Indian Pediatrics - Editorial

Letters to the Editor

Indian Pediatrics 2003; 40:368-369

Post Injection Sciatic Nerve Injury

Sciatic nerve injury leading to paralysis of the foot and permanent sequelae following intramuscular injection in the gluteal region has been recognised since long(1-3). The lateral aspect of thigh at the junction of middle and lower third is recommended as an ideal site for intramuscular injection in children(4). However, the practice of giving injections in the gluteal region is being continued by medical and paramedical personnel especially in private set up. The exact extent of problem in our country is not known, where injections are given by health care providers even for minor ailments. With Acute Flaccid Paralysis (AFP) surveillance progress, where traumatic neuritis is one of the reporting condition large number of cases have come into notice recently. Last year 16 cases of traumatic sciatic neuritis following intra gluteal injections were seen at our center; 9 cases (12%) were reported as AFP out of 74 AFP cases. Till July 2002, 7 cases (14%) have been reported as traumatic neuritis out of 49 AFP cases. This communication highlights the long-term complications of sciatic nerve injury and strongly condemns the practice of giving intramuscular injections in the gluteal region in children.

The sciatic nerve injury can occur at any age if site of the injection is not upper outer quadrant of the buttock. In children due to variation in the thickness of subcutaneous tissue and depth of gluteal musculature, the chances of involvement of sciatic nerve are more. In neonates, malnourished children and non-cooperative children the problem is further compounded. It has also been observed that nerve is within the reach of standard needle even when injection is given in the upper outer quadrant of the buttock(1). Damage to the nerve may be due to the needle itself or due to ischemia. Weakness of the foot may be noted one or more days after the injection and at times precise onset may be difficult to date in a sick child(4). The paralytic foot’s deformity in many instances may be erroneously attributed to congenital clubfoot or sequelae of poliomyelitis.

Common peroneal division of sciatic nerve is more frequently involved resulting in foot drop due to weakness of ankle dorsiflexors. The sensory features may be prominent in older children with pain and loss of sensation in lateral aspect of leg and foot(4). The posterior tibial nerve is occasionally affected causing paralysis of planter flexors of the foot and knee-flexors. The total injury of sciatic nerve would lead to completely paralysed flail foot.

In long term follow up of 50 cases of post injection traumatic neuritis of sciatic nerve from our center, complete recovery was seen in 36% of cases, 40% showed no recovery and 24% showed partial recovery; out of these 68% required ankle foot arthosis for ambulation, pedal growth arrest of the affected limb was seen in 75% and 2 children had to undergo corrective surgery for fixed deformities(5).

It is recommended that rational and judicious use of injections should be considered in children and gluteal site for intramuscular injections should be universally discarded to prevent serious problem of sciatic nerve injury. As members of IAP, we all should take up this issue of well recognized totally preventable childhood morbidity.

Bina Ahuja,
Incharge,
Department of Physical Medicine and Rehabilitation,
Kalwati Saran Children’s Hospital,
New Delhi 110 001, India.
E-mail: [email protected]

References

1. Gills FH, French JH. Post-injection sciatic nerve palsies in infants and children. J Pediatr 1961; 58: 195-204.

2. Combes MA, Clark WK, Gregar CF. Sciatic nerve injury in infants. JAMA 1960; 173; 1336-1339.

3. Gills FH, Matson D. Sciatic nerve injury following misplaced gluteal injection. J Pediatr 1970; 76: 247-256.

4. Brett EM. Neuromuscular disorders II Peripheral Neuropathy. In: Pediatric Neurology, 3rd Edn. Eds. Edward M Brett. New York: Churchil Livingston 1997; p 138.

5. Ahuja B, Dhameja K. Sciatic neuropathy. Indian Pediatr 1984; 21: 797-801.