol. ‘Enna, C. D., Jacobson, R. R. and Rausch, R. 0. ( 1971) : “Bone Changes in Leprosy.” Radiology, 100, 295-306.
“Karat, S., Karat, A. B. A. and Foster, R., (1968). “Radiological Changes in Bones of the Limbs in Leprosy.” Leprosy Review, 1938,3, 147-169. “Mdler-Christenssen, V. (1961): “Bone Changes in Leprosy.” Copenhagen: Ejnar Munksgaard, 33 and 43. ‘Lechat, M. F. (1962): “Bone Lesions in Leprosy.” International Journal of Leprosy, 30, 125-1 37.
Ausfralasian Radiology, Vol. XX,No. 3, September, I976
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