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http://tdo.sagepub.com/content/40/4/223The online version of this article can be found at:

 DOI: 10.1258/td.2010.090354

2010 40: 223Trop DoctFred Chuma Sitati, Edward Naddumba and Tito Beyeza

Injection-induced sciatic nerve injury in Ugandan children  

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Short Report

Injection-induced sciaticnerve injury in UgandanchildrenFred Chuma Sitati MMed FCS*Edward Naddumba MMed FCS†

Tito Beyeza MMed FCS‡

*PCEA Kikuyu Hospital, Orthopedic Unit, Kikuyu, Nairobi00200, Kenya; †Mulago Hospital, Kampala; ‡MakerereeUniversity, Mulago Orthopedic Hospital, Kampala, Uganda

Correspondence to: Dr Fred Chuma Sitati,PO Box 895-00200, Nairobi, KenyaEmail: fredsitati@gmail.com

TROPICAL DOCTOR 2010; 40: 223–224DOI: 10.1258/td.2010.090354

SUMMARY In developing countries, sciatic nerve injuryfollowing gluteal intramuscular injection is a persistentproblem. A study over 6months involving133 children seenin Mulago hospital with acute flaccid paralysis revealed124(93%) childrenwith injection-induced sciatic nerve injury.The identityof the drug in 79 cases (59.4%)was quinine. It isrecommended that the gluteal region should not be usedas an intramuscular injection site in children.

Introduction

Every year an estimated 12 billion injections are administeredworldwide.1

Approximately each person in the developing countriesreceives two injections per year, of which 75% are unnecess-ary.1,2 The most common site of intramuscular injection isthe gluteal region.

In the developing countries, sciatic nerve injury followinggluteal intramuscular (IM) injection is persistent, despitethe widespread teaching that the upper outer quadrant of thegluteal region should be the site for the injection or thatalternative sites should be used in children.1

In the Mulago Hospital, a marked increase has beennoticed in the number of children presenting withinjection-induced sciatic nerve injury.

Materials and methods

A cross-sectional descriptive study was conducted at theMulago Hospital – Uganda’s national referral and teachinghospital – during October 2006 to March 2007. The researchcommittee of the Mulago Hospital approved the study andinformed consent was obtained and data collected using a

structured, pretested questionnaire. A thorough clinicalevaluation was made and relevant laboratory tests were done.

In this study, acute flaccid paralysis (AFP) is defined as thesudden onset of asymmetrical lower limb weakness andinjection-induced injury of the sciatic nerve is defined as acase in which there is flaccid paralysis of one limb and a defi-nite history of injection in that limb less than 24h before theonset of paralysis.3

The data were analysed using SPSS version 10.0. AP value of less than 0.05 was considered to be statisticallysignificant.

Results

A total of 135 cases of AFP were diagnosed; two wereexcluded due to a failure to give consent. The study involved133 cases of AFP, of which 124 cases were due toinjection-induced injury. The percentage of patients withAFP due to injection-induced sciatic nerve injury was93.2%. Two cases of Guillain-Barre syndrome were diag-nosed (Table 1). Stool culture for polio virus was carriedout in 47 cases and all were negative.

The age range was 4 months to 12 years with a peak at 1year and mean of 3.7 years: 81 males (60.9%) and 52(39.1%) females. Malaria was the reason for most patients(65.3%) receiving gluteal intramuscular injections thatresulted in injection injury of the sciatic nerve (Table 2).Private clinics accounted for about two-thirds (66.1%) ofthe facilities where injections resulting in injury of thesciatic nerve were administered. The majority of the intra-muscular injections resulting in injury of the sciatic nervewere given by nurses (77; 62.1%). The identity of the drugin 79 cases (59.4%) was quinine; other drugs included anti-biotics (9.0%), antipyretics (6.8%) and chloroquine (4.5%).

In the univariate analysis, quinine was found to be the drugstatistically more likely to cause injection-induced injury ofthe sciatic nerve (P value ¼ 0.005, odds ratio ¼ 12.02, confi-dence interval ¼ 1.43–100.82).

Discussion

A large percentage of AFP cases in children in the MulagoHospital was as a result of injection-induced injury of thesciatic nerve. The high percentage observed in this studycould be due to the hospital being a national referral hospital.4,5

Table 1 Differential diagnosis of patients with acute flaccidparalysis

Diagnosis Frequency (%)

Injection-induced injury 124 (93.2)Unknown 7 (5.3)Guillain-Barre syndrome 2 (1.5)Total 133 (100)

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The problem of injection-induced injury of the sciaticnerve was noted to be particularly common in childrenaged less than 5 years (76.7%), as a result of having asmaller and less developed gluteal region.6,7 Males weremore affected than females (1.6:1) due to the greater priorityfor health care given to boys.8 The majority of injectionswere administered in a private health facility (75%) and,for most of the guardians, senior school had been theirhighest level of education and they had unskilled jobs(65.3%) – they were, therefore, more likely to have a lowsocioeconomic status.

Malaria is endemic in Uganda, and so it was the leadingindication for the administration of the injection that resultedin injury of the sciatic nerve in 81 cases (65.3%).9,10

The majority of the intramuscular injections resulting ininjury of the sciatic nerve were given by nurses (62.1%). Inover half of the cases (59.4%), quinine was the drug used.Studies have revealed that quinine is notorious for causinginjury of the sciatic nerve when administered by intramuscu-lar gluteal injection.5,9 There was a statistical significancebetween quinine and injection-induced sciatic nerve injury(P value ¼ 0.005).

Conclusion

Injection-induced injury of the sciatic nerve is the leadingcause of AFP in children presenting to the Mulago

Hospital. There was a statistical significant associationbetween quinine and the occurrence of injection-induced injury of the sciatic nerve in children presentingwith AFP. It is recommended that the gluteal regionshould not be used as an intramuscular injection site inchildren.

Appropriate health education about injections should begiven to the health workers and the public.

References

1 World Health Organization. Safety of Injections: A Brief

Background. Fact sheet No. 231. Geneva: WHO, 1999

2 World Health Organization. Unsafe injection practice and

transmission of blood borne pathogens. WHO Bull 1999;77:

787–99

3 Mansoor Faisal. Case definition of traumatic injection neuropa-

thy. Pakistan J Med Res 2004;43:100–9

4 Huang Y, Yan Q, Lei W. [Gluteal sciatic nerve injury and its

treatment (article in Chinese)] Zhongguo. Xiu Fu Chong Jian

Wai Ke Za Zhi 2000;14:83–6

5 Ohaegbulam SC. Peripheral nerve injuries from intramuscular

injection of drugs. West Afr J Pharmacol Drug Res 1976;3:

161–7

6 Ahuja B. Post injection sciatic nerve injury. Indian Pediatr

2003;40:368–9

7 Sharma S, Kale R. Post injection palsy in Chatisgarh region.

Indian Pediatr 2003;40:580–1

8 Pandian JD, Bose S, Daniel V, Singh Y, Abraham AP. Nerve

injuries following intramuscular injections: a clinical and neuro-

physiological study from Northwest India. J Peripher Nerv Syst

2006;11:165

9 Naddumba EK, Ndoboli P. Sciatic nerve palsy associated with

intramuscular quinine injection in children. East and Central

African Journal of Surgery 1999;4:17–20

10 Ndiaye A, Sakho Y, Fall F, Dia A, Sow ML. Sciatic nerve in

gluteal portion: application of sciatic nerve post injection lesion

Morphologie 2004;88:135–8

Table 2 Reason for injection

Reason for injection Frequency (%)

Malaria 81 (65.3)Unspecified febrile illness 19 (15.3)Pneumonia 9 (7.3)Convulsions 7 (5.6)Chronic illness 5 (4.0)Vomiting 3 1.6Unknown 9 7.3Total 133 100.0

Short Report

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